Table of Contents
1. Cover
2. Preface
1. CHANGES TO CCD
2. EFFICIENT UP‐TO‐DATE COVERAGE
3. PEDAGOGICAL STRENGTHS
4. APPRECIATION
5. REFERENCE
3. About the Authors
4. SECTION ONE: The Multiple Dimensions of Multicultural Counseling and Therapy
1. PART I: The Affective and Conceptual Dimensions of Multicultural Counseling
and Therapy
1. 1 Obstacles to Developing Cultural Competence and Cultural Humility
1. REACTIONS TO READING COUNSELING THE CULTURALLY
DIVERSE
2. EMOTIONAL SELF‐REVELATIONS AND FEARS: MAJORITY
GROUP MEMBERS
3. EMOTIONAL INVALIDATION VERSUS AFFIRMATION:
MARGINALIZED GROUP MEMBERS
4. RECOGNIZING AND UNDERSTANDING RESISTANCE TO
MULTICULTURAL TRAINING
5. CULTURAL COMPETENCE AND EMOTIONS
6. SUMMARY
7. GLOSSARY TERMS
8. REFERENCES
2. 2 Multicultural Counseling and Therapy (MCT)
1. CULTURE‐UNIVERSAL (ETIC) VERSUS CULTURE‐SPECIFIC
(EMIC) FORMULATIONS
2. THE NATURE OF MULTICULTURAL COUNSELING
COMPETENCE
3. A TRIPARTITE FRAMEWORK FOR UNDERSTANDING THE
MULTIPLE DIMENSIONS OF IDENTITY
4. INDIVIDUAL AND UNIVERSAL BIASES IN PSYCHOLOGY AND
MENTAL HEALTH
5. THE IMPACT OF GROUP IDENTITIES ON COUNSELING AND
PSYCHOTHERAPY
6. WHAT IS MULTICULTURAL COUNSELING AND THERAPY
(MCT)?
7. WHAT IS CULTURAL COMPETENCE?
8. SOCIAL JUSTICE AND CULTURAL COMPETENCE
9. SUMMARY
10. GLOSSARY TERMS
11. REFERENCES
3. 3 Multicultural Counseling Competence for Counselors and Therapists of
Marginalized Groups
1. INTERRACIAL AND INTERETHNIC BIASES
2. IMPACT ON INTERRACIAL COUNSELING RELATIONSHIPS
3. STEREOTYPES HELD BY SOCIALLY MARGINALIZED GROUP
MEMBERS
4. THE WHO‐IS‐MORE‐OPPRESSED GAME
5. COUNSELORS FROM MARGINALIZED GROUPS WORKING
WITH MAJORITY AND OTHER MARGINALIZED GROUP
CLIENTS
6. THE POLITICS OF INTERETHNIC AND INTERRACIAL BIAS AND
DISCRIMINATION
7. THE HISTORICAL AND POLITICAL RELATIONSHIPS BETWEEN
GROUPS OF COLOR
8. DIFFERENCES BETWEEN RACIAL/ETHNIC GROUPS
9. COUNSELORS OF COLOR AND DYADIC COMBINATIONS
10. SUMMARY
11. GLOSSARY TERMS
12. REFERENCES
2. PART II: The Impact and Social Justice Implications of Counseling and
Psychotherapy
1. 4 The Political and Social Justice Implications of Counseling and
Psychotherapy
1. THE MENTAL HEALTH IMPACT OF SOCIOPOLITICAL
OPPRESSION
2. SOCIOPOLITICAL OPPRESSION AND THE TRAINING OF
COUNSELING/MENTAL HEALTH PROFESSIONALS
3. DEFINITIONS OF MENTAL HEALTH
4. COUNSELING AND MENTAL HEALTH LITERATURE
5. SOCIAL JUSTICE COUNSELING
6. SUMMARY
7. GLOSSARY TERMS
8. REFERENCES
2. 5 The Impact of Systemic Oppression Within the Counseling Process
1. LOCATING CLIENTS' PROBLEMS ENTIRELY INSIDE THE
CLIENTS
2. CULTURALLY RELATED RESPONSES THAT REPRODUCE
STEREOTYPES
3. RESPONDING WHEN THE ISSUES ARE OUR OWN: WHITE
FRAGILITY
4. EFFECTS OF HISTORICAL AND CURRENT OPPRESSION
5. COUNSELOR CREDIBILITY AND ATTRACTIVENESS
6. FORMATION OF INDIVIDUAL AND SYSTEMIC WORLDVIEWS
7. FORMATION OF WORLDVIEWS
8. SUMMARY
9. GLOSSARY TERMS
10. REFERENCES
3. 6 Microaggressions in Counseling and Psychotherapy
1. CONTEMPORARY FORMS OF OPPRESSION
2. THE EVOLUTION OF THE “ISMS”: MICROAGGRESSIONS
3. THE DYNAMICS AND DILEMMAS OF MICROAGGRESSIONS
4. THERAPEUTIC IMPLICATIONS
5. MANIFESTATIONS OF MICROAGGRESSIONS IN
COUNSELING/THERAPY
6. THE PATH FORWARD
7. SUMMARY
8. GLOSSARY TERMS
9. REFERENCES
3. PART III: The Practice Dimensions of Multicultural Counseling and Therapy
1. 7 Multicultural Barriers and the Helping Professional
1. MY THERAPIST DIDN'T UNDERSTAND
2. STANDARD CHARACTERISTICS OF MAINSTREAM
COUNSELING
3. CULTURE‐BOUND VALUES
4. CLASS‐BOUND VALUES
5. LANGUAGE BARRIERS
6. PATTERNS OF “AMERICAN” CULTURAL ASSUMPTIONS AND
MULTICULTURAL FAMILY COUNSELING/THERAPY
7. OVERGENERALIZING AND STEREOTYPING
8. SUMMARY
9. GLOSSARY TERMS
10. REFERENCES
2. 8 Communication Style and Its Impact on Counseling and Psychotherapy
1. COMMUNICATION STYLES
2. SOCIOPOLITICAL FACETS OF NONVERBAL COMMUNICATION
3. COUNSELING AND THERAPY AS COMMUNICATION STYLE
4. SUMMARY
5. GLOSSARY TERMS
6. REFERENCES
3. 9 Multicultural Evidence‐Based Practice (EBP)
1. EVIDENCE‐BASED PRACTICE (EBP) AND
MULTICULTURALISM
2. EVIDENCE‐BASED PRACTICE (EBP) AND DIVERSITY ISSUES
IN COUNSELING
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
4. 10 Non‐Western Indigenous Methods of Healing
1. WORLDVIEWS AND CULTURAL SYNDROMES
2. THE PRINCIPLES OF INDIGENOUS HEALING
3. EXAMPLES OF INDIGENOUS HEALING APPROACHES
4. DANGERS AND BENEFITS OF SPIRITUALITY
5. SUMMARY
6. GLOSSARY TERMS
7. REFERENCES
4. PART IV: Racial, Ethnic, Cultural (REC) Attitudes in Multicultural Counseling and
Therapy
1. 11 Racial, Ethnic, Cultural (REC) Identity Attitudes in People of Color
1. RACIAL AWAKENING
2. REC IDENTITY ATTITUDE MODELS
3. A GENERAL MODEL OF REC IDENTITY
4. COUNSELING IMPLICATIONS OF THE R/CID MODEL
5. VALUE OF A GENERAL REC IDENTITY FRAMEWORK
6. SUMMARY
7. GLOSSARY TERMS
8. REFERENCES
2. 12 White Racial Identity Development
1. UNDERSTANDING THE DYNAMICS OF WHITENESS
2. MODELS OF WHITE RACIAL IDENTITY DEVELOPMENT
3. THE PROCESS OF WHITE RACIAL IDENTITY DEVELOPMENT: A
DESCRIPTIVE MODEL
4. DEVELOPING A NONRACIST AND ANTIRACIST WHITE
IDENTITY
5. SUMMARY
6. GLOSSARY TERMS
7. REFERENCES
5. SECTION TWO: Multicultural Counseling and Specific Populations
1. PART V: Understanding Specific Populations
1. 13 Culturally Competent Assessment
1. THERAPIST VARIABLES AFFECTING DIAGNOSIS
2. CULTURAL COMPETENCE AND PREVENTING DIAGNOSTIC
ERRORS
3. CONTEXTUAL AND COLLABORATIVE ASSESSMENT
4. INFUSING CULTURAL RELEVANCE INTO STANDARD
CLINICAL ASSESSMENTS
5. SUMMARY
6. GLOSSARY TERMS
7. REFERENCES
2. PART VI: Counseling and Therapy with Racial/Ethnic Minority Group Populations
1. 14 Counseling African Americans
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
2. 15 Counseling American Indians/Native Americans and Alaska Natives
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
3. 16 Counseling Asian Americans and Pacific Islanders
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
4. 17 Counseling Latinx Populations
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
5. 18 Counseling Multiracial Populations
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
3. PART VII: Counseling and Special Circumstances Involving Racial/Ethnic
Populations
1. 19 Counseling Arab Americans and Muslim Americans
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
2. 20 Counseling Immigrants and Refugees
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
3. 21 Counseling Jewish Americans
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
4. PART VIII: Counseling and Therapy with Other Multicultural Populations
1. 22 Counseling Individuals with Disabilities
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
2. 23 Counseling LGBTQ Populations
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
3. 24 Counseling Older Adults
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
4. GLOSSARY TERMS
5. REFERENCES
4. 25 Counseling Individuals Living in Poverty
1. CHARACTERISTICS AND STRENGTHS
2. SPECIFIC CHALLENGES
3. SUMMARY
List of Tables
1. Chapter 3
1. TABLE 3.1 Ten Common Challenges Counselors of Color Face When Working
with Wh...
2. Chapter 6
1. TABLE 6.1 Examples of Microaggressions
2. TABLE 6.2 Examples of Microaggressions in Therapeutic Practice
3. Chapter 7
1. TABLE 7.1 Components of White Culture: Values and Beliefs
2. TABLE 7.2 Cultural Value Preferences of Middle‐Class White EuroAmericans
and Peop...
4. Chapter 8
1. TABLE 8.1 Communication Style Differences (Overt Activity Dimension—
Nonverbal/Ver...
5. Chapter 9
1. TABLE 9.1 Examples of Empirically Supported Treatments (ESTs)
2. TABLE 9.2 Empirically Supported Relationship (ESR) Variables
3. TABLE 9.3 Relational‐Style Counselor Preferences of Ethnic Group Clients
6. Chapter 10
1. TABLE 10.1 Culture‐Bound Syndromes
7. Chapter 11
1. TABLE 11.1 The R/CID Model
8. Chapter 22
1. TABLE 22.1 Things to Remember When Interacting with Individuals with
Disabili...
List of Illustrations
1. Chapter 2
1. FIGURE 2.1 Tripartite Development of Personal Identity
2. Chapter 4
1. FIGURE 4.1 Levels of Counseling Interventions
3. Chapter 5
1. FIGURE 5.1 Graphic Representation of Worldviews
4. Chapter 9
1. FIGURE 9.1 Three Pillars of Evidence‐Based Practice (EBP)
5. Chapter 14
1. FIGURE 14.1 The Interaction of Four Sets of Factors in the Jones Model
EIGHTH EDITION
Counseling the Culturally Diverse
Theory and Practice
Derald Wing Sue | David Sue | Helen A. Neville | Laura Smith
This edition first published 2019.
© 2019 John Wiley & Sons, Inc.
Edition History
John Wiley and Sons, Inc. (7e, 2015)
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the Culturally Diverse: Theory and Practice, Eighth Edition has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Sue, Derald Wing, author.
Title: Counseling the culturally diverse : theory and practice / Derald Wing Sue [and three others].
Description: Eighth edition. | Hoboken, NJ : John Wiley & Sons, Inc., 2019. | Includes bibliographical references and index. |
Identifiers: LCCN 2018042673 (print) | LCCN 2018044428 (ebook) | ISBN 9781119448235 (Adobe PDF) | ISBN
9781119448280 (ePub) | ISBN 9781119448242 (paperback)
Subjects: LCSH: Cross‐cultural counseling.
Classification: LCC BF636.7.C76 (ebook) | LCC BF636.7.C76 S85 2019 (print) | DDC 158.3–dc23
LC record available at https://lccn.loc.gov/2018042673
Cover Design: Wiley
Cover Image: © Anthony Carpinelli / EyeEm / Getty Images
Preface
For nearly four decades, Counseling the Culturally Diverse: Theory and Practice (CCD) has
been the cutting‐edge text in multicultural counseling and mental health, used in an
overwhelming majority of graduate training programs in counseling and clinical psychology.
It now forms part of the multicultural knowledge base of licensing and certification exams at
both the master's and the doctoral levels. In essence, it has become a “classic” in the field,
and continues to lead the profession in the research, theory, and practice of multicultural
counseling and therapy (MCT). CCD upholds the highest standards of scholarship and is the
most frequently cited text in multicultural psychology and ethnic minority mental health.
With the addition of two new co‐authors, Dr. Helen Neville and Dr. Laura Smith, to the
eighth edition, instructors will note a fresh, new, and exciting perspective to the content of
CCD, and their scholarly input guarantees it will continue to rank as the most up‐to‐date
text in the field. Both have been foremost leaders in multicultural psychology, and their
voices become obvious in this revised edition.
CHANGES TO CCD
Much new research has been conducted in multicultural counseling, cultural competence,
social justice advocacy, new roles of the helping professional, White allyship, and culture‐
specific interventions over the past few years. In essence, the topical areas covered in each
chapter continue to be anchors for multicultural counseling coverage. As a result, while the
chapters remain similar, each has undergone major revisions; some are quite extensive in the
updating of references, introduction of new research and concepts, and discussion of future
directions in counseling, therapy, and mental health.
We maintain our two‐part division of the book, with 12 separate chapters in Section One:
The Multiple Dimensions of Multicultural Counseling and Therapy, and 13 population‐
specific chapters in Section Two: Multicultural Counseling and Specific Populations. We
introduce Section Two by providing a chapter, “Culturally Competent Assessment” (Chapter
13), that outlines the many variables that influence assessment, diagnosis, and case
conceptualization—which, hopefully, guide the reader's understanding of each specific
population presented. All have been thoroughly updated using common topical headings
(when possible) that allow better cross‐comparisons between and among the groups.
EFFICIENT UP‐TO‐DATE COVERAGE
We have heard from textbook adopters that the breadth and depth of coverage has made it
very difficult for instructors and students to digest the amount of material in a single course.
Although reviewers suggested that CCD be shortened, they did not recommend eliminating
topics, but rather condensing, summarizing, streamlining, or eliminating certain subtopics.
We have tried our best to do so without violating the integrity of the content. Each of the
major chapters 1 through 12) has been shortened by an average of 10%, but the special
population chapters have maintained their original length. This latter decision was based on
our belief that further shortening would result in the chapters having a “checklist” quality.
Further, we are also aware that most instructors do not assign all special population chapters,
but rather pick and choose the ones most relevant to their classes.
Despite shortening major sections of the text, new advances and important changes in
multicultural counseling suggest additional areas that need to be addressed. These include
building on the previous groundbreaking edition, which has become the most widely used,
frequently cited, and critically acclaimed multicultural text in the mental health field, and
updating concepts to be consistent with Diagnostic and Statistical Manual of Mental
Disorders (DSM‐5) categories and principles, the multicultural guidelines of the American
Psychological Association, the American Counseling Association's (ACA) multicultural and
social justice competencies, and Council for Accreditation of Counseling & Related
Educational Programs (CACREP) standards.
We also include the most recent research and theoretical formulations that introduce and
analyze emerging important multicultural topics. These include the concept of “cultural
humility” as a domain of cultural competence; the important roles of White allies in the
struggle for equal rights; the emerging call for social justice counseling; the important
concept of “minority stress” and its implications in work with marginalized populations;
greater focus on developmental psychology that speaks to raising and educating children
about race, gender, and sexual orientation; reviewing and introducing the most recent
research on lesbian, gay, bisexual, transgender, and queer (LGBTQ) issues; major research
developments in the manifestation, dynamics, and impact of microaggressions; and many
others.
PEDAGOGICAL STRENGTHS
One of the main goals of the eighth edition has been to better engage students in the material
and allow them to actually become active participants in digesting multicultural counseling
concepts. We have increased our focus on pedagogy by providing instructors with exercises
and activities to facilitate experiential learning for students. We open every chapter with
broad chapter objectives, followed by more specific—and oftentimes controversial
—reflection and discussion questions interspersed throughout, which allow for more
concentrated and detailed discussion by students on identifiable topical areas.
Further, every chapter opens with a clinical vignette, longer narrative, or situational example
that previews the major concepts and issues discussed within. Many of these are new and
serve to anchor the multicultural issues to follow. They add life and meaning to the chapter
concepts and research. The chapter focus questions serve as prompts to address the opening
“course objectives,” but instructors and trainers can also use them as discussion questions
throughout the course or workshop. As in the previous edition, we have retained the
“Implications for Clinical Practice” and “Summary” sections at the end of every chapter.
There are two other major resources available for instructor use:
1. A series of brief simulated multicultural counseling videos that can be used in the
classroom or viewed online. Each video relates to issues presented in one of the first 13
chapters. They are excellent training aids that allow students to witness multicultural
blunders by counselors, identify cultural and sociopolitical themes in the counseling
process, discuss and analyze what can go wrong in a session, and suggest culturally
appropriate intervention strategies.
Following each video, Dr. Derald Wing Sue and Dr. Joel M. Filmore discuss
and analyze each session in the context of the themes of the chapter.
Instructors have many ways to use the videos to stimulate classroom
discussion and understanding.
2. In keeping with the importance of applying research and theory to work with client and
client systems, we encourage instructors to use Case Studies in Multicultural Counseling
and Therapy, edited by Sue, Gallardo, and Neville (2014), alongside CCD.
APPRECIATION
There is an African American proverb that states, “We stand on the head and shoulders of
many who have gone on before us.” Certainly, this book would not have been possible
without their wisdom, commitment, and sacrifice. We thank them for their inspiration,
courage, and dedication, and hope they will look down on us and be pleased with our work.
We would like to acknowledge all the dedicated multicultural pioneers in the field who have
journeyed with us along the path of multiculturalism before it became fashionable. We also
wish to thank the staff of John Wiley & Sons for the enormous time and effort they have
placed in obtaining, evaluating, and providing us with the necessary data and feedback to
produce this edition of CCD. Their help was no small undertaking, and we feel fortunate in
having Wiley as our publisher.
Working on this eighth edition continues to be a labor of love. It would not have been
possible, however, without the love and support of our families, who provided the patience
and nourishment that sustained us throughout our work on the text. Derald Wing Sue wishes
to express his love for his wife, Paulina, his son, Derald Paul, his daughter, Marissa
Catherine, and his grandchildren, Caroline, Juliette, and Niam. Helen A. Neville wishes to
express her deepest love and appreciation for her life partner, Sundiata K. Cha‐Jua, her
daughters, and the memory of her parents. Laura Smith expresses love and appreciation for
the support of her partner, Sean Kelleher, as well as her extended family. David Sue wishes to
express his love and appreciation to his wife and children.
We hope that Counseling the Culturally Diverse: Theory and Practice, eighth edition, will
stand on “the truth” and continue to be the standard bearer of multicultural counseling and
therapy texts in the field.
Derald Wing Sue
David Sue
Helen A. Neville
Laura Smith
REFERENCE
1. Sue, D. W., Gallardo, M., & Neville, H. (2014). Case studies in multicultural counseling
and therapy. Hoboken, NJ: Wiley.
About the Authors
Derald Wing Sue is Professor of Psychology and Education in the Department of Counseling
and Clinical Psychology at Teachers College, Columbia University. He served as president of
the Society for the Psychological Study of Culture, Ethnicity and Race, the Society of
Counseling Psychology, and the Asian American Psychological Association. Dr. Sue
continues to be a consulting editor for numerous publications. He is author of more than 160
publications, including 21 books, and is well known for his work on racism/antiracism,
cultural competence, multicultural counseling and therapy, and social justice advocacy. Three
of his books, Counseling the Culturally Diverse: Theory and Practice, Microaggressions in
Everyday Life, and Overcoming our Racism: The Journey to Liberation (John Wiley & Sons),
are considered classics in the field. Dr. Sue's most recent research on racial, gender, and
sexual orientation microaggressions has provided a major breakthrough in understanding how
everyday slights, insults, and invalidations toward marginalized groups create psychological
harm to their mental and physical health and create disparities for them in education,
employment, and health care. His most recent book, Race Talk and the Conspiracy of
Silence: Understanding and Facilitating Difficult Dialogues on Race promises to add to the
nationwide debate on racial dialogues. A national survey has identified Derald Wing Sue as
“the most influential multicultural scholar in the United States,” and his works are among the
most frequently cited.
David Sue is Professor Emeritus of Psychology at Western Washington University, where he
has served as the director of both the Psychology Counseling Clinic and the Mental Health
Counseling program. He is also an associate of the Center for Cross‐Cultural Research at
Western Washington University. He and his wife, Diane M. Sue, have coauthored the books
Foundations of Counseling and Psychotherapy: Evidence‐Based Practices for a Diverse
Society, Understanding Abnormal Psychology (12th edition), and Essentials of Abnormal
Psychology (2nd edition). He is coauthor of Counseling the Culturally Diverse: Theory and
Practice. He received his PhD in Clinical Psychology from Washington State University. His
writing and research interests revolve around multicultural issues in individual and group
counseling and the integration of multicultural therapy with evidence‐based practice. He
enjoys hiking, snowshoeing, traveling, and spending time with his family.
Helen A. Neville is Professor of Educational Psychology and African American Studies at
the University of Illinois at Urbana‐Champaign. Before coming to Illinois in 2001, she was
on the faculty in Psychology, Educational and Counseling Psychology, and Black Studies at
the University of Missouri‐Columbia, where she cofounded and codirected the Center for
Multicultural Research, Training, and Consultation. Dr. Neville has held leadership positions
on campus and nationally. She was a Provost Fellow and participated in the CIC/Big 10
Academic Alliance Academic Leadership Academy. Currently, she serves as president for the
Society for the Psychological Study of Culture, Ethnicity, and Race (2018), which is a
division of the American Psychological Association (APA). She has co‐edited five books
and (co)authored nearly 90 journal articles and book chapters in the areas of race, racism,
racial identity, and diversity issues related to well‐being. Dr. Neville has been recognized
for her research and mentoring efforts, including receiving the Association of Black
Psychologists' Distinguished Psychologist of the Year Award, the APA Minority Fellowship
Award, Dalmas Taylor Award for Outstanding Research Contribution, APA Graduate
Students Kenneth and Mamie Clark Award, the APA Division 45 Charles and Shirley
Thomas Award for mentoring/contributions to African American students/community, and
the Winter Roundtable Janet E. Helms Mentoring Award.
Laura Smith is Professor of Psychology and Education and Director of Clinical Training in
the Counseling Psychology Program at Teachers College, Columbia University. Laura was
formerly the Training Director of Pace University's American Psychological Association
(APA)‐accredited predoctoral internship program and later the founding Director of the
Rosemary Furman Counseling Center at Barnard College. She was subsequently Director of
Psychological Services at the West Farms Center in the Bronx, where she provided services,
training, and programming within a multifaceted community‐based organization. Laura's
research interests include social inclusion/exclusion and emotional well‐being, the influence
of classism and racism in psychological theory and practice, whiteness and white antiracism,
and participatory action research (PAR) in schools and communities. She is the author of the
book Psychology, Poverty, and the End of Social Exclusion and the former Chair of the APA
Committee on Socioeconomic Status, and she was awarded the 2017 APA Distinguished
Leadership Award on behalf of that committee.
SECTION ONE
The Multiple Dimensions of Multicultural
Counseling and Therapy
Becoming culturally competent in working with diverse populations is a complex interaction
of many dimensions that involve broad theoretical, conceptual, research, and practice issues.
This section is divided into four parts (each part contains a number of chapters) that describe,
explain, and analyze necessary conditions that mental health practitioners must address on
issues related to multicultural counseling and therapy, cultural competence, and sociopolitical
influences that cut across specific populations.
Part I: The Affective and Conceptual Dimensions of Multicultural Counseling and
Therapy
Part II: The Impact and Social Justice Implications of Counseling and Psychotherapy
Part III: The Practice Dimensions of Multicultural Counseling and Therapy
Part IV: Racial, Ethnic, Cultural (REC) Attitudes in Multicultural Counseling and
Therapy
PART I
The Affective and Conceptual Dimensions of
Multicultural Counseling and Therapy
Chapter
1
Obstacles to Developing Cultural Competence and Cultural Humility:
Understanding Resistance to Multicultural Training
Chapter
2
Multicultural Counseling and Therapy (MCT)
Chapter
3
Multicultural Counseling Competence for Counselors and Therapists of
Marginalized Groups
1
Obstacles to Developing Cultural Competence and Cultural
Humility: Understanding Resistance to Multicultural Training
Chapter Objectives
1. 1. Acknowledge and understand personal resistance to multicultural training.
2. 2. Identify how emotional reactions to topics of prejudice, discrimination, and
oppression can act as obstacles to developing cultural competence and cultural
humility.
3. 3. Understand worldview differences between majority and socially devalued group
members in U.S. society.
4. 4. Make sense of why majority group members often react differently from
marginalized group members when issues of racism, sexism, or heterosexism are
discussed.
5. 5. Be cognizant of how worldviews may influence the ability to understand,
empathize, and work effectively with diverse clients.
6. 6. Realize that becoming an effective multicultural counselor is a lifelong journey.
Reading and digesting the content of this book may prove difficult and filled with powerful
feelings for many of you. Students who have taken a course on multicultural counseling and
therapy (MCT) or multicultural mental health issues have almost universally felt both positive
and negative feelings that affect their ability to learn about diversity issues. It is important not
to allow those emotions to go unacknowledged, or to avoid exploring the psychological
meanings they may have for you. As you begin your journey to becoming a culturally
competent or culturally responsive counselor/mental health professional, the road will be
filled with obstacles to self‐exploration, to understanding yourself as a racial/cultural being,
and to understanding the worldview of those who differ from you in race, gender, ethnicity,
sexual orientation, and other sociodemographic characteristics.
The subject matter in this book and course requires you to explore your biases and prejudices,
a task that often evokes defensiveness and resistance. It is important to recognize personal
resistance to the material, to explore its meanings, and to learn about yourself and others.
Sometimes what is revealed about you may prove disturbing, but having the courage to
continue is necessary to becoming a culturally competent counselor or therapist. This chapter
is specifically written to help readers understand and overcome their emotive reactions to the
substance of the text, and the course you are about to take. Let us begin by sharing reactions
from four past students to reading Counseling the Culturally Diverse: Theory and Practice
(CCD) and discuss their meaning for them, and the implications for mental health practice.
Video 1.0: Introduction
Introduction to the book and videos.
REACTIONS TO READING COUNSELING THE CULTURALLY
DIVERSE
Reaction #1
White Female Student:
“How dare you and your fellow caustic co‐author express such vitriol against my
people? You two are racists, but of a different color … I can't believe you two are
counselors. Your book does nothing but to weaken our nationalism, our sense of unity
and solidarity. If you don't like it here, leave my country. You are both spoiled hate‐
mongers who take advantage of our educational system by convincing others to use such
a propagandistic book! Shame on you. Your book doesn't make me want to be more
multicultural, but take ungrateful people like you and export them out of this great land
of mine.” (Name withheld)
Analysis: This response reveals immense anger at the content of CCD, and especially at the
authors, whom she labels “hate‐mongers” and “racists.” It is obvious that she feels the book
is biased and propagandistic. The language of her words seems to indicate defensiveness on
her part as she easily dismisses the material covered. More important, there is an implicit
suggestion in the use of “people like you” and “land of mine” that conveys a perception that
only certain groups can be considered “American” and that others are “foreigners.” This is
similar to statements often made to people of color: “If you don't like it here, go back to
China, Africa, or Latin America.” Likewise, the implication is that this land does not belong
to persons of color who are U.S. Citizens, but only to White Americans.
Reaction #2
White Male Student:
“I am a student in the field of Professional Counseling and feel compelled to write you
because your text is required reading in our program. I am offended that you seem to
think that the United States is the only perpetrator of prejudice and horrific acts. Excuse
me sir, but racism and oppression are part of every society in the world ad infinitum, not
just the United States. I do not appreciate reading biased material that does not take into
account all forms of prejudice including those from minorities. You obviously have a
bone to grind with White people. Minorities are equally racist. Why do you take such
pleasure in attacking whites when we have done so much to help you people?”
(Anonymous)
Analysis: Similar to the first response, the male student is also angry and offended about the
content. There is a strong feeling of defensiveness, however, that emanates from his narrative.
It appears he feels unjustly accused of being bigoted and that we are implying that only U.S.
society and not others are racist. To make himself feel less guilty, he emphasizes that “every
society” oppresses “minority” constituents and it is not Whites alone who are prejudiced.
These are actually accurate statements, but they mask the defensiveness of the student, and
have the goal of exonerating him and other Whites for being prejudiced. If he can get other
groups to admit they too are racist, then he feels less guilt and responsibility for his own
beliefs and actions.
Reaction #3
Latina Student:
“I am currently embarking on the journey of becoming a Marriage and Family
Therapist at a California State University. I just want to thank you for writing
Counseling the Culturally Diverse. This book has spoken to me and given me so much
knowledge that is beyond words to express. Finally, there is someone willing to tell it
like it is. You have truly made an impact in my life because, being an ethnic minority, I
could empathize with many of the concepts that were illustrated. Although some White
classmates had difficulty with it, you truly validated much of my experiences. It
reaffirmed how I see the world, and it felt good to know that I am not crazy! Once again
thanks for writing the book.” (Name withheld)
Analysis: The reaction from the Latina student is diametrically opposite to that of her White
counterparts. She reacts positively to the material, finds the content helpful in explaining her
experiential reality, feels validated and reaffirmed, and realizes that she is “not crazy.” In
other words, she finds the content of the book truthful and empathetic to her situation. The
important question to ask is, “Why does she react so differently from the two White
students?” After all, the content of the book remains the same, but the perceptions appear
worlds apart.
Reaction #4
African American Male Student:
“When I first took this course (multicultural counseling) I did not have much hope that it
would be different from all the others in our program, White and Eurocentric. I felt it
would be the typical cosmetic and superficial coverage of minority issues. Boy was I
wrong. I like that you did not ‘tip toe’ around the subject. Your book Counseling the
Culturally Diverse was so forceful and honest that it made me feel liberated … I felt like
I had a voice, and it allowed me to truly express my anger and frustration. Some of the
white students were upset and I could see them squirming in their seats when the
professor discussed the book. I felt like saying ‘good, it's about time Whites suffer like
we have. I have no sympathy for you. It's about time they learned to listen.’ Thank you,
thank you, and thank you for having the courage to write such an honest book.” (Name
withheld)
Analysis: Like the Latina student, the African American male finds the book compelling,
honest, and truthful. He describes how it makes him feel liberated, provides him with a voice
to describe his experiences, and taps into and allows him to express his anger and frustration,
and he thanks the authors for writing CCD. He implies that most courses on multicultural
psychology are taught from a EuroAmerican perspective, but the book content “tells it like it
is.” Additionally, the student seems to take pleasure in observing the discomfort of White
students, expresses little sympathy for their struggle in the class, and enjoys seeing them
being placed on the defensive. (We will return to the meaning of this last point shortly.)
Reading CCD is very likely to elicit strong emotions among readers. These four reactions,
two by White students and two by readers of color, reveal the range of emotions and reactions
likely to be expressed in classes that use the text. For nearly four decades, we have received
literally hundreds of emails, letters, and phone calls from students, trainees, professors, and
mental health professionals reacting strongly to the content and substance of CCD. Many of
the readers praise the book for its honest portrayal of multicultural issues in mental health
practice. Indeed, it has become the most widely used and cited text in multicultural
psychology, considered a classic in the field (Ponterotto, Fingerhut, & McGuinness, 2013;
Ponterotto & Sabnani, 1989), and now forms the knowledge base of licensing and
certification exams for counseling and mental health professionals.
Despite the scholarly status that CCD has achieved, some readers (generally those from the
majority group) find the substance of the book difficult to digest and have reacted very
strongly to the content. According to instructors of MCT classes, the powerful feelings
aroused in some students prevent them from being open to diversity issues, and from making
classroom discussions on the topic a learning opportunity. Instead, conversations on diversity
become “shouting matches” or become monologues rather than dialogues. These instructors
indicate that the content of the book challenges many White students about their racial,
gender, and sexual orientation realities, and that the book's writing style (passionate, direct,
and hard‐hitting) also arouses deep feelings of defensiveness, anger, anxiety, guilt, sadness,
hopelessness, and a multitude of other strong emotions in many. Unless properly processed
and understood, these emotions act as roadblocks to exploring issues of race, gender, and
sexual orientation. Learning about multicultural psychology is much more than an intellectual
exercise devoid of emotions.
It would be a mistake, however, to conclude from these examples that White students and
students of color respond uniformly in one way. As we will explore in future chapters, many
White students react positively to the book and some students of color report negative
reactions. But, in general, there are major worldview differences and reactions to the material
between the groups. For example, many socially marginalized group members find solace in
the book; they describe a deep sense of validation, release, elation, joy, and even feelings of
liberation as they read the text. What accounts for these two very different reactions?
For practicing professionals and trainees in the helping professions, understanding the
differing worldviews of our racially, ethnically, and culturally diverse clients is tantamount to
effective multicultural counseling. But understanding our own reactions to issues of diversity,
multiculturalism, oppression, race, gender, and sexual orientation is equally important to our
development as counselors/therapists (Collins, Arthur, & Brown, 2013; Todd & Abrams,
2011). As we will shortly see, that understanding can be quite anxiety‐provoking, especially
when we are asked to confront our own biases, prejudices, and stereotypes. The old adage
“counselor or therapist, know thyself” is the basic building block to cultural competence and
cultural humility in the helping professions. Let us take a few moments here to dissect the
reactions of the four readers in our opening narratives and attempt to make meaning of them.
This is a task that we encourage you to personally take throughout your educational journey
as well. Likewise, as a counselor or therapist working with culturally diverse clients,
understanding differences in worldviews is an important first step to becoming culturally
competent.
Video 1.1: Reacting to Race and Racism
Select the video link to view a conversation with the author about reacting to race and racism.
EMOTIONAL SELF‐REVELATIONS AND FEARS: MAJORITY
GROUP MEMBERS
It is clear that the two White students are experiencing strong feelings in reaction to the
content of CCD. As you will shortly see, the book's subject matter (a) deals with prejudice,
bias, stereotyping, discrimination, and bigotry; (b) makes a strong case that counseling and
psychotherapy may serve as instruments of cultural oppression rather than therapeutic
liberation (Sue, 2015; Wendt, Gone, & Nagata, 2015); (c) indicates that well‐intentioned
mental health professionals are not immune from inheriting the racial, gender, and other
biases of the larger society; and (d) suggests therapists and trainees may be unconsciously
biased toward clients from marginalized groups (Ratts & Pedersen, 2014).
Although supported by the research literature and by clinical observations and reports, these
assertions can be quite disturbing to members of the majority group. If you are a majority
group member and beginning the journey to developing cultural competence and cultural
humility, it is possible that you may share similar reactions to those of the students. Both
White students, for example, are reacting with anger and resentment; they believe that the
authors are unjustly accusing U.S. society and White Americans of racism, and claim the
authors are themselves “racist” but of a different color. They have become defensive and are
actively resisting and rejecting the content of the book. If these feelings persist throughout the
course unabated, they will act as barriers to learning and further self‐exploration. But what
do these negative reactions mean to the students? Why are they so upset? Dr. Mark Kiselica
(Sue & Sue, 2013, pp. 8–9), a White psychologist and now provost of a college in New York,
writes about his own negative emotional reactions to reading the book during his graduate
training. His personal and emotional reactions to the book provide us with some clues.
I was shaken to my core the first time I read Counseling the Culturally Different (now
Counseling the Culturally Diverse) … At the time, I was a doctoral candidate at The
Pennsylvania State University's counseling psychology program, and I had been reading
Sue's book in preparation for my comprehensive examinations, which I was scheduled to
take toward the end of the spring semester…
I wish I could tell you that I had acquired Sue's book because I was genuinely interested
in learning about multicultural counseling … I am embarrassed to say, however, that
that was not the case. I had purchased Sue's book purely out of necessity, figuring out
that I had better read the book because I was likely to be asked a major question about
cross‐cultural counseling on the comps. During the early and middle 1980s, taking a
course in multicultural counseling was not a requirement in many graduate counseling
programs, including mine, and I had decided not to take my department's pertinent
course as an elective. I saw myself as a culturally sensitive person, and I concluded that
the course wouldn't have much to offer me. Nevertheless, I understood that … the
professor, who taught the course, would likely submit a question to the pool of materials
being used to construct the comps. So, I prudently went to the university bookstore and
purchased a copy … because that was the text … used for his course.
I didn't get very far with my highlighting and note‐taking before I started to react to
Sue's book with great anger and disgust. Early on in the text, Sue blasted the mental
health system for its historical mistreatment of people who were considered to be ethnic
minorities in the United States. He especially took on White mental health professionals,
charging them with a legacy of ethnocentric and racist beliefs and practices that had
harmed people of color and made them leery of counselors, psychologists, and
psychiatrists. It seemed that Sue didn't have a single good thing to say about White
America. I was ticked off at him, and I resented that I had to read his book. However, I
knew I had better complete his text and know the subject matter covered in it if I wanted
to succeed on the examinations. So, out of necessity, I read on and struggled with the
feelings that Sue's words stirred in me.
Developing culturally competence and cultural humility in counseling/mental health practice
demands that nested or embedded emotions associated with race, culture, gender, and other
social identity differences be openly experienced and discussed. It is these intense feelings
that often block our ability to hear the voices of those most oppressed and disempowered
(Sue, 2011). How we, as helping professionals, deal with these strong feelings can either
enhance or impede a deeper understanding of ourselves as racial, ethnic, and cultural beings
and our understanding of the worldviews of culturally diverse clients. Because Mark did not
allow his defensiveness and anger to get the best of him, he was able to achieve insights into
his own biases and false assumptions about people of color. The following passage reveals
the internal struggle that he courageously fought and the disturbing realization of his own
racism.
I tried to make sense of my emotions—to ascertain why I was drawn back to Sue's book
again and again in spite of my initial rejection of it. I know it may sound crazy, but I
read certain sections of Sue's book repeatedly and then reflected on what was happening
inside of me … I began to discover important lessons about myself, significant insights
prompted by reading Sue's book that would shape the direction of my future … I now
realized that Sue was right! The system had been destructive toward people of color, and
although my ancestors and I had not directly been a part of that oppressive system, I had
unknowingly contributed to it. I began to think about how I had viewed people of color
throughout my life, and I had to admit to myself that I had unconsciously bought into the
racist stereotypes about African Americans and Latinos. Yes, I had laughed at and told
racist jokes. Yes, I had used the “N” word when referring to African Americans. Yes, I
had been a racist.
Sue's book forced me to remove my blinders. He helped me to see that I was both a
product and an architect of a racist culture.
(Sue & Sue, 2013, pp. 9–10)
Years after first reading the book, Mark Kiselica (1999) talks about his racial awakening and
identifies some of the major fears many well‐intentioned Whites struggle with as they begin
studying racism, sexism, or heterosexism on a personal level. This passage, perhaps,
identifies the major psychological obstacle that confronts many Whites as they process the
content and meaning of the book.
You see, the subjects I [White psychologist] am about to discuss—ethnocentrism and
racism, including my own racism—are topics that most Whites tend to avoid. We shy
away from discussing these issues for many reasons: We are racked with guilt over the
way people of color have been treated in our nation; we fear that we will be accused of
mistreating others; we particularly fear being called the “R” word—racist—so we grow
uneasy whenever issues of race emerge; and we tend to back away, change the subject,
respond defensively, assert our innocence and our “color blindness,” denying that we
could possibly be ethnocentric or racist. (p. 14)
It is important to note Mark's open admission to racist thoughts, feelings, and behaviors. As a
White psychologist, he offers insights into the reasons why many White trainees fear open
dialogues on race; they may ultimately reveal unpleasant secrets about themselves. In his own
racial awakening, he realizes that discussing race and racism is so difficult for many Whites
because they are racked with guilt about how people of color have been treated in the United
States and are fearful that they will be accused of being a racist and be blamed for the
oppression of others. Rejecting and avoiding racial topics are major strategies used to hold on
to one's self‐image as a good, moral, and decent human being who is innocent of racial bias
and discrimination.
Mark's honesty in confronting his own racism is refreshing, and his insights are invaluable to
those who wish to develop culturally competence and become allies in the struggle for equal
rights (Chao, Wei, Spanierman, Longo, & Northart, 2015; Spanierman & Smith, 2017). He is
a rarity in academic circles, even rarer because he was willing to put his words on paper for
the whole world to read as a means to help others understand the meaning of racism on a
human level. Mark's courageous and open exploration of his initial reactions to CCD
indicates what we have come to learn is a common, intensely emotional experience for many
readers.
Video 1.2: Same Material, Different Reaction
The different reactions to the material that majority students may have compared to their
minority counterparts.
EMOTIONAL INVALIDATION VERSUS AFFIRMATION:
MARGINALIZED GROUP MEMBERS
It is clear that the same subject matter in CCD often arouses a different emotional response
from marginalized group members; for the two students of color, for example, they felt heard,
liberated, and validated. They describe the book content as “honest” and “truthful,” indicating
that their lived experiences had finally been validated rather than silenced or ignored. One of
the more interesting comments is made by the Latina student: “it felt good to know that I am
not crazy.” What did she mean by that? Many people of color describe how their thoughts
and feelings about race and racism are often ignored, dismissed, negated, or seen as having no
basis in fact by majority group members. They are told that they are misreading things, overly
sensitive, unduly suspicious, or even paranoid when they bring up issues of bias and
discrimination; in other words, they are “crazy” to think or feel that way.
As can be seen from the students of color, many marginalized group members react equally
strongly as their White counterparts when issues of oppression are raised, especially when
their stories of discrimination and pain are minimized or neglected. Their reality of racism,
sexism, and homophobia, they contend, is relatively unknown or ignored by those in power
because of the discomfort that pervades such topics. Worse yet, many well‐intentioned
majority persons seem disinclined to hear the personal stories of suffering, humiliation, and
pain that accrue to persons of color and other marginalized groups in our society (Sue, 2015).
The following quote gives some idea of what it is like for a Black man to live his life day in
and day out in a society filled with both covert and overt racist acts that often are invisible to
well‐intentioned White Americans.
I don't think white people, generally, understand the full meaning of racist
discriminatory behaviors directed toward Americans of African descent. They seem to
see each act of discrimination or any act of violence as an “isolated” event. As a result,
most white Americans cannot understand the strong reaction manifested by blacks when
such events occur … They forget that in most cases, we live lives of quiet desperation
generated by a litany of daily large and small events that, whether or not by design,
remind us of our “place” in American society. [Whites] ignore the personal context of
the stimulus. That is, they deny the historical impact that a negative act may have on an
individual. “Nigger” to a white may simply be an epithet that should be ignored. To
most blacks, the term brings into sharp and current focus all kinds of acts of racism—
murder, rape, torture, denial of constitutional rights, insults, limited opportunity
structure, economic problems, unequal justice under the law and a myriad of … other
racist and discriminatory acts that occur daily in the lives of most Americans of African
descent.
(Feagin & Sikes, 1994, pp. 23–24)
The lived experience of people of color is generally invisible to most White Americans, as
this quotation portrays. As we will discuss in Chapter 6, racial, gender, and sexual orientation
microaggressions are experienced frequently by people of color, women, and lesbian, gay,
bisexual, transgender, and queer (LGBTQ) persons in their day‐to‐day interactions with
well‐intentioned members of the dominant society (Nadal, Griffin, Wong, Davidoff, &
Davis, 2017; Velez, Moradi, & DeBlaere, 2015). Microaggressions are the everyday slights,
put‐downs, invalidations, and insults directed to socially devalued group members by
well‐intentioned people who often are unaware that they have engaged in such biased and
harmful behaviors. A lifetime of microaggressions can have a major harmful impact on the
psychological well‐being of victims. Note the following narratives provided by American
Indians as they describe day‐to‐day experiences with microaggressions that serve to
undermine their humanity through exposure to racial hostility and assumptions of inferiority.
I know my dad has a lot of white friends, and they get comfortable with him and they say
really insulting things. They call us wagon burners, dirty Indians. And, it's, it's, it's when
they get, when they start getting out of line ‘cause my dad wouldn't say anything. I
would, start saying stuff and then they'd come back to my dad and be like “oh, what's
wrong with your son? Can't he take a joke?” Well it's not funny when, when someone
insults you to your face and then they just expect you to laugh at it like they do. (name
withheld)
…so I filled out the little form and I took it up to the girl behind the glass and said “I've
got this thing for the parking permit” [at the local university] And she looked at it and
looked at me, and she said “So are you delivering this for Dr. X?” and I said “No,
actually I am Dr. X.” And she got really red and embarrassed, you know, but I don't
really know what was in her mind. You know, maybe I just don't look professorial or
something like that.
(Senter & Ling, 2017, pp. 266, 269)
Here, it is important to note the emotional toll of having to listen to racially hostile name
calling among “so‐called” friends or to have to continually prove your legitimacy as a
professional. These narratives are part of a larger study on racial microaggresions against
American Indians (Senter & Ling, 2017). People retold stories of being assumed to be poor,
addicted to alcohol or drugs, lazy, and dirty. Narrators described costs associated with
microaggressions including being followed, receiving poor service, and getting overcharged.
Over time, these experiences left people with hurt and anger; some people coped by
distancing themselves from non‐Natives or trying to hide. But, people of color are also
strong. Like so many others who experience racial microaggressions, many used these
moments as an opportunity to educate others.
Given the fact that the majority of people of color have experienced microaggressoins in their
lifetime, covering these topics in class can serve to validate their lived realities. Dr. Le Ondra
Clark, now an African American psychologist in California, describes her experiences of
being one of the few Black students in a graduate program and the feeling of affirmation that
flooded her when taking a multicultural counseling course and using CCD as the textbook.
I, a native of Southern California, arrived at the University of Wisconsin, Madison, and
was eager to learn. I remember the harsh reality I experienced as I confronted the
Midwest culture. I felt like I stood out, and I learned quickly that I did. As I walked
around the campus and surrounding area, I remember counting on one hand the number
of racial and ethnic minorities I saw. I was not completely surprised about this, as I had
done some research and was aware that there would be a lack of racial and ethnic
diversity on and around campus. However, I was baffled by the paucity of exposure that
the 25 members of my master's cohort had to racial and ethnic minority individuals. I
assumed that because I was traveling across the country to attend this top‐ranked
program focused on social justice, everyone else must have been as well. I was wrong…
I did not begin to feel comfortable until I attended the Multicultural Counseling course
later that week. Students were assigned a number of textbooks as part of this course,
including CCD … I never imagined a textbook would bring me so much comfort. I
vividly remember reading each chapter and vigorously taking notes in the margins. I
also remember the energy I felt as I wrote about my reactions to the readings each week.
I felt like the book legitimized the experiences of racial and ethnic minorities and helped
me understand what I was encountering in my Midwest surroundings. It became a
platform from which I could explain my own experience as a racial and ethnic minority
from Southern California who was transplanted to the Midwest. The personal stories,
concepts, and theories illustrated in CCD resonated with me and ultimately helped me
overcome my feelings of isolation. CCD provided me with the language to engage in
intellectual discourse about race, ethnicity, social class, privilege, and disparities. I
remember the awareness that swept over the class as we progressed through the
textbook … I felt that they were beginning to view things through my cultural lens, and I
through theirs. We were gaining greater understanding of how our differing cultural
realities had shaped us and would impact the work we conducted as therapists.
(Sue & Sue, 2013, pp. 17–18)
Le Ondra's story voices a continuing saga of how persons of color and many marginalized
individuals must function in an ethnocentric society that unintentionally invalidates their
experiences and enforces silence upon them. She talks about how the text provided a
language for her to explain her experiences and how she resonated with its content and
meaning. To her, the content of the book tapped into her experiential reality and expressed a
worldview that is too often ignored or not even discussed in graduate‐level programs. Le
Ondra found comfort and solace in the book, and she has been fortunate in finding significant
others in her life that have validated her thoughts, feelings, and aspirations and allowed her to
pursue a social justice direction in counseling. As a person of color, Le Ondra has been able
to overcome great odds and to obtain her doctorate in the field without losing her sense of
integrity or racial/cultural identity.
A Word of Caution
There is a word of caution that needs to be directed toward students of marginalized groups as
they read CCD and find it affirming and validating. In teaching the course, we have often
encountered students of color who become very contentious and highly outspoken toward
White classmates. A good example is provided in the reaction of the African American
student in the fourth scenario. It is clear that the student seems to take delight in seeing his
White classmates “squirm” and be uncomfortable. In this respect, he may be taking out his
own anger and frustration upon White classmates, and his concern has less to do with helping
them understand than having them feel some of the pain and hurt he has felt over the years. It
is important to express and understand one's anger (it can be healing), but becoming verbally
abusive toward another is counterproductive to building rapport and mutual respect. As
people of color, for example, we must realize that our enemies are not White Americans, but
White supremacy! And, by extension, our enemy is not White Western society, but racism
and ethnocentrism.
Second, because the book discusses multicultural issues, some students of color come to
believe that multicultural training is only for White students; the implicit assumption is that
they know the material already and are the experts on the subject. Since many students of
color have not explored their beliefs about other groups, and sometimes their own, such a
perspective prevents self‐exploration and constitutes a form of resistance. As will be seen in
Chapter 3, people of color, for example, are not immune from prejudice, bias, and
discrimination. Further, such a belief prevents the exploration of interracial and interethnic
misunderstandings and biases. Multicultural training is more than White–African American,
White–Latinx American, White–Asian American, White–Native American, and so on. It is
also about African American–Asian American, Asian American–Native American, and
Latinx–Native American relationships; and it includes multiple combinations of other social
identity differences, like gender, sexual orientation, disability, religious orientation, and so
forth. Race, culture, ethnicity, gender, and sexual orientation/identity are about everyone; it is
not just a “minority thing.”
REFLECTION AND DISCUSSION QUESTIONS
Look at the opening quotes by the four students, then answer these questions.
1. In what ways are the reactions of the White students different from those of the students
of color? Why do you think this is so?
2. Which of the four reactions can you relate to best? Which reaction can you empathize
least with? Why?
3. As you continue reading the material in this text, you are likely to experience strong and
powerful reactions and emotions. Being able to understand the meaning of your feelings
is the first step to cultural competence. Ask yourself, why am I reacting this way? What
does it say about my worldview, my experiential reality, and my ability to relate to
people who differ from me in race, gender, and sexual orientation?
4. As a counselor working with clients who are racially or ethnically different from
yourself, would you be able to truly relate to their worldviews?
5. What do you think “understanding yourself as a racial, ethnic, cultural being” means?
RECOGNIZING AND UNDERSTANDING RESISTANCE TO
MULTICULTURAL TRAINING
As a counselor or therapist working with clients, you will often encounter psychological
resistance or, more accurately, client behaviors that obstruct the therapeutic process or
sabotage positive change (Ridley & Thompson, 1999). Clients may change the topic when
recalling unpleasant memories, externalize blame for their own failings, fail to acknowledge
strong feelings of anger toward loved ones, or be chronically late for counseling
appointments. All of these client behaviors are examples of resistance or avoidance of
acknowledging and confronting unpleasant personal revelations. Oftentimes, these represent
unconscious maneuvers to avoid fearful personal insights, to avoid personal responsibility,
and to avoid painful feelings. In most cases, resistance masks deeper meanings outside the
client's awareness; tardiness for appointments is unacknowledged anger toward therapists,
and changing topics in a session is an unconscious deflection of attention away from
frightening personal revelations. In many respects, multicultural training can be likened to
“therapy” in that trainees are analogous to clients, and trainers are comparable to therapists
helping clients with insights about themselves and others.
As we shall see in Chapter 2, the goal of multicultural training is cultural competence. It
requires trainees to become aware of their own worldviews, their assumptions of human
behavior, their misinformation and lack of knowledge, and, most importantly, their biases and
prejudices. Sometimes, this journey is a painful one, and trainees will resist moving forward.
For trainers or instructors, the job is to help trainees in their self‐exploration as
racial/cultural beings, and the meaning this has for their future roles as multicultural
counselors. For trainees, being able to recognize, understand, and overcome resistance to
multicultural training is important in becoming a culturally competent counselor or therapist.
In the next few sections, we focus upon identifying how resistance manifests itself in training
and propose reasons why many well‐intentioned trainees find multicultural training
disconcerting and difficult to undertake. By so doing, we are hopeful that trainees will attend
to their own reactions when reading the text or when participating in classroom dialogues on
the subject. Ask yourself the following questions as you continue reading in the next sections
and throughout the book.
REFLECTION AND DISCUSSION QUESTIONS
1. What type of reactions or emotions am I feeling as I study the material on multicultural
counseling? Am I feeling defensive, angry, anxious, guilty, or helpless? Am I feeling
affirmed, valued or engaged? Where are these feelings coming from? Why am I feeling
this way, and what does it possibly mean?
2. In what ways may these emotions affect my ability to understand the worldview of
clients who differ from me, and how might that affect my work?
3. Does having a different point of view mean I am resisting the multicultural material?
List all those reasons that support your stance. List all those reasons that do not support
it.
4. How applicable are the resistances outlined in the following sections to me?
In work with resistance to diversity training, research reveals how it is likely to be manifested
in three forms: cognitive resistance, emotional resistance, and behavioral resistance (Sue,
2015). Recognizing the manifestation and hidden meanings of resistance is one of the first
priorities of multicultural training for both trainees and trainers. For trainees, it is finding the
courage to confront their own fears and apprehensions, to work through the powerful
emotions they are likely to experience, to explore what these feelings mean for them as
racial/cultural beings, to achieve new insights about themselves, and to develop multicultural
skills and behaviors in their personal lives and as mental health professionals. For trainers, it
means understanding the nature of trainee resistance, creating a safe but challenging
environment for self‐exploration, and using intervention strategies that facilitate difficult
dialogues on race, gender, sexual orientation, and other topics in the area of diversity.
Cognitive Resistance—Denial
To date, my biggest discovery is that I didn't really believe that people were being
discriminated against because of their race. I could hear them say it, but in my head, I
kept running a parallel reason from the White perspective. A Chinese lady says that her
party had to wait longer while Whites kept getting seated in front of them. I say, other
people had made reservations. A black man says that the receptionist was rude, and
made him wait longer because he's Black. I say she had a bad day, and the person he
was there to see was busy. A Puerto Rican couple says that the second they drove into
Modesto … a cop started tailing them, and continued to do so until they reached their
hotel, which they opted to drive right on by because they didn't feel safe. I say, there's
nothing to be afraid of in Modesto. It's a nice little town. And surely the cop wasn't
following you because you're Puerto Rican. I bet your hotel was on his way to the
station. I know that for every story in which something bad happens to someone because
of their race, I can counter it with a White interpretation. And while I was listening with
a sympathetic ear, I silently continued to offer up alternative explanations, benign
explanations that kept my world in equilibrium.
(Rabow, Venieris, & Dhillon, 2014, p. 189)
This student account reveals a pattern of entertaining alternative explanations to the stories
told by persons of color about their experiences of prejudice and discrimination. Although the
author describes “listening sympathetically,” it was clear that he or she silently did not
believe that these were instances of racism; other more plausible and “benign” explanations
could account for the events. This is not an atypical response for many White trainees when
they listen to stories of discrimination from classmates of color (Sue, 2015; Young, 2003).
Because of a strong belief that racism is a thing of the past, that we live in a post‐racial
society, and that equal access and opportunity are open to everyone, people of color are seen
as exaggerating or misperceiving situations. When stories of prejudice and discrimination are
told, it directly challenges these cherished beliefs. The student's quote indicates as much
when he says that his “benign explanations” preserves his racial reality (“kept my world in
equilibrium”).
The fact that the student chose not to voice his thoughts is actually an impediment to learning
and understanding. In many classrooms, teachers have noted how silence is used by some
White students to mask or conceal their true thoughts and feelings about multicultural issues
(van Dijk, 1992; Sue, 2010; Sue, Torino, Capodilupo, Rivera, & Lin, 2010). Denial through
disbelief, unwillingness to consider alternative scenarios, distortion, fabrication, and
rationalizations are all mechanisms frequently used by some trainees during racial
conversations to prevent them from thinking about or discussing topics of race and racism in
an honest manner (van Dijk, 1992; Feagin, 2001; Sue, Rivera, Capodilupo, Lin, & Torino,
2010). In our teaching in multicultural classes, we have observed many types of denials that
work against honest diversity discussions. There are denials that students are prejudiced, that
racism still exists, that they are responsible for the oppression of others, that Whites occupy
an advantaged and privileged position, that they hold power over people of color, and even
denial that they are White (Feagin & Vera, 2002; McIntosh, 2002; Sue, 2010; Tatum, 1992;
Todd & Abrams, 2011). This latter point (Whiteness and White privilege) is an especially
“hot topic” that will be thoroughly discussed in Chapter 12. As a trainee in this course, you
will be presented with opportunities to discuss these topics in greater detail, and explore what
these denials may mean about you and your classmates. We hope you will actively participate
in such discussions, rather than passively dealing with the material.
Emotional Resistance
Emotional resistance is perhaps the major obstacle to multicultural understanding, because it
blocks a trainee's ability to acknowledge, understand, and make meaning out of strong and
powerful feelings associated with multicultural or diversity topics. The manifestation and
dynamics of emotional resistance are aptly described by Sara Winter (1977, p. 24), a White
female psychologist. She also provides some insights as to why this occurs: it serves to
protect people from having to examine their own prejudices and biases.
When someone pushes racism into my awareness, I feel guilty (that I could be doing so
much more); angry (I don't like to feel like I'm wrong); defensive (I already have two
Black friends … I worry more about racism than most whites do—isn't that enough);
turned off (I have other priorities in my life with guilt about that thought); helpless (the
problem is so big—what can I do?). I HATE TO FEEL THIS WAY. That is why I
minimize race issues and let them fade from my awareness whenever possible.
The Meaning of Anxiety and Fear
Anxiety is the primary subjective emotion encountered by White trainees exposed to
multicultural content and its implications. In one study, it was found that when racial
dialogues occurred, nearly all students described fears of verbal participation because they
could be misunderstood, or be perceived as racist (Sue, Rivera, et al., 2010). Others went
further in describing having to confront the realization that they held stereotypes, biases, and
prejudices toward people of color. This insight was very disturbing and anxiety‐provoking
to them because it directly challenged their self‐image as good, moral, and decent human
beings who did not discriminate. Facing this potential awareness creates high levels of
anxiety, and often results in maneuvers among students to avoid confronting their meanings.
I have a fear of speaking as a member of the dominant group … My feelings of fear stem
from not wanting to be labeled as being a racist. I think that fear also stems from the
inner fear that I do not want to know what happens to people of color every day. I may
not directly be a racist, but not reacting or speaking up to try to change things is a result
of my guilt … This is a frightening prospect because I do not want to see the possibility
that I have been a racist. Awareness is scary.
(Rabow et al., 2014, p. 192)
In the preceding quote, the student talks about “fear” being a powerful force in preventing
him or her from wanting to learn about the plight of people of color. The strong emotions of
guilt and fear, and possibly “being racist,” are too frightening to consider. For many students,
these feelings block them from exploring and attempting to understand the life experience of
people of color. In one major study, for example, silence or not participating in diversity
discussions, denials of personal and societal racism, and physically leaving the situation were
notable avoidant ploys used by students. The apprehensions they felt affected them physically
as well (Sue, Rivera, et al., 2010; Sue, Torino, et al., 2010). Some students described
physiological reactions of anxiety like a pounding heart, dry mouth, tense muscles, and
perspiration. One student stated, “I tried hard to say something thoughtful and it's hard for me
to say, and my heart was pounding when I said it.” Others described feeling intimidated in the
discussions, stammering when trying to say something, being overly concerned about
offending others, experiencing a strong sense of confusion as to what was going on, censoring
thoughts or statements that could be misunderstood, feeling reluctant in expressing their
thoughts, being overwhelmed by the mix of emotions they felt, and hearing constriction in
their own voices.
These thoughts, feelings, and concerns blocked participants from fully participating in
learning and discussing diversity issues, because they became so concerned about themselves
(turning inward) that they could not freely be open and listen to the messages being
communicated by socially devalued group members. Indeed, their whole goal seemed to be to
ward off the messages and meanings being communicated to them, which challenged their
worldviews, and themselves as racial beings, and highlighted their potential roles as
oppressors.
For those who are able to listen to stories about racial and other forms of oppression, some
allow their anxiety and fear to immobilize them: “I think sometimes I'm afraid to say things
because I don't want to offend people, and so I just decide … to sit and be quiet” (Linder,
2015, p. 545). One's fear of appearing racist or offensive thus undermines learning because
one remains silent in discussion and allows others to do the difficult work of self‐
exploration; oftentimes, the brunt of the work is then unduly put on the shoulders of the
people of color or other marginalized group members in the class.
The Meaning of Defensiveness and Anger
Although defensiveness and anger are two different emotions, studies seem to indicate a high
relationship between the two (Apfelbaum, Sommers, & Norton, 2008; Sue, Torino, et al.,
2010; Zou & Dickter, 2013). One represents a protective stance and the other an attempt to
strike back at the perpetrator (in many cases, statements by people of color). In the opening
quotes for this chapter, note that both White students became angry at the authors and
accused them of being racist and propagandistic. In absorbing diversity content, many White
students describe feeling defensive (unfairly accused of being biased or racist, blamed for
past racial injustices, and responsible for the current state of race relations). “I'm tired of
hearing ‘White people this … White people that’ … why are we always blamed for
everything?”
When the text discusses bias and bigotry, or when classmates of color bring up the issue, for
example, some White students seem to interpret this as a personal accusation, and rather than
reach out to understand the content, respond in a defensive and protective posture. In many
cases, even statements of racial facts and statistics, such as definitions of racism, disparities in
income and education, segregation of neighborhoods, hate crime figures, and so forth, arouse
defensiveness in many White students. Their defense response to a racial dialogue is seen as
protection against (a) criticism (“You just don't get it!”), (b) revealing personal shortcomings
(“You are racist!”), or (c) perceived threat to their self‐image and ego (“I'm not a racist—
I'm a good person.”). Because of this stance, we have observed that many White students who
feel attacked may engage in behaviors or argumentative ploys that present denials and
counterpoints because they view the racial dialogue as a win–lose proposition. Warding off
the legitimacy of the points raised by people of color and maintaining their tightly guarded
color‐blind racial perspective becomes the primary goals, rather than listening and
attempting to understand the material or point of view.
When White students feel wrongly accused, they may respond with anger and engage in a
counterattack when a racial topic arises. It appears that anger stems from three sources: (a)
feeling unfairly accused, (b) being told the substance or stance they take is wrong, and (c)
confronting information suggesting they have benefited from racial privilege. Many White
students may feel offended and perceive the allegations as a provocation or an attack that
requires retaliation. Anger may be aroused when students feel offended (“How dare you
imply that about me?”), wronged (“I am deeply hurt you see me that way”), misunderstood
(“You make it seem like I didn't work hard for everything I have”), or that their good
standing is denied (“Don't associate me with racists!”). Defensiveness is designed to uphold
one's own stance. Sometimes, we see students in class searching the Internet for information
to refute data documenting racial disparities or a story about someone's experiences with
discrimination. Anger, on the other hand, turns its attention to attacking the threatening
behavior of others. Given the choice of the fight‐or‐flight response, some White students'
anger turns to rage; they make a choice to take action in stopping the threatening accusations
(Spanierman & Cabrera, 2015). The strategy used is to discredit the substance of an argument
and/or to derogate the communicator, often through a personal attack (“He or she is just an
angry Black man or woman”). Sometimes, White rage lies beneath the surface as students
seethe in silence, and sometimes it leads to hostile actions, like making official complaints
about the teacher for covering the material in class. In many respects, anger, rage, and
defensiveness may become so aroused that one loses control of one's self‐monitoring
capacities and the ability to accurately assess the external environment. These latter two
abilities are extremely important for effective multicultural counseling.
The Meaning of Guilt, Regret, and Remorse
When discussing diversity issues, many White trainees admit to feeling guilty, although most
tend to say that they “are made to feel guilty” by people of color, especially when unjustly
accused (Sue, 2003). This statement actually suggests a distancing strategy in localizing guilt
as external to oneself rather than as rightfully residing and being felt internally. Guilt as an
emotion occurs when we believe we have violated an internal moral code, and have
compromised our own standards of conduct. The question becomes, why should White
trainees feel guilty when topics of race, racism, or Whiteness are discussed? If indeed they
are not racist, not responsible for the racial sins of the past, and not responsible for current
injustices, then why should they feel guilt and how could they be made to feel guilty?
Some have coined the term “White guilt” to refer to the individual and collective feelings of
culpability experienced by some Whites for the racist treatment of people of color, both
historically and currently (Goodman, 2001; Spanierman, Todd, & Anderson, 2009; Tatum,
1992). In diversity discussions, many White trainees find guilt extremely uncomfortable,
because it means that they have violated a moral standard and are disinclined to acknowledge
their violation. What is that moral standard? Being a good, moral, and decent human being
who does not discriminate, being a nonracist, living a life that speaks to equality and justice,
and being a humane person who treats everyone with respect and dignity are the positive
standards that are being breached. Compromising these moral standards and beliefs and
acting in ways that violate them bring on bad feelings of guilt and remorse.
Behavioral Resistance
White racial guilt involves realizing one's potential culpability over past deeds; guilt is
compounded by the knowledge that continued inaction on one's part allows for the
perpetuation of racism in oneself and others. Thus, taking action is a means to alleviate
feelings of guilt. The emotions of helplessness and hopelessness make themselves felt in two
different arenas: one is internal (personal change) and the other is external (system change).
In becoming aware of their racial/cultural identity, for example, White students at this
juncture of development may begin to ask two primary questions.
First, “How does one change?” What needs to be changed? How does one become a
nonracist or an unbiased person? How does one break the shackles of social conditioning
that have taught one that some groups are more worthy than others, and that other groups are
less worthy? Many trainees often make these comments: “I don't know where to begin.” “If I
am not aware of my racism, how do I become aware of it?” “Tell me what I must do to rid
myself of these prejudices.” “Should I attend more workshops?” “I feel so confused, helpless,
impotent, and paralyzed.”
Second, “What must I do to eradicate racism in the broader society?” While self‐change
requires becoming a nonracist person, societal change requires becoming an antiracist one.
Impacting an ethnocentric mental health delivery system falls into this category. This role
means becoming an advocate and actively intervening when injustice makes its presence felt
at the individual level (for example, objecting to a racist joke or confronting friends,
neighbors, or colleagues about their prejudices) and at the institutional level (for example,
opposing biased mental health practices, supporting civil rights issues, making sure a
multicultural curriculum is being taught in schools, or openly supporting social justice
groups).
The helplessness that is felt by White students in diversity studies, unless adequately
deconstructed, can easily provide an excuse or rationalization for inaction. “What good would
it do?” “I'm only one person, how can I make any difference?” “The problem is so big,
whatever I do will only be a drop in the bucket.” Feeling helpless and hopeless is legitimate
unless it is used as an excuse to escape responsibility for taking any form of action.
Helplessness is modifiable when students are provided options and strategies that can be used
to increase their awareness and personal growth, and when they are provided with the tools to
dismantle racism in our society. Hopefully, this course and the readings will provide you with
suggestions of where to begin, especially in mental health practice.
Hopelessness is a feeling of despair and of giving up, a self‐belief that no action will matter
and no solution will work. Helplessness and hopelessness associated with the need for change
and action can be paralytic. The excuse for inaction, and thus the avoidance of racial
exploration, resides not simply in not knowing what to do, but in some very basic fears
eloquently expressed by Tatum (2002).
Fear is a powerful emotion, one that immobilizes, traps words in our throats, and stills
our tongues. Like a deer on the highway, frozen in the panic induced by the lights of an
oncoming car, when we are afraid it seems that we cannot think, we cannot speak, we
cannot move … What do we fear? Isolation from friends and family, ostracism for
speaking of things that generate discomfort, rejection by those who may be offended by
what we have to say, the loss of privilege or status for speaking in support of those who
have been marginalized by society, physical harm caused by the irrational wrath of
those who disagree with your stance? (pp. 115–116)
In other words, helplessness and hopelessness are emotions that can provide cover for not
taking action. They allow many of us to not change for fear that our actions will result in the
negative consequences previously outlined. Becoming a multiculturally competent counselor
CULTURAL COMPETENCE AND EMOTIONS
There are many other powerful emotions often experienced by students during the journey to
developing cultural competence. They include sadness, disappointment, humiliation, blame,
invalidation, and so on. These feelings, along with those already discussed, can make their
appearance in dialogues on multiculturalism or diversity.
The unpleasantness of some emotions and their potentially disturbing meanings makes for
avoidance of honest multicultural dialogues and hence a blockage of the learning process.
Rather than seeing emotions as a hindrance and barrier to mutual understanding, and rather
than shutting them down, allowing them to bubble to the surface actually frees the mind and
body to achieve understanding and insight. The cathartic relationship between memories,
fears, stereotypic images, and the emotional release of feelings is captured in the following
passage, which describes the racial awakening of Reese, a White male social justice advocate.
I remember when I was first introduced to [intergroup dialogue] … I thought it was the
most bullshit pedagogy … And, I fought it so hard … I don't know why I would ever sign
up for another course … I really thought it was stupid … [L]ike the taking in a circle
with the whole dialogue pedagogy was a huge hang‐up … [Later, reading about
Friere] was a really important moment in my life when I think about development.
(Ford, 2017, p. 124)
Years after his work as an intergroup dialogue facilitator, Reese reflected that the experience
had a “big impact” on his development and influenced his “perspectives.” He also recognized
that his journey was influenced by his varying levels of racial awareness as a White male
along the way.
We are aware that the content of this chapter has probably already pushed hot emotional
buttons in many of you. For trainees in the dominant group, we ask the following questions:
Are you willing to look at yourself, to examine your assumptions, your attitudes, your
conscious and unconscious behaviors, the privileges you enjoy as a dominant group member,
and how you may have unintentionally treated others in less than a respectful manner? For
socially marginalized group members, we ask whether you are willing to confront your own
biases and prejudices toward dominant group members, be honest in acknowledging your
own biases toward other socially devalued group members, and work to build bridges of
mutual understanding and respect for all groups.
Trainees who bravely undertake the journey to developing cultural competence and cultural
humility eventually realize that change is a lifelong process, and that it does not simply occur
in a workshop, classroom, or singular event. It is a monumental task, but the rewards are
many when we are successful. A whole body of literature supports the belief that
encountering diverse points of view, being able to engage in honest diversity conversations,
and successfully acknowledging and integrating differing perspectives lead to an expansion
of critical consciousness (Gurin, Dey, Hurtado, & Gurin, 2002; Jayakumar, 2008). On a
cognitive level, many have observed that cross‐racial interactions and dialogues, for
example, are necessary to increase racial literacy, expand the ability to critically analyze
racial ideologies, and dispel stereotypes and misinformation about other groups (Bolgatz,
2005; Ford, 2012; Pollock, 2004; Stevens, Plaut, & Sanchez‐Burks, 2008). On an emotional
level, trainees of successful diversity training report less intimidation and fear of differences,
an increased compassion for others, a broadening of their horizons, appreciation of people of
all colors and cultures, and a greater sense of belonging and connectedness with all groups
(American Psychological Association, 2017; APA Presidential Task Force, 2012; Bell, 2002;
President's Initiative on Race, 1999; Sue, 2003).
In closing, we implore you not to allow your initial negative feelings to interfere with your
ultimate aim of learning from this text as you journey toward cultural competence. Sad to
say, this empathic ability is blocked when readers react with defensiveness and anger upon
hearing the life stories of those most disempowered in our society. We have always believed
that our worth as human beings is derived from the collective relationships we hold with all
people; that we are people of emotions, intuitions, and spirituality; and that the lifeblood of
people can be understood only through lived realities. Although we believe strongly in the
value of science and the importance psychology places on empiricism, CDC is based on the
premise that a profession that fails to recognize the heart and soul of the human condition is a
discipline that is spiritually and emotionally bankrupt. As such, this book not only touches on
the theory and practice of multicultural counseling and psychotherapy, but also reveals the
hearts and souls of our diverse clienteles.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Listen and be open to stories of those most disempowered in U.S. society. Counseling
has always been about listening to our clients. Don't allow your emotional reactions to
negate their voices because you become defensive.
2. Know that although you were not born wanting to be racist, sexist, or heterosexist, or to
be prejudiced against any other group, your cultural conditioning has imbued certain
biases and prejudices in you. No person or group is free from inheriting the biases of
U.S. society.
3. Understand and acknowledge your intense emotions and what they mean for you. CCD
speaks about unfairness, racism, sexism, and prejudice, making some feel accused and
blamed. The “isms” of our society are not pleasant topics, and we often feel unfairly
accused.
4. It is important that helping professionals understand how they may still benefit from the
past actions of their predecessors and continue to reap the benefits of the present
social/educational arrangements.
5. Understand that multicultural training requires more than book learning. In your journey
to developing cultural competence, it is necessary to supplement your intellectual
development with experiential reality.
6. Don't be afraid to explore yourself as a racial, ethnic, and cultural being. An
overwhelming number of mental health practitioners believe they are good, decent, and
moral people. Because most of us would not intentionally discriminate, we often find
great difficulty in realizing that our belief systems and actions may have oppressed
others.
7. Open dialogue—to discuss and work through differences in thoughts, beliefs, and values
—is crucial to becoming culturally competent. It is healthy when we are allowed to
engage in free dialogue with one another. To a large extent, unspoken thoughts and
feelings serve as barriers to open and honest dialogue about the pain of discrimination
and how each and every one of us perpetuates bias through our silence or obliviousness.
8. Finally, continue to use these suggestions in reading throughout the text. What emotions
or feelings are you experiencing? Where are they coming from? Are they blocking your
understanding of the material? What do these reactions mean for you personally and as a
SUMMARY
Students who take a course on multicultural counseling and mental health issues have almost
universally felt both positive and negative feelings that affect their ability to learn about
diversity issues. Those from marginalized groups often feel validated by the content while
majority group members often feel a range of emotions like defensiveness, anxiety, anger,
and guilt. It is important not to allow these nested or embedded emotions to go
unacknowledged, or to avoid exploring the psychological meanings they may have for
trainees. The journey to becoming culturally competent therapists is filled with obstacles to
self‐exploration, to understanding oneself as a racial/cultural being, and to understanding
the worldview of those who differ from others in terms of race, gender, ethnicity, sexual
orientation, and other sociodemographic dimensions. The subject matter in this book requires
students to explore their biases and prejudices, a task that often evokes strong resistance from
both majority and oppressed group members.
It is important to recognize personal resistance to the material, to explore its meaning, and to
learn about yourself and others. Sometimes, what is revealed about you may prove disturbing,
but having the courage to continue is necessary to becoming a culturally competent counselor
or therapist. Recognizing the manifestation and hidden meanings of resistance is one of the
first priorities of multicultural training for both trainees and trainers. For trainees, it is finding
the courage to confront their own fears and apprehensions, to work through the powerful
emotions they are likely to experience, to explore what these feelings mean for them as
racial/cultural beings, to achieve new insights about themselves, and to develop multicultural
skills and behaviors in their personal lives and as mental health professionals. For trainers, it
means understanding the nature of trainee resistance, creating a safe but challenging
environment for self‐exploration, and using intervention strategies that facilitate difficult
dialogues on race, gender, sexual orientation, and other sociodemographic dimensions. This
chapter is specifically written to help readers understand and overcome their emotive
reactions to the substance of the text and the course they are about to take.
GLOSSARY TERMS
Antiracist
Behavioral resistance (to multicultural education)
Cognitive resistance (to multicultural education)
Cultural competence
Cultural humility
Culturally responsive
Emotional affirmation
Emotional invalidation
Emotional resistance (to multicultural education)
Emotional self‐revelation
Microaggressions
Multiculturalism
Nested/Embedded emotions
Nonracist
Self‐reflection
Worldview
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2
Multicultural Counseling and Therapy (MCT)
Chapter Objectives
1. 1. Compare and contrast similarities and differences between “traditional
counseling/clinical practice” and culturally responsive counseling.
2. 2. Understand the etic and emic orientation to multicultural counseling.
3. 3. Become cognizant of differences between counseling/clinical competence and
multicultural counseling competence and cultural humility.
4. 4. Identify Eurocentric assumptions inherent in our standards of clinical practice.
5. 5. Discuss and understand the characteristics of the three levels of personal
identity.
6. 6. Develop awareness of possible differences in counseling culturally diverse clients
who differ in race, gender, sexual orientation, and other group identities.
7. 7. Provide examples of ways that other special populations may constitute a distinct
cultural group.
8. 8. Define multicultural counseling and therapy, cultural competence, and cultural
humility.
9. 9. Explain how cultural humility is different from cultural competence.
The following is the third counseling session between Dr. D. (a White counselor) and
Gabriella, a 29‐year‐old single Latina, who was born and raised in Brazil but came to the
United States when she was 10 years old.
Dr. D:
So how did it go last week with Russell [White boyfriend of six months].
Gabriella:
Okay, I guess. [seems withdrawn and distracted]
Dr. D:
You don't sound too sure to me.
Gabriella:
What do you mean?
Dr. D:
Well, from the last session, I understood that you were going to talk to him [Russell]
about your decision to live together, but that you wanted to clarify what moving into his
apartment meant for him.
Gabriella:
I didn't get a chance to talk about it. I was going to bring it up, but I had another attack,
so I didn't get a chance. It was awful! [begins to fidget in the chair] Why does this
always happen to me?
Dr. D:
Tell me what happened.
Gabriella:
I don't know. I had a disagreement with him, a big stupid argument over Jennifer Lopez's
song “Booty.”
Dr. D:
“Booty”?
Gabriella:
Yeah, he kept watching the video over and over on the computer. He loves the song, but
I find it vulgar.
Dr. D:
Lots of songs press the limits of decency nowadays … Tell me about the attack.
Gabriella:
I don't know what happened. I lost control and started screaming at him. I threw dishes
at him and started to cry. I couldn't breathe. Then it got really bad, and I could feel the
heat rise in my chest. I was scared to death. Everything felt unreal and I felt like fainting.
My mother used to suffer from similar episodes of ataques. Have I become like her? …
God, I hope not!
Dr. D:
Sounds like you had another panic attack. Did you try the relaxation exercises we
practiced?
Gabriella:
No, how could I? I couldn't control myself. It was frightening. I started to cry and
couldn't stop. Russell kept telling me to calm down. We finally made up and got it on.
Dr. D:
I'm glad things got smoothed over. But you always say that you have no control over
your attacks. We've spent lots of time on learning how to manage your panic attacks by
nipping them in the bud … before they get out of control. Maybe some medication might
help.
Gabriella:
Yes, I know, but it doesn't seem to do any good. I just couldn't help it.
Dr. D:
Did you try?
Gabriella:
Do you think I enjoy the attacks? [shouts] How come I always feel worse when I come
here? I feel blamed … Russell says I'm a typical emotional Latina. What am I to do? I
come here to get help, and I just get no understanding. [stated with much anger]
Dr. D:
You're angry at me because I don't seem to be supportive of your predicament, and you
think I'm blaming you. But I wonder if you have ever asked yourself how you contribute
to the situation as well. Do you think that fighting over a song is the real issue here?
Gabriella:
Maybe not, but I just don't feel like you understand.
Dr. D:
Understand what?
Gabriella:
Understand what it is like to be a Latina woman dealing with all those stereotypes. My
parents don't want me living with Russell … they think he benefits from having sex with
no commitment to marriage, and that I'm a fool. They think he is selfish and just wants a
Latina … like a fetish…
Dr. D:
I think it's more important what you think and want for yourself, not what your parents
would like you to do. Be your own person. And we've talked about cultural differences
before, in the first session, remember? Cultural differences are important, but it's more
important to recognize that we are all human beings. Granted, you and I are different
from one another, but most people share many more similarities than differences.
Gabriella:
Yes, but can you really understand what's it like to be a Latina, the problems I deal with
in my life? Aren't they important?
Dr. D:
Of course I can. And of course they [differences] are … but let me tell you, I've worked
with many Latinos in my practice. When it comes right down to it, we are all the same
under the skin.
Gabriella:
[period of silence]
Dr. D:
Now, let's go back and talk about your panic attacks and what you can do to prevent and
reduce them.
REFLECTION AND DISCUSSION QUESTIONS
1. What are your thoughts and feelings about the counseling encounter between Dr. D. and
Gabriella?
2. Do you think that Dr. D. demonstrated cultural awareness? Is this an example of “good
counseling”? If not, why not?
3. When Gabriella described her episodes as ataques, do you know what she meant?
4. What are the potential counseling and cultural issues in this case?
5. Is it important for the counselor to know what the song “Booty” is about?
6. When the parents suggest that their daughter might be a “fetish,” what could they
possibly mean? Is it important?
7. What images of Latinas exist in our society? How might they affect Gabriella's
relationship with Russell?
8. If you were the counselor, how would you have handled the situation?
Video 2.0: Introduction
Introduction to counseling session by Dr. Joel Filmore.
Culturally competent care has become a major force in the helping professions (American
Psychological Association, 2003, 2017; Arredondo et al., 1996; CACREP, 2015; Cornish,
Schreier, Nadkarni, Metzger, & Rodolfa, 2010; Sue, Arredondo, & McDavis, 1992). The
therapy session between Dr. D. and Gabriella illustrates the importance of cultural awareness
and sensitivity in mental health practice. There is a marked worldview difference between the
White therapist and the Latina client. In many cases, such differences reflect the therapist's (a)
belief in the universality of the human condition, (b) belief that disorders are similar and cut
across societies, (c) lack of knowledge of Latinx culture, (d) task orientation, (e) failure to
pick up clinical clues provided by the client, (f) lack of awareness of the influence of
sociopolitical forces in the lives of marginalized group members, and (g) lack of openness to
professional limitations. Let us briefly explore these factors in analyzing the preceding
transcript.
CULTURE‐UNIVERSAL (ETIC) VERSUS CULTURE‐SPECIFIC
(EMIC) FORMULATIONS
First and foremost, it is important to note that Dr. D. is not a bad counselor per se, but like
many helping professionals is culture‐bound and adheres to EuroAmerican assumptions and
values that encapsulate and prevent him from seeing beyond his Western therapeutic training
(Comas‐Diaz, 2010). One of the primary issues raised in this case relates to the etic
(culturally universal) versus emic (culturally specific) perspectives in psychology and mental
health. Dr. D. operates from the former position. His training has taught him that disorders
such as panic attacks, depression, schizophrenia, and sociopathic behaviors appear in all
cultures and societies; that minimal modification in their diagnosis and treatment is required;
and that Western concepts of normality and abnormality can be considered universal and
equally applicable across cultures (Arnett, 2009; Howard, 1992; Suzuki, Kugler, & Aguiar,
2005). Many culturally responsive psychologists, however, operate from an emic position and
challenge these assumptions. In Gabriella's case, they argue that lifestyles, cultural values,
and worldviews affect the expression and determination of behavior disorders (Ponterotto,
Utsey, & Pedersen, 2006). They stress that all theories of human development arise within a
cultural context and that using the EuroAmerican values of normality and abnormality may
be culture‐bound and biased (Locke & Bailey, 2014). From this case, we offer five tentative
cultural/clinical observations that may help Dr. D. in his work with Gabriella.
Cultural Concepts of Distress
It is obvious that Dr. D. has concluded that Gabriella suffers from a panic disorder and that
her attacks fulfill criteria set forth in the Diagnostic and Statistical Manual of Mental
Disorders (DSM‐5) (American Psychiatric Association, 2013). When Gabriella uses the
term ataques to describe her emotional outbursts, episodes of crying, feeling faint, somatic
symptoms (“heat rising in her chest”), feeling of depersonalization (unreal), and loss of
control, a Western‐trained counseling/mental health professional may very likely diagnose a
panic attack. Is a panic attack diagnosis the same as ataques? Is ataque simply a Latin
American translation of an anxiety disorder? We now recognize that ataque de nervios
(“attack of the nerves”) is a cultural syndrome, occurs often in Latin American countries (in
individuals of Latinx descent), and is distinguishable from panic attacks (American
Psychological Association, 2013). Cultural syndromes that do not share a one‐to‐one
correspondence with psychiatric disorders in DSM‐5 have been found in South Asia,
Zimbabwe, Haiti, China, Mexico, Japan, and other places. Failure to consider the cultural
context and manifestation of disorders often results in inaccurate diagnosis and inappropriate
treatment (Sue, Sue, Sue, & Sue, 2016). Chapter 10 will discuss these cultural syndromes and
treatments in greater detail.
Acknowledging Group Differences
Dr. D. seems to easily dismiss the importance of Gabriella's Latinx culture as a possible
barrier to their therapeutic work together. Gabriella wonders aloud whether he can understand
her as a Latina (being a racial, ethnic, cultural being), and the unique problems she faces as a
person of color. Dr. D. attempts to reassure Gabriella that he can, in several ways. He stresses
(a) that people are more similar than different, (b) that we are all “human beings,” (c) that he
has much experience in working with Latinx individuals, and (d) that everyone is the “same
under the skin.” Although there is much truth to these statements, he has unintentionally
negated Gabriella's racialized experiences, and the importance that she places on her
racial/ethnic identity. In multicultural counseling, this response often creates an impasse to
therapeutic relationships (Arredondo, Gallardo‐Cooper, Delgado‐Romero, & Zapata,
2014). Note, for example, Gabriella's long period of silence following Dr. D.'s response. He
apparently misinterprets this as agreement. We will return to this important point shortly.
Being Aware of Collectivistic Cultures
It is obvious that Dr. D. operates from an individualistic approach and values individualism,
autonomy, and independence. He communicates to Gabriella that it is more important for her
to decide what she wants for herself than to be concerned about her parents' desires. Western
European concepts of mental health stress the importance of independence and “being your
own person,” because this leads to healthy development and maturity, rather than dependency
(in Gabriella's case, “pathological family enmeshment”). Dr. D. fails to consider that in many
collectivistic cultures, such as Latinx and Asian American cultures, independence may be
considered undesirable and interdependence as valuable (Ivey, Ivey, & Zalaquett, 2014; Kail
& Cavanaugh, 2013). When the norms and values of Western European concepts of mental
health are imposed universally upon culturally diverse clients, there is the very real danger of
cultural oppression, resulting in “blaming the victim.”
Attuning to Cultural and Clinical Clues
There are many cultural clues in this therapeutic encounter that might have provided Dr. D.
with additional insights into Latinx culture and its meaning for culturally competent
assessment, diagnosis, and treatment. We have already pointed out his failure to explore more
in depth Gabriella's description of her attacks (ataques de nervios), and her concern about her
parents' approval. But many potential sociocultural and sociopolitical clues were present in
their dialogue as well. For example, Dr. D. failed to follow up on why the song “Booty” by
Jennifer Lopez precipitated an argument, and what the parents' use of the term “fetish” shows
us about how Russell may view their daughter.
The four‐minute music video “Booty” shows Jennifer Lopez and Iggy Azalea with many
anonymous women shaking their derrieres (“booties”) in front of the camera while chanting
“Big, big booty, big, big booty” continuously. It has been described as provocative,
exploitative, and “soft porn.” Nevertheless, the video has become a major hit. And while Dr.
D. might be correct in saying that the argument couldn't possibly be over a song (implying
that there is a more meaningful reason), he doesn't explore the possible cultural or political
implications for Gabriella. Is there meaning in her finding the song offensive and Russell's
enjoying it? We know, for example, that Latinas and Asian women are victims of widespread
societal stereotyping that objectifies them as sex objects. Could this be something that
Gabriella is wrestling with? At some level, does she suspect that Russell is only attracted to
her because of these stereotypes, as her parents' use of the word “fetish” implies? In not
exploring these issues, or worse yet, not being aware of them, Dr. D. may have lost a valuable
opportunity to help Gabriella gain insight into her emotional distress.
Balancing the Culture‐Specific and Culture‐Universal Orientations
Throughout our analysis of Dr. D., we have made the point that culture and life experiences
affect the expression of abnormal behavior and that counselors need to attune to these
sociodemographic variables. Some have even proposed the use of culture‐specific strategies
in counseling and therapy (American Psychological Association, 2017; Ivey et al., 2014;
Parham, Ajamu, & White, 2011). Such professionals point out that current guidelines and
standards of clinical practice are culture‐bound and often inappropriate for racial/ethnic
minority groups. Which view is correct? Should treatment approaches be based on cultural
universality or cultural relativism? Few mental health professionals today embrace the
extremes of either position.
Proponents of cultural universality focus on disorders and their consequent treatments and
minimize cultural factors, whereas proponents of cultural relativism focus on the culture and
on how the disorder is manifested and treated within it. Both views have validity. It would be
naive to believe that no disorders cut across different cultures or share universal
characteristics. Likewise, it is naive to believe that the relative frequencies and manners of
symptom formation for various disorders do not reflect the dominant cultural values and
lifestyles of a society. Nor would it be beyond our scope to entertain the notion that various
diverse groups may respond better to culture‐specific therapeutic strategies. A more fruitful
approach to these opposing views might be to address the following three questions: (a) What
is universal in human behavior that is also relevant to counseling and therapy? (b) What is the
relationship between cultural norms, values, and attitudes, on the one hand, and the
manifestation of behavior disorders and their treatments, on the other? and (c) Are there ways
to both examine the universality of the human condition and acknowledge the role of culture
in the manifestation of both the presenting concern and the treatment approach? Recently,
researchers have systematically addressed the last question. Mounting evidence supports the
superiority of culturally adaptive treatment interventions compared to culturally universal
ones (Hall, Ibaraki, Huang, Marti, & Stice, 2016; Smith & Trimble, 2016).
Video 2.1: We Are All the Same, We Are All Unique
When to apply etic and emic views based on race/ethnicity as well as culture, and how they
differ based on culture.
THE NATURE OF MULTICULTURAL COUNSELING COMPETENCE
Clinicians have oftentimes asserted that “good counseling is good counseling” and that good
clinical practice subsumes cultural competence, which is simply a subset of good clinical
skills. In this view, they would make a strong case that if Dr. D. had simply exercised these
therapeutic skills, he would have worked effectively with Gabriella. Our contention, however,
is that cultural competence is superordinate to counseling competence. How Dr. D. worked
with Gabriella contains the seeds of a therapeutic bias that makes him susceptible to cultural
errors in therapy. Traditional definitions of counseling and psychotherapy are culture‐bound
because they are defined from a primarily White Western European perspective (Gallardo,
2014). Let us briefly explore the rationale for our position.
The Harm of Cultural Insensitivity
Although there are disagreements over the definition of cultural competence, many of us
know cultural insensitivity when we see it; we recognize it by its horrendous outcomes or by
the human toll it takes on our marginalized clients. For some time now, multicultural
specialists have described Western‐trained counseling/mental health professionals in very
unflattering terms: (a) they are insensitive to the needs of their culturally diverse clients; do
not accept, respect, and understand cultural differences; are arrogant and contemptuous; and
have little understanding of their prejudices (Ridley, 2005); (b) clients of color, women across
race and ethnicity, and lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals
frequently complain that they experience microaggressions in counseling (Hook et al., 2016;
Sue, 2010); (c) discriminatory practices in mental health delivery systems are deeply
embedded in the ways in which the services are organized and in how they are delivered to
minority populations, and are reflected in biased diagnoses and treatment, in indicators of
dangerousness, and in the type of people occupying decision‐making roles (Cross, Bazron,
Dennis, & Isaacs, 1989; Parham et al., 2011); and (d) mental health professionals continue to
be trained in programs in which the issues of ethnicity, gender, and sexual orientation are
ignored, regarded as deficiencies, portrayed in stereotypic ways, or included as an
afterthought (Ponterotto et al., 2006; Ratts & Pedersen, 2014).
Good Counseling Is Culturally Responsive Counseling
As we have discussed, values of individualism and psychological mindedness, and the use of
rational approaches to solve problems, have much to do with how competence is defined.
Many of our colleagues continue to hold firmly to the belief that “good counseling is good
counseling,” dismissing in their definitions the centrality of culture. The problem with
traditional definitions of counseling, therapy, and mental health practice is that they arose
from monocultural and ethnocentric norms that excluded other cultural groups. Mental health
professionals must realize that “good counseling” uses White EuroAmerican norms that
exclude most of the world's population. In a hard‐hitting article, Arnett (2009) indicates that
psychological research, which forms the knowledge base of our profession, focuses on
Americans, who constitute only 5% of the world's population. He concludes that the
knowledge of human behavior neglects 95% of the world's population and is an inadequate
representation of humanity. It is clear to us that good counseling takes into consideration the
cultural context in which counseling occurs and the cultural realities of the client and
counselor. Standards of helping derived from such a philosophy and framework are inclusive.
Thus, clinical or “counseling competence is multicultural counseling competence” (Ridley,
Mollen, & Kelly, 2011, p. 841).
A TRIPARTITE FRAMEWORK FOR UNDERSTANDING THE
MULTIPLE DIMENSIONS OF IDENTITY
All too often, counseling and psychotherapy seem to ignore the group dimension of human
existence. For example, a White counselor who works with an African American client might
intentionally or unintentionally avoid acknowledging the client's racial or cultural background
by stating, “We are all the same under the skin” or “Apart from your racial background, we
are all unique.” We have already indicated possible reasons why this happens, but such
avoidance tends to negate an intimate aspect of the client's group identity (Apfelbaum,
Sommers, & Norton, 2008; Neville, Gallardo, & Sue, 2016). Dr. D.'s responses toward
Gabriella seem to have had this effect. These forms of microinvalidation will be discussed
more fully in Chapter 6. As a result of these invalidations, a client of color might feel
misunderstood and resentful toward the helping professional, hindering the effectiveness of
the counseling. Besides unresolved personal issues arising from counselors, the assumptions
embedded in Western forms of therapy exaggerate the chasm between therapists and
culturally diverse clients.
First, the concepts of counseling and psychotherapy are uniquely EuroAmerican in origin, as
they are based on certain philosophical assumptions and values that are strongly endorsed by
Western civilizations. On the one side are beliefs that people are unique and that the
psychosocial unit of operation is the individual; on the other side are beliefs that clients are
the same and that the goals and techniques of counseling and therapy are equally applicable
across all groups. Taken to its extreme, this latter approach nearly assumes that persons of
color, for example, are White, and that race and culture are insignificant variables in
counseling and psychotherapy (Sue, 2010). Statements such as “There is only one race, the
human race” and “Apart from your racial/cultural background, you are no different from me”
are indicative of the tendency to avoid acknowledging how race, culture, and other group
dimensions may influence identity, values, beliefs, behaviors, and the perception of reality
(Lum, 2011; Sue, 2015).
Second, related to the negation of race, we have indicated that a most problematic issue deals
with the inclusive or exclusive nature of multiculturalism. A number of psychologists have
indicated that an inclusive definition of multiculturalism (one that includes gender,
ability/disability, sexual orientation, and so forth) can obscure the understanding and study of
race as a powerful dimension of human existence (Carter, 2005; Helms & Richardson, 1997).
This stance is not intended to minimize the importance of the many cultural dimensions of
human identity, but rather emphasizes the greater discomfort that many psychologists
experience in dealing with issues of race as compared to other sociodemographic differences
(Sue, Lin, Torino, Capodilupo, & Rivera, 2009). As a result, race becomes less salient and
allows us to avoid addressing problems of racial prejudice, racial discrimination, and
systemic racial oppression. This concern appears to have great legitimacy. We have noted, for
example, that when issues of race are discussed in the classroom, a mental health agency, or
some other public forum, it is not uncommon for participants to refocus the dialogue on
differences related to gender, socioeconomic status, or religious orientation. In fact, even
when asked to define racism, many people will avoid mentioning the word “race” and instead
talk about gender or other forms of discrimination.
On the other hand, many groups often rightly feel excluded from the multicultural debate and
find themselves in opposition to one another. Thus, enhancing multicultural understanding
and sensitivity means balancing our understanding of the sociopolitical forces that dilute the
importance of race, on the one hand, and our need to acknowledge the existence of other
group identities related to social class, gender, ability/disability, age, religious affiliation, and
sexual orientation, on the other (Anderson & Middleton, 2011; Sue, 2010).
There is an East Asian saying that goes something like this: “All individuals, in many
respects, are (a) like no other individuals, (b) like some individuals, and (c) like all other
individuals.” Although this statement might sound confusing and contradictory, many East
Asians believe these words to have great wisdom and to be entirely true with respect to
human development and identity. We have found the tripartite framework shown in Figure
2.1 (Sue, 2001) to be useful in exploring and understanding the formation of personal
identity. The three concentric circles illustrated in Figure 2.1 denote individual, group, and
universal levels of personal identity.
FIGURE 2.1 Tripartite Development of Personal Identity
Select this link to open an interactive version of Figure 2.1.
Individual Level: “All Individuals Are, in Some Respects, Like No Other
Individuals”
There is much truth in the saying that no two individuals are identical. We are all unique
biologically, and recent breakthroughs in mapping the human genome have provided some
startling findings. Biologists, anthropologists, and evolutionary psychologists had looked to
the Human Genome Project as potentially providing insights into comparative and
evolutionary biology that would allow us to find the secrets to life. Although the project has
provided valuable answers to many questions, scientists have discovered even more complex
questions. For example, they had expected to find 100,000 genes in the human genome, but
only about 20,000 were initially found, with the possible existence of another 5,000—only
two or three times more than are found in a fruit fly or a nematode worm. Of those 25,000
genes, only 300 unique genes distinguish us from the mouse. In other words, human and
mouse genomes are about 85% identical! Although it may be a blow to human dignity, the
important question is how so relatively few genes can account for our humanness.
Likewise, if so few genes can determine such great differences between species, what about
within the species? Human inheritance almost guarantees differences, because no two
individuals ever share the same genetic endowment. Further, no two of us share the exact
same experiences in our society. Even identical twins, who theoretically share the same gene
pool and are raised in the same family, are exposed to both shared and nonshared
experiences. Different experiences in school and with peers, as well as qualitative differences
in how parents treat them, will contribute to individual uniqueness. Research indicates that
psychological characteristics, behavior, and mental disorders are more affected by
experiences specific to a child than are shared experiences (Bale et al., 2010; Foster &
MacQueen, 2008).
Group Level: “All Individuals Are, in Some Respects, Like Some Other
Individuals”
As mentioned earlier, each of us is born into a cultural matrix of beliefs, values, rules, and
social practices. By virtue of social, cultural, and political distinctions made in our society,
perceived group membership exerts a powerful influence over how society views
sociodemographic groups and over how its members view themselves and others. Group
markers such as race and gender are relatively stable and not very subject to change. Some
markers, such as education, socioeconomic status, marital status, and geographic location, are
more fluid and changeable. Although ethnicity is fairly stable, some argue that it can also be
fluid. Likewise, debate and controversy surround discussions about whether sexual
orientation is determined at birth and whether we should be speaking of sexuality or
sexualities (Sue et al., 2016). Nevertheless, membership in these groups may result in shared
experiences and characteristics. Group identities may serve as powerful reference groups in
the formation of worldviews. On the group level of identity, Figure 2.1 reveals that people
may belong to more than one cultural group (e.g., an Asian American female with a
disability), that some group identities may be more salient than others (e.g., race over
religious orientation), and that the salience of cultural group identity may shift from one to
the other depending on the situation. For example, a gay man with a disability may find that
his disability identity is more salient among the able‐bodied but that his sexual orientation is
more salient among those with disabilities. We are drawn to exploring experiences based on
our social identities; we often read books, listen to music, watch TV shows or movies by or
about people who are similar to us in terms of race, gender, sexual orientation, or any
combination thereof.
Universal Level: “All Individuals Are, in Some Respects, Like All Other
Individuals”
Because we are members of the human race and belong to the species Homo sapiens, we
share many similarities. Universal to our commonalities are (a) biological and physical
similarities, (b) common life experiences (birth, death, love, sadness, and so forth), (c) self‐
awareness, and (d) the ability to use symbols, such as language. In Shakespeare's Merchant of
Venice, Shylock attempts to acknowledge the universal nature of the human condition by
asking, “When you prick us, do we not bleed?” Again, although the Human Genome Project
indicates that a few genes may cause major differences between and within species, it is
startling how similar the genetic material within our chromosomes is and how much we share
in common. However, that we are similar at a broad human level does not erase our
individual and cultural uniqueness.
REFLECTION AND DISCUSSION QUESTIONS
1. Select three group identities you possess (e.g., race, gender, sexual orientation,
disability, religion, socioeconomic status, and so forth). Of the three you have chosen,
which one is most salient to you? Why? Does it shift or change? How aware are you of
other social group identities?
2. Using the tripartite framework just discussed, can you outline ways in which you are
unique, share characteristics with only certain groups, and share similarities with
everyone?
3. Can someone truly be color‐blind to race? What makes seeing and acknowledging
differences so difficult? In what ways does a color‐blind approach hinder the
counseling relationship when working with diverse clients?
Video 2.3: It's Not Always About Being a Minority, but Sometimes It Is
Maintaining self-awareness during the counseling session so that you aren't dismissive of
your client's unique, lived experience.
INDIVIDUAL AND UNIVERSAL BIASES IN PSYCHOLOGY AND
MENTAL HEALTH
Psychology—and mental health professionals in particular—has generally focused on either
the individual or the universal levels of identity, placing less importance on the group level.
There are several reasons for this orientation. First, our society arose from the concept of
rugged individualism, and we have traditionally valued autonomy, independence, and
uniqueness. Our culture assumes that individuals are the basic building blocks of our society.
Sayings such as “Be your own person (à la Dr. D.),” “Stand on your own two feet,” and
“Don't depend on anyone but yourself” reflect this value. Psychology and education represent
the carriers of this value, and the study of individual differences is most exemplified in the
individual intelligence testing movement that pays homage to individual uniqueness (Suzuki
et al., 2005).
Second, the universal level is consistent with the tradition of psychology, which has
historically sought universal facts, principles, and laws in explaining human behavior.
Although this is an important quest, the nature of scientific inquiry has often meant studying
phenomena independently of the context in which human behavior originates. Thus,
therapeutic interventions from which research findings are derived may lack external validity
(Chang & Sue, 2005).
Third, we have historically neglected the study of identity at the group level for sociopolitical
and normative reasons. As we have seen, issues of race, gender, sexual orientation, and
disability seem to touch hot buttons in all of us because they bring to light issues of
oppression and the unpleasantness of personal biases (Lo, 2010; Zetzer, 2011). In addition,
racial and ethnic differences have frequently been interpreted from a deficit perspective and
have been equated with being abnormal or pathological (Guthrie, 1997; Parham et al., 2011).
We have more to say about this in Chapter 4.
Disciplines that hope to understand the human condition cannot neglect any level of our
identity. For example, psychological explanations that acknowledge the importance of group
influences such as gender, race, ethnicity, sexual orientation, socioeconomic class, and
religious affiliation lead to a more accurate understanding of human psychology. Failure to
acknowledge these influences may skew research findings and lead to biased conclusions
about human behavior that are culture‐bound, class‐bound, and gender‐bound.
Thus, it is possible to conclude that all people possess individual, group, and universal levels
of identity. A holistic approach to understanding personal identity demands that we recognize
all three levels: individual (uniqueness), group (shared cultural values, beliefs, and
experiences), and universal (common features of being human). Because of the historical
scientific neglect of the group level of identity, this text focuses primarily on this category.
Although the concentric circles in Figure 2.1 might unintentionally suggest a clear boundary,
each level of identity must be viewed as permeable and ever‐changing in salience. In
counseling and psychotherapy, for example, a client might view his or her uniqueness as
important at one point in the session and stress commonalities of the human condition at
another. Even within the group level of identity, multiple forces may be operative. As
mentioned earlier, the group level of identity reveals many reference groups, both fixed and
nonfixed, that might impact our lives. Being an elderly gay male Latino, for example,
represents four potential reference groups operating on the person; the cultural groups also
includes membership in multiple social identities, such as American Indian queer woman and
White heterosexual man. The culturally responsive helping professional must be willing and
THE IMPACT OF GROUP IDENTITIES ON COUNSELING AND
PSYCHOTHERAPY
Accepting the premise that race, ethnicity, and culture are powerful variables in influencing
how people think, make decisions, behave, and define events, it is not far‐fetched to
conclude that such forces may also affect how different groups define a helping relationship
(Herlihy & Corey, 2015). Culturally responsive psychologists have long noted, for example,
that different theories of counseling and psychotherapy represent different worldviews, each
with its own values, biases, and assumptions about human behavior (Geva & Wiener, 2015).
Given that U.S. schools of counseling and psychotherapy arise from Western European
contexts, the worldview that they espouse as reality may not be shared by racial/ethnic
minority groups in the United States, or by those who reside in different countries (Parham et
al., 2011). Each racial, ethnic, or cultural group has its own perspective on the nature of
people, the origin of disorders, standards for judging normality and abnormality, and
therapeutic approaches.
Among many Asian Americans, for example, a self‐orientation is considered undesirable,
whereas a group orientation is highly valued (Kim, 2011). The Japanese have a saying that
goes like this: “The nail that stands up should be pounded back down.” The meaning seems
clear: healthy development is considering the needs of the entire group, whereas unhealthy
development is thinking only of oneself. Likewise, relative to their EuroAmerican
counterparts, many African Americans value the emotive and affective qualities of
interpersonal interactions as qualities of sincerity and authenticity (West‐Olatunji &
Conwill, 2011). EuroAmericans often view the passionate expression of affect as irrational,
impulsive, immature, and lacking objectivity on the part of the communicator. Thus, the
autonomy‐oriented goal of counseling and psychotherapy and the objective focus of the
therapeutic process might prove antagonistic to the worldviews of some Asian Americans and
African Americans, respectively.
It is therefore highly probable that different racial and ethnic minority groups perceive the
competence of the helping professional differently than do mainstream client groups. Further,
if race and ethnicity affect perception, what about other group differences, such as gender and
sexual orientation? Minority clients may see a clinician who exhibits therapeutic skills that
are associated primarily with mainstream therapies as having lower credibility. The important
question to ask is, “Do such groups as racial/ethnic minorities define cultural competence
differently than do their EuroAmerican counterparts?” Anecdotal observations, clinical case
studies, conceptual analytical writings, and some empirical studies seem to suggest an
affirmative response (Fraga, Atkinson, & Wampold, 2002; Garrett & Portman, 2011; Guzman
& Carrasco, 2011; McGoldrick, Giordano, & Garcia‐Preto, 2005).
Video 2.5: Switching Up the Game
Emphasizing the counseling relationship as a two-way street, rather than a one-way tunnel, in
counseling minority populations.
WHAT IS MULTICULTURAL COUNSELING AND THERAPY (MCT)?
In light of the previous analysis, let us define multicultural counseling and therapy (MCT) as
it relates to the therapy process and the roles of the mental health practitioner:
Multicultural counseling and therapy can be defined as both a helping role and a
process that uses modalities and defines goals consistent with the life experiences and
cultural values of clients; recognizes client identities to include individual, group, and
universal dimensions; advocates the use of universal and culture‐specific strategies
and roles in the healing process; and balances the importance of individualism and
collectivism in the assessment, diagnosis, and treatment of client and client systems.
(Sue & Torino, 2005)
This definition often contrasts markedly with traditional views of counseling and
psychotherapy. A more thorough analysis of these characteristics is described in Chapter 7.
For now, let us extract the key phrases in our definition and expand their implications for
clinical practice.
1. Helping role and process. MCT broadens the roles that counselors play and expands the
repertoire of therapy skills considered helpful and appropriate in counseling. The more
passive and objective stance taken by therapists in clinical work is seen as only one
method of helping. Likewise, teaching, consulting, and advocacy can supplement the
conventional counselor or therapist role.
2. Consistent with life experiences and cultural values. Effective MCT means using
modalities and defining goals for culturally diverse clients that are consistent with their
racial, cultural, ethnic, gender, and sexual‐orientation backgrounds. Advice and
suggestions, for example, may be effectively used for some client populations.
3. Individual, group, and universal dimensions of existence. As we have already seen,
MCT acknowledges that our existence and identity are composed of individual
(uniqueness), group, and universal dimensions. Any form of helping that fails to
recognize the totality of these dimensions negates important aspects of a person's
identity.
4. Universal and culture‐specific strategies. MCT believes that different racial and ethnic
minority groups might respond best to culture‐specific strategies of helping or
culturally adaptive interventions. Such counseling takes into consideration how the
client defines or understands their concern over and incorporation of culturally relevant
concepts such as intergenerational stress, face‐saving, cultural mistrust, and racial and
ethnic socialization.
5. Individualism and collectivism. MCT broadens the perspective of the helping
relationship by balancing the individualistic approach with a collectivistic reality that
acknowledges our embeddedness in families, relationships with significant others,
communities, and cultures. A client is perceived not just as an individual, but as an
individual who is a product of his or her social and cultural context.
6. Client and client systems. MCT assumes a dual role in helping clients. In many cases, for
example, it is important to focus on individual clients and to encourage them to achieve
insights and learn new behaviors. However, when problems of clients of color reside in
prejudice, discrimination, and racism of employers, educators, and neighbors or in
organizational policies or practices in schools, mental health agencies, government,
businesses, and society, the traditional therapeutic role appears ineffective and
inappropriate. The focus for change must shift to altering client systems rather than
individual clients.
Video 2.6: Unlearning How to Counsel Cultural Minorities
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
WHAT IS CULTURAL COMPETENCE?
Consistent with the definition of MCT, it becomes clear that culturally responsive healers are
working toward several primary goals (American Psychological Association, 2003, 2017; Sue
et al., 1992, 1998). First, culturally competent helping professionals are ones who are actively
in the process of becoming aware of their own values, biases, assumptions about human
behavior, preconceived notions, personal limitations, and so forth. Second, culturally
competent helping professionals are ones who actively attempt to understand the worldview
of their culturally diverse clients and the sociohistorical context in which that worldview
develops. In other words, what are the client's values and assumptions about human behavior,
biases, and so on? Third, culturally competent helping professionals are ones who are in the
process of actively developing and practicing appropriate, relevant, and sensitive intervention
strategies and skills in working with their culturally diverse clients. These three attributes
make it clear that cultural competence is an active, developmental, and ongoing process and
that it is aspirational rather than achieved. Specifically, we define cultural competence in the
following manner.
Cultural competence is a lifelong process in which one works to develop the ability to
engage in actions or create conditions that maximize the optimal development of client
and client systems. Multicultural counseling competence is aspirational and consists of
counselors acquiring awareness, knowledge, and skills needed to function effectively in
a pluralistic democratic society (ability to communicate, interact, negotiate, and
intervene on behalf of clients from diverse backgrounds), and on an
organizational/societal level, advocating effectively to develop new theories, practices,
policies, and organizational structures that are more responsive to all groups.
(Sue & Torino, 2005)
This definition of cultural competence in the helping professions makes it clear that the
conventional one‐to‐one, in‐the‐office, objective form of treatment aimed at
remediation of existing problems may be at odds with the sociopolitical and cultural
experiences of clients. Like the complementary definition of MCT, it addresses not only
clients (individuals, families, and groups) but also client systems (institutions, policies, and
practices that may be unhealthy or problematic for healthy development). Addressing client
systems is especially important if problems reside outside rather than inside the client. For
example, prejudice and discrimination such as racism, sexism, and homophobia may impede
the healthy functioning of individuals and groups in our society.
Second, cultural competence can be seen as residing in three major domains: (a)
attitudes/beliefs component—an understanding of one's own cultural conditioning and how
this conditioning affects the personal beliefs, values, and attitudes of a culturally diverse
population; (b) knowledge component—understanding and knowledge of the worldviews and
cultural contexts of culturally diverse individuals and groups; and (c) skills component—an
ability to determine and use culturally appropriate intervention strategies when working with
different groups in our society. Cultural humility is a key component of cultural competence,
as it serves as the conduit in which awareness, knowledge, and skills are expressed. Box 2.1
provides an outline of cultural competencies related to the three major domains; cultural
humiliation is discussed later.
BOX 2.1 MULTICULTURAL COUNSELING COMPETENCIES
1. Awareness
1. Moved from being culturally unaware to being aware and sensitive to their own
cultural heritage and to valuing and respecting differences.
2. Aware of their own values and biases and of how they may affect diverse clients.
3. Comfortable with differences that exist between themselves and their clients in
terms of race, gender, sexual orientation, and other social identity variables.
Differences are not seen as deviant.
4. Sensitive to circumstances (personal biases; stage of racial, gender, and sexual
orientation identity; sociopolitical influences; etc.) that may dictate referral of
clients to members of their own social identity group(s) or to different therapists in
general.
5. Aware of their own racist, sexist, heterosexist, or other detrimental attitudes,
beliefs, and feelings.
2. Knowledge
1. Knowledgeable and informed on a number of culturally diverse groups, especially
groups with whom therapists work.
2. Knowledgeable about the sociopolitical system's operation in the United States with
respect to its treatment of marginalized groups in society.
3. Possessing specific knowledge and understanding of the generic characteristics of
counseling and therapy.
4. Knowledgeable about the institutional barriers that prevent some diverse clients
from using mental health services.
3. Skills
1. Able to generate a wide variety of verbal and nonverbal helping responses.
2. Able to communicate (send and receive both verbal and nonverbal messages)
accurately and appropriately.
3. Able to exercise institutional intervention skills on behalf of clients, when
appropriate.
4. Able to anticipate the impact of one's helping styles and of their limitations on
culturally diverse clients.
5. Able to play helping roles characterized by an active systemic focus, which leads to
environmental interventions. Not restricted by the conventional counselor/therapist
mode of operation.
Sources: Sue et al. (1992, 1998). Readers are encouraged to review the original 34 multicultural competencies,
which are fully elaborated in both publications.
Third, in a broad sense, this definition is directed toward two levels of cultural competence:
the personal/individual and the organizational/system levels. The work on cultural
competence has generally focused on the micro level: the individual. In the education and
training of psychologists, for example, the goals have been to increase the level of self‐
awareness of trainees (potential biases, values, and assumptions about human behavior); to
impart knowledge of the history, culture, and life experiences of various minority groups; and
to aid in developing culturally appropriate and adaptive interpersonal skills (clinical work,
management, conflict resolution, etc.). Less emphasis is placed on the macro level: the
profession of psychology, organizations, and the society in general (Lum, 2011; Sue, 2001).
We suggest that it does little good to train culturally competent helping professionals when
the very organizations that employ them are monocultural and discourage or even punish
psychologists for using their culturally competent knowledge and skills. If our profession is
interested in the development of cultural competence, then it must become involved in
impacting systemic and societal levels as well.
Fourth, our definition of cultural competence speaks strongly to the development of
alternative helping roles. Much of this comes from recasting healing as involving more than
one‐to‐one therapy. If part of cultural competence involves systemic intervention, then
such roles as consultant, change agent, teacher, and advocate supplement the conventional
role of therapy. In contrast to this role, alternatives are characterized by the following:
Having a more active helping style
Working outside the office (home, institution, or community)
Being focused on changing environmental conditions, as opposed to changing the client
Viewing the client as encountering problems rather than as having a problem
Being oriented toward prevention rather than remediation
Shouldering increased responsibility for determining the course and the outcome of the
helping process
It is clear that these alternative roles and their underlying assumptions and practices have not
been historically perceived as activities consistent with counseling and psychotherapy.
Last, cultural competence incorporates an orientation of cultural humility (American
Psychological Association, 2017; Gallardo, 2014). The concept of cultural humility was first
coined in medical education, where it was associated with an open attitudinal stance or a
multicultural open orientation to diverse patients (Tervalon & Murray‐Garcia, 1998). The
term has found its way into the MCT field, where it also refers to an openness to working
with culturally diverse clients (Hook, Davis, Owen, Worthington, & Utsey, 2013; Owen et
al., 2014). As more counselors and psychologists have begun to study cultural humility, it has
become clear that this concept is a “way of being” rather than a “way of doing,” which
characterizes cultural competence (Owen, Tao, Leach, & Rodolfa, 2011). Cultural humility as
an orientation or disposition is thus necessary to facilitate cultural awareness, knowledge, and
skills. A counselor must adopt an open, inquisitive orientation in order to engage in self‐
reflection and to learn from clients and marginalized communities, which are key ingredients
of cultural competence. In a therapeutic context, cultural humility of therapists (a) is
considered very important to many socially marginalized clients, (b) correlates with a higher
likelihood of continuing in treatment, (c) strongly relates to the strength of the therapeutic
alliance, and (d) is related to perceived benefit and improvement in therapy (Hook et al.,
2016). Thus, cultural humility as a dispositional orientation may be equally important as three
major cultural competence domains (awareness, knowledge, and skills) in MCT. We further
discuss the relevance of cultural humility in Chapter 4 and throughout the text.
SOCIAL JUSTICE AND CULTURAL COMPETENCE
Building on the multicultural counseling competencies devised by D. W. Sue et al. (1992),
the American Counseling Association (ACA) developed Multicultural and Social Justice
Counseling Competencies (MSJCC) (Ratts, Singh, Nassar‐McMillan, Butler, &
McCullough, 2015). As indicated in Chapter 4, at the heart of the MSJCC is the integration of
social justice competencies with multicultural competencies. Acknowledging that
multiculturalism leads to social justice initiatives and actions, the MSJCC propose a
conceptual framework that includes quadrants (privilege and oppressed statuses), domains
(counselor self‐awareness, client worldview, counseling relationships, and counseling and
advocacy interventions), and competencies (attitudes and beliefs, knowledge, skills, and
action).
Perhaps the most important aspect of the proposed MSJCC is seen in the quadrants category,
where they identify four major relationships between counselor and client that directly
address matters of power and privilege: (a) a privileged counselor working with an oppressed
client, (b) a privileged counselor working with a privileged client, (c) an oppressed counselor
working with a privileged client, and (d) an oppressed counselor working with an oppressed
client. When applied to racial/ethnic counseling/therapy, various combinations can occur: (a)
a White counselor working with a racial or ethnic minority client, (b) a White counselor
working with a White client, (c) a racial or ethnicity minority client working with a White
client, and (d) a racial or ethnic minority counselor working with a racial or ethnic minority
client. Analysis and research regarding these dyadic combinations have seldom been carried
out in the multicultural psychology field. Further, little in the way of addressing counseling
work with interracial/interethnic combinations is seen in the literature. We address this topic
in the next chapter. We will also cover the issues raised in the MSJCC framework more
thoroughly in Chapters 3–5. In Chapter 3, we focus on enumerating the quadrants of power
and privilege relationships between counselor and client, in Chapter 4, we address the
importance of social justice advocacy and action on behalf of the client, and in Chapter 5, we
deal with individual and systems‐level work.
REFLECTION AND DISCUSSION QUESTIONS
1. If the basic building blocks of acquiring cultural competence in clinical practice are
awareness, knowledge, and skills, how do you hope to develop competency? Can you
list the various educational and training activities you would need in order to work
effectively with a client who differed from you in terms of race, gender, or sexual
orientation?
2. What are your thoughts about the basic building blocks of cultural competence? What
are your thoughts regarding cultural humility, especially as a conduit to developing
cultural awareness, knowledge, and skills? How would you define cultural competence?
3. Look at the six characteristics that define alternative roles for helping culturally diverse
clients. Which of these roles are you most comfortable playing? Why? Which of these
activities would make you uncomfortable? Why?
IMPLICATIONS FOR CLINICAL PRACTICE
1. Know that the definition of multiculturalism is inclusive and encompasses race, culture,
gender, religious affiliation, sexual orientation, age, disability, and so on.
2. When working with diverse populations, attempt to identify culture‐specific and
culture‐universal domains of helping.
3. Be aware that persons of color, LGBTQ people, women, and other groups may perceive
mental illness/health and the healing process differently than do EuroAmerican men.
4. Do not disregard differences and impose the conventional helping role and process on
culturally diverse groups, as such actions may constitute cultural oppression.
5. Be aware that EuroAmerican healing standards originate from a cultural context and
may be culture‐bound. As long as counselors and therapists continue to view
EuroAmerican standards as normative, they may judge others as abnormal.
6. Realize that the concept of cultural competence is more inclusive and superordinate than
is the traditional definition of clinical competence. Do not fall into the trap of thinking
“good counseling is good counseling.”
7. If you are planning to work with the diversity of clients in our world, you must play
roles other than that of the conventional counselor.
8. Use modalities that are consistent with the lifestyles and cultural systems of your clients,
as well as with your training.
9. Understand that one's multicultural orientation (cultural humility) is very important to
successful multicultural counseling.
Video Lecture: Cultural Competence in the Helping Professions
SUMMARY
Traditional definitions of counseling, therapy, and mental health practice arise from
monocultural and ethnocentric norms that may be antagonistic to the lifestyles and cultural
values of diverse groups. These Western worldviews reflect a belief in the universality of the
human condition, a belief that disorders are similar and cut across societies, and a conviction
that mental health concepts are equally applicable across all populations and disorders. These
worldviews also often fail to consider the different cultural and sociopolitical experiences of
marginalized group members. As a result, counseling and therapy may often be inappropriate
to marginalized groups in our society, resulting in cultural oppression. The movement to
redefine counseling/therapy and identify aspects of cultural competence in mental health
practice has been advocated by nearly all multicultural counseling specialists.
MCT is defined as both a helping role and a process that uses modalities and defines goals
consistent with the life experiences and cultural values of clients; that recognizes client
identities to include individual, group, and universal dimensions; that advocates the use of
universal and culture‐specific strategies and roles in the healing process; and that balances
the importance of individualism and collectivism in the assessment, diagnosis, and treatment
of clients and client systems. Thus, cultural competence is the ability to engage in actions or
create conditions that maximize the optimal development of clients and client systems.
On a personal developmental level, multicultural counseling competence is defined as a
counselor's acquisition of the awareness, knowledge, and skills and the cultural humility
needed to function effectively in a pluralistic democratic society (ability to communicate,
interact, negotiate, and intervene on behalf of clients from diverse backgrounds); on an
organizational/societal level, it is defined as advocating effectively to develop new theories,
practices, policies, and organizational structures that are more responsive to all groups.
Another attribute, cultural humility, seems central to effective multicultural counseling.
Cultural humility appears more like a “way of being” than a “way of doing.” The attitudinal
components of respect for others, an egalitarian stance, and diminished superiority over
clients mean an “other‐orientation” rather than a self‐focus. Finally, it appears that there is
a strong need to integrate social justice competencies with cultural competence. Becoming
culturally competent is a lifelong journey but promises much in providing culturally
appropriate services to all groups in our society.
GLOSSARY TERMS
Awareness
Collectivism
Cultural competence
Cultural humility
Cultural relativism
Culturally responsive
Culture bound syndromes
Emic (culturally specific)
Etic (culturally universal)
Group level of identity
Individual level of identity
Knowledge
Multicultural counseling and therapy (MCT)
Multiculturalism
Skills
Social justice
Universal level of identity
Worldview
Video 2.10: Counseling Session Analysis
Introduction to the counseling session.
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3
Multicultural Counseling Competence for Counselors and
Therapists of Marginalized Groups
Chapter Objectives
1. 1. Learn the importance of cultural competence and cultural humility for trainees
of color, and other marginalized group trainees.
2. 2. Identify the major obstacles that prevent honest dialogue between and among
groups of color and other socially marginalized group members.
3. 3. Describe the common stereotypes that people of color have toward one another.
4. 4. Learn how the historical relationships between groups of color affect their
current attitudes toward one another.
5. 5. Identify group differences that may serve as barriers to multicultural counseling.
6. 6. Become aware of how attitudes and beliefs between groups of color can interfere
with interracial and interethnic counseling.
7. 7. Identify therapeutic barriers likely to arise between a counselor of color and a
White client.
8. 8. Identify therapeutic barriers likely to arise between a counselor of color and a
client of color.
As a professor of color who has taught many courses on multicultural counseling and therapy
(MCT) and conducted numerous workshops on race relations, I [Derald Sue] have always
been aware that my teaching and training were primarily directed at educating White trainees
and counselors to their own biases and assumptions about human behavior. I operated from
the assumption that people of color knew much of the material on oppression, discrimination,
and stereotyping. After all, I reasoned, we were members of the oppressed group and had
experiential knowledge of how racism harmed us.
Additionally, there is legitimacy as to why greater emphasis has been placed on the education
of White trainees: (a) the majority of counseling and mental health providers are White or
members of the majority group; (b) the theories and practices of counseling/therapy arise
from a predominantly White, Western perspective and form the educational foundations of
our graduate programs; and (c) White, male, and straight EuroAmericans continue to control
and hold power in being able to determine the definitions of normality and abnormality and to
define mental health reality for marginalized groups. Even if counselors and therapists of
color work with other culturally diverse groups, they are generally educated in White,
Western ways of describing, explaining, diagnosing, and treating mental disorders. Thus,
there is great justification for continuing to focus primarily upon the education and training of
those who control the gateways to the delivery of mental health services to socially devalued
client populations.
Yet, even in the face of these legitimate reasons, in the back of my mind, I knew that I was
shortchanging my trainees of color. I knew that although they most likely had experiential
knowledge about the harms of racism, they had biases and prejudices toward one another. I
also knew that oftentimes their strong negative reactions toward White fellow students (albeit
often justified) could prevent their development toward cultural competence (Ratts &
Pedersen, 2014). I understood that much of my trepidation in addressing interracial and
interethnic relations had to do with presenting a united front among people of color, and I
erroneously operated from a “common enemy” perspective (Sue, 2015). I recognized that by
taking this stance, I was perpetuating the belief that only Whites needed to change. It was
clear that avoiding broader discussions of interethnic relations blocked the ability of people of
color to more deeply explore their own biased beliefs about their own group and one another.
With this realization, I became more active in addressing these issues in my classes and
workshops, often pushing emotional hot buttons in some participants of color. The following
journal entry made by a former African American student, “Briana,” illustrates this point.
I've been angry at Professor Sue for this whole semester. I wish that they would have
had a Black professor teach the class. How could he possibly have given me a B− in the
midterm [racial counseling lab course]? I'll bet the White students got better grades. As
a Black woman I know racism firsthand. They [White students] don't get it and still get
better grades. And then we have to keep this stupid journal so he [the professor] can
have the TA help us process our feelings. I don't care if you read this stupid journal or
not … I know what I feel and why … Well, I'm angry and furious that you gave me a low
grade … I'm angry at the White students who hide their racism and just say the right
things in class. They are phonies. They are scared to death of me … I just won't put up
with their lies and I don't care if I make them cry …. I'm sure they think I'm just an angry
Black woman …
Why am I not getting an A in the course? I know why. It has to do with our role‐play
last week. The class thought I should have been more empathetic with Sandy [Asian
American female who played the role of a client]. They said I couldn't relate to her and
didn't explore her feelings of discrimination as an Asian. Well, I did. But you can't tell
me that she suffers like Blacks do. I felt like saying … good, now you know what it feels
like!!!! …
Then, Dr. Sue had to stop us from continuing and made process observations. He said I
seemed to have difficulty being empathic with the client and believing her. What does he
know? How does he know what's going on inside my head? But truth be told, Sandy
doesn't have anything to complain or whine about. She doesn't understand what
discrimination really is … maybe she has been treated poorly … but … but … well, I
don't consider Asians people of color anyway. How can they claim to be oppressed when
they are so successful? On this campus, they are everywhere, taking slots away from us.
Sometimes I think they are whiter than Whites. I'll probably get an even worst grade
because of what I'm saying, but who cares.
Video 3.0: Introduction
Select the video link to view an introduction to the counseling session by Dr. Joel Filmore.
INTERRACIAL AND INTERETHNIC BIASES
It took much class time and several individual meetings to finally get the student to begin
examining her reactions to White students and her images and prejudices toward Asians and
Asian Americans. I [Derald Sue] tried to focus the discussion on the meaning of her extreme
reactions to other group members and what significance it would have if they were her
clients. Although the student did not change significantly because of her classroom
experience, the lessons that came out from that role‐play provided an opportunity for the
entire class to enter a discussion of interracial and interethnic counseling topics. Some
important themes are the following.
IMPACT ON INTERRACIAL COUNSELING RELATIONSHIPS
First, we must contextualize Briana's views and her strong feelings of anger, resentment, and
bitterness. It is important to understand and be empathic to the fact that these reactions are
most likely the result of cumulative years of prejudice and discrimination directed toward her
as a socially devalued group member (Parham, Ajamu, & White, 2011; Ridley, 2005); these
experiences also might be compounded by other life traumas. Is Briana justified in her anger?
The answer is probably “yes.” But is her anger and bitterness misdirected and likely to cause
her difficulty in working with Asian American and White clients? Again, the answer is
probably “yes.”
In working with White clients, members of oppressed groups might (a) be unable to contain
their anger and rage toward their clients, as they view them as the oppressor, especially those
with relative privilege; (b) have difficulty understanding the worldview of their clients; (c) be
hindered in their ability to establish rapport with their clients; (d) have difficulty empathizing
with their clients; and (e) be guilty of imposing their racial realities upon their clients. The
following quote illustrates the complexity of this type of dilemma.
The challenge for me lately has been empathizing with my male clients who have been
triggered by the #MeToo campaign. They—mostly White heterosexual males—are
coming into therapy and wanting to process their anxieties about whether they may be
guilty of sexually harassing women in the past. I am having a hard time being patient
and empathic listening to their stories. (Latino male therapist)
STEREOTYPES HELD BY SOCIALLY MARGINALIZED GROUP
MEMBERS
Second, Briana possesses many stereotypes and inaccurate beliefs about Asian Americans.
She seems to operate from the assumptions that Asian Americans “are not people of color,”
that they know little about racism and discrimination, and that they are like Whites. These
statements and her desire that a Black professor should teach the course rather than an Asian
American reflect these beliefs. As you will see in Chapter 16, headlines in the national press
such as “Asian Americans: Outwhiting Whites” and “Asian Americans: The Model Minority”
have perpetuated the success myth and belief that Asians are a “model minority” and
somehow immune to prejudice and racism (Kiang, Huynh, Cheah, Wang, & Yoshikawa,
2017; Sue, 2010b).
These false stereotypes of Asian Americans and of African Americans have often played into
major misunderstandings and conflicts between these communities (Kim & Park, 2013). The
issue here is the stereotypes that various racial and ethnic groups hold toward one another.
For example, in one study, it was found that more than 40% of African Americans and
Hispanics believe that Asian Americans are unscrupulous, crafty, and devious in business
(National Conference of Christians and Jews, 1994). How do these beliefs affect interethnic
relations, and how do they affect the counseling/therapy process? No racial or ethnic group is
immune from inheriting biased beliefs, misinformation, and stereotypes of other groups. This
is a reality often not discussed in courses on diversity and multiculturalism.
THE WHO‐IS‐MORE‐OPPRESSED GAME
Third, we have some flavor of the “who's more oppressed?” trap being played out in Briana's
narrative. She believes that Sandy can in no way equate her experiences of discrimination and
prejudice with the Black experience. And perhaps she is right! There is little doubt that a
racial hierarchy exists in our society in which various groups can be ordered along a
continuum. The fact that African Americans have historically been and continue to be in the
national forefront of the civil rights debate must be acknowledged and appreciated by all.
There is also, however, little doubt that each group—Native American, African American,
Latinx American, and Asian American—can claim that it has suffered immensely from
racism. What we need to realize is that all oppression is damaging, whether experienced
through occupation and genocide, slavery, labor exploitation on railroads and plantations,
internment camps, or in some other form. Even today, the plurality of people of color report
being discriminated against in public and private spaces, including in their interactions with
police and in applying for jobs (Neel, 2017a, 2017b). The lack of understanding and respect
for our unique histories and contemporary experiences serve to separate rather than unify.
Playing the “who's more oppressed?” game is destructive to group unity and
counterproductive to combating racism. If we understand our own group's oppression,
shouldn't it be easier to recognize the oppression of another? To use one group's oppression to
negate that of another group is to diminish, dismiss, or negate the claims of another. This
leads to separation rather than mutual understanding.
COUNSELORS FROM MARGINALIZED GROUPS WORKING WITH
MAJORITY AND OTHER MARGINALIZED GROUP CLIENTS
Counseling the Culturally Diverse has never shied away from tackling controversial issues
and topics, especially when they are central to the education and training of culturally
competent mental health professionals. Persons of color, for example, have major hesitations
and concerns about publicly airing interracial and interethnic conflicts, differences, and
misunderstandings, because of the possible political ramifications for group unity. But it
appears that cultural competency and cultural humility objectives are equally applicable to
therapists of color and to other clinicians from marginalized groups.
It is clear that all groups can benefit from learning to work with one another. Being a helping
professional or trainee of color does not automatically denote cultural competence in working
with other clients of color or with White clients. Being a member of an oppressed or
marginalized group (e.g., a gay man or a woman therapist) does not mean you are more
effective in treating other culturally diverse clients than if you were a straight or male
therapist. It is important to recognize that in the area of racial interactions, MCT is more than
White–Black, White–Asian, or White–Latinx. To be a truly multicultural discipline, we must
also recognize that MCT involves combinations such as Asian–Black, Latinx–Native
American, Black–Latinx, and so on.
The American Counseling Association (ACA) has begun to recognize in their Multicultural
and Social Justice Counseling Competencies (MSJCC) that the dimensions of privilege and
oppressed statuses vary in the therapeutic relationship between counselors and clients (Ratts,
Singh, Nassar‐McMillan, Butler, & McCullough, 2015). Most discussions of multicultural
counseling focus upon White therapists (privileged status) and clients of color (oppressed
status), and little emphasis is placed on other combinations: counselors of color (oppressed
status) working with White clients (privileged status) or counselors of color (oppressed
status) working with clients of color (oppressed status).
REFLECTION AND DISCUSSION QUESTIONS
1. How does a counselor of color work with a White client who expresses racist thoughts
and feelings in the therapeutic session? Should he or she confront the client about these
biased attitudes? Is this therapeutic?
2. What biases and prejudices do people of color have toward one another?
3. What advantages and disadvantages do you foresee in counselors of color working with
people of color from a different racial or ethnic background than the one(s) to which
they belong?
Video 3.1 Cultural Competence and Marginalized Groups
Awareness of cultural competence as a universal necessity in counseling and not just a
majority requirement.
We address these issues from a number of perspectives: sociopolitical group relationships,
cultural differences, racial identity attitudes, and practice implications. We start with the
assumption that people in the United States, regardless of race and ethnicity, are exposed to
the racial, gender, and sexual orientation socialization processes of this society and also
inherit racial, gender, and sexual orientation biases about various populations. We focus
primarily on racial/ethnic combinations, but similar analyses using gender, sexual orientation,
disability, social class, and other combinations are also important to consider. We are hopeful
that these other relationships may be explored further in your classes and workshops.
THE POLITICS OF INTERETHNIC AND INTERRACIAL BIAS AND
DISCRIMINATION
People of color generally become very wary about discussing interethnic and interracial
misunderstandings and conflicts between various groups for fear that such problems may be
used by those in power to
assuage their own guilt feelings and excuse their racism—“People of color are equally
racist, so why should I change when they can't even get along with one another?”
divide and conquer—“As long as people of color fight among themselves, they can't
form alliances to confront the establishment,” and
divert attention away from the injustices of society by defining problems as residing
between various racial minority groups.
Further, readers must understand that prejudice toward other groups occurs under an umbrella
of White racial superiority and supremacy; although members of socially devalued groups
may discriminate, they do not have the systemic power to oppress on a large‐scale basis
(Steinberg, 2007; Sue, 2015). In other words, although they may be able to hurt one another
on an individual basis and to individually discriminate against White Americans, they possess
little power to cause systemic harm, especially to White Americans. Some people of color
have even suggested that interethnic prejudice among minorities serves to benefit only those
in power.
As a result, people of color are sometimes cautioned not to “air dirty laundry in public.” This
admonition speaks realistically to the existence of miscommunications, disagreements,
misunderstandings, and potential conflicts between and among groups of color. When they
constituted a small percentage of the population, it was to their advantage to become allies in
a united front against sources of injustice. Avoiding or minimizing interethnic group
differences and conflicts served a functional purpose: to allow them to form coalitions of
political, economic, and social power to effect changes in society. Although this solidarity
may have been historically beneficial on a political and systemic level, the downside has been
neglected in dealing with interracial differences that have proven to become problematic.
This issue is even more pressing when, for example, one considers that people of color are
rapidly becoming the numerical majority. In 2020, more than half of the children in the
United States will be a person of color (U.S. Census Bureau, 2015), and the number of
majority minority states and cities is growing—so much so that most estimates indicate that
by 2050, people of color will be the majority in the United States as a whole (U.S. Census
Bureau, 2012).
As the United States becomes more diverse and people of color are placed in close proximity
to and often pitted against one another through a system of White supremacy, a pattern of
misunderstandings and mistrust emerges. In the early 1990s, the racial discourse in urban
America was dominated by African American boycotts of Korean mom‐and‐pop grocery
stores, which was followed by looting, firebombing, and mayhem that engulfed Los Angeles
(Chang, 2001). Many in the Black community felt that Koreans were exploiting their
communities as had White businesses. Instances of Hispanic and Black conflicts in the inner
cities have also been reported throughout the country. As Latinx individuals have surpassed
Blacks in numbers, they have increasingly demanded a greater voice in communities and in
the political process. Since Latinx and Black individuals tend to gravitate toward the same
inner‐city areas and compete for the same jobs, great resentment has grown between the
groups (Wood, 2006).
In essence, the discourse of race that once was confined to Black–White relations has become
increasingly multiethnic and multiracial. It is not surprising that most Americans believe that
race relations have worsened with the election of Donald Trump as President of the United
States and that there was a significant increase in Blacks' and Latinx' perception of race
relations getting worse between 2016 and 2017 (Pew Research Center, 2017). Several
national surveys (Jones, 2013a, 2013b; National Conference of Christians and Jews, 1994;
Pew Research Center, 2008, 2012) have found the following:
More than 40% of African Americans and Hispanics, and one of every four Whites,
believe that Asian Americans are “unscrupulous, crafty, and devious in business.”
Nearly half the Hispanic Americans surveyed and 40% of African Americans and
Whites believe Muslims “belong to a religion that condones or supports terrorism.”
Blacks think they are treated far worse than Whites and worse than other minority
groups when it comes to getting equal treatment in applying for mortgages, in the media,
and in job promotions.
Although an overwhelming number of people rate racial/ethnic relations between racial
group combinations as positive, the most favorable ratings are Whites–Asians (80%),
with Blacks–Hispanics in last place.
Nearly 50% of African Americans believe Latinx immigrants reduce job opportunities
for them, while fewer than 40% of Latinx Americans agree.
Approximately 70% of Asian Americans rate their relations with Hispanics as good, and
60% say that of Blacks. Interestingly, and consistent with our earlier analysis, 50% of
Korean Americans have negative views of their relations with Blacks.
Only 10% of African Americans—a staggeringly low number—believe the police treat
them as fairly as other groups.
There is tremendous resentment of Whites by all minority groups.
Two‐thirds of minorities think Whites “believe they are superior and can boss people
around,” “are insensitive to other people,” “control power and wealth in America,” and
“do not want to share it with non‐Whites.”
Three primary conclusions are noteworthy here: First, racial/ethnic groups harbor
considerable mistrust, envy, and misunderstandings toward one another. Surprisingly, African
Americans and Latinx Americans held stronger negative beliefs about Asian Americans than
did White Americans (40% versus 25%). Second, and not surprisingly, people of color
continue to hold beliefs and attitudes toward Whites that are very negative and filled with
resentment, anger, and strong mistrust. Third, dialogue between people of color must come
out of the closet in order to make important and long‐lasting progress toward mutual respect
and understanding, rather than a relationship simply based upon political convenience.
REFLECTION AND DISCUSSION QUESTIONS
1. What effect does interracial or interethnic bias on the part of therapists of color have
upon their culturally diverse clients?
2. Think of an interracial or interethnic people of color dyad (for example, African
American therapist and Korean American client). What therapeutic issues are likely to
arise in the dyad you selected?
3. Likewise, in light of the strong negative feelings expressed by all groups of color against
Whites, how might a therapist of color react intentionally and unintentionally toward a
White client?
Some might argue that a therapist of color working with a White client might be different
from a therapist of color working with a client of color because power differentials still exist
on a systemic level for White clients. Little in the way of research or conceptual scholarly
contributions has addressed these issues. It may not be far‐fetched, however, to surmise that
these racial combinations may share some similar dynamics and clinical issues to White
therapist/client of color dyads. Some increased understanding of these issues may come from
a brief review of the historical analysis of interracial and interethnic relationships between
groups of color in other venues of their lives.
Video 3.2 Roadblocks and Resistance
How transference and countertransference can negatively impact the counseling relationship.
THE HISTORICAL AND POLITICAL RELATIONSHIPS BETWEEN
GROUPS OF COLOR
There is a paucity of literature that focuses specifically on interracial interactions between
counselors and clients of different racial/ethnic minority groups (e.g., Asian, Black, Latinx, or
American Indian). This may falsely convey that there is limited tension between groups of
color and that discrimination and stereotyping does not occur between these groups. Given
the history of the United States, it is apparent that discrimination and stereotyping does occur
between all racial groups.
During the civil rights movement, people of color banded together to combat economic and
social injustices that were against them. As a result, people of color have avoided public
dialogue (on both individual and group levels) about historical and existing tensions among
their groups. Because individuals of color have experienced racism throughout their lives, it
may prove difficult for them to understand the biases they hold toward other groups. Some
people of color believe that they would not be able to discriminate, stereotype, or pass
judgment on others because they themselves have been racially victimized. Other people of
color may recognize their biases but believe that because they do not have any systemic
power, these biases are excusable or insignificant. Regardless of these perspectives,
examining the history of interracial and interethnic relations may prove enlightening.
African Americans and Asian Americans
The conflicting relationships between African Americans and Asian Americans remained
relatively unspoken until the Los Angeles Riots in 1992, in which some Black Americans
looted Korean American businesses. The tensions were brewing for quite a long time, but
came to a head with the killing of 15‐year‐old LaTasha Harlins, who was shot in the head
by a Korean storeowner for allegedly stealing a carton of milk in 1991. The riot occurred
when African Americans became outraged by the years of perceived injustices symbolized by
the acquittal of four White officers from the Los Angeles Police Department in the beating of
Rodney King, a Black motorist. Of the 4,500 stores that were looted and burned, however,
2,300 were Korean‐owned (Yoon, 1997). Although hard feelings existed prior to the riots,
this experience led to overt tension between the groups throughout the United States (Kim,
1999).
In interviews with several Korean American business owners, it was clear that they
stereotyped Black American customers as likely to steal or become violent; likewise, some
Black Americans who acted out against Korean businesses stereotyped Asian Americans as
being racist and hostile toward them and thought that they took economic advantage of their
communities. This may have even led to overt racist behaviors between the groups, with
Asian American store owners blatantly refusing business from Black American patrons or
following them around their stores, and Black Americans blatantly using racial slurs such as
“Chinaman” and “chink” when speaking to Korean workers (Myers, 2001).
Asian Americans and Latinx Americans
The historical relationship between Asian Americans and Latinx Americans is almost never
discussed and is usually invisible in discussions of race (De Genova, 2006). However, there
are several ways in which these two groups may share a sense of camaraderie with one
another, along with divisive tension. Both groups share the experience of immigration; the
majority of Asian Americans and Latinx Americans are first‐ or second‐generation
Americans (De Genova, 2006; Kim, 2011). This shared history may lead to similar
experiences of biculturalism (maintaining both Asian or Latinx and American values) and
culture conflicts, similar linguistic concerns (bilingualism), and similar experiences of
pursuing the American dream. One of the dominant similarities between the two groups is
their shared experience of being treated like foreigners in their own country (particularly
those who were born and raised in the United States); another is that both groups are often
left out of the Black–White racial paradigm debate.
When issues or matters of race are discussed in the news media, for example, the dialogue is
usually Black–White and seldom includes Asian Americans or Latinx Americans. This
invisibility as groups of color in the racial debate has often created hard feelings in these two
groups toward African Americans. Because these groups can feel invisible, they may compete
with each other in order to have their voices heard. Historically, there was a moment, during
the Chicano‐Filipino United Farm Workers Movement in the 1930s, in which Mexican and
Filipino Americans worked cohesively for farm workers' rights in California. Yet, they
disbanded when the two groups could not agree upon common interests (Scharlin &
Villanueva, 1994). Currently, this may be exemplified in U.S. politics, in which Asian and
Latinx Americans may run against each other in local elections instead of working
harmoniously to form a unified alliance.
Latinx Americans and Black Americans
The history between Latinx Americans and Black Americans also has both solidarity and
discord. Historically, there has been solidarity between the two groups, particularly in their
quest for equality during the civil rights era (Behnken, 2011). Traditionally, both groups
recognized each other as oppressed minority groups, understanding that the other may
experience racism, be subjected to widespread stereotyping, and be denied equal access and
opportunities to White people. However, there are also points of contention between these
two groups.
First, similar to the relationships between Asian and Latinx Americans, there may be tension
between Latinx and Black Americans as a result of each group fighting for its own
sociopolitical issues and needs. In recent years, Latinx Americans have overwhelmingly
exceeded Black Americans in regard to population; this has led to Latinx Americans gaining
more visibility in politics and education (Wood, 2006). The rise of Latinx demands has also
created tension amongst Latinx and Black Americans because they now find themselves
competing for jobs, which has forced some Black Americans to oppose many Latinx
Americans in the immigration debate (Behnken, 2011). This competition for jobs has often
resulted in problems related to a lack of alliance between the two groups, particularly when it
comes to advocacy in government, education, and community organizing (Samad et al.,
2006).
Second, it is important to recognize that racism within the Latinx community has historical
roots as a result of Spanish colonialism in Latin America. The term Latinx is an ethnic
designator and not a racial one. Hence, Latinx people may be members of any racial
grouping. As a result, they may range phenotypically from Black to White, with many
appearing to be somewhere in between (Bautista, 2003). However, because of the colonial
mentality, mestizos, or light‐skinned Latinx people, are valued more highly than darker‐
skinned Latinx people, who may be viewed as inferior, unintelligent, or unattractive
(colorism) (Adames, Chavez‐Dueñas, & Organista, 2016). This may lead to a hierarchy
within the Latinx community, in which light‐skinned groups, such as Argentineans,
Colombians, and Cubans, may view themselves as superior to darker‐skinned groups, such
as Dominicans and Mexicans. This colonial mentality may transcend a Latinx individual's
view of a Black American; this observation is supported by studies showing that Latinx
Americans hold negative stereotypes of Black Americans as being lazy and untrustworthy,
whereas Black Americans do not feel the same way about Latinx Americans (McClain et al.,
2006).
American Indians and Black, Latinx, and Asian Americans
The relationship between American Indians and Black, Latinx, and Asian Americans may not
be discussed or known, due to the small numbers of American Indians in the United States.
Black, Latinx, and Asian Americans may have little interaction with American Indians, which
may lead to less obvious tensions or dynamics between American Indians and another racial
group. Concurrently, because 40% of the American Indian population may be of mixed racial
background (U.S. Census Bureau, 2005), many American Indians may physically look like
members of other racial groups, causing others to perceive them and treat them in different
ways. However, an American Indian interacting with members of these racial groups may
share similarities or experience tensions with individuals of other races, perhaps empathizing
with a Black American's experiences of oppression or bonding with a Latinx or Asian
American's feelings of being an invisible minority. At the same time, a Black, Latinx, or
Asian American individual who does not recognize the American Indian's racial identity,
realities, history, or experiences may cause the American Indian to feel dismissed, ignored, or
invalidated.
Video 3.3 Biases and Belief Systems
Historical biases and their impact on our beliefs, both consciously and unconsciously, within
the counseling session.
DIFFERENCES BETWEEN RACIAL/ETHNIC GROUPS
To further understand interracial and interethnic dynamics, it is important to recognize that
groups of color may hold values, beliefs, and behaviors unique to their cultures. Many of
these differences in cultural values are addressed in Chapter 7. Specifically, previous
literature has found that racial/ethnic groups have differences in worldviews and
communication styles. These groups may have different views of therapy, based on cultural
stigma and the group's historical experiences with mental health institutions. Knowledge of
these cultural differences may aid mental health practitioners to better understand the types of
dynamics that occur in a therapeutic relationship. Let us explore a few of these differences.
Cultural Values
Shared and nonshared values held by groups of color may lead to an experience of
camaraderie or to one of tension and antagonism. For example, although many White
Americans typically believe that people have mastery and control over the environment,
persons of color typically believe that people and nature are harmonious with one another
(Chen, 2005; McCormick, 2005). Additionally, whereas Whites adhere to the value of
individualism, Asian, Native, Black, and Latinx Americans may maintain the values of
collectivism, in which the needs of the group/family/community are paramount. Within
collectivism, emphasis is placed on the family, what Latinx people call familialism or
familismo; a high value is placed on family loyalty and unity (Arredondo, Gallardo‐Cooper,
Delgado‐Romero, & Zapata, 2014; Guzman & Carrasco, 2011). If a Latinx counselor
ascribes to familismo and works with a client of color who does not place the same central
importance on the family, the counselor may inadvertently interpret this person to be
emotionally disconnected and isolated.
Although sharing a cultural value may lead to a therapeutic working relationship between two
different individuals of color, its expression may potentially cause a misunderstanding in
therapy as well. For example, respect for elders is a value traditionally held by people of color
(Evans, 2013; Kim & Park, 2013). However, expression of this value may differ among
members of different racial groups. In some Asian American and American Indian cultures,
respect is shown by not talking unless spoken to and by averting one's eyes and thus not
making direct eye contact with the elder or respected person (Nadal, 2011). An African
American counselor may misinterpret an avoidance of eye contact by an American Indian
client to be a sign of disrespect, avoidance, or disengagement.
Communication Styles
The previous examples lead to our discussion of differences in communication styles between
various racial/ethnic groups. Communication style differences (see Chapter 8) displayed by
therapists can impact the expectations or responsiveness of clients from different
backgrounds. American Indians, for example, are more likely to speak softly, use an indirect
gaze, and interject less frequently, whereas White Americans are more likely to speak louder,
have direct eye contact, and show a direct approach (Duran, 2006). These same
characteristics may be displayed by therapists when they interact with clients. Hence,
therapists need to be aware of their verbal and nonverbal styles and to determine how they
may either facilitate or act as a barrier to the formation of a therapeutic alliance.
Communication styles may include overt verbal communication that may occur between two
people (the content of what is said), but may also include nonverbal communication (body
language, tone of voice, volume of speech, what is not said, and the directness of speech),
which is equally as important as the spoken word. African American communication style
tends to be direct, passionate, and forthright (an indication of sincerity and truthfulness)
(Kochman, 1981; Parham et al., 2011). However, Asian cultures highly prize subtlety and
indirectness in communication, as it is considered a sign of respect to the person one is
talking to (Kim, 2011). Even when disagreements are present, differences are discussed
tactfully, avoiding direct confrontation.
American Indians and Latinx Americans may be nonconfrontational like Asian Americans,
but their communication styles may change depending on the varying levels of authority
between the people involved (Garrett & Portman, 2011). For example, Latinx children are
expected to respect their parents, to speak only when spoken to, to have younger siblings
defer to older ones, and to yield to the wishes of someone with higher status and authority.
Latinx students, thus, may feel uncomfortable challenging or speaking directly to their
teachers (Santiago‐Rivera, Arredondo, & Gallardo‐Cooper, 2002). This value may also
conflict with the White American value of egalitarianism, where children are encouraged to
freely express their thoughts and feelings. Although African American communication styles
may be egalitarian as well, they are likely to be more animated and interpersonal, generating
affect and feeling (Hecht, Jackson, & Ribeau, 2002; Weber, 1985). Given this, if an African
American counselor communicates in a more animated and passionate fashion, it may
negatively impact the willingness of Latinx or Asian American clients to open up in therapy.
Issues Regarding Stage of Ethnic Identity
The processes of assimilation and acculturation for various racial and ethnic minority groups
in the United States are powerful forces in the development of identity. Studies continue to
indicate that as groups of color are exposed to the values, beliefs, and standards of the larger
society, many become increasingly Westernized. This process is described more fully in
Chapter 11, so we will not elaborate here. People of color who are born and raised in the
United States may continue to value their traditional racial/ethnic group heritage, actively
reject it in favor of an “American identity,” or form an integrated new identity. Depending on
where they fall on this continuum, their reactions to other people of color (both within and
outside their own group) and to majority individuals may differ considerably. The stage of
identity of ethnic minority therapists is likely to affect their work with clients.
Video 3.4 Differences Don't Have to Be Detrimental
Client and therapist differences as a way to enrich the conversation instead of hindering or
blocking rapport.
COUNSELORS OF COLOR AND DYADIC COMBINATIONS
The analysis in this chapter indicates how important sociopolitical factors, historical
relationships between racial and ethnic minority groups, differences in cultural values, and
the racial identity of counselors and clients can serve either to enhance or to undermine the
counseling process (Comas‐Diaz & Jacobsen, 1995; Greenberg, Vinjamuri, Williams‐
Gray, & Senreich, 2017; Ratts & Pedersen, 2014). Little actual research has been conducted
on the challenges and difficulties that counselors of color face when working with other
culturally diverse groups. Less yet has been done on the subject of cultural competence as it
relates to therapists of color. Nevertheless, the foregoing analysis would imply several
situational challenges that therapists and trainees of color might expect on their journey to
cultural competence. Table 3.1 outlines five common challenges therapists of color encounter
as they work with White clients and five for working with clients of color.
TABLE 3.1 Ten Common Challenges Counselors of Color Face When Working with
White Clients and Clients of Color
Counselor of color and White client dyads
1. Challenging the competency of counselors of color
2. Needing to prove competence
3. Transferring racial animosity toward White clients
4. Viewing the counselor of color as a super minority therapist
5. Dealing with client expressions of racism
Counselor of color and client of color dyads
1. Overidentifying with the client
2. Encountering clashes in cultural values
3. Experiencing clashes in communication and counseling styles
4. Receiving and expressing racial animosity
5. Dealing with the racial identity status of the client or counselor
Challenges Associated with Counselor of Color and White Client Dyads
When working with White clients, a counselor of color is likely to operate in a situation of
power reversal (Comas‐Diaz, 2012; Comas‐Diaz & Jacobsen, 1995). When the counselor
is White and the client is a person of color, the power relationship is congruent with historical
and sociopolitical racial roles and structures in our society. The roles of colonizer–colonized,
master–slave, and oppressor–oppressed have defined relationships of who are leaders and
followers, who is superior and inferior, and who is given higher or lower status (Ratts &
Pedersen, 2014). When the counselor is a person of color, however, it fosters a role reversal,
because the status of therapist denotes a person who possesses a set of expertise that
surpasses that of the White client. In this case, the White client is in need of help, and the
counselor of color is in a position to provide it (to diagnose, treat, advise, teach, and guide).
Many White clients may find this dependent role very disturbing and manifest it in various
ways. Some may, however, find the new relationship exotic or even a positive development.
Counselors of color may also misuse the power reversal to harm or to deny appropriate help
to their White clients.
Situation 1: Challenging the Competency of Counselors of Color
Whether White clients are conscious of it or not, they may directly or indirectly engage in
maneuvers that challenge the credibility of the counselor of color, question the counselor's
competence, negate the counselor's insights and advice, and undermine the therapeutic
process (Sue, 2010a). Such challenges are not necessarily conscious to the client or expressed
overtly. They may be manifested through an excessive interest in seeking greater information
about the counselor's training and background, types of degree received, place of training,
and number of years in clinical practice. Or, they may be expressed through a tendency to be
hypercritical of even the smallest omissions, oversights, and mistakes of the counselor.
Behind these resistant behaviors is a presumption that therapists of color are less qualified
than White ones—that therapists of color achieved their positions not through their own
internal attributes (intelligence and abilities) or efforts (motivation and actions) but through
external circumstance, such as attending lesser qualified schools or being recipients of
affirmative action programs. A study exploring both White and African American therapists'
experiences in working with White clients supports these observations. Ethnic minority
therapists consistently reported being the recipient of greater hostility, resistance, and mistrust
in cross‐racial practice than their White counterparts (Davis & Gelsomino, 1994).
For counselors of color, there are no easy answers or solutions to dealing with challenges to
their credibility. A decision to explore or confront a White client's resistance to the counselor
of color depends on many internal and contextual factors: (a) the counselor of color's comfort
with his or her racial/ethnic identity, (b) the clinical significance of the behavior, (c) the
timeliness of the intervention, (d) the strength of the relationship, and (e) the form in which
the intervention would take place. Regardless, several overarching guidelines may prove
helpful here. First and foremost, a challenge to one's competence is not a pleasant thing,
especially if it is tinged with racial overtones, especially for new counselors. Although the
counselor may become upset with the client, become defensive, and allow the defensiveness
to dictate actions in the therapeutic session, these reactions are counterproductive to helping
the client. Second, before an effective intervention can take place, a counselor must recognize
the resistance for what it is. This means an accurate diagnosis separating out behaviors such
as questioning one's qualifications from other clinical motivations. Third, a decision to
intervene must be dictated by timeliness: it should occur at an opportune time that will
maximize the insight of the client. Last, as the therapist of color will need to address racial
issues, he or she must feel comfortable with engaging in a difficult dialogue on race.
Situation 2: Needing to Prove Competence
The fact that some Whites may consciously and unconsciously harbor beliefs that persons of
color are less capable than Whites may affect counselors of color; the counselors may
internalize these beliefs and stereotypes about themselves and their own group. In such cases,
counselors of color may be trapped in the need to prove their competence and capabilities;
unfortunately, this proof must come from White society, other White helping professionals,
and even White clients. In the counseling session, this type of conflict may be played out in
seeking affirmation from White clients and in the counselor abdicating their role as expert in
the relationship. Counselors of color may also have a disinclination to see clients of color
because it may bring to mind their own internalized racism and create discomfort for them. In
such instances, they may be paralyzed in discussing racial dynamics, experience extreme
anxiety when racial issues arise, and allow their clients to take the lead in the sessions.
Alternatively, some counselors may overcompensate by talking too much in an attempt to
demonstrate to the client that they are knowledgeable and competent.
Situation 3: Transferring Racial Animosity toward White Clients
This situation is likely to arise through a process of countertransference, where the counselor
of color transfers feelings of resentment, anger, and antagonism toward White society to the
client. In general, the therapist of color is unable to separate out the experiences of racism,
discrimination, and prejudice experienced through years of oppression from their feelings
toward the client. The White client may become a symbol of the inherent mistrust that exists
in majority–minority interpersonal relationships; thus, the counselor/therapist may harbor
negative feelings that infect and distort the counseling relationship. In most cases, these
grudges do not operate at a conscious level, but they are likely to present themselves in
various forms: (a) dismissing or diluting the pain and suffering of the White client, (b) being
unable to form a working alliance, (c) having difficulty in being empathetic to the client's
plight, (d) being ultrasensitive to potential racial slights, (e) distorting or misinterpreting the
client's actions to include a racial motivation, and in rare cases (f) possessing an unconscious
desire to harm rather than help the client. This is potentially a toxic situation and is best
resolved early in clinical training.
Situation 4: Viewing the Counselor of Color as a Super Minority Counselor
It may appear contradictory, but evidence exists, in the form of counselor preference studies
and clinical narratives, that some White clients actually prefer a therapist of color over a
White one (Sue & Sue, 2013). It has been found, for example, that some White college
students indicate a preference for seeing a Black helping professional. The reason behind
such a preference flies in the face of traditional race relations and is difficult to explain. In our
own work with White clients and in speaking to colleagues of color, however, several
possibilities have arisen.
First, many White clients may possess an exaggerated sense of the therapist of color's
qualifications, reasoning that to have achieved the status of therapist must have required a
nearly superhuman effort against the forces of discrimination. The therapist's
accomplishments could have come only from high intelligence, outstanding abilities, and
high motivation. Thus, the therapist of color is seen as immensely superior and likely to better
help the client. Second, many clients, regardless of race, often feel rejected, invalidated,
misunderstood, and put down, and suffer from pangs of inferiority and feelings of
worthlessness. White clients may possess a mistaken notion that a therapist of color (who
him‐ or herself has suffered from racism and stigmatization) may better be able to
sympathize and empathize with them. Third, the therapist of color may be perceived as an
expert on race relations, and some Whites may be consciously or unconsciously attempting to
deal with their own racial attitudes. At times, the White client may be coping either with a
conscious interracial relationship (e.g., dating a person of another race) or with more subtle
unconscious personal dilemmas (e.g., White guilt and issues of privilege).
There is certainly a seductive quality to being perceived in such a favorable light, being
viewed as an expert, and being accorded such high respect. This challenge is particularly
difficult for therapists of color who in their daily lives outside of therapy sessions are not
easily accorded the respect and dignity given to others. Yet, to allow the “super minority
counselor” image to persist is to perpetuate a false illusion of the White client and to
potentially harm therapeutic progress. In this situation, the White client may abdicate
responsibility for their own improvements and become overly dependent on the counselor for
answers to their problems. Counselors of color need to have a good sense of themselves as
racial, ethnic, and cultural beings and to not fall into the all‐omnipotent trap.
Situation 5: Dealing with Client Expressions of Racism
It goes without saying that counselors/therapists of color often encounter racist, sexist, and
heterosexist statements and reactions from their clients. Whereas many White lesbian, gay,
bisexual, transgender, and queer (LGBTQ) people may remain invisible, people of color
represent a visible racial/ethnic minority with distinguishable physical features. Counselors of
color, through appearance, speech, or other characteristics, generate reactions. These
perceived differences may influence the development of a therapeutic relationship. As Asian
American therapists, we've had clients make statements such as, “I like Chinese food” or
“The Chinese are very smart and family‐oriented,” or exhibit some discomfort when
meeting us for the first time. In one study (Fuertes & Gelso, 2000), male Hispanic counselors
who spoke with a Spanish accent were rated lower in expertise by EuroAmerican students
than those counselors without an accent. This phenomenon may also exist for therapists with
other accents and may need to be discussed in therapy to allay anxiety in both the therapist
and the client. One graduate student from Bosnia would discuss her accent and would let
clients know that English was her second language. Although her command of English was
good, this explanation helped establish a more collaborative relationship.
Acknowledging differences or investigating the reasons for client reactions is important, since
they may affect the therapeutic process. In one instance, an American Indian psychology
intern working with a woman in her 40s noticed that upon learning she was American Indian,
the client began to tell stories about her daughter being “part Native.” After one such story,
the client asked, “What special power do you have?; My daughter has extra‐ordinary
hearing.” Without missing a beat, the intern matter‐of‐factly responded to the question.
This led to a discussion of client concerns that she was being judged for her “Whiteness” and
also about what it meant to have a younger American Indian woman therapist.
White counselors facing an ethnic minority client often struggle with whether to ask, “How
do you feel working with a White helping professional?” This situation is also faced by
counselors of color working with White clients. When differences between therapist and
client are apparent (e.g., ethnicity, gender, ability, age) or revealed (e.g., religion, sexual
orientation), acknowledging them is important (Zane & Ku, 2014). Culturally responsive
counselors are encouraged to broach the topic of race, ethnicity, and culture during therapy
(Day‐Vines et al., 2007). Broaching these issues can strengthen the working relationship.
Both African American and White American students revealed a preference for openness and
self‐disclosure when asked to imagine a counselor of a different ethnicity (Cashwell,
Shcherbakova, & Cashwell, 2003). Self‐disclosure, or the acknowledgment of differences,
may increase feelings of similarity between therapist and client and reduce concerns about
differences. The same applies when both therapist and client are persons of color but are from
different racial or ethnic groups (Sanchez, del Prado, & Davis, 2010).
Challenges Associated with Counselor of Color and Client of Color Dyads
Many of the challenges facing therapists of color working with White clients can also make
their appearance in counseling dyads where both are from marginalized groups. Like their
White counterparts, people of color are socialized into the dominant values and beliefs of the
larger society. As a result, they may inherit perceptions and beliefs about other racial/ethnic
minority groups. In this case, the biases and stereotypes held about other groups of color may
not be all that different from those held by White Americans. A Latinx American client can
harbor doubts about the qualifications of an American Indian counselor; an Asian American
client can act out racist attitudes toward an African American counselor; and an African
American counselor may downplay the role that prejudice and discrimination play in the life
of Asian Americans. Other interracial and interethnic specific challenges may also make their
appearance in the counseling dyad.
Situation 1: Overidentifying with the Client
Overidentification with clients of color, whether with in‐group or out‐group dyadic
counseling racial relationships, is often manifested through countertransference.
Although it is accepted that the transference of symbolic feelings, thoughts, and experiences
of the client of color can occur in relation to the counselor, an equally powerful
countertransference can occur from therapist to client, especially in interracial and interethnic
dyadic combinations.
Sometimes when I had Black clients, I identified with them and invested in them so much
that I might not have pushed them in the way they needed to be pushed. Or I might not
have helped them develop something they may have needed to develop. Because I was so
busy caring about … being helpful (Black male therapist with Black clients).
(Goode‐Cross & Grim, 2016, p. 42)
In reflecting on his early clinical experiences, this therapist noted that his overidentification
with clients may have actually hindered the therapy process. Thus, while there may be
potential rewards in working with someone with a similar racial or ethnic background,
especially if they also share another social identity such as gender or sexual orientation, there
are also pitfalls, which sometimes remain outside of one's awareness. This speaks to the
importance of having culturally responsive supervisors working with beginning trainees.
It is said that people of color share a sense of peoplehood in that, despite cultural differences,
they know what it is like to live and deal with a monocultural society. They have firsthand
experience with prejudice, discrimination, stereotyping, and oppression. It is a constant
reality in their lives. They know what it is like to be “the only one,” to have their thoughts
and feelings invalidated, to have their sons and daughters teased because of their differences,
to be constantly seen as inferior or lesser human beings, and to be denied equal access and
opportunity (Sue, 2010a). For these reasons, countertransference among counselors of color
working with clients of color is a real possibility. Thus, although therapists of color must
work hard not to dismiss the stated experiences of their clients, they must work equally hard
to separate out their own experiences from those of their clients.
Situation 2: Encountering Clashes in Cultural Values
As we have mentioned earlier, cultural differences can impact the way we perceive events.
This was clearly seen in a study involving Chinese American and White American
psychiatrists (Li‐Repac, 1980). Both groups of therapists viewed and rated recorded
interviews with Chinese and White patients. When rating White patients, White therapists
were more likely to use terms such as affectionate, adventurous, and capable, whereas
Chinese therapists used terms such as active, aggressive, and rebellious to describe the same
patients. Similarly, White psychiatrists described Chinese patients as anxious, awkward,
nervous, and quiet, whereas Chinese psychiatrists were more likely to use the terms
adaptable, alert, dependable, and friendly. It is clear that both majority and minority
therapists are influenced by their ethnocentric beliefs and values.
Many cultural value differences between groups of color are as great and prone to
misinterpretation and conflict as are those among groups of color and White Americans. In
the previous study, it was clear that both the Chinese and the White psychiatrists made such
evaluations based upon a number of cultural values. Chinese psychiatrists saw the more
active and direct expressions of feeling as aggressive, hostile, and rebellious and the more
controlled, sedate, and indirect expressions of emotion as indicative of dependable and
healthy responding. A prime example of how different cultural dictates affect interpersonal
behavior and interpretation is seen in the ways that emotions are expressed among Asian,
Latinx, and Black Americans. Restraint of strong feelings is considered a sign of maturity,
wisdom, and control among many Asian cultures. The wise and mature “man” is considered
able to control feelings (both positive and negative). Thus, Asian Americans may avoid
overtly displaying emotions and even discussing them with others (Kim & Park, 2013). This
is in marked contrast to African Americans, who often operate from a cultural context in
which the expression of affect and passion in interpersonal interactions is a sign of sincerity,
authenticity, and humanness (Parham et al., 2011). Likewise, many Latinx Americans value
emotional and physical closeness when communicating with each other (Guzman & Carrasco,
2011).
Therapists of color who operate from their own worldview without awareness of the different
worldviews held by other clients of color may be guilty of cultural oppression, imposing their
values and standards upon culturally diverse clients. The outcome can be quite devastating
and harmful to clients of color. Let us use the example of a potential misunderstanding likely
to occur between a Latina counselor and an Asian American client (both holding the values
described earlier). As the Latina counselor encounters the Asian American client who values
restraint of strong feelings, several potential culture‐clash scenarios are likely to occur in a
situation where the expression of feelings seems called for: First, the Asian American client's
reluctance to express feelings in an emotional situation (loss of a job, death of a loved one,
etc.) might be perceived as denial, or as emotionally inappropriate or unfeeling. Second, in a
situation where the feelings are being discussed and the client does not desire to, or appears
unable to, express them, the counselor may potentially interpret the client as resistant, unable
to access emotions, repressed, or inhibited. These potentially negative misinterpretations have
major consequences for the client, who may be misdiagnosed and treated inappropriately. It is
clear that counselors of color, when working with clients of color, must be aware of their own
worldviews and those of their diverse clients.
Situation 3: Experiencing Clashes in Communication and Counseling Styles
One area of a possible clash in communication styles is in how groups use personal space
when speaking to one another. African Americans and Latinos, as a rule, have a much closer
conversing distance than either White Americans or Asian Americans (Jensen, 1985; Nydell,
1996). How culture dictates conversation distances is well defined, and varies according to
many sociodemographic differences, including race, ethnicity, and gender. Whereas an Asian
American therapist may value distance to an African American client in therapy (e.g., sitting
further away and leaning back in a chair), the latter may feel quite uncomfortable and find
such conversing distances to be aloof. Worse yet, the client may interpret the counselor as
rude, disrespectful, or racially insensitive. The Asian American therapist, on the other hand,
may view the African American client as overly emotional. Further, major differences may be
exaggerated by the manner of communication. Blacks tend to be more direct in their
communication styles (thoughts and feelings), whereas Asian Americans tend to be more
indirect and subtle in communication; an African American client may not feel comfortable
with or trust an Asian American therapist who expresses him‐ or herself in such an indirect
manner.
Therapy is a context in which communication is paramount, and there are many ways that
these differences in communication styles across races and cultures manifest in the
therapeutic relationship. First, because Asian Americans, Latinx Americans, and American
Indians may be indirect in their communication styles and may avoid eye contact when
listening and speaking, they are often pathologized as being resistant to therapy (Sue, 2010a).
At the same time, because Black Americans are stereotyped as being quick to anger and
prone to violence and crime, they are often viewed as threatening and can trigger fear in
people (Sue, 2010b). The combination of these two contrary types of communication can lead
to various tensions in a therapeutic relationship. Again, counselors of color must (a)
understand their communication and therapeutic styles and the potential impact they have on
other clients of color, (b) be aware of and knowledgeable about the communication styles of
other groups of color, and (c) be willing to modify their intervention styles to be consistent
with the cultural values and life experiences of their culturally diverse clients.
Situation 4: Receiving and Expressing Racial Animosity
A counselor of color may be the object of racial animosity from clients of color simply
because he or she is associated with the mental health system. Many people of color have
viewed mental health practice and therapy as a White middle‐class activity with values that
are often antagonistic to the ones held by groups of color. African Americans, for example,
may have a negative view of therapy, often holding a “historical hostility” response because
of the history of oppression of Blacks in the United States (Ridley, 2005). Therapy is highly
stigmatizing among many in the Asian American community, who often view it as a source
of shame and disgrace (Kim & Park, 2013). Latinx Americans may react similarly, believing
not only that therapy is stigmatizing but that “talk therapies” are less appropriate and helpful
than concrete advice and suggestions (de las Fuentes, 2006). American Indians may vary in
their views of therapy, depending on their level of assimilation; traditional American Indians
may view Westernized institutions and practices as not trustworthy or as ineffective in
comparison to spiritual healing or indigenous practices (Duran, 2006).
Given these different views of therapy and mental health practices, there are several dynamics
that can occur between racial groups. Black American clients may view therapy as a symbol
of political oppression and may perceive a Latinx American therapist or even a Black
counselor as a sellout to the broader society. Or, because traditional forms of therapy
oftentimes emphasize insight through the medium of verbal self‐exploration, many Asian
and Latinx clients may view the process as inappropriate and question the qualifications of
the therapist. American Indian clients who value nontraditional counseling or spiritual healing
may not seek or continue therapy, especially if a counselor of any race does not recognize
alternatives to Western practices. All of these factors may influence the dynamics in a
counseling relationship in which the therapist of color is responded to as a symbol of
oppression and as someone who cannot relate to the client's problems. The therapist's
credibility and trustworthiness are suspect, and will be frequently tested in the session. These
tests may vary from overt hostility to other forms of resistance.
We have already spent considerable time discussing the racial animosity that has historically
existed between racial groups and how it may continue to affect the race relations between
groups of color. Like Situations 3 and 5 for therapists of color working with White clients,
similar dynamics can occur between racial/ethnic minority individuals in the therapy sessions.
Therapists of color may be either targets or perpetrators of racial animosity in therapy
sessions. This is often exaggerated by differences in cultural values and communication styles
that trigger stereotypes that affect their attitudes toward one another. Counselors of color may
transfer their animosity toward minority clients; or, as with hostility from White clients, they
may receive racial animosity from clients of color. Our clinical analysis and suggestions in
those situations would be similar for counselors of color working with clients of color.
Situation 5: Dealing with the Racial Identity Status of Counselors and Clients
We have already stressed the importance of considering the racial and ethnic identity status of
both therapists of color and clients of color. How it affects within‐group and between‐
group racial and ethnic minority counseling is extremely important for cultural competence.
The following quote from a qualitative study on Black therapists working with Black clients
succinctly captures potential difficulties in this area.
I found, particularly with the first African American client I worked with … I was so
pumped. And I was like, “Ooo, a Black woman!” And I had all these thoughts in mind of
what working with her would be like. And she was more Pre‐Encounter
[assimilationist views] in terms of her racial identity. So it was more challenging than I
thought, and actually I was her positive encounter with Blackness that helped her to
shift. And I didn't realize that until after the fact. So I think early on I had expectations,
and because that was my first experience, it helped me to shift and see, “Okay, we might
look alike but there's some very different dynamics that can take place, just identity‐
wise.”
(Goode‐Cross & Grim, 2016, pp. 42–43)
As illustrated in this example, the degree of assimilation/acculturation and racial identity of
both the counselor and the client of color can result in dyadic combinations that create major
conflicts. We explore this issue in detail in Chapter 11, “Racial, Ethnic, Cultural (REC)
Identity Attitudes in People of Color: Counseling Implications.”
REFLECTION AND DISCUSSION QUESTIONS
1. What are some of the therapeutic issues that face counselors of color working with
members of their own group or with another minority group member?
2. Which minority group member do you anticipate would be most difficult to work with in
counseling? Why?
3. If you were a client of color and had to choose the race of the counselor, whom would
you choose? Why?
4. As a White person, would working with a minority group counselor bother you? What
reactions or thoughts do you have about this question?
5. For each of the challenges noted in this chapter, can you provide suggestions of how best
to handle these situations? What are the pros and cons of your advice?
It is clear that cultural competence goals do not apply only to White helping professionals.
All therapists and counselors, regardless of race, culture, gender, and sexual orientation, need
to (a) become aware of their own worldviews and their biases, values, and assumptions about
human behavior; (b) understand the worldviews of their culturally diverse clients; and (c)
develop culturally appropriate intervention strategies in working with culturally diverse
clients.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Working toward cultural competence and cultural humility are functions of everyone,
regardless of race, gender, sexual orientation, religious preference, and so on.
2. Marginalized group members are not immune from having biases and prejudices toward
majority group members and one another.
3. Because all oppression is damaging and serves to separate rather than unify, playing the
“who's more oppressed?” game is destructive to group unity and counterproductive to
combating racism.
4. In order to improve interracial and interethnic counseling relationships, we must face the
fact that there is also much misunderstanding and bias among and between groups of
color.
5. Be aware that not all bad things that happen to people of color are the results of racism.
Although we need to trust our intuitive or experiential reality, it is equally important that
we do not externalize everything.
6. Despite sharing similar experiences of oppression, cultural differences may infect the
therapeutic process and render your attempts to help the client ineffective.
7. Realize how your communication style (direct versus subtle, passionate versus
controlled) and nonverbal differences may impact the client.
8. Therapists must evaluate their own and the client's racial and ethnic identity status and
determine how these factors might impact work with clients of the same or different
ethnicity.
9. Addressing or broaching racial, ethnic, or other differences between the therapist and the
client can be useful in facilitating a helping relationship.
10. Counselors of color should be aware of and prepared to deal with the many therapeutic
challenges they are likely to encounter when working with White clients and clients of
color.
Video 3.5 Impact of Attitudes
Our conscious and unconscious beliefs influence the counseling session as well as the
client/therapist relationship.
SUMMARY
Persons of color have major hesitations and concerns about publicly airing
interracial/interethnic conflicts, differences, and misunderstandings because of the possible
political ramifications for group unity. But it appears that cultural competency and cultural
humility objectives are applicable both to therapists of color and to other clinicians from
marginalized groups. In addition to historical relationships and sociopolitical factors that have
created possible animosity between groups, differences in cultural values, communication
styles, and racial and ethnic identity also contribute to misunderstanding and conflict. Little
actual research has been conducted on the challenges and difficulties that counselors of color
face when working with other culturally diverse groups. Less yet has been done on the
subject of cultural competence as it relates to therapists of color.
In working with White clients, however, people of color might (a) be unable to contain their
anger and rage toward their clients, as they view them as oppressors, (b) have difficulty
understanding the worldview of their clients, (c) be hindered in their ability to establish
rapport, (d) have difficulty empathizing with their clients, and (e) be guilty of imposing their
racial realities upon their clients. The five challenges counselors of color are likely to
encounter are (a) questioning their competence, (b) desiring to prove their competence, (c)
controlling racial animosity toward White clients, (d) being viewed as super minorities, and
(e) dealing with client expressions of racism.
Many of the challenges facing therapists of color working with White clients can also make
their appearance in counseling dyads where both are from marginalized groups. Like their
White counterparts, people of color are socialized into the dominant values and beliefs of the
larger society. As a result, they may inherit the perceptions and beliefs of other racial/ethnic
minority groups as well. In this case, the biases and stereotypes held for other groups of color
may not be all that different from those of White Americans. Other interracial‐ and
interethnic‐specific challenges may also make their appearance in the counseling dyad,
including overidentifying with the client, encountering clashes in cultural values,
experiencing clashes in communication and therapeutic styles, receiving and expressing racial
animosity, and dealing with the stage of racial identity of counselors and clients.
GLOSSARY TERMS
Broaching
Communication styles
Cultural values
Historical stereotypes
Interracial/interethnic bias
Interracial/interethnic conflict
Interracial/interethnic discrimination
Interracial/interethnic group relations
Model minority myth
Multicultural counseling
Racial/Ethnic identity
Socially marginalized groups
“Who's more oppressed?” game
Video 3.6 Counseling Session Analysis
Analysis of the counseling session.
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PART II
The Impact and Social Justice Implications of
Counseling and Psychotherapy
Chapter
4
The Political and Social Justice Implications of Counseling and Psychotherapy
Chapter
5
The Impact of Systemic Oppression Within the Counseling Process: Client
Worldviews and Counselor Credibility
Chapter
6
Microaggressions in Counseling and Psychotherapy
4
The Political and Social Justice Implications of Counseling and
Psychotherapy
Chapter Objectives
1. 1. Understand how the sociopolitical climate affects the manifestation, etiology,
diagnosis, and treatment of psychological disturbances in socially devalued groups
in our society.
2. 2. Learn why traditional counseling/mental health practice may represent cultural
oppression for marginalized groups.
3. 3. Become knowledgeable about how the educational and mental health field has
historically portrayed persons of color.
4. 4. Understand the racial realities (worldviews) of people of color and those of White
Americans.
5. 5. Know how these differences may pose problems in race relations and
multicultural counseling and therapy (MCT).
6. 6. Learn how systemic factors (institutional policies, practices, and regulations)
affect mental health and counseling practices.
7. 7. Define and describe social justice counseling and the importance it plays in the
mental health professions.
AN OPEN LETTER TO BROTHERS AND SISTERS OF COLOR
In 1997, I, Derald Wing Sue, was privileged to testify before President Clinton's Race
Advisory Board on the President's Initiative on Race (1998) about the impact of racism
on people of color. The televised public testimony evoked strong negative reactions
from primarily White viewers, who claimed my colleagues and I were simply
exaggerating, and that racism was now a thing of the past. In reaction to those criticisms,
I published an open letter to brothers and sisters of color in 2003. A brief portion is
reproduced here.
Dear Brothers and Sisters of Color:
I write … to you and to those White folks who have marched with us against racism
and shown that their hearts are in the right place. Throughout our people's
histories, we have had to contend with invalidation, oppression, injustice,
terrorism, and genocide. Racism is a constant reality in our lives. It is a toxic force
that has sought to
strip us of our identities,
take away our dignity,
make us second‐class citizens,
destroy our peoples, cultures, and communities,
steal our land and property,
torture, rape, and murder us,
imprison us on reservations, concentration camps, inferior schools, segregated
neighborhoods, and jails,
use us as guinea pigs in medical experiments, and
blame our victimization upon the faults of our own people.
Attempts to express these thoughts have generally been met with disbelief and/or
incredulity by many of our well‐intentioned White brothers and sisters. We have
been asked, “Aren't you distorting the truth? Where is your proof? Where is your
evidence?”
When we attempt to provide it, we are interrogated about its legitimacy, told that
we are biased or paranoid, and accused of being dishonest in how we present the
facts. After all, they say, “Our nation is built upon life, liberty, and the pursuit of
happiness. It was founded upon the principles of freedom, democracy, and
equality.” Yet, these guiding principles seem intended for Whites only! In the
classic book, Animal Farm (Orwell, 1945), when the issue of inequality arose, the
character in a position of power justified the treatment by stating, “Some are more
equal than others.” Rather than offer enlightenment and freedom, education and
healing, and rather than allowing for equal access and opportunity, historical and
current practices in our nation have restricted, stereotyped, damaged, and
oppressed persons of color.
For too long people of color have not had the opportunity or power to express their
points of view. For too long our voices have not been heard. For too long our
worldviews have been diminished, negated, or considered invalid. For too long we
have been told that our perceptions are incorrect, that most things are well with
our society, and that our concerns and complaints are not supported. For too long
we have had to justify our existence, and to fight for our dignity and humanity. No
wonder that we are so tired, impatient, and angry. Yet, as people of color, we
cannot let fatigue turn into hopelessness, nor anger into bitterness. Hopelessness is
the forerunner to surrender, and bitterness leads to blind hatred. Either could spell
our downfall!
(D. W. Sue, 2003, pp. 257–259)
Video 4.0: Introduction
Awareness of cultural competence as a universal necessity in counseling and not just a
majority requirement.
THE MENTAL HEALTH IMPACT OF SOCIOPOLITICAL
OPPRESSION
Multicultural counseling and therapy (MCT) means understanding the worldviews and life
experiences of diverse groups in our nation. To be culturally competent means to understand
the history of oppression experienced by marginalized groups in our society. The stories of
discrimination and pain of the oppressed are often minimized and neglected. Many, for
example, contend that the reality of racism, sexism, and homophobia is relatively unknown or
ignored by those in power because of the discomfort that pervades such topics among people
of every political persuasion. Ignoring or dismissing Whiteness, according to author and
social critic Ta‐Nehisi Coates, has one primary motivation.
The motive is clear: escapism. To accept that the bloody heirloom remains potent even
now, some five decades after Martin Luther King Jr. was gunned down on a Memphis
balcony—even after a black president; indeed, strengthened by the fact of that black
president—is to accept that racism remains, as it has since 1776, at the heart of this
country's political life.
(Coates, 2017, para. 14)
Vernon E. Jordan, Jr., an African American attorney and former confidant of President Bill
Clinton, spoke about racism's continuing impact in startling terms. In making an analogy
between the terrorist attacks of September 11, 2001, and the racism directed at African
Americans, Jordan stated that
None of this is new to Black people. War, hunger, disease, unemployment, deprivation,
dehumanization, and terrorism define our existence. They are not new to us. Slavery was
terrorism, segregation was terrorism, and the bombing of the four little girls in Sunday
school in Birmingham was terrorism. The violent deaths of Medgar, Martin, Malcolm,
Vernon Dahmer, Chaney, Shwerner, and Goodman were terrorism. And the difference
between September 11 and the terror visited upon Black people is that on September 11,
the terrorists were foreigners. When we were terrorized, it was by our neighbors. The
terrorists were Americans.
(Excerpted from a speech by Vernon E. Jordan, June 2002)
Such experiences have been represented more recently by Black Lives Matter, a grassroots
movement that was initiated in response to the killing of Trayvon Martin in 2012 and that
went on to represent the perspectives of many Black Americans (and others) regarding the
deaths of their community members at the hands of law enforcement (Hargons et al., 2017).
Likewise, in speaking about the history of psychological research conducted on ethnic
minority communities by White social scientists, the late Charles W. Thomas, a respected
African American psychologist, voiced his concerns strongly.
White psychologists have raped Black communities all over the country. Yes, raped.
They have used Black people as the human equivalent of rats run through Ph.D.
experiments and as helpless clients for programs that serve middle‐class White
administrators better than they do the poor. They have used research on Black people as
green stamps to trade for research grants. They have been vultures.
(Thomas, 1970, p. 52)
To many people of color, the “Tuskegee experiment” represents a prime example of the
allegation by Thomas. The Tuskegee experiment was carried out from 1932 to 1972 by the
U.S. Public Health Service; more than 600 Alabama Black men were used as guinea pigs in
the study of what damage would occur to the body if syphilis were left untreated.
Approximately 399 were allowed to go untreated, even when medication was available.
Records indicate that 7 died as a result of syphilis, and an additional 154 died of heart disease
that may have been caused by the untreated syphilis! In a moving ceremony in 1997,
President Clinton officially expressed regret for the experiment to the few survivors and
apologized to Black America.
Likewise, in August 2011, a White House bioethics panel heard about American‐run
venereal disease experiments conducted on Guatemalan prisoners, soldiers, and mental
patients from 1946 to 1948: the United States paid for syphilis‐infected Guatemalan
prostitutes to have sex with prisoners. Approximately 5,500 Guatemalans were enrolled,
1,300 were deliberately infected, and 83 died (McNeil, 2011). The aim of the study was to see
whether penicillin could prevent infection after exposure. When these experiments came to
light, President Obama apologized to President Alvaro Colom of Guatemala. Dr. Amy
Gutman, the chairwoman of the bioethics panel and president of the University of
Pennsylvania, described the incident as a dark chapter in the history of medical research.
Experiments of this type are ghastly and give rise to suspicions that people of color are being
used as guinea pigs in other medical and social experiments as well.
REFLECTION AND DISCUSSION QUESTIONS
1. Are these beliefs by people of color accurate?
2. Might they simply be exaggerations from overly mistrustful individuals?
3. Aren't people of color making a mountain out of a molehill?
4. As indicated in Chapter 1, what emotional roadblocks might you (or other readers) now
be feeling? What meaning do you impute to them?
5. What has all this to do with counseling and psychotherapy?
Because the worldviews of culturally diverse clients are often linked to the historical and
current experiences of oppression in the United States (American Psychological Association
Presidential Task Force on Preventing Discrimination and Promoting Diversity 2012;
Ponterotto, Utsey, & Pedersen, 2006), it is necessary to understand the worldview of
culturally diverse clients from both a cultural and a political perspective (Owens, Queener, &
Stewart, 2016; Ridley, 2005). Clients of color, for example, are likely to approach counseling
and therapy with a great deal of healthy skepticism regarding the institutions from which
therapists work and even the conscious and unconscious motives of the helping professional.
The main thesis of this book is that counseling and psychotherapy do not take place in a
vacuum, isolated from the larger sociopolitical influences of our societal climate
(Constantine, 2006; Katz, 1985; Liu, Hernandez, Mahmood, & Stinson, 2006; Prilleltensky,
1989). Multicultural counseling often mirrors the nature of race relations in the wider society,
as well as the dominant–subordinate relationships of other marginalized groups (lesbian, gay,
bisexual, transgender, and queer [LGBTQ] people, women, and the physically challenged).
As explained in the American Psychological Association's Multicultural Guidelines (2017),
multicultural counseling is fluid, multilayered, and complex; it requires comprehension of the
interwoven, intersectional nature of these group memberships, in that both privileged and
subordinated individuals always embody more than one identity simultaneously (Moradi &
Grzanka, 2017). It serves as a microcosm, reflecting Black–White, Asian–White, Hispanic–
SOCIOPOLITICAL OPPRESSION AND THE TRAINING OF
COUNSELING/MENTAL HEALTH PROFESSIONALS
While national interest in the mental health needs of people of color has increased, the human
service professions have historically neglected this population. Evidence reveals that these
marginalized groups, in addition to the common stresses experienced by everyone else, are
more likely to encounter problems such as immigrant status, poverty, cultural racism,
prejudice, and discrimination (Choudhuri, Santiago‐Rivera, & Garrett, 2012; West‐
Olatunji & Conwill, 2011). Yet, studies continue to reveal that American Indians, Asian
Americans, African Americans, and Latinx Americans tend to underutilize traditional mental
health services in a variety of contexts (Kearney, Draper, & Baron, 2005; Owen, Imel,
Adelson, & Rodolfa, 2012; Smith & Trimble, 2016; Wang & Kim, 2010).
Some researchers have hypothesized that people of color underutilize and prematurely
terminate counseling/therapy because of the biased nature of the services themselves
(Kearney et al., 2005). The services offered are frequently antagonistic or inappropriate to the
life experiences of culturally diverse clients; they lack sensitivity and understanding, and they
are oppressive and discriminating toward clients of color (Cokley, 2006). Many believe that
the presence of ill‐prepared mental health professionals is the direct result of a culture‐
bound and biased training system (Mio, 2005; Utsey, Grange, & Allyne, 2006). As will be
discussed in the following section, the manifestations of these biases can be seen within
professional approaches to the definition of mental health, as well as within the scholarly
literature that supports them.
Video 4.1: Counseling Through a Western Lens
How transference and countertransference can negatively impact the counseling relationship.
DEFINITIONS OF MENTAL HEALTH
If we look at the criteria used by the mental health profession to judge normality and
abnormality, their ethnocentricity becomes glaring. Several fundamental approaches that
have particular relevance to our discussion have been identified (Sue, Sue, Sue, & Sue, 2016):
(a) normality as a statistical concept, (b) normality as ideal mental health, and (c) abnormality
as the presence of certain behaviors (research criteria).
Normality as a Statistical Concept
First, statistical criteria equate normality with those behaviors that occur most frequently in
the population. Abnormality is defined in terms of those behaviors that occur least frequently.
Despite the word statistical, however, these criteria need not be quantitative in nature:
individuals who talk to themselves, disrobe in public, or laugh uncontrollably for no apparent
reason are considered abnormal according to these criteria simply because most people do not
behave in that way. Statistical criteria undergird our notion of a normal probability curve, so
often used in IQ tests, achievement tests, and personality inventories. Statistical criteria may
seem adequate in specific instances, but they fail to take into account differences in time,
community standards, cultural values, and the power that different social groups have to
define such classifications. When we resort to a statistical definition, it is generally the group
in power that determines what constitutes normality and abnormality. For example, if African
Americans were to be administered a personality test and it was found that they were more
suspicious than their White counterparts, what would this mean? Some psychologists and
educators have used such findings to label African Americans as paranoid, yet this
interpretation has been challenged by many Black psychologists (Grier & Cobbs, 1968, 1971;
Parham et al., 2011), who point out that marginalized groups have good reason to be
suspicious and mistrustful of White society.
Normality as Ideal Mental Health
Second, humanistic psychologists have proposed the concept of ideal mental health as
providing the criteria of normality (Cain, 2010). Such criteria stress the importance of
attaining some positive goal like consciousness‐insight, self‐actualization/creativity,
competence, autonomy, resistance to stress, or psychological mindedness. The biased nature
of such approaches is grounded in the belief in a universal application (all populations in all
situations) and reveals a failure to recognize the value base from which the criteria are
derived. The particular goal or ideal used is intimately linked with the theoretical frame of
reference and values held by the practitioner (psychodynamic, humanistic/existential, or
cognitive/behavioral). For example, the psychoanalytic emphasis on insight as a determinant
of mental health is a value in itself (London, 1988).
It is important for the mental health professional to be aware, however, that certain ethnic and
cultural groups may not define insight in the same ways that they do. A characteristic often
linked to the healthy personality is the ability to talk about the deepest and most intimate
aspects of one's life: to self‐disclose. This orientation is very characteristic of our
counseling and therapy process, in which clients are expected to talk about themselves in a
very personal manner. The fact that many people of color are initially reluctant to self‐
disclose can place them in a situation where they are judged to be mentally unhealthy and, in
this case, paranoid (Parham, 2002). Similarly, definitions of mental health that focus on
competence, autonomy, and resistance to stress are related to White middle‐class notions of
individualism (Ivey, D'Andrea, Ivey, & Simek‐Morgan, 2007), a perspective according to
which people succeed solely because of their own efforts and abilities. Conversely, when
people fail, the cause is assumed to be their own lack of ability, interest, or maturity, or some
inherent weakness of the ego. Ryan (1971) was the first to coin the phrase “blaming the
victim” to refer to this process, which does not account for factors such as the stress and
discrimination related to minority status. A broader systems‐level analysis would show that
the economic, social, and psychological conditions faced by marginalized groups are related
to their oppressed status in the United States.
Abnormality as the Presence of Certain Behaviors
A third understanding involves the political and societal implications of psychiatric diagnosis
and hospitalization, as forcefully pointed out years ago by Szasz (1970, 1971). Notably,
although it appears that minorities underutilize outpatient services, they also appear to face
greater levels of involuntary hospital commitments (Snowden & Cheung, 1990). Szasz states
his opinion of the relationship between these statistics.
In my opinion, mental illness is a myth. People we label “mentally ill” are not sick, and
involuntary mental hospitalization is not treatment. It is punishment … The fact that
mental illness designates a deviation from an ethnical rule of conduct, and that such
rules vary widely, explains why upper‐middle‐class psychiatrists can so easily find
evidence of “mental illness” in lower‐class individuals and why so many prominent
persons in the past fifty years or so have been diagnosed by their enemies as suffering
from some types of insanity. Barry Goldwater was called a paranoid schizophrenic …
Woodrow Wilson, a neurotic … Jesus Christ, according to two psychiatrists … was a
born degenerate with a fixed delusion system.
(Szasz, 1970, pp. 167–168)
Szasz (1987, 1999) views the mental health professional as an inquisitor, an agent of society
for the exertion of social control. Psychiatric hospitalization is, accordingly, seen as a form of
control for persons who disturb us or who have lifestyles that differ from the accepted norms
of society—a concept with frightening implications for people in marginalized social groups.
In addition, the use of “objective” psychological inventories as indicators of maladjustment
may also place people of color at a disadvantage. Many are aware that the test instruments
used on them have been constructed and standardized according to White middle‐class
norms. The lack of culturally unbiased instruments makes many feel that the results obtained
are invalid. Indeed, in a landmark decision in the State of California (Larry P. v. California,
1986), a judge ruled in favor of the Association of Black Psychologists' claim that individual
intelligence tests, such as versions of the WISC, WAIS, and Stanford Binet, could not be used
in the public schools on Black students. The improper use of such instruments can lead to an
exclusion of minorities from jobs and promotion, to discriminatory educational decisions, and
to biased determination of what constitutes pathology and cure in counseling/therapy
(Samuda, 1998).
Further, when a diagnosis becomes a label, it can have serious consequences. First, a label
can cause people to interpret all activities of the affected individual as pathological. No
matter what African Americans may do or say that breaks a stereotype, their behaviors will
seem to reflect the fact that they are less intelligent than others around them. Second, the label
may cause others to treat affected individuals differently, even when they are perfectly
normal. Third, a label may cause those who are labeled to believe that they do indeed possess
such characteristics (Rosenthal & Jacobson, 1968) or that the threats of being perceived as
less capable can seriously impair their performance (Steele, 2003).
Curriculum and Training Deficiencies
It appears that many of the universal definitions of mental health that have pervaded the
profession have primarily been due to severe deficiencies in training programs. Educators
(Chen, 2005; Mio & Morris, 1990; Sue, 2010) have asserted that the major reason for
ineffectiveness in working with culturally diverse populations is the lack of culturally
sensitive material taught in the curricula. It has been ethnocentrically assumed that the
material taught in traditional mental health programs is equally applicable to all groups. Even
now, when there is high recognition of the need for multicultural curricula, it has become a
battle to infuse such concepts into course content (Vera, Buhin, & Shin, 2006). As a result,
course offerings continue to lack a non‐White perspective, to treat cultural issues as an
adjunct or add‐on, to portray cultural groups in stereotypic ways, and to create an academic
environment that does not support their concerns, needs, and issues (Turner, Gonzalez, &
Wood, 2008).
Further, a major criticism has been that training programs purposely leave out antiracism,
antisexism, and antihomophobia curricula for fear of requiring students to explore their own
biases and prejudices (Carter, 2005; Vera et al., 2006). Because multicultural competence
cannot occur without students or trainees confronting these harmful and detrimental attitudes
about race, gender, and sexual orientation, the education and training of psychologists remain
in the cognitive and objective domain, preventing self‐exploration (Sue, 2015). This allows
students to study the material from a position of safety. An effective curriculum must enable
students to understand feelings of helplessness and powerlessness, low self‐esteem, and
poor self‐concept, and how they contribute to low motivation, frustration, hate,
ambivalence, and apathy. Each course should contain (a) a consciousness‐raising
component, (b) an affective/experiential component, (c) a knowledge component, and (d) a
skills component. Importantly, the American Psychological Association Presidential Task
Force on Evidence‐Based Practice (2006) recommends that psychology training programs at
all levels provide information on the political nature of the practice of psychology and that
psychologists practice with an understanding of the professional relevance of their value
positions.
Video 4.2: A History of Pathology
Historical biases and their impact on our beliefs, both consciously and unconsciously, within
the counseling session.
COUNSELING AND MENTAL HEALTH LITERATURE
Many psychologists have noted how the social science literature, and specifically research,
has failed to create a realistic understanding of various ethnic groups in the United States
(Cokley, 2006; Guthrie, 1997). In fact, certain practices are felt to have done great harm to
persons of color by ignoring them, maintaining false stereotypes, and/or presenting a distorted
view of their lifestyles. Mental health practice may be viewed as encompassing the use of
social power and functioning as a handmaiden of the status quo (Halleck, 1971; Katz, 1985).
Social sciences are part of a culture‐bound social system, from which researchers are
usually drawn; moreover, organized social science is often dependent on the status quo for
financial support. People of color frequently see the mental health profession in a similar way
—as a discipline concerned with maintaining the status quo (Ponterotto et al., 2006). As a
result, the person collecting and reporting data is often perceived as possessing the social bias
of his or her society (Ridley, 2005).
Social sciences, for example, have historically ignored the study of Asians in the United
States (Hong & Domokos‐Cheng Ham, 2001; Nadal, 2011). This deficit has contributed to
the perpetuation of false stereotypes, which has angered many younger Asians concerned
with raising consciousness and group esteem. When studies have been conducted on people
of color, research has been appallingly unbalanced. Many social scientists (Cokley, 2006;
Jones, 2010) have pointed out how “White social science” has tended to reinforce a negative
view of African Americans among the public by concentrating on unstable Black families
instead of on the many stable ones. Such unfair treatment has also been the case in studies on
Latinx Americans, which have focused on the psychopathological problems encountered by
Mexican Americans (Falicov, 2005). Other ethnic groups, such as Native Americans (Sutton
& Broken Nose, 2005) and Puerto Ricans (Garcia‐Preto, 2005), have fared no better. Even
more disturbing is the assumption that the problems encountered by people of color are due to
intrinsic factors (racial inferiority, incompatible value systems, etc.) rather than to the failure
of society to address racism and other oppressive systems (Sue, 2003). Although there are
many aspects to how persons of color are portrayed in social science literature, it seems
crucial to explore the application of pathologizing diagnoses to people of color and the role of
scientific racism in this process.
Pathology and Persons of Color
When we seriously study the “scientific” literature of the past relating to people of color, we
are immediately impressed with how an implicit equation of them with pathology and
inferiority is a common theme. Some examples of this literature focus upon the presumed
genetic inferiority of people of color, while others locate the “problems” within their cultural
heritage.
The Genetically Deficient Model
The portrayal of people of color in the literature has generally taken the form of stereotyping
them as deficient in certain desirable attributes. For example, de Gobineau's (1915) The
Inequality of the Human Races and Darwin's (1859) On the Origin of Species by Natural
Selection were used to support the belief in the genetic intellectual superiority of Whites and
the genetic inferiority of the “lower races.” Galton (1869) wrote explicitly that African
“Negroes” were “half‐witted men” who made “childish, stupid, and simpleton‐like
mistakes,” while Jews were inferior physically and mentally and only designed for a
parasitical existence on other nations of people.
Educators and psychologists have also historically portrayed people of color in pathological
ways. The belief that various human groups exist at different stages of biological and
emotional development was promoted by G. Stanley Hall, the turn‐of‐the‐century
psychologist who became the first president of the American Psychological Association in
1892. He stated explicitly in 1904 that Africans, Indians, and Chinese were members of
adolescent races and in a stage of incomplete development (Hall, 1904). In most cases, the
evidence used to support such conclusions was fabricated, extremely flimsy, or distorted to fit
the belief in non‐White inferiority (Thomas & Sillen, 1972).
As recently as 1989, Professor Rushton of the University of Western Ontario claimed that
human intelligence and behavior are largely determined by race, that Whites have bigger
brains than Blacks, and that Blacks are more aggressive (Rushton, 1989; Samuda, 1998).
Shockley (1972) expressed fears that the accumulation of weak or low‐intelligence genes in
the Black population would seriously affect overall intelligence; he thus advocated that
people with low IQs not be allowed to bear children—that they be sterilized. Allegations of
scientific racism can also be seen in the work of Cyril Burt, the eminent British psychologist,
who fabricated data to support his contention that intelligence is inherited and that Blacks
have inherited inferior brains. Such an accusation is immensely important when one considers
that Burt is a major influence in American and British psychology, is considered by many to
be the father of educational psychology, was the first psychologist to be knighted, and was
awarded the American Psychological Association's Thorndike Prize, as well as that his
research findings form the foundation for the belief that intelligence is inherited.
A belief that race and gender dictate intelligence continues to be expressed in modern times
and even by our most educated populace. In 2005, then‐Harvard President Larry Summers
(former director of President Obama's National Economic Council) suggested that innate
differences between the sexes might help explain why relatively few women become
professional scientists or engineers. His comments set off a furor, with demands that he be
fired. Women academicians were reported to have stormed out in disgust as Summers used
“innate ability” as a possible explanation for sex differences in test scores. Ironically,
Summers was lecturing to a room of the most accomplished women scholars in engineering
and science in the nation.
The questions about whether there are differences in intelligence between races are both
complex and emotional. The difficulty in clarifying these questions is compounded by many
factors. Besides the difficulty in defining race, which has no significant biological basis,
questionable assumptions exist regarding whether research on the intelligence of Whites can
be generalized to other groups, whether middle‐ and lower‐class ethnic minorities grow up
in environments similar to those of middle‐ and lower‐class Whites, and whether test
instruments are valid for both minority and White subjects. Moreover, the historical use of
science in the investigation of racial differences seems to be linked with White supremacist
notions (Jones, 1997, 2010). The classic work of Thomas and Sillen (1972) refers to this as
scientific racism and cites several historical examples to support this contention:
Fabricated 1840 census figures were used to support the notion that Blacks living under
unnatural conditions of freedom were prone to anxiety.
Influential medical journals presented fantasies as facts, supporting the belief that
anatomical, neurological, or endocrinological aspects of Blacks were always inferior to
those of Whites.
The following misconceptions were presented as facts:
Mental health for Blacks is contentment with subservience.
Psychologically normal Blacks are faithful and happy‐go‐lucky.
Black persons' brains are smaller and less developed.
Blacks are less prone to mental illness because their minds are so simple.
The dreams of Blacks are juvenile in character and not as complex as those of
Whites.
More frightening, perhaps, is a survey that found that many of these stereotypes have
persisted among White Americans: 20% publicly expressed a belief that African Americans
are innately inferior in thinking ability, 19% believed that Blacks have thicker craniums,
23.5% believed they have longer arms, 50% believed Blacks have achieved equality, and
30% believed the problems of Blacks reside in their own group (Babbington, 2008; Pew
Research Center, 2007; Plous & Williams, 1995). One wonders how many White Americans
hold similar beliefs privately but, because of social pressures, do not publicly voice them.
The Culturally Deficient Model
Well‐meaning social scientists who challenged the genetic deficit model by placing heavy
reliance on environmental factors nevertheless tended to perpetuate a view that saw people of
color as culturally disadvantaged, deficient, or deprived. Instead of a biological condition that
caused differences, the blame now shifted to the lifestyles or values of various ethnic groups.
The term cultural deprivation was first popularized by Riessman's widely read book, The
Culturally Deprived Child (1962). It was used to indicate that many groups perform poorly
on tests or exhibit deviant characteristics because they lack many of the advantages of
middle‐class culture (education, books, toys, formal language, etc.). In essence, these
groups are culturally impoverished!
While Riessman was well‐intentioned in trying to not attribute blame to “genes” and
intended to improve the condition of African Americans in the United States, some educators
strenuously objected to the term. First, culturally deprived means to lack a cultural
background (e.g., as though enslaved Blacks arrived in America culturally naked), which is
incongruous, because everyone inherits a culture. Second, such terms cause conceptual and
theoretical confusions that may adversely affect social planning, educational policy, and
research; for example, the oft‐quoted Moynihan Report asserts that “at the heart of
deterioration of the Negro society is the deterioration of the Black family. It is the
fundamental source of the weakness in the Negro community” (Moynihan, 1965, p. 5).
Action was thus directed toward infusing White concepts of the family into those of Blacks.
Third, “cultural deprivation” is used synonymously with deviation from and inferiority to
White middle‐class values. Fourth, these deviations in values become equated with
pathology, in which a group's cultural values, families, or lifestyles transmit the pathology.
Thus, the term “cultural deprivation” provides a convenient rationalization and alibi for the
perpetuation of racism and the inequities of the socioeconomic system.
The Culturally Diverse Model
Many now maintain that the culturally deficient model serves only to perpetuate the myth of
people of color's inferiority. The focus tends to be one of blaming the person, with an
emphasis on pathology and a use of White middle‐class definitions of desirable and
undesirable behavior. The social science use of a common, standard assumption implies that
to be different is to be deviant, pathological, or sick. Is it possible that intelligence and
personality scores for minority children are really measures of how Anglicized the child has
become? To arrive at a more accurate understanding, people of color should no longer be
viewed as deficient, but rather as culturally diverse. The goal of society should be to
recognize the legitimacy of alternative lifestyles, the advantages of being bicultural (capable
of functioning in two different cultural environments), and the value of differences.
REFLECTION AND DISCUSSION QUESTIONS
1. What reactions are you experiencing in learning that the history of the mental health
movement was filled with racist formulations? As a White trainee, what thoughts and
feelings are you experiencing? As a trainee of color (or a member of a marginalized
group), what thoughts and feelings do you have?
2. Go back to Chapter 1 and reread the reactions to this book. Do the reactions in that
chapter provide insights about your own thoughts and feelings?
3. Given the preceding discussion, in what ways may counseling and psychotherapy
represent instruments of cultural oppression? How is this possibly reflected in
definitions of normality and abnormality, the goals you have for therapy, and the way
you conduct your practice with marginalized groups in our society?
CASE STUDY
THE NEED TO TREAT SOCIAL PROBLEMS—SOCIAL JUSTICE
COUNSELING
DARYL
Daryl Williams (a pseudonym) is a 12‐year‐old African American student attending a
predominantly White grade school in Santa Barbara, California. He was referred for
counseling by his homeroom teacher because of “constant fighting” on the school
grounds, inability to control his anger, and “a potential to seriously injure others.” In
addition, his teachers reported that Daryl was doing poorly in class and was inattentive,
argumentative toward authority figures, and disrespectful. He appeared withdrawn in his
classroom and seldom participated, but when he spoke, he was “loud and aggressive.”
Teachers would often admonish Daryl “to calm down.”
The most recent problematic incident, an especially violent one, required the assistant
principal to physically pull Daryl away to prevent him from seriously injuring a fellow
student. He was suspended from school for three days and subsequently referred to the
school psychologist, who conducted a psychological evaluation. Daryl was diagnosed
with a conduct disorder, and the psychologist recommended immediate counseling to
prevent the untreated disorder from leading to more serious antisocial behaviors. He
worried that Daryl was on his way to developing an antisocial personality disorder. The
recommended course of treatment consisted of medication and therapy aimed at
eliminating Daryl's aggressive behaviors and “controlling his underlying hostility and
anger.”
Daryl's parents, however, objected strenuously to the school psychologist's diagnosis and
treatment recommendations. They described their son as a “normal child” at home and
said he had not had a behavior problem before moving from Los Angeles to Santa
Barbara. They described him as feeling isolated at his new school, having few friends,
being rejected by classmates, feeling invalidated by teachers, and feeling “removed”
from the content of his classes. They also noted that all of the “fights” were generally
instigated through “baiting” and “name‐calling” by his White classmates, that the
school climate was hostile toward their son, that the curriculum was entirely Eurocentric,
and that school personnel and teachers seemed naive about racial or multicultural issues.
They hinted strongly that racism was at work in the school district and attempted to
enlist the aid of the only Black counselor in the school, Ms. Jones. Although Ms. Jones
appeared to be understanding and empathic toward Daryl's plight, she seemed reluctant
to intercede on behalf of the parents. Being a recent graduate from the local college, Ms.
Jones seemed to fear being ostracized by other school personnel.
The concerns of Daryl's parents were quickly dismissed by school officials as having
little validity. In fact, the principal was incensed by these “accusatory statements of
possible racism.” He indicated to the parents that their Los Angeles community did not
have a history of academic pursuit and that discipline in the home was usually the
culprit. School officials contended that Daryl needed to be more accommodating, to
reach out and make friends rather than isolating himself, to take a more active interest in
his schoolwork, and to become a good citizen. Further, they asserted that the school
climate was not hostile and that Daryl needed to “learn to fit in.” “We treat everyone the
same, regardless of race. This school doesn't discriminate,” stated the principal. He went
on to say, “It may have been a mistake to move to Santa Barbara. For the sake of your
son, perhaps you should consider returning to L.A. so he can better fit in with his
people.” These statements greatly angered Daryl's parents.
Adapted from D. W. Sue & Constantine (2003, pp. 214–215).
Video 4.4: Systems of Oppression
Our conscious and unconscious beliefs influence the counseling session as well as the
client/therapist relationship.
Video 4.5: Levels of Care
Introduction to counseling session by Dr. Joel Filmore.
If you were a counselor, how would you address this case? Where would you focus your
energies? Traditional clinical approaches would direct attention to what they perceive as the
locus of the problem: Daryl and his aggressive behavior with classmates, his inattentiveness
in class, and his disrespect of authority figures. This approach, however, makes several
assumptions: (a) that the locus of the problem resides in the person, (b) that behaviors that
violate socially accepted norms are considered maladaptive or disordered, (c) that
remediation or elimination of problem behaviors is the goal, (d) that the social context or
status quo guides the determination of normal versus abnormal and healthy versus unhealthy
behaviors, and (e) that the appropriate role for the counselor is to help the client “fit in” and
become “a good citizen.”
As we have just seen, mental health assumptions and practices are strongly influenced by
sociopolitical factors. An enlightened approach that acknowledges potential oppression in the
manifestation, diagnosis, etiology, and treatment is best accomplished by taking a social
justice approach (Flores et al., 2014; McAuliffe & Associates, 2013). In the American
Counseling Association (ACA)'s Multicultural and Social Justice Counseling Competencies
(MSJCC) (Ratts, Singh, Nassar‐McMillan, Butler, & McCullough, 2016), a strong case is
made that multiculturalism is intimately related to social justice and that counselors must
engage in actions that require both individual‐ and systems‐level work. Such an approach
might mean challenging the traditional assumptions of therapy, and even reversing them as
follows.
1. The locus of the problem may reside in the social system (other students, hostile campus
environment, alienating curriculum, lack of minority teachers/staff/students, etc.) rather
than in the individual.
2. Behaviors that violate social norms may not be disordered or unhealthy.
3. The social norms, prevailing beliefs, and institutional policies and practices that
maintain the status quo may need to be challenged and changed.
4. Although remediation is important, the more effective long‐term solution is prevention.
5. Organizational change requires a macrosystems approach involving other roles and skills
beyond the traditional clinical ones.
Along with these five assumptions, implementing social justice counseling means
recognizing that interventions can occur at four different foci, as Figure 4.1 depicts. These
are: (a) individual, or the traditional focus on personal insight and change; (b) professional, or
the modification and evolution of professional codes of practice; (c) organizational, or the
need to address monocultural institutional procedures; and (d) societal, or social policies that
undermine the emotional well‐being of marginalized racial‐cultural groups. A basic
premise of social justice counseling is that culturally competent helping professionals must
not confine their perspectives to just individual treatment but must be able to intervene
effectively at the professional, organizational, and societal levels as well.
FIGURE 4.1 Levels of Counseling Interventions
Select this link to open an interactive version of Figure 4.1.
Often, psychologists treat individuals who are the victims of failed systemic processes.
Nevertheless, psychology concentrates primarily on the individual and has been deficient in
developing more systemic and large‐scale change strategies. Using the case of Daryl, let us
illustrate some social justice principles as they apply to multicultural counseling.
Principle 1: A Failure to Develop a Balanced Perspective Between Person
and System Focus Can Result in False Attribution of the Problem
It is apparent that school officials have attributed the locus of the problem—that he is
impulsive, angry, inattentive, unmotivated, disrespectful, and a poor student—to reside in
Daryl. He is labeled as having a conduct disorder with potential antisocial personality traits.
Diagnosis of the problem is internal; that is, it resides in Daryl. When the focus of therapy is
primarily on the individual, there is a strong tendency to see the locus of the problem as
residing solely in the person (Cosgrove, 2006; Ratts & Pedersen, 2014) rather than in the
school system, curriculum, or wider campus community. As a result, well‐intentioned
counselors may mistakenly blame the victim (e.g., by seeing the problem as a deficiency of
the person) when, in actuality, the problem may reside in the environment (prejudice,
discrimination, racial/cultural invalidation, etc.) (Metzl & Hansen, 2014).
We would submit that it is highly probable that Daryl is the victim of (a) a monocultural
educational environment that alienates and denigrates him (Davidson, Waldo, & Adams,
2006); (b) a curriculum that does not deal with the contributions of African Americans or
portrays them in a demeaning fashion; (c) teaching styles that may be culturally biased
(Cokley, 2006); (d) a campus climate that is hostile to minority students (perceives them as
less qualified) (Sue et al., 2011); (e) support services (counseling, study skills, etc.) that fail to
understand the minority student experience; and (f) a lack of role models (presence of only
one Black counselor in the school) (Alexander & Moore, 2008). For example, would it
change your analysis and focus of intervention if Daryl got into fights because he was bullied
by fellow students? In other words, suppose there is good reason that this 12‐year‐old
feels isolated, rejected, devalued, and misunderstood.
Principle 2 : A Failure to Develop a Balanced Perspective Between Person
and System Focus Can Result in an Ineffective and Inaccurate Treatment
Plan Potentially Harmful to the Client
Failure to understand how systemic factors contribute to individual behavior can result in an
ineffective and inaccurate treatment plan; the treatment itself may be potentially harmful (Ali
& Sichel, 2014). A basic premise of a broad ecological approach is the assumption that
person–environment interactions are crucial to diagnosing and treating problems (Goodman,
2009; Goodman et al., 2004). Clients, for example, are not viewed as isolated units but as
embedded in their families, social groups, communities, institutions, cultures, and major
systems of our society (Vera & Speight, 2003). If Daryl's problems are interpreted as solely
internal and intrapsychic, then it makes sense that therapy be directed toward changing the
individual—Daryl. The fighting behavior is perceived as dysfunctional and should be
eliminated through therapy or medication that may correct his internal biological dysfunction.
But what if the problem is external? Will having Daryl stop his fighting behavior result in the
elimination of teasing from White classmates? Will it make him more connected to the
campus? Will it make him feel more valued and accepted? Treating the symptoms and
eliminating self‐defensive behavior may actually make Daryl more vulnerable to racism.
Principle 3: When the Client Is an Organization or a Larger System and Not
an Individual, a Major Paradigm Shift Is Required to Attain a True
Understanding of Problem and Solution Identification
Let us assume that Daryl is getting into fights because of the hostile school climate and the
invalidating nature of his educational experience. Given this assumption, we ask the question,
“Who is the client?” Is it Daryl or the school? Where should we direct our therapeutic
interventions? In his analysis of schizophrenia, R. D. Laing (1969), an existential psychiatrist,
once asked the following question: “Is schizophrenia a sick response to a healthy situation, or
is it a healthy response to a sick situation?” In other words, if it is the school system that is
dysfunctional (sick) and not the individual client, do we or should we adjust the client to that
sick situation? In this case, do we focus on stopping the fighting behavior? If we view the
fighting behavior as a healthy response to a sick situation, then eliminating the unhealthy
situation (teasing, insensitive administrators and teachers, monocultural curriculum, etc.)
should receive top priority for change (Lee, 2007). In other words, rather than individual
therapy, social therapy may be the most appropriate and effective means of intervention. Yet,
mental health professionals are ill‐equipped and untrained as social change agents (Ali &
Sichel, 2014; Lopez‐Baez & Paylo, 2009).
Principle 4: Organizations Are Microcosms of the Wider Society From
Which They Originate; As a Result, They Are Likely to Be Reflections of the
Monocultural Values and Practices of the Larger Culture
As we have repeatedly emphasized, we are all products of our cultural conditioning and
inherit the biases of the larger society (Sue, 2015). Likewise, organizations are microcosms of
the wider society from which they originate. As a result, they are likely to be reflections of
the monocultural values and practices of the larger culture. In this case, it is not far‐fetched
to assume that White students, helping professionals, and educators may have inherited the
racial biases of their forebears. Further, multicultural education specialists have decried the
biased nature of the traditional curriculum. Although education is supposed to liberate and
convey truth and knowledge, we have seen how it has oftentimes been the culprit in
perpetuating false stereotypes and misinformation about various groups in our society. It has
done this, perhaps not intentionally, but through omission, fabrication, distortion, or selective
emphasis of information, designed to enhance the contributions of certain groups over others
(Cokley, 2006). The result is that institutions of learning become sites that perpetuate myths
and inaccuracies about certain groups in society, with devastating consequences for students
of color. Further, policies and practices that claim to “treat everyone the same” may
themselves be culturally biased. If this is the institutional context from which Daryl is
receiving his education, little wonder that he exhibits so‐called problem behaviors. Again,
the focus of change must be directed at the institutional level.
Principle 5: Organizations Are Powerful Entities That Inevitably Resist
Change and Possess Many Ways to Force Compliance Among Workers;
Going against the Policies, Practices, and Procedures of the Institution, for
Example, Can Bring About Major Punitive Actions
Let us look at the situation of Ms. Jones, the Black teacher. There are indications in this case
that she understands that Daryl may be the victim of racism and a monocultural education
that invalidates him. If she is aware of this factor, why is she so reluctant to act on behalf of
Daryl and his parents? First, it is highly probable that, even if she is aware of the true
problem, she lacks the knowledge, expertise, and skill to intervene on a systemic level.
Second, institutions have many avenues open to them that can be used to force compliance on
the part of employees. Voicing an alternative opinion against prevailing beliefs can result in
ostracism by fellow workers, a poor job performance rating, denial of a promotion, or even an
eventual firing (Sue et al., 2011). This creates a very strong ethical dilemma for mental health
workers or educators when the needs of their clients differ from those of the organization or
employer. The fact that counselors' livelihoods depend on the employing agency (school
district) creates additional pressures to conform. How do counselors handle such conflicts?
Organizational knowledge and skills become a necessity if the therapist is to be truly effective
(Toporek, Lewis, & Crethar, 2009). So, even the most enlightened educators and counselors
may find their good intentions thwarted by their lack of systems intervention skills and their
fears of punitive actions.
Principle 6: When Multicultural Organizational Development Is Required,
Alternative Helping Roles That Emphasize Systems Intervention and
Advocacy Skills Must Be Part of the Repertoire of the Mental Health
Professional
Because the traditional counseling/therapy roles focus on one‐to‐one or small‐group
relationships, they may not be productive when dealing with larger ecological and systemic
issues. Competence in changing organizational policies, practices, procedures, and structures
within institutions requires a different set of knowledge and skills that are more action‐
oriented. Among them, consultation and advocacy become crucial in helping institutions
move from a monocultural to a multicultural orientation (Davidson et al., 2006). Daryl's
school and the school district need a thorough cultural audit, institutional change in the
campus climate, sensitivity training for all school personnel, increased racial/ethnic personnel
at all levels of the school, revamping of the curriculum to be more multicultural, and so on.
This is a major task that requires multicultural awareness, knowledge, and skills on the part of
the mental health professional.
Principle 7: Although Remediation Will Always Be Needed, Prevention Is
Better
Conventional practice at the micro level continues to be oriented toward remediation rather
than prevention. Although no one would deny the important effects of biological and internal
psychological factors on personal problems, much research now acknowledges the
importance of sociocultural factors (inadequate or biased education, poor socialization
practices, biased values, and discriminatory institutional policies) in creating many of the
difficulties encountered by individuals (Flores et al., 2014). As therapists, we are frequently
placed in a position of treating clients who represent the aftermath of failed and oppressive
policies and practices. We have been trapped in the role of remediation (attempting to help
clients once they have been damaged by sociocultural biases). Although treating troubled
clients (remediation) is a necessity, our task will be an endless and losing venture if the true
sources of the problem (stereotypes, prejudice, discrimination, and oppression) are not
changed. Would it not make more sense to take a proactive and preventive approach by
attacking the cultural and institutional bases of the problem?
REFLECTION AND DISCUSSION QUESTIONS
1. Exactly how do organizational policies and practices oppress?
2. What do you need to know in order to effectively be a social‐change agent?
3. Is organizational change difficult?
4. If individual counseling/therapy is ineffective in systems intervention, what alternative
roles will you need to play?
Video 4.3: Stereotyping and Stigma
Client and therapist differences as a way to enrich the conversation instead of hindering or
blocking rapport.
SOCIAL JUSTICE COUNSELING
The case of Daryl demonstrates strongly the need for a social justice orientation to counseling
and therapy (Neville, 2015). Indeed, MCT competence is intimately linked to the values of
social justice (Koch & Juntunen, 2014; Ratts et al., 2016). If mental health practice is
concerned with bettering the life circumstances of individuals, families, groups, and
communities in our society, then social justice is the overarching umbrella that guides our
profession. The welfare of a democratic society very much depends on equal access and
opportunity, fair distribution of power and resources, and empowering individuals and groups
with a right to determine their own lives (Ratts & Hutchins, 2009). J. M. Smith (2003) defines
a socially just world as having access to
adequate food, sleep, wages, education, safety, opportunity, institutional support, health
care, child care, and loving relationships. “Adequate” means enough to allow
[participation] in the world … without starving, or feeling economically trapped or
uncompensated, continually exploited, terrorized, devalued, battered, chronically
exhausted, or virtually enslaved (and for some reason, still, actually enslaved). (p. 167)
Bell (1997) states that the goal of social justice is
full and equal participation of all groups in a society that is mutually shaped to meet
their needs. Social justice includes a vision of society in which the distribution of
resources is equitable and all members are physically and psychologically safe and
secure. (p. 3)
Given these broad descriptions, we propose the following working definition of social justice
counseling/therapy.
Social justice counseling/therapy is an active philosophy and approach aimed at
producing conditions that allow for equal access and opportunity; reducing or
eliminating disparities in education, health care, employment, and other areas that
lower the quality of life for affected populations; encouraging mental health
professionals to consider micro, meso, and macro levels in the assessment, diagnosis,
and treatment of clients and client systems; and broadening the role of the helping
professional to include not only counselor/therapist but also advocate, consultant,
psychoeducator, change agent, community worker, and so on.
Thus, social justice counseling/therapy has the following goals:
1. to produce conditions that allow for equal access and opportunity;
2. to reduce or eliminate disparities in education, health care, employment, and other areas
that lower the quality of life for affected populations;
3. to encourage mental health professionals to consider micro, meso, and macro levels in
the assessment, diagnosis, and treatment of clients and client systems; and
4. to broaden the role of the helping professional to include not only counselor/therapist but
also advocate, consultant, psychoeducator, change agent, community worker, and so on.
Advocacy for Organizational Change
All helping professionals need to understand two things about mental health practice: (a) they
often work within organizations that may be monocultural in policies and practices; and (b)
the problems encountered by clients are often due to organizational or systemic factors. This
is a key component of the ecological or person‐in‐environment perspective (Fouad,
Gerstein, & Toporek, 2006). In the first case, the policies and practices of an institution may
thwart the ability of counselors to provide culturally appropriate help for their diverse
clientele. In the second case, the structures and operations of an organization may unfairly
deny equal access and opportunity (access to health care, employment, and education) for
certain groups in our society. It is possible that many problems of mental health are truly
systemic problems caused by racism, sexism, and homophobia. Thus, understanding
organizational dynamics and possessing multicultural institutional intervention skills are part
of the social justice framework (Pieterse, Evans, Risner‐Butner, Collins, & Mason, 2009).
Making organizations responsive to a diverse population ultimately means being able to help
them become more multicultural in outlook, philosophy, and practice.
Social justice counseling (a) takes a social‐change perspective that focuses on ending
oppression and discrimination in our society (e.g., within organizations, communities,
municipalities, governmental entities); (b) believes that inequities that arise within our society
are due not necessarily to misunderstandings, poor communication, lack of knowledge, and
so on, but to monopolies of power; and (c) assumes that conflict is inevitable and not
necessarily unhealthy. Diversity trainers, consultants, and many industrial‐organizational
(I/O) psychologists increasingly endorse multicultural change, based on the premise that
organizations vary in their awareness of how racial, cultural, ethnic, sexual orientation, and
gender issues impact their clients or workers. Increasingly, leaders in the field of counseling
psychology have indicated that the profession should promote the general welfare of society;
be concerned with the development of people, their communities, and their environment; and
promote social, economic, and political equity consistent with the goals of social justice
(Toporek, Gerstein, Fouad, Roysircar, & Israel, 2006).
Thus, social justice counseling includes social and political action that seeks to ensure that all
people have equal access to the resources, employment, services, and opportunities they
require to meet their basic human needs and to develop fully (Goodman et al., 2004; Ibrahim
& Heuer, 2016). If mental health professionals are concerned with the welfare of society, and
if society's purpose is to enhance the quality of life for all persons, then these professionals
must ultimately be concerned with the injustices and obstacles that oppress, denigrate, and
harm those in our society (Chavez, Fernandez, Hipolito‐Delgado, & Rivera, 2016; Warren
& Constantine, 2007). They must be concerned with issues of classism, racism, sexism,
homophobia, and all the other “isms” that deny equal rights to everyone. As mentioned
previously, counselors/therapists practice at three levels: micro—where the focus is on
individuals, families, and small groups; meso—where the focus is on communities and
organizations; and macro—where the focus is on the larger society (e.g., statutes and social
policies).
Social Justice Advocacy and Cultural Humility
Mental health practitioners who take up social justice goals come to their counseling sessions
with years of formal training, numerous advanced degrees, and a sincere commitment to
social change. These qualifications provide them with valuable tools, but they also leave them
at the risk of prioritizing their own knowledge and approaches over their clients' perspectives.
Cultural humility (Hook, Davis, Owen, Worthington, & Utsey, 2013) refers to the crucial
importance of maintaining an interpersonally open and genuinely respectful stance regarding
clients' cultural identities, backgrounds, and experiences. In particular, professionals must
remember that the clients are the experts on their own cultural journeys.
Culturally humble therapists rarely assume competence (i.e., letting prior experience
and even expertise lead to overconfidence) for working with clients just based on their
prior experience working with a particular group. Rather, therapists who are more
culturally humble approach clients with respectful openness and work collaboratively
with clients to understand the unique intersection of clients' various aspects of identities
and how that affects the developing therapy alliance.
(Hook et al., 2013, p. 354)
Not only is a culturally humble approach a more accurate one (in that clients do, in fact, hold
personal cultural expertise), it may also be a key element of culturally competent, socially just
counseling practice. Research that explored the occurrence and impact of racial
microaggressions during therapy found that clients who perceived their therapists as
culturally humble (a) reported fewer microaggressive interactions and (b) experienced a less
negative impact when microaggressions did occur (Hook et al., 2016). Conscious cultivation
of a respectful, humble attitude may help therapists become more sensitive and aware
regarding the commission of microaggressions, and it may also enable them to work through
microaggressions in an open, nondefensive fashion that allows the therapeutic relationship to
repaired afterward (Hook et al., 2016).
Social Justice Advocacy and Counseling Roles
To achieve conditions of social equity is truly an uphill battle. But, just as the history of the
United States is the history of racism, so it is the history of antiracism as well. There have
always been people and movements directed toward the eradication of racism, including
abolitionists, civil rights workers, private organizations (e.g., the Southern Poverty Law
Center, the National Association for the Advancement of Colored People [NAACP], B'nai
Brith), political leaders, and especially people of color. Racism, like sexism, homophobia,
and all intersecting forms of oppression, must be on the forefront of social justice work
(Crenshaw, 1989, 1991; Moradi & Grzanka, 2017; Rosenthal, 2016). Efforts must be directed
at social change in order to eradicate bigotry and prejudice. In this respect, psychologists and
counselors must use their knowledge and skills to (a) impact the channels of socialization
(e.g., education, media, groups, organizations) to spread a curriculum of multiculturalism, and
(b) aid in the passage of legislation and social policy (e.g., affirmative action, civil rights
voting protections, sexual harassment laws) (Goodman, 2009; Lopez‐Baez & Paylo, 2009;
Ratts, 2010). To accomplish these goals, we will need to broaden our practice beyond
individual psychotherapy to embrace the systems intervention roles identified by Atkinson,
Thompson, and Grant (1993): advocate, change agent, consultant, adviser, facilitator of
indigenous support systems, and facilitator of indigenous healing methods.
IMPLICATIONS FOR CLINICAL PRACTICE
1. The mental health profession must take the initiative in confronting the potential
political nature of mental health practice. The practice of counseling/therapy and the
knowledge base that underlies the profession are not morally, ethically, and politically
neutral.
2. We must critically reexamine our concepts of what constitutes normality and
abnormality, begin mandatory training programs that deal with these issues, critically
examine and reinterpret past and continuing literature dealing with socially marginalized
groups in society, and use research in such a manner as to improve the life conditions of
the researched populations.
3. The study of marginalized group cultures must receive equal treatment and fair portrayal
at all levels of education.
4. The education and training of psychologists have, at times, created the impression that
the theories and practices of psychology are apolitical and value‐free.
5. The psychological problems of marginalized group members may reside not within but
outside of them.
6. Too much research has concentrated on the mental health problems and pathologies of
groups of color, while little has been done to determine the advantages of being
bicultural and the strengths and assets of these groups.
7. Psychological disturbances and problems in living are not necessarily caused by internal
attributes (low intelligence, lack of motivation, character flaws, etc.) but may result from
external circumstances, such as prejudice, discrimination, and disparities in education,
employment, and health care.
8. Social justice counseling may dictate social and political actions that seek to ensure that
all people have equal access to the resources, employment, services, and opportunities
they require to meet their basic human needs.
9. Social justice advocacy dictates playing roles that involve advocating on behalf of
clients who are victimized by the social system that creates disparities in health care,
education, and employment.
10. Culturally humble counselors remember that their formal social justice training does not
make them the experts on clients' individual cultural journeys—the clients themselves
hold that expertise, and counselors should, first and foremost, seek to learn from them.
Video 4.6: Equity in Counseling
The client's truth and how to be intentional about honoring his or her personal experiences
and personal truth.
SUMMARY
Mental health practice is strongly influenced by historical and current sociopolitical forces
that impinge on issues of race, culture, and ethnicity. The therapeutic session is often a
microcosm of race relations in our larger society; therapists often inherit the biases of their
forebears; and therapy represents a primarily EuroAmerican activity. These failures can be
seen in (a) the education and training of mental health professionals, (b) biased mental health
literature, and (c) an equation of pathology with differences. The genetic and culturally
deficient models have perpetuated these failures by graduating mental health practitioners
from programs with the belief that people of color are lacking the right genes or the right
White middle‐class values to succeed in U.S. society. The culturally diverse model,
however, no longer views people of color as deficient, but recasts differences as alternative
lifestyles and addresses the advantages of being bicultural and the inherent value of
differences.
Social justice counseling recognizes that problems do not necessarily reside in individuals but
may be externally located in organizations and the social system. As a result, mental health
professionals must be prepared to direct their foci of interventions to the individual,
professional, organizational, and societal levels. Specifically, when organizational
interventions are required, seven principles are identified. Students are encouraged to study
them thoroughly. All stress the importance of understanding how systemic factors (person–
environment interactions) contribute to individual behavior, and all are necessary for accurate
assessment, diagnosis, and treatment. Clients are viewed not as isolated units but as
embedded in their families, social groups, communities, institutions, and cultures, as well as
in major systems of our society.
If mental health practice is concerned with bettering the life circumstances of individuals,
families, groups, and communities, then social justice is the overarching umbrella that guides
our profession. The welfare of a democratic society very much depends on equal access and
opportunity, fair distribution of power and resources, and the empowerment of individuals
and groups with a right to determine their own lives. To accomplish this goal, therapists must
be prepared to treat social and systemic problems and play alternative helping roles that have
not traditionally been considered therapy. Advocacy roles in counseling fall into this
category.
GLOSSARY TERMS
Abnormality
Antiracism
Cultural encapsulation
Cultural humility
Culture‐bound training
Cultural paranoia
Cultural deprivation
Culturally deficient model
Culturally diverse model
Ethnocentricity
Genetically deficient model
Levels of intervention
Scientific racism
Social justice counseling
Video 4.7: Counseling Session Analysis
Pathologizing and blaming the victim as a way of explaining away cultural bias and
discrimination.
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5
The Impact of Systemic Oppression Within the Counseling
Process: Client Worldviews and Counselor Credibility
Chapter Objectives
1. 1. Understand how historical oppression in the lives of people of color influences
reactions to counselors and the counseling process.
2. 2. Describe how traditional counseling and therapy may be antagonistic to the
lifestyles, cultural values, and sociopolitical experiences of marginalized clients.
3. 3. Learn how counseling and psychotherapy may represent microcosms of race
relations in the wider society between majority group counselors and clients of
color.
4. 4. Describe the manifestation, dynamics, and impact of ethnocentric
monoculturalism in theories of counseling and psychotherapy and in therapeutic
practice.
5. 5. Identify the special challenges that White helping professionals may encounter
regarding their credibility (expertness and trustworthiness) when working with
clients of color.
6. 6. Understand the concepts of locus of control and locus of responsibility and apply
them to multicultural counseling.
7. 7. Define and describe how racial worldviews are formed.
8. 8. Discuss how culturally diverse clients with particular worldviews may respond in
the therapy process.
CASE STUDY
COUNSELING PRACTICE AS A RACIAL‐CULTURAL MICROCOSM
Can racial dynamics be detected even within a psychotherapeutic dyad—an interaction
where counselors are attempting to attend to every nuance of their own and their clients'
communications? The three quotes that follow are from three different posters on a
weblog where participants' cross‐racial therapy dyads were being discussed
(MetaFilter, 2016).
1. [My therapist] kind of steers me towards the notion that I have the power to react any
way I want (which is true, I guess, except when you're a minority and the fact is you
wear that skin 24/7 whether you like it or not, and people do treat you differently…)
2. [My therapist] said, “Yes, well, it's common for unmarried Asian women in their thirties
to feel like they've failed because they're single and don't have families.” I was like,
where are you getting that from??! Being single and not having a family was pretty low
on my list of problems.
3. One thing I was working on was my terrible relationship with my mother, and my
therapist was really hung up on this idea of “culture” being the problem … I think my
therapist was genuinely trying to relate to me because she knew that our life experiences
weren't similar. It's just that she had very limited tools to do so.
REFLECTION AND DISCUSSION QUESTIONS
1. For each example, describe the sources of client unease and/or tension.
2. What are the possible consequences of ruptures like these in a therapeutic relationship?
3. If these clients had revealed in session the feelings that they are sharing here, how do
you imagine the therapists might have reacted? How could they have most helpfully
reacted?
The preceding examples illustrate some of the ways in which the racial dynamics that
characterize society at a broad level can enter into the therapeutic dyad. We question neither
the sincerity of these White therapists nor their desire to work effectively with their clients of
color. Rather, we present these remarks to exemplify the blind spots, missed opportunities,
and distress that represent the manifestations of systemic oppression within counseling
practice.
Video 5.0: Introduction
The use of stereotyping, pathology, and stigma as tools of oppression.
LOCATING CLIENTS' PROBLEMS ENTIRELY INSIDE THE CLIENTS
In the first example, the client notes that her therapist's inclination was to neglect race and
culture as part of the client's narrative; rather, her default tendency was to direct the focus of
the session toward individual characteristics. Mental health practice has been characterized as
primarily a White male middle‐class activity that is based on values that include rugged
individualism, individual responsibility, and autonomy (Ivey, Ivey, & Zalaquett, 2014).
Within this framework, the traditional therapist's role is to encourage self‐exploration so
that the client can act on his or her own behalf (Lum, 2011). Within this individual‐centered
approach, problems are generally assumed to reside within the clients themselves, and clients
should be helped to take responsibility for them in order to change them. However, many
problems encountered by marginalized clients actually reside externally to them (such as bias,
discrimination, and prejudice). Such clients should not be faulted for encountering these
obstacles, nor for the emotions that they experience as a consequence.
Along these lines, we can surmise that the therapist in Example 1 is attempting to encourage
her client to take control of her therapeutic issues by resolving to change the feelings that she
is having about them. There is, of course, nothing inherently wrong with supporting clients'
examination of their own reactions in many situations; however, to do so with a client of
color without addressing the simultaneous and uncontrollable impact of racism represents a
form of victim blaming (Ratts & Pedersen, 2014; Ryan, 1971).
CULTURALLY RELATED RESPONSES THAT REPRODUCE
STEREOTYPES
Two of the examples do not show complete inattention to racial dynamics. Two therapists
initiated interventions in which they attempted to helpfully reference race. However, in these
examples (2 and 3), the therapists were not integrating a sociohistorical awareness of racism
with their developing knowledge of who their clients were as individuals. Instead, they
created interventions based on cultural biases and generalities that left their clients feeling
stereotyped, unseen, and in the case of Example 2, angry. Even when therapists have learned
useful information about the cultural histories of other social groups, a formulaic “cookie‐
cutter” application of cultural learning represents an inadequate understanding of how to use
these tools, as the client in Example 3 observed.
RESPONDING WHEN THE ISSUES ARE OUR OWN: WHITE
FRAGILITY
As already mentioned, the client in Example 2 seems to have felt some anger in response to
her therapist's attempted intervention. Our reflection question asked you to imagine the
therapist's possible response if the client had shared those feelings. Counselors are trained to
prioritize the therapeutic alliance and to competently process client responses such as these,
so it is worth anticipating how this unfolding might be experienced in the context of cultural
competence.
Many contemporary counselors and therapists will have participated in a multicultural course
or workshop; for White therapists, this may be the only time that they have reflected upon
their racial identity and worldview. Although valuable, these instructional settings are limited
in scope: they are orderly, protected environments; they are time‐limited; they allow for a
primarily passive role for participants; they may represent race‐related attitudes as lying
“out there” somewhere within other people; and they often do not tackle topics such as White
supremacy in an explicit way. Participants can leave such experiences feeling comfortable
that they have obtained a satisfactory level of competence, despite little exploration of depth
having taken place. Inadequately prepared yet highly confident, such individuals can be
derailed and even moved to anger themselves by race‐related dialogues; these reactions
have been anecdotally observed in therapists by their own clients (e.g., Babu, 2017).
DiAngelo (2011) introduced this phenomenon as White fragility. White fragility responses are
triggered by racial stress, which can result from interruptions to what is racially familiar, such
as:
Someone's suggesting that a White person's viewpoint comes from a racialized frame of
reference (challenge to objectivity);
People of color talking directly about their racial perspectives (challenge to White racial
codes);
People of color choosing not to protect the racial feelings of White people in regards to
race (challenge to White racial expectations and the need/entitlement to racial comfort);
People of color not being willing to tell their stories or answer questions about their
racial experiences (challenge to colonialist relations);
A fellow White not providing agreement with a White person's interpretations (challenge
to White solidarity);
A White person's receiving feedback that their behavior had a racist impact (challenge to
white liberalism);
The suggestion that group membership is significant (challenge to individualism);
An acknowledgment that access is unequal between racial groups (challenge to
meritocracy);
Being presented with a person of color in a position of leadership (challenge to White
authority);
Being presented with information about other racial groups, for example movies in
which people of color drive the action but are not in stereotypical roles, or multicultural
education (challenge to White centrality) (DiAngelo, 2011, p. 57).
When therapists have not received training that directly addresses the historical and systemic
realities of oppression or have not been prepared for personally challenging identity‐related
dialogues via direct experience, they are at risk of acting out their fragility to the detriment of
their marginalized clients. We have mentioned several times that a counselor's inability to
establish rapport and a relationship of trust with culturally diverse clients is a major
therapeutic barrier. If the emotional climate is realistically positive and if trust and
understanding exist between the parties, the two‐way communication of thoughts and
feelings can proceed with optimism. This latter condition is often referred to as “rapport” and
sets the stage on which other essential conditions can become effective. This chapter
discusses trust–mistrust and worldviews as they relate to marginalized groups.
EFFECTS OF HISTORICAL AND CURRENT OPPRESSION
Persons of color and members of other marginalized groups (women; lesbian, gay, bisexual,
transgender, and queer (LGBTQ) individuals; those with disabilities) live under a societal
umbrella of individual, institutional, and cultural forces that often demean them, disadvantage
them, and deny them equal access and opportunity (Toporek & Worthington, 2014).
Experiences of prejudice and discrimination are a social reality for many marginalized groups
and affect the perception of the helping professional in multicultural counseling (Parham &
Caldwell, 2015). Thus, mental health practitioners must become aware of the sociopolitical
dynamics that form not only their clients' worldviews, but their own as well. As in the three
examples at the start of this chapter, racial/cultural dynamics may intrude into the helping
process and cause misdiagnosis, confusion, pain, and a reinforcement of the biases and
stereotypes that both groups have of one another.
It is important for therapists to realize that the history of race relations in the United States
has influenced us to the point where we are extremely cautious about revealing to strangers
our feelings and attitudes about race. In an interracial or intercultural encounter with a
stranger (i.e., therapy), each party will attempt to discern gross or subtle racial attitudes on the
part of the other while minimizing their own vulnerability. Ethnocentric monoculturalism lies
at the heart of oppressor–oppressed relationships, affecting trust–mistrust and self‐
disclosure in the therapeutic encounter.
Ethnocentric Monoculturalism
Most mental health professionals have not been trained to work with anyone other than
mainstream individuals or groups. This is understandable in light of the historical origins of
education, counseling/guidance, and our mental health systems, which have their roots in
EuroAmerican or Western cultures (Arredondo, Gallardo‐Cooper, Delgado‐Romero, &
Zapata, 2014). As a result, U.S. psychology has been severely criticized as being
ethnocentric, monocultural, and inherently biased against racial/ethnic minorities, women,
LGBTQ persons, and other culturally diverse groups (Constantine & Sue, 2006; Ridley,
2005). In light of the increasing diversity of our society, mental health professionals will
inevitably encounter client populations that differ from themselves in terms of race, culture,
and ethnicity. Such differences are believed to pose no problems as long as psychologists
adhere to the notion of an unyielding, universal psychology that is applicable across all
populations.
Although few mental health professionals would voice such a belief, in reality the very
policies and practices of mental health delivery systems do reflect such an ethnocentric
orientation. The theories of counseling and psychotherapy, the standards used to judge
normality–abnormality, and the actual process of mental health practice are culture‐bound
and reflect a monocultural perspective of the helping professions (Highlen, 1994; Jones,
2010). As such, they are often culturally inappropriate and antagonistic to the lifestyles and
values of diverse groups in our society. Indeed, some mental health professionals assert that
counseling and psychotherapy may be “handmaidens of the status quo,” instruments of
oppression, and transmitters of society's values (Halleck, 1971; Prilleltensky, 1989; Thomas
& Sillen, 1972).
We believe that ethnocentric monoculturalism is dysfunctional in a pluralistic society such as
that of the United States. It is a powerful force, however, in forming, influencing, and
determining the goals and processes of mental health delivery systems. Hence, it is very
important for mental health professionals to unmask or deconstruct the values, biases, and
assumptions that reside in it. Ethnocentric monoculturalism combines what Wrenn (1962)
calls cultural encapsulation and what J. M. Jones (1997) refers to as cultural racism. Five
components of ethnocentric monoculturalism have been identified (Sue, 2004).
Belief in the Superiority of the Dominant Group
First, there is a strong belief in the superiority of one group's cultural heritage (history,
values, language, traditions, arts/crafts, etc.). The group norms and values are seen positively,
and descriptors may include such phrases as “more advanced” and “more civilized.”
Members of the society may possess conscious and unconscious feelings of superiority and
feel that their way of doing things is the best way. In our society, White EuroAmerican
cultural characteristics are seen as not only desirable but also normative. Physical
characteristics such as light complexion, blond hair, and blue eyes; cultural characteristics
such as a belief in Christianity (or monotheism), individualism, a Protestant work ethic, and
capitalism; and behavioral characteristics such as standard English, control of emotions, and
the written tradition are highly valued components of EuroAmerican culture (Anderson &
Middleton, 2011; Katz, 1985). People possessing these traits are perceived more favorably
and often are allowed easier access to the privileges and rewards of the larger society
(Furman, 2011).
Belief in the Inferiority of Others
Second, there is a belief in the inferiority of the cultural heritage of persons of color, which
extends to their customs, values, traditions, and language (Jones, 1997). Other societies or
groups may be perceived as less developed, uncivilized, primitive, or even pathological.
These groups' lifestyles or ways of doing things are considered to be inferior or to represent
exotic curiosities. Physical characteristics such as dark complexion, black hair, and brown
eyes; cultural characteristics such as belief in non‐Christian religions (Islam, Confucianism,
polytheism, etc.), collectivism, present‐time orientation, and the importance of shared
wealth; and linguistic characteristics such as bilingualism, nonstandard English, speaking
with an accent, use of nonverbal and contextual communication, and reliance on the oral
tradition are usually seen as less desirable by the society (Sue, 2010). Studies consistently
reveal that individuals who are physically different, who speak with an accent, and who
adhere to different cultural beliefs and practices are more likely to be evaluated more
negatively in our schools and workplaces. Culturally diverse groups may be seen as less
intelligent, less qualified, and less popular, and as possessing more undesirable traits.
Power to Impose Standards
Third, the dominant group possesses the power to impose its standards and beliefs on less
powerful groups (Ratts & Pedersen, 2014; Ridley, 2005). This third component of
ethnocentric monoculturalism is very important. All groups are to some extent ethnocentric;
that is, they feel positive about their cultural heritage and way of life. People from
marginalized groups can be biased, can hold stereotypes, and can strongly believe that their
way is the best way. Yet, if they do not possess the sociocultural power to impose their values
on others, then they lack the ability to enforce them via oppression. It is the power
differential, or the unequal status relationship between groups, that enables oppression and
that defines ethnocentric monoculturalism. Ethnocentric monoculturalism is the individual,
institutional, and cultural expression of the belief in the superiority of one group's cultural
heritage over that of another, combined with the possession of the power to impose one's
standards broadly on less powerful groups. Since marginalized groups do not possess a share
of economic, social, and political power equal to that of Whites in our society, they are
generally unable to discriminate on a large‐scale basis (Ponterotto, Utsey, & Pedersen,
2006), although as mentioned, they may certainly hold prejudiced attitudes of their own.
Manifestation in Institutions
Fourth, the ethnocentric values and beliefs of the dominant group are manifested in the
programs, policies, practices, structures, and institutions of the society. For example, chain‐
of‐command systems, training and educational systems, communications systems,
management systems, and performance‐appraisal systems dictate and control many aspects
of our lives. Ethnocentric values attain untouchable and unquestioned status within
organizations. Because most systems are monocultural in nature and demand compliance,
persons of color and women may be oppressed. J. M. Jones (1997) labels institutional racism
as a set of policies, priorities, and accepted normative patterns designed to subjugate and
oppress individuals and groups, and force their dependence on a larger society. It does this by
sanctioning unequal goals, unequal status, and unequal access to goods and services.
Institutional racism has fostered the enactment of discriminatory statutes, the selective
enforcement of laws, the blocking of economic opportunities and outcomes, and the
imposition of forced assimilation/acculturation on the culturally diverse.
The Invisible Veil
Fifth, since people are the products of cultural conditioning, their values and beliefs
(worldviews) represent an invisible veil that operates outside the level of conscious awareness
(Neville, Gallardo, & Sue, 2016). As a result, people assume universality: that, regardless of
race, culture, ethnicity, or gender, everyone shares the nature of reality and truth. This
assumption is erroneous but is seldom questioned because it is firmly ingrained in our
worldview. It is well‐intentioned individuals who consider themselves moral, decent, and
fair‐minded who may have the greatest difficulty in understanding how their belief systems
and actions may be biased and prejudiced. It is clear that no one is born wanting to be racist,
sexist, or homophobic. Misinformation related to culturally diverse groups is not acquired by
our free choice but rather is imposed through a relentless, often subconscious, process of
social conditioning; all of us were taught to hate and fear others who are different in some
way (Sue, 2003). Likewise, because all of us live, play, and work within organizations, those
policies, practices, and structures that may be less than fair to minority groups are invisible in
controlling our lives. Perhaps the greatest obstacle to a meaningful movement toward a
multicultural society is our failure to understand our unconscious and unintentional
complicity in perpetuating bias and discrimination via our personal values/beliefs and our
institutions. The power of racism, sexism, and homophobia is related to the invisibility of the
powerful forces that control and dictate our lives.
Historical Manifestations of Ethnocentric Monoculturalism
The EuroAmerican worldview can be described as possessing the following values and
beliefs: rugged individualism, competition, mastery and control over nature, a unitary and
static conception of time, religion based on Christianity, separation of science and religion,
and competition (Katz, 1985; Ratts & Pedersen, 2014). It is important to note that worldviews
are neither right nor wrong, good nor bad. They become problematic, however, when they are
expressed and enforced through the process of ethnocentric monoculturalism. In the United
States, the historical manifestations of this process are quite clear. The European colonization
efforts toward the Americas, for example, operated from the assumption that the enculturation
of indigenous peoples was justified because European culture was superior. Forcing
colonized people to adopt European beliefs and customs was seen as civilizing them. This
practice was clearly evident in the treatment of Native Americans, whose lifestyles, customs,
and practices were seen as backward and uncivilized; these attitudes were used to justify the
conversion of the “heathens” (Duran, 2006; Gone, 2010).
Monocultural ethnocentric bias has a long history in the United States, as reflected in the
uneven application of the Bill of Rights, which favored White immigrants/descendants over
minority populations (Barongan et al., 1997). In 1776, Britain's King George III accepted a
Declaration of Independence from his former subjects who had moved to this new country.
This proclamation was destined to shape and reshape the geopolitical and sociocultural
landscape of the world many times over. The lofty language penned by its principal architect,
Thomas Jefferson, and signed by those present, was indeed inspiring: “We hold these truths
to be self evident, that all men are created equal.”
Yet, as we now view the historic actions of that time, we cannot help but be struck by the
paradox inherent in them. First, all 56 of the signatories were White males of European
descent—hardly a representation of the current racial and gender composition of the
population. Second, the language of the declaration suggests that only men are created equal;
what about women? Third, many of the founding fathers were slave owners who seem not to
have recognized the hypocritical personal standards that they used because they considered
Blacks to be subhuman. Fourth, the history of this land did not start with the Declaration of
Independence or the formation of the United States of America; nevertheless, our textbooks
continue to teach us an ethnocentric perspective (“Western Civilization”) that ignores the
natives of this country. Last, it is important to note that those early Europeans who came to
this country were immigrants attempting to escape persecution (oppression), but who failed to
recognize their own role in the oppression of the indigenous peoples (American Indians) who
had already resided in the land for centuries.
While ethnocentric monoculturalism is much broader than the concept of racial oppression,
race and color have been primary determinants of the social order: the White race has been
seen as superior and White culture as normative. Thus, a study of U.S. history must include a
study of racism and racist practices directed at people of color (e.g., Zinn, 2015). The
oppression of the indigenous people of this country (Native Americans), the enslavement of
African Americans, the widespread segregation of Hispanic Americans, the passage of
exclusionary laws against the Chinese, and the forced internment of Japanese Americans are
social realities. Telling “the rest of the story” is important. Thus, it should be of no surprise
that our racial/ethnic‐minority citizens may view EuroAmericans and our institutions with
considerable mistrust and suspicion. Likewise, in counseling and psychotherapy, which
demand a certain degree of trust between therapist and client, an interracial encounter may be
fraught with historical and current psychological baggage related to issues of discrimination,
prejudice, and oppression.
Video 5.1: Access and Accessibility
The impact of institutional and political oppression on the experiences of clients of color.
Surviving Systemic Oppression
Many multicultural specialists (Parham, Ajamu, & White, 2011; Ponterotto et al., 2006) have
pointed out how African Americans, in responding to their forced enslavement, the history of
discrimination against them, and majority reactions to their skin color, have adopted toward
Whites behavior patterns that are important for survival in a racist society. These behavior
patterns may include indirect expressions of hostility, aggression, and fear. During slavery, to
raise children who would fit into a segregated system and who could physically survive it,
African American mothers were forced to teach them (a) to express aggression indirectly, (b)
to read the thoughts of others while concealing their own, and (c) to engage in ritualized
accommodating/subordinating behaviors designed to create as few waves as possible. This
process involved a “mild dissociation,” whereby African Americans separated their true
selves from their role as “Negroes” (Boyd‐Franklin, 2010; Jones, 1997). In this dual
identity, the true self is revealed to fellow Blacks, while the dissociated self is revealed to
meet the expectations of prejudiced Whites.
For example, playing it cool has been identified as style of interaction by which African
Americans or other minorities may conceal their true feelings (Boyd‐Franklin, 2010; Cross,
Smith, & Payne, 2002; Grier & Cobbs, 1971; Jones, 1985). This behavior is intended to
prevent Whites from knowing what the minority person is thinking or feeling and to instead
express feelings and behaviors in such a way as to prevent offending or threatening them
(Jones & Shorter‐Gooden, 2003; Ridley, 2005). Similarly, the Uncle Tom syndrome may be
used by Blacks to appear docile, nonassertive, and happy‐go‐lucky. Especially during
slavery, Blacks learned that the performance of passivity was at times a necessary survival
technique.
In summary, it becomes all too clear that past and present discrimination against certain
culturally diverse groups is a tangible basis for distrust of the majority society (McAuliffe &
Associates, 2013). White people are often perceived as potential oppressors unless proved
otherwise. Under such a sociopolitical atmosphere, marginalized groups may use several
adaptive devices to prevent Whites from knowing their true feelings. Because multicultural
counseling may mirror the sentiments of the larger society, these modes of behavior and their
detrimental effects may be reenacted in sessions. The fact that many marginalized clients are
suspicious, mistrustful, and guarded in their interactions with White or otherwise privileged
therapists is certainly understandable in light of the foregoing analysis.
Despite their conscious desire to help, therapists are not immune from inheriting racist
attitudes, beliefs, myths, and stereotypes about individuals from marginalized social groups
(Sue, 2004). Such stereotypes result in their failure to understand the following
considerations:
1. As a group, African Americans tend to communicate nonverbally more than their White
counterparts and to assume that nonverbal communication is a more accurate barometer
of one's true thoughts and feelings. E. T. Hall (1976) observed that African Americans
are frequently better able to read nonverbal messages (high context) than are their White
counterparts and that they rely less on verbalizations than on nonverbal communication
to make a point. Whites, on the other hand, tune in more to verbal messages than to
nonverbal messages (low context). Because they rely less on nonverbal cues, Whites
often need greater verbal elaboration to get a point across (Sue, Ivey, & Pedersen, 1996).
Being unaware of and insensitive to these differences, White therapists are prone to feel
that African American clients are unable to communicate in complex ways. This
judgment is based on the high value that therapy places on intellectual/verbal activity.
2. Rightfully or not, White therapists are often perceived as symbols of institutionalized
privilege who have inherited the racial biases of their forebears. Thus, socially
marginalized clients may impute all the negative experiences of oppression to them. This
may prevent clients from responding to helping professionals as individuals. While
therapists may be possessed of the most admirable motives, clients may reject helping
professionals simply because they are White. Thus, communication may be directly or
indirectly shut off.
3. Some culturally diverse clients may lack confidence in the counseling and therapy
process because White counselors often propose White solutions to their concerns
(Atkinson, Kim, & Caldwell, 1998). Many pressures are placed on clients of color to
accept a White‐identified value system and reject their own. We have already indicated
how counseling and psychotherapy may be perceived as instruments of oppression
whose function is to force assimilation and acculturation. As some racial/ethnic minority
clients have asked, “Why do I have to become White in order to be considered healthy?”
4. The playing it cool and Uncle Tom responses of many people of color are also present in
therapy sessions. As already pointed out, these mechanisms are attempts to conceal true
feelings, to hinder self‐disclosure, and to prevent the therapist from getting to know the
client. Such adaptive survival mechanisms have been acquired through generations of
experience with a hostile and invalidating society. The therapeutic dilemma encountered
by the helping professional in working with a client of color is how to gain trust so that
the client gradually feels encouraged to bring more of their true self into the room. What
therapists ultimately do in sessions will determine their trustworthiness.
In closing, culturally diverse clients entering counseling or therapy are likely to experience
considerable anxiety about ethnic/racial/cultural differences. Suspicion, apprehension, verbal
constriction, unnatural reactions, open resentment and hostility, and passive or cool behavior
may all be expressed. Self‐disclosure and the possible establishment of a working
relationship can be seriously delayed or prevented from occurring. In all cases, the therapist's
trustworthiness may be put to severe test. Culturally effective therapists are ones who (a) can
view these behaviors in a nonjudgmental manner (i.e., they are not necessarily indicative of
pathology but are a manifestation of adaptive survival mechanisms), (b) can avoid
personalizing any potential hostility expressed toward them, and (c) can adequately resolve
challenges to their credibility. Thus, it becomes important for us to understand those
dimensions that may enhance or diminish the culturally different client's receptivity to self‐
disclosure.
COUNSELOR CREDIBILITY AND ATTRACTIVENESS
Counselors who are perceived by their clients as credible (expert and trustworthy) and
attractive (similar) are better able to establish rapport with them than those who are not
(Heesacker & Carroll, 1997). Regardless of the counseling orientation (psychodynamic,
humanistic, behavioral, etc.), a therapist's effectiveness depends on client perceptions of their
expertness, trustworthiness, and attractiveness. Most studies on social influence and
counseling, however, have dealt exclusively with a White population (Heesacker, Conner, &
Pritchard, 1995; Strong, 1969). Thus, counselor attributes traditionally associated with
credibility and attractiveness may not be so perceived by culturally diverse clients. It is
entirely possible that credibility, as defined by professional credentials or advanced degrees,
might only indicate to a Latinx client that the White therapist has no knowledge or expertise
in working with Latinx individuals. It seems important, therefore, for helping professionals to
understand what factors/conditions may enhance or negate counselor credibility and
attractiveness when working with diverse clients.
Counselor Credibility
Credibility may be defined as the constellation of characteristics that makes certain
individuals appear worthy of belief, capable, entitled to confidence, reliable, and trustworthy.
Credibility has two components: expertness and trustworthiness. Expertness is an ability
variable, whereas trustworthiness is a motivation variable. Expertness depends on how well
informed, capable, or intelligent others perceive the communicator (counselor/therapist) to
be. Trustworthiness is dependent on the degree to which people perceive the communicator as
motivated to make valid or invalid assertions. The weight of evidence supports our
commonsense belief that the helping professional who is perceived as expert and trustworthy
can influence clients more than can one who is perceived not to be so.
Expertness
Clients often go to a therapist not only because they are in distress and in need of relief but
also because they believe the counselor is an expert, and has the necessary knowledge, skills,
experience, training, and tools (problem‐solving set) to help them. Perceived expertness is
typically a function of (a) reputation, (b) evidence of specialized training, and (c) behavioral
evidence of proficiency/competency. Clients seeing a therapist of a different race/culture
seem to raise the issue of therapist expertness more often than do those who see a therapist of
their own culture and race (Okun, Chang, Kanhia, Dunn, & Easley, 2017). The fact that
therapists have degrees and certificates from prestigious institutions (authority set) may not
enhance perceived expertness. This is especially true of socially marginalized clients who are
aware that institutional bias exists in training programs. Indeed, it may have the opposite
effect, by reducing credibility! Additionally, reputation‐expertness (authority set) is
unlikely to impress diverse clients unless the favorable testimony comes from someone of
their own group.
Thus, behavior‐expertness, or a demonstration of the ability to help the client, becomes the
critical form of expertness in effective multicultural counseling (problem‐solving set). It
appears that using counseling skills and strategies appropriate to the life values of the
culturally diverse client is crucial. We have already mentioned evidence that certain minority
groups often prefer a much more active approach to counseling. A counselor playing a
relatively inactive role may be perceived as being incompetent and unhelpful. The following
example shows how the therapist's approach can lower perceived expertness.
Asian American Male Client:
It's hard for me to talk about these issues. My parents and friends … they wouldn't
understand … if they ever found out I was coming here for help …
White Male Therapist:
I sense it's difficult to talk about personal things. How are you feeling right now?
Asian American Client:
Oh, all right.
White Therapist:
That's not a feeling. Sit back and get in touch with your feelings. [pause] Now tell
me, how are you feeling right now?
Asian American Client:
Somewhat nervous.
White Therapist:
When you talked about your parents and friends not understanding, the way you
said it made me think you felt ashamed and disgraced at having to come. Was that
what you felt?
Although this exchange appears to indicate that the therapist could (a) see the client's
discomfort and (b) interpret his feelings correctly, it also points out the therapist's lack of
understanding and knowledge of Asian cultural values. Although we do not want to be guilty
of stereotyping Asian Americans, many believe that publicly expressing feelings to a stranger
is inappropriate. The therapist's persistent attempts to focus on feelings and his direct and
blunt interpretation of them may indicate to the Asian American client that the therapist lacks
the more subtle skills of dealing with a sensitive topic or that the therapist is shaming the
client.
Furthermore, it is possible that the Asian American client in this case is much more used to
discussing feelings in an indirect or subtle manner. A direct response from the therapist
addressed to a feeling may not be as effective as one that deals with it indirectly. In many
traditional Asian groups, subtlety is a highly prized art, and the traditional Asian client may
feel much more comfortable when dealing with feelings in an indirect manner.
Many educators claim that specific therapy skills are not as important as the attitude one
brings into the therapeutic situation. Behind this statement is the belief that universal
attributes of genuineness, love, unconditional acceptance, and positive regard are the only
things needed. Yet, the question remains: How does a therapist communicate these things to
culturally diverse clients? While a therapist may have the best of intentions, it is possible that
these might be misunderstood. Let us use another example with the same Asian American
client.
Asian American Client:
I'm even nervous about others seeing me come in here. It's so difficult for me to talk
about this.
White Therapist:
We all find some things difficult to talk about. It's important that you do.
Asian American Client:
It's easy to say that. But do you really understand how awful I feel, talking about
my parents?
White Therapist:
I've worked with many Asian Americans, and many have similar problems.
Here we find a distinction between the therapist's intentions and the effects of his comments.
The therapist's intentions were to reassure the client that he understood his feelings, to imply
that he had worked with similar cases, and to make the client feel less isolated (i.e., that
others have the same problems). The effects, however, were to dilute and dismiss the client's
feelings and concerns and to take the uniqueness out of the situation.
Trustworthiness
Perceived trustworthiness encompasses such factors as sincerity, openness, honesty, and
perceived lack of motivation for personal gain. A therapist who is perceived as trustworthy is
likely to exert more influence over a client than one who is not. In our society, many people
assume that certain roles, such as minister, doctor, psychiatrist, and counselor, exist to help
people. With respect to minorities, self‐disclosure can be associated with this attribute of
perceived trustworthiness. Because mental health professionals are often perceived by
minorities to be agents of the Establishment, trust is something that does not come with the
role. Indeed, many minorities may perceive that therapists cannot be trusted unless otherwise
demonstrated. Again, the role and reputation that the therapist has as being trustworthy must
be evidenced in behavioral terms. More than anything, challenges to the therapist's
trustworthiness will be a frequent theme blocking further exploration and movement until
they are resolved to the satisfaction of the client. These verbatim transcripts illustrate the trust
issue.
White Male Therapist:
I sense some major hesitations … It's difficult for you to discuss your concerns with
me.
Black Male Client:
You're damn right! If I really told you how I felt about my [White] coach, what's to
prevent you from telling him? You Whities are all of the same mind.
White Therapist [angry]:
Look, it would be a lie for me to say I don't know your coach. He's an acquaintance
but not a personal friend. Don't put me in the same bag with all Whites! Anyway,
even if he were a close friend, I hold our discussion in strictest confidence. Let me
ask you this question: What would I need to do that would make it easier for you to
trust me?
Black Client:
You're on your way, man!
This verbal exchange illustrates several issues related to trustworthiness. First, the African
American client is likely to test the therapist constantly regarding issues of confidentiality.
Second, the onus of responsibility for proving trustworthiness falls on the therapist. Third, to
prove that one is trustworthy requires, at times, self‐disclosure on the part of the mental
health professional. That the therapist did not hide the fact that he knew the coach (openness),
became angry about being lumped with all Whites (sincerity), assured the client that he would
not tell the coach or anyone else about their sessions (confidentiality), and asked the client
how he could work to prove he was trustworthy (genuineness) were all elements that
enhanced his trustworthiness.
Handling the “prove to me that you can be trusted” ploy is very difficult for many therapists.
It is difficult because it demands self‐disclosure, something that graduate training programs
have taught us to avoid. It places the focus on the therapist rather than on the client. In
addition, it is likely to evoke defensiveness on the part of many mental health practitioners.
Here is another verbatim exchange in which defensiveness is evoked, destroying the helping
professional's trustworthiness.
Black Female Client:
Students in my drama class expect me to laugh when they do “Stepin Fechit”
routines and tell Black jokes … I'm wondering whether you've ever laughed at any
of those jokes.
White Male Therapist:
[long pause] Yes, I'm sure I have. Have you ever laughed at any White jokes?
Black Client:
What's a White joke?
White Therapist:
I don't know [nervous laughter]; I suppose one making fun of Whites. Look, I'm
Irish. Have you ever laughed at Irish jokes?
Black Client:
People tell me many jokes, but I don't laugh at racial jokes. I feel we're all
minorities and should respect each other.
Again, the client tested the therapist indirectly by asking him if he ever laughed at racial
jokes. Since most of us probably have, to say “no” would be a blatant lie. The client's
motivation for asking this question was to find out (a) how sincere and open the therapist was
and (b) whether the therapist could recognize his racist attitudes without letting it interfere
with therapy. While the therapist admitted to having laughed at such jokes, he proceeded to
destroy his trustworthiness by becoming defensive. Rather than simply stopping with his
statement of “Yes, I'm sure I have” or making some other similar remark, he defends himself
by trying to get the client to admit to similar actions. Thus, the therapist's trustworthiness is
seriously impaired. He is perceived as motivated to defend himself rather than to help the
client.
The therapist's obvious defensiveness in this case has prevented him from understanding the
intent and motive of the question. Is the African American female client really asking the
therapist whether he has laughed at Black jokes before? Or is the client asking the therapist if
he is a racist? Both of these speculations have a certain amount of validity, but it is our belief
that the Black female client is actually asking the following important question of the
therapist: “How open and honest are you about your own racism, and will it interfere with our
session here?” Again, the test is one of trustworthiness, a motivational variable that the White
male therapist has obviously failed.
REFLECTION AND DISCUSSION QUESTIONS
1. Think about yourself, your characteristics, and your interaction style. Think about your
daily interactions with friends, coworkers, colleagues, or fellow students. How
influential are you with them? What makes you influential?
2. As a counselor or therapist, what makes you credible with your clients? Using the
psychological sets outlined earlier, how do you convey expertness and trustworthiness?
3. What do you believe would stand in the way of your trustworthiness with clients of
color? How would you overcome it?
Video 5.2: Challenges and Triumphs
The level of care, or foci, can impact how counseling is performed; knowing how to assess
your client's issues is key to a more positive outcome.
FORMATION OF INDIVIDUAL AND SYSTEMIC WORLDVIEWS
The dimensions of trust–mistrust and credibility in the helping professions are strongly
influenced by worldviews. Worldviews determine how people perceive their relationship to
the world (nature, institutions, other people, etc.), and they are highly correlated with a
person's cultural upbringing and life experiences (Koltko‐Rivera, 2004). Put in a much more
practical way, not only are worldviews composed of our attitudes, values, opinions, and
concepts, but they also affect how we think, define events, make decisions, and behave. For
marginalized groups in the United States, a strong determinant of worldviews is very much
related to the subordinate position assigned to them in society. Helping professionals who
hold a worldview different from that of their clients and who are unaware of the basis for this
difference are most likely to impute negative traits to clients and to engage in cultural
oppression. To understand this assertion, we discuss two different psychological orientations
considered important in the formation of worldviews: (a) locus of control and (b) locus of
responsibility.
Locus of Control
Locus of control can be conceptualized as having two dimensions (Rotter, 1966). Internal
locus of control (IC) refers to the belief that reinforcements are contingent on our own actions
and that we can shape our own fate. External locus of control (EC) refers to the belief that
reinforcing events occur independently of our actions and that the future is determined more
by chance and luck. Research suggests that high internality is associated with multiple
positive attributes such as higher achievement motivation, belief in mastery over the
environment, superior intellect, superior coping skills, and so on (Lefcourt, 1966; Rotter,
1966, 1975). These attributes are highly valued by U.S. society and seem to constitute some
of the core features of Western mental health.
On the other hand, it has been found that people of color, women, and people with low
socioeconomic status score significantly higher on the external end of the locus‐of‐control
continuum (Sue, 1978; Koltko‐Rivera, 2004). Using the IC–EC dimension as a criterion of
mental health would mean that people of color and poor or female clients would be viewed as
possessing less desirable attributes. Thus, a clinician who encounters a minority client with a
high external orientation (e.g., “It's no use trying,” “There's nothing I can do about it,” “You
shouldn't rock the boat”) might interpret the client as being inherently apathetic, prone to
procrastinating, lazy, depressed, or anxious about trying. The problem with an unqualified
application of the IC–EC dimension is that it fails to take into consideration different cultural
and social experiences of the individual. This failure may lead to highly inappropriate and
destructive applications in therapy. It seems plausible that different cultural groups, women,
and people with a lower socioeconomic status have learned that control in their lives operates
differently from how it operates for society at large (American Psychological Association,
2007; Ridley, 2005). For example, externality related to impersonal forces (chance and luck)
is different from that ascribed to cultural forces and from that ascribed to powerful others.
Externality and Culture
Chance and luck operate equally across situations for everyone. However, the forces that
determine locus of control from a cultural perspective may be viewed by a particular ethnic
group as acceptable and benevolent. In this case, externality is viewed positively. U.S.
culture, for example, values the uniqueness, independence, and self‐reliance of individuals.
It places a high premium on self‐reliance, individualism, and status achieved through one's
own efforts. In contrast, the situation‐centered Chinese culture places importance on the
group, on tradition, on social roles expectations, and on harmony with the universe (Kim,
2011; Ratts & Pedersen, 2014). Thus, the cultural orientation of the more traditional Chinese
tends to elevate the external scores. In contrast to U.S. society, Chinese society values
externality highly.
Externality and Sociopolitical Factors
Likewise, high externality may constitute a realistic sociopolitical presence. A major force in
the literature dealing with locus of control is that of powerlessness. Powerlessness may be
defined as the expectancy that a person's behavior cannot determine the outcomes or
reinforcements that he or she seeks. For example, low‐socioeconomic status individuals and
Blacks are not given an equal opportunity to obtain the material rewards of Western culture.
Because of racism, African Americans may perceive, in a realistic fashion, a discrepancy
between their ability and their attainment. For this reason, focusing on external forces may be
motivationally healthy if it results from assessing one's chances for success against real
systematic and external obstacles rather than unpredictable fate. The IC–EC continuum is
useful for therapists only if they make clear distinctions about the meaning of the EC
dimension. High externality may be due to (a) chance/luck, (b) cultural dictates that are
viewed as benevolent, and (c) political forces (racism and discrimination) that represent
malevolent but realistic obstacles.
Locus of Responsibility
Another important dimension in world outlooks is the concept of locus of responsibility
(Jones, 1997). In essence, this dimension measures the degree of responsibility or blame
placed on an individual or system. In the case of Latinx Americans, their lower standard of
living may be primarily attributed to either their personal shortcomings or to racial
discrimination and lack of opportunities. The former orientation blames the individual, while
the latter blames the system.
The degree of emphasis placed on the individual as opposed to the system in affecting a
person's behavior is important in the formation of life orientations. Those who hold a
person‐centered orientation believe that success or failure is attributable to the individual's
skills or personal inadequacies, and that there is a strong relationship between ability, effort,
and success in society. In essence, these people adhere strongly to the Protestant ethic that
idealizes rugged individualism.
On the other hand, situation‐centered people may view the sociocultural and sociopolitical
environment as more potent than the individual. Social, economic, and political forces are
powerful; success or failure is seen in the context of social forces and not attributed solely to
personal characteristics. Defining the problem as residing in the person enables society to
ignore the influence of external factors and to protect and preserve existing social institutions
and belief systems. Thus, the individual/system‐blaming continuum may need to be viewed
differentially for socially devalued groups. An internal response (acceptance of blame for
one's failure) might be considered normative for the White middle class, but for minorities it
may be extreme and intropunitive to disregard the impact of social forces.
Video 5.3: Internal or External Control
The importance of meeting your clients where they are and empathizing with their reality.
FORMATION OF WORLDVIEWS
The two psychological orientations, locus of control and locus of responsibility, are
independent of one another. As shown in Figure 5.1, both may be placed on the continuum in
such a manner that they intersect, forming four quadrants: internal locus of control–internal
locus of responsibility (IC‐IR), external locus of control–internal locus of responsibility
(EC‐IR), external locus of control–external locus of responsibility (EC‐ER), and internal
locus of control–external locus of responsibility (IC‐ER). Each quadrant represents a
different worldview or orientation to life.
FIGURE 5.1 Graphic Representation of Worldviews
Source: D. W. Sue (1978). Eliminating Cultural Oppression in Counseling: Toward a General Theory. Journal of
Counseling Psychology, 25, 422. Copyright © 1978 Journal of Counseling Psychology. Reprinted with permission.
Select this link to open an interactive version of Figure 5.1.
Internal Locus of Control (IC)–Internal Locus of Responsibility (IR)
As mentioned earlier, individuals high in IC believe that they are masters of their fate and that
their actions do affect their life outcomes. Likewise, people high in IR attribute their current
status and life conditions to their own unique attributes; success is due to one's own efforts,
and lack of success to one's shortcomings or inadequacies. Perhaps the greatest
exemplification of the IC–IR philosophy is U.S. society. American culture can be described
as the epitome of the individual‐centered approach that emphasizes uniqueness,
independence, and self‐reliance. A high value is placed on personal resources for solving all
problems, on self‐reliance, on pragmatism, on individualism, on status achievement through
one's own effort, and on power or control over others, things, animals, and forces of nature.
Democratic ideals such as “equal access to opportunity,” “liberty and justice for all,” “God
helps those who help themselves,” and “fulfillment of personal destiny” all reflect this
worldview. The individual is held accountable for all that transpires. Most members of the
White upper and middle classes would fall within this quadrant.
Counseling Implications
Most Western‐trained therapists are of the opinion that people must take major
responsibility for their own actions, and they assume that people can always improve their lot
in life by their own efforts. Clients who occupy this quadrant tend to be White middle‐class
clients, and for these clients such approaches might be entirely appropriate. In working with
clients from different cultures, however, such an approach might be inappropriate. Cultural
oppression in therapy becomes an ever‐present danger.
External Locus of Control (EC)–Internal Locus of Responsibility (IR)
Individuals who fall into this quadrant are most likely to accept the dominant culture's
definition of self‐responsibility but to have very little real control over how they are defined
by others. The term marginal man (person) was first coined by Stonequist (1937) to describe
a person living on the margins of two cultures and not fully accommodated to either.
Marginal individuals deny the existence of racism; believe that the plight of their own people
is the result of laziness, stupidity, and a clinging to outdated traditions; reject their own
cultural heritage and believe that their ethnicity represents a handicap in Western society;
evidence racial self‐hatred; accept White social, cultural, and institutional standards;
perceive physical features of White men and women as an exemplification of beauty; and are
powerless to control their sense of self‐worth because approval must come from an external
source. As a result, they are high in person focus and EC.
Counseling Implications
The psychological dynamics for the EC–IR minority client are likely to reflect his or her
marginal status and self‐hate or internalized racism (e.g., Choi, Israel, & Maeda, 2017;
Watts‐Jones, 2002). For example, White therapists might be perceived as more competent
and preferred than are therapists of the client's own race. To EC–IR individuals, focusing on
feelings may be very threatening because it ultimately might reveal the presence of self‐
hate. A culturally encapsulated White counselor or therapist who does not understand the
sociopolitical dynamics of the client's concerns may unwittingly perpetuate the conflict. For
example, the client's preference for a White therapist, coupled with the therapist's implicit
belief in the values of U.S. culture, becomes a barrier to effective counseling. Culturally
competent therapists need to help clients (a) understand the particular dominant–subordinate
political forces that have created this dilemma and (b) distinguish between positive attempts
to acculturate and a negative rejection of one's own cultural values.
External Locus of Control (EC)–External Locus of Responsibility (ER)
A person high in system blame and EC feels that there is very little one can do in the face of
systemic oppression. In essence, the EC response may be a manifestation of (a) having given
up or (b) attempting to placate those in power. In the former case, individuals internalize their
powerlessness even though they are aware of the external basis of their plight. In its extreme
form, oppression may result in a form of learned helplessness. When marginalized groups
learn that their responses have minimal effect on the environment, the resulting phenomenon
can best be described as an expectation of helplessness. People's susceptibility to helplessness
depends on their experience with controlling the environment. In the face of continued
oppression, many may give up in their attempts to achieve personal goals, and instead act to
accommodate or placate the powerful others in their environment.
The dynamics of the placater, however, are not equivalent to the response of giving up.
Rather, social forces in the form of prejudice and discrimination are seen as too powerful to
combat at that particular time. The best one can hope to do is to suffer the inequities in
silence for fear of retaliation. The phrases that most describe this mode of adjustment include
“Don't rock the boat,” “Keep a low profile,” and “Survival at all costs.” Life is viewed as
relatively fixed, and there appears to be little that the individual can do. Passivity in the face
of oppression is a primary reaction and survival strategy of the placater. Slavery was one of
the most important historical factors in shaping the sociopsychological adaptation of the
African American community. Interpersonal relations between Whites and Blacks were
highly structured and placed African Americans in a subservient and inferior role. Those
Blacks who broke the rules or did not show proper deferential behavior were severely
punished. The spirits of most African Americans, however, were not broken. Conformity to
White EuroAmerican rules and regulations was dictated by the need to survive in an
oppressive environment. Direct expressions of anger and resentment were dangerous, but
indirect expressions were frequent.
Counseling Implications
EC–ER individuals are very likely to see a more privileged therapist as symbolic of any other
dominant–subordinate social relations. They are likely to show “proper” deferential behavior
and not to take seriously admonitions by the therapist that they are the masters of their own
fate. As a result, an IC–IR therapist may perceive the culturally different client as lacking in
courage and ego strength and as being passive. A culturally effective therapist, however,
would realize the basis of these adaptations. Unlike EC–IR clients, EC–ER individuals do
understand the political forces that have subjugated their existence. The most helpful
approaches on the part of the therapist would include (a) teaching the client new coping
strategies, (b) having them experience successes, and (c) validating who and what they
represent.
Internal Locus of Control (IC)–External Locus of Responsibility (ER)
Individuals who score high in IC and system focus believe that they are able to shape events
in their own life if given a chance. They do not accept the idea that their present state is due
to their own inherent weakness. However, they also realistically perceive that external
barriers of discrimination, prejudice, and exploitation can operate to block their paths to the
successful attainment of goals. Recall that the IC dimension was correlated with greater
feelings of personal efficacy, higher aspirations, and so forth, and that ER was related to
collective action in the social arena. Hence, we would expect that IC–ER people would be
more likely to participate in civil rights activities and to value racial identity and activism.
The low self‐esteem engendered by widespread prejudice and racism is actively challenged,
and there is an attempt to redefine a group's existence by stressing consciousness and pride in
one's cultural heritage. For example, such phrases as “Black is beautiful” accompany the
historical relabeling of identity from “Negro” and “colored” to “Black” or “African
American.”
Counseling Implications
Much evidence indicates that people with marginalized group memberships are becoming
increasingly conscious of their own cultural and racial identities as they relate to oppression
in U.S. society. In keeping with these trends, it is also probable that more and more
individuals are likely to hold an IC–ER worldview. Thus, therapists who work with culturally
diverse clients will increasingly be exposed to clients with an IC–ER worldview. In many
respects, these clients may pose the most challenging problems for the White IC–IR therapist,
as the helping professional is likely to be seen as a part of the establishment that has
oppressed minorities. Self‐disclosure on the part of the client is not likely to come quickly;
more than with any other worldview, the IC–ER client is likely to play a much more active
part in the therapy process and to seek action and accountability from a more privileged
therapist.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Understand and apply the concepts of ethnocentric monoculturalism to the wider society
and to marginalized groups; understand how it may manifest and affect the dynamics in
dominant–subordinate counseling relationships.
2. Distinguish between behaviors indicative of a true mental disorder and those that result
from oppression and survival tactics.
3. Do not personalize the suspicions a client may have of your motives. If you become
defensive, insulted, or angry with the client, your effectiveness will be seriously
diminished.
4. Be willing to understand and overcome your stereotypes, biases, and assumptions about
other cultural groups.
5. Know that expertness and trustworthiness are important components of any therapeutic
relationship, but that this relationship may be affected by experiences of oppression.
6. Know that your credibility and trustworthiness will be tested when working with
culturally diverse clients. Tests of credibility may occur frequently in the therapy
session, and the onus of responsibility for proving expertness and trustworthiness lies
with the therapist.
7. Understanding the worldviews of culturally diverse clients means understanding how
they are formed.
8. Know that traditional counseling and therapy operate from the assumption of high IC
and responsibility. Be able to apply and understand how Western therapeutic
characteristics may detrimentally interact with other worldviews.
Video 5.4: Personal Worldview Formulation
Introduction to counseling session by Dr. Joel Filmore.
SUMMARY
The history of race relations in the United States has influenced most of us to the point where
we are extremely cautious about revealing to strangers our feelings and attitudes about race.
In an interracial or intercultural encounter with a stranger (i.e., therapy), each party will
attempt to discern gross or subtle racial attitudes of the other while minimizing their own
vulnerability. Ethnocentric monoculturalism lies at the heart of oppressor–oppressed
relationships, affecting trust–mistrust and self‐disclosure in the therapeutic encounter. The
five components of ethnocentric monoculturalism are belief in the superiority of one group
over another, belief in the inferiority of all other groups, power to impose standards on
socially devalued groups, manifestation and support of institutions, and invisibility of the
imposition process.
It is clear that past and present discrimination against certain culturally marginalized groups
is a tangible basis for minority distrust of the majority society. Majority group members are
often perceived as potential oppressors unless proved otherwise. Under such a sociopolitical
atmosphere, marginalized group members may use several adaptive behaviors to prevent
Whites from knowing their true feelings. Because multicultural counseling may mirror the
sentiments of the larger society, these modes of behavior and their detrimental effects may be
reenacted in the sessions. The fact that many marginalized clients are suspicious, mistrustful,
and guarded in their interactions with White therapists is certainly understandable in light of
the foregoing analysis.
Counselors who are perceived by their clients as credible (expert and trustworthy) and
attractive (similar) are better able to establish rapport with them than those who are not.
Social psychologists have identified the psychological mindsets of people who work toward
establishing communicator and therapist credibility. In multicultural counseling, client testing
of trustworthiness and expertness is likely to enhance or negate the counselor's credibility in
the client's mind. Such tests are likely to prove challenging to well‐intentioned therapists.
Cultural competence means seeking to understand the worldviews of diverse clients. Locus of
control (people's belief that they can shape their own fate—IC, or that chance or luck
determines outcomes—EC) and locus of responsibility (people's belief that causation resides
in the person—IR, or that it lies in the system—ER) interact to form four major worldviews
that explain possible majority and diverse client perceptions and interactions: IC–IR, EC–IR,
EC–ER, and IC–ER, each of which carries therapeutic implications.
GLOSSARY TERMS
Attractiveness
Credibility
Cultural oppression
Ethnocentric monoculturalism
Expertness
Institutional racism
Invisible veil
Locus of control
Locus of responsibility
Playing it cool
Stereotyping
Trustworthiness
Uncle Tom syndrome
Victim blaming
White fragility
White privilege
Worldview
Video 5.5: Counseling Session Analysis
The counselor functions as a tool for change by recognizing oppressive behaviors in order to
reestablish a connection to the client.
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6
Microaggressions in Counseling and Psychotherapy
Christina M. Capodilupo, Ph.D
Teachers College, Columbia University
Chapter Objectives
1. 1. Define and describe microaggressions.
2. 2. Differentiate between the intentions (by the aggressor) and the impact (on the
victim) of microaggressions.
3. 3. Understand the psychological impact of microaggressions on marginalized
groups.
4. 4. Describe the various psychological dynamics involved in microaggressions.
5. 5. Apply knowledge of microaggressions to understanding the therapeutic process
and client/counselor dynamics.
CASE STUDY
TOO TIRED TO STUDY: THE CASE OF MARSHALL
Marshall is a 20‐year‐old Black male attending an undergraduate university in a large
metropolitan city. His mother and father emigrated from Trinidad and Tobago just
before he was born, moving to an urban neighborhood that was predominantly
Caribbean American. Marshall attended the public school system, where he excelled in
his studies and graduated at the top of his class. He chose an extremely well regarded
university that was not too far from home, where he is currently in his second year of
study, majoring in economics. In his first year, Marshall was heavily involved in campus
life: he joined several academic and social groups, played intermural soccer, and rushed
a fraternity. Over the course of that first year, Marshall experienced several similar
events on campus: multiple times he was (a) randomly asked by security to show a
school ID, (b) referred to a door for package deliveries when he was headed in for
classes, and (c) assumed to be an institutional worker rather than a student by faculty,
staff, and other students. Marshall wrote the experiences off each time as being
circumstantial.
Then one night in the spring, Marshall was leaving the library after studying for finals.
As he entered the cold, he put his hood up over his head. Within minutes he found
himself face down on the pavement being told not to move and to put his hands behind
his back. He was immediately taken into a police car for questioning, where it was
explained to him that earlier that evening a woman had been accosted and robbed by a
“male in a hooded sweatshirt.” Marshall was searched on site and asked multiple times
what he was doing there so late. His explanation that he was studying in the library was
reluctantly accepted once Marshall showed his student ID and study materials. He was
let go.
In his second year, Marshall was less involved in activities and felt less motivated to
engage in campus life. He noticed he was having more difficulty getting out of bed in
the mornings and feeling somewhat disinterested in his studies. He started to regularly
skip classes, and found himself traveling home on weekends, reluctant to return. One
day, in a political science class, the students were debating whether the Black Lives
Matter (BLM) movement was tied to a political party. Marshall noticed his heart racing
and his head pounding during the conversation. One of his fellow students asked how a
crowd of angry Black people protesting police brutality and therefore perpetrating
violence against police and White people is any different from a White supremacist
rally. The professor did not have an answer and instead opened it up to the class to
debate. There was minimal engagement for that question, but almost immediately a
classmate asked, “don't all lives matter?” Marshall wanted to respond but felt a sense of
speechlessness wash over him; he wanted to share his experience from the spring with
the police but was not sure anyone would understand. He did not want to be labeled an
“angry Black man” by his professor or his peers. So he stayed silent.
Eventually, with dropping attendance and grades, Marshall's advisor called him in for a
meeting. During their conversation, Marshall revealed how tired and disinterested he
felt. He also reported feeling like he was constantly being watched and surveyed on
campus. Marshall's advisor strongly recommended that he attend the college counseling
center for a consultation and potential therapy.
At the college counseling center, Marshall was assigned to Marie, a White female
graduate student in her early 30s. In the first session, Marshall described feeling like he
did not belong at the university. Marie wondered if the coursework was too challenging
for him and asked if he was having trouble keeping up. He shared his experience of
being perpetually asked for ID by school security and how he often felt disregarded by
his peers and professors. Marie suggested that Marshall may be “reading into his
interactions too intensely” and asked if his body language and posture might suggest to
people that he is “unapproachable.” Marshall felt his heart racing and decided to share
his wrongful accusations by campus police in the spring. Marie looked thoughtful and
after a long pause she shared, “I cannot help but wonder about the hoodie you were
wearing, and I'm thinking that without it, you may not have been accused.” Marshall had
also wondered about the hoodie but ultimately felt that his daily experiences on campus
were those of being treated like a suspect. He felt himself getting angry but thought that
if he expressed this, he would scare Marie. Instead, he shared that he was just so tired, it
felt difficult to attend to his studies.
Marie explained that depression can manifest as feelings of tiredness, trouble getting out
of bed, difficulty focusing, and disengaging from activities one used to enjoy. She
referred to the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5)
(American Psychiatric Association, 2013), pointing out that Marshall met many of the
criteria for a depressive episode. Marshall shared with Marie that he often felt invisible
in the classroom, ignored and unimportant, but that when he stepped out of the
classroom on to campus, he suddenly felt hyper‐visible: like everyone was seeing him
as potentially dangerous, criminal, and certainly out of place. Marie shared that when
under stress, people can feel paranoid and jumpy, and she wondered if that was
happening to Marshall. She told him that around midterms and finals, many students
come into the center reporting similar feelings of depression and anxiety. She wanted
Marshall to know that he was not alone. In fact, Marshall had never felt more alone. He
did not return to the center for a second session.
REFLECTION AND DISCUSSION QUESTIONS
1. What are some of the assumptions that Marie makes about Marshall? Why might she be
making these?
2. Can you describe the psychological impact these assumptions may be having on
Marshall?
3. How might race, gender, and age be affecting the therapeutic relationship between
Marshall and Marie?
4. If you were Marshall's therapist, how would you approach your work with him? What
sociocultural dynamics would exist between you, and how might they influence the
therapeutic process?
5. What could Marie do to repair this therapeutic rupture with Marshall? What role might
cultural mistrust play in this process?
There is clearly misunderstanding and miscommunication between Marshall and Marie.
Marshall was attending therapy in hopes of understanding his experiences and getting re‐
engaged in school; however, his initial session has served as a microcosm for university life,
where he feels disregarded and misunderstood. Marie does not acknowledge Marshall's race
at all in their session, instead depending entirely on diagnosis to explain his feelings. She
locates the problem as an internal one, rather than one caused by the environment and a larger
climate of racism. Marshall's feelings and experiences are unknowingly invalidated, negated,
and dismissed by Marie. This anecdote illustrates how microaggressions can have a
detrimental impact upon marginalized groups and undermine the therapeutic process. Let us
briefly review Marshall's interactions with others from his perspective.
On the college campus, Marshall experiences persistent feelings of not belonging. His
professors and students often mistake him for a service worker and he is frequently asked to
“prove” his position at the school by showing his ID to security. He is keenly aware of the
stereotype of the “angry Black man” and does not want to be typecast should he express his
frustrations. He is aware that if he is experienced as hostile and angry, then people may avoid
him in the future, further compounding his feelings of alienation. Therefore, Marshall feels a
persistent need to monitor his authentic reactions and his tone of voice, impeding his ability
to be his true self (and using a lot of psychic energy!) while at school.
Although the therapist may be attempting to help Marshall by providing him with a diagnosis,
she is actually undermining and invalidating Marshall's experiential reality. Instead of
exploring the school environment and considering that racism causes people to see a Black
man such as Marshall as less capable, less intelligent, and potentially dangerous, Marie
immediately locates the problem within Marshall (“blaming the victim”). She does not
acknowledge his race as the potential common denominator in his experiences, instead
relying entirely on the DSM‐5 to explain his problems. While he may in fact meet criteria
for a depressive episode, Marshall is unlikely to be helped by this information without
consideration of the trigger: racism. Further, Marie questions Marshall's academic abilities,
thereby enacting a stereotype of intellectual inferiority and compounding Marshall's feelings
of not belonging at the university. She goes on to further alienate him by suggesting that
many students have feelings like his when facing the stress of finals. She eliminates race from
every aspect of their conversation, sending a message to Marshall that his race should be
invisible and nonimportant.
The incidents experienced by Marshall are examples of microaggressions. The term “racial
microaggression” was originally coined by Chester Pierce to describe the subtle and often
automatic put‐downs that African Americans face (Pierce, Carew, Pierce‐Gonzalez, &
Willis, 1978). Since then, the definition has expanded to apply to any marginalized group.
Microaggressions can be defined as brief, everyday exchanges that send denigrating messages
to a target group, such as people of color, religious minorities, women, people with
disabilities (PWDs), and lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals
(Sue, 2010, 2017; Sue, Capodilupo, et al., 2007). These microaggressions are often subtle in
nature and can be manifested in the verbal, nonverbal, visual, or behavioral realm.
When professors and peers assume that Marshall is a service worker, they are sending a
message that they do not believe Marshall belongs as a student at the university, that he is not
academically capable. When Marshall is consistently asked for school ID on campus, he is
made to feel like a suspect and criminal for no reason other than that he is a Black male. This
is similar to the concept of “driving while Black,” which refers to the racial profiling of
African American drivers. The underlying thought process seems to be that Black men are
less qualified, less competent, less educated, and more likely to be criminal or dangerous. As
we shall see, microaggressions create hostile and toxic environments where it is difficult to
advance because of unconscious biases and beliefs held by professors and colleagues. In
Marshall's case, the toxicity may prevent him from being able to learn and excel in his
studies.
To help in understanding the effects of microaggressions on marginalized groups, we will be
(a) reviewing related literature on contemporary forms of oppression (e.g., racism, sexism,
heterosexism, ableism, and religious discrimination); (b) presenting a framework for
classifying and understanding the hidden and damaging messages of microaggressions; and
(c) presenting findings from studies that have explored people's lived experiences of
microaggressions.
Video 6.0: Introduction
The clinician as both the expert and the learner, helping clients bridge the divide between
culture and cultural competence.
CONTEMPORARY FORMS OF OPPRESSION
Most people associate racism with blatant and overt acts of discrimination that are epitomized
by White supremacy and hate crimes. Studies suggest, however, that more subtle and
ambiguous forms of racism are just as detrimental (if not more so) than overt expressions and
are frequent, sometimes daily occurrences for people of color (Sue, 2015; Sue, Capodilupo, et
al., 2007) have taken its place. A similar process seems to have occurred with sexism. Subtle
sexism represents “unequal and unfair treatment of women that is not recognized by many
people because it is perceived to be normative, and therefore does not appear unusual”
(Swim, Mallett, & Stangor, 2004, p. 117). Whereas overt and covert sexism are intentional,
subtle sexism is not deliberate or conscious. An example of subtle sexism is sexist language,
such as the use of the pronoun he to convey universal human experience.
In many ways, subtle sexism contains many of the features that define aversive racism, a
form of subtle and unintentional racism (Dovidio & Gaertner, 2000; Dovidio, Gaertner, &
Pearson, 2017). Aversive racism is manifested in individuals who consciously assert
egalitarian values but unconsciously hold antiminority feelings; therefore, “aversive racists
consciously sympathize with victims of past injustice, support the principles of racial
equality, and regard themselves as nonprejudiced. At the same time, however, they possess
negative feelings and beliefs about historically disadvantaged groups, which may be
unconscious” (Gaertner & Dovidio, 2006, p. 618). Inheriting such negative feelings and
beliefs about members of marginalized groups (e.g., people of color, women, LQBTQ
populations) is unavoidable and inevitable due to the socialization process in the United
States (Sue, 2004a, 2004b), where biased attitudes and stereotypes reinforce group hierarchy
(Dovidio et al., 2017). Much like aversive racism, subtle sexism devalues women, dismisses
their accomplishments, and limits their effectiveness in a variety of social and professional
settings (Calogero & Tylka, 2014). Researchers have begun to underscore the importance of
these daily experiences of subtle sexism, arguing that they are in fact harmful and need to be
recognized as such (Becker & Swim, 2012; Cundiff, Zawadzki, Danube, & Shields, 2014).
Researchers have used the templates of modern forms of racism and sexism to better
understand the various forms of modern heterosexism (Smith & Shin, 2014; Walls, 2008) and
modern homonegativity (Morrison & Morrison, 2002). Heterosexism and antigay harassment
have a long history and are currently prevalent in the United States. Studies find the following
for LGBTQ persons in the workplace: (a) between 15 and 43% experience discrimination or
harassment; (b) 7–41% report verbal or physical abuse or have had their workplace
vandalized; and (c) 10–28% have not been promoted because they are gay or transgender
(Burns & Krehely, 2011). Antigay harassment can be defined as “verbal or physical behavior
that injures, interferes with, or intimidates lesbian women, gay men, and bisexual individuals”
(Burn, Kadlec, & Rexler, 2005, p. 24). While antigay harassment includes comments and
jokes that convey that LGBTQ individuals are pathological, abnormal, or unwelcome, it can
also take more subtle forms (Burn et al., 2005). For example, blatant heterosexism would be
calling a lesbian a dyke, whereas subtle heterosexism would be referring to something as gay
to convey that it is stupid. For sexual minorities, hearing this remark may result in a vicarious
experience of insult and invalidation (Burn et al., 2005; Marzullo & Libman, 2009). It may
also encourage individuals to remain closeted, as the environment can be perceived as hostile.
The discriminatory experiences of transgendered people have been very rarely studied in
psychology (Nadal, Rivera, & Corpus, 2010), yet there is evidence to suggest that the
pervasive daily discrimination faced by this population is associated with an elevated risk for
suicide (Marzullo & Libman, 2009). One term used to define prejudice against transgendered
individuals is transphobia, “an emotional disgust toward individuals who do not conform to
society's gender expectations” (Hill & Willoughby, 2005, p. 533). There is recent evidence to
suggest that the microaggressions experienced by transgender individuals are distinct from
those experienced by lesbian, gay, and bisexual people (Nadal, Skolnik, &Wong, 2012;
Nadal, Griffin, Wong, Davidoff, & Davis, 2017).
Although it is increasingly considered politically incorrect to hold racist, sexist, and, to some
extent, heterosexist beliefs, gender roles and expectations tend to be rigid in the United
States, and people may feel more justified in adhering to their transphobic views (Nadal et al.,
2012, 2017). Another area that has received limited attention in the psychological literature is
religious discrimination, despite a high prevalence of religious‐based hate crimes in the
United States (Nadal, Issa, Griffin, Hamit, & Lyons, 2010). The largest percentage of
religious harassment and civil rights violations in the United States are committed against
Jewish and Muslim individuals (Nadal, Issa, et al., 2010). The prejudice experienced by
Muslims is often referred to as Islamophobia and is well documented in Western European
countries both before and since the September 11, 2001 terrorist attacks (Nadal, Issa, et al.,
2010). The media tend to depict Muslims as religious fanatics and terrorists (James, 2008),
and one study reveals that Americans hold both implicit and explicit negative attitudes toward
this group (Rowatt, Franklin, & Cotton, 2005).
Finally, although discriminatory practices toward PWDs is longstanding in the United States
and even believed to be increasing in frequency and intensity (Leadership Conference on
Civil Rights Education Fund [LCCREF], 2009, as cited in Keller & Galgay, 2010), ableism is
rarely included in discussions about modern forms of oppression (Keller & Galgay, 2010).
The expression of ableism “favors people without disabilities and maintains that disability in
and of itself is a negative concept, state, and experience” (Keller & Galgay, 2010).
What makes the phenomenon of subtle discrimination particularly complex is that ambiguity
and alternative explanations obscure the true meaning of the behavior not only for the person
who engages in it, but also for the person on the receiving end.
Video 6.1: Mistakes in Microaggressions
Goal setting as a way of addressing internal and external locus of control issues with clients
of color
THE EVOLUTION OF THE “ISMS”: MICROAGGRESSIONS
Microaggressions are “brief and commonplace daily verbal or behavioral indignities, whether
intentional or unintentional, that communicate hostile, derogatory, or negative racial slights
and insults that potentially have a harmful or unpleasant psychological impact on the target
person or group” (Sue, Bucceri, Lin, Nadal, & Torino, 2007). They can also be delivered
environmentally through the physical surroundings of target groups, where they are made to
feel unwelcome, isolated, unsafe, and alienated.
Authors have further introduced the term “macroaggression” (Huber & Solorzano, 2015) to
refer to systemic and institutional forms of discrimination that impact entire cultural groups.
For example, in the current political climate, the travel ban on Muslim‐majority countries
represents a macroaggression. As explained by Sue et al. (in press, p. 7), “In many respects,
racial macroaggressions represent an overarching umbrella that validates, supports, and
enforces the manifestation of individual acts of racial microaggressions.”
Based on the literature on subtle forms of oppression, one might conclude the following about
microaggressions: they (a) tend to be subtle, unintentional, and indirect; (b) often occur in
situations where there are alternative explanations; (c) represent unconscious and ingrained
biased beliefs and attitudes; and (d) are more likely to occur when people pretend not to
notice differences, thereby denying that race, sex, sexual orientation, religion, or ability had
anything to do with their actions (Sue, Capodilupo, et al., 2007). Three types of
microaggression have been identified: microassault, microinsult, and microinvalidation.
Microassault
The term “microassault” refers to a blatant verbal, nonverbal, or environmental attack
intended to convey discriminatory and biased sentiments. This notion is related to overt
racism, sexism, heterosexism, ableism, and religious discrimination, in which individuals
deliberately convey derogatory messages to target groups. Using epithets like “spic,”
“faggot,” or “kyke”; requesting not to sit next to a Muslim on an airplane; and deliberately
serving disabled patrons last are examples. Unless we are talking about White supremacists,
most perpetrators with conscious biases will engage in overt discrimination only under three
conditions: (a) when some degree of anonymity can be insured; (b) when they are in the
presence of others who share or tolerate their biased beliefs and actions; or (c) when they lose
control of their feelings and actions.
Two high‐profile examples exemplify the first condition: (a) President Trump using vulgar
terms about groping and trying to have sex with women (caught on tape); and (b) Justin
Bieber's use of the N‐word and racial jokes (caught on video). There are also high‐profile
examples of the last: (a) actor Mel Gibson making highly inflammatory anti‐Semitic public
statements to police officers when arrested for driving while intoxicated; and (b) comedian
Michael Richards, who played Kramer on Seinfeld, going on an out‐of‐control rant at a
comedy club and publicly insulting African Americans by hurling racial epithets at them.
Gibson and Richards denied being anti‐Semitic or racist and issued immediate apologies,
but it was obvious both had lost control. Because microassaults are most similar to old‐
fashioned racism, no guessing game is likely to occur as to their intent: to hurt or injure the
recipient. Both the perpetrator and the recipient are clear about what has transpired.
Microinsult
Microinsults are unintentional behaviors or verbal comments that convey rudeness or
insensitivity or demean a person's racial heritage/identity, gender identity, religion, ability, or
sexual orientation identity. Despite being outside the level of conscious awareness, these
subtle snubs are characterized by an insulting hidden message. For example, when a person
frantically rushes to help a person with a disability on to public transportation, the underlying
message is that disabled people are in constant need of help and dependent on others. When
Marshall's therapist assumes that he is having trouble keeping up with his schoolwork, she is
conveying a message of intellectual inferiority.
In fact, messages of intellectual inferiority are prevalent in educational settings for Black and
Latinx Americans (Morales, 2014; Ramirez, 2014; Sue, Capodilupo, & Holder, 2008; Von
Robertson & Chaney, 2017). Latinx Americans report a variety of incidences in which their
academic success is questioned or they are assumed to be less qualified (Minikel‐Lacocque,
2013; Ramirez, 2014; Rivera, Forquer, & Rangel, 2010). Black students have reported a
minimization and devaluation of African American culture by professors and peers, as well as
facing stereotypes of being lazy, uneducated, and dangerous (Brooms, 2016; Harper, 2009;
Von Robertson & Chaney, 2017).
Microinvalidation
Microinvalidations are verbal comments or behaviors that exclude, negate, or dismiss the
psychological thoughts, feelings, or experiential reality of a target group. Like microinsults,
they are unintentional and usually outside the perpetrator's awareness. When Marie dismissed
Marshall's experiences of constantly being asked for ID on campus, she negated his racial
reality. The hidden message delivered to Marshall was that he was the problem, not racism.
Because Marie is in a position of power as a White therapist, she is able not only to define
Marshall's experiential reality but also to direct the course of therapy.
Another common microinvalidation is when individuals claim that they do not see religion or
color but instead see only the human being. When Marshall's classmate states that “all lives
matter,” they are negating the sociohistorical and political lived experience of Black people.
Such statements have been coined by researchers as “color‐blind” attitudes, and research
shows that among White adults in a workplace setting, higher color‐blind attitudes are
associated with lower likelihoods of perceiving microaggressions (Offermann et al., 2014).
To further illustrate the concepts of microinsults and microinvalidations, Table 6.1 provides
some common examples, as well as their accompanying hidden messages and assumptions.
Some of these categories are more applicable to certain forms of microaggression (racial,
gender, religion, ability, or sexual orientation), but they all seem to share commonalities.
TABLE 6.1 Examples of Microaggressions
Themes Microaggression Message
Alien in Own Land
When Asian Americans and Latinx
Americans are assumed to be foreign‐
born
“Where are you from?”
“Where were you born?”
You are not American
“You speak good English” You are a foreigner
A person asking an Asian
American to teach them
words in their native
language
Ascription of Intelligence
Assigning intelligence to a person of
color or a woman based on his or her
race/gender
“You are a credit to your
race”
People of color are
generally not as
intelligent as Whites
“Wow! How did you
become so good in math?”
It is unusual for a
woman to be smart in
math
Asking an Asian person to
help with a math or
science problem
All Asians are
intelligent and good
in math/sciences
“You only got into college
because of affirmative
action”
You are not smart
enough on your own
to get into college
Color Blindness
Statements that indicate that a White
person does not want to acknowledge
race
“When I look at you, I
don't see color”
Denying a person of
color's racial/ethnic
experiences
“America is a melting pot”
Assimilate/acculturate
to dominant culture
“There is only one race,
the human race”
Denying the
individual as a
racial/cultural being
Criminality/Assumption of Criminal
status
Assuming a person of color to be
dangerous, criminal, or deviant based on
their race
A White man or woman
clutching their purse or
checking their wallet as a
Black or Latinx individual
approaches or passes
You are a criminal
A store owner following a
customer of color around
the store
You are going to
steal/You are
poor/You do not
belong
A White person waits to
ride the next elevator
when a person of color is
on it
You are dangerous
Use of Sexist/Heterosexist Language
Terms that exclude or degrade women
and lesbian, gay, bisexual, transgender,
and queer (LGBTQ) persons
Use of the pronoun “he” to
refer to all people
Male experience is
universal
Female experience is
meaningless
Although a male‐to‐
female transgendered
employee has consistently
referred to herself as
“she,” coworkers continue
to refer to her as “he”
Our language does
not need to change to
reflect your identity;
your identity is
meaningless
Two options for
Relationship Status:
Married or Single
LGBTQ partnerships
do not matter/are
meaningless
An assertive woman is
labeled a “bitch”
Women should be
passive
A heterosexual man who
often hangs out with his
female friends more than
his male friends is labeled
a “faggot”
Men who act like
women are inferior
(women are
inferior)/gay men are
inferior
Denial of Individual
Racism/Sexism/Heterosexism/Religious
Discrimination
A statement made when bias is denied
“I'm not racist; I have
several Black friends”
I am immune to
racism because I have
friends of color
“I am not prejudiced
against Muslims; I am just
fearful of Muslims who
are religious fanatics”
I can separate
Islamophobic social
conditioning from my
feelings about
Muslim people in
general
“As an employer, I always
treat men and women
equally”
I am incapable of
sexism
Myth of Meritocracy
Statements that assert that race or gender
does not play a role in life successes
“I believe the most
qualified person should
get the job”
People of color are
given extra unfair
benefits because of
their race
“Men and women have
equal opportunities for
achievement”
The playing field is
even, so if women
cannot make it, the
problem is with them
Pathologizing Cultural
Values/Communication Styles
The notion that the values and
communication styles of the
dominant/White culture are ideal
Asking a Black person:
“Why do you have to be
so loud/animated? Just
calm down”
Assimilate to the
dominant culture
To an Asian or Latinx
person: “Why are you so
quiet? We want to know
what you think. Be more
verbal. Speak up more”
Dismissing an individual
who brings up race/culture
in a work/school setting
Leave your cultural
baggage outside
Second‐Class Citizen
When a target group member receives Mistaking a person of
People of color are
servants to Whites;
differential treatment from the power
group
color for a service worker they couldn't possibly
occupy high‐status
positions
Mistaking a female doctor
for a nurse
Women occupy
nurturing roles
Having a taxi cab pass a
person of color and pick
up a White passenger
You are likely to
cause trouble and/or
travel to a dangerous
neighborhood
Ignoring a person of color
at a store counter and
giving attention to the
White customer behind
them
Whites are more
valued customers than
people of color
Not inviting a lesbian
woman out with a group
of female friends because
they think she will be
bored if they talk to men
You don't belong
Traditional Gender Role Prejudicing
and Stereotyping
When expectations of traditional roles or
stereotypes are conveyed
A male professor asking a
female student working on
a chemistry assignment,
“What do you need to
work on this for anyway?”
Women are less
capable in math and
science
Asking a woman her age
and, upon hearing she is
31, looking quickly at her
ring finger
Women should be
married during
child‐bearing ages
because that is their
primary purpose
Assuming a woman is a
lesbian because she does
not put a lot of effort into
her appearance
Lesbians do not care
about being attractive
to others
Sexual Objectification
When women are treated like objects at
men's disposal
A male stranger putting
his hands on a woman's
hips or on the swell of her
back as he passes her
Your body is not
yours
Whistling at and catcalling
a woman as she walks
down the street
Your
body/appearance is
for men's enjoyment
and pleasure
Using the term “gay” to
describe a fellow student
who is socially ostracized
at school
Gay people are weird
and different
You should keep your
Assumption of Abnormality
When it is implied that there is something
wrong with being LGBTQ
Two men holding hands in
public receiving stares
from strangers
displays of affection
private because they
are offensive
“Did something terrible
happen to you in your
childhood?” to a
transgendered person
Your choices must be
the result of a trauma
and not your
authentic identity
Helplessness
a
When people frantically try to help
people with disabilities (PWDs)
Helping someone with a
disability on to a bus or
train, even when they need
no help
You can't do anything
by yourself because
you have a disability
People feeling they need
to rescue someone from
their disability
Having a disability is
a catastrophe
Denial of Personal Identity
b
When any aspect of a person's identity
other than disability is ignored or denied
“I can't believe you are
married!”
Your life is not
normal or like mine;
the only thing I see
when I look at you is
your disability
Exoticization
When an LGBTQ person, woman of
color, or member of a religious minority
is treated as a foreign object for the
pleasure/entertainment of others
“I've always wanted an
Asian girlfriend! They
wait hand and foot on their
men”
Asian American
women are
submissive and meant
to serve the physical
needs of men
“Tell me some of your
wild sex stories!” to an
LGBTQ person
Your privacy is not
valued; you should
entertain with stories
Asking a Muslim person
incessant questions about
his or her diet, dress, and
relationships
Your privacy is not
valued; you should
educate me about
your cultural
practices, which are
strange and different
Assumption of One's Own Religion as
Normal
c
Saying “Merry Christmas”
as a universal greeting
Your religious beliefs
are not important;
everyone should
celebrate Christmas
Acknowledging only
Christian holidays in work
and school
Your religious
holidays need to be
celebrated on your
time; they are
unimportant
a
Adapted from D. W. Sue, Bucceri et al. (2007).
b
Themes and examples are taken from Keller and Galgay (2010).
c
Themes and examples are taken from Nadal, Issa, et al. (2010).
Select this link to open an interactive version of Table 6.1.
REFLECTION AND DISCUSSION QUESTIONS
1. In looking at Table 6.1, can you identify how you may have committed
microaggressions related to race, gender, sexual orientation, religion, or ability?
2. Compile a list of possible microaggressions you may have committed. Explore the
potential hidden messages they communicated to their recipients.
3. What do your microaggressions tell you about your unconscious perception of
marginalized groups?
4. If microaggressions are mostly outside the level of conscious awareness, what must you
do to make them visible? What steps must you take to personally stop microaggressions?
5. What solutions can you offer that would be directed at individual change, institutional
change, and societal change?
Video 6.2: Overt and Covert Microaggressions
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
THE DYNAMICS AND DILEMMAS OF MICROAGGRESSIONS
The study of microaggressions presents “a complex scientific challenge because it deals with
both explicit and implicit bias; explores the lived realities of marginalized groups in our
society; frames microaggressive dynamics as an interaction between perpetrator, target, and
the external environment; pushes powerful emotional buttons in the actors; and is difficult to
separate from the sociopolitical dimensions of oppression, power, and privilege” (Sue, 2017,
p. 171). Not only does the subtle and insidious nature of racial microaggressions render them
outside the level of awareness of their perpetrators, but recipients also find their ambiguity
difficult to handle. Victims are placed in an unenviable position of questioning not only the
perpetrators, but themselves as well (e.g., “Did I misread what happened?”). Victims often
replay an incident over and over again to try to understand its meaning.
Yet, despite attribution ambiguity, microaggressions significantly shape experiences and
environments. Researchers have consistently identified microaggressions as creating a hostile
and invalidating campus climate (Von Robertson & Chaney, 2017; Yosso, Smith, Ceja, &
Solorzano, 2009), even referring to them as “toxic rain” that corrodes the educational
experience of students of color (Suarez‐Orozco et al., 2015). If Marie had been familiar
with the literature on Black students' experiences of primarily White institutions (PWIs), she
would have quickly identified Marshall's fatigue, declining academic interest, and falling
grades as being related to this “toxic rain.” The cumulative effect of microaggressions has
been shown to impede learning by depleting cognitive and psychological resources (Smith,
Hung, & Franklin, 2011; Watkins, Labarrie, & Appio, 2010), resulting in a phenomenon
labeled “racial battle fatigue” (Smith, Allen, & Danley, 2007). In work that looks extensively
at Black males' experiences at PWIs, Harper (2013, p.189) refers to this same concept as
“onlyness,” defined as the “psychoemotional burden of having to strategically navigate a
racially politicized space occupied by few peers, role models, and guardians from one's same
racial or ethnic group.”
Understanding Marshall's lethargy, declining grades, and academic disengagement from a
framework of racial battle fatigue and onlyness would allow Marshall and his therapist to
consider how his context and daily experience are assailing his spirit and academic identity. It
would also allow them to create strategies for dealing with daily microaggressions; joining a
group such as the Black Student Union, for example, where Marshall's experiences could be
validated and supported, has been shown to decrease racial battle fatigue and resultant
academic disengagement (Harper, 2013). Creating the opportunity to consider
microaggressions as the source of Marshall's feelings is extremely important, as their subtle,
innocuous nature makes them challenging to interpret, and sometimes just the process of
naming a microaggression for what it is (i.e., racism) is empowering enough to disarm its
effects.
Let us use the case of Marshall to illustrate the four psychological dilemmas that take place
when microaggressions occur (Sue, Capodilupo, et al., 2007).
Dilemma 1: The Clash of Sociodemographic Realities
For Marshall, one major question was: Were people assuming he did not belong because of
his race? Although lived experience told him that many Whites fear and devalue Black men,
chances are that his professors and peers would be offended at such a suggestion. They would
likely deny they possessed any stereotypes and perhaps point to Marshall's own demeanor
(i.e., not friendly enough, wearing a hoodie) as being responsible. In other words, they would
emphasize that they and their organizations do not discriminate on the basis of color, sex,
sexual orientation, or creed. The question becomes: Whose reality is the true reality?
Oftentimes, the perceptions held by the dominant group differ significantly from those of
marginalized groups in our society. For example, studies show that many Whites believe that
racism is no longer prevalent in society and not important in the lives of people of color (Sue,
2010), that heterosexuals believe that homophobia is a “thing of the past” and that antigay
harassment is on the decline (Nadal, 2013), and that men (and women) assert that women
have achieved equal status and are no longer discriminated against (Cundiff et al., 2014;
Swim & Cohen, 1997). Most importantly, individuals in power positions do not consider
themselves capable of discrimination based on race, gender, or sexual orientation because
they are free of bias.
On the other hand, people of color perceive Whites to be racially insensitive, to enjoy holding
power over others, and to think that they are superior (Sue, Capodilupo, et al., 2007). LGBTQ
individuals consider homonegativity and antigay harassment to be a crucial aspect of their
everyday existence (Burn et al., 2005; Nadal, 2013). Women contend that sexism is alive and
well in social and professional settings. Although research supports the idea that those who
are most disempowered are more likely to have an accurate perception of reality, it is the
groups in power that have the ability to define reality. Thus, people of color, women, and
LGBTQ individuals are likely to experience their perceptions and interpretations being
negated or dismissed. This becomes particularly salient in the therapeutic encounter, which
represents an unequal power dynamic.
For Marshall, who has had countless experiences of being taken as a suspect or criminal, it
feels clear that those around him fear him and do not see him as a student capable of
academic achievement. Marie, however, has not experienced this racial reality and tries to
“objectively” reason that Marshall may be reading too much into or misinterpreting the
situation, or even contributing to others' perceptions of him as criminal by wearing his
hoodie. Further, her racial reality blinds her against considering how a PWI might be
affecting Marshall; she does not even bring race into their conversation, because in her own
daily experiences, race is invisible and nonimportant.
Dilemma 2: The Invisibility of Unintentional Expressions of Bias
How could Marshall “prove” that colleagues doubted his intelligence or worth? His only
evidence is his felt experience and interpretation, which are easily explained away and
disregarded by coworkers, students, and professors with alternative explanations.
Further compounding the situation is the idea that Marshall is experiencing these
microaggressions at his school, an environment that should be fostering and supporting his
intellectual growth. Actually, Marshall's scholastic achievement is being hampered by the
stress he is experiencing on campus, and his academic disengagement is a common reaction
to these hostile environments (Harper, 2013; Von Robertson & Chaney, 2017). During the
classroom conversation about the BLM movement, neither his classmates nor his professor
take issue with the classmate who likens BLM protestors to KKK rally‐goers or when the
question is raised, “Don't all lives matter?” Even if they do not actually agree with these
sentiments, staying silent conveys complicit agreement and/or apathy. When one hardly ever
experiences their own race in their daily interactions, it is easy to dismiss the notion that race
matters. Marshall, on the other hand, cannot dismiss race as it is salient part of his everyday
life. He experiences a physical reaction during the classroom conversation and worries that a
passionate response may enact stereotypes of angry and scary Black males. So, he stays
silent, despite having a powerful reaction. As Smith et al. (2011, p.77) explain, “these stacked
conditions present a challenge and barrier for African American men … which is not
acknowledged by most Whites, recognized by student support services, human resources, or
health providers.” That the microaggression is essentially invisible to the perpetrator creates a
psychological dilemma for the victim that can leave them feeling frustrated, powerless, and
even questioning their own sanity (Bostwick & Hequembourg, 2014; Harper, 2013; Sue,
Capodilupo, & Holder, 2008; Watkins et al., 2010).
Dilemma 3: The Perceived Minimal Harm of Microaggressions
Oftentimes, when perpetrators are confronted about microaggressions, they accuse the victim
of overreacting or being hypersensitive or touchy. Because the microaggressions are often
invisible to the perpetrators, they cannot understand how the events could cause any
significant harm to the victims. Trivializing the impact of racial microaggressions can be an
automatic, defensive reaction on the part of some White people, to avoid feeling blamed and
guilty (Sue, Capodilupo, Nadal, & Torino, 2008). Despite a lack of acknowledgement by
majority groups that everyday experiences of discrimination can be harmful to minorities,
research is mounting to suggest otherwise: a large‐scale meta‐analysis reveals that
perceived discrimination has cumulative and harmful effects on psychological well‐being
(Schmitt, Branscombe, Postmes, & Garcia, 2014), and an American Psychological
Association (2016) survey of over 3,000 respondents found that daily experiences of
discrimination were significantly associated with poor physical health and high stress levels.
Further, recent work links microaggressions to post‐trauma symptoms and depression
(Bryant‐Davis, 2018; Torres & Taknint, 2015).
Multiple studies that look at racial microaggressions in the lived experience of African
Americans find that the cumulative effect of these events is feelings of self‐doubt,
frustration, isolation, powerlessness, and invisibility (Harper, 2013; Smith et al., 2011; Sue,
Capodilupo, & Holder, 2008). In a two‐week daily diary study of Asian American college
students' experiences of microaggressions, it was found that 78% experienced at least one
microaggression, and the reporting of such events predicted higher negative affect and more
somatic symptoms (Ong, Burrow, Fuller‐Rowell, Ja, & Sue, 2013). This supports earlier
qualitative work that reported Asian Americans feeling belittled, angry, invalidated, invisible,
and trapped by their experiences of racial microaggressions (Sue, Bucceri, et al., 2007).
Multiple studies suggest that Latinx and Chicano/a students feel marginalized and frustrated
by microaggressive experiences in educational settings (Huber & Cueva, 2012; Nadal,
Mazzula, Rivera, & Fujii‐Doe, 2014; Ramirez, 2014).
Investigations link the experience of microaggressions on college campuses with serious
behavioral and psychological consequences. For example, college students of color who
experienced greater numbers of microaggressions were at increased risk for higher anxiety
and binge drinking (Blume, Lovato, Thyken, & Denny, 2012). Other studies link the
experience of microaggressions with low self‐esteem, depression, fatigue, pain, and lower
energy levels (Nadal, Wong, Griffin, Davidoff, & Sriken, 2014; Nadal et al., 2017; Wong‐
Padoongpat, Zane, Okazaki, & Saw, 2017). Specifically, microaggressions experienced in
educational and workplace settings were found to be especially harmful to participants' self‐
esteem (Nadal, Wong, et al., 2014). Likewise, homonegative microaggressions were
associated with lower self‐esteem, negative feelings about one's sexual orientation identity,
and obstacles to developing one's sexual identity (Wright & Wegner, 2012). A higher number
of homonegative microaggressions experienced has also been linked to a high level of post‐
traumatic stress disorder (PTSD) symptoms (Robinson & Rubin, 2016).
Dilemma 4: The Catch‐22 of Responding to Microaggressions
When a microaggression occurs, the recipient is often placed in an unenviable position of
having to decide what to do. Numerous questions are likely to go through their mind: Did
what I think happened really happen? If it did, how can I possibly prove it? How should I
respond? Will it do any good if I bring it to the attention of the perpetrator? If I do, will it
affect my relationship with my professor, other students, coworkers, or friends? Many well‐
intentioned perpetrators are unaware of the exhausting nature of these internal questions, as
they sap the spiritual and psychic energy of victims. Marshall was obviously caught in a
conflict, asking himself: Should I voice my feelings about reactions to the BLM movement,
or will I be misunderstood? Worse, will I be typecast and alienated?
The fundamental issue is that responding to a microaggression can have detrimental
consequences for the victim. In work settings, hiring and firing practices hang in the balance.
In school settings, academic performance can be impacted. Sometimes, the consequences of
responding to microaggressions are relational. Over and over again we see Marshall
suppressing his natural reactions (to campus police, in the classroom, to the therapist).
Unfortunately, it has been found that this takes a psychological toll on the recipient, because
it requires them to withhold and obscure their authentic thoughts and feelings in order to
avoid further discrimination and stereotypic labeling (Franklin, 2004). Authors have
described this process as “failure syndrome” (Kunjunfu, 1986, cited in Von Robertson &
Chaney, 2017), linking it to academic achievement: “when black students, particularly males,
are viewed in stereotypic ways (i.e., black males are stupid, academically incapable, and
thugs) … it is possible they will internalize those negative caricatures and underperform
academically.” (Von Robertson & Chaney, 2017, p. 262). A similar process has been
described for girls and women, in whom it is referred to as “self‐silencing.” This has been
linked to “compromising women's success by heightening feelings of alienation and reducing
motivation” (London, Downey, et al. 2012, p. 219).
Confronting sexual orientation microaggressions can be complicated by LGBTQ individuals
who are not out of the closet. The reality of looming antigay harassment and differential
(unequal) treatment may prevent LGBTQ persons from coming out in a variety of settings,
especially when there is evidence to suggest that the environment is heterosexist. Antigay
slurs and pervasive use of the word “gay” to communicate that someone or something is
inferior, stupid, or abnormal (Nadal et al., 2017) all contribute to hostile educational and
workplace environments. The therapeutic room can be equally as unwelcoming and hostile:
qualitative work reports that “fear of being seen as different had a suppressive and muting
effect on some participants' disclosure of their sexual orientation to their therapists” (Shelton
& Delgado‐Romero, 2013, p.66).
Video 6.3: Counseling Distress
Introduction to counseling session by Dr. Joel Filmore.
THERAPEUTIC IMPLICATIONS
Clients of color tend to prematurely terminate counseling and therapy at a 50% rate after only
the first initial contact with a mental health provider (à la Marshall). We submit that racial
microaggressions may lie at the core of the problem. For example, one study found that more
than half of racial‐ and ethnic‐minority clients at a college counseling center reported
experiencing a microaggression from their therapist (Owen, Tao, Imel, Wampold, & Rodolfa,
2014), and other studies report between 43 and 81% of clients experiencing at least one
microaggression in therapy (Hook et al., 2016; Owen et al., 2012, 2015). A recent study
found that the most commonly experienced microaggressions involved therapists' subtle
expression of cultural stereotypes and avoidance of or minimization of cultural issues (Hook
et al., 2016). A similar study of LGBTQ clients revealed that “clients were left feeling
doubtful about the effectiveness of therapy, the therapists' abilities, and the therapists'
investment in the therapeutic process when therapists minimized their sexual reality” (Shelton
& Delgado‐Romero, 2011, p. 217).
There is growing evidence to suggest that racial, gender, and sexual orientation
microaggressions have a detrimental effect on the therapeutic alliance for clients of color
(Owen et al., 2014), women (Owen, Tao, & Rodolfa, 2010), and LGBTQ individuals (Shelton
& Delgado‐Romero, 2011, 2013). Specifically, “microaggressions can be thought of as a
special case of ruptures in therapy, wherein experiences of discrimination and oppression
from the larger society are recapitulated, which places the therapeutic relationship under
duress and strain” (Owen et al., 2014, p. 287). Qualitative work with LGBTQ clients supports
this finding, where the therapeutic alliance has been diminished by the presence of sexual
orientation microaggressions: “affective consequences of sexual orientation microaggressions
included clients feeling uncomfortable, confused, powerless, invisible, rejected, and forced or
manipulated to comply with treatment” (Shelton & Delgado‐Romero, 2013, p. 66).
One study found that microaggressions that went unaddressed by therapists were associated
with a weaker working alliance compared to situations with (a) no microaggression or (b) a
resolved microaggression (Owen et al., 2015). Although studies on microaggressions in
therapy suggest that they are frequent and harmful, evidence also shows that when
microaggressions are acknowledged and addressed, the therapeutic alliance can be restored
with positive clinical outcomes (Owen et al., 2014). Therefore, it is paramount that helping
professionals examine their own biases and beliefs and remain aware of how they may
unintentionally communicate these when working with clients who are culturally diverse.
Although therapy provides an ideal opportunity for exploring microaggressions both within
the therapeutic dyad and in presenting concerns, many therapists are unsure how to approach
such conversations. The multicultural orientation (MCO) framework (Owen, 2013) can be
used to help therapists engage in a discourse on race, culture, racism, and microaggressions.
This framework includes three pillars: (a) cultural humility, (b) cultural opportunities, and (c)
cultural comfort. These pillars involve therapists being (a) aware of their own cultural values
and those of others, (b) curious about others' cultural identities and values, and (c) at ease and
comfortable with discussions that involve race, racism, and culture. Studies suggest that these
variables are associated with more positive therapeutic outcomes. Specifically, counselors
who score higher on cultural humility (a) are less likely to microaggress and (b) have more
positive therapy outcomes (Hook et al., 2016; Owen et al., 2014, 2017).
Video 6.4: Counselor Reconciliation
The sophistication of racism and discrimination makes it challenging to emphatically point
out bias within microaggressions. But allowing yourself to be open to self-reflection can
minimize these incidents.
MANIFESTATIONS OF MICROAGGRESSIONS IN
COUNSELING/THERAPY
The importance of understanding how microaggressions manifest in the therapeutic
relationship cannot be overstated, especially as this phenomenon may underlie the high
prevalence of drop‐out rates among people of color and other marginalized groups. Let us
use the case of Marshall to illustrate how microaggressions may operate in the counseling
process. Marshall revealed to Marie his experiences of racial and gender microaggressions,
using therapy as a space for deeper exploration of a meaningful issue. Because Marshall and
Marie are not the same race or gender, they do not share similar racial realities (Dilemma 1:
clash of sociodemographic realities) or worldviews. The therapist has minimal understanding
of what constitutes racial or ethnic microaggressions, how they make their appearance in
everyday interactions, how she herself may be guilty of microaggressive behaviors, the
psychological toll microaggressions take on minorities, and the negative effects they have on
the therapeutic relationship. We have already emphasized that cultural competence requires
helping professionals to understand the worldviews of their culturally diverse clients.
Marie tends to minimize the importance of Marshall's feelings of not belonging and of being
disregarded, to believe these feelings are trivial, and to relate them to the stress that all
college students feel around finals. She cannot relate to the negative impact these feelings
have on her client and thus minimizes their emotional and psychological effect (Dilemma 3:
minimal harm). For Marshall, on the other hand, the experience of being regularly taken as
less intelligent, less capable, and/or a thug represents one of many cumulative messages of
inferiority and criminal assumptions about his race. He is placed in a constant state of
vigilance in maintaining his sense of integrity in the face of constant invalidations and insults.
Racial microaggressions are a constant reality for people of color, as they assail group
identities and experiences. White people seldom understand how much time, energy, and
effort are expended by people of color to retain some semblance of worth and self‐esteem.
Another major detrimental event in the first session is that Marie enacts a stereotype of
intellectual inferiority by initially asking if Marshall is having difficulty keeping up with his
studies. As a mental health professional, Marie probably considers herself unbiased and
objective. However, she has cut off meaningful exploration for Marshall by removing the
salience of race from the conversation (Dilemma 2: invisibility). For example, had she
engaged Marshall about what was was like to be a Black male at the university, she would
have learned about his frequent experiences of onlyness and of being treated like a suspect.
As a client, Marshall is caught in a “damned if you do, damned if you don't” conflict
(Dilemma 4: catch‐22). Both inside and outside of therapy, Marshall is probably internally
wrestling with a series of questions: Did what I think happened really happen? Was this a
deliberate act or an unintentional slight? How should I respond: sit and stew on it or confront
the person? What are the consequences if I do confront them? These questions take a
tremendous psychological toll on many marginalized groups. If Marshall chooses to do
nothing, he may suffer emotionally by having to deny his own experiential reality or allow his
sense of integrity to be assailed. Feelings of powerlessness, alienation, and frustration may
take not only a psychological toll but also a physical one.
Table 6.2 provides several more therapy‐specific examples of microaggressions, using the
same organizing themes presented in Table 6.1. We ask that you study these themes and ask
if you have ever engaged in these or similar actions. If so, how can you prevent your own
personal microaggressions from impairing the therapy process?
TABLE 6.2 Examples of Microaggressions in Therapeutic Practice
Adapted from D. W. Sue, Bucceri, et al. (2007).
Themes Microaggression Message
Alien in Own Land
When Asian Americans and
Latinx Americans are assumed
to be foreign‐born
A White client does not want to work
with an Asian American therapist
because she “will not understand my
problem”
You are not
American
A White therapist tells an American‐
born Latinx client that he or she should
seek a Spanish‐speaking therapist
Ascription of Intelligence
Assigning a degree of
intelligence to a person of
color or a woman based on
race or gender
A school counselor reacts with surprise
when an Asian American student says
they have had trouble on the math
portion of a standardized test
All Asians are
smart and good at
math
A career counselor asking a Black or
Latinx student, “Do you think you're
ready for college?”
It is unusual for
people of color to
succeed
A school counselor reacting with
surprise at hearing that a female student
scored high on the math portion of a
standardized test
It is unusual for
women to be smart
and good at math
Color Blindness
Statements that indicate that a
White person does not want to
acknowledge race
A therapist says, “I think you are being
too paranoid. We should emphasize
similarities, not people's differences”
when a client attempts to discuss her
feelings about being the only person of
color at her job and feeling alienated
and dismissed by her coworkers
Race and culture
are not important
variables that affect
people's lives
A client of color expresses concern in
discussing racial issues with her
therapist; her therapist replies, “When I
see you, I don't see color”
Your racial
experiences are not
valid
Criminality/Assumption of
Criminal Status
A person of color is presumed
to be dangerous, criminal, or
deviant based on their race
When a Black client shares that she
was accused of stealing from work, her
therapist encourages her to explore
how she might have contributed to her
employer's mistrust of her
You are a criminal
A therapist takes great care to ask all
substance‐abuse questions in an
intake with a Native American client
and is suspicious of the client's
nonexistent history with substances
You are deviant
Use of Sexist/Heterosexist
Language
Terms that exclude or degrade
During the intake session, when a
female client discloses that she has
Heterosexuality is
women and lesbian, gay,
bisexual, transgender, and
queer (LGBTQ) groups
been in her current relationship for 1
year, the therapist asks how long the
client has known her boyfriend
the norm
When an adult female client explains
she is feeling isolated at work, her male
therapist asks, “Aren't there any girls
you can gossip with there?”
Application of
language that
implies to
adolescent or adult
females, “your
problems are
trivial”
Denial of Individual
Racism/Sexism/Heterosexism
A statement made when a
member of the power group
renounces their biases
When a client of color asks his or her
therapist about how race affects their
working relationship, the therapist
replies, “Race does not affect the way I
treat you”
Your racial/ethnic
experience is not
important
When a client of color expresses
hesitancy in discussing racial issues
with his White female therapist, she
replies, “I understand. As a woman, I
face discrimination also”
Your racial
oppression is no
different than my
gender oppression.
A therapist's nonverbal behavior
conveys discomfort when a bisexual
male client is describing a recent sexual
experience with a man; when he asks
her about it, she insists she has “no
negative feelings toward gay people”
and says it is important to keep the
conversation on him
I am incapable of
homonegativity, yet
I am unwilling to
explore this
Myth of Meritocracy
Statements that assert that race
or gender does not play a role
in succeeding in career
advancement or education
A school counselor tells a Black
student that “if you work hard, you can
succeed like everyone else”
People of color are
lazy and need to
work harder; if you
don't succeed, you
have only yourself
to blame (blaming
the victim)
When a female client visits a career
counselor to share her concerns that a
male coworker was chosen for a
managerial position over her, despite
the fact that she was better qualified
and has been in the job longer, the
counselor responds that “he must have
been better suited for some of the job
requirements”
Women are
incompetent and
need to work
harder; if you don't
succeed, you have
only yourself to
blame (blaming the
victim)
Pathologizing Cultural
Values/Communication
When a Black client is loud, emotional,
Styles
The notion that the values and
communication styles of the
dominant/White culture are
ideal
and confrontational in a counseling
session, the therapist diagnoses her
with borderline personality disorder
Assimilate to the
dominant culture
When a client of Asian or Native
American descent has trouble
maintaining eye contact with his
therapist, she diagnoses him with a
social anxiety disorder
Asking a client, “Do you really think
your problem stems from racism?”
Leave your cultural
baggage outside
Second‐Class Citizen
When a member of the power
group is given preferential
treatment over a target group
member
When a male client calls and requests a
session time that is currently taken by a
female client, the therapist grants him
the appointment without calling the
female client to see if she can change
times
Male clients are
more valued than
female clients
A client of color is not welcomed or
acknowledged by a receptionist
White clients are
more valued than
clients of color
Traditional Gender Role
Prejudicing and
Stereotyping
When expectations of
traditional roles or stereotypes
are conveyed
A therapist continually asks a middle‐
aged female client about dating and
“putting herself out there” despite the
client not having expressed interest in
exploring this area
Women should be
married, and dating
should be an
important topic/part
of your life
A gay male client has been with his
partner for 5 years; his therapist
continually probes his desires to meet
other men and be unfaithful
Gay men are
promiscuous/cannot
have monogamous
relationships
A therapist raises her eyebrows when a
female client mentions that she has had
a one‐night stand
Women should not
be sexually
adventurous
Sexual Objectification
When women are treated like
objects at men's disposal
A male therapist puts his hands on a
female client's back as she walks out of
the session
Your body is not
yours
A male therapist looks at his female
client's breasts while she is talking
Your
body/appearance is
for men's
enjoyment and
pleasure
Assumption of Abnormality
Occurs when it is implied that
there is something wrong with
being lesbian, gay, bisexual,
When discussing his client's
bisexuality, a therapist repeatedly
implies that there is a “crisis of
Bisexuality
represents a
confusion about
transgender, and queer
(LGBTQ)
identity” sexual orientation
When a lesbian comes in for career
counseling, the therapist continually
insists that she needs to discuss her
sexuality
Your sexual
orientation
represents
pathology
The therapist of a 20‐year‐old
lesbian inadvertently refers to sexuality
as a “phase”
Your sexuality is
something that is
not stable
Select this link to open an interactive version of Table 6.2.
THE PATH FORWARD
With a solid foundation of support for the pervasive existence and harmful impact of
microaggressions against all marginalized groups, recent work has begun to explore how
microaggressions can be combated on the interpersonal level. Researchers refer to this as
“microintervention” (Sue et al., in press, p. 13), defined as “everyday words or deeds,
whether intentional or unintentional, that communicate to targets of microaggressions (a)
validation of their experiential reality, (b) value as a person, (c) affirmation of their racial or
group identity, (d) support and encouragement and (e) reassurance that they are not alone.”
Sue et al. (in press) have put forth a conceptual framework of microinterventions that serves
to help targets, allies, and bystanders make the invisible visible and create a productive and
potentially empowering experience when microaggressions occur.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Be aware that racial, gender, and sexual orientation microaggressions are a constant
reality in the lives of culturally diverse groups and take a major psychological toll.
2. Be aware that everyone has engaged in and continues to engage in unintentional
microaggressions. For helping professionals, these microaggressions may serve as
impediments to effective multicultural counseling and therapy (MCT).
3. Entertain the notion that culturally diverse groups may have a more accurate perception
of reality than you do, especially when it comes to issues of racism, sexism, or
heterosexism. Try to understand worldviews and sociocultural realities, and don't be
quick to dismiss or negate racial, gender, and sexual orientation issues.
4. If your culturally different client implies that you have engaged in a microaggressive
remark or behavior, engage in a nondefensive discussion and try to clarify the situation
by showing you are open and receptive to conversations on race, gender, and sexual
orientation. Remember, it's how the therapist “recovers,” not how he or she “covers up”
that is important.
SUMMARY
Microaggressions represent daily stressors in the lives of marginalized groups in the United
States. There is now ample research to support the idea that microaggressions are frustrating,
psychologically taxing, and emotionally harmful to those who experience them.
Clients trust mental health professionals to take an intimate and deeply personal journey of
self‐exploration with them through the process of therapy. They grant these professionals
the opportunity to look into their inner world and invite them to walk with them in their
everyday lives. Therapists and counselors have an obligation to their clients, especially when
their clients differ from them in terms of race, gender, ability, religion, or sexual orientation,
to work to understand their experiential reality. Research suggests that when therapist and
client are able to successfully discuss microaggressions, the therapeutic alliance can be
restored. Therefore, therapists must be open to the idea that they can commit
microaggressions against their clients and be willing to examine their role in this process.
Therapists and counselors are in a position to learn from their clients about microaggressions
and their relationship to their presenting concerns and developmental issues. It is imperative
to encourage clients to explore their feelings about incidents that involve their race, gender,
and sexual orientation so that the status quo of silence and invisibility can be destroyed.
GLOSSARY TERMS
Ableism
Aversive racism
Covert sexism
Heterosexism
Homonegativity
Islamaphobia
Microaggression
Microassault
Microinsult
Microinvalidation
Overt sexism
Racism
Religious discrimination
Subtle sexism
Transphobia
Video 6.5: Counseling Session Analysis
Clinicians who are obtuse or oblivious can have a negative impact on their client's mental
state. Addressing the concerns of clients of color requires that therapists suspend their opinion
and focus on the client's experiential truth.
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PART III
The Practice Dimensions of Multicultural
Counseling and Therapy
Chapter
7
Multicultural Barriers and the Helping Professional: The Individual Interplay of
Cultural Perspectives
Chapter
8
Communication Style and Its Impact on Counseling and Psychotherapy
Chapter
9
Multicultural Evidence‐Based Practice (EBP)
Chapter
10
on‐Western Indigenous Methods of Healing: Implications for Multicultural
Counseling and Therapy (MCT)
7
Multicultural Barriers and the Helping Professional: The
Individual Interplay of Cultural Perspectives
Chapter Objectives
1. 1. Identify the basic values, beliefs, and assumptions that characterize U.S. society,
and how these are manifested in counseling practice.
2. 2. Determine how the generic characteristics of counseling and psychotherapy may
be barriers to culturally diverse clients.
3. 3. Describe how the cultural values of diverse populations may affect the counseling
process.
4. 4. Describe how socioeconomic class issues may impact mental health services.
5. 5. Understand the linguistic barriers that are likely to arise in working with clients
whose first language is not English.
6. 6. Learn how Western definitions of the family may detrimentally impact
counseling and therapy with diverse families.
Dior Vargas, a 28‐year‐old Latina mental health activist, recalls a therapist in
college—her second one—who she stopped going to after realizing she was “culturally
incompetent.”
“She wasn't aware of how close‐knit Latino families are. That they are a part of my
decision‐making process. My therapist didn't understand that, she would say: ‘No, you
need to stand up to your mother.’ That felt very disrespectful to me. Maybe sometimes
you do, but the way she said it made me very defensive.”
Vargas's two positive experiences were with therapists with whom she felt she shared a
piece of identity: one with a woman with the same Ecuadorian background as her, and
another with a woman who was openly gay. “I identify as queer. I felt like I could trust
her,” she says.
(Hackman, 2016, para. 5)
Video 7.0: Introduction
A breakdown in communication doesn't necessarily signal the end of the client/therapist
relationship. As long as the client is present you have the opportunity to mend a breach in the
counseling relationship.
MY THERAPIST DIDN'T UNDERSTAND
In the preceding excerpt, a client reflects upon an impasse that prevented her therapist from
being helpful to her. Her therapist maintained a view of how family members should relate to
each other—a view that excluded the cultural experiences of her client. We can assume that
this therapist had every intention of being helpful, but because she could not see beyond the
limits of her own values and assumptions, her client was left feeling disrespected and
defensive.
The client went on to form an effective therapeutic relationship with other therapists who
shared her Latina and queer identities. We can understand that shared identities can increase
feelings of trust—but can therapists who do not share their clients' identities increase their
awareness and effectiveness in order to help them? In this chapter, we discuss the culture‐
related differences that can act as barriers between helping professionals and culturally
diverse clients.
STANDARD CHARACTERISTICS OF MAINSTREAM COUNSELING
All theories of counseling and psychotherapy are influenced by assumptions that theorists
make regarding the goals for therapy, the methodology used to invoke change, and the
definition of mental health and mental illness (Corey, 2013). Counseling and psychotherapy
have historically and traditionally been conceptualized in Western individualistic terms (Ivey,
Ivey, Myers, & Sweeney, 2005). Whether a particular theory is psychodynamic, existential‐
humanistic, or cognitive behavioral in orientation, a number of multicultural specialists (Ivey,
Ivey, & Zalaquett, 2014; Ponterotto, Utsey, & Pedersen, 2006) indicate that it shares certain
common components of White Western Eurocentric culture in its values and beliefs. Because
this cultural worldview predominates in U.S. society, the mark that it has made on practices
like psychotherapy can almost be invisible to dominant‐culture professionals, yet for
individuals from other cultural backgrounds, it can be readily apparent, as in the passage that
opened the chapter.
In addition to their origins in White Western culture, psychotherapeutic practices originated
among middle‐class (or higher) segments of the population (Smith, 2010). For this reason,
the values, assumptions, and goals associated with psychotherapy largely correspond to the
lives and experiences of people with social class privilege rather than those of people living
in poverty. Privileged social class memberships have often been included, therefore, among
the assumed characteristics of psychotherapeutic clients. As a result, culturally diverse clients
may not share all the values and characteristics seen in both the goals and the processes of
therapy, and neither may clients from poor or working‐class backgrounds (APA Task Force
on Socioeconomic Status, 2007; Reed & Smith, 2014). Schofield (1964) famously
summarized some of these characteristics by noting that therapists seem to prefer clients who
exhibit the YAVIS syndrome: young, attractive, verbal, intelligent, and successful. Such
preferences predispose therapists against people from lower socioeconomic classes and
various minority groups. This preference is more than theoretical: research indicates that
therapists respond differently to service‐seeking voicemails left by clients who seem to be
of different racial backgrounds. For example, a hypothetical client with a stereotypically
Black name (“Lakisha”) received fewer therapist callbacks that offered services than did a
client with a potentially White name (“Allison”) (Shin, Smith, Welch, & Ezeofor, 2016).
Katz (1985) has isolated some of the components of White culture that are reflected in the
goals and processes of clinical work. These components are summarized in Table 7.1. The
sections that follow will explore the ways in which culturally diverse clients may be excluded
or inappropriately served by therapists who cannot see beyond these dominant‐culture
assumptions.
TABLE 7.1 Components of White Culture: Values and Beliefs
Source: Katz, J. (1985). The Counseling Psychologist. Beverly Hills, CA: Sage. Copyright 1985 by Sage Publications,
Inc. Reprinted by permission.
Rugged individualism
Individual is primary unit
Individual has primary responsibility
Independence and autonomy are highly
valued and rewarded
Individual can control environment
Protestant work ethic
Working hard brings success
Progress and future orientation
Plan for future
Delay gratification
Value continual improvement and progress
Competition
Emphasis on scientific method
Winning is everything
Win/lose dichotomy
Objective, rational, linear thinking
Cause‐and‐effect relationships
Quantitative emphasis
Action orientation
Must master and control nature
Must always do something about a
situation
Pragmatic/utilitarian view of life
Status and power
Measured by economic possessions
Credentials, titles, and positions
Believe “own” system
Believe better than other systems
Owning goods, space, property
Communication
Standard English
Written tradition
Direct eye contact
Limited physical contact
Control of emotions
Family structure
Nuclear family is the ideal social unit
Male is breadwinner and the head of the
household
Female is homemaker and subordinate to the
husband
Patriarchal structure
Time
Adherence to rigid time
Time is viewed as a commodity
Holidays
Based on Christian religion
Based on White history and male leaders
Aesthetics
Music and art based on European cultures
Women's beauty based on blonde, blue‐eyed,
thin, young
Men's attractiveness based on athletic ability,
power, economic status
History
Based on European immigrants' experience
in the United States
Romanticize war
Religion
Belief in Christianity
No tolerance for deviation from single god
concept
Select this link to open an interactive version of Table 7.1.
CULTURE‐BOUND VALUES
Culture consists of all those things that people have learned to do, believe, value, and enjoy.
It is the totality of the ideals, beliefs, skills, tools, customs, and institutions into which
members of society are born (Ratts & Pedersen, 2014). Although being bicultural is a source
of strength, the process of negotiating dual group membership may cause problems for many
marginalized group members. Persons of color are placed under strong pressures to adopt the
ways of the dominant culture. Cultural‐deficit models tend to view culturally diverse groups
as possessing dysfunctional values and belief systems, which they often considered handicaps
to be overcome and sources of shame. In essence, marginalized groups may be taught that to
be different is to be deviant, pathological, or sick. Several culture‐bound characteristics of
therapy may be responsible for reinforcing these negative beliefs.
Focus on the Individual
Most forms of counseling and psychotherapy tend to be individual‐centered. Accordingly,
Ivey et al. (2014) note that U.S. culture and society are based on the concept of individualism
and that competition between individuals for status, recognition, achievement, and so forth
forms the basis of Western tradition. Individualism, autonomy, and the ability to become your
own person are perceived as healthy and desirable goals. Pedersen and Pope (2010) observe
that not all cultures view individualism as a positive orientation; rather, it may be perceived
by some as a handicap to attaining enlightenment, one that may divert us from important
spiritual goals. In many non‐Western cultures, identity is not seen apart from the group
orientation (collectivism). For example, the notion of atman in India defines itself as
participating in unity with all things and not being limited by the temporal world.
Many societies do not define the psychosocial unit of operation as the individual. In many
cultures and subgroups, the psychosocial unit of operation tends to be the family, group, or
collective society. In traditional Asian American culture, one's identity is defined within the
family constellation. The greatest punitive measure to be taken against an individual by the
family is to be disowned. What this means, in essence, is that the person no longer has an
identity. Although being disowned by a family in Western European culture is equally
negative and punitive, it does not have the same connotations as in traditional Asian society.
Although they may be disowned by a family, Westerners are always told that they have an
individual identity as well. Likewise, many Hispanic individuals tend to see the unit of
operation as residing within the family. African American psychologists (Parham, Ajamu, &
White, 2011) also point out how the African view of the world encompasses the concept of
“groupness.”
Collectivism is often reflected in many aspects of behavior. Traditional Asian American and
Hispanic elders, for example, tend to greet one another with the question, “How is your
family today?” Contrast this with how most Americans tend to greet each other: “How are
you today?” One emphasizes the family (group) perspective, while the other emphasizes the
individual perspective. Likewise, affective expressions in therapy can also be strongly
influenced by the particular orientation one takes. When individuals engage in wrongful
behaviors in the United States, they are most likely to experience feelings of guilt. In societies
that emphasize collectivism, however, the most dominant affective element to follow a
wrongful behavior is shame, not guilt. Guilt is an individual affect, whereas shame appears to
be a group one (it reflects on the family or group).
Verbal/Emotional/Behavioral Expressiveness
Many counselors and therapists tend to emphasize the fact that verbal/emotional/behavioral
expressiveness is important in individuals. As therapists, we like our clients to be verbal,
articulate, and able to express their thoughts and feelings clearly, as this most easily and
effectively allows us to use our conventional skills with them. Indeed, therapy is often
referred to as “talk therapy,” indicating the importance placed on Standard English as the
medium of expression. Emotional expressiveness is also valued, as we like individuals to be
in touch with their feelings and to be able to verbalize their emotional reactions. We value
behavioral expressiveness as well. We like individuals to be assertive, to stand up for their
own rights, and to engage in activities that indicate they are not passive beings.
All these characteristics of mainstream therapy can place culturally diverse clients at a
disadvantage. For example, Native Americans and Asian Americans tend not to value
verbalizations in the same way as White Americans. In traditional Chinese culture, children
have been taught not to speak until spoken to. Patterns of communication tend to be vertical,
flowing from those of higher prestige and status to those of lower prestige and status. In a
therapy situation, many Chinese clients, to show respect for a therapist who is older and wiser
and who occupies a position of higher status, may respond with silence. Unfortunately, an
unenlightened counselor or therapist may perceive such clients as being inarticulate and less
intelligent.
Emotional expressiveness in counseling and psychotherapy is frequently a highly desired
goal. Yet, many cultural groups value restraint of strong feelings. For example, traditional
Latinx and Asian cultures emphasize that maturity and wisdom are associated with one's
ability to control emotions and feelings. This applies not only to public expressions of anger
and frustration but also to public expressions of love and affection. Unfortunately, therapists
unfamiliar with these cultural ramifications may perceive their clients in a very negative
psychiatric light. Indeed, these clients are often described as inhibited, lacking in spontaneity,
or repressed.
In therapy, it has become increasingly popular to emphasize expressiveness in a behavioral
sense—look at the proliferation of cognitive behavioral assertiveness training programs
throughout the United States (Craske, 2010) and the number of self‐help books being
published in the popular mental health literature. This orientation fails to realize that there are
cultural groups in which subtlety is a highly prized art. Doing things indirectly can be
perceived by the mental health professional as evidence of passivity and the need to learn
assertiveness skills. In their excellent review of assertiveness training, Wood and
Mallinckrodt (1990) warn that therapists need to make certain that gaining such skills is a
value shared by a client of color, and not one imposed by therapists.
Insight
Another generic characteristic is the use of insight in both counseling and psychotherapy.
This approach assumes that it is mentally beneficial for individuals to obtain insight or
understanding into their underlying dynamics and motivations (Corey, 2013; Levenson,
2010). Educated in the tradition of psychoanalytic theory, many theorists tend to believe that
clients who obtain better insight into themselves will be better adjusted. Although many
behavioral schools of thought may not subscribe to this, most therapists use insight in their
individual practice, either as a process of therapy or as an end product or goal (Antony &
Roemer, 2011).
We need to realize that insight is not highly valued by many culturally diverse clients. In
traditional Chinese society, psychology has little relevance. It must be noted that a client who
does not seem to work well in an insight approach may not be lacking in insight or
psychological‐mindedness; a person who does not value insight is not necessarily one who
is incapable of insight. Simply put, many cultural groups do not value this method of self‐
exploration. It is interesting to note that many Asian elders believe that thinking too much
about something can cause problems. Many older Chinese believe the way to achieve to
mental health is to “avoid morbid thoughts.” Advice from Asian elders to their children when
they are frustrated, angry, depressed, or anxious is simply, “Don't think about it.” Indeed, it is
often believed that experiencing anger or depression is related to cognitive rumination. The
traditional Asian way of handling these affective elements is to “keep busy and not think
about it.” There can be class‐related differences as well (APA Task Force on
Socioeconomic Status, 2007). People from lower socioeconomic classes may not perceive
insight as appropriate to their life situations and circumstances. Their immediate concerns
may instead revolve around such questions as “Where do I find a job?”, “How do I feed my
family?”, and “How can I afford to take my sick daughter to a doctor?”
Self‐Disclosure (Openness and Intimacy)
Most forms of counseling and psychotherapy tend to prioritize one's ability to self‐disclose
and to talk about the most intimate aspects of one's life. Indeed, self‐disclosure has often
been discussed as a primary characteristic of a healthy personality. Clients who do not self‐
disclose readily in counseling and psychotherapy are seen as possessing negative features
(i.e., being guarded, mistrustful, or paranoid). There are two difficulties in this orientation
toward self‐disclosure: cultural and sociopolitical.
First, intimate revelations of personal or social problems may not be acceptable to Asian
Americans, because such admissions reflect not only on the individual but also on their whole
family (Chang, McDonald, & O'Hara, 2014). Thus, the family may exert strong pressures on
the Asian American client not to reveal personal matters to strangers or outsiders. Similar
conflicts have been reported for Latinx Americans (Torres‐Rivera & Ratts, 2014), American
Indians (Thomason, 2014), and Polynesian Americans (Allen, Kim, Smith, & Hafoka, 2016).
A therapist who works with a client from a different cultural background may erroneously
conclude that they are repressed, inhibited, shy, or passive. All these traits are seen as
undesirable by Western standards.
Related to this example is many health practitioners' belief in the desirability of self‐
disclosure. Self‐disclosure refers to clients' willingness to tell therapists what they feel,
believe, or think. Jourard (1964) suggests that mental health is related to one's openness in
disclosing. Although this may be true, the parameters need clarification. As mentioned in
Chapter 4, people of African descent may be reluctant to disclose to White counselors
because of their previous experience of racism (Ratts & Pedersen, 2014). African Americans
may initially perceive a White therapist as an agent of society who might use any information
they provide against them, rather than as a person of good will. From the African American
perspective, noncritical self‐disclosure to others is not healthy.
The actual structure of the therapy situation may also work against intimate revelations.
Among many American Indians and Latinx Americans, intimate aspects of life are shared
only with close friends. Relative to White middle‐class standards, deep friendships are
developed only after prolonged contacts. Once friendships are formed, they tend to be
lifelong in nature. In contrast, White Americans form relationships relatively quickly, but the
relationships may not necessarily persist over long periods of time. Counseling and therapy
also seem to reflect these values. Clients talk about the most intimate aspects of their lives
with a relative stranger once every week for a 50‐minute session. To many culturally
diverse groups that stress friendship as a precondition to self‐disclosure, the counseling
process seems utterly inappropriate and absurd. After all, how is it possible to develop a
friendship with brief contacts once a week?
Scientific Empiricism
Counseling and psychotherapy in Western culture and society have been described as being
highly linear, analytic, and verbal in their attempt to mimic the physical sciences. As
indicated by Table 7.1, Western society tends to emphasize the so‐called scientific method,
which involves objective, rational, linear thinking. Likewise, we often see descriptions of
therapists as objective, neutral, rational, and logical (Utsey, Walker, & Kwate, 2005).
Therapists rely heavily on the use of linear problem solving, as well as on quantitative
evaluation that includes psychodiagnostic tests, intelligence tests, personality inventories, and
so forth. This cause–effect orientation emphasizes left‐brain functioning. That is, theories of
counseling and therapy are distinctly analytical, rational, and verbal, and they strongly stress
the discovery of cause–effect relationships.
The emphasis on symbolic logic contrasts markedly with the philosophies of many cultures
that value a more nonlinear, holistic, and harmonious approach (Sue, 2015). For example, the
American Indian worldview emphasizes harmonious aspects of the world, intuitive
functioning, and a holistic approach—a worldview characterized by right‐brain activities,
minimizing analytical and reductionistic inquiries. Thus, when American Indians undergo
therapy, the analytic approach may violate their basic philosophy of life (Garrett & Portman,
2011).
In the mental health fields, the most dominant way of asking and answering questions about
the human condition tends to involve the scientific method. The epitome of this approach is
the experiment. In graduate schools, we are often told that only through experiments can we
impute cause–effect relationships. By identifying independent and dependent variables, and
controlling for extraneous ones, we are able to test a cause–effect hypothesis. Although
correlation studies, historical research, and other approaches may be of benefit, we are told
that the experiment represents the epitome of our science. Other cultures, however, may value
different ways of asking and answering questions about the human condition. We will explore
this further in Chapter 10.
Distinctions Between Mental and Physical Functioning
Many American Indians, Asian Americans, African Americans, and Latinx Americans hold
different concepts of what constitutes mental health, mental illness, and adjustment. Among
the Chinese, the concept of mental health or psychological well‐being is not understood in
the same way as it is in the Western context. Latinx Americans do not make the same
Western distinction between mental and physical health as do their White counterparts
(Guzman & Carrasco, 2011). Thus, nonphysical health problems are most likely to be
referred to a physician, priest, or minister. Culturally diverse clients operating under this
orientation may enter therapy expecting the therapist to treat them in the same manner that
doctors and priests do, and to offer them immediate solutions and concrete tangible forms of
treatment (advice, confession, consolation, and medication).
Patterns of Communication
The cultural upbringing of many minorities dictates different patterns of communication that
may place them at a disadvantage in therapy. Counseling, for example, initially demands that
communication move from client to counselor. The client is expected to take the major
responsibility for initiating conversation in the session, while the counselor plays a less active
role.
However, American Indians, Asian Americans, and Latinx Americans function under
different cultural imperatives, which may make this difficult. These three groups may have
been reared to respect elders and authority figures and not to speak until spoken to. Clearly
defined roles of dominance and deference are established in the traditional family. Evidence
indicates that Asians associate mental health with exercising will power, avoiding unpleasant
thoughts, and occupying one's mind with positive thoughts. They see therapy as an
authoritative process in which a good therapist is direct and active, and represents a kind of
father figure. A racial/ethnic minority client who is asked to initiate conversation may
become uncomfortable and respond with only short phrases or statements. The therapist may
be prone to interpret this behavior negatively, when in actuality it may be a sign of respect.
We have much more to say about these communication style differences in the next chapter.
Video 7.3: Culturally-Specific Issues
International clients have the added struggle of communicating in a foreign language. This
can be very difficult if there is no word in their own language to describe what they are
experiencing. Also, their limited understanding of English can hinder the counseling
relationship.
CLASS‐BOUND VALUES
Social class and classism have been identified as two of the most overlooked topics in
psychology and mental health practice (APA Task Force on Socioeconomic Status, 2007).
Although many believe that the gap in income is closing, statistics suggest the opposite— that
income inequality is increasing. Those in the top 5% of income have enjoyed huge increases,
whereas those in the bottom 40% are stagnant (APA Task Force on Socioeconomic Status,
2007). In the United States, 12.7% of citizens live in poverty. Segmented by race, the poverty
rate for Whites was 11.0% in 2016, while for African Americans, it was twice that at 22.0%.
The poverty rate for Latinx Americans was 19.4%, and for Asians, it was 10.1% (Semega,
Fontenot, & Kollar, 2017). The poverty rates for American Indians are the highest in the
nation at 26.2% (U.S. Census Bureau, 2017). These statistics underscore the intertwined
nature of race with social class in the United States as the result of historic events such as the
transatlantic slave trade, the seizing of lands from native people, and institutional barriers to
wealth creation (Lui, Robles, Leondar‐Wright, Brewer, & Adamson, 2006).
Impact of Poverty
Research indicates that life in poverty is related to higher incidence of depression (Lorant et
al., 2003), lower sense of control (Chen, Matthews, & Boyce, 2002), poorer physical health
(Gallo & Matthews, 2003), and exclusion from the mainstream of society (Reed & Smith,
2014). Mental health professionals are often not aware of the additional stressors likely to
confront clients who lack financial resources, nor do they fully appreciate how those stressors
affect their clients' daily lives. For the therapist who comes from a middle‐ to upper‐class
background, it is often difficult to relate to the circumstances and hardships affecting the
client who lives in poverty.
The phenomenon of poverty and its effects on individuals and institutions can be devastating
(Liu, Hernandez, Mahmood, & Stinson, 2006). The impoverished individual's life is
characterized by low wages, unemployment, underemployment, little property ownership, no
savings, and lack of reliable food reserves. Meeting even the most basic family needs is
precarious. Pawning personal possessions and borrowing money at exorbitant interest rates
only leads to greater debt. Moreover, people living in poverty are subject to daily experiences
of discrimination and bias. People at higher social class positions often stereotype the poor as
being lazy, inferior, drug‐abusing, or unintelligent, and frequently seek to distance
themselves from the poor as a result (Lott, 2002). Feelings of helplessness, dependence, and
inferiority develop easily under these circumstances. Therapists may unwittingly attribute
attitudes that result from physical and environmental adversity to the cultural or individual
traits of the client.
Therapeutic Class Bias
Considerable bias against people who are poor has been well documented (APA Task Force
on Socioeconomic Status, 2007; Smith, 2013). For example, clinicians perceive clients who
live in poverty more unfavorably than more affluent clients (as, for example, being more
dysfunctional and making poorer progress in therapy). Research concerning the inferior and
biased quality of treatment of lower‐class clients is historically legend (APA Task Force on
Socioeconomic Status, 2007). In the area of diagnosis, it has been found that an attribution of
mental illness is more likely when a person's history suggests a lower rather than a higher
socioeconomic class origin (Liu et al., 2006). Many studies demonstrate that clinicians who
are given identical clinical vignettes tend to make more negative prognostic statements and
judgments of greater maladjustment when the individual is said to come from a poor or
working‐class background rather than from the middle class (Lee & Temerlin, 1970; Smith,
Mao, Perkins, & Ampuero, 2011; Stein, Green, & Stone, 1972).
In addition, the class‐bound nature of mental health practice emphasizes the importance of
assisting the client in self‐direction through the results of assessment instruments and
through self‐exploration via verbal interactions between client and therapist. However, the
assumptions underlying these activities are permeated by middle‐class values that do not
always apply to life in poverty. In an extensive historic research of services delivered to
minorities and low‐socioeconomic‐status clients, Lorion (1973) found that psychiatrists
refer to therapy those persons who are most like themselves—White rather than non‐White
and of upper socioeconomic status. Lorion (1974) pointed out that the expectations of poor
and working‐class clients are often different from those of psychotherapists. For example,
low‐income clients who are concerned with survival on a day‐to‐day basis may expect
advice and suggestions from the counselor.
Appointments made weeks in advance with short, weekly, 50‐minute contacts are not
consistent with the need to survive chaotic circumstances and seek immediate solutions.
Additionally, many people living in poverty, through multiple experiences with public
agencies, may operate under what is called minority standard time (Schindler‐Rainman,
1967). Poor people have learned that endless waits are associated with medical clinics, police
stations, and government agencies. One usually waits hours for a 10‐ to 15‐minute
appointment. Arriving promptly does little good and can be a waste of valuable time.
Therapists, however, rarely understand this aspect of life and are prone to see late arrival as a
sign of resistance, indifference, or hostility (Schnitzer, 1996).
People from poor and working‐class backgrounds may view insight and attempts to
discover underlying intrapsychic problems as inappropriate, and some may expect to receive
advice or some form of concrete tangible treatment. A harsh environment, where the future is
uncertain and immediate needs must be met, makes long‐range planning of little value.
Such clients may be unable to relate to the future orientation of therapy. To be able to sit and
talk about things is perceived as a luxury of the middle and upper classes. A low‐income
client's unfamiliarity with the therapy process may hinder success and cause the therapist to
blame the client for the failure. Thus, the client may be perceived as hostile and resistant. The
results of this interaction may be a premature termination of therapy. Considerable evidence
exists that clients from more privileged socioeconomic backgrounds have significantly more
exploratory interviews with their therapists and that middle‐class patients tend to remain in
treatment longer than lower‐class patients (Gottesfeld, 1995; Leong, Wagner, & Kim, 1995;
Neighbors, Caldwell, Thompson, & Jackson, 1994).
As people of color are overrepresented among individuals living below the poverty line,
poverty undoubtedly contributes to the mental health problems among racial/ethnic minority
groups, and social class can intersect with the type of treatment that a minority client is likely
to receive. In addition, as Atkinson, Morten, and Sue (1998, p. 64) conclude,
Ethnic minorities are less likely to earn incomes sufficient to pay for mental health
treatment, less likely to have insurance, and more likely to qualify for public assistance
than European Americans. Thus ethnic minorities often have to rely on public
(government‐sponsored) or nonprofit mental health services to obtain help with their
psychological problems.
Working effectively with clients who are poor requires several major conditions. First, the
therapist must spend time understanding his or her own biases and prejudices. Confronting
one's own classism can help detect the influence of commonplace social stereotypes of poor
people, which can vary in association with race. For example, poor White people can be seen
through the lens of “White trash” or “redneck” stereotypes, while poor Black women can be
stigmatized as “welfare queens” (Smith & Redington, 2010). These attitudes can affect the
diagnosis and treatment of clients. Second, it becomes essential that counselors understand
how poverty affects the lives of people who lack financial resources; behaviors associated
with survival should not be pathologized. Third, counselors should consider that a more
active approach in treatment that allows for information‐giving activities might be more
appropriate for some clients than the passive, insight‐oriented, and long‐term models of
therapy. Last, poverty and the economic disparities that are the root causes of emotional
distress among the poor demand a social justice approach.
Several conclusions are suggested at this point: (a) poverty and classism present
overwhelming stressors to people and may seriously undermine the mental and physical
health of clients; (b) a failure to understand the life circumstance of clients who lack financial
resources, along with unintentional class bias, may affect the ability of helping professionals
to deliver appropriate mental health services; and (c) classism can make its appearance in the
assessment, diagnosis, and treatment of lower‐socioeconomic‐class clients.
LANGUAGE BARRIERS
Ker Moua, a Laotian refugee, suffered from a variety of ailments but was unable to
communicate with her doctor. The medical staff enlisted the aid of 12‐year‐old Jue as
the liaison between the doctor and the mother. Ker was diagnosed with a prolapsed
uterus, the result of bearing 12 children. She took medication in the doses described by
her son but became severely ill after two days. Fortunately, it was discovered that she
was taking an incorrect dosage that could have caused lasting harm. The hospital staff
realized that Jue had mistranslated the doctor's orders. When inquiries about the
translation occurred, Jue said, “I don't know what a uterus is. The doctor tells me things
I don't know how to say.”
(Burke, 2005, p. 5B)
Asking children to translate information concerning medical or legal problems is common in
many communities with high immigrant and refugee populations but may have devastating
consequences: (a) it can create stress and hurt the traditional parent–child relationship; (b)
children lack the vocabulary and emotional maturity to serve as effective interpreters; (c)
children may be placed in a situation where they are privy to confidential medical or
psychiatric information about their relatives; and (d) children may be unfairly burdened with
emotional responsibilities that only adults should carry (Coleman, 2003). In 2008, California
Assembly Bill 775 was introduced to ban the use of children as interpreters. Further, the
federal government has acknowledged that not providing adequate interpretation for client
populations is a form of discrimination.
The National Council on Interpreting in Health Care (2005) has published national standards
for interpreters of health care that address issues of cultural awareness and confidentiality.
These standards are based upon a number of important findings derived from focus groups of
immigrants (Ngo‐Metzger et al., 2003). First, nearly all immigrants interviewed expressed a
preference for professional translators rather than family members. They wanted translators
who were knowledgeable and respectful of their cultural customs. Second, using family
members to interpret—especially children—was negatively received for fear of their inability
to translate correctly. Third, discussing very personal or familial issues was often very
uncomfortable (shame, guilt, and other emotional reactions) when a family member acted as
the interpreter. Last, there was great concern that interpretation by a family member could be
affected by the family dynamics or vice versa.
Some general guidelines in selecting and working with professional interpreters are as
follows:
Make sure that the interpreter speak the same dialect as the client. Monitor carefully
whether the interpreter and client appear to have significant cultural or social
differences.
Establish a degree of familiarity with the interpreter; they should be understanding and
comfortable with your therapeutic style. Use the same interpreter consistently with the
same client.
Be aware that the interpreter is not just an empty box in the therapeutic relationship;
rather than a two‐person interaction, this is most likely a three‐person alliance.
Clients may initially develop a stronger relationship with the interpreter than with the
counselor.
Provide plenty of extra time in the counseling session.
Ensure that the interpreter realizes the code of confidentiality.
If you believe the interpreter is not fully translating the client's words or is interjecting
their own beliefs, opinions, and assumptions, it is important to have a frank and open
discussion about your observations.
Be aware that interpreters may also experience intense emotions when traumatic events
are discussed. Be alert for overidentification or countertransference. You may need to
work closely with the interpreter, allowing them periodic debriefing sessions.
Clearly, use of Standard English in health care delivery may unfairly discriminate against
those from a bilingual or lower socioeconomic background, with potentially devastating
consequences (Ratts & Pedersen, 2014; Vedantam, 2005). This inequity occurs in our
educational system and in the delivery of mental health services as well. Schwartz,
Rodriguez, Santiago‐Rivera, Arredondo, and Field (2010) indicate that psychologists are
increasingly finding that they must interact with clients who have English as a second
language or who do not speak English at all. The lack of bilingual therapists and the
requirement that clients communicate in English may limit the ability to progress in
counseling and therapy. If bilingual individuals do not use their native tongue in therapy,
many aspects of their emotional experience may not be available for treatment; they may be
unable to use the wide complexity of language to describe their particular thoughts, feelings,
and unique situations. Clients who are limited in English tend to feel like they are speaking as
a child and choosing simple words to explain complex thoughts and feelings. If they were
able to use their native tongue, they could easily explain themselves (Arredondo, Gallardo‐
Cooper, Delgado‐Romero, & Zapata, 2014).
Video 7.5: Barriers to Understanding
International clients can struggle in counseling if they do not have a cultural support system.
Identifying your client's needs related to community can have a positive impact on their
outcomes.
PATTERNS OF “AMERICAN” CULTURAL ASSUMPTIONS AND
MULTICULTURAL FAMILY COUNSELING/THERAPY
Family systems theory may be equally as culture‐bound as any other form of therapy, and
this limitation may be manifested in marital or couple counseling, parent–child counseling, or
work with more than one member of a family. Family systems therapy possesses several
important characteristics (Corey, 2013; McGoldrick, Giordano, & Garcia‐Preto, 2005):
It highlights the importance of the family (versus the individual) as the unit of identity.
It focuses on resolving concrete issues.
It is concerned with family structure and dynamics.
It assumes that these family structures and dynamics are historically passed on from one
generation to another.
It attempts to understand the communication and alliances via reframing.
It places the therapist in an expert position.
Many of these qualities would be consistent with the worldviews of persons of color. The
problem arises in how they are translated into concepts of “the family” or what constitutes a
“healthy” family. Some of the characteristics of healthy families may pose problems in
therapy with various culturally diverse groups. They tend to be heavily loaded with value
orientations that are incongruent with the value systems of many culturally diverse clients
(McGoldrick et al., 2005). According to family systems theory, healthy families:
Allow and encourage the free and open expression of emotion.
View each member as having a right to be his or her own unique self (individuate from
the emotional field of the family).
Strive for an equal division of labor among family members.
Consider egalitarian role relationships between spouses desirable.
Hold the nuclear family as the standard.
These orientations were first described by Kluckhohn and Strodtbeck (1961) as patterns of
“American” values. Table 7.2 outlines the five major dimensions of White culture, and
contrasts them with those of four major groups of color.
TABLE 7.2 Cultural Value Preferences of Middle‐Class White EuroAmericans and
People of Color: A Comparative Summary
Source: Ho, M. K. (1987). Family Therapy with Ethnic Minorities (p. 232). Newbury Park, CA: Sage. Copyright 1987
by Sage Publications. Reprinted by permission.
Area of
relationships
Middle‐class
White Americans
Asian
Americans
American
Indians
Black
Americans
Hispanic
Americans
People to
nature/environment
Mastery over
Harmony
with
Harmony
with
Harmony
with
Harmony
with
Time orientation Future
Past–
present
Present Present
Past–
present
People relations Individual Collateral Collateral Collateral Collateral
Preferred mode of
activity
Doing Doing
Being‐in‐
becoming
Doing
Being‐
in‐
becoming
Nature of man Good and bad Good Good
Good and
bad
Good
Select this link to open an interactive version of Table 7.2.
People–Nature Dimension
Traditional Western thinking believes in mastery and control over nature. As a result, most
therapists operate from a framework that subscribes to the belief that problems are solvable
and that both therapist and client must take an active part in solving problems via
manipulation and control. Active intervention is stressed in controlling or changing the
environment. The four other ethnic groups listed in Table 7.2 view people as harmonious with
nature.
Confucian philosophy, for example, stresses a set of rules aimed at promoting loyalty,
respect, and harmony among family members (Moodley & West, 2005). Harmony within the
family and the environment leads to harmony within the self. Dependence on the family unit
and acceptance of the environment seem to dictate differences in solving problems. Western
culture advocates defining and attacking problems directly. Asian cultures tend to
accommodate or deal with problems through indirection. In child rearing, many Asians
believe that it is better to avoid direct confrontation and to use deflection. A White family
might deal with a child who has watched too many hours of TV by saying, “Why don't you
turn the TV off and study?” To be more threatening, the parent might say, “You'll be
grounded unless the TV goes off!” An Asian parent might respond by saying, “That looks
like a boring program; I think your friend John must be doing his homework now,” or, “I
think Father wants to watch his favorite program.” Such an approach stems from the need to
avoid conflict and to achieve balance and harmony among members of the family and the
wider environment—values that continue to be associated with emotional well‐being among
Chinese people (Wang, Wong, & Yeh, 2016).
Thus, it is apparent that U.S. values that call for us to dominate nature (i.e., conquer space,
tame the wilderness, or harness nuclear energy) through control and manipulation of the
universe are reflected in family counseling. Family systems counseling theories attempt to
describe, explain, predict, and control family dynamics. The therapist actively attempts to
understand what is going on in the family system (structural alliances and communication
patterns), identify the problems (dysfunctional aspects of the dynamics), and attack them
directly or indirectly through manipulation and control (therapeutic interventions). Ethnic
minorities or subgroups that view people as harmonious with nature or believe that nature
may overwhelm people (“acts of God”) may find the therapist's mastery‐over‐nature
approach inconsistent with or antagonistic to their worldview. Indeed, attempts to intervene
actively in family patterns and relationships may be perceived as the problem, because they
might unbalance the existing harmony.
Time Dimension
How different societies, cultures, and people view time exerts a pervasive influence on their
lives. U.S. society may be characterized as preoccupied with the future (Katz, 1985;
Kluckhohn & Strodtbeck, 1961). Furthermore, our society seems very compulsive about time,
in that we divide it into seconds, minutes, hours, days, weeks, months, and years. Time may
be viewed as a commodity (“time is money” and “stop wasting time”) in fixed and static
categories, rather than as a dynamic and flowing process. It has been pointed out that the
United States' future orientation may be linked to other values as well: (a) stress on youth and
achievement, in which children are expected to “better their parents”; (b) controlling one's
own destiny by future planning and saving for a rainy day; and (c) optimism and hope for a
better future. The spirit of the nation may be embodied in an old General Electric slogan,
“Progress is our most important product.”
Table 7.2 reveals that both American Indians and Black Americans tend to value a present‐
time orientation, whereas Asian Americans and Hispanic Americans have a combination
past–present focus. Historically, Asian societies have valued the past, as reflected in ancestor
worship and the equating of age with wisdom and respectability. This contrasts with U.S.
culture, in which youth is valued over age and one's usefulness in life is believed to be over
once one hits the retirement years. As compared to EuroAmerican middle‐class norms,
Latinx Americans also exhibit a past–present time orientation. Strong hierarchical structures
in the family, respect for elders and ancestors, and the value of personalismo all combine in
this direction. American Indians also differ from their White counterparts in that they are very
grounded in the here and now, rather than the future. American Indian philosophy relies
heavily on the belief that time is flowing, circular, and harmonious. Artificial division of time
(schedules) is disruptive to the natural pattern. African Americans also value the present,
because of the spiritual quality of their existence and their history of victimization by racism.
Several difficulties may occur when the counselor or therapist is unaware of the differences
of time perspective (Hines & Boyd‐Franklin, 2005).
First, if time differences exist between a family of color and the White EuroAmerican
therapist, it will most likely be manifested in a difference in the pace of time: both may sense
things are going too slowly or too fast. An American Indian family that values being in the
present and the immediate experiential reality of being may feel that the therapist lacks
respect for them and is rushing them (Sutton & Broken Nose, 2005) while ignoring the
quality of the personal relationship. On the other hand, the therapist may be dismayed by the
“delays,” “inefficiency,” and lack of “commitment to change” among the family members.
After all, time is precious, and the therapist has only limited time to impact upon the family.
The result is frequently dissatisfaction among the parties, a failure to establish rapport,
misinterpretation of behaviors or situations, and discontinuation of future sessions.
Second, Inclan (1985) pointed out how confusions and misinterpretations can arise because
Hispanics, particularly Puerto Ricans, mark time differently than do their U.S. White
counterparts. The language of clock time in counseling (50‐minute hour, rigid time
schedule, once‐a‐week sessions) can conflict with minority perceptions of time (Garcia‐
Preto, 1996). The following dialogue illustrates this point clearly:
“Mrs. Rivera, your next appointment is at 9:30 a.m. next Wednesday.”
“Good, it's convenient for me to come after I drop off the children at school.”
Or “Mrs. Rivera, your next appointment is for the whole family at 3:00 p.m. on
Tuesday.”
“Very good. After the kids return from school we can come right in.”
(Inclan, 1985, p. 328)
Since school starts at 8 a.m., the client is bound to show up very early, whereas in the second
example, the client will most likely be late (school ends at 3 p.m.). In both cases, the
counselor is likely to be inconvenienced, but worse yet is the negative interpretation that may
be made of the client's motives (anxious, demanding, or pushy in the first case, and resistant,
passive‐aggressive, or irresponsible in the latter). The counselor needs to be aware that
many Hispanics may mark time by events rather than by the clock.
Relational Dimension
In general, the United States can be characterized as an achievement‐oriented society, which
is most strongly manifested in the prevailing Protestant work ethic. Basic to the ethic is the
concept of individualism: (a) the individual is the psychosocial unit of operation; (b) the
individual has primary responsibility for his or her own actions; (c) independence and
autonomy are highly valued and rewarded; and (d) one should be internally directed and
controlled. In many societies and groups within the United States, however, this value is not
necessarily shared. Relationships in Japan and China are often described as being lineal, and
identification with others is both wide and linked to the past (ancestor worship). Obeying the
wishes of ancestors or deceased parents and perceiving one's existence and identity as linked
to the historical past are inseparable. Almost all racial/ethnic minority groups in the United
States tend to be more collateral (collectivistic) in their relationships with people. In an
individualistic orientation, the definition of the family tends to be linked to a biological
necessity (nuclear family), whereas a collateral or lineal view encompasses various concepts
of the extended family. Not understanding this distinction and the values inherent in these
orientations may lead the family therapist to erroneous conclusions and decisions. Following
is a case illustration of a young American Indian.
A young probationer was under court supervision and had strict orders to remain with
responsible adults. His counselor became concerned because the youth appeared to
ignore this order. The client moved around frequently and, according to the counselor,
stayed overnight with several different young women. The counselor presented this case
at a formal staff meeting, and fellow professionals stated their suspicion that the client
was either a pusher or a pimp. The frustrating element to the counselor was that the
young women knew each other and appeared to enjoy each other's company. Moreover,
they were not ashamed to be seen together in public with the client. This behavior
prompted the counselor to initiate violation proceedings.
(Red Horse, Lewis, Feit, & Decker, 1981, p. 56)
If an American Indian professional had not accidentally come upon this case, a revocation
order initiated against the youngster would surely have caused irreparable alienation between
the family and the social service agency. The counselor had failed to realize that the
American Indian family network is structurally open and may include several households of
relatives and friends along both vertical and horizontal lines. The young women were all first
cousins to the client, and each was as a sister, with all the households representing different
units of the family.
Likewise, African Americans have strong kinship bonds that may encompass both blood
relatives and friends. Traditional African culture values the collective orientation over
individualism (Franklin, 1988; Hines & Boyd‐Franklin, 2005). This group identity has also
been reinforced by what many African Americans describe as the sense of “peoplehood”
developed as a result of the common experience of racism and discrimination. In a society
that has historically attempted to destroy the Black family, near and distant relatives,
neighbors, friends, and acquaintances have arisen in an extended family support network
(Black, 1996). Thus, the Black family may appear quite different from the ideal nuclear
family. The danger is that certain assumptions made by a White therapist may be totally
without merit or may be translated in such a way as to alienate or damage the self‐esteem of
African Americans. For example, the absence of a father in the Black family does not
necessarily mean that the children do not have a father figure. This function may be taken
over by an uncle or male family friend.
We give one example here to illustrate that the moral evaluation of a behavior may depend on
the value orientation of the cultural group: because of their collective orientation, Puerto
Ricans view obligations to the family as primary over all other relationships (Garcia‐Preto,
2005). When a family member attains a position of power and influence, it is expected that he
or she will favor his or her relatives over objective criteria. Businesses that are heavily
weighted by family members and appointments of family members to government positions
are not unusual in many countries. Failure to hire a family member may result in moral
condemnation and family sanctions (Inclan, 1985). This is in marked contrast to what we
ideally believe in the United States. Here, appointment of family members over objective
criteria of individual achievement is condemned. It would appear that differences in the
relationship dimension between the mental health provider and the minority family receiving
services can cause great conflict. Although family therapy may be the treatment of choice for
many minorities (over individual therapy), its values may again be antagonistic and
detrimental to minorities. Family approaches that place heavy emphasis on individualism and
freedom from the emotional field of the family may cause great harm. Our approach should
be to identify how we might capitalize on collaterality to the benefit of minority families.
Activity Dimension
One of the primary characteristics of White U.S. cultural values and beliefs is an action
(doing) orientation: (a) we must master and control nature; (b) we must always do things
about a situation; and (c) we should take a pragmatic and utilitarian view of life. In
counseling, we expect clients to master and control their own lives and environment, to take
action to resolve their own problems, and to fight against bias and inaction. The doing mode
is evident everywhere and is reflected in how White Americans identify themselves by what
they do (occupations), how children are asked what they want to do when they grow up, and
how a higher value is given to inventors over poets and to doctors of medicine over doctors of
philosophy. An essay topic commonly given to schoolchildren returning to school in the fall
is, “What I Did on My Summer Vacation.”
It appears that both American Indians and Latinx Americans prefer a being or being‐in‐
becoming mode of activity. The American Indian concepts of self‐determination and
noninterference are examples. Value is placed on the spiritual quality of being, as manifested
in self‐containment, poise, and harmony with the universe. Value is placed on the
attainment of inner fulfillment and an essential serenity of one's place in the universe.
Because each person is fulfilling a purpose, no one should have the power to interfere or
impose values. Often, those unfamiliar with American Indian values perceive them as stoic,
aloof, passive, noncompetitive, or inactive. In working with families, the counselor role of
active manipulator may clash with American Indian concept of being‐in‐becoming
(noninterference).
Likewise, Latinx culture may be said to have a more here‐and‐now or being‐in‐
becoming orientation. Like their American Indian counterparts, Hispanics believe that people
are born with dignidad (dignity) and must be given respeto (respect). They are born with
innate worth and importance; the inner soul and spirit are more important than the body.
People cannot be held accountable for their lot in life (status, role, etc.) because they are born
into this life state (Inclan, 1985). A certain degree of fatalismo (fatalism) is present, and life
events may be viewed as inevitable (Lo que Dios manda, “what God wills”). Philosophically,
it does not matter what people have in life or what position they occupy (farm laborer, public
official, or attorney). Status is possessed by existing, and everyone is entitled to respeto.
Since this belief system deemphasizes material accomplishments as a measure of success, it is
clearly at odds with EuroAmerican middle‐class society. Although a doing‐oriented
family may define a member's worth via achievement, a being orientation equates worth
simply to belonging. Thus, when clients complain that someone is not an effective family
member, what do they mean? This needs to be clarified by the therapist. Is it a complaint that
the family member is not performing and achieving (doing), or does it mean that they are not
respectful and accommodating to family structures and values (being)?
Ho (1987) describes both Asian Americans and African Americans as operating from the
doing orientation. However, it appears that “doing” in these two groups is manifested
differently than in the White American lifestyle. The active dimension in Asians is related not
to individual achievement, but to achievement via conformity to family values and demands.
Controlling one's own feelings, impulses, desires, and needs in order to fulfill responsibility
to the family is strongly ingrained in Asian children. The doing orientation tends to be more
ritualized in the roles of and responsibilities toward members of the family. African
Americans also exercise considerable control in the face of adversity (endure the pain and
suffering of racism) to minimize discrimination and to maximize success.
Nature of People Dimension
Middle‐class EuroAmericans generally perceive the nature of people as neutral.
Environmental influences, such as conditioning, family upbringing, and socialization, are
believed to be dominant forces in determining the nature of the person. People are neither
good nor bad, but are a product of their environment. Although several minority groups may
share features of this belief with Whites, there is a qualitative and quantitative difference that
may affect family structure and dynamics. For example, Asian Americans and American
Indians tend to emphasize the inherent goodness of people. We have already discussed the
Native American concept of noninterference, which is based on the belief that people have an
innate capacity to advance and grow (self‐fulfillment) and that problematic behaviors are
the result of environmental influences that thwart the opportunity to develop. Goodness will
always triumph over evil if a person is left alone. Likewise, Asian philosophy (Buddhism and
Confucianism) believes in people's innate goodness and prescribes role relationships that
manifest the “good way of life.” Central to Asian belief is the idea that the best healing source
lies within the family (Daya, 2005; Walsh & Shapiro, 2006) and that seeking help from the
outside (e.g., counseling and therapy) is nonproductive and against the dictates of Asian
philosophy.
Latinx Americans may be described as holding the view that human nature is both good and
bad (mixed). Concepts of dignidad and respeto undergird the belief that people are born with
positive qualities. Yet, some Hispanics, such as Puerto Ricans, spend a great deal of time
appealing to supernatural forces so that children may be blessed with a good human nature
(Inclan, 1985). Thus, a child's “badness” may be accepted as destiny, so parents may be less
inclined to seek help from educators or mental health professionals. The preferred mode of
help may be religious consultations and venting to neighbors and friends who sympathize and
understand the dilemma (change means reaching the supernatural forces).
African Americans may also be characterized as having a mixed concept of people, but in
general they believe, like their White counterparts, that people are basically neutral.
Environmental factors have a great influence on how people develop. This orientation is
consistent with African American beliefs that racism, discrimination, oppression, and other
external factors create problems for the individual. Emotional disorders and antisocial acts are
caused by external forces (system variables) rather than by internal, intrapsychic,
psychological forces. For example, high crime rates, poverty, and the current structure of the
African American family are the result of the historical and current oppression of Black
people.
White Western concepts of genetic inferiority and pathology (African American people are
born that way) hold little validity for the Black person.
Video 7.6: Assumptions and Identity
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
OVERGENERALIZING AND STEREOTYPING
Although it is critical for therapists to have a basic understanding of the generic
characteristics of counseling and psychotherapy and the culture‐specific life values of
different groups, overgeneralizing and stereotyping are ever‐present dangers. For example,
the listing of racial/ethnic minority group variables does not indicate that all persons coming
from the same minority group will share all or even some of these traits. Generalizations are
necessary for us; without them, we would become inefficient creatures. However, they are
guidelines for our behaviors, to be tentatively applied in new situations, and they should be
open to change and challenge. The information provided in Tables 7.1 and 7.2 should act as
guidelines rather than absolutes. These generalizations should serve as the background from
which the figure emerges.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Become cognizant of the generic characteristics of counseling and psychotherapy:
culture‐bound values, class‐bound values, and linguistic factors.
2. Know that we are increasingly becoming a multilingual nation and that the linguistic
demands of clinical work may place minority populations at a disadvantage.
3. Consider the need to provide community counseling services that reach out to the
minority population.
4. Realize that the problems and concerns of many groups of color are related to systemic
and external forces rather than to internal psychological problems (Chavez, Fernandez,
Hipolito‐Delgado, & Rivera, 2016).
5. Know that our increasing diversity presents us with different cultural conceptions of the
family. One definition cannot be seen as superior to another.
6. Realize that families cannot be understood apart from the cultural, social, and political
dimensions of their functioning. The traditional definition of the nuclear family as
consisting of heterosexual parents in a long‐term marriage, raising their biological
children, and having the father as sole wage earner now refers to a statistical minority.
7. Be careful not to overgeneralize or stereotype. Knowing general group characteristics
and guidelines is different from rigidly holding on to preconceived notions.
Video 7.7: Limitation of Stereotypes
Introduction to counseling session by Dr. Joel Filmore.
Video Lecture: Overcoming Barriers to Effective Multicultural Counseling and Therapy
SUMMARY
Theories of counseling and psychotherapy are influenced by assumptions that theorists make
regarding the goals for therapy, the method used to invoke change, and the definition of
mental health and illness. Counseling and psychotherapy have traditionally been
conceptualized in Western individualistic terms that may lead to premature termination of
counseling and underutilization of mental health services by marginalized groups in our
society. The culture‐bound values that may prove antagonistic to members of diverse
groups include the following: focus on the individual, verbal/emotional/behavioral
expressiveness, insight orientation, self‐disclosure, scientific empiricism, separation of
mental and physical functioning, and pattern of communication.
In addition to this category, both class‐bound values and linguistic factors may prove biased
against culturally diverse groups. For the therapist who comes from a middle‐ to upper‐
class background, it is often difficult to relate to the circumstances and hardships affecting the
client who lives in poverty. The phenomenon of poverty and its effects on individuals and
institutions can be devastating. Use of Standard English in health care delivery may also
unfairly discriminate against those from a bilingual or lower socioeconomic background,
leading to devastating consequences. The lack of bilingual therapists and the requirement that
the client communicate in English may limit progress in counseling and therapy. If bilingual
individuals do not use their native tongue, many aspects of their emotional experience may
not be available for treatment.
Family systems theory, while seemingly consistent with the collectivistic orientation of many
diverse groups, may be equally culture‐bound, as may be manifested in marital or couple
counseling, parent–child counseling, or work with more than one member of a family. For
example, the following Western beliefs and assumptions about healthy families may be
incongruent with diverse groups: (a) allow and encourage the free and open expression of
emotion; (b) view each family member as having a right to be his or her own unique self; (c)
strive for an equal division of labor among family members; (d) consider egalitarian role
relationships between spouses desirable; and (e) hold the nuclear family as the standard.
Especially useful for counselors to explore is the Kluckholn and Strodtbeck (1961) model of
“American” cultural patterns and their manifestation in five dimensions: people–nature
relationship, time orientation, relational focus, activity, and nature of people.
GLOSSARY TERMS
Activity dimension
Biculturalism
Class‐bound values
Collectivism
Culture‐bound values
Egalitarian roles
Emotional expressiveness
Extended families
Family systems
Individual‐centered
Individualism
Insight
Linguistic barriers
Minority standard time
Nature of people dimension
Nuclear families
Patriarchal roles
Relational dimension
Scientific empiricism
Self‐disclosure
Social class
Time dimension
YAVIS syndrome
Video 7.8: Counseling Session Analysis
Clients from different cultures may adhere to generalized roles. But it is important to follow
your clients' lead to determine the most appropriate way to interact with them during the
counseling session.
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8
Communication Style and Its Impact on Counseling and
Psychotherapy
Chapter Objectives
1. 1. Compare and contrast styles of communication between various racial/ethnic
and other sociodemographic groups.
2. 2. Define and recognize nonverbal communications and their cultural meanings.
3. 3. Acquire knowledge and understandings of how counseling styles and roles may
create barriers to effective multicultural counseling.
4. 4. List several ways how nonverbal communication can (a) trigger off racial biases
and fears and (b) reflect our true beliefs and feelings.
5. 5. Describe differences in how proxemics, kinesics, paralanguage, and high/low‐
context communication are likely to affect communication.
6. 6. Learn how different theories of counseling and psychotherapy can be
distinguished by their communication or helping styles.
7. 7. Explain the implications communication styles have for therapeutic intervention
techniques.
“Why are you so loud?”
“You need to calm down.”
“Why are you upset?”
These are all comments I have had said to me from non‐Black people when I wasn't
yelling, I felt pretty calm, and I wasn't upset. When I was young, these questions came as
a surprise. I didn't understand how my own perception of myself could be so different
from a person in the same space as me. It was alarming to think that I was
unintentionally making people uncomfortable with my communication style.
(Bowen, 2017, para. 1)
It's important to note that just because communications are indirect does not mean the
message is unclear … for indirect communicators, it IS clear. They pick up on the
context and get the message, it's just that direct communicators are not observant
enough to catch it. I was surprised to hear that my friends [who used an]
accommodating communication style sometimes found direct communicators
paternalistic. If someone is too direct, it's like “I understand you perfectly, you don't
need to explain it like I'm five”
(Aston, 2017, para. 32)
It would be weeks of replaying that conversation (over and over again in my head)
before I would pick up the phone and call [the therapist's] office … I told you about me,
my struggles and how I was feeling inside. You sat there in your expensive clothing, your
perfectly decorated office, and smiled at me the entire time. When I finished being open,
vulnerable and raw, you said words that would haunt me to this day: “You seem like a
strong Black woman, and found ways to cope. I'm proud of you. Please come back if you
feel like life is too much to handle” … Why didn't you hear me? Why didn't you
acknowledge the internal battle between me, my culture and my faith that I had to
overcome? Why didn't you see all of me? Why did you ignore the tears that streamed
down my cheeks? Why didn't you know that I had had enough of being “strong?”
(Cooper, 2017, para. 5)
“You're always moderating yourself,” [says] a Latina executive, who feels Latinas “are
always tagged with the emotional thing. They're always told, ‘Calm down. You've got to
be more cool. Be careful with your voice, be careful with your hands’.” Hispanic men
echo her observations. One ruefully told of moving from a Hispanic‐dominated
company, where he could gesture eloquently and speak passionately, to a Caucasian
workplace where he had to “scale back” his expressiveness.
(Hewlett, Allwood, and Sherbin, 2016)
Asian cultures generally don't have a huge vocabulary for feelings or value them highly
in the first place; we simply aren't encouraged to pay attention to them. Thus, many of us
have limited awareness of our emotional experiences, let alone words to describe them.
On top of that, talking about yourself is generally viewed as immodest in Asian cultures,
which place a high premium on modesty. Through that lens, making regular
appointments to talk about yourself seems self‐indulgent at worst and uncomfortable at
best. The hurdles don't end there. Asian cultures tend to be vastly different than the
Western ones from which most therapists, and the process of therapy itself, originated.
In some regards, such as the emphasis on the individual vs. the group, the cultures are
diametrically opposed. Thus, there's often a fear that cultural issues will be
misunderstood or pathologized in therapy. (These fears are not unwarranted; the field
has an embarrassing history of misinterpreting cultural nuances as personal
shortcomings.)
(Lin, 2014, para. 32)
REFLECTION AND DISCUSSION QUESTIONS
1. Based on what you've learned thus far, discuss the connections between culture,
historical/sociopolitical factors, and the communication impasses mentioned in these
examples.
2. How can you imagine similar impasses playing out in a session between a therapist and
a client?
3. What might their effect be on the client? On the therapist? On the treatment?
As we discussed in the previous chapter, cultural differences can act as barriers between
therapists and clients when therapists lack multicultural awareness and skills. Culture‐
related communication barriers are among the most relevant of these pitfalls for counselors,
given that verbal communication is the basic vehicle by which counseling and therapy take
place. In this chapter, we focus upon the essential elements of verbal and nonverbal
communication, their relationships to culture, and the implications for mental health
professionals.
Video 8.0: Introduction
The clinician can use testing as a way of gathering information about their client's boundaries
without having to verbalize or ask direct questions. This can be effective when working with
international clients.
COMMUNICATION STYLES
Effective helping depends on the counselor and the client being able to send and receive both
verbal and nonverbal messages accurately and appropriately. It requires that the counselor not
only sends messages (makes themself understood) but also receives messages (attends to
clients). The definition of effective counseling also includes verbal (content of what is said)
and nonverbal (how something is said) elements. Most counselors seem more concerned with
the accuracy of communication (getting to the heart of the matter) than with whether their
communication is appropriate. Moreover, the preceding examples illustrate the potential for
therapists to completely miss the essence of their clients' communications when they do not
appreciate the ways that their own assumptions and blind spots interact with clients' cultural
backgrounds and experiences. In most cases, therapists have been trained to tune in to the
content of what is said rather than to how something is said.
Communication style refers to those factors that go beyond the content of what is said.
Communication specialists have historically found that only 30–40% of what is
communicated conversationally is verbal (Ramsey & Birk, 1983; Singelis, 1994). What
people say and do is usually qualified by other things that they say and do. A gesture, tone,
inflection, posture, or degree of eye contact may enhance or negate the content of a message.
Communication styles have a tremendous impact on our face‐to‐face encounters with
others (Geva & Wiener, 2015). Whether our conversation proceeds in fits and starts, whether
we interrupt one another continually or proceed smoothly, the topics we prefer to discuss or
avoid, the depth of our involvement, the forms of interaction (e.g., ritual, repartee,
argumentative, persuasive), and the channel we use to communicate (verbal–nonverbal versus
nonverbal–verbal) are all aspects of communication style. Some refer to these factors as the
social rhythms that underlie all our speech and actions. Communication styles are strongly
correlated with race, culture, and ethnicity (Garrett & Portman, 2011; Ivey, Ivey, & Zalaquett,
2014); gender has been found to be a powerful determinant of communication style as well
(Pearson, 1985; Robinson & Howard‐Hamilton, 2000).
Reared in a EuroAmerican middle‐class society, mental health professionals may assume
that certain behaviors or rules of speaking are universal and possess the same meaning. This
may create major problems for therapists and clients of varying cultural backgrounds. Since
differences in communication style are strongly manifested in nonverbal communication, this
chapter concentrates on those aspects of communication that transcend the written or spoken
word. First, we explore how race/culture may influence several areas of nonverbal behavior:
(a) proxemics, (b) kinesics, (c) paralanguage, and (d) high/low‐context communication.
Second, we briefly discuss the function and importance of nonverbal behavior as it relates to
the stereotypes and preconceived notions that we may have of diverse groups. Last, we
propose a basic thesis that various racial minorities, such as Asian Americans, American
Indians, African Americans, Arab Americans, and Latinx Americans, possess unique
communication styles that may have major implications for mental health practice.
Nonverbal Communication
Although language, class, and cultural factors all interact to create problems in
communication between culturally diverse clients and therapists, an oft neglected area is
nonverbal behavior (Duran, 2006; Singelis, 1994). What people say can be either enhanced or
negated by their nonverbals. When a man raises his voice, tightens his facial muscles, pounds
the table violently, and proclaims, “Goddamn it, I'm not angry!”, he is clearly contradicting
the content of his communication. If we all share the same cultural and social upbringing, we
may all arrive at the same conclusion. Interpreting nonverbals, however, is difficult for
several reasons. First, the same nonverbal behavior on the part of an American Indian client
may mean something quite different than if it were enacted by a White person (Locke &
Bailey, 2014; Garrett & Portman, 2011). Second, nonverbals often occur outside our level of
awareness but influence our evaluation and behavior. It is important to note that our
discussion of nonverbal codes will not include all possible areas, like olfaction (taste and
smell), tactile cues, and artifactual communication (clothing, hairstyle, display of material
things, etc.).
Proxemics
The study of proxemics refers to perception and the use of personal and interpersonal space.
Clear norms exist concerning the use of physical distance in social interactions. Edward Hall
(1959) identified four interpersonal distance zones characteristic of U.S. culture: intimate,
from contact to 1.5 ft.; personal, from 1.5 to 4 ft.; social, from 4 to 12 ft.; and public (lectures
and speeches), greater than 12 ft.
In our society, individuals seem to grow uncomfortable when others stand too close rather
than too far away. The range of feelings and reactions associated with a violation of personal
space includes flight, withdrawal, anger, and conflict (Pearson, 1985). On the other hand, we
tend to allow closer proximity to people whom we like or feel interpersonal attraction toward.
Some evidence exists that personal space can be reframed in terms of dominance and status.
Those with greater status, prestige, and power may occupy more space (larger homes, cars, or
offices).
However, different cultures dictate different distances in personal space. For many Latinx
Americans, Africans, Black Americans, Indonesians, Arabs, South Americans, and French,
conversing with a person allows for a much closer stance than is normally comfortable for
EuroAmericans (Jensen, 1985; Nydell, 1996). A Latinx American client's closeness may
cause the therapist to back away. The client may interpret this as aloofness, coldness, or a
desire not to communicate on the part of the therapist. In some cross‐cultural encounters, it
may even be perceived as a sign of haughtiness and superiority. On the other hand, the
therapist may misinterpret the client's behavior as an attempt to become inappropriately
intimate, a sign of pushiness or aggressiveness. Both therapists and culturally diverse clients
may benefit from understanding that their reactions and behaviors are attempts to create the
spatial dimension to which they are culturally conditioned.
Research on proxemics leads to the inevitable conclusion that conversational distances are
functions of the racial and cultural backgrounds of the conversants (Mindess, 1999; Susman
& Rosenfeld, 1982; Wolfgang, 1985). The factor of personal space has major implications for
how furniture is arranged, where seats are located, and where and how far apart therapists and
clients sit. Latinx Americans, for example, may not feel comfortable speaking to a person
behind a desk. Many EuroAmericans, however, like to keep a desk between themselves and
others. Some Inuit may actually prefer to sit side by side rather than across from one another
when talking about intimate aspects of their lives.
Kinesics
Whereas proxemics refers to personal space, kinesics is the term used to refer to bodily
movements. It includes such things as facial expression, posture, characteristics of movement,
gestures, and eye contact. Again, kinesics appears to be culturally conditioned. Many of our
counseling assessments are based upon expressions on people's faces. We assume that facial
cues express emotions and demonstrate the degree of responsiveness or involvement of the
individual. For example, smiling is a type of expression in our society that is believed to
indicate liking or positive affect. People attribute greater positive characteristics to others
who smile; they see them as intelligent, have a good personality, and are pleasant (Singelis,
1994).
On the other hand, some Asians believe that smiling may suggest other meanings or even
weakness. When Japanese smile and laugh, it does not necessarily indicate happiness but may
convey other meanings (e.g., embarrassment, discomfort, shyness). Among some Chinese and
Japanese, restraint of strong feelings (anger, irritation, sadness, and love or happiness) is
considered to be a sign of maturity and wisdom. Children learn that outward emotional
displays (facial expressions, body movements, and verbal content) are discouraged except in
extreme situations. Unenlightened counselors may assume that their Asian American client is
lacking in feelings or is out of touch with them. Alternatively, the lack of facial expressions
may be the basis of stereotypes, such as the idea that Asians are “inscrutable,” “sneaky,”
“deceptive,” and “backstabbing.”
A number of gestures and bodily movements have been found to have different meanings
when the cultural context is considered (LaBarre, 1985). In the Sung Dynasty in China,
sticking out the tongue was a gesture of mock terror and meant as ridicule; to the Ovimbundu
of Africa, it means “You're a fool” (when coupled with bending the head forward); a
protruding tongue in the Mayan statues of gods signifies wisdom; and in U.S. culture, it is
generally considered to be a juvenile, quasi‐obscene gesture of defiance, mockery, or
contempt.
Head movements also have different meanings (Eakins & Eakins, 1985; Jensen, 1985). An
educated Englishman may consider the lifting of the chin when conversing as a poised and
polite gesture, but to EuroAmericans it may connote snobbery and arrogance (“turning up
one's nose”). Whereas we shake our head from side to side to indicate “no,” Mayan tribe
members say “no” by jerking the head to the right. In Sri Lanka, one signals agreement by
moving the head from side to side like a metronome (Singelis, 1994).
Most EuroAmericans perceive squatting (often done by children) as improper and childish. In
other parts of the world, people have learned to rest by taking a squatting position. On the
other hand, when we put our feet up on a desk, it is believed to signify a relaxed and informal
attitude. Yet, Latinx Americans and Asians may perceive it as rudeness and arrogance,
especially if the bottoms of the feet are shown to them.
Shaking hands is another gesture that varies from culture to culture and may have strong
cultural/historical significance. Latinx Americans tend to shake hands more vigorously,
frequently, and for a longer period of time. Interestingly, most cultures use the right hand
when shaking. Since most of the population of the world is right‐handed, this may not be
surprising. However, some researchers believe that shaking with the right hand may be a
symbolic act of peace, as in older times it was the right hand that generally held the weapons.
In some Muslim and Asian countries, touching anyone with the left hand may be considered
an obscenity (the left hand aids in the process of elimination and is “unclean,” whereas the
right one is used for the intake of food and is “clean”). Offering something with the left hand
to a Muslim may be an insult of the most serious type.
Eye contact is, perhaps, the nonverbal behavior most likely to be addressed by mental health
providers. It is not unusual for us to hear someone say, “Notice that the husband avoided eye
contact with the wife,” or “Notice how the client averted his eyes when…” Behind these
observations is the belief that eye contact or lack of eye contact has diagnostic significance.
We would agree with that premise, but in most cases, counselors attribute negative traits to
the avoidance of eye contact: shy, unassertive, sneaky, or depressed.
This lack of understanding has been played out in many different situations when Black–
White interactions have occurred. In many cases, it is not necessary for Blacks to look one
another in the eye at all times when communicating. An African American may be actively
involved in doing other things when engaged in a conversation. Many White therapists are
prone to view the African American client as being sullen, resistant, or uncooperative. Smith
(1981, p. 155) provides an excellent example of such a clash in communication styles.
For instance, one Black female student was sent to the office by her gymnasium teacher
because the student was said to display insolent behavior. When the student was asked
to give her version of the incident, she replied, “Mrs. X asked all of us to come over to
the side of the pool so that she could show us how to do the backstroke. I went over with
the rest of the girls. Then Mrs. X started yelling at me and said I wasn't paying attention
to her because I wasn't looking directly at her. I told her I was paying attention to her
(throughout the conversation, the student kept her head down, avoiding the principal's
eyes), and then she said that she wanted me to face her and look her squarely in the eye
like the rest of the girls [who were all White]. So I did. The next thing I knew she was
telling me to get out of the pool, that she didn't like the way I was looking at her. So
that's why I'm here.”
As this example illustrates, African American styles of communication not only may be
different from those of their White counterparts but also may lead to misinterpretations. Many
Blacks do not nod their heads or say “uh‐huh” to indicate that they are listening (Hall, 1976;
Kochman, 1981). Statistics indicate that when White U.S. Americans listen to a speaker, they
make eye contact with them about 80% of the time. When speaking to others, however, they
tend to look away (avoid eye contact) about 50% of the time. This is in marked contrast to
many African Americans, who make greater eye contact when speaking and make infrequent
eye contact when listening!
Paralanguage
The term paralanguage is used to refer to other vocal cues that individuals use to
communicate. For example, loudness of voice, pauses, silences, hesitations, rate of speech,
inflections, and the like all fall into this category. Paralanguage is very likely to be
manifested forcefully in conversation conventions such as how we greet and address others
and how we take turns in speaking. It can communicate a variety of different features about a
person, such as their age, gender, sex, race, and emotional responses.
There are complex rules regarding when to speak and when to yield to another. For example,
EuroAmericans frequently feel uncomfortable with a pause or silent stretch in the
conversation, feeling obligated to fill it with more talk. However, silence is not always a sign
for the listener to take up the conversation. While it may be viewed negatively by many, other
cultures interpret it differently. The British and Arabs use silence for privacy, while the
Russians, French, and Spanish read it as agreement among the parties (Hall, 1976). In Asian
culture, silence is traditionally a sign of respect for elders. Furthermore, silence by many
Chinese and Japanese is not a floor‐yielding signal inviting others to pick up the
conversation. Rather, it may indicate a desire to continue speaking after making a particular
point. Often silence is a sign of politeness and respect rather than a lack of desire to continue
speaking.
The amount of verbal expressiveness in the United States, relative to other cultures, is quite
high. Most EuroAmericans encourage their children to enter freely into conversations, and
teachers encourage students to ask many questions and state their thoughts and opinions. This
has led many from other countries to observe that EuroAmerican youngsters are brash,
immodest, rude, and disrespectful (Irvine & York, 1995; Jensen, 1985). Likewise, teachers of
children of color may see reticence in speaking out as a sign of ignorance, lack of motivation,
or ineffective teaching (Banks & Banks, 1993), when in reality the students may be showing
proper respect (to ask questions is disrespectful because it implies that the teacher was
unclear). American Indians, for example, have been taught that to speak out, ask questions, or
even raise one's hand in class is immodest.
A mental health professional who is uncomfortable with silence or who misinterprets it may
fill in the conversation and prevent the client from elaborating. An even greater danger is to
impute incorrect motives to the minority client's silence. One can readily see how therapy,
which emphasizes talking, may place many minorities at a disadvantage.
Volume and intensity of speech in conversation are also influenced by cultural values. The
overall loudness of speech displayed by many EuroAmerican visitors to foreign countries has
earned them the reputation of being boisterous and shameless. In Asian countries, people tend
to speak more softly and would interpret the loud volume of a U.S. visitor as a sign of
aggressiveness, loss of self‐control, or anger. When compared to Arabs, however, people in
the United States are soft‐spoken. Many Arabs like to be bathed in sound, and the volume of
their radios, DVDs, and televisions is quite loud. In some countries where such entertainment
units are not plentiful, it is considered a polite and thoughtful act to allow neighbors to hear
by keeping the volume high. We in the United States would view such behavior as being a
thoughtless invasion of privacy.
A therapist or counselor working with clients would be well advised to be aware of possible
cultural misinterpretations as a function of speech volume. Speaking loudly may not indicate
anger and hostility, and speaking in a soft voice may not be a sign of weakness, shyness, or
depression.
The directness of a conversation or the degree of frankness also varies considerably among
various cultural groups. Observing the British in their parliamentary debates will drive this
point home. The long heritage of open, direct, and frank confrontation leads to heckling of
public speakers and quite blunt and sharp exchanges. Britons believe and feel that these are
acceptable styles and may take no offense at being the object of such exchanges. However,
U.S. citizens feel that such exchanges are impolite, abrasive, and irrational. Relative to
Asians, EuroAmericans are seen as being too blunt and frank. Great care is taken by many
Asians not to hurt others' feelings or embarrass them. As a result, use of euphemisms and
ambiguity is the norm.
Since many groups of color may value indirectness, the U.S. emphasis on “getting to the
point” and “not beating around the bush” may alienate them. Asian Americans, American
Indians, and some Latinx Americans can see this behavior as immature, rude, and lacking in
finesse. On the other hand, they may themselves be negatively labeled as evasive and afraid
to confront the problem.
REFLECTION AND DISCUSSION QUESTIONS
1. How can proxemics affect conversation distances and the use of personal space in
therapy with culturally diverse clients?
2. When conversing with others, how aware are you of using your hands to talk, making
eye contact, smiling or frowning, and other bodily movements?
3. Why is awareness of kinesics important in therapy?
4. Are you loud or soft‐spoken? Do you speak quickly or slowly? When you are speaking
to a person and there is a pause in the conversation, are you comfortable or
uncomfortable? Does silence bother you in counseling? How do you define a silent
period: one second, two seconds, three seconds, or a minute? How might differences in
paralanguage play out in the counseling session?
High/Low‐Context Communication
Edward Hall, author of such classics as The Silent Language (1959) and The Hidden
Dimension (1969), is a well‐known anthropologist who has proposed the concept of high‐
and low‐context cultures (Hall, 1976). A high‐context (HC) communication or message is
one that is anchored in the physical context (situation) or internalized in the person. Less
reliance is placed on the explicit code or message content. An HC communication relies
heavily on nonverbals and the group identification/understanding shared by those
communicating. For example, a normal‐stressed “no” by a EuroAmerican might be
interpreted by an Arab as a “yes.” A real negation in Arab culture would be stressed much
more emphatically. In Filipino culture, a mild, hesitant “yes” is interpreted by those who
understand as a “no” or a polite refusal. In traditional Asian society, many interactions are
understandable only in light of HC cues and situations. For example, to extend an invitation
for dinner only once would be considered an affront, as it would imply that the invitation was
not sincere. One must extend an invitation several times, encouraging the invitee to accept.
Arabs may also refuse an offer of food several times before giving in. Most EuroAmericans
believe that a host's offer can be politely refused with just a “no, thank you.”
If we pay attention to only the explicit coded part of a message, we are likely to
misunderstand the communication (Geva & Wiener, 2015). According to Hall (1976), low‐
context (LC) cultures place a greater reliance on the verbal part of the message. In addition,
LC cultures have been associated with being more opportunistic, being more individual‐
oriented than group‐oriented, and emphasizing rules of law and procedure.
It appears that the United States is an LC culture (although it is still higher than the Swiss,
Germans, and Scandinavians in the amount of context required). China, perhaps, represents
the other end of the continuum; its complex culture relies heavily on context. Asian
Americans, African Americans, Hispanics, American Indians, and other minority groups in
the United States also emphasize HC cues.
In contrast to LC communication, HC is faster, more economical, more efficient, and more
satisfying. Because it is so bound to the culture, it is slow to change and tends to be cohesive
and unifying. LC communication does not unify, but changes rapidly and easily.
Twins who have grown up together can and do communicate more economically (HC) than
do two lawyers during a trial (LC). Bernstein's (1964) classic work in language analysis refers
to restricted codes (HC) and elaborated codes (LC). Restricted codes are observed in families
where words and sentences collapse and are shortened without loss of meaning. Elaborated
codes, where many words are used to communicate the same content, are seen in classrooms,
diplomacy, and law.
African American culture has been described as HC. For example, it is clear that many
Blacks require fewer words than their White counterparts to communicate the same content
(Irvine & York, 1995). An African American male who enters a room and spots an attractive
woman may stoop slightly in her direction, smile, and tap the table twice while vocalizing a
long drawn out “uh huh.” What he has communicated would require many words from his
White brother! The fact that African Americans may communicate more by HC cues has led
many to characterize them as nonverbal, inarticulate, unintelligent, and so forth.
Video 8.2: Communicating Through Connection
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
SOCIOPOLITICAL FACETS OF NONVERBAL COMMUNICATION
There is a common saying among African Americans: “If you really want to know what
White folks are thinking and feeling, don't listen to what they say, but how they say it.” In
most cases, such a statement refers to the biases, stereotypes, and racist attitudes that Whites
are believed to possess but consciously or unconsciously conceal.
Rightly or wrongly, many minority individuals, through years of personal experience, operate
from three assumptions. First, that all Whites in U.S. society are racist. Through their own
cultural conditioning, they have been socialized into a culture that espouses the superiority of
White culture over all others (Jones, 1997; Ridley, 2005; Sue, 2015). Second, that most
Whites find such a concept disturbing and will go to great lengths to deny that they are racist
or biased. Some of this is done deliberately and with awareness, but in most cases their
racism is largely unconscious (Todd & Abrams, 2011). Last, that nonverbal behaviors are
more accurate reflections of what a White person is thinking or feeling than what they say.
There is considerable evidence to suggest that these three assumptions are indeed accurate
(McIntosh, 1989; Ridley, 2005; Sue, 2010). Counselors and mental health practitioners need
to be very cognizant of nonverbal cues from a number of different perspectives. In the last
section, we discussed how nonverbal behavior is culture‐bound and how the counselor or
therapist cannot make universal interpretations about it. Likewise, nonverbal cues are
important because they often (a) unconsciously reflect our biases and (b) trigger off
stereotypes we have of other people.
Nonverbals as Reflections of Bias
Some time ago, a TV program called Candid Camera was all the rage in the United States. It
operated from a unique premise, which involved creating very unusual situations for naive
subjects who were filmed as they reacted to them. One of these experiments involved
interviewing housewives about their attitudes toward African American, Latinx, and White
teenagers. The intent was to select a group of women who by all standards appeared sincere
in their beliefs that Black and Latinx Americans were no more prone to violence than were
their White counterparts. Unknown to them, they were filmed by a hidden camera as they left
their homes to go shopping at the local supermarket.
The creator of the program had secretly arranged for an African American, a Latino, and a
White youngster (dressed casually but nearly identically) to pass these women on the street.
The experiment was counterbalanced; that is, the race of the first youngster to approach easy
woman was randomly assigned. What occurred was a powerful statement on unconscious
racist attitudes and beliefs.
All the youngsters had been instructed to pass the shoppers on the purse side of the street. If
the woman was holding the purse in her right hand, the youngster would approach and pass
on her right. If the purse was held with the left hand, the youngster would pass on her left.
Studies of the film revealed consistent outcomes. Many of the women, when approached by
the Black or the Latino youngster (approximately 15 ft. away), would casually switch their
purse from one arm to the other! This occurred infrequently with the White subject. Why?
The answer appears quite obvious to us. The women subjects who switched their purses were
operating from biases, stereotypes, and preconceived notions about what minority youngsters
are like: they are prone to crime, more likely to snatch a purse or rob, more likely to be
juvenile delinquents, and more likely to engage in violence (Sue, 2010). The disturbing part
of this experiment was that the selected subjects were, by all measures, sincere individuals
who on a conscious level denied harboring racist attitudes or beliefs. They were not liars, nor
were they deliberately deceiving the interviewer. They were normal, everyday people. They
honestly believed that they did not possess these biases, yet when tested, their nonverbal
behavior (purse switching) gave them away.
The power of nonverbal communication is that it tends not to be under conscious control.
Studies support the conclusion that nonverbal cues operate primarily on an unaware level
(DePaulo, 1992; Singelis, 1994), that they tend to be spontaneous and difficult to censor or
falsify, and that they are more trusted than words. In our society, we have learned to use
words (spoken or written) to mask or conceal our true thoughts and feelings. Note how our
politicians and lawyers are able to address an issue without revealing much of what they think
or believe.
Nonverbal behavior provides clues to conscious deceptions or unconscious biases (Utsey,
Gernat, & Hammar, 2005). There is evidence that the accuracy of nonverbal communication
varies with the part of the body used: facial expression is more controllable than the hands,
followed by the legs and the rest of the body (Hansen, Stevic, & Warner, 1982). The
implications for multicultural counseling are obvious. Therapists who have not adequately
dealt with their own biases and racist attitudes may unwittingly communicate them to
culturally diverse clients. Studies suggest that women and persons of color are better readers
of nonverbal cues than are White males (Hall, 1976; Jenkins, 1982). Much of this may be due
to their HC orientation, but another reason may be survival. For an African American person
to survive in a predominantly White society, he or she has to rely on nonverbal cues more
often than verbal ones.
One of our male African American colleagues gives the example of how he must constantly
be vigilant when traveling in an unknown part of the country. Just to stop at a roadside
restaurant may be dangerous to his physical well‐being. As a result, when entering a diner,
he is quick to observe not only the reactions of the staff (waiter/waitress, cashier, cook, etc.)
but those of the patrons as well. Do they stare at him? What type of facial expressions do they
have? Do they fall silent? Does he get served immediately, or is there an inordinate delay?
These nonverbal cues reveal much about the environment around him. He may choose to be
himself or to play the role of a “humble” Black person who leaves quickly if the situation
poses danger.
Interestingly, this very same colleague talks about tuning in to nonverbal cues as a means of
psychological survival. He believes it is important for minorities to accurately read where
people are coming from in order to prevent invalidation of the self. For example, a Black
person driving through an unfamiliar part of the country may find him‐ or herself forced to
stay at a motel overnight. Seeing a vacancy light flashing, he or she stops and knock on the
manager's door. Upon opening the door and seeing the Black person, the White manager
shows hesitation, stumbles around in his or her verbalizations, and apologizes for having
forgotten to turn off the vacancy light. The Black person is faced with the dilemma of
deciding whether the White manager is telling the truth or is simply not willing to rent to an
African American.
Some of you might ask, “Why is it important for you to know? Why don't you simply find
someplace else? After all, would you stay at a place where you were unwelcome?” But
finding another place to stay may not be as important as the psychological well‐being of the
minority person. Racial/ethnic minorities have encountered too many situations in which
double messages are given to them (microaggressions). For the African American to accept
the simple statement, “I forgot to turn off the vacancy light,” might be to deny his or her own
true feelings at being the victim of discrimination. This is especially true when the nonverbals
(facial expression, anxiety in voice, and stammering) reveal other reasons.
Too often, culturally diverse individuals are placed in situations where they are asked to deny
their true feelings in order to perpetuate White deception. Statements that minorities are
oversensitive (paranoid?) may represent a form of denial (Sue, Bucceri, Lin, Nadal, & Torino,
2007). Thus, it is clear that racial/ethnic minorities are very tuned in to nonverbals. For
therapists who have not adequately dealt with their own racism, clients of color will be quick
to assess such biases. In many cases, clients of color may believe that the biases are too great
to be overcome and will simply not continue in therapy. This is despite the good intentions of
the White therapists.
Nonverbals as Triggers to Biases and Fears
Often, people assume that being an effective multicultural therapist is a straightforward
process that involves the acquisition of knowledge about the various racial/ethnic groups. If
we know that Asian Americans and African Americans have different patterns of eye contact
and if we know that these patterns signify different things, then we should be able to
eliminate the biases and stereotypes that we possess. Were it so easy, we might have
eradicated racism years ago. Although increasing our knowledge base about the lifestyles and
experiences of marginalized groups is important, it is not a sufficient condition in itself. Our
biased attitudes, beliefs, and feelings are deeply ingrained in our total being. Through years of
conditioning, they have acquired a strong irrational base, replete with emotional symbolism
about each particular racial group. Simply opening a text and reading about Black and Latinx
Americans will not deal with our deep‐seated fears and biases.
One of the major barriers to effective understanding is the common assumption that different
cultural groups operate according to identical speech and communication conventions. In the
United States, it is often assumed that distinctive racial, cultural, and linguistic features are
deviant, inferior, or embarrassing (Kochman, 1981; Singelis, 1994; Stanback & Pearce,
1985). These value judgments then become tinged with beliefs that we hold about Black
people: that they are racially inferior, that they are prone to violence and crime, that they are
quick to anger, and that they are a threat to White folks. The communication style of Black
people (manifested in nonverbals) can often trigger off these fears.
African American styles of communication are often high‐key, animated, heated,
interpersonal, and confrontational. Many emotions, affects, and feelings are generated (Hall,
1976; Shade & New, 1993; Weber, 1985). In a debate, African Americans tend to act as
advocates of a position, and to test ideas in the crucible of argument (Kochman, 1981). White
middle‐class styles, however, are characterized as being detached and objective, impersonal
and nonchallenging. A person acts not as an advocate of an idea but as a spokesperson for it
(truth resides in the idea). A discussion of issues should be devoid of affect, because emotion
and reason work against one another. One should talk things out in a logical fashion without
getting personally involved. African Americans characterize their own style of
communication as indicating that a person is sincere and honest, whereas EuroAmericans
consider their style to be reasoned and objective (Irvine & York, 1995). Many African
Americans readily admit that they operate from a point of view and, as mentioned previously,
are disinclined to believe that White folks do not. Smith (1981, p. 154) aptly describes the
Black orientation in the following passage.
When one Black person talks privately with another, he or she might say: “Look, we
don't have to jive each other or be like White folks; let's be honest with one another.”
These statements reflect the familiar Black saying that “talk is cheap,” that actions
speak louder than words, and that Whites beguile each other with words … In contrast,
the White mind symbolizes to many Black people deceit, verbal chicanery, and sterile
intellectivity. For example, after long discourse with a White person, a Black individual
might say: “I've heard what you've said, but what do you really mean?”
Although African Americans may misinterpret White communication styles, it is more likely
that Whites will misinterpret Black styles. The direction of the misunderstanding is generally
linked to the activating of unconscious triggers or buttons about racist stereotypes and the
fears they represent. As we have repeatedly emphasized, one of the dominant stereotypes of
African Americans in our society is that of the hostile, angry, prone‐to‐violence Black
male. The more animated and affective communication style, closer conversing distance,
prolonged eye contact when speaking, greater bodily movements, and tendency to test ideas
in a confrontational/argumentative format lead many Whites to believe that their lives are in
danger. It is not unusual for White mental health practitioners to describe their African
American clients as being hostile and angry. We have also observed that some White trainees
who work with Black clients respond nonverbally in such a manner as to indicate anxiety,
discomfort, or fear (e.g., leaning away from their African American clients, tipping their
chairs back, crossing their legs or arms). These are nonverbal distancing moves that may
reflect the unconscious stereotypes that they hold of Black Americans. Although we would
entertain the possibility that a Black client is angry, most occasions we have observed do not
justify such a descriptor.
It appears that many EuroAmericans operate from the assumption that when an argument
starts, it may lead to a ventilation of anger and the outbreak of fighting. What many Whites
fail to realize is that African Americans distinguish between an argument used to debate a
difference of opinion and one that ventilates anger and hostility (DePaulo, 1992; Irvine &
York, 1995; Kochman, 1981; Shade & New, 1993). In the former, the affect indicates
sincerity and seriousness, there is a positive attitude toward the material, and the validity of
ideas is challenged. In the latter, the affect is more passionate than sincere, there is a negative
attitude toward the opponent, and the opponent is abused.
To understand African American styles of communication and to relate adequately to Black
communication would require much study in the origins, functions, and manifestations of
Black language (Jenkins, 1982). Weber (1985) believes that the historical and philosophical
foundations of Black language have led to the existence of several verbal styles among
Blacks. For example, playing the dozens is considered by many Blacks to be a high form of
verbal warfare and impromptu speaking (Jenkins, 1982; Kochman, 1981; Weber, 1985). To
the outsider, it may appear cruel, harsh, and provocative. Yet, to many in the Black
community, it has historical and functional meanings.
The term dozens was used by slave owners to refer to Black people with disabilities. Because
they were considered damaged goods, disabled Black people would often be sold at a
discount rate with 11 other disabled or injured slaves (making one dozen) (Weber, 1985).
Professor and folklorist Mona Lisa Saloy explains how this history gave rise to a
contemporary form of verbal skillfulness.
The practice of word play hedged on verbal insult was meant to toughen these already
maligned individuals from the additional hardships they were sure to face. The purpose
of the dozens is “not to lose your cool, [to] control your response,” Saloy says.
“Because if you're sold in cheap blocks of a dozen on the slave block because you're
deformed, for punishment, or for whatever reason, and you're so taunted by the outside
society, the only way you can tolerate this is to make some play out of it, to literally turn
it on its head, and so you learn how to control your reaction, because to react was to be
killed or maimed further or punished … so it's the tradition … we've kept that.”
(TheGrio, 2010, para. 9.)
Often played in jest, the dozens requires an audience to act as judge and jury over the
originality, creativity, and humor of the combatants. Here are three examples:
Say man, your girlfriend so ugly, she had to sneak up on a glass to get a drink of water
… Man, you so ugly, yo mamma had to put a sheet over your head so sleep could sneak
up on you.
(Weber, 1985, p. 248)
A:
Eat shit.
B:
What should I do with your bones?
A:
Build a cage for your mother.
B:
At least I got one.
A:
She is the least. (Labov, 1972, p. 321)
A:
Got a match?
B:
Yeah, my ass and your face or my farts and your breath. (Kochman, 1981, p. 54)
Other minority groups also have characteristic styles that may be unfamiliar or confusing for
counselors who do not share their background. One way of contrasting such communication
style differences may be in the overt activity dimension (the pacing/intensity) of nonverbal
communication. Table 8.1 contrasts five different groups along this continuum. How these
styles affect the therapist's perception and ability to work with culturally different clients is
important for each and every one of us to consider.
TABLE 8.1 Communication Style Differences (Overt Activity Dimension—
Nonverbal/Verbal)
American Indians
Asian Americans and
Hispanics
Whites Blacks
1. Speak
1. Speak
loud/fast
softly/slowly
2. Indirect gaze
when listening
or speaking
3. Interject less;
seldom offer
encouraging
communication
4. Delayed
auditory
(silence)
5. Manner of
expression
low‐keyed,
indirect
1. Speak softly
2. Avoidance of eye
contact when listening
or speaking to high‐
status persons
3. Similar rules
4. Mild delay
5. Low‐keyed, indirect
to control
listener
2. Greater
eye
contact
when
listening
3. Head
nods,
nonverbal
markers
4. Quick to
respond
5. Objective,
task‐
oriented
1. Speak with affect
2. Direct eye contact
(prolonged) when
speaking, but less
when listening
3. Interrupt (turn‐
taking) when able
4. Quicker to respond
5. Affective,
emotional,
interpersonal
Video 8.3: Utilizing Space to Create Closeness
Introduction to counseling session by Dr. Joel Filmore.
COUNSELING AND THERAPY AS COMMUNICATION STYLE
Throughout this book, we have repeatedly emphasized that different theories of counseling
and psychotherapy represent different communication styles (Ivey et al., 2014). Just as race,
culture, ethnicity, and gender may affect communication styles, so there is considerable
evidence that theoretical orientations in counseling will influence helping styles. When one
watches Carl Rogers (Person‐Centered Counseling) and Albert Ellis (Rational Emotive
Behavior Therapy) conducting therapy, one is struck by how differently they interact with
clients.
Differential Skills in MCT
There is strong support for the belief that different cultural groups may be more receptive to
certain counseling/communication styles because of cultural and sociopolitical factors
(Choudhuri, Santiago‐Rivera, & Garrett, 2012; Diller, 2011; West‐Olatunji & Conwill,
2011). Indeed, the literature on multicultural counseling and therapy (MCT) strongly suggests
that American Indians, Asian Americans, Black Americans, and Hispanic Americans may
tend to prefer more active‐directive forms of helping to nondirective ones (Brammer, 2012;
Ratts & Pedersen, 2014). We briefly describe two of these group differences here to give the
reader some idea of their implications.
Asian American clients, who may value restraint of strong feelings and believe that intimate
revelations are to be shared only with close friends, can cause problems for the counselor who
is oriented toward insight or feelings. It is entirely possible that such techniques as reflecting
on feelings, asking questions of a deeply personal nature, and making in‐depth
interpretations may be perceived as lacking in respect for the client's integrity (Locke &
Bailey, 2014). Asian American clients may not initially value insight approaches. For
example, some clients who come for vocational information may be perceived by counselors
as needing help in finding out what motivates their actions and decisions. Requests for advice
or information from the client are seen as indicative of deeper, more personal conflicts. The
blind application of techniques that clash with cultural values places many Asian Americans
in a seriously uncomfortable and oppressed position (Chang et al., 2014). Indeed, while
research suggests that most clients of color stay in treatment longer with a therapist of their
own race and ethnicity, this effect appears to be strongest with Asian American clients (Smith
& Trimble, 2016).
Many years ago, Atkinson, Maruyama, and Matsui (1978) tested this hypothesis with a
number of Asian American students. They prepared two tape recordings of a contrived
counseling session in which the client's responses were identical but the counselor's responses
differed, being directive in one case and nondirective in the other. Their findings indicated
that the counselor who used the directive approach was rated more credible and approachable
than the one who used the nondirective approach. Asian Americans seem to prefer a logical,
rational, structured counseling approach to an affective, reflective, and ambiguous one. Other
researchers have drawn similar conclusions (Atkinson & Lowe, 1995; Leong, 1986; Lin,
2001).
In a classic and groundbreaking study, Berman (1979) found similar results with a Black
population. The weakness of previous studies was their failure to compare equal responses
with a White population. Berman's study compared the use of counseling skills between
Black and White, male and female counselors. A videotape of culturally varied client
vignettes was viewed by Black and White counselor trainees. They responded to the question,
“What would you say to this person?” The data were scored and coded according to a
microcounseling taxonomy that divided counseling skills into attending and influencing ones
(Ivey et al., 2014). The hypothesis made by the investigator was that Black and White
counselors would give significantly different patterns of responses to their clients.
Data supported the hypothesis. Black males and females tended to use the more active
expressive skills (directions, expression of content, and interpretation) with greater frequency
than did their White counterparts. White males and females tended to use a higher percentage
of attending skills. Berman concluded that the counselor's race/culture appears to be a major
factor in his or her choice of skills, and that Black and White counselors appear to adhere to
two distinctive styles of counseling. Berman also concluded that the more active styles of the
Black counselor tend to include practical advice and allow for the interjection of the
counselor's values and opinions.
The implications for therapy are glaringly apparent. Mental health training programs tend to
emphasize the more passive attending skills. Therapists so trained may be ill equipped to
work with culturally different clients who might find the active approach more relevant to
their own needs and values (Parham, Ajamu, & White, 2011).
Implications for MCT
Ivey's continuing contributions (Ivey, 1986; Ivey, D'Andrea, & Ivey, 2011; Ivey et al., 2014)
in the field of microcounseling, multicultural counseling, and developmental counseling seem
central to our understanding of counseling/communication styles. He believes that different
theories are concerned with generating different sentences and constructs and that different
cultures may also be expected to generate different sentences and constructs. Counseling and
psychotherapy may be viewed as special types of temporary cultures (Ivey et al., 2011).
When the counseling style of the counselor does not match the communication style of his or
her culturally diverse clients, many difficulties may arise, including premature termination of
the session, inability to establish rapport, and cultural oppression of the client. It is clear that
effective multicultural counseling occurs when the counselor and the client are able to send
and receive both verbal and nonverbal messages appropriately and accurately. When the
counselor can engage in such activities, his or her credibility and attractiveness are increased.
Communication styles manifested in the clinical context may either enhance or negate the
effectiveness of multicultural counseling. Several major implications for counseling can be
discerned.
As practicing clinicians who work with a culturally diverse population, we need to move
decisively in educating ourselves about the differential meanings of nonverbal behavior and
the broader implications for communication styles. We need to realize that proxemics,
kinesics, paralanguage, and high/low‐context factors are important elements of
communication, that they may be highly culture‐bound, and that we should guard against
possible misinterpretation in our assessment of clients. Likewise, it is important that we begin
to become aware of and understand our own communication/helping style.
We believe that therapists must be able to shift their therapeutic styles to meet the
developmental needs of clients. We contend further that effective mental health professionals
are those who can also shift their helping styles to meet the cultural dimensions of their
clients. Therapists of differing theoretical orientations will tend to have different preferred
skill patterns. These skill patterns may be antagonistic or inappropriate to the
communication/helping styles of clients. In the research cited earlier, it was clear that White
counselors (by virtue of their cultural conditioning and training) tended to use the more
passive attending and listening skills in counseling/therapy, whereas racial/ethnic minority
populations often appeared more oriented toward an active influencing approach. There are
several reasons why this may be the case.
First, we contend that the use of more directive, active, and influencing skills is more likely to
provide personal information about where the therapist is coming from (self‐disclosure).
Giving advice or suggestions, interpreting, and telling the client how one feels are all acts of
counselor self‐disclosure. Although the use of attending or more nondirective skills may
also include self‐disclosure, many counselors tend to use active or influencing skills only
minimally. In multicultural counseling, the culturally diverse client is likely to approach the
counselor with trepidation: “What makes you any different from all the Whites out there who
have oppressed me?” “What makes you immune from inheriting the racial biases of your
forebears?” “Before I open up to you [self‐disclose], I want to know where you are coming
from.” “How open and honest are you about your own racism, and will it interfere with our
relationship?” “Can you really understand what it's like to be Asian, Black, Hispanic,
American Indian, or the like?” In other words, a culturally diverse client may not open up (or
self‐disclose) until you, the helping professional, self‐disclose first. Thus, to many
minority clients, therapists who express their thoughts and feelings, as well as their ideas
about the direction of the work, may be better received in a counseling situation.
Second, studies support the thesis that White therapists are more likely to focus their problem
diagnosis in individual rather than societal terms. In a society where individualism prevails, it
is not surprising to find that EuroAmerican counselors tend to view their clients' problems as
residing within the individual rather than in society. Thus, the role of the therapist will be
person‐focused, and the skills they utilize will be individual‐centered (attending), aimed at
changing the person. Many marginalized groups accept the importance of individual
contributions to a problem, but they also give great weight to systemic or societal factors that
may adversely impact their lives. People of color who have been the victims of discrimination
and oppression perceive that the problem resides externally to the person (societal forces).
Active systems intervention is called for, and the most appropriate way to attack the
environment (stressors) is through an active approach (Ratts & Pedersen, 2014). If the
counselor shares this perception, he or she may take a more active role in sessions, giving
advice and suggestions and teaching strategies (becoming a partner to the client).
Finally, although it would be ideal if we could effectively engage in the full range of
therapeutic responses, such a wish may prove unrealistic. We cannot be all things to all
people; that is, there are personal limits to how much we can change our communication
styles to match those of our clients. The difficulty in shifting styles may be a function of
inadequate practice, the inability to understand the other person's worldview, or personal
biases or racist attitudes that have not been adequately resolved. In these cases, the counselor
might consider several alternatives: (a) seek additional training/education; (b) seek
consultation with a more experienced counselor; (c) refer the client to another therapist; or (d)
become aware of their personal communication style limitations and try to anticipate how
they might impact the culturally diverse client. Often, a therapist who recognizes the
limitations of his or her helping style and knows how they will impact a culturally diverse
client can take steps to minimize possible conflicts.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Recognize that no one style of counseling or therapy will be appropriate for all
populations and situations. A counselor or therapist who is able to engage in a variety of
helping styles and roles is most likely to be effective in working with a diverse
population.
2. Become knowledgeable about how race, culture, and gender affect communication
styles.
3. Your clinical observation skills will be greatly enhanced if you sharpen your nonverbal
powers of observation of clients.
4. Become aware of your own communication and helping styles. Know your social impact
on others and anticipate how it affects your clients.
5. Try to obtain additional training and education on a variety of theoretical orientations
and approaches in order to expand your helping styles.
6. Realize that we are feeling, thinking, behaving, social, cultural, spiritual, and political
beings. Try to think holistically rather than in a reductionist manner when it comes to
conceptualizing the human condition.
7. It is important for training programs to use an approach that calls for openness and
flexibility both in conceptualizing the issues and in actual skill building. Develop and
use helping strategies, techniques, and styles that consider not only individual
characteristics, but cultural and racial factors as well.
Video 8.1: Expression and Understanding
International clients' spatial requirements are different than Western clients. It's imperative to
quickly understand and gather as much information about your clients in order to facilitate
rapport and improve communication.
Video Lecture: Multicultural Counseling/Therapy: Culturally Appropriate Intervention
Strategies
SUMMARY
Counseling styles and approaches must be adapted to meet the sociodemographic
characteristics of a diverse clientele. Helping professionals who are unaware of culture, age,
and gender differences as they affect communication and helping styles may make inaccurate
assessments, diagnoses, and treatments. They may assume that certain behaviors or rules of
speaking are universal and always possess the same meaning. Communication style refers to
those factors that go beyond the content of what is said. Communication specialists have
historically found that only 30–40% of what is communicated conversationally is verbal. A
gesture, tone, inflection, posture, or degree of eye contact may enhance or negate the content
of a message.
Differences in communication style are most strongly manifested in nonverbal
communication, or those aspects of communication that transcend the written or spoken word.
Race and culture may influence several areas of nonverbal behavior, leading to
misunderstandings. Nonverbal communication includes the following dimensions: (a)
proxemics, the use of personal space between conversants; (b) kinesics or bodily movements,
including facial expression, posture, characteristics of movement, gestures, and eye contact;
(c) paralanguage or the vocal cues that individuals use to communicate, such as loudness of
voice, pauses, silences, hesitations, rate of speech, and inflections; and (d) high/low‐context
communication, referring to whether a person relies more on the context or the content of a
message in order to interpret its meaning. Race, culture, ethnicity, and gender all influence
how people communicate in these four dimensions.
Nonverbal cues are important because they often (a) unconsciously reflect our biases and (b)
trigger off stereotypes we have of other people. Several important findings have implications
for work with diverse clients. First, nonverbal communication is less under our conscious
control than is verbal communication. Second, marginalized group members are better
readers of nonverbal cues than their majority counterparts. Third, in multicultural counseling,
an unenlightened mental health professional may unintentionally communicate his or her
biases and fears to clients. Last, in working with Asian Americans, American Indians,
African Americans, and Latinx Americans, it is important to be cognizant of their unique
communication styles, which have major implications for mental health practice.
GLOSSARY TERMS
Communication style
High/low‐context communication
High‐context cultures
Kinesics
Low‐context cultures
Nonverbal communication
Nonverbals as triggers to bias
Paralanguage
Playing the dozens
Proxemics
Therapeutic style
Verbal communication
Video 8.5: Counseling Session Analysis
Utilizing evidence-based practices in conjunction with minority client cultural beliefs can
affect the greatest change in favor of client outcomes.
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9
Multicultural Evidence‐Based Practice (EBP)
Chapter Objectives
1. 1. Become familiar with the role and importance of using research to determine
what therapy treatment is best suited for diverse clients.
2. 2. Define empirically supported treatments (ESTs).
3. 3. Know the rationale for the development of empirically supported relationships
(ESRs). Be able to describe the relationship variables that are considered to be
research‐supported.
4. 4. Become aware of how evidence‐based practice (EBP) and multicultural
counseling are converging.
5. 5. Describe the modifications that need to be made in the counseling alliance
(empathy and relationship building) to work with different ethnic groups.
6. 6. Describe how EBP differs from ESTs and ESRs. Be able to outline the
advantages of focusing on client values and preferences.
7. 7. Describe similarities and differences between EBP and cultural competence.
8. 8. Become cognizant of the advantages and disadvantages of using “culturally
adapted” forms of research‐based psychotherapies.
How do counselors decide on the most appropriate treatment for the individuals with whom
they work? Certainly, this question is relevant to the treatment of all clients, regardless of
race, culture, or other identities. Most often, professionals choose an approach that is
consistent with their chosen and preferred theoretical orientation. Several of these many
perspectives may be applicable, yet all may be limited in how they view the totality of the
human condition: the psychodynamic perspective views clients as historical‐developmental
beings, the cognitive‐behavioral approach views them as behaving‐and‐thinking beings,
multicultural perspectives view them as sociocultural beings (Ivey, Ivey, & Zalaquett, 2014),
and so forth. As we have emphasized throughout, the fact is that we are all of these and more.
In addition, given the intersecting nature of cultural identities, our lived experiences comprise
multiple identities simultaneously, and each one shapes the others (Moradi & Grzanka, 2017).
Historically, therapeutic strategies chosen for treatment were often based on (a) the clinician's
therapeutic orientation, (b) ideas shared by “experts” in psychotherapy, and/or (c) “clinical
intuition and experience” derived from years of work with clients. These selection approaches
are problematic because there are countless “experts” and some 400 schools of
psychotherapy, each claiming that their techniques are valid (Corey, 2013); moreover,
treatment is often implemented without questioning the relevance or appropriateness of a
particular technique or approach for a specific client. Furthermore, reliance on clinical
“intuition” to guide one's therapeutic approach can result in ineffective treatment. Given these
points, who are we to believe, and how do we resolve this problem?
This question has propelled the field of mental health practice to assign a more central role to
science and research in the treatment of mental disorders (Morales & Norcross, 2010). To
prioritize the evidentiary basis for a particular treatment makes immediate sense, yet the
following excerpts demonstrate that treatment selection and implementation is still not a
simple, one‐size‐fits‐all matter. Each example concerns a therapeutic approach that is
regarded as an evidence‐supported practice: cognitive behavioral therapy (CBT), solution‐
focused brief therapy (SFBT), and dialectical behavioral therapy (DBT).
[A] common component of traditional CBT for anxiety is the use of cognitive
restructuring. CBT often focuses on assumptions that individuals experiencing
pathological anxiety are victims of faulty, irrational thinking and that therapy should
help clients become aware of these irrational or automatic thoughts and change them
through cognitive restructuring. When working with clients from traditionally
marginalized backgrounds clinicians need to think deeply about the ways they are
teaching clients to restructure their thoughts and the implications of these decisions.
One of the challenges is that individuals from marginalized groups often have negative
and automatic thoughts that are not irrational given their experiences. For instance, a
client of color may express that they fear social situations with their White peers
because they fear that their White peers may say something racist in their interactions.
(Graham, Sorenson, & Hayes‐Skelton, 2013, p. 104)
One possible limitation of SFBT [with Muslim American clients] is related to the
discrimination and violence that Muslim Americans face as in the United States in the
post 9/11 era. When these individuals enter therapy, their problem is far more
complicated than simply an individual concern. They also need change and advocacy at
a system or institutional level as well as strategies to cope with adverse social
conditions. However, a SFBT therapist may not have the tools to expand their work
beyond the one‐on‐one sessions recommended. Also, as a product of this oppression,
individuals seeking therapy may have a low self‐efficacy regarding making
improvements in their mental health and life satisfaction. These individuals need more
than a solution‐focused approach and may require longer term care focused on
improving self‐esteem and self‐confidence.
Another limitation that may arise is related to the interconnectedness and closeness of
Muslim families. There is a tendency to keep important and personal information within
the immediate family, extended family and religious community. If a therapist is hoping
to get his client to open up either alone or in the context of a family session, it is
important to be trusted by the family and community network. This may be a long
process, even with a solution‐focused approach. Any information, even that which is
relevant to the problem, may be too personal to share in the context of short‐term
therapy. The trust and confidence needed to affect change in an individual or family
system may require a longer‐term approach.
(Chaudhry & Li, 2011, p. 112)
DBT skills training groups have been effective in treating eating disorders in various
clinical settings … The overarching goals of DBT are to develop a dialectical
worldview, to develop an ability to accept one's current situations and at the same time
make changes, and to develop skills (i.e., mindfulness, emotion regulation, distress
tolerance, and interpersonal effectiveness) … DBT as a structured teaching intervention,
with an emphasis on doing homework and discussion, fits the emphasis on structure and
education in Chinese culture … However, some modifications were made. These include
adjusting the content and application of DBT homework assignments. For instance,
some of the interpersonal effectiveness skills may not be appropriate given that in
Chinese culture, indirect communication and maintaining harmony in a relationship are
priorities. Recognizing this, the therapist asked Cheng‐Yin [not her real name] to
identify the anticipated interpersonal repercussions of using the proposed skills and to
identify ways that she might use the skills to communicate her opinions while being able
to preserve her own cultural expectations. In addition, the therapist was mindful not to
suggest that Cheng‐Yin do things that would only make sense in the American culture.
For example, discussions about “assertiveness” were tempered by individual
exploration of, and reactions to, this concept.
(Cheng & Merrick, 2017, pp. 43 and 54)
REFLECTION AND DISCUSSION QUESTIONS
1. Discuss the linkages between culture and treatment techniques in each of the preceding
examples.
2. To what other client identities might these same kinds of considerations apply? Which
identities, if any, might not be relevant in light of these treatment approaches?
3. How would you characterize your own evolving therapeutic orientation? How would
you evaluate its suitability for clients of various racial‐cultural identities? What
modifications or adaptations might you propose for certain clients?
Video 9.0: Introduction
Introduction to counseling session by Dr. Joel Filmore.
EVIDENCE‐BASED PRACTICE (EBP) AND MULTICULTURALISM
As the preceding examples suggest, culture has consequential relevance for the appropriate
application of evidence‐based practices (EBPs). At the same time, the importance of EBP is
becoming increasingly accepted in the field of multicultural counseling. Discussions of EBP
originally focused on research‐supported therapies for specific disorders, but the dialogue
has now broadened to include clinical expertise, such as “understanding the influence of
individual and cultural differences on treatment” and the importance of considering client
“characteristics, culture, and preferences in assessment, treatment plans, and therapeutic
outcome” (APA Presidential Task Force on Evidence‐Based Practice, 2006). In an article
titled “Evidence‐Based Practices with Ethnic Minorities: Strange Bedfellows No More,”
Morales and Norcross (2010) describe how multiculturalism and evidence‐based treatment
(EBT), two forces that were “inexorable” and “separate,” are now converging, and how they
can complement each other. The authors state: “Multiculturalism without strong research
risks becoming an empty political value, and EBT without cultural sensitivity risks
irrelevancy” (p. 823).
Although the authors are optimistic about the convergence of these forces, there is still
resistance to EBP among some individuals within the field of multicultural counseling (Sue,
2015; Wendt, Gone, & Nagata, 2015). As BigFoot and Schmidt (2010) note, “Historically,
government and social service organization utilization of nonadapted or poorly adapted
mental health treatments with diverse populations has led to widespread distrust and
reluctance in such populations to seek mental health services” (p. 849). Conflicts often exist
between the values espoused in conventional psychotherapy and the cultural values and
beliefs of ethnic minorities (Lau, Fung, & Yung, 2010; Nagayama‐Hall, 2001; Owens,
Queener, & Stewart, 2016). As we have discussed in previous chapters, Western approaches
to psychological treatment are often based on individualistic value systems instead of on the
interdependent values found in many ethnic minority communities. Additionally,
conventional therapies often ignore cultural influences, disregard spiritual and other healing
processes, and pathologize the behavior and values of ethnic minorities and other diverse
groups (Sue, Zane, Nagayama‐Hall, & Berger, 2009).
It is apparent that conventional delivery of Western‐based therapies may not be meeting the
needs of many individuals from ethnic and other cultural minorities. These groups tend to
underutilize mental health services (Smith & Trimble, 2016a; Thurston & Phares, 2008) and
are more likely to attend fewer sessions or to drop out of therapy sooner, compared with their
White counterparts (Fortuna, Alegria, & Gao, 2010; Lester, Resick, Young‐Xu, & Artz,
2010; Smith & Trimble, 2016b; Triffleman & Pole, 2010). Unfortunately, research on the
effectiveness of empirically supported therapies for ethnic minorities is limited, as these
groups are often not included or specifically identified in research investigations of particular
treatments.
Although questions remain regarding the validity of evidence‐based approaches for ethnic
minority and other diverse populations (Bernal & Sáez‐Santiago, 2006), we believe that
EBPs offer an opportunity for infusing multicultural and diversity sensitivity into
psychotherapy. In addition, all mental health professions (psychiatry, social work, clinical
psychology, and counseling) now espouse the view that treatment should have a research
base. Evidence‐based interventions are increasingly promoted in social work (Bledsoe et al.,
2007; Gibbs & Gambrill, 2002), school psychology (Kratochwill, 2002), clinical psychology
(Deegear & Lawson, 2003), counseling (American Counseling Association, 2014; Chwalisz,
2001), and psychiatry.
In this chapter, we will discuss the evolution of EBP, the integration of empirically supported
treatment (EST) and empirically supported relationship (ESR) variables into multicultural
counseling, and the relevance of enhancing cultural elements in therapy. We will also show
how culturally sensitive strategies can become an important component of EBPs.
Empirically Supported Treatment (EST)
The concept of ESTs was popularized when the American Psychological Association began
promoting the use of “validated” or research‐supported treatments—specific treatments
confirmed as effective for specific disorders. Not only were ESTs seen as an effective
response to concerns about the use of unsupported techniques and psychotherapies, but they
also addressed the issue of unintended harm that can result from ineffective or hazardous
treatments (Lilienfeld, 2007; Wendt et al., 2015). ESTs typically involve a very specific
treatment protocol for specific disorders. Because variability among therapists might produce
error variance in research studies and because it is important for ESTs to be easily replicable
as originally designed, ESTs are conducted using manuals.
According to the guidelines of the task force charged with defining and identifying ESTs
(Chambless & Hollon, 1998), they must demonstrate (a) superiority to a placebo in two or
more methodologically rigorous, controlled studies, (b) equivalence to a well‐established
treatment in several rigorous and independent controlled studies, usually randomized
controlled trials, or (c) efficacy in a large series of single‐case controlled designs (i.e.,
within‐subjects designs that systematically compare the effects of a treatment with those of
a control condition).
ESTs have been identified for anxiety, depressive, and stress‐related disorders; obesity and
eating disorders; severe mental conditions such as schizophrenia and bipolar disorder;
substance abuse and dependence; childhood disorders; and borderline personality disorder.
Several hundred different manualized treatments are listed as empirically supported
(Chambless & Ollendick, 2001; Society of Clinical Psychology, 2011; see Table 9.1 for a few
examples of empirically supported therapies).
TABLE 9.1 Examples of Empirically Supported Treatments (ESTs)
Source: Chambless, D. L., & Hollon, S. (1998). Defining empirically supported therapies. Journal of Consulting and
Clinical Psychology, 66, 7–18.
“Well‐established” treatments “Probably efficacious” treatments
Cognitive behavioral therapy for panic
disorder
Cognitive therapy for obsessive‐compulsive
disorder (OCD)
Exposure/guided mastery for specific phobias
Exposure treatment for post‐traumatic
stress disorder (PTSD)
Cognitive therapy for depression Brief dynamic therapy for depression
Cognitive behavioral therapy for bulimia Interpersonal therapy for bulimia
Cognitive behavioral relapse prevention for
cocaine dependence
Brief dynamic therapy for opiate dependence
Behavior therapy for headache Reminiscence therapy for geriatrics patients
Behavioral marital therapy Emotionally focused couples therapy
Additionally, the American Psychological Association has developed a list of ESTs and
practice guidelines for ethnic minorities (American Psychological Association, 1993), women
and girls (American Psychological Association, 2007), older adults (American Psychological
Association, 2014), and lesbian, gay, bisexual, transgender, and queer (LGBTQ) clients (APA
Division 44, 2012). These guidelines can be consulted and modified, if necessary, in working
with clients from these groups.
The rationale behind the establishment of ESTs is admirable; we believe that decisions
regarding treatment approaches for particular issues or disorders should be based on research
findings rather than on idiosyncratic, personal beliefs or sketchy theories. We owe it to our
clients to provide them with treatment that has demonstrated efficacy. However, it is our
contention that relying only on manualized treatment methods, albeit research‐supported
ones, is insufficient with many clients and many mental health problems (Sue, 2015).
Additionally, most ESTs have not been specifically demonstrated to be effective with ethnic
minorities or other diverse populations. The shortcomings of the EST approach are
summarized here:
Owing to the focus on choosing treatment based on the specific disorder, contextual,
cultural, and other environmental influences are not adequately considered (Sue, 2015).
The validity of ESTs for minority group members is often questionable, because these
groups are not included in many clinical trials (Bernal & Sáez‐Santiago, 2006; Sue et
al., 2006).
The importance of the therapist–client relationship is not adequately acknowledged. A
number of studies have found that therapist effects contribute significantly to the
outcome of psychotherapy. In many cases, these effects exceed those produced by
specific techniques (Wampold, 2001).
Too much emphasis is placed on randomized controlled trials versus other forms of
research, such as qualitative research designs.
When treating clients with specific disorders, multicultural therapists have had the choice of
ignoring ESTs or adapting them. Increasingly, there have been attempts to develop “cultural
adaptations” of certain ESTs. For example, Organista (2000) made the following
modifications to empirically supported cognitive behavioral strategies when working with
low‐income Latinx individuals suffering from depression:
1. Engagement strategies. Recognizing the importance of personalismo (the value of
personal relationships), initial sessions are devoted to relationship‐building. Time is
allotted for presentaciones (introductions), during which personal information is
exchanged between counselor and client and issues that may affect ethnic minorities,
such as acculturation difficulties, culture shock, and discrimination, are discussed.
2. Activity schedules. In the treatment of depression, a common recommendation is for
clients to take some time off for themselves. This idea may run counter to the Latinx
value of connectedness and putting the needs of the family ahead of oneself. Therefore,
instead of solitary activities, clients can choose social activities they find enjoyable, such
as visiting neighbors, family outings, or taking children to the park. In recognizing the
income status of clients, activities discussed are generally free or affordable.
3. Assertiveness training. Assertiveness is discussed within the context of Latinx values.
Culturally acceptable ways of expressing assertiveness, such as prefacing statements
with con todo respeto (with all due respect) and ¿me permite expresar mis sentimientos?
(is it okay if I express my feelings?) are discussed, as well as strategies for using
assertion with spouses or higher‐status individuals.
4. Cognitive restructuring. Rather than labeling thoughts that can reduce or increase
depression as rational or irrational, the terms “helpful thoughts” and “unhelpful
thoughts” are used. Recognizing the religious nature of many Latinx individuals, the
saying, Ayudate, que Dios te ayudara (God helps those who help themselves) is used to
encourage follow‐through with behavioral assignments.
This adapted approach, which maintains fidelity to both empirically supported techniques and
cultural influences, has resulted in a lower dropout rate and better outcome for low‐income
Latinx clients compared to nonmodified therapy. Cultural adaptations can include factors
such as: (a) matching the language and racial or ethnic backgrounds of the client and the
therapist; (b) incorporating cultural values in the specific treatment strategies; (c) utilizing
cultural sayings or metaphors in treatment; and (d) considering the impact of environmental
variables, such as acculturation conflicts, discrimination, and income status.
Culturally adapted ESTs have been successfully used with Latinx and Haitian American
adolescents (Duarte‐Velez, Guillermo, & Bonilla, 2010; Nicolas, Arntz, Hirsch, &
Schmiedigen, 2011), Asian Americans experiencing phobias (Huey & Pan, 2006), Latinx
adults experiencing depression (Aguilera, Garza, & Munoz, 2010), American Indians
suffering from trauma (BigFoot & Schmidt, 2010), clients of urban American Indian health
organizations (Pomerville & Gone, 2018), African Americans recovering from substance
abuse (Cunningham, Foster, & Warner, 2010), and Chinese immigrant families (Lau et al.,
2010).
Horrell (2008) reviewed 12 studies on the effectiveness of CBT for African, Asian, and
Hispanic Americans experiencing a variety of psychological disorders; the majority of these
studies involved some type of cultural modification. Although the results for African
American clients were mixed, Asian and Hispanic American clients demonstrated significant
treatment gains over those in placebo or wait‐list control conditions. Overall, evidence is
increasing that ESTs can be effective with ethnic minorities, particularly when the approach
includes cultural adaptation.
A meta‐analysis of studies involving the adaptation of ESTs to clients' cultural backgrounds
revealed that adapted treatments for clients of color are moderately more effective than
nonadapted treatments and that the most effective therapies are those that have the most
cultural adaptations (Smith, Rodriguez, & Bernal, 2011). In a review of both published and
unpublished studies of culturally adapted therapies, it was found that culturally adapted
psychotherapy is more effective than nonadapted psychotherapy for ethnic minorities
(Benish, Quintana, & Wampold, 2011).
Implications
The applicability of many ESTs for diverse groups has been insufficiently researched.
Statistical overviews of existing research do suggest that cultural adaptations tend to result in
improved results for clients of color, and that some of the most important adaptations may be
those that incorporate clients' own goals, cultural contexts, and preferred languages (Smith &
Trimble, 2016c). Nevertheless, guidance is limited for mental health practitioners who are
faced with the challenge of selecting effective interventions for their clients' mental health
issues. For clients of color, we have the option of using a standard EST for the disorder,
finding an EST (or adapted EST) with research demonstrating effectiveness for members of
the client's ethnic group with the client's disorder (which is highly unlikely), or taking the
time to develop and research a culture‐specific EBT for the client's disorder. The latter
would be inordinately difficult for most practitioners to accomplish. Additionally, culture‐
specific treatments may not be effective with people of color who are more acculturated.
Thus, in choosing a treatment strategy, we believe that the best approach (given the current
state of research) is for the counselor to select an intervention that is research‐based and
adapt it for the individual client according to the client's individual characteristics, values, and
preferences.
REFLECTION AND DISCUSSION QUESTIONS
1. What are your thoughts concerning the use of ESTs in your own practice? What
reactions do you have to the idea of using research on therapeutic effectiveness to guide
your work? Has your training exposed you to EBP? What challenges would you face in
trying to implement such an approach?
2. What would you need to know about ESTs and the cultural background of diverse
clients in order to develop a culturally adapted therapeutic approach? Although it would
be a massive undertaking, discuss with your classmates what specific steps would need
to be taken to culturally adapt an EST to African Americans, Asian Americans, and
Latinx Americans.
3. Do you believe that simply adapting ESTs to the cultural context of the client is
sufficient in working with people of color?
Empirically Supported Relationships (ESRs)
Not everyone believes that cultural adaptations of ESTs are sufficient to deal with cultural
differences, and some express concern that such adaptations result in the imposition of
EuroAmerican norms on ethnic minorities.
As Gone (2009) argues, ESTs cannot be “adorned” with “a few beads here, some feathers
there” (p. 760). Those critical of reliance on ESTs alone cite the multitude of other factors
impacting treatment outcome, such as the therapeutic relationship, client values and beliefs,
and the working alliance between client and therapist (DeAngelis, 2005; Sue, 2015). To
remedy this shortcoming, the American Psychological Association Division 29
Psychotherapy Task Force was formed to review research and identify characteristics
responsible for effective therapeutic relationships and to determine means of tailoring therapy
to individual clients (Ackerman et al., 2001).
This focus provided the first opportunity for the inclusion of multicultural concerns within the
evidence‐based movement. It is widely agreed that the quality of the working relationship
between the therapist and the client (i.e., the therapeutic alliance) is consistently related to
treatment outcome (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Weinberger, 2002).
This relationship may assume even greater significance for clients from diverse backgrounds
(Davis, Ancis, & Ashby, 2015). In fact, difficulties in the therapeutic alliance may be a factor
in the underutilization of mental health services and early termination of therapy seen with
minority clients. After reviewing the research on therapist–client relationship variables as
they relate to treatment outcome, the task force reached these conclusions (Ackerman et al.,
2001):
1. The therapeutic relationship makes substantial and consistent contributions to
psychotherapy outcome, independent of the specific type of treatment.
2. The therapy relationship acts in concert with discrete interventions, client characteristics,
and clinician qualities in determining treatment effectiveness.
3. Adapting or tailoring the therapy relationship to specific client needs and characteristics
(in addition to diagnosis) enhances the effectiveness of treatment.
4. Practice and treatment guidelines should explicitly address therapist behaviors and
qualities that promote a facilitative therapy relationship.
According to the task force, a number of relationship variables are considered
“demonstratively effective” or “promising and probably effective” based on research findings
(see Table 9.2). ESR variables include the development of a strong therapeutic alliance, a
solid interpersonal bond (i.e., a collaborative, empathetic relationship based on positive
regard, respect, warmth, and genuineness), and effective management of countertransference
—all factors known to be critical for effective multicultural counseling. We elaborate on
these relationship variables in the next few sections.
TABLE 9.2 Empirically Supported Relationship (ESR) Variables
Source: Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso, C. J., Goldfried, M. R., Hill, C., … & Rainer, J.
(2001). Empirically supported therapy relationships: Conclusions and recommendations of the Division 29 Task
Force. Psychotherapy, 38, 495–497.
Demonstrably effective Promising and probably effective
Therapeutic alliance Positive regard
Cohesion in group therapy Congruence/genuineness
Empathy Feedback
Goal consensus and collaboration Repair of alliance ruptures
Customizing therapy Self‐disclosure
Management of countertransference
The Therapeutic Alliance
Research on ESRs has consistently identified the importance of a strong therapeutic alliance,
which includes the core conditions of effective treatment described by Rogers (1957):
empathy, respect, genuineness, and warmth. These dynamics typify a therapeutic relationship
in which a client feels understood, safe, and encouraged to disclose intimate material. They
transcend the therapist's therapeutic orientation or approach to treatment. The therapeutic
relationship, or working alliance, is an important factor in effective treatment. Clients
specifically asked about what contributed to the success of treatment often point to a sense of
connection with their therapist. Connectedness has been described as having feelings of
closeness with the therapist, working together in an enabling atmosphere, receiving support
for change, and being provided an equality of status within the working relationship (Ribner
& Knei‐Paz, 2002). As we noted in Chapter 2, cultural humility may be a major aspect in
the therapeutic alliance contributing to cultural competence (Hook, Davis, Owen,
Worthington, & Utsey, 2013; Owen et al., 2014).
Similarly, clients report that therapist behaviors such as “openness to ideas, experiences, and
feelings” or being “nonjudgmental and noncritical,” “genuine,” “warm,” and “validating of
experiences” are helpful in therapy (Curtis, Field, Knann‐Kostman, & Mannix, 2004). A
counselor's relationship skills and ability to develop a therapeutic alliance contribute
significantly to satisfaction among clients of color (Constantine, 2002). Mulvaney‐Day,
Earl, Diaz‐Linhart, and Alegria (2011) found that relationship variables with the therapist
were particularly important for African American and Latinx clients, and concluded that “the
basic yearning for authentic connection with a provider transcends racial categories.” (p. 36).
Thus, the importance of feeling accepted by a therapist on an emotional and cognitive level
seems to be a universal prerequisite for an effective therapeutic alliance.
Conceptualization of the therapeutic alliance often comprises three elements: (a) an
emotional or interpersonal bond between the therapist and the client; (b) mutual agreement on
appropriate goals, with an emphasis on changes valued by the client; and (c) intervention
strategies or tasks that are viewed as important and relevant by both the client and the
therapist (Garber, 2004). Defined in this manner, the therapeutic alliance exerts positive
influences on outcomes across different treatment modalities, accounting for a substantial
proportion of outcome variance (Hojat et al., 2011; Zuroff & Blatt, 2006). In fact, the
therapist–client relationship contributes as much as 30% to the variance in therapeutic
outcome (Lambert & Barley, 2001).
We believe that the therapeutic alliance is of critical importance in the outcome of therapy
for ethnic minority clients and will describe possible modifications that may help clinicians
enhance this relationship. It is important to remember that there is no set formula or response
that will ensure the formation of a strong therapeutic alliance with a particular client. In fact,
counselors often need to demonstrate behavioral flexibility to achieve a good working
relationship with clients; this may be particularly true when working with individuals from
diverse populations.
In a qualitative study involving Black, Asian, Latinx, and multiracial clients, most preferred
an active counselor role, which was characterized by the counselor offering concrete
suggestions, providing direct answers, challenging the client's thinking with thought‐
provoking questions, and providing psychoeducation regarding the therapy (Chang & Berk,
2009). Mulvaney‐Day et al. (2011) found variability in the counseling relational style
preferred by ethnic minority clients. A summary of the preferred relationship styles reported
by the African American, Latinx, and non‐Latinx White clients in their sample is presented
in Table 9.3.
TABLE 9.3 Relational‐Style Counselor Preferences of Ethnic Group Clients
Source: Mulvaney‐Day, N. E., Earl, T. R., Diaz‐Linhart, Y., & Alegria, M. (2011). Preferences for relational style
with mental health clinicians: A qualitative comparison of African American, Latino and Non‐Latino White patients.
Journal of Clinical Psychology, 67, 31–44.
Themes
African American
clients
Latinx clients
Non‐Latinx White
clients
Listening
Listen to who the client
really is; recognize that
clients are experts on
themselves
Listen in a way that
communicates “paying
attention”
Listen so that the client is
comfortable enough to
talk and express feelings
Understanding
Understand beyond
immediate impressions;
understand hidden aspects
of the client
Understand feelings of
client
Understand complexity of
client choices and
circumstances
Counselor
qualities
Counselor should “lower”
self to client's level;
egalitarian relationship
Be authoritative, but
connect first, then offer
concrete advice and
solutions
Not judge because of
social distance; maintain
professional distance but
be human
Select this link to open an interactive version of Table 9.3.
Mental health practitioners need to be adaptable with their relationship skills in order to
address the preferences and expectations of their clients. For example, many African
American clients appear to value social interaction as opposed to problem‐solving
approaches, especially during initial sessions, whereas Latinx clients seem to prefer a more
interpersonal approach, rather than clinical distance (Gloria & Peregoy, 1996; Kennedy,
2003). We have also seen that many Asian American clients may prefer a problem‐solving
approach initially. However, these are broad generalizations, and counselors must test out the
effectiveness of different relational skills with a particular client, assessing the impact of their
interactions with the client, asking themselves questions such as “Does the client seem to be
responding positively to my relational style?” and “Have I succeeded in developing a
collaborative and supportive relationship with this client?”, and modifying the approach when
necessary. Although it is important not to react to clients in a stereotypic manner, counselors
must be continually be aware of cultural and societal issues that may affect them. Asian,
Black, Latinx, and multiracial clients who were dissatisfied in cross‐racial therapy
complained about their therapist's lack of knowledge about racial identity development; the
dynamics of power and privilege; the effects of racism, discrimination, and oppression due to
their minority status (or multiple minority statuses); and cultural stigma associated with
seeking help (Chang & Berk, 2009).
Cultural information is useful in providing general guidelines regarding an ethnic minority
client's counseling‐style preference or issues that need to be addressed in therapy. However,
as a counselor develops a comprehensive understanding of each client's background, values,
strengths, and concerns, it is essential that they determine whether general cultural
information “fits” the individual. This ongoing “search for understanding” is important with
respect to each of the following components of the therapeutic alliance.
Emotional or Interpersonal Bond
The formation of a bond between the therapist and the client is a very important aspect of the
therapeutic relationship and is defined as a collaborative partnership based on empathy,
positive regard, genuineness, respect, warmth, and self‐disclosure. For an optimal outcome,
the client must feel connected with, respected by, and understood by the therapist. In addition,
the therapist must identify issues that may detract from the relationship, such as
countertransference (i.e., reactions to the client based on the therapist's own personal issues).
These qualities are described in detail later; their importance may vary according to the type
of mental health issue being addressed and the characteristics of the client (e.g., gender,
socioeconomic status, ethnicity, cultural background).
The development of an emotional bond is enhanced by collaboration, a shared process in
which a client's views are respected and his or her participation is encouraged in all phases of
the therapy. An egalitarian stance and encouragement of sharing and self‐disclosure
facilitate the development of empathy (Dyche & Zayas, 2001) and reduce the power
differential between therapist and client. The potential for a positive therapeutic outcome is
increased when the client is “on board” regarding the definition of the problem, identification
of goals, and choice of interventions. When differences exist between a client's view of a
problem and the therapist's theoretical conceptualization, negative dynamics are likely to
occur. Collaboration regarding definition of the problem reduces this possibility and is most
effective when employed consistently throughout therapy.
Empathy
Empathy is known to significantly enhance the therapeutic bond. Empathy is defined as the
ability to place oneself in the client's world, to feel or think from the client's perspective, or to
be attuned to the client. Empathy allows therapists to form an emotional bond with clients,
helping the clients to feel understood. It is not enough for the therapist to simply
communicate this understanding; the client must perceive the responses from the therapist as
empathetic. This is why it is vital for therapists to be aware of client receptivity by evaluating
both verbal and nonverbal responses from the client (“How is the client responding to what I
am saying?”, “What are the client's verbal and bodily cues communicating?”). Empathy can
be demonstrated in several different ways—having an emotional understanding or emotional
connection with the client (emotional empathy) or understanding the client's predicament
cognitively, whether on an individual, family, or societal level (cognitive empathy).
Following is an illustration of emotional empathy:
A White male therapist in his late 20s is beginning therapy with a recently immigrated
39‐year‐old West Indian woman. The client expresses concern about her adolescent
daughter, who she describes as behaving in an angry, hostile way toward her fiancé.
The woman is well dressed and is somewhat abrupt, seeming to be impatient with the
therapist. Though not a parent himself, the therapist recognizes the distress behind his
client's sternness, and thinking of the struggles he had with his own father, he responds
to the woman's obvious discomfort saying, “I imagine that must hurt you.” This intuitive
response from the therapist reduces the woman's embarrassment, and she pauses from
the angry story of her daughter's ungratefulness to wipe a tear. (Dyche & Zayas, 2001,
p. 249)
Many counselors are trained to be very direct with emotional responses, using statements
such as “You feel hurt” or “You sound hurt” in an effort to demonstrate empathy. The
response “I imagine that must hurt you” would be rated a more intermediate response.
Statements that are even less direct might include “Some people might feel hurt by that” or
“If I was in the same situation, I would feel hurt.” We have found that people differ in their
reaction to the directness of emotional empathy, depending on such factors as the gender,
ethnicity, or cultural background of the counselor or the client; the degree of comfort and
emotional bonding with the therapist; and the specific issue involved.
For example, when working with Asian international students, we have found that although
there are individual differences in preference, many prefer a less direct style of emotional
empathy. However, some Asian international students are fine with direct emotional empathy
(this is why the counselor must be flexible and test out different forms of empathy with
clients, rather than prejudging them because of membership in a specific group). In general,
recognition of emotional issues through either indirect or direct empathy increases the client's
feeling of being understood. Effective therapists continually evaluate client responses and
thus are able to determine if the degree and style of emotional empathy being used is
enhancing (or detracting) from the emotional bond between therapist and client.
Cognitive empathy involves the therapist's ability to understand the issues facing the client.
For example, in the case just described, the therapist might explore the possibility that the
daughter's anger is related to her immigration experiences by saying, “Sometimes moving to
a new country can be difficult.” The degree of directness can be varied by making the
observation tentative by prefacing statements with “I wonder if … ?” or “Is it possible that …
?” Cognitive empathy can also be demonstrated by communicating an understanding of the
client's worldview, including the influences of family issues or discriminatory experiences,
such as racism, heterosexism, ageism, or sexism. By exploring or including broader societal
elements such as these, the therapist is able to incorporate diversity or cross‐cultural
perspectives and potentially enhance understanding of the client's concerns.
Communicating an understanding of different worldviews and acknowledging the possibility
of cultural influences can increase the therapist's credibility with the client. When working
with diverse clients, we believe that empathy must include the ability to accept and be open to
multiple perspectives of personal, societal, and cultural realities. This can be achieved by
exploring the impact of cultural differences or diversity issues on client problems, goals, and
solutions (Chung & Bernak, 2002; Dyche & Zayas, 2001).
Empathy may be difficult in multicultural counseling if counselors are unable to identify
personal cultural blinders or values they may hold. For example, among counselors working
with African American clients, those with color‐blind racial attitudes (i.e., a belief that race
is not a significant factor in determining one's chances in society) showed lower levels of
empathy than those who were aware of the significance of racial factors (Burkard & Knox,
2004). Some research suggests that counselors' multicultural counseling competence
(awareness of issues of race and discrimination, and knowledge of their social impact on
clients) accounts for a large proportion of the variance in ratings of counselor competence,
expertise, and trustworthiness made by clients of color (Constantine, 2002; Fuertes & Brobst,
2002).
In a study of LGBTQ clients, a counselor's universal–diversity orientation (i.e., interest in
diversity, contact with diverse groups, comfort with similarities and differences) was
positively related to client ratings of the therapeutic alliance, whereas, surprisingly,
similarities in sexual orientation between therapist and client were not. Universal–diversity
orientation may facilitate therapy through affirmation and understanding of the issues that
culturally diverse clients are facing (Stracuzzi, Mohr, & Fuertes, 2011).
In contrast, the therapeutic alliance can be adversely affected when ethnic minority clients
perceive a therapist to be culturally insensitive or believe that the therapist is minimizing the
importance of racial and cultural issues or pathologizing cultural values or communication
styles (Constantine, 2007; Sue, Bucceri, Lin, Nadal, & Torino, 2007). This finding is likely
true with other diverse groups who may endure heterosexism, ageism, religious intolerance,
and/or prejudice against disability. Sensitivity to the possible impact of racial and societal
issues can be made through statements such as the following:
“How have experiences with discrimination or unfairness had an impact on the problems
you are dealing with?”
“Sometimes it's difficult to meet the societal demands of being a man/woman. How has
this influenced your expression of emotions?”
“Some people believe that family members should be involved in making decisions for
individuals in the family. Is this true in your family?”
“Being or feeling different can be related to messages we receive from our family,
society, or religious institutions. Have you considered whether your feelings of isolation
are related to messages you are getting from others?”
“Families change over time. What are some of the standards or values you learned as a
young child? I wonder if the conflicts in your family are related to differences in
expectations between you and your parents.”
These examples are stated in a very tentative manner. If a counselor has sufficient
information, more direct statements of cognitive empathy can be made. We believe that the
perception of and response to empathy varies from individual to individual. There are no set
responses that will convey empathy and understanding to all clients. In general, therapists
must learn to evaluate their use of both cognitive and emotional empathy to determine
whether it is improving the emotional bond with the client and to make modifications, if
needed, to enhance the client's perception of empathy within the relationship.
Positive Regard, Respect, Warmth, and Genuineness
The characteristics of positive regard, respect, warmth, and genuineness are important
qualities in establishing an emotional bond. Positive regard is the demonstration by the
therapist that he or she sees the strengths and positive aspects of the client, including
appreciation for his or her values and differences. Positive regard is demonstrated when the
therapist identifies and focuses on the strengths and assets of the client rather than attending
only to deficits or problems. This is especially important for members of ethnic minorities
and other diverse groups, whose behaviors are often pathologized. Respect is shown by the
therapist's being attentive and demonstrating that he or she views the client as an important
person. Behaviors such as asking clients how they would like to be addressed, showing that
their comments and insights are valuable, and tailoring one's interaction according to their
needs or values are all ways of communicating respect. Warmth is the emotional feeling
received by the client when the therapist conveys verbal and nonverbal signs of appreciation
and acceptance. Smiling, the use of humor, and showing interest in the client can all convey
this feeling. Genuineness can be displayed in many different ways. It generally means the
therapist is responding to the client openly and in a “real” manner, rather than in accordance
with expected roles. These interpersonal attributes can strengthen the therapist–client alliance
and increase the client's trust, cooperation, and motivation to participate in therapy.
Self‐Disclosure
Although self‐disclosure is considered to be a “promising and probably effective” technique
(Ackerman et al., 2001), the topic of a therapist revealing personal thoughts or personal
information remains controversial. In one study, brief or limited therapist self‐disclosure in
response to comparable self‐disclosure by the client was associated with reductions in
symptom distress and greater liking for the therapist (Barrett & Berman, 2001).
Counselor disclosure in cross‐cultural situations (e.g., sharing reactions to clients'
experiences of racism or oppression) may also enhance the therapeutic alliance (Burkard,
Knox, Groen, Perez, & Hess, 2006; Cashwell, Shcherbakova, & Cashwell, 2003). Self‐
disclosures may show the therapist's human qualities and lead to the development of closer
ties with the client. Research to determine the impact of therapist self‐disclosure is difficult
since it depends on many variables, such as the type of disclosure, its timing and frequency,
and client characteristics. Although many clients report that therapist self‐disclosure
enhances the therapeutic relationship, some self‐disclosures by a therapist (e.g., that they are
wealthy or politically conservative) can actually interfere with it (Chang & Berk, 2009).
Some therapists feel that self‐disclosure is not appropriate in therapy, and they either will
not answer personal questions or will bounce such questions back to the client. However,
some clients who ask, “Has this ever happened to you?” may be doing so in an attempt to
normalize their experience. Bouncing the question back to the client by saying, “Let's find out
why you want to know this” can be perceived as patronizing rather than helpful (Hays, 2001).
Should you make self‐disclosures to a client? The answer is, “It depends.” Sharing
experiences or reactions can strengthen the emotional bond between therapist and client.
However, such self‐disclosure should be limited and aimed at helping the client with his or
her issues. If the requests for self‐disclosure become frequent or too personal, the therapist
should explore with the client the reason for their inquiries.
Management of Countertransference
Appropriate management of countertransference can enhance the therapeutic alliance, as
well as minimize ruptures in the therapeutic relationship. Countertransference involves the
therapist's emotional reaction to the client based on the therapist's own set of attitudes,
beliefs, values, or experiences. These emotional reactions, whether negative or positive, can
bias a therapist's judgment when working with a client. For example, a therapist might exhibit
negative reactions to a client owing to factors such as heterosexism, racism, or classism.
Additionally, difficulty can occur when clients demonstrate values and perspectives similar to
the therapist's own; such similarity may reduce therapist objectivity. Therapists sometimes
over‐identify with clients who are similar to them and subsequently underestimate the
client's role in interpersonal difficulties. As we have seen in Chapter 3, this is most likely to
happen in interracial/interethnic therapeutic relationships. These unconscious reactions can
interfere with the formation of a healthy therapeutic emotional bond with the client. Because
of the negative impact of countertransference, clinicians should examine their experiences,
values, and beliefs when experiencing an emotional reaction to a client that is beyond what is
expected from a therapy session.
A scientific frame of mind necessitates the examination of one's own values and beliefs in
order to anticipate the impact of possible differences and similarities in worldviews on the
therapeutic alliance. Multicultural therapists have been in the forefront of stressing the
importance of acknowledging the influence of values, preferences, and worldviews on
psychotherapy and the psychotherapist. It is important to be self‐aware, to recognize when
personal needs or values are being activated in the therapeutic relationship, and not to project
our reactions on to clients (Brems, 2000).
Goal Consensus
An agreement on goals between the therapist and the client (i.e., goal consensus) is another
important relationship variable. Unless the client agrees on what the goals should be, little
progress will be made. As therapists, we too easily envision what the appropriate outcome
should be when working with a client and become dismayed or discouraged when the client
does not feel the same way or seems satisfied with more limited solutions. Goals should be
determined in a collaborative manner, with input from both client and therapist. Although it is
very important to get the client's response in regard to the problem and goals, the therapist has
the important task of clarifying client statements and providing tentative suggestions.
Clients often identify global goals, such as “wanting to improve self‐esteem.” The
therapist's job is to help them define their goal more specifically and to foster alternative
ways of interpreting situations (Hilsenroth & Cromer, 2007). Concrete goals enhance the
ability to measure progress in therapy. To obtain more specificity regarding a global goal,
therapists can ask such questions as, “What does your low self‐esteem prevent you from
doing?”, “How would your life be different if you had high self‐esteem?”, “What would you
be able to do if you had more self‐esteem?”, or “How would you know if you are improving
in self‐esteem?”. The answer to these questions, such as “Being able to hold a job or ask for
a raise,” “Feeling more comfortable in group situations,” or “Standing up for myself,” can
help identify aspects of self‐esteem that are more concrete. Each of these responses can be
used to define subgoals. A client might be asked, “What are small steps that you can make
that will show you are moving in the direction of higher self‐esteem?”
Once goals are identified, the client and the therapist can work together to identify which
strategies and techniques will be employed to help the client achieve the stated goals. In order
for interventions to be useful, they need to make sense to the client. For ethnic minority
clients, interventions may require “cultural adaptation,” such as that described in the study by
Huey and Pan (2006), where the treatment of phobias was modified for Asian Americans by
emphasizing the strategy of emotional control and maximizing a directive role for the
therapist.
Although the selection of interventions depends upon the presenting problem and diagnosis,
psychological interventions are most effective when they are consistent with client
characteristics, including the client's culture and values (La Roche, Batista, & D'Angelo,
2011). It is also important that the client believe that the therapeutic approach will be helpful.
In a study by Coombs, Coleman, and Jones (2002), clients who reported “understanding the
therapy process” and “having positive expectations of the therapy” were more likely to
improve.
REFLECTION AND DISCUSSION QUESTIONS
1. What was your therapy training in regard to the formation of the therapeutic alliance
with a client? Indicate how the relationship skills were discussed in relation to cross‐
cultural competence.
2. What is your experience in working with ethnic minorities or other diverse populations?
Did they appear to require different relationship skills? Did you evaluate the
effectiveness of your responses?
Video 9.1: Supporting Counseling with Evidence
Utilizing evidence-based practices in conjunction with minority client cultural beliefs can
affect the greatest change in favor of client outcomes.
EVIDENCE‐BASED PRACTICE (EBP) AND DIVERSITY ISSUES IN
COUNSELING
The American Psychological Association's focus on ESRs provided an opening for
counselors to address multicultural concerns within an evidence‐based framework.
However, the broader and more recent focus on EBP has more formally introduced cultural
sensitivity as an essential consideration in assessment, case conceptualization, and selection
of interventions. Specifically, EBP refers to “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; see Figure 9.1).
FIGURE 9.1 Three Pillars of Evidence‐Based Practice (EBP)
Source: Morales, E., & Norcross, J. (2010). Evidence based practices with ethnic minorities: Strange bedfellows no
more.” Journal of Clinical Psychology, 66(8), 824. Reprinted with permission of John Wiley & Sons, Inc.
Select this link to open an interactive version of Figure 9.1.
Empirically based practice includes both EBTs and relationship variables but is broader and
more comprehensive than a combination of the two. How does EBP differ from the EST and
ESR frameworks?
First, the assumption underlying EBP is that the search for the “best research evidence”
begins with a comprehensive understanding of the client's background and problem and goes
on to consider which therapeutic approach is most likely to provide the best outcome. In other
words, the selection of intervention occurs only after individual characteristics, such as
cultural background, values, and preferences, are assessed. This allows for the individualizing
of therapy, with strong consideration given to client background and characteristics.
Second, unlike ESTs, which rely primarily on randomized controlled trials, EBP also accepts
research evidence from qualitative studies, clinical observations, systematic case studies, and
interventions delivered in naturalistic settings. This broadening of the definition of research
allows mental health professionals greater latitude in deciding which therapy may be the best
match for a particular client. For example, the National Registry of Evidence‐based
Programs and Practices (NREPP) provides specific information regarding treatments for
substance abuse that consider the race and ethnicity of the participants, as well as treatments
designed for certain ethnic groups, such as the American Indian Life Skills Development
Program (Berke, Rozell, Hogan, Norcross, & Karpiak, 2011).
Third, the definition of clinical expertise within the EBP framework focuses not only on the
quality of the therapeutic relationship and therapeutic alliance but also on the skills essential
for comprehensive assessment of the client's problem and strengths. Additionally, EBP
considers clinical expertise involving factors such as knowledge about cultural differences;
best practices in assessment, diagnosis, and case conceptualization; strategies for evaluating
and selecting appropriate research‐based treatments; and adaptation of selected treatments
in a manner that respects the client's worldview, values, and preferences.
Fourth, EBP is based on an ongoing emphasis on client characteristics, culture, and
preferences and the importance of working collaboratively with the client to develop goals
and treatment strategies that are mutually agreeable. Identification of client variables includes
(a) age and life stage, (b) sociocultural factors (e.g., gender, sexual orientation, ethnicity,
disability), (c) environmental stressors (e.g., unemployment, recent life events, racism, health
disparities), and (d) personal treatment preferences (i.e., treatment expectations, goals, and
beliefs).
Because the focus is on the client and the consideration of cultural variables, EBP sets the
stage for a multiculturally sensitive counseling relationship. The following illustration of how
EBP and multicultural sensitivity can be integrated is based on the case of Anna, an American
Indian female who developed post‐traumatic stress disorder (PTSD) following a sexual
assault.
Anna is a 14‐year‐old American Indian female who was sexually abused by a 22‐
year‐old male in her small community. Anna disclosed the abuse to her school
counselor, who then reported the incident to tribal law enforcement. After word of the
incident spread through the community, several individuals accused Anna of lying and
then harassed her in an attempt to recant her allegation. Anna began isolating herself at
home and stopped attending school. Anna became increasingly depressed and
demonstrated symptoms consistent with PTSD.
(BigFoot & Schmidt, 2010, p. 854)
BigFoot and Schmidt (2010) were able to meld American Indian traditional healing processes
and cultural teachings within an EBP framework. Aspects of this process included assessment
of Anna's personal characteristics and preferences, as well as the influence of culture on her
reactions to the trauma. Following careful assessment, intervention strategies were selected
based on assessment data, therapist expertise, research regarding effective treatments for
post‐traumatic stress, and cultural adaptation of the therapy selected. The steps involved the
following:
Research‐supported treatments for childhood or adolescent trauma were identified.
Trauma‐focused cognitive behavioral therapy (TF‐CBT) was chosen because it was
seen to complement many of the traditional healing practices used in Anna's tribe,
including traditional beliefs about the relationship between emotions, beliefs, and
behaviors. TF‐CBT is a conjoint child and family psychotherapy that has been
comprehensively evaluated and designated by the National Crime Victims Research and
Treatment Center (NCVC) as having the highest level of research support as an
“efficacious treatment” for childhood abuse and trauma.
TF‐CBT has been evaluated with Caucasian and African American children
and adapted for American Indian/Alaska Native populations, Latinx
Americans, hearing‐impaired individuals, immigrant Cambodians, and
children of countries including Zambia, Uganda, South Africa, Pakistan, the
Netherlands, Norway, Sweden, Germany, and Cambodia (National Child
Traumatic Stress Network, 2008). The components of TF‐CBT include a
focus on reducing negative emotional and behavioral responses resulting from
trauma and correcting trauma‐related beliefs through gradual exposure to
memories and emotional associations with the traumatic event. Relaxation
training is used to reduce negative emotions. Parents are included in the
treatment process as emotional support for the child; parents are provided with
strategies for helping to manage their child's emotional reaction to the trauma.
Client characteristics and values were identified through interviews with Anna and her
family and by assessing their tribal and cultural identity. In Anna's case, both she and her
family agreed that she had a strong American Indian identity and valued traditional
healing approaches. Thus, it was decided that a culturally adapted TF‐CBT would be
the most appropriate form of treatment. (If Anna and her family had expressed minimal
tribal or American Indian cultural identification, standard TF‐CBT might have been the
treatment of choice.)
Cultural adaptations of TF‐CBT were developed. Because of cultural beliefs that
trauma can bring about disharmony and result in distorted beliefs and unhealthy
behaviors, traditional healing efforts focus on returning the individual to a state of
harmony through teachings, ceremonies, and tribal practices, including a ritual called
Honoring Children, Mending the Circle (HC‐MC). The Circle represents the
interconnectedness of spirituality and healing and the belief that all things have a
spiritual nature; prayers, tribal practices, and rituals connect the physical and the
spiritual worlds, bringing wellness and harmony. Additionally, adaptation of the affect
management, relaxation, cognitive coping, and enhancing the parent–child relationship
aspects of TF‐CBT incorporated spiritual (saying prayers), relational (support from
friends and family), mental (hearing messages of love and support), and physical
(helping Anna reacquire physical balance) supports, thus increasing Anna's feelings of
safety and security.
Further adaptation involved the TF‐CBT goal of extinguishing the fear
response using a “trauma narrative,” during which the child “revisits” the
traumatic incident and is gradually exposed to threatening cues. In the
adaptation, culturally accepted methods for telling the trauma story—including
use of a journey stick, tribal dances, and storytelling procedure—were used to
facilitate exposure. Relaxation techniques were also adapted by having Anna
breathe deeply while focused on culturally relevant images, such as the “sway
of wind‐swept grasses” or the movement of a “woman's shawl during a
ceremonial dance.”
As BigFoot and Schmidt (2010) concluded, “the adaption of TF‐CBT within an American
Indian/Alaskan Native well‐being framework can enhance healing through the blending of
science and indigenous cultures … The HC‐MC adaptation seeks to honor what makes
American Indians and Alaska Natives culturally unique through respecting beliefs, practices,
and traditions within their families, communities, tribes, and villages that are inherently
healing” (p. 855).
REFLECTION AND DISCUSSION QUESTIONS
1. What is your reaction to EBP, especially as it applies to ethnic minorities and other
diverse populations?
2. It is clear that using an EBP approach requires great time and effort on the part of
clinicians to develop a treatment plan. The implication is that counselors must do out‐
of‐office education or consultation regarding what is available in the research literature
that might help inform their practice. Is such an approach too time‐consuming? Given
that EBP research is exploding in the field, how would you keep current or informed as a
practitioner?
IMPLICATIONS FOR CLINICAL PRACTICE
1. Realize that the early EST formulations inadequately addressed the needs of
marginalized groups in our society, but that ESTs have begun to incorporate cultural
contexts in modifying evidence‐based approaches. The standards used to determine
ESTs and ESRs were often too rigid and ignored the cultural context in advocating for
the role of science and research in the selection of therapeutic treatments and
interventions.
2. Be aware that most mental health professionals have moved to the concept of EBP, (a)
allowing for a broader array of means to determine the selection, process, and outcome
of effective treatments and (b) integrating cultural factors and/or modifying approaches
to fit the needs of diverse clients.
3. Know that multicultural counseling and EBP are “strange bedfellows no more” and that
it is no longer adequate to devise a treatment plan solely on the basis of one's theoretical
orientation, clinical intuition, or clinical expertise.
4. Be aware that EBP models focusing on client characteristics and evaluating the degree
of fit between a therapeutic approach and an individual client have actually legitimized
the outcry of those in the field of multicultural counseling—that it is essential to
consider the cultural beliefs and values of the client and that relational counselor styles
may need to vary according to an individual's cultural background.
5. Know that the integration of EBP and multiculturalism is resulting in an explosion of
research. With the former emphasizing client characteristics, values, preference, and
culture, EBP and multicultural therapy are becoming inextricably entwined, with each
adding strengths to the other.
6. Understand that EBP can provide clinicians with information regarding which therapies
are most effective with which specific disorders and which specific population. Thus, in
choosing a treatment strategy, the best approach (given the current state of research) is
for the counselor to select an intervention that is research‐based (if available) and adapt
it for the individual client according to his or her individual characteristics, values, and
preferences.
7. Know that culturally competent counseling and therapy is more than a technique‐
driven search for effective techniques and strategies. We now know that the therapeutic
alliance or working relationship is crucial to therapeutic outcome.
8. Be prepared to modify your therapeutic style to be consistent with the cultural values,
lifestyles, and needs of culturally diverse clients. Remember, respect, unconditional
positive regard, warmth, and empathy are most effective in the therapeutic alliance
when they are communicated in a culturally consistent manner.
9. Be aware that some research suggests that a counselor's multicultural counseling
competence and humility (awareness of issues of race and discrimination and knowledge
of their social impact on clients) accounts for a large proportion of the variance in
ratings of counselor competence, expertise, and trustworthiness made by clients of color.
10. Note that most approaches to counseling and therapy attempt to adapt the research
findings of EBP to fit the unique cultural characteristics and needs of diverse
populations. But what if we approach the challenge to develop culturally appropriate
therapeutic techniques and relationships from an indigenous perspective first? This is a
question we address in Chapter 10 on Non‐Western Indigenous Methods of Healing.
Video 9.2: Client Values and Evidence-Based Practice
Reconciling EBP with cultural values can be challenging but isn't impossible. Openness in
dialogue can be the fastest, clearest means to an end. Explaining the purpose of EBPs, and
how they can impact change, are important when working with minority clients.
Video Lecture: Science, Ethnicity and Bias: Where Have We Gone Wrong? by Stanley Sue
SUMMARY
The importance of EBP is becoming increasingly accepted in the field of multicultural
counseling. Discussions of EBP originally focused on research‐supported therapies for
specific disorders, but the dialogue has now broadened to contain clinical expertise, including
understanding the influence of individual and cultural differences on treatment and the
importance of considering client characteristics and culture. Although optimism about the
convergence of these forces is increasing, there is still resistance to EBP among some
individuals within the field of multicultural counseling. The applicability of EBP for many
diverse groups has been insufficiently researched, and the concept of “evidence” has
historically been very narrow. Furthermore, the therapist–client relationship is not adequately
acknowledged in the EBT and EST formulations.
It is now widely agreed that the quality of the working relationship between the therapist and
the client is consistently related to treatment outcome and has led to the formulation of ESRs.
A number of relationship variables are considered effective based on research findings. ESR
variables include the development of a strong therapeutic alliance, a solid interpersonal bond
(i.e., a collaborative, empathetic relationship based on positive regard, respect, warmth, and
genuineness), effective management of countertransference, and goal consensus—all factors
known to be critical for effective multicultural counseling.
The assumption underlying EBP is that the best research evidence begins with a
comprehensive understanding of the client's background and problem and goes on to consider
which therapeutic approach is most likely to provide the best outcome. This allows for the
individualizing of therapy with strong consideration of client background and characteristics.
It broadens the definition of research and allows mental health professionals greater latitude
in deciding which therapy may be the best match for a particular client. EBP is based on an
ongoing emphasis on client characteristics, culture, and preferences and the importance of
working collaboratively with the client to develop goals and treatment strategies that are
mutually agreeable. Because the focus is on the client and the consideration of cultural
variables, EBP sets the stage for a multiculturally sensitive counseling relationship.
GLOSSARY TERMS
Cognitive empathy
Countertransference
Cultural adaptations
Emotional bond
Emotional empathy
Empathy
Empirically supported relationships
Empirically supported treatments
Evidence‐based practices
Therapeutic alliance
Therapeutic bond
Universal–diversity orientation
Video 9.3: Counseling Session Analysis
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
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10
Non‐Western Indigenous Methods of Healing: Implications
for Multicultural Counseling and Therapy (MCT)
Chapter Objectives
1. 1. Outline basic assumptions of indigenous healing and shamanism.
2. 2. Explain shamanic and indigenous explanations of illness.
3. 3. Identify commonalities between what therapists and shamans/traditional healers
do.
4. 4. Describe how shamanism and traditional healing makes different assumptions
from Western scientific approaches in mental health treatment.
5. 5. Discuss the belief in altered states of consciousness or different planes of
existence.
6. 6. Explain how religion and spirituality affect the belief systems of indigenous
groups.
7. 7. Articulate your beliefs about your level of comfort in talking to clients about
religion and spirituality.
8. 8. Outline the argument for the role religion and spirituality play in counseling and
therapy.
9. 9. Discuss implications of non‐Western indigenous beliefs and practices for work
with diverse populations.
Yemi is a freshman majoring in computer science at an elite university in the Northeast
United States; he moved there shortly after graduating from secondary school in
Nigeria. Yemi shared with his professor that he was unable to complete his assignment
because of the intense burning and crawling sensations in his head, which worsened
when he worked on the project; he explained studying left him too exhausted to do much
else during the day. The professor referred him to the student health center; there
appeared to be no physiological explanation for his symptoms.
After resettling in Chicago from Laos, Vang was visited by spirits while he slept, making
it difficult for him to move or breathe beneath their weight. In the middle of the night, he
would wake up screaming and in complete terror. His fear of dying in his sleep was not
unfounded because he had heard of other Hmong refugee men who had died in this
manner. Vang most likely did not fall victim to Hmong sudden death syndrome because
he sought help from a shaman. She identified the problem vexing Vang and his family,
and by performing local rituals they were able to free the spirits haunting him.
Joy has been in therapy with Dr. Spencer to deal with trauma associated with a recent
sexual assault and relationship difficulties for nearly half a year. Her grandmother's
sister died about a month ago after a long battle with lung cancer. A series of
unfortunate events prevented Joy from attending the funeral, which she regrets dearly.
The past few therapy sessions have felt very different for both Joy and Dr. Spencer. Joy
reports thinking about death much more than she ever had in her life; she relays the
terror she feels after the nightmares she has started having. She has lost nearly 10
pounds because she hasn't felt like eating. It seems like with each passing week, she
experiences increasing levels of anxiety and feeling weak. Dr. Spencer becomes
particularly concerned when Joy said she now has daily dizzy spells. She encourages
Joy to get a physical, which ultimately suggests there are no physical explanations for
her symptoms. Dr. Spencer begins to explore with Joy her understanding of the
symptoms. She asks Joy if she has had these symptoms before and what she thinks is
causing them. Joy shares her mother's interpretation of the symptoms. According to her
mother, who is from the Navajo nation, Joy is experiencing ghost sickness. At the urging
of her mother, Joy returns to her community. They seek guidance from spiritual leaders
and the tribal members perform sacred rituals allowing her great aunt's spirit to find
peace.
Clinical knowledge regarding cultural syndromes suggests that Yemi's, Vang's, and Joy's
experiences are consistent with a pattern of troubling, even dangerous, symptoms that are
rooted within a particular cultural context. Meditation and learning muscle relaxation
techniques provided Yemi some relief from brain fag (a response to academic stress in some
West African countries). Western treatments, however, provided no answers or relief for
Vang and Joy. Remedies came in the form of traditional healing practices, drawing on
centuries of knowledge about health and disease. After participating in indigenous healing
ceremonies that “released the unhappy spirits,” Vang has reported no more problems with
nightmares or with his breathing during sleep, and Joy's appetite has returned and she is
getting restful sleep. Theories about Hmong sudden death syndrome and ghost sickness may
appear unbelievable and akin to mysticism to many people, especially after reading the last
chapter on evidence‐based practice (EBP). After all, most of us have been trained in a
Western ontology that does not embrace indigenous or alternative healing approaches.
Indeed, if anything, it actively rejects such approaches as unscientific and supernatural.
Mental health professionals are encouraged to rely on sensory information, defined by the
physical plane of existence rather than the spiritual plane (Pedersen & Pope, 2010; Walsh &
Shapiro, 2006). Such a rigid stance is unfortunate and shortsighted, because there is much
that Western healing can learn from these age‐old forms of treatment.
Video 10.0: Introduction
Introduction to counseling session by Dr. Joel Filmore.
WORLDVIEWS AND CULTURAL SYNDROMES
Western science remains skeptical of using supernatural interpretations to explain phenomena
and certainly does not consider the existence of spirits to be a scientifically sound belief. Yet,
belief in spirits and its parallel relationship to religious, philosophic, and scientific
worldviews has existed in every known culture, including the United States (e.g., the witch
hunts of Salem, Massachusetts). Among many Southeast Asian, African, and indigenous
groups, it is not uncommon to posit the existence of good and evil spirits, to assume that they
are intelligent beings, and to believe that they are able to affect the life circumstances of the
living (Fadiman, 1997; E. Lee, 1996; Moodley, 2005). Vang, for example, believed strongly
that his problems were due to spirits who were unhappy with him and were punishing him.
Such worldview differences pose problems for Western‐trained mental health professionals,
who may quickly dismiss these belief systems and impose their own explanations and
treatments on culturally diverse clients. Working outside of the belief system of such clients
may not have the desired therapeutic effect, and the risk of unintentional harm (in this case,
the potential death of Vang) is great (Wendt, Gone, & Nagata, 2015). That the sudden death
and ghost sickness phenomena are cultural forms of disorder is being increasingly recognized
by Western science (Kamarck & Jennings, 1991). Most researchers now acknowledge that
attitudes, beliefs, and emotional states are intertwined and can have a powerful effect on
physiological responses and physical well‐being. For example, death from bradycardia
(slowing of the heartbeat) seems correlated with feelings of helplessness.
Beginning with the fourth and continuing into the fifth edition, the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders (DSM‐ IV‐TR and
DSM‐5; American Psychiatric Association, 2000, 2013) has made some strides in
recognizing the importance of ethnic and cultural factors related to psychiatric diagnosis. The
manual warns that mental health professionals who work with immigrant and ethnic
minorities must take into account (a) the predominant means of manifesting disorders (e.g.,
possessing spirits, nerves, fatalism, inexplicable misfortune), (b) the perceived causes or
explanatory models, and (c) the preferences for professional and indigenous sources of care.
Culture‐bound syndromes and cultural idioms of distress are now recognized in the DSM‐
5 and the International Statistical Classification of Diseases and Related Health Problems
(ICD‐10); some of these are listed in Table 10.1.
TABLE 10.1 Culture‐Bound Syndromes
Culture‐bound syndromes include disorders with a unique combination of psychological
and somatic symptoms that are recognized within a specific cultural group as an illness.
These disorders are not easily captured in Western classification systems. They have local
names and a shared understanding of the etiology and course of treatment.
Amok
(“attacking
furiously”)
Mainly considered a disorder in Malaysia, but is found in other Southeast
Asian countries (e.g., Laos, the Philippines, Papua New Guinea), as well as
Puerto Rico and among Navajo. It is a dissociative episode often preceded
by social isolation or humiliation and followed by an outburst of violent,
aggressive, or homicidal behavior toward people and objects. Persecutory
ideas, amnesia, and exhaustion signal a return to the premorbid state.
Ataque de
nervios (“attack
Occurs in many Latinx and Caribbean cultures in reaction to a stressful life
event, typically related to a family member (e.g., a death). People may feel
out of control and experience acute anxiety, inconsolable crying, chest
of nerves”) tightness, and uncontrollable screaming or shouting,
Dhat, Shen‐
K'uei, Shenkui
Fear over excessive semen discharge in India (Dhat), Taiwan (Shen‐
K'uei), and China (Shenkui) can create tremendous anxiety in some men,
resulting in a range of somatic concerns. The fear is associated with loss of
semen through excessive sexual activity such as intercourse and
masturbation or through nocturnal emissions. Worry over loss of semen
often leads to the man's feeling weak and fatigued, and may cause sexual
dysfunction. In Chinese culture, loss of semen causes an unbalance in the
body and represents the loss of one's vital essence.
Ghost sickness
Observed among members of American Indian tribes, this disorder is a
preoccupation with death and the deceased. It is sometimes associated with
witchcraft and includes bad dreams, weakness, feelings of danger, loss of
appetite, fainting, dizziness, anxiety, and a sense of suffocation.
Koro
This Malaysian term refers to an intense fear of the shrinkage or retraction
of one's genitals—typically the penis for males or the breasts for females. It
is sometimes referred to as the “genital retraction syndrome.” For some, the
“penis panic” is believed to lead to the removal of the male organ and, in
some cases, death. It can occur in epidemic proportions in local areas and
has been reported in China, Thailand, and other South and East Asian
countries.
Nervios
(“nervousness,”
“anxiety”)
This idiom of distress is mainly found among Latinx individuals in the
United States and throughout the Americas. Common symptoms include
nervousness, easy tearfulness, shaking, dizziness, tingling sensations, and
feelings of sadness and hopelessness. Nervios symptoms appear over a
period of time and are less severe in expression than ataque de nervios.
Susto (“fright”)
This disorder is associated with fright or soul loss and is a prevalent folk
illness among some Latinx individuals in the United States and throughout
the Americas Typically attributed to a traumatic event that causes the soul
or spirit to leave the body. Common symptoms include depression, anxiety,
heart palpitations, insomnia, fever, and lack of appetite.
In summary, it is very important for mental health professionals not only to become familiar
with the cultural background of their clients but also to be knowledgeable about specific
cultural syndromes. A primary danger from lack of cultural understanding is the tendency to
overpathologize (overestimate the degree of pathology); the mental health professional would
have been wrong in diagnosing Vang as a paranoid schizophrenic suffering from delusions
and hallucinations or Joy as experiencing post‐traumatic stress disorder (PTSD) symptoms
or signs of depression and anxiety. Most psychiatrists would have prescribed powerful
psychotropic medication. The fact that both Vang and Joy were cured so quickly indicates
that such a diagnosis would have been erroneous. Interestingly, it is equally dangerous to
underestimate the severity or complexity of a person's emotional condition.
The Shaman and Traditional Healer as Therapist: Commonalities
It is probably safe to conclude that every society and culture has individuals or groups
designated as healers—those who comfort the ailing. Their duties involve not only physical
ailments but also those related to psychological distress or behavioral deviance (Harner,
1990; Ross, 2014). Although every culture has multiple healers, in non‐Western cultures the
shaman is perhaps the most powerful of all, because only he or she possesses the ultimate
magico‐religious powers that go beyond the senses (Eliade, 1972). The shaman treating
Vang was well‐known and respected in the Hmong community. Although her approach
(incense, candle burning, newspaper, trance‐like chanting, spirit diagnosis, and even her
home visit) might resemble mysticism on the surface, there is much in her behavior that is
similar to Western psychotherapy.
First, as we saw in Chapter 5, the healer's credibility is crucial to the effectiveness of therapy.
In the case of Vang, the traditional healer had the cultural credentials of a shaman; she was a
specialist and professional with long years of training and experience dealing with similar
cases. By reputation and behavior, she acted in a manner familiar to Vang and his family.
More importantly, she shared their worldview as to the definition of the problem. Like the
Western therapist, she offered herself as the chief instrument of cure. The healing rituals she
performed helped to get in touch with the hidden world of the spirits (in Western terms, the
unconscious?) and helped Vang to understand (become conscious of) the mysterious power of
the spirits (unconscious) to effect a cure.
Similarly, in the case of Joy, the traditional healers her family sought help from shared a
similar cultural understanding of the problem and the appropriate course of treatment. They
were acknowledged within the community for their training and expertise in treating ghost
sickness. Additionally, as with Vang, treatment incorporated family participation in the sacred
rituals. For Joy, non‐Western and Western forms of healing were combined for maximum
effect. Dr. Spencer practiced culturally informed therapy, welcomed cultural interpretation of
the new symptoms, and encouraged Joy to also seek indigenous healers as part of the
treatment plan.
Not all people of color and immigrants are so fortunate as to have access to culturally
informed therapy and/or the services of a traditional healer in the United States. Witness the
case of the Nguyen family.
CASE STUDY
THE NGUYEN FAMILY
Mr. and Mrs. Nguyen and their four children left Vietnam in a boat with 36 other people.
Several days later, they were set upon by Thai pirates. The occupants were all robbed of
their belongings; some were killed, including two of the Nguyens' children. Nearly all
the women were raped repeatedly. The trauma of the event is still very much with the
Nguyen family, who now reside in St. Paul, Minnesota. The event was most disturbing
to Mr. Nguyen, who had watched two of his children drown and his wife being raped.
The pirates had beaten him severely and tied him to the boat railing during the rampage.
As a result of his experiences, he continued to suffer feelings of guilt, suppressed rage,
and nightmares.
The Nguyen family came to the attention of the school and social service agencies
because of suspected child abuse. Their oldest child, 12‐year‐old Phuoc, came to
school one day with noticeable bruises on his back and down his spinal column. In
addition, obvious scars from past injuries were observed on the child's upper and lower
torso. His gym teacher saw the bruises and scars and immediately reported them to the
school counselor. The school nurse was contacted about the possibility of child abuse,
and a conference was held with Phuoc. He denied that he had been hit by his parents and
refused to remove his garments when requested to do so. Indeed, he became quite
frightened and hysterical about taking off his shirt. Since there was still considerable
doubt about whether this was a case of child abuse, the counselor decided to let the
matter drop for the moment. Nevertheless, school personnel were alerted to this
possibility.
Several weeks later, after 4 days of absence, Phuoc returned to school. The homeroom
teacher noticed bruises on his forehead and the bridge of his nose. When the incident
was reported to the school office, the counselor immediately called Child Protective
Services to report a suspected case of child abuse. Because of their heavy caseload, a
social worker was unable to visit the family until weeks later. The social worker, Mr. P.,
called the family and visited the home late on a Thursday afternoon. Mrs. Nguyen
greeted Mr. P. upon his arrival. She appeared nervous, tense, and frightened. Her
English was poor, and it was difficult to communicate with her. Since Mr. P. had
specifically requested to see Mr. Nguyen as well, he inquired about his whereabouts.
Mrs. Nguyen answered that he was not feeling well and was in the room downstairs. She
said he was having “a bad day,” had not been able to sleep last night, and was having
flashbacks. In his present condition, he would not be helpful.
When Mr. P. asked about Phuoc's bruises, Mrs. Nguyen did not seem to understand what
he was referring to. The social worker explained in detail the reason for his visit. Mrs.
Nguyen explained that the scars were due to the beating given to her children by the
Thai pirates. She became very emotional about the topic and broke into tears. Although
this had some credibility, Mr. P. explained that there were fresh bruises on Phuoc's body
as well. Mrs. Nguyen seemed confused, denied that there were new injuries, and denied
that she and her husband would hurt Phuoc. The social worker pressed Mrs. Nguyen
about the new injuries until she suddenly looked up and said, “Thùôc Nam.” It was
obvious that Mrs. Nguyen now understood what Mr. P. was referring to. When asked to
clarify what she meant by the phrase, Mrs. Nguyen pointed at several thin bamboo sticks
and a bag of coins wrapped tightly in a white cloth. It looked like a blackjack! She then
pointed downstairs in the direction of the husband's room. It was obvious from Mrs.
Nguyen's gestures that her husband had used these implements to beat her son.
A Case of Child Abuse?
There are many similarities between the case of the Nguyen family and that of Vang. One of
the most common experiences of refugees forced to flee their country is the extreme stressors
that they experience. Constantly staring into the face of death is, unfortunately, all too
common an experience. Seeing loved ones killed, tortured, and raped; being helpless to
change or control such situations; living in temporary refugee or resettlement camps; leaving
familiar surroundings; encountering a strange and alien culture—these experiences can only
be described as multiple severe traumas.
It is highly likely that many Cambodian, Hmong/Laotian, and Vietnamese refugees suffer
from serious PTSD and other forms of major affective disorder. Mr. and Mrs. Nguyen's
behaviors (flashbacks, desire to isolate the self, emotional fluctuations, anxiety, and
tenseness) might all be symptoms of PTSD. Accurate understanding of refugees' life
circumstances will prevent a tendency to overpathologize or underpathologize their
symptoms. These symptoms, along with a reluctance to disclose to strangers and discomfort
with social workers, should be placed in the context of the stressors that they have
experienced and their cultural background. More important, as in the case of the Nguyen
family, behaviors should not be interpreted to indicate guilt or a desire not to disclose the
truth about child abuse.
Mental health professionals must consider potential linguistic and cultural barriers when
working with refugees, especially when they lack both experience and expertise. In the case
of the Nguyens, it is clear that the teacher, the school counselor, the school nurse, and even
the social worker did not have sufficient understanding or experience in working with
Southeast Asian refugees. For example, the social worker's failure to understand Vietnamese
phrases and Mrs. Nguyen's limited English placed serious limitations on their ability to
communicate accurately (Schwartz et al., 2010). The social worker might have avoided much
of the misunderstanding if an interpreter had been present. In addition, the school personnel
may have misinterpreted many culturally sanctioned forms of behavior on the part of the
Vietnamese. Phuoc's reluctance to disrobe in front of strangers (the nurse) may have been
prompted by cultural taboos rather than by attempts to hide his injuries. Traditional Asian
culture dictates strongly that family matters are handled within the family. Many Asians
believe that family affairs should not be discussed publicly, and especially not with strangers
(Chang, McDonald, & O'Hara, 2014). Disrobing publicly and telling others about the scars or
the trauma of the Thai pirates would not be done readily. Such knowledge is required by
educators and social service agencies in order to make enlightened decisions.
Both school and social service personnel were obviously also unenlightened about indigenous
healing beliefs and practices. In the case of Vang, we saw how knowledge and understanding
of cultural beliefs led to appropriate and helpful treatment. In the case of the Nguyen family,
lack of understanding led to charges of child abuse. But is this really a case of child abuse?
When Mrs. Nguyen said “Thùôc Nam,” what was she referring to? What did the fresh bruises
along Phuoc's spinal column, forehead, and bridge of the nose mean? And didn't Mrs. Nguyen
admit that her husband used the bamboo sticks and bag of coins to “beat” Phuoc?
In Southeast Asia, traditional medicine derives from three sources: Western medicine (Thùôc
Tay), Chinese or Northern medicine (Thùôc Bac), and Southern medicine (Thùôc Nam).
Many forms of these treatments continue to exist among Asian Americans, especially
Vietnamese refugees (Hong & Domokos‐Cheng Ham, 2001). Thùôc Nam involves using
natural fruits, herbs, plants, animals, and massage to heal the body. Massage treatment is the
most common cause of misdiagnosis of child abuse, because it leaves bruises on the body.
Three common forms of massage treatment are Băt Gió (“catching the wind”), Cao Gió
(“scratching the wind” or “coin treatment”), and Giác Hoi (“pressure massage” or “dry cup
massage”). Băt Gió involves using both thumbs to rub the temples and massaging toward the
bridge of the nose at least 20 times. Fingers are used to pinch the bridge of the nose. Cao Gió
involves rubbing the patient with a mentholated ointment and then using coins or spoons to
strike or scrape lightly along the ribs and both sides of the neck and shoulders. Giác Hoi
involves steaming bamboo tubes so that the insides are low in pressure, applying them to a
portion of the skin that has been cut, and sucking out “bad air” or “hot wind.” All three
treatments leave bruises on the parts of the body treated.
If the social worker had been able to understand Mrs. Nguyen, he would have known that
Phuoc's 4‐day absence from school was due to illness and that he was treated by his parents
via traditional folk medicine. Massage treatments are a widespread custom practiced not only
by Vietnamese but also by Cambodians, Laotians, and Chinese. These treatments are aimed at
curing a host of physical ailments, such as colds, headaches, backaches, and fevers. In the
mind of the practitioner, such treatments have nothing to do with child abuse. Yet, the
question still remains: Is it child abuse when traditional healing practices result in bruises?
This is a very difficult question to answer because it raises a larger question: Can culture
justify a practice, especially when it is harmful? Although we are unable to answer this
second question directly (we encourage you to engage in dialogue about it), we would point
out that many medical practitioners in California do not consider Thùôc Nam child abuse
because: (a) the medical literature reveals no physical complications as a result of it; (b) the
intent is not to hurt the child but to help him or her; and (c) it is frequently used in
conjunction with Western medicine. However, we would add that health professionals and
educators have a responsibility to educate parents concerning the potential pitfalls of many
folk remedies and indigenous forms of treatment.
Video 10.1: Eastern vs. Western Cultural Norms
Belief systems of non-Western clients need to be incorporated into counseling sessions much
the same way Western religious beliefs are incorporated.
THE PRINCIPLES OF INDIGENOUS HEALING
Ever since the beginning of human existence, all societies and cultural groups have developed
not only their own explanations of abnormal behaviors but also culture‐specific ways of
dealing with human problems and distress (Gone, 2010; Solomon & Wane, 2005). Within the
United States, counseling and psychotherapy are the predominant psychological healing
methods. In other cultures, however, indigenous healing approaches continue to be widely
used (Mpofu, 2011). Although there are similarities between EuroAmerican helping systems
and the indigenous practices of many cultural groups, there are major dissimilarities as well.
Indigenous healing can be defined as helping beliefs and practices that originate within a
culture or society (Edwards, 2011). It is not transported from other regions, and it is designed
to treat the inhabitants of the given group.
Western forms of counseling, for example, rely on sensory information defined by the
physical plane of reality (Western science), whereas most indigenous methods rely on the
spiritual plane of existence in seeking a cure. In keeping with the cultural encapsulation of
our profession, Western healing has been slow to acknowledge and learn from these age‐old
forms of wisdom (Constantine, Myers, Kindaichi, & Moore, 2004; Gone, 2010). In its
attempt to become culturally responsive, however, the mental health field must begin to put
aside the biases of Western science, to acknowledge the existence of intrinsic help‐giving
networks, and to incorporate the legacy of ancient wisdom that may be contained in
indigenous models of healing.
What is called the universal shamanic tradition, which encompasses the centuries‐old
recognition of healers (shamans) within a community, refers to people often called witches,
witch doctors, wizards, medicine men or women, sorcerers, and magic men or women (E.
Lee, 1996). These individuals are believed to possess the power to enter an altered state of
consciousness and journey to other planes of existence beyond the physical world during their
healing rituals (Garrett et al., 2011; Moodley, 2005). Such was the case with the shaman
working with Vang, who journeyed to the spirit world in order to find a cure for him.
Indigenous healing in non‐Western countries usually involves three approaches (Lee, Oh, &
Mountcastle, 1992). First, there is heavy reliance on the use of communal, group, and family
networks to shelter the disturbed individual (Saudi Arabia), to problem‐solve in a group
context (Nigeria), and to reconnect the individual with family or significant others (Korea).
Second, there is the use of spiritual and religious beliefs and traditions of the community in
the healing process. Examples include reading verses from the Qur'an and using religious
houses or churches. Third, there is the use of shamans (called piris and fakirs in Pakistan and
Sudan), who are perceived to be the keepers of timeless wisdom. In many cases, the person
conducting the healing ceremony may be a respected elder of the community or a family
member.
Let us now consider three core assumptions related to the principles of indigenous healing:
holistic outlook, interconnectedness, and harmony; belief in metaphysical levels of existence;
and acceptance of spirituality in life and the cosmos.
Holistic Outlook, Interconnectedness, and Harmony
The concepts of separation, isolation, and individualism are hallmarks of the EuroAmerican
worldview. On an individual basis, modern psychology takes a reductionist approach to
describing the human condition (i.e., id, ego, and superego; belief, knowledge, and skills;
cognitions, emotions, and behaviors). The search for cause and effect is linear and allows us
to identify the independent variables, the dependent variables, and the effects of extraneous
variables that we attempt to control. It is analytical and reductionist in character. The attempt
to maintain objectivity, autonomy, and independence in understanding human behavior is
also stressed. Such tenets have resulted in the separation of the person from the group
(valuing of individualism and uniqueness), science from spirituality, and man/woman from
the universe.
Most non‐Western indigenous forms of healing take a holistic outlook on well‐being, in
that they make minimal distinctions between physical and mental functioning and believe
strongly in the unity of spirit, mind, and matter. The interrelatedness of life forms, the
environment, and the cosmos is a given. As a result, the indigenous peoples of the world tend
to conceptualize reality differently (Mpofu, 2011). The psychosocial unit of operation for
many culturally diverse groups, for example, is not the individual but the group
(collectivism). In many cultures, acting in an autonomous and independent manner is seen as
the problem, because it creates disharmony within the group.
Illness, distress, and problematic behaviors are seen as an imbalance in people relationships, a
disharmony between the individual and his or her group, or a lack of synchrony with internal
or external forces. Harmony and balance are the healer's goal. Among American Indians, for
example, harmony with nature is symbolized by the circle, or hoop of life (Garrett &
Portman, 2011; McCormick, 2005; Sutton & Broken Nose, 2005). Mind, body, spirit, and
nature are seen as a single unified entity, with little separation between the realities of life,
medicine, and religion. All forms of nature (not just the living) are to be revered, because
they reflect the creator or deity. Illness is seen as a break in the hoop of life, an imbalance, or
a separation between the elements. Many indigenous beliefs come from a metaphysical
tradition. They accept the interconnectedness of cosmic forces in the form of energy or subtle
matter (less dense than the physical) that surrounds and penetrates the physical body and the
world.
Both the ancient Chinese practice of acupuncture and chakras in Indian yoga philosophy
involve the use of subtle matter to rebalance and heal the body and mind (Highlen, 1996).
Chinese medical theory is concerned with the balance of yin (cold) and yang (hot) in the
body, and believes that strong emotional states or an imbalance in the types of food eaten
may create illness (Pedersen & Pope, 2010; So, 2005). As we saw in the case of Phuoc
Nguyen, treatment might involve using massage treatment to suck out “bad” or “hot” air, as
well as eating specific types or combinations of foods. Such concepts of illness and health can
also be found in the Greek theory of balancing body fluids (blood, phlegm, black bile, and
yellow bile; Bankart, 1997).
Many indigenous African approaches to spirituality also teach that human beings are part of a
holistic fabric—that they are interconnected and should be oriented toward collective rather
than individual survival (Boyd‐Franklin, 2010; Parham & Caldwell, 2015). The indigenous
Japanese assumptions and practices of Naikan and Morita therapy attempt to move clients
away from individualism and toward interdependence, connectedness, and harmony with
others (Bankart, 1997; Chen, 2005). Naikan therapy, which derives from Buddhist practice,
requires clients to reflect on three aspects of human relationships: (a) what other people have
done for them; (b) what they have done for others; and (c) how they cause difficulties to
others (Walsh & Shapiro, 2006). The overall goal is to expand awareness of how much we
receive from others, how much gratitude is due to them, and how little we demonstrate such
gratitude. This leads to a realization of the interdependence of the parts to the whole.
Working for the good of the group ultimately benefits the individual.
Belief in Metaphysical Levels of Existence
Some time back, two highly popular books—Embraced by the Light (Eadie, 1992) and Saved
by the Light (Brinkley, 1994)—and several television specials described fascinating cases of
near‐death experiences. All had certain commonalities: the individuals who were near death
felt like they were leaving their physical bodies, observed what was happening around them,
saw a bright beckoning light, and journeyed to higher levels of existence. Although the
popularity of such books and programs might indicate that the American public is inclined to
believe in such phenomena, science has been unable to validate these personal accounts and
remains skeptical of their existence. Yet, many societies and non‐Western cultures accept as
given the existence of different levels or planes of consciousness, experience, or existence.
They believe the means of understanding and ameliorating the causes of illness or the
problems of life are often found in a plane of reality separate from the physical world of
existence.
Asian psychologies posit detailed descriptions of states of consciousness and outline
developmental levels of enlightenment that extend beyond the concepts of Western
psychology. Asian perspectives concentrate less on psychopathology and more on
enlightenment and ideal mental health (Cashwell & Bartley, 2014; Pankhania, 2005). The
normal state of consciousness in many ways is not considered optimal and may be seen as a
“psychopathology of the average” (Maslow, 1968). Moving to higher states of consciousness
has the effect of enhancing perceptual sensitivity and clarity, concentration, and the sense of
identity, as well as emotional, cognitive, and perceptual processes. Such movement,
according to Asian philosophy, frees one from the negative pathogenic forces of life.
Attaining enlightenment and liberation can be achieved through the classic practices of
meditation and yoga.
Research findings indicate that meditation and yoga are the most widely used of all therapies
(Goldberg et al., 2017; Walsh & Shapiro, 2006). They have been shown to reduce anxiety,
specific phobias, and substance abuse (Kwee, 1990; Shapiro, 1982; West, 1987); to benefit
those with medical problems by reducing blood pressure and aiding in the management of
chronic pain (Kabat‐Zinn, 1990); to enhance self‐confidence, sense of control, marital
satisfaction, and so on (Alexander, Rainforth, & Gelderloos, 1991); and to extend longevity
(Alexander, Langer, Newman, Chandler, & Davies, 1989). Today, meditation and yoga have
become accepted practices among millions in the United States, especially for relaxation and
stress management. For their practitioners, altered states of consciousness are unquestioned
aspects of reality.
According to some cultures, nonordinary reality states allow some healers to access an
invisible world surrounding the physical one. Puerto Ricans, for example, believe in
espiritismo (spiritism), the idea that spirits can have major impacts on the people residing in
the physical world (Chavez, 2005). Espiritistas, or mediums, are culturally sanctioned
indigenous healers who possess special faculties allowing them to intervene positively or
negatively on behalf of their clients. Many cultures strongly believe that human destiny is
often decided in the domain of the spirit world. Mental illness may be attributed to the
activities of hostile spirits, often in reaction to transgressions of the victim or the victim's
family (C. C. Lee, 1996; Mullavey‐O'Byrne, 1994). Shamans, mediums, and indigenous
healers often enter the spirit world on behalf of their clients in order to seek answers, enlist
the help of spirits, or aid in realigning the spiritual energy field that surrounds the body and
extends throughout the universe.
Ancient Chinese methods of healing and the Hindu concept of chakras also acknowledge
another reality that parallels the physical world. Accessing this world allows the healer to use
these special energy centers to balance and heal the body and mind. Occasionally, the shaman
may aid the helpee or novice to access the other plane of reality so that he or she may find the
solutions for him‐ or herself. The vision quest, for example, in conjunction with the sweat
lodge experience, is used by some American Indians as a form of religious renewal or rite of
passage (Garrett et al., 2011; Heinrich, Corbin, & Thomas, 1990; Smith, 2005). The
ceremony of the vision quest is intended to prepare a young man for the proper frame of
mind; it includes rituals and sacred symbols, prayers to the Great Spirit, isolation, fasting, and
personal reflection. Whether in a dream state or in full consciousness, another world of reality
is said to reveal itself. Mantras, chants, meditation, and the taking of certain drugs (peyote) all
have as their purpose a journey into another world of existence (Duran, 2006).
Acceptance of Spirituality in Life and the Cosmos
Although people may not have a formal religion, indigenous helpers believe that spirituality
is an intimate aspect of the human condition. Western psychology acknowledges the
behavioral, cognitive, and affective realms, but it makes only passing reference to the
spiritual one. Yet, indigenous helpers believe that spirituality transcends time and space,
mind and body, and our behaviors, thoughts, and feelings (Lee & Armstrong, 1995; Smith,
2005).
One does not have to look beyond the United States to see such spiritual orientations; many
racial/ethnic minority groups in this country are strongly spiritual. Traditional American
Indians look on all things as having life, spiritual energy, and importance. A fundamental
belief is that all things are connected. The universe consists of a balance among all of these
things and a continuous flow of cycling of this energy. American Indians believe that we have
a sacred relationship with the universe that is to be honored. All things are connected, all
things have life, and all things are worthy of respect and reverence. Spirituality focuses on the
harmony that comes from our connection with all parts of the universe—in which everything
has a purpose and value exemplary of personhood, including plants (e.g., “tree people”), the
land (“Mother Earth”), the winds (“the Four Powers”), “Father Sky,” “Grandfather Sun,”
“Grandmother Moon,” and “The Red Thunder Boys.” Spiritual being essentially requires
only that we seek our place in the universe; everything else will follow in good time. Because
everyone and everything was created with a specific purpose to fulfill, no one should have the
power to interfere or to impose on others the best path to follow (Garrett & Garrett, 1994, p.
187).
The Lakota Sioux often say “Mitakuye Oyasin” at the end of a prayer or as a salutation.
Translated, it means, “to all my relations,” which acknowledges the spiritual bond between
the speaker and all people present and extends to forebears, the tribe, the family of humanity,
and Mother Nature. It speaks to the philosophy that all life forces, Mother Earth, and the
cosmos are sacred beings and that the spiritual is the thread that binds all together.
African Americans, Asian Americans, and Latinx Americans all place strong emphasis on the
interplay and interdependence of spiritual life and healthy functioning (Boyd‐Franklin,
2010; Garrett & Portman, 2011). Puerto Ricans, for example, may sacrifice material
satisfaction in favor of values pertaining to the spirit and the soul. Likewise, a strong spiritual
orientation has always been a major aspect of life in Africa, and this was carried into the
slavery era in the United States.
Highly emotional religious services conducted during slavery were of great importance
in dealing with oppression. Often signals as to the time and place of an escape were
given then. Spirituals contained hidden messages and a language of resistance (e.g.,
“Wade in the Water” and “Steal Away”). Spirituals (e.g., “Nobody Knows the Trouble
I've Seen”) and the ecstatic celebrations of Christ's gift of salvation provided Black
slaves with outlets for expressing feelings of pain, humiliation, and anger.
(Hines & Boyd‐Franklin, 1996, p. 74)
The African American church has a strong influence over the lives of many Black people and
is often the hub of religious, social, economic, and political life (Boyd‐Franklin, 2010).
Religion is not separated from the daily functions of the church, as it acts as a complete
support system for the African American community, with the minister, deacons,
deaconesses, and church members operating as one big family. A strong sense of peoplehood
is fostered via social activities, choirs, Sunday school, health‐promotion classes, daycare
centers, tutoring programs, and counseling. For many African Americans, especially women,
the road to mental health and the prevention of mental illness lies in the health potentialities
of their spiritual life (Reed & Neville, 2014).
Mental health professionals are becoming increasingly open to the potential benefits of
spirituality as a means for coping with hopelessness, identity issues, and feelings of
powerlessness (Eriksen et al., 2013). As an example of this movement, the Association for
Counselor Education and Supervision (ACES) adopted a set of competencies related to
spirituality. It defines spirituality as:
the animating force in life, represented by such images as breath, wind, vigor, and
courage. Spirituality is the infusion and drawing out of spirit in one's life. It is
experienced as an active and passive process. Spirituality is also described as a capacity
and tendency that is innate and unique to all persons. This spiritual tendency moves the
individual towards knowledge, love, meaning, hope, transcendence, connectedness, and
compassion. Spirituality includes one's capacity for creativity, growth, and the
development of a values system. Spirituality encompasses the religious, spiritual, and
transpersonal.
(American Counseling Association, 1995, p. 30)
Interestingly enough, it appears that many in the United States are experiencing a “spiritual
hunger,” or a strong need to reintegrate spiritual or religious themes into their lives (Hage,
2004; Thoresen, 1998). For example, it appears that there is a marked discrepancy between
what patients want from their doctors and what doctors supply. Often, patients want to talk
about the spiritual aspects of their illness and treatment, but doctors are either unprepared or
disinclined to do so (Eriksen et al., 2013). Likewise, most mental health professionals feel
uncomfortable, disinclined, or unprepared to speak with their clients about religious or
spiritual matters.
The relationship between spirituality and health is highly positive (Aldwin, Park, Jeong, &
Nath, 2014; Thoresen, 1998). Those with higher levels of spirituality have lower disease risk,
fewer physical health problems, and higher levels of psychosocial functioning. It appears that
people require faith as well as reason to be healthy and that psychology may profit from
allowing the spirit to rejoin matters of mind and body (Strawbridge, Cohen, Shema, &
Kaplan, 1997).
In general, indigenous healing methods have much to offer to EuroAmerican forms of mental
health practice. The contributions are valuable not only because multiple belief systems now
exist in our society but also because counseling and psychotherapy have historically
neglected the spiritual dimension of human existence. Our heavy reliance on science and the
reductionist approach to treating clients has made us view human beings and human behavior
as composed of separate noninteracting parts (cognitive, behavioral, and affective). There has
been a failure to recognize our spiritual being and to take a holistic outlook on life (Cashwell
& Bartley, 2014). Indigenous models of healing remind us of these shortcomings and
challenge us to look for answers in realms of existence beyond the physical world.
Video 10.2: Incorporating Non-Western Beliefs
Research shows that incorporating religious and spiritual beliefs into the counseling session
can positively impact outcomes. Allowing your client to be the expert regarding
religious/spiritual non-Western beliefs can build rapport and self-esteem.
EXAMPLES OF INDIGENOUS HEALING APPROACHES
Ho'oponopono
An excellent example that incorporates various principles of indigenous healing is the Native
Hawaiian ho'oponopono healing ritual (Nishihara, 1978; Rezentes, 2006). Translated literally,
this means “a setting to right, to make right, to correct.” In cultural context, ho'oponopono
attempts to restore and maintain good relations among family members and between the
family and the supernatural powers. It is a kind of family conference (family therapy) aimed
at restoring good and healthy harmony. Many Native Hawaiians consider it to be one of the
soundest methods of restoring and maintaining good relations that any society has ever
developed. Such a ceremonial activity usually occurs among members of the immediate
family, but it may involve the extended family and even nonrelatives if they were involved in
the pilikia (trouble). The process of healing consists of the following:
1. The ho'oponopono begins with pule weke (opening prayer) and ends with pule ho'opau
(closing prayer). The pule creates the atmosphere for the healing and involves asking the
family gods for guidance. These gods are not asked to intervene, but to grant wisdom,
understanding, and honesty.
2. The ritual elicits ’oia’i’o (truth telling), sanctioned by the gods, and makes compliance
among participants a serious matter. The leader states the problem, prays for spiritual
fusion among members, reaches out to resistant family members, and attempts to unify
the group.
3. Once this occurs, the actual work begins through mahiki, a process of getting to the
problems. Transgressions, obligations, righting the wrongs, and forgiveness are all
aspects of ho'oponopono. The forgiving/releasing/severing of the wrongs, the hurts, and
the conflicts produces a deep sense of resolution.
4. Following the closing prayer, the family participates in pani, the termination ritual, in
which food is offered to the gods and to the participants.
In general, we can see several principles of indigenous Hawaiian healing: (a) problems reside
in relationships with people and spirits; (b) harmony and balance in the family and in nature
are desirable; (c) healing must involve the entire group and not just an individual; (d)
spirituality, prayer, and ritual are important aspects of healing; (e) the healing process comes
from a respected elder of the family; and (f) the method of healing is indigenous to the culture
(Rezentes, 2006).
Native American Sweat Lodge Ceremony
Another example of indigenous healing increasingly being employed by Western cultures in
medicine, mental health, substance abuse, and correctional facilities is the Native American
sweat lodge ceremony (sweat therapy) (Garrett & Portman, 2011; Garrett et al., 2011).
Among Native Americans, the sweat lodge and the ensuing rituals are filled with cultural and
spiritual symbolism and meaning. The sweat lodge itself is circular or oval and symbolizes
the universe and/or womb from which life originates; the stone pit represents the power of the
creator, and the stones (healing power of the earth) are heated by the sacred fire; the water
used in the ceremony is essential for all life; the steam that rises when water is thrown on the
stones represents both the prayers of the participants and ancient knowledge; and the sweat of
the participants is part of the purification process. Consistent with most indigenous mandates,
the sweat lodge ceremony is conducted under the following conditions, as described by
Garrett et al. (2011):
1. The lodge is constructed from materials garnered from Mother Earth. Permission is
sought from the wood, bark, rocks, and other materials to participate in the sacred ritual.
The reciprocity involved in requesting permission and giving thanks is part of the belief
in the interrelationship of all things and the maintenance of balance and harmony.
2. A Fire Keeper has the responsibility of tending the sacred fire in which the stones will be
heated.
3. Participants strip themselves of all clothing and jewelry and enter on their hands and
knees to show respect for Mother Earth. They then sit in a sacred circle (hoop of life).
4. The ceremony begins in silence (true voice of the Creator); then invocation and thanks
are given to the Great Spirit, Mother Earth, the four directions, spirits, and all relations
in nature.
5. Water or an herbal mixture is poured on the heated rocks, producing a purifying steam.
1. The ritualized cleansing of the body is meant to ensure harmony, balance, and
wellness in the person. The participants purify themselves by joining with the
powers of Mother Earth and the Universal Circle that connects living and nonliving
beings.
2. Unlike most Western forms of healing, the sweat lodge ceremony takes place in the
presence of a person's support network: the family, clan, and community. Not only
does the ceremony cleanse the body, mind, and spirit, but it also brings together
everyone to honor the energy of life.
As mentioned previously, sweat therapy has been increasingly adopted in Western society as
a form of treatment. Its use, however, is based on other Western therapeutic rationales rather
than that ascribed to Native Americans.
REFLECTION AND DISCUSSION QUESTIONS
1. What thoughts do you have about the role of spirituality and religion in psychology and
mental health?
2. Should therapists avoid discussing these matters with clients and leave it to religious or
spiritual leaders?
3. What are the possible positive and negative outcomes of doing so?
4. Would you feel comfortable talking about religion with your clients? How about
spirituality?
5. If you were in therapy, how important would it be to discuss your religious beliefs? Your
spirituality?
6. Are you a religious person? A spiritual person? Is one more important to you than the
other?
Video 10.3: Benefitting from Religion and Spirituality
Creating a safe space within the counseling session where your clients can discuss their
beliefs can often be key to successfully transitioning. Clients may not feel comfortable simply
because they don't know if the clinician is a 'safe' person to share with.
DANGERS AND BENEFITS OF SPIRITUALITY
Although we have discussed the important role that indigenous healing plays in many
societies and cultures, there are downsides reflected in our historical past, where an uncritical
acceptance of religious or spiritual belief systems may actually harm rather than heal or
enlighten. Such was the case during the Middle Ages, when supernatural explanations of
human behavior led to a total eclipse of science and resulted in the deaths of many innocent
people, primarily those accused of being witches (women, the mentally ill, those with
disfigurements, gypsies, and scientists who voiced beliefs that differed from the Church's
doctrines). Early Christianity did little to promote science and in many ways actively
discouraged it. The Church demanded uncompromising adherence to its tenets. Christian
fervor brought with it the concepts of heresy and punishment; certain truths were deemed
sacred, and those who challenged them were denounced as heretics. Scientific thought that
was in conflict with Church doctrine was not tolerated.
The role of demons, witches, and possessions in explaining abnormal behavior has been part
and parcel of many cultures and societies. There is good reason why Western science has
viewed religion with skepticism. Until recently, the mental health profession has been largely
silent about the influence or importance of spirituality and religion in mental health. During
therapy or work with clients, therapists have generally avoided discussing such topics. It has
been found, for example, that many therapists (a) do not feel comfortable or competent in
discussing spiritual or religious issues with their clients, (b) are concerned they will appear
proselytizing or judgmental if they touch on such topics, (c) believe they may usurp the role
of the clergy or other religious leaders by doing so, and (d) may feel inauthentic addressing
client concerns, especially if they are atheists or agnostics (Gonsiorek, Richards, Pargament,
& McMinn, 2009; Knox, Catlin, Casper, & Schlosser, 2005).
Yet, it has been found that about 75% of Americans say that religion is important in their
lives, that in both medical and mental health care patients express a strong desire for
providers to discuss spiritual and faith issues with them, and that persons of color believe that
spiritual issues are intimately linked to their cultural identities (Gallup Organization, 2017).
More compelling are findings that reveal a positive association between spirituality/religion
and optimal health outcomes, longevity, and lower levels of anxiety, depression, suicide, and
substance abuse (Cornah, 2006). Studies on the relationship of spirituality and health have
found that higher levels of spirituality are associated with lower disease risk, fewer physical
health problems, and higher psychosocial functioning (Thoresen, 1998). On a therapeutic
level, these findings provide a strong rationale for professionals in the field of counseling and
psychology to incorporate spirituality into their research and practice.
Surveys support the inescapable conclusion that many in the United States are experiencing a
spiritual hunger, or a strong need to reintegrate spiritual or religious themes into their lives
(Hage, 2004). Many counseling/mental health professionals are becoming increasingly open
to the potential benefits of spirituality in the treatment of clients. As part of that process,
psychologists are making distinctions between spirituality and religion. Spirituality is an
animating life force that is inclusive of religion and speaks to the thoughts, feelings, and
behaviors related to a transcendent state. Religion is narrower, involving a specific doctrine
and particular system of beliefs. Spirituality can be pursued outside a specific religion
because it is transpersonal and includes one's capacity for creativity, growth, and love
(Eriksen et al., 2013). Mental health professionals are increasingly recognizing that people
are thinking, feeling, behaving, social, cultural, and spiritual beings and that the human
condition is broad, complex, and holistic.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Do not invalidate the indigenous belief systems of your clients. Entertaining alternative
realities does not mean that the counselor must subscribe to a particular belief system. It
does mean, however, that he or she must avoid being judgmental.
2. Become knowledgeable about indigenous beliefs and healing practices. Counselors have
a professional responsibility to become knowledgeable and conversant about the
assumptions and practices of indigenous healing so that a process of desensitization and
normalization can occur.
3. Avoid overpathologizing a culturally diverse client's problems. Therapists or counselors
who are culturally unaware and who believe primarily in a universal psychology may
often be culturally insensitive and inclined to see differences as deviance.
4. Avoid underpathologizing a culturally diverse client's problems. While being
understanding of a client's cultural context, having knowledge of culture‐bound
syndromes, and being aware of cultural relativism is desirable, being oversensitive to
these factors may predispose the therapist to minimize problems.
5. Be willing to consult with traditional healers or to make use of their services. Mental
health professionals must be willing and able to form partnerships with indigenous
healers or to develop community liaisons.
6. Recognize that spirituality is an intimate aspect of the human condition and a legitimate
aspect of mental health work.
7. A counselor or therapist who does not feel comfortable dealing with the spiritual needs
of clients or who believes in an artificial separation of the spirit (soul) from the everyday
life of the culturally different client may not be providing the needed help.
8. Be willing to expand your definition of the helping role to community work and
involvement. More than anything else, indigenous healing is community‐oriented and
community‐focused.
SUMMARY
Since the beginning of human existence, all societies and cultural groups have developed
their own explanations of abnormal behaviors and forms of healing. Within the United States,
counseling and psychotherapy are the predominant psychological treatment methods. In other
cultures, however, indigenous healing approaches continue to be widely used, and many
people of color continue to be influenced by such beliefs and practices. In many societies, the
centuries‐old recognition of healers (shamans) within a community refers to people often
called witches, witch doctors, wizards, medicine men or women, sorcerers, and magic men or
women. These individuals are believed to possess the power to enter an altered state of
consciousness and journey to other planes of existence beyond the physical world during their
healing rituals.
There are both similarities and differences between EuroAmerican helping systems and
non‐Western indigenous practices. Shamans share many common characteristics with
Western therapists. In the eyes of clients, for example, both have high credibility, show
compassion and a professional stance, share one another's worldviews, and offer themselves
as the chief instruments for change. The differences, however, are great. Western forms of
counseling rely on sensory information defined by the physical plane of reality (Western
science), whereas most indigenous methods rely on the spiritual plane of existence in seeking
a cure. Indigenous healing operates under three guiding principles: (a) holistic outlook,
interconnectedness, and harmony; (b) belief in metaphysical levels of existence; and (c)
spirituality in life and the cosmos. Western healing has been slow to acknowledge and learn
from these age‐old forms of wisdom. In its attempt to become culturally responsive,
however, the mental health field must begin to put aside the biases of Western science, to
acknowledge the existence of intrinsic help‐giving networks, and to incorporate the legacy
of ancient wisdom that may be contained in indigenous models of healing.
Such reconciliation may be found in the desire among many Americans for religious and
spiritual integration. Studies show that an overwhelming number of Americans say that
religion is important in their lives, that both medical and mental health care patients express a
strong desire for providers to discuss spiritual and faith issues with them, and that persons of
color believe that spiritual issues are intimately linked to their cultural identities.
GLOSSARY TERMS
Băt Gió
Brain fag
Cao Gió
Enlightenment
Espiritismo
Ghost sickness
Giác Hoi
Hmong sudden death syndrome
Ho'oponopono
Holistic outlook
Indigenous healing
Mahiki
’Oia’i’o
Pani
Pule ho'opau
Pule weke
Shaman
Spirituality
Sweat lodge ceremony
Thùôc Nam
Universal shamanic tradition
Western healing
Video 10.4: Counseling Session Analysis
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
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11
Racial, Ethnic, Cultural (REC) Identity Attitudes in People of
Color: Counseling Implications
Chapter Objectives
1. 1. Learn the important factors that are influential in the development of racial,
ethnic, cultural (REC) identity in people of color.
2. 2. Describe how sociopolitical forces influence the REC identity attitudes of people
of color.
3. 3. Outline key REC models and describe how they incorporate attitudes, beliefs,
and behaviors toward oneself, toward members of one's own group, and toward
majority group members.
4. 4. Become knowledgeable about how the REC identity attitudes of people of color
impact the counseling/therapy situation.
5. 5. Describe the various common characteristics of clients at each of the following
levels of identity formation: conformity, dissonance, resistance and immersion,
introspection, and integrative awareness.
6. 6. Discuss the therapeutic challenges likely to confront a counselor or therapist
working with clients at each of the five levels of identity development.
CASE STUDY
“JENNY”: SANSEI (THIRD‐GENERATION) JAPANESE AMERICAN
WOMAN
For nearly all my life I have never seriously attempted to dissect my feelings and
attitudes about being a Japanese American woman. Aborted attempts were made, but
they were never brought to fruition, because it was unbearably painful. Having been
born and raised in Arizona, I had no Asian friends. I suspect that given an opportunity to
make some, I would have avoided them anyway. That is because I didn't want to have
anything to do with being Japanese American. Most of the Japanese images I saw were
negative. Japanese women were ugly; they had “cucumber legs,” flat yellow faces, small
slanty eyes, flat chests, and were stunted in growth. The men were short and stocky,
sneaky and slimy, clumsy, inept, “wimpy looking,” and sexually emasculated. I wanted
to be tall, slender, large eyes, full lips, and elegant looking; I wasn't going to be typical
Oriental!
At Cal [University of California, Berkeley], I've been forced to deal with my Yellow‐
White identity. There are so many “yellows” here that I can't believe it. I've come to
realize that many White prejudices are deeply ingrained in me; so much so that they are
unconscious. To accept myself as a total person, I also have to accept my Asian identity
as well. But what is it? I just don't know. Are they the images given me through the filter
of White America, or are they the values and desires of my parents?
Yesterday, I had a rude awakening. For the first time in my life I went on a date with a
Filipino boy. I guess I shouldn't call him a “boy,” as my ethnic studies teacher says it is
derogatory toward Asians and Blacks. I only agreed to go because he seemed different
from the other “Orientals” on campus. (I guess I shouldn't use that word either.) He’s
president of his Asian fraternity, very athletic and outgoing. When he asked me, I
figured, “Why not?” It'll be a good experience to see what it's like to date an Asian boy.
Will he be like White guys who will try to seduce me, or will he be too afraid to make
any move when it comes to sex? We went to San Francisco's Fisherman's Wharf for
lunch. We were seated and our orders were taken before two other White women. They
were, however, served first. This was painfully apparent to us, but I wanted to pretend
that it was just a mix‐up. My friend, however, was less forgiving and made a public
fuss with the waiter. Still, it took an inordinate amount of time for us to get our lunches,
and the filets were overcooked (purposely?). My date made a very public scene by
placing a tip on the table, and then returning to retrieve it. I was both embarrassed but
proud of his actions.
This incident and others made me realize several things. For all my life I have attempted
to fit into White society. I have tried to convince myself that I wasn't different, that I was
like all my other White classmates, and that prejudice and discrimination didn't exist for
me. I wonder how I could have been so oblivious to prejudice and racism. I now realize
that I cannot escape from my ethnic heritage and from the way people see me. Yet I
don't know how to go about resolving many of my feelings and conflicts. While I like
my newly found Filipino “male” friend (he is sexy), I continue to have difficulty seeing
myself married to anyone other than a White man. (Excerpts from “Jenny,” a Sansei
student class journal)
Video 11.0: Introduction
Introduction to counseling session by Dr. Joel Filmore.
RACIAL AWAKENING
Oriental, Asian, or White?
Jenny is experiencing a racial awakening that has strong implications for her racial, ethnic,
cultural (REC) identity. Her previous belief systems concerning White Americans and Asian
Americans are being challenged by social reality and the experiences of being a “visible
racial/ethnic minority.” First, a major theme involving societal portrayals of Asian Americans
is clearly expressed in her beliefs about REC characteristics: Jenny describes the Asian
American man and woman in highly unflattering terms. She seems to have internalized these
beliefs and to be using White standards to judge Asian Americans as being desirable or
undesirable. For this student, the process of incorporating these standards has not only
attitudinal but also behavioral consequences. In Arizona, she would not have considered
making Asian American friends even if the opportunity had presented itself. In her mind, she
was not a “typical Oriental”; she disowned or felt ashamed of her ethnic heritage. She even
concludes that she has trouble picturing marrying anyone but a White man.
Denial Breakdown
Jenny's denial that she is an Asian American is beginning to crumble. Being immersed in the
student body on a campus in which there are many fellow Asian Americans in attendance
forces her to explore REC identity issues—a process she has been able to avoid while living
in a predominantly White area. Part of the avoidance may have been a REC coping
mechanism to fit in at all cost. In the past, when she encountered prejudice or discrimination,
she was able to deny it or to rationalize it away. The differential treatment she received at the
restaurant and her friend's labeling of it as “discrimination” makes such a conclusion
inescapable. The shattering of illusions is manifest in her realization that (a) despite her
efforts to “fit in,” it is not enough to gain social acceptance among many White Americans,
(b) she cannot escape her REC heritage, and (c) she has been brainwashed into believing that
one group is superior to another.
The Internal Struggle for Identity
Jenny's internal struggle to cast off the cultural conditioning of her past and the attempts to
define her REC identity are both painful and conflicting. We have clear evidence of the
internal turmoil she is undergoing when she (a) refers to her “Yellow‐White” identity, (b)
writes about her negative images of Asian American men but winds up dating one, (c) uses
the terms “Oriental” and “boy” (in reference to her Asian male friend) but acknowledges their
derogatory racist nature, (d) describes Asian men as “sexually emasculated” but sees her
Filipino date as “athletic,” “outgoing,” and “sexy,” (e) expresses embarrassment at
confronting the waiter about discrimination but feels proud of her friend for doing so, and (f)
states that she finds her friend attractive but would have trouble considering marrying anyone
but a White man. Understanding the process by which REC identity attitudes develop and
change over time in persons of color is crucial for effective multicultural counseling and
therapy (MCT).
Locus of the Problem
It is clear that Jenny is a victim of ethnocentric monoculturalism. As we mentioned
previously, the problem she is experiencing does not reside in her but in our society: a society
that portrays REC characteristics as inferior, primitive, deviant, pathological, or undesirable.
The resulting damage strikes at the self‐esteem and self/group identity of many people of
color; many, like this student, may come to believe that their REC heritage or characteristics
are burdens to be changed or overcome. Understanding REC identity attitudes and their
relationship to therapeutic practice are the goals of this chapter.
Video 11.1: Clients of Color and Self-Awareness
Clients of color go through a developmental process in which they become aware of their
'differentness'. It is during this process that they achieve an awakening related to their
race/ethnicity.
REC IDENTITY ATTITUDE MODELS
The historic work on REC identity attitudes among people of color has led to major
breakthroughs in the field of multicultural psychology (Atkinson, Morten, & Sue, 1998;
Cross, 1971, 1995; Cross, Smith, & Payne, 2002; Helms, 1984, 1995; Horse, 2001; Kim,
1981; Ruiz, 1990). Most would agree that Asian Americans, African Americans, Latinx
Americans, and American Indians have distinct REC heritages that make each different from
the others. The rise of the REC identity models in the 1970s and the current extensions of
them allow researchers and counselors opportunities to acknowledge within‐group
differences among the distinct REC groups; that is, to challenge the erroneous belief that all
Asians are the same, all Blacks are the same, all Latinx are the same, or all American Indians
are the same. Treating REC groups as monolithic has led to numerous therapeutic problems,
including early termination from counseling/therapy (Owen et al., 2017). The high failure‐
to‐return rate of many clients seems to be intimately connected to the mental health
professional's inability to assess their cultural identities accurately (Ivey, D'Andrea, & Ivey,
2011).
Another important contribution of REC identity models is their acknowledgment of
sociopolitical influences in shaping identity (à la “Jenny”). Early models of REC identity all
incorporated the effects of racism and prejudice (oppression) upon the identity transformation
of their victims. Vontress (1971), for instance, theorized that African Americans moved
through decreasing levels of dependence on White society to emerging identification with
Black culture and society (Colored, Negro, and Black). Other similar models for African
Americans have been proposed (Cross, 1971; Jackson, 1975; Thomas, 1970, 1971). The fact
that other marginalized groups, such as Asian Americans (Kim, 2012; Sue & Sue, 1971),
Latinx Americans (Ferdman & Gallegos, 2012), Native Americans (Horse, 2012), women
(Downing & Roush, 1985; McNamara & Rickard, 1989), lesbian, gay, bisexual, transgender,
and queer (LGBTQ) individuals (Cass, 1979), and individuals with disabilities (Olkin, 1999),
have similar processes may indicate experiential validity for such models as they relate to
various oppressed groups. More recent REC identity conceptualizations also provide insights
about how to consider the ways in which multiple identity attitudes influence the
counseling/therapy process; that is, the consideration of REC identity attitudes along with
other social identity attitudes such as gender, sexual orientation, and religion (Robinson‐
Wood, 2016).
Foundational REC Models
Early attempts to define a process of minority identity transformation came primarily through
the works of Black social scientists and educators (Cross, 1971; Jackson, 1975; Thomas,
1971). Although there are several Black identity development models, the Cross model of
psychological nigrescence (the process of becoming Black) is perhaps the most influential
and well documented (Cross, 1971, 1991, 1995). The original Cross model was developed
during the civil rights movement and delineates a five‐stage process in which Blacks in the
United States move from a White frame of reference to a positive Black frame of reference:
preencounter, encounter, immersion‐emersion, internalization, and internalization‐
commitment.
The preencounter stage is characterized by African Americans consciously or
unconsciously devaluing their own Blackness and concurrently valuing White values
and ways. There is a strong desire to assimilate and acculturate into White society.
Blacks at this stage evidence self‐hate, low self‐esteem, and poor mental health
(Vandiver, 2001).
In the encounter stage, a two‐step process begins to occur. First, the Black person
encounters a profound crisis or event that challenges his or her previous mode of
thinking and behaving; second, he or she begins to reinterpret the world, resulting in a
shift in worldviews. Cross points out how the slaying of Martin Luther King Jr. was such
a significant experience for many African Americans. More recently, the shooting of
Michael Brown in Ferguson, Missouri and the choking death of Eric Garner in New
York, both in 2014, are other examples. The person experiences both guilt and anger
over being brainwashed by White society.
In the third stage, immersion‐emersion, the person withdraws from the dominant
culture and becomes immersed in African American culture. Black pride begins to
develop, but internalization of positive attitudes toward one's own Blackness is minimal.
In the emersion phase, feelings of guilt and anger begin to dissipate with an increasing
sense of pride.
The next stage, internalization, is characterized by inner security, as conflicts between
the old and new identities are resolved. Global anti‐White feelings subside as the
person becomes more flexible, more tolerant, and more bicultural/multicultural.
The last stage, internalization‐commitment, speaks to the commitment that such
individuals have toward social change, social justice, and civil rights. It is expressed not
only in words but also in actions that reflect the essence of their lives.
Cross's original model makes a major assumption: the evolution from the preencounter stage
to the internalization stage reflects a movement from psychological dysfunction to
psychological health (Vandiver, 2001).
Confronted with evidence that these stages, which some psychologists now refer to as
“statuses,” may mask multiple racial identities; questioning his original assumption that all
Blacks at the preencounter stage possess self‐hatred and low self‐esteem; and aware of the
complex issues related to race salience, Cross (1991) revised his theory of nigrescence in his
book Shades of Black. His changes, which are based on a critical review of the literature on
Black racial identity, have increased the model's explanatory powers and promise high
predictive validity (Vandiver, Fhagen‐Smith, Cokley, Cross, & Worrell, 2001; Worrell,
Cross, & Vandiver, 2001). In essence, the revised model contains nearly all the features from
the earlier formulation, but it differs in several significant ways.
First, Cross introduces the concept of race salience, the degree to which race is an important
and integral part of a person's approach to life. The Black person may function with “race”
consciousness playing either a large or a minimal role in his or her identity. In addition,
salience for Blackness can possess positive (pro‐Black) or negative (anti‐Black) valence.
Instead of using the term “pro‐White” in describing the preencounter stage, Cross now uses
the term race salience. Originally, Cross believed that the rejection of Blackness and the
acceptance of an American perspective were indicative of only one identity, characterized by
self‐hate and low self‐esteem. His current model now describes three identity subtypes: (a)
preencounter assimilation; (b) preencounter miseducation; and (b) preencounter anti‐Black.
People represented in the first subtype have low salience for race and a neutral valence
toward Blackness; the second subtype reflects internalization of negative messages in society
about Blacks but an ability to separate one's personal identity from one's racial group
membership; the third describes individuals who hate Blacks and hate being Black (high
negative salience). In other words, it is possible for a Black person in preencounter to
experience the salience of race as very minor and to have his or her identity oriented toward
an “American” perspective, without self‐hate or low self‐esteem.
The sense of low self‐esteem, however, is linked to the preencounter anti‐Black
orientation. According to Cross, such a psychological perspective is the result of
miseducation and self‐hatred. The miseducation results from the negative portrayal of
Blacks in the mass media, among neighbors, friends, and relatives, and in educational
literature (Blacks are unintelligent, criminal, lazy, and prone to violence). The result is an
incorporation of such negative images into the personal identity of the Black person.
Interestingly, the case of Jenny, although Japanese American, would seem to possess many of
the features of Cross's preencounter anti‐Black identity.
Second, the immersion‐emersion stage once described one fused identity (anti‐
White/pro‐Black) but is now divided into two subtypes: anti‐White alone and anti‐Black
alone. While Cross speaks about two separate identities, it appears that there are three
possible combinations: anti‐White, pro‐Black, and an anti‐White/pro‐Black
combination.
Third, Cross collapsed the fourth and fifth stages (internalization and internalization‐
commitment) into one: internalization. He observed that minimal differences existed between
the two stages except in the characteristic of “sustained interest and commitment.” This last
stage is characterized by Black self‐acceptance and can be manifested in three types of
identity: (a) Black nationalist (high Black positive race salience); (b) biculturalist (Blackness
and fused sense of Americanness); and (c) multiculturalist (multiple identity formation,
including race, gender, sexual orientation, etc.).
Cross's nigrescence model influenced a generation of REC and other social identity models,
including models of Asian American (e.g., Kim 1981), Latinx (e.g., Ruiz 1990), and people
of color and White identity (e.g., Helms, 1995). In the next section, we describe one of the
only general REC identity models that accounts for the attitudes and activities related to one's
own REC group as well as other REC groups.
A GENERAL MODEL OF REC IDENTITY
In the past several decades, Asian Americans, Latinx Americans, and American Indians have
experienced sociopolitical identity transformations so that a Third World consciousness has
emerged, with the awareness of cultural oppression as the common unifying force. As a result
of studying these models and integrating them with their own clinical observations, Atkinson
et al. (1998) proposed a five‐stage Minority Identity Development (MID) model in an
attempt to pull out common features that cut across the population‐specific proposals. Sue
and Sue (1990, 1999) later elaborated on the MID, renaming it the Racial/Cultural Identity
Development (R/CID) model, to (a) encompass a broader population and (b) avoid the
disempowering term “minority.” As discussed shortly, this model may be applied to White
identity development as well.
The R/CID model proposed here is not a comprehensive theory of personality, but rather a
conceptual framework or heuristic to aid therapists in understanding their REC diverse
clients' attitudes and behaviors. Five levels of development that oppressed people experience
as they struggle to understand themselves in terms of their own culture, the dominant culture,
and the oppressive relationship between the two are described: conformity, dissonance,
resistance and immersion, introspection, and integrative awareness. At each level, there are
four corresponding beliefs and attitudes, the understanding of which may help therapists
better understand their clients. These attitudes/beliefs are an integral part of identity, and are
manifest in how a person views (a) the self, (b) others of the same minority, (c) others of
another minority, and (d) majority individuals. Table 11.1 outlines the R/CID model and the
interaction of its phases with these attitudes and beliefs.
TABLE 11.1 The R/CID Model
Source: Atkinson, D. R., Morten, G., & Sue, D. W. (1998). Counseling American minorities: A cross‐cultural
perspective (5th ed.). Boston, MA: McGraw‐Hill. Copyright © 1998 McGraw‐Hill. All rights reserved. Reprinted
by permission.
Phases of
minority
development
model
Attitude
toward self
Attitude toward others
of the same group
Attitude
toward others
of a different
marginalized
group
Attitude
toward
dominant
group
Status 1—
Conformity
Self‐
depreciating or
neutral due to
low race
salience
Group‐depreciating or
neutral due to low race
salience
Discriminatory
or neutral
Group‐
appreciating
Status 2—
Dissonance
Conflict
between self‐
depreciating
and group‐
appreciating
Conflict between group‐
depreciating views of
minority hierarchy and
feelings of shared
experience
Conflict
between
dominant‐
held and
group‐
depreciating
Conflict
between
group‐
appreciating and
group‐
depreciating
Status 3—
Resistance
and
immersion
Self‐
appreciating
Group‐appreciating
experiences and feelings
of culturocentrism
Conflict
between
feelings of
empathy for
Group‐
depreciating
other minority
Status 4—
Introspection
Concern with
basis of self‐
appreciation
Concern with nature of
unequivocal appreciation
Concern with
ethnocentric
basis for
judging others
Concern with
the basis of
group
depreciation
Status 5—
Integrative
awareness
Self‐
appreciating
Group‐appreciating
Group‐
appreciating
Selective
appreciation
Select this link to open an interactive version of Graphic 11.1: The R/CID Model
Conformity Status
Similar to individuals mostly in preencounter (Cross, 1991), persons of color are
distinguished by their unequivocal preference for dominant cultural values over those of their
own culture. White Americans in the United States represent their reference group, and the
identification set is quite strong. Lifestyles, value systems, and cultural/physical
characteristics that most resemble those of White society are highly valued, whereas those
most associated with their own group of color may be viewed with disdain or may hold low
salience. We agree with Cross that individuals at this stage can be oriented toward a pro‐
American identity without subsequent disdain or negativism toward their own group. Thus, it
is possible for a Chinese American to feel positive about U.S. culture, values, and traditions
without evidencing disdain for Chinese culture or feeling negatively about their self (absence
of self‐hate). Nevertheless, we believe that such individuals represent a small proportion of
persons of color at this stage. Research on their numbers, on how they have handled the
social‐psychological dynamics of majority–minority relations, on how they have dealt with
their marginalized status, and on how they fit into the models (progression issues) needs to be
conducted.
We believe that the conformity phase continues to be most characterized by individuals who
have bought into majority societal definitions about their marginalized status in society.
Because the conformity phase represents, perhaps, the most damning indictment of White
racism and because it has such a profound negative impact on persons of color, understanding
its sociopolitical dynamics is of utmost importance for the helping professional. Those in the
conformity phase are really victims of larger social‐psychological forces operating in our
society. The key issue here is the dominant–subordinate relationship between two different
cultures (Atkinson et al., 1998; Freire, 1970). It is reasonable to believe that members of one
cultural group tend to adjust themselves to the group possessing the greater prestige and
power in order to avoid feelings of inferiority. Yet, it is exactly this act that creates
ambivalence in the individual. The pressures for assimilation and acculturation (melting‐pot
theory) are strong, creating possible culture conflicts. These individuals are victims of
ethnocentric monoculturalism: (a) belief in the superiority of one group's cultural heritage—
its language, traditions, arts‐crafts, and ways of behaving (White) over all others; (b) belief
in the inferiority of all other lifestyles (non‐White); and (c) the power to impose such
standards on to the less powerful group.
Internalized racism has been the term used to describe the process by which persons of color
absorb the racist messages that are omnipresent in our society and internalize them (Kohli,
2013; Pyke, 2010). Constantly bombarded on all sides by reminders that Whites and their
way of life are superior and that all other lifestyles are inferior, many begin to wonder
whether they themselves are somehow inadequate, whether members of their own group are
not to blame, and whether subordination and segregation are not justified. Clark and Clark
(1947) first brought this to the attention of social scientists by stating that racism may
contribute to a sense of confused self‐identity among Black children. In a study of racial
awareness and preference among Black and White children, they found that (a) Black
children preferred playing with a White doll over a Black one, (b) the Black doll was
perceived as being “bad,” and (c) approximately one‐third, when asked to pick the doll that
looked like them, picked the White one.
It is unfortunate that the perceived inferior status of people of color is constantly reinforced
and perpetuated by the mass media through television, movies, newspapers, radio, books, and
magazines. This contributes to widespread stereotypes that tend to trap them: Blacks are
superstitious, childlike, ignorant, fun loving, dangerous, and criminal; Latinx individuals are
lazy, sneaky, and criminal; Asian Americans are sneaky, sly, cunning, and passive; Native
Americans are drunkards, violent, and primitive savages. The incorporation of the larger
society's standards may lead group members to react negatively toward their own racial and
cultural heritage. They may become ashamed of who they are, reject their own group
identification, and attempt to identify with the desirable “good” White minority; such
individuals come to accept White standards as a means of measuring physical attractiveness,
attractiveness of personality, and social relationships. Internalized racism—or racial self‐
hatred, in which people dislike themselves for being Asian, Black, Hispanic, or Native
American—has a widespread influence on the mental health of people of color (e.g., Choi,
Israel, & Maeda, 2017; Mouzon & McLean, 2017).
People primarily in conformity have, to some degree, internalized negative messages about
their own group. They seem to possess the following characteristics:
1. Attitudes and beliefs toward the self (self‐depreciating attitudes and beliefs). Physical
and cultural characteristics identified with one's own REC group are perceived
negatively, as something to be avoided, denied, or changed. Physical characteristics
(black skin color, “slant‐shaped eyes” of Asians), traditional modes of dress and
appearance, and behavioral characteristics associated with the minority group are a
source of shame. There may be attempts to mimic what is perceived as White
mannerisms, speech patterns, dress, and goals. Low internal self‐esteem is
characteristic of persons in this state.
2. Attitudes and beliefs toward members of the same group (group‐depreciating attitudes
and beliefs). Majority cultural beliefs and attitudes about the minority group are also
held by the person in this stage. These individuals may have internalized the majority of
White stereotypes about their group. In the case of Hispanics, for example, the person
may believe that members of his or her own group have high rates of unemployment
because “they are lazy, uneducated, and unintelligent.” Little thought or validity is given
to other viewpoints, such as unemployment's being a function of job discrimination,
prejudice, racism, unequal opportunities, and inferior education. Because persons in the
conformity stage find it psychologically painful to identify with these negative traits,
they divorce themselves from their own group. The denial mechanism most commonly
used is, “I'm not like them; I've made it on my own; I'm the exception.”
3. Attitudes and beliefs toward members of different marginalized groups (discriminatory).
Because the conformity‐stage person most likely strives for identification with White
society, he or she shares similar dominant attitudes and beliefs not only toward his or her
own group but toward other marginalized groups as well. Groups most similar to White
cultural groups are viewed more favorably, whereas those most different are viewed less
favorably.
For example, Asian Americans may be viewed more favorably than African
Americans or Latinx Americans in some situations. Although stratification
probably exists, we caution readers that such a ranking is fraught with hazards
and potential political consequences. It often manifests itself in debates over
which group is more oppressed and which has done the best. Such debates are
counterproductive when used to (a) negate another groups' experience of
oppression, (b) foster an erroneous belief that hard work alone will result in
success in a democratic society, (c) shortchange a marginalized group (i.e.,
Asian Americans) from receiving the necessary resources in our society, and
(d) pit one marginalized group against another (divide and conquer) by
holding one up as an example to others.
4. Attitudes and beliefs toward members of the dominant group (group‐appreciating
attitude and beliefs). This status is characterized by a belief that White cultural, social,
and institutional standards are superior. Members of the dominant group are admired,
respected, and emulated. White people are believed to possess superior intelligence.
Some individuals may go to great lengths to appear White. In the Autobiography of
Malcolm X (Haley, 1966), the author relates how he tried desperately to appear as White
as possible. He went to painful lengths to straighten and dye his hair so that he would
appear more like White males. Reports that Asian women have undergone surgery to
reshape their eyes to conform to White female standards of beauty may typify this
dynamic.
Dissonance Status
No matter how much an individual attempts to deny his or her own REC heritage, he or she
will encounter information or experiences that are inconsistent with culturally held beliefs,
attitudes, and values. An Asian American who believes that Asians are inhibited, passive,
inarticulate, and poor in people relationships may encounter an Asian person who seems to
break all these stereotypes (e.g., Jenny). A Latinx person who feels ashamed of his or her
cultural upbringing may encounter another Latinx person who seems proud of it. An African
American who believes that race problems are due to laziness, untrustworthiness, or personal
inadequacies of his or her own group may suddenly encounter racism on a personal level.
Denial begins to break down, which leads to a questioning and challenging of the
attitudes/beliefs of the conformity stage. This was clearly what happened when Jenny
encountered discrimination at the restaurant.
In all probability, transition into dissonance is a gradual process. Its very definition indicates
that the individual is in conflict between disparate pieces of information or experiences that
challenge his or her current self‐concept. People generally begin to experience this conflict
slowly, but a traumatic event may propel some individuals to move into dissonance at a much
more rapid pace. Cross (1971) stated that a monumental event such as the assassination of a
major leader like Martin Luther King Jr. can often push people quickly into the dissonance.
Coates (2015) suggested the killing of teenager Michael Brown and the acquittal of the
officer who shot him in Ferguson, Missouri pushed many youth, like his son, into an
existential questioning of race and its meaning in the United States.
1. Attitudes and beliefs toward the self (conflict between self‐depreciating and self‐
appreciating attitudes and beliefs). There is now a growing sense of personal awareness
that racism does exist, that not all aspects of one's own culture or of the majority culture
are good or bad, and that one cannot escape one's cultural heritage. For the first time, the
person begins to entertain the possibility of positive attributes in his or her own group's
culture and, with them, a sense of pride in self. Feelings of shame and pride are mixed in
the individual, and a sense of conflict develops. This conflict is most likely to be brought
to the forefront quickly when other members of the group express positive feelings
toward the person: “We like you because you are Asian [or Black, American Indian, or
Latinx].” At this stage, an important personal question is being asked: “Why should I
feel ashamed of who and what I am?”
2. Attitudes and beliefs toward members of the same group (conflict between group‐
depreciating and group‐appreciating attitudes and beliefs). Dominant‐held views of
the person's own group's strengths and weaknesses begin to be questioned as new,
contradictory information is received. Certain aspects of his or her culture begin to have
appeal. For example, a Latinx person who values individualism may marry, have
children, and then suddenly realize how Latinx cultural values that hold the family as the
psychosocial unit possess positive features. Or a person may find certain members of his
or her group to be very attractive as friends, colleagues, lovers, and so forth.
3. Attitudes and beliefs toward members of a different marginalized group (conflict
between dominant‐held views of minority hierarchy and feelings of shared
experience). The person begins to question stereotypes associated with other
marginalized groups, and feels a growing sense of comradeship with other oppressed
groups. It is important to keep in mind, however, that little psychic energy is associated
with resolving conflicts with other marginalized groups. Almost all energies are
expended toward resolving conflicts toward the self, one's own group, and the dominant
group.
4. Attitudes and beliefs toward members of the dominant group (conflict between group‐
appreciating and group‐depreciating attitudes). The person experiences a growing
awareness that not all cultural values of the dominant group are beneficial. This is
especially true when the person experiences personal discrimination. Growing suspicion
and some distrust of certain members of the dominant group develop.
Resistance and Immersion Status
The primary orientation of individuals in this status is the tendency to endorse minority‐held
views completely and to reject values of the dominant society and culture. Desire to eliminate
oppression becomes an important motivation of the individual's behavior. In the resistance
and immersion status, the three most active types of affective feeling are guilt, shame, and
anger. There are considerable feelings of guilt and shame that in the past the individual has
sold out his or her own racial and cultural group. These feelings of guilt and shame extend to
the perception that during this past “sellout,” he or she was a contributor to and participant in
the oppression of his or her own group and other marginalized groups. This is coupled with a
strong sense of anger at the oppression, and feelings of having been brainwashed by forces in
White society. Anger is directed outwardly in a very strong way toward oppression and
racism. Movement into this stage seems to occur for two reasons. First, a resolution of the
conflicts and confusions of the previous stage allows greater understanding of social forces
(racism, oppression, and discrimination) and one's own role as a victim. Second, a personal
questioning of why people should feel ashamed of themselves develops. The answer to this
question evokes feelings of guilt, shame, and anger.
1. Attitudes and beliefs toward the self (self‐appreciating attitudes and beliefs). The
individual with this status is oriented toward self‐discovery of his or her own history
and culture. There is an active seeking out of information and artifacts that enhance the
person's sense of identity and worth. Cultural and racial characteristics that once elicited
feelings of shame and disgust become symbols of pride and honor. The individual moves
into this status primarily because he or she asks the question, “Why should I be ashamed
of who and what I am?” The original low self‐esteem engendered by widespread
prejudice and racism that was most characteristic of the conformity status is now actively
challenged in order to raise self‐esteem. Phrases such as “Black is beautiful” and
“Black lives matter” represent a symbolic relabeling of identity for many Blacks.
Unapologetic racial pride is embraced.
2. Attitudes and beliefs toward members of the same group (group‐appreciating attitudes
and beliefs). The individual experiences a strong sense of identification with and
commitment to his or her group as enhancing information about the group is acquired.
There is a feeling of connectedness with other members of the racial and cultural group,
and a strengthening of the new identity begins to occur. Members of one's group are
admired, respected, and often viewed as the new reference group or ideal. Cultural
values of the group are accepted without question. As indicated, the pendulum swings
drastically from original identification with White ways to unquestioning identification
with the group's ways. Persons in this phase are likely to restrict their interactions as
much as possible to members of their own group.
3. Attitudes and beliefs toward members of a different marginalized group (conflict
between feelings of empathy for other marginalized group experiences and feelings of
culturocentrism). Although members at this status experience a growing sense of
comradeship with persons from other socially devalued groups, a strong culturocentrism
develops as well. Alliances with other groups tend to be transitory and based on short‐
term goals or some global shared view of oppression. There is less of an attempt to reach
out and understand other racial‐cultural groups and their values and ways, and more of
a superficial surface feeling of political need. Alliances generally are based on
convenience factors or are formed for political reasons, such as combining together as a
large group to confront an enemy perceived to be larger.
4. Attitudes and beliefs toward members of the dominant group (group depreciating
attitudes and beliefs). The individual is likely to perceive the dominant society and
culture as an oppressor and as the group most responsible for the current plight of
minorities in the United States. Characterized by both withdrawal from the dominant
culture and immersion in one's cultural heritage, this status also gives rise to
considerable anger and hostility directed toward White society. There is a feeling of
distrust and dislike for all members of the dominant group in an almost global anti‐
White demonstration and feeling. White people, for example, are not to be trusted
because they are the oppressors or enemies. In extreme form, members may advocate
complete destruction of the institutions and structures that have been characteristic of
White society.
Introspection Status
Several factors seem to work in unison to move the individual from the resistance and
immersion phase into the introspection phase. First, the individual begins to discover that this
level of intensity of feelings (anger directed toward White society) is psychologically
draining and does not permit one to really devote crucial energies to understanding oneself or
one's own racial‐cultural group. The resistance and immersion phase tends to be a reaction
against the dominant culture and is not proactive in allowing the individual to use all energies
to discover who or what he or she is. Self‐definition in the previous status tends to be
reactive (against White racism), and now a need for positive self‐definition in a proactive
sense emerges.
Second, the individual experiences feelings of discontent and discomfort with group views
that may be quite rigid in the resistance and immersion phase. Often, in order to please the
group, the person is asked to submerge individual autonomy and individual thought in favor
of the group good. Many group views may now be seen as conflicting with individual ones. A
Latinx individual who forms a deep relationship with a White person may experience
considerable pressure from his or her culturally similar peers to break off the relationship
because that White person is the “enemy.” However, the personal experiences of the
individual may not support this group view.
It is important to note that some clinicians often confuse certain characteristics of the
introspective status with parts of the conformity status. A person in the introspective status
who speaks against the decisions of his or her group may often appear similar to the
conformity‐status person. The dynamics are quite different, however. While the
conformity‐status person is motivated by global racial self‐hatred, the introspective person
has no such global negativism directed at his or her own group.
1. Attitudes and beliefs toward the self (concern with basis of self‐appreciating attitudes
and beliefs). Although the person originally, in the conformity phase, held predominant
majority group views and notions, to the detriment of his or her own group, the person
now feels that he or she has too rigidly held on to the group views and notions in order
to submerge personal autonomy. The conflict becomes quite great between
responsibility and allegiance to one's own group and notions of personal independence
and autonomy. The person begins to spend more and more time and energy trying to sort
out these aspects of self‐identity and begins increasingly to demand individual
autonomy.
2. Attitudes and beliefs toward members of the same group (concern with the unequivocal
nature of group appreciation). Although attitudes of identification are continued from the
preceding resistance and immersion status, concern begins to build up regarding the
issue of group‐usurped individuality. Increasingly, the individual may see his or her
own group taking positions that might be considered quite extreme. In addition, there is
now increasing resentment over how his or her group attempts to pressure or influence
the individual into making decisions that may be inconsistent with his or her values,
beliefs, and outlooks. Indeed, it is not unusual for a minority group to make it clear to
individual members that if they do not agree with the group, they are against it. A
common ploy used to hold members in line is exemplified in questions such as “How
Asian are you?” and “How Black are you?”
3. Attitudes and beliefs toward members of a different marginalized group (concern with
the ethnocentric basis for judging others). There is now greater uneasiness with
culturocentrism, and an attempt is made to reach out to other groups to find out what
types of oppression they experience and how this has been handled. Although
similarities are important, there is a movement toward understanding potential
differences in oppression that other groups might have experienced.
4. Attitudes and beliefs toward members of the dominant group (concern with the basis of
group depreciation). The individual experiences conflict between attitudes of complete
distrust for the dominant society and culture and attitudes of selective trust and distrust
according to a dominant individual's demonstrated behaviors and attitudes. Conflict is
most likely to occur here because the person begins to recognize that there are many
elements in U.S. culture that are highly functional and desirable, yet feels confusion
about how to incorporate these elements into his or her own culture. Would acceptance
of certain White cultural values make the person a sellout to his or her own race? There
is a lowering of intense feelings of anger and distrust toward the dominant group and a
continued attempt to discern elements that are acceptable.
Integrative Awareness Status
Persons with this status have developed an inner sense of security and can now own and
appreciate unique aspects of their culture as well as those of U.S. culture. The person's own
culture is not necessarily in conflict with White dominant cultural ways. Conflicts and
discomforts experienced in the previous status become resolved, allowing greater individual
control and flexibility. There is now the belief that there are acceptable and unacceptable
aspects in all cultures and that it is very important for the person to be able to examine and
either accept or reject those aspects of a culture that he or she does not see as desirable. With
the integrative awareness status, the person has a strong commitment and desire to eliminate
all forms of oppression.
1. Attitudes and beliefs toward the self (self‐appreciating attitudes and beliefs). The
individual develops a positive self‐image and experiences a strong sense of self‐
worth and confidence. Not only is there an integrated self‐concept that involves racial
pride in identity and culture, but the person develops a high sense of autonomy. Indeed,
he or she becomes bicultural or multicultural without a sense of having “sold out his or
her integrity.” In other words, the person begins to perceive his or her self as an
autonomous individual who is unique (individual level of identity), a member of his or
her own racial‐cultural group (group level of identity), a member of a larger society,
and a member of the human race (universal level of identity).
2. Attitudes and beliefs toward members of same group (group‐appreciating attitudes and
beliefs). The individual experiences a strong sense of pride in the group without having
to accept group values unequivocally. There is no longer conflict over disagreeing with
group goals and values. Strong feelings of empathy with the group experience are
coupled with awareness that each member of the group is also an individual. In addition,
tolerant and empathic attitudes are likely to be expressed toward members of the
individual's own group who may be functioning in a less adaptive manner to racism and
oppression.
3. Attitudes and beliefs toward members of a different marginalized group (group‐
appreciating attitudes). There is now literally a reaching out toward different oppressed
groups in order to understand their cultural values and ways of life. There is a strong
belief that the more the various ethnic groups can understand one another's cultural
values and beliefs, the greater the likelihood of respect between them. Support for all
oppressed people, regardless of similarity to the individual's minority group, tends to be
emphasized.
4. Attitudes and beliefs toward members of the dominant group (attitudes and beliefs of
selective appreciation). The individual experiences selective trust and liking for and
from members of the dominant group who seek to eliminate oppressive activities of the
group. The individual also experiences openness to the constructive elements of the
dominant culture. The emphasis here tends to be on the fact that White racism is a
sickness in society and that White people are also victims who are in need of help.
Video 11.2: Developmental Impact of Race/Ethnicity
The development of a person-of-color's identity can be positively or negatively affected based
on their personal experiences around differentness as well as the support system that is in
place to provide comfort through this transition.
Video 11.3: Identity Development
During the different stages of identity development clients of color may experience diverse
emotional responses. Clinicians can utilize this opportunity to engage clients to process their
emotional responses to the stage in which they find themselves.
COUNSELING IMPLICATIONS OF THE R/CID MODEL
Let us first point out some broad general clinical implications of the R/CID model before
discussing specific meanings within each of the phases. First, an understanding of REC
identity formation should sensitize therapists and counselors to the role that oppression plays
in an individual's understanding of the world and lived experiences. In many respects, it
should make us aware that our role as helping professionals should extend beyond the office
and include dealing with the many manifestations of racism. Although individual therapy is
needed, combating the forces of racism means a proactive approach for both the therapist and
the client. For the helping professional, social justice advocacy and systems intervention are
often the answers. For REC diverse clients, it means the need to understand, control, and
direct those forces in society that negate the process of positive identity. Thus, a wider
sociocultural approach to therapy is mandatory.
Second, the model will aid counselors in recognizing differences between members of the
same REC group with respect to their identity. In many cases, an accurate delineation of the
dynamics and characteristics of the phases may result in more culturally responsive case
conceptualization and treatment with REC diverse clients. Counselors who are familiar with
the various identity attitude expressions are better able to identify appropriate intervention
strategies for REC diverse clients. For example, a client experiencing feelings of isolation and
alienation in the conformity phase may require a different approach from the same client in
the introspection phase.
Third, the model allows helping professionals to realize the potentially changing nature of
identity among clients. If the goal of MCT is to move a client toward integrative awareness,
then the therapist must be able to anticipate the potential feelings, beliefs, attitudes, and
behaviors that are likely to arise. Acting as a guide and providing a comprehensible end point
will allow the client to understand more quickly and work through issues related to his or her
own identity. We now turn our attention to the R/CID model and its implications for the
counseling process.
Conformity Status
For the vast majority of those in the conformity phase, several therapeutic implications can be
derived. First, persons of color are most likely to prefer a White counselor or therapist over
those from other groups. This flows logically from the belief that Whites are more competent
and capable than are members of their own race. Such a racial preference can be manifested
in the client's reaction to a counselor of color via negativism, resistance, or open hostility. In
some instances, the client may even request a change in counselor (preferably to someone
White). Likewise, the conformity individual who is seen by a White therapist may be quite
pleased about it. In many cases, the client, in identifying with White culture, may be overly
dependent on the White therapist. Attempts to please, appease, and seek approval from the
helping professional may be quite prevalent.
Second, most conformity individuals will find that attempts to explore issues of race, racism,
or cultural identity or to focus upon feelings are very threatening. Clients with this status
generally prefer a task‐oriented, problem‐solving approach because an exploration of
identity may eventually touch upon feelings of low self‐esteem, dissatisfaction with
personal appearance, vague anxieties, and racial self‐hatred, and may challenge the client's
self‐deception that he or she is not like the other members of his or her race.
Whether you are White or a counselor of color working with a conformity individual, the
general goal may be the same. There is an obligation to help the client sort out conflicts
related to REC identity through some process of reeducation. Somewhere in the course of
counseling or therapy, issues of cultural racism, majority–minority group relations, racial
self‐hatred, and racial cultural identity need to be dealt with in an integrated fashion. We are
not suggesting a lecture or a solely cognitive approach, to which clients with this status may
be quite intellectually receptive, but exercising good clinical skills that take into account the
client's socioemotional state and readiness to deal with feelings. Only in this manner will the
client be able to distinguish the difference between positive attempts to adopt certain values
of the dominant society and a negative rejection of his or her own cultural value (an ability
characteristic of integrative awareness).
Although the goals for the White counselor and for the counselor of color are the same, the
way a therapist works toward them may be different. For example, a counselor of color will
likely have to deal with hostility from the racially and culturally similar client. As we saw in
Chapter 3, a therapist of color working with a client of his or her own race or with any person
of color may symbolize all that the client is trying to reject. Because therapy stresses the
building of a coalition, establishment of rapport, and to some degree a mutual identification,
the process may be especially threatening. The opposite may be true of work with a White
counselor. The client of color may be overeager to identify with the White professional in
order to seek approval.
Rather than being detrimental to MCT, these two processes can be used quite effectively and
productively. If the therapist of color can aid the client in working through his or her feelings
of antagonism and if the majority therapist can aid the client in working through his or her
need to overidentify, then the client will be moved closer to awareness and away from self‐
deception. In the former case, the therapist can take a nonjudgmental stance toward the client
and provide a positive person of color role model. In the latter, the White therapist needs to
model positive attitudes toward cultural diversity. Both need to guard against unknowingly
reinforcing the client's self‐denial and rejection.
Dissonance Status
As individuals become more aware of inconsistencies between dominant‐held views and
those of their own group, a sense of dissonance develops. Preoccupation and questions
concerning self, identity, and self‐esteem are most likely to be brought in for therapy. More
culturally aware than their conformity counterparts, dissonance clients may prefer a counselor
or therapist who possesses good knowledge of their cultural group, although there may still
be a preference for a White helper. However, the fact that minority helping professionals are
generally more knowledgeable of the client's cultural group may serve to heighten the
conflicting beliefs and feelings. Since the client is so receptive toward self‐exploration, the
therapist can capitalize on this orientation in helping him or her come to grips with his or her
identity conflicts.
Resistance and Immersion Status
Clients with high levels of resistance and immersion are likely to view their psychological
problems as products of oppression and racism. They may believe that only issues of racism
are legitimate areas to explore in therapy. Furthermore, they may see openness or self‐
disclosure to therapists not of their own group as dangerous because White counselors or
therapists are “enemies” and members of the oppressing group.
Clients in resistance and immersion believe that society is to blame for their present dilemma
and actively challenge the establishment. They are openly suspicious of institutions such as
mental health services because they view them as agents of the establishment. Very few of
the more ethnically conscious and militant minorities will use mental health services because
of their identification with the status quo. When they do, they are usually suspicious and
hostile toward the helping professional. A therapist working with a client with this status
needs to realize several important things.
First, he or she will be viewed by the client as a symbol of the oppressive society. If the
therapist becomes defensive and personalizes the attacks, he or she will lose effectiveness in
working with the client. It is important not to be intimidated or afraid of the anger that is
likely to be expressed; often, it is not personal and is quite legitimate. White guilt and
defensiveness can serve only to hinder effective MCT. It is not unusual for clients with this
status to make sweeping negative generalizations about White Americans. The White
therapist who takes a nondefensive posture will be better able to help the client explore the
basis of his or her racial tirades.
In general, clients with this status prefer a therapist of their own race. However, the fact that a
therapist shares the same race or culture as the client will not insulate him or her from the
attacks. Again, as outlined in Chapter 3, therapists of color working with a same‐race client
in resistance can encounter unique challenges. For example, an African American client may
perceive a Black counselor as a sellout to his or her own race, or as an Uncle Tom. Indeed,
the anger and hostility directed at the therapist of color may be even more intense than that
which would directed at a White one.
Second, clients in this status will constantly test the therapist. In earlier chapters, we
described how minority clients will pose challenges to therapists in order to test their
trustworthiness (sincerity, openness, and nondefensiveness) and expertise (competencies).
Because of the active nature of client challenges, therapy sessions may become quite
dynamic. Many therapists find that working with people with high levels of resistance is more
challenging, because counselor self‐disclosure is often necessary in order to establish
credibility.
Third, individuals at this phase are especially receptive to approaches that are more action‐
oriented and aimed at external change (challenging racism). Also, group approaches with
persons experiencing similar REC issues are well received. It is important that the therapist is
willing to help the culturally different client explore new ways of relating to both minority
and White persons.
Introspection Status
Clients in the introspection phase may continue to prefer a counselor of their own race, but
they are also receptive to help from therapists of other cultures, as long as the therapist
understands the client's worldview. Clients with this status may, on the surface, appear
similar to conformity persons. Introspection clients are in conflict between their need to
identify with their own group and their need to exercise greater personal freedom. Exercising
personal autonomy may occasionally mean going against the wishes or desires of their own
group. This is often perceived by people of color and their REC group as a rejection of their
own cultural heritage. This is not unlike conformity persons, who also reject their REC
heritage. The dynamics within the two groups, however, are quite dissimilar. It is very
important for therapists to distinguish the differences. The conformity person moves away
from his or her own group because of perceived negative qualities associated with it. The
introspection person wants to move away on certain issues but perceives the group positively.
Again, self‐exploration approaches aimed at helping the client integrate and incorporate a
new sense of identity are important. Believing in the functional values of White American
society does not necessarily mean that a person is selling out or going against his or her own
group.
Integrative Awareness Status
Clients in integrative awareness have acquired an inner sense of security around their self‐
identity. They have pride in their REC heritage but can exercise a desired level of personal
freedom and autonomy. Other cultures and races are appreciated, and there is a development
toward becoming more multicultural in perspective. Although discrimination and oppression
remain a powerful part of their existence, persons in integrative awareness possess greater
psychological resources to deal with these problems. Being action‐ or systems‐oriented,
clients respond positively to the designing and implementation of strategies aimed at
community and societal change. Preferences for therapists are based not on race, but on the
ability to share, understand, and accept the client's worldviews. In other words, attitudinal
similarity between therapist and client is a more important dimension than membership‐
group similarity.
Video 11.4: Racial Consciousness
A client's racial consciousness can provide a safe space that allows for non-defensive
dialogue with a counselor around the issues of race/ethnicity and can also increase a client's
self-efficacy.
VALUE OF A GENERAL REC IDENTITY FRAMEWORK
The R/CID framework is a useful heuristic tool for counselors who work with culturally
diverse populations. The model reminds therapists of several important clinical imperatives:
(a) Within‐group differences are very important to acknowledge in clients of color because
not all members of a REC group are the same. Depending on their levels of racial
consciousness, the attitudes, beliefs, and orientations of different clients of color may be quite
different. (b) A culturally responsive counselor needs to be cognizant of and to understand
how sociopolitical factors influence and shape identity. REC identity attitudes and expression
are not solely due to cultural differences but a result of how the differences are perceived in
our society. (c) The model alerts clinicians working with clients of color to certain likely
challenges associated with each status or level of REC consciousness. Not only may it serve
as a useful diagnostic tool, but it provides suggestions of what may be the most appropriate
treatment intervention. (d) Other socially marginalized or devalued groups undergo similar
identity processes. For example, formulations for women, LGBTQ groups, those with
disabilities, and so forth can now be found in the psychological literature. Mental health
professionals hoping to work with these specific populations would be well served to become
familiar with these models as well.
One important aspect relatively untouched in the clinical and research literature is the racial
identity development of helping professionals. We have spent considerable time describing
the identity development of people of color from the perspective of clients. In Chapter 3, we
also indicated that the level of racial consciousness of the minority therapist may impact that
of the client of color. In the next chapter, we address the issue of White identity development
and discuss how it may impact clients of color. It is equally important for counselors of color
to consider their own racial consciousness and how it may interact with a client from their
own group.
REFLECTION AND DISCUSSION QUESTIONS
1. What types of conflict and/or challenge might confront a therapist of color with the
conformity status when working with a client of color with the resistance and immersion
status? How might they perceive one another? How might they respond to one another?
What therapeutic issues are likely to arise? What needs to be done in order for the
therapist to be helpful?
2. Discuss other REC identity attitude combinations and their implications for therapists
and clients of color working with one another.
3. Does a counselor of color have to be in integrative awareness to be helpful to clients of
color?
Empirical research on REC identity and its relation to counseling and therapy processes has
slowed considerably since the 1990s (Ponterotto & Mallinckrodt, 2007; Yoon, 2011). Instead,
newer research has expanded the understanding of how people enact and change their REC
attitudes (Cross et al., 2017; Neville & Cross, 2017) and the ways that multiple and
intersecting identities play out in people's lives (e.g., Lewis et al., 2017). The enduring nature
of key REC models and the emerging scholarship in this area reflect the widespread
acceptance of the importance of identity development and how much it has become a part of
the social‐psychological and mental health landscape (Wijeyesinghe & Jackson, 2012).
However, the state of the field is not without significant limitations; there is confusion about
the theory and measurement of REC identity, especially the difference between racial (the
focus in this chapter) and ethnic identities. Indeed, a special issue of the Journal of
Counseling Psychology in 2007 (Cokley, 2007; Helms, 2007) discussed in detail the
conceptual and methodological challenges confronting the field. It is clear that we have
encountered an impasse that can be broken only through the development of more
sophisticated and better measures of racial and ethnic identity and further qualitative research
about the meaning of and changes in REC identity among diverse groups of people of color.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Be aware that the R/CID model should not be viewed as a global personality theory with
specific identifiable phases that serve as fixed categories. The process of cultural identity
development is dynamic, not static.
2. Do not fall victim to stereotyping in using these models. Most clients of color may
evidence a dominant characteristic, but there are mixtures from other statuses as well.
3. Know that identity development models are conceptual aids and that human
development is much more complex.
4. Know that a number of issues and questions still exist. Is cultural identity development
primarily a linear process? Do individuals always start at the beginning of these stages?
Is it possible to skip statuses? Can people regress?
5. Be careful of the implied value judgments given in almost all development models. They
assume that some cultural resolutions are healthier than others. For example, the R/CID
model obviously holds the integrative awareness status as a higher form of healthy
functioning.
6. Be aware that REC identity attitude models seriously lack an adequate integration of
gender, class, sexual orientation, and other sociodemographic group identities.
7. Begin to look more closely at the possible therapist and client stage combinations. As
mentioned earlier, therapeutic processes and outcomes are often the function of the
identity stage of both therapist and client. White identity development of the therapist
can either enhance or retard effective therapy.
Video Lecture: Racial/Cultural Identity Development: Implications for Counseling/Therapy
SUMMARY
In the past several decades, work on REC identity attitudes among people of color has led to
major breakthroughs in the field of MCT. Racial identity attitude models have proven helpful
in many respects. First, they reveal major within‐group differences that occur depending on
one's level of identity. Second, research suggests that reactions to counseling and the
counseling process are influenced by REC identity and are not simply linked to minority
group membership. Third, they clarify the impact of sociopolitical forces in shaping racial
identity. Fourth, identity models that discuss the oppressor–oppressed relationship seem
equally applicable to other marginalized groups, such as women, LGBTQ individuals, and
individuals with disabilities.
The R/CID model proposed is a conceptual framework to aid therapists in understanding their
culturally diverse clients' attitudes and behaviors. Five general types of attitude expression
that oppressed people experience as they struggle to understand themselves in terms of their
own culture, the dominant culture, and the oppressive relationship between the two are
described: conformity, dissonance, resistance and immersion, introspection, and integrative
awareness. At each level of identity, four corresponding beliefs and attitudes, the
understanding of which may help therapists better understand their clients, are discussed.
These attitudes/beliefs are an integral part of identity, and are manifest in how a person views
(a) the self, (b) others of the same minority, (c) others of another minority, and (d) majority
individuals.
Each specific level of racial identity offers unique challenges for the counselor. Clients in the
conformity status are dealing with internalized racism and may not respond well to therapists
of color; dissonance clients are dealing with racial inconsistencies in their previous belief
systems; resistance and immersion clients are likely to reveal strong anger about racism;
introspection clients struggle with group loyalties and self‐autonomy; and integrative
awareness clients are self‐secure and motivated toward multicultural integration. A
culturally competent counselor needs to be cognizant of and to understand how sociopolitical
factors influence and shape identity. Identity development is not solely due to cultural
differences but a result of how the differences are perceived in our society.
GLOSSARY TERMS
Conformity
Dissonance
Encounter
Identity synthesis
Immersion‐emersion
Integrative awareness
Internalization
Internalization‐commitment
Internalized racism
Introspection
Nigrescence
Preencounter
Race salience
Racial awakening
R/CID model
Resistance and immersion
Video 11.6: Counseling Session Analysis
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
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12
White Racial Identity Development: Counseling Implications
Chapter Objectives
1. 1. Acquire understanding of what it means to be White. Be able to discern
differences between how Whites and people of color see the meaning of
“Whiteness.”
2. 2. Analyze resistance by White Americans to identifying themselves as “White.”
3. 3. Learn the meaning of nested or embedded emotions experienced by Whites as
they come to accept their Whiteness.
4. 4. Define White privilege.
5. 5. Understand how Whiteness advantages Whites and disadvantages people of
color.
6. 6. Describe and discuss the various conceptualizations of White racial identity
development.
7. 7. Learn how the level of White racial consciousness may affect the counseling
process.
8. 8. Understand how White racial identity development may influence the definition of
normality–abnormality, assessment, diagnosis, and treatment of culturally diverse
clients.
9. 9. Learn what a White person needs to do in order to develop a nonracist and
antiracist White identity.
10. 10. Learn what White helping professionals need to do in order to prevent their
Whiteness from negatively impacting clients of color.
Thus far, we have examined many different facets of the impact of race and culture
within mental health theory and practice. As vital as it has been to understand the
significance of racism and racial‐cultural identity in the lives of people of color, it is
equally consequential to consider their operations among White individuals. What does
it mean to be White? What do White people learn about the meaning of Whiteness in
their own lives? As the following excerpts illustrate, White people's perspectives on such
questions vary widely.
As a person of color, I have often wondered how White people identify themselves as
racial/cultural beings. At times, I have noted that White trainees often seemed to believe
race was confined to persons of color and did not apply to them. To explore this
phenomenon more deeply, I asked people in downtown San Francisco “What does it
mean to be White?”
Q:
[D.W. Sue]: What does it mean to be White?
A:
[42‐year‐old White male businessperson]: Frankly, I don't know what
you're talking about!
Q:
Aren't you White?
A:
Yes, but I come from Italian heritage. I'm Italian, not White.
Q:
Well then, what does it mean to be Italian?
A:
Pasta, good food, love of wine (obviously agitated). This is getting ridiculous!
(Sue, 2003, pp. 115)
We never see signs with “Hispanic Lives Matter,” or “White Lives Matter,” or even
“All Lives Matter” protesting police violence. Are we only concerned about police
brutality toward African Americans? Shouldn't we be promoting a decrease in deadly
force toward all people, independent of race? Or, do “Black Lives Matter … more?”
Because that is the message I'm getting from political leaders, activists, professional
athletes and this newspaper.
(Stevenson, 2017, para. 4)
When he was 4, my son brought home a library book about the slaves who built the
White House. I didn't tell him that slaves once accounted for more wealth than all the
industry in this country combined, or that slaves were, as Ta‐Nehisi Coates writes,
“the down payment” on this country's independence, or that freed slaves became, after
the Civil War, “this country's second mortgage.” Nonetheless, my overview of slavery
and Jim Crow left my son worried about what it meant to be white, what legacy he had
inherited. “I don't want to be on this team,” he said, with his head in his hands. “You
might be stuck on this team,” I told him, “but you don't have to play by its rules.”
Even as I said this, I knew that he would be encouraged, at every juncture in his life, to
believe wholeheartedly in the power of his own hard work and deservedness, to ignore
inequity, to accept that his sense of security mattered more than other people's freedom
and to agree, against all evidence, that a system that afforded him better housing, better
education, better work, and better pay than other people was inherently fair.
(Biss, 2015, para. 13)
“We're coming to the realization that white self‐hatred is a sickness,” said Timothy
Murdock, a 46‐year‐old alt‐right podcaster from Dearborn, Mich. He said he
considers himself “pro‐white,” but feels the alt‐right movement could get better
traction by going to battle against “diversity.”
“There is great attention to the term ‘diversity’, that it means ‘too white’, coupled with
open borders,” said Murdock, whose podcasts frequently talk about “white genocide.”
(Kaleem, 2016, para. 27)
REFLECTION AND DISCUSSION QUESTIONS
1. With regard to the four passages above, what emerges from each about the meaning
and/or experience of Whiteness?
2. Can you discern any commonalities among any of the passages? In what ways do they
differ?
3. Which (if any) of these perspectives are more familiar to you, either because you or
someone you know has a similar view? Which (if any) do you find to be more
unfamiliar?
4. If they were asked what it means to be White, do you think people of color would also
find difficulty answering the question? Why or why not?
Research on Whiteness, White privilege, and White racial identity development points to one
of the greatest barriers to racial understanding for White Americans: the invisibility of their
Whiteness and/or its impact on their lives (Bell, 2003; Hegarty, 2017; Helms, 1990;
Spanierman, Poteat, Beer, & Armstrong, 2006; Tatum, 1992; Todd & Abrams, 2011). Just as
ethnocentric monoculturalism and implicit bias achieve their oppressive powers through
invisibility, so too does Whiteness (Boysen, 2010; Sue, 2004). During racial interactions or
conversations, many Whites appear oblivious to the meaning of their Whiteness, how it
intrudes and disadvantages people of color, and how it affects the way they perceive the
world (Bell, 2002; Sue, 2013).
It appears that the denial and mystification of Whiteness for White EuroAmericans are related
to two underlying factors. First, most people seldom think about the air that surrounds them
and about how it provides an essential life‐giving ingredient, oxygen. We take it for granted
because it appears plentiful; only when we are deprived of it does it suddenly become
frighteningly apparent. Whiteness is transparent precisely because of its everyday occurrence
—its institutionalized normative features in our culture—and because Whites are taught to
think of their lives as morally neutral, average, and ideal (Sue, 2004). To people of color,
however, Whiteness is not invisible because it may not fit their normative qualities (e.g.,
values, lifestyles, experiential reality). Persons of color find White culture quite visible
because even though it is nurturing to White EuroAmericans, it may invalidate the lifestyles
of multicultural populations.
Second, EuroAmericans often deny that they are White, seem angered by being labeled as
such, and become very defensive when so labeled (e.g., saying, “I'm not White; I'm Irish,”
“You're stereotyping, because we're all different,” or “There isn't anything like a White
race”). In many respects, these statements have validity, in that race is a social rather than a
biological construct. Nonetheless, many White Americans would be hard pressed to describe
their Irish, Italian, German, or Norwegian heritage in any but the most superficial manner.
One of the reasons is related to the processes of assimilation and acculturation. Although
there are many ethnic groups, being White allows for assimilation. While persons of color are
told to assimilate and acculturate; the assumption is that there exists a receptive society.
People of color are told in no uncertain terms that they are allowed only limited access to the
fruits of our society.
Third, the question of how Whiteness defines a race is largely irrelevant. What is more
relevant is that Whiteness is associated with unearned privilege—advantages that are
systematically conferred on White Americans but not on persons of color. It is our contention
that much of the denial associated with being White is related to the denial of White privilege.
As will be discussed in this chapter, White privilege connotes a number of overarching
characteristics, such as: (a) having the power to define reality; (b) possessing unconscious
stereotypes that people of color are less competent and capable; (c) deceiving the self that one
is not prejudiced; and (d) being oblivious to how Whiteness disadvantages people of color and
advantages White people. Strangely enough, Whiteness often becomes especially visible
when it is denied and evokes puzzlement or negative reactions among White individuals, or
when it is equated with normalcy. Few people of color react negatively when asked what it
means to be Black, Asian American, Latinx, or whatever applicable race. Most could readily
inform the questioner about what it means to be a person of color.
UNDERSTANDING THE DYNAMICS OF WHITENESS
Our analysis of the responses from both Whites and people of color leads us to the inevitable
conclusion that part of the problem of race relations (and by inference multicultural
counseling and therapy [MCT]) lies in the different worldviews of both groups. It goes
without saying that the racial reality of Whites is radically different from that of people of
color (Sue, 2010). Which group, however, has the more accurate assessment related to this
topic? The answer seems to be contained in the following series of questions: If you want to
understand oppression, should you ask the oppressor or the oppressed? If you want to learn
about sexism, do you ask men or women? If you want to understand homophobia, do you ask
heterosexuals or homosexuals? If you want to learn about racism, do you ask Whites or
persons of color? It appears that the most accurate assessment of bias comes not from those
who enjoy the privilege of power, but from those who are most disempowered (Hanna,
Talley, & Guindon, 2000; Sue, 2015). Taking this position, the following conclusions are
made about the dynamics of Whiteness.
First, it is clear that most Whites perceive themselves as unbiased individuals who do not
harbor racist thoughts and feelings; they see themselves as working toward social justice and
possessing a conscious desire to better the life circumstances of those less fortunate than
themselves. Although these are admirable qualities, this self‐image serves as a major barrier
to recognizing and taking responsibility for admitting and dealing with one's own prejudices
and biases. To admit to being racist, sexist, or homophobic requires people to recognize that
the self‐images they hold so dear are based on false notions of the self.
Second, being a White person in this society means chronic exposure to ethnocentric
monoculturalism as manifested in White supremacy (Hays, 2014). It is difficult, if not
impossible, for anyone to avoid inheriting the racial biases, prejudices, misinformation,
deficit portrayals, and stereotypes of their forebears (Cokley, 2006). To believe that one is
somehow immune from inheriting such aspects of White supremacy is to be naive or to
engage in self‐deception. Such a statement is not intended to assail the integrity of Whites
but to suggest that they also have been victimized. It is clear to us that no one was born
wanting to be racist, sexist, or homophobic. Misinformation is not acquired by free choice but
is imposed upon White people through a painful process of cultural conditioning (Gallardo &
Ivey, 2014). In general, lacking awareness of their biases and preconceived notions,
counselors may function in a therapeutically ineffective manner.
Third, if White helping professionals are ever to become effective multicultural counselors or
therapists, they must free themselves from the cultural conditioning of their past and move
toward the development of a nonracist White identity. Unfortunately, many White
EuroAmericans seldom consider what it means to be White in our society. Such a question is
vexing to them because they seldom think of race as belonging to them—nor of the privileges
that come their way by virtue of their white skin (Toporek & Worthington, 2014). Katz
(1985) points out a major barrier blocking the process of White EuroAmericans investigating
their own cultural identity and worldview.
Because White culture is the dominant cultural norm in the United States, it acts as an
invisible veil that limits many people from seeing it as a cultural system … Often, it is
easier for many Whites to identify and acknowledge the different cultures of minorities
than accept their own racial identity … The difficulty of accepting such a view is that
White culture is omnipresent. It is so interwoven in the fabric of everyday living that
Whites cannot step outside and see their beliefs, values, and behaviors as creating a
distinct cultural group.
(pp. 616–617)
As we witnessed in Chapter 6, the invisible veil allows for racial, gender, and sexual
orientation microaggressions to be delivered outside the level of awareness of their
perpetrators. Ridley (1995) asserts that this invisible veil can be unintentionally manifested in
therapy, with harmful consequences to clients of color.
Unintentional behavior is perhaps the most insidious form of racism. Unintentional
racists are unaware of the harmful consequences of their behavior. They may be well‐
intentioned, and on the surface, their behavior may appear to be responsible. Because
individuals, groups, or institutions that engage in unintentional racism do not wish to do
harm, it is difficult to get them to see themselves as racists. They are more likely to deny
their racism.
(p. 38)
The conclusion drawn from this understanding is that White counselors and therapists may be
unintentional racists: (a) they are unaware of their biases, prejudices, and discriminatory
behaviors; (b) they often perceive themselves as moral, good, and decent human beings and
find it difficult to see themselves as racist; (c) they do not have a sense of what their
Whiteness means to them; and (d) their therapeutic approaches to multicultural populations
are likely to be more harmful (unintentionally) than helpful.
I used to consider myself “color‐blind.” I thought I was so admirable in that I did not
see my friends as Chinese, Japanese, Black, or White. However, I now realize that by not
seeing their individual races as a part of who they are, I was seeing them as White,
through my own perspectives and value systems, and was doing them a disservice. Race
is an important part of how people identify and by not recognizing their different races I
am not seeing all aspects of the individual. This is something I definitely need to keep in
mind when conducting therapy … It would be detrimental to my clients if I was “color‐
blind.”
(Counseling student quoted in Fu, 2015, p. 281)
These conclusions are often difficult for White helping professionals to accept because of the
defensiveness and feelings of blame they are likely to engender. Nonetheless, we ask White
therapists and students not be turned off by the message and lessons of this chapter. We ask
you to reread Chapter 1, where we discussed the emotive reactions likely to impede learning.
And, we ask you to continue your multicultural journey in this chapter as we explore the
question, “What does it mean to be White?”
Video 12.1: White Self-Awareness and Understanding
Nested and embedded emotions can make it difficult for White clinicians to understand or
empathize with clients of color. Taking regular internal checks can help clinicians develop
self-awareness as a way of increasing client rapport.
MODELS OF WHITE RACIAL IDENTITY DEVELOPMENT
A number of multicultural experts in the field have emphasized the need for White therapists
to deal with their concepts of Whiteness and to examine their own racism (Gallardo & Ivey,
2014; Ponterotto, Utsey, & Pedersen, 2006; Todd & Abrams, 2011). These specialists point
out that while racial/cultural identity for minority groups proves beneficial in our work as
therapists, more attention should be devoted toward the White therapist's racial identity. Since
the majority of therapists and trainees are White middle‐class individuals, it would appear
that White identity development and its implication for MCT are important aspects to
consider, both in the actual practice of clinical work and in professional training.
For example, research has found that the level of White racial identity awareness is predictive
of racism and internal interpersonal characteristics (Miville, Darlington, Whitlock, &
Mulligan, 2005; Perry, Dovidio, Murphy, & van Ryn, 2015; Pope‐Davis & Ottavi, 1994;
Spanierman, Todd, & Anderson, 2009; Vinson & Neimeyer, 2000, 2003; Wang et al., 2003):
(a) the less aware subjects were of their White identity, the more likely they were to exhibit
increased levels of racism; (b) the higher the level of White identity development, the greater
the reported multicultural counseling competence, positive opinions toward minority groups,
and good therapeutic alliances; (c) higher levels of mature interpersonal relationships and a
better sense of personal well‐being were associated with higher levels of White identity
consciousness; and (d) as a group, women were more likely than men to exhibit higher levels
of White consciousness and were less likely to be racially biased. It was suggested that this
last finding was correlated with women's greater experiences with discrimination and
prejudice. Evidence also exists that MCT competence is correlated with White racial identity
attitudes (Neville, Awad, Brooks, Flores, & Bluemel, 2013). Other research suggests that a
relationship exists between a White EuroAmerican therapist's racial identity and his or her
readiness for training in multicultural awareness, knowledge, and skills (Falender,
Shafranske, & Falicov, 2014; Utsey, Gernat, & Hammar, 2005). Since developing
multicultural sensitivity is a long‐term developmental task, the work of many researchers
has gradually converged toward a conceptualization of the stages/levels/statuses of
consciousness of racial/ethnic identity development for White EuroAmericans. A number of
these models describe the salience of identity for establishing relationships between the White
therapist and the culturally different client, and some have now linked stages of identity with
stages for appropriate training.
The Hardiman White Racial Identity Development Model
One of the earliest integrative attempts at formulating a White racial identity development
model was that of Rita Hardiman (1982). Intrigued with why certain White Americans exhibit
a much more nonracist identity than do other White Americans, Hardiman studied the
autobiographies of individuals who had attained a high level of racial consciousness. This led
her to identify five White developmental stages: (a) naiveté—lack of social consciousness,
(b) acceptance, (c) resistance, (d) redefinition, and (e) internalization.
1. The naiveté stage (lack of social consciousness) is characteristic of early childhood,
when we are born into the world innocent, open, and unaware of racism and the
importance of race. Curiosity and spontaneity in relating to race and racial differences
tend to be the norm. A young White child who has almost no personal contact with
African Americans, for example, may see a Black man in a supermarket and loudly
comment on the darkness of his skin.
2. The acceptance stage is marked by a conscious belief in the democratic ideal—that
everyone has an equal opportunity to succeed in a free society and that those who fail
bear all the responsibility for their own failure. White EuroAmericans become the social
reference group, and the socialization process consistently instills messages of White
superiority and minority inferiority into the child. Victim blaming is strong, as the
existence of oppression, discrimination, and racism is denied. Hardiman believes that
although the naiveté stage is brief in duration, the acceptance stage can last a lifetime.
3. In the resistance stage, the individual begins to challenge assumptions of White
superiority and the denial of racism and discrimination. The White person's denial
system begins to crumble as the result of a monumental event or a series of events that
not only challenge but also shatter his or her denial system. A White person might, for
example, make friends with a coworker of color and then discover that the images he or
she has of “these people” are untrue. The racial realities of life in the United States can
no longer be denied. The person becomes conscious of being White, is aware that he or
she harbors racist attitudes, and begins to see the pervasiveness of oppression in our
society. Feelings of anger, pain, hurt, rage, and frustration are present.
4. In the redefinition stage, asking the painful question of who one is in relation to one's
racial heritage, honestly confronting one's biases and prejudices, and accepting
responsibility for one's Whiteness are the culminating characteristics. New ways of
defining one's social group and one's membership in that group become important.
5. The internalization stage is the result of forming a new social and personal identity.
With the greater comfort in understanding oneself and the development of a nonracist
White identity comes a commitment to social action. The individual accepts
responsibility for effecting personal and social change, without always relying on
persons of color to lead the way.
The Helms White Racial Identity Development Model
Working independently of Hardiman, Janet Helms (1984, 1990, 1994, 1995) created perhaps
the most elaborate and sophisticated White racial identity model in the field. Not only has her
model led to the development of an assessment instrument to measure White racial identity,
but it has been scrutinized empirically (Carter, 1990; Helms & Carter, 1990) and has
generated much research and debate in the psychological literature. Like Hardiman (1982),
Helms assumes that racism is an intimate and central part of being a White American. To her,
developing a healthy White identity requires movement through two phases: (a) abandonment
of racism and (b) defining a nonracist White identity (Helms, 2015).
Six specific racial identity statuses (originally called stages) are distributed equally in the two
phases: contact, disintegration, and reintegration; and pseudo‐independence,
immersion/emersion, and autonomy.
1. Contact status. People in this status are oblivious to and unaware of racism, believe that
everyone has an equal chance for success, lack an understanding of prejudice and
discrimination, have minimal experiences with persons of color, and may profess to be
color‐blind. They may make such statements as “People are people,” “I don't notice a
person's race at all,” and “You don't act Black.”
2. Disintegration status. Although in the previous status the individual does not recognize
the polarities of democratic principles of equality and the unequal treatment of minority
groups, such obliviousness may eventually break down. The White person becomes
conflicted over irresolvable racial moral dilemmas that are frequently perceived as polar
opposites: believing one is nonracist, yet not wanting one's son or daughter to marry a
minority group member; believing that all men are created equal, even though society
treats people of color as second‐class citizens; and not acknowledging that oppression
exists and then witnessing it (e.g., the killings of Michael Brown and Eric Garner in
2014).
3. Reintegration status. This status can best be characterized as a regression in which the
pendulum swings back to the most basic beliefs of White superiority and minority
inferiority. In the individual's attempts to resolve the dissonance created from the
previous process, there is a retreat to the dominant ideology associated with race and
their own socioracial group identity. This ego status results in idealizing the White
EuroAmerican group and the positives of White culture and society; there is a
consequent negation and intolerance of minority groups. In general, a firmer and more
conscious belief in White racial superiority is present. Racial/ethnic minorities are
blamed for their own problems.
4. Pseudo‐independence status. This status initiates the second phase of Helms's model,
which involves defining a nonracist White identity. As in the Hardiman model, a person
is likely to be propelled into this phase because of a painful or insightful encounter or
event that jars them from the reintegration status. The awareness of visible racial/ethnic
minorities, the unfairness of their treatment, and a discomfort with their racist White
identity may lead the individual to identify with the plight of persons of color. However,
the well‐intentioned White person with this status may suffer from several problematic
dynamics: (a) although intending to be socially conscious and helpful to minority
groups, they may unknowingly perpetuate racism by helping minorities adjust to the
prevailing White standards; and (b) they identify with minority individuals based on how
similar they are to them, and the primary mechanism they use to understand racial issues
is intellectual and conceptual.
5. Immersion/emersion status. If the person is reinforced to continue a personal exploration
of him‐ or herself as a racial being, questions become focused on what it means to be
White. There is an increasing willingness to confront one's own biases, to redefine
Whiteness, and to become more active in directly combating racism and oppression. This
status is different from the previous one in two major ways: it is marked by (a) a shift in
focus from trying to change people of color to changing the self and other Whites and
(b) an increasing experiential and affective understanding that was lacking in the
previous status. The ability to achieve this affective/experiential upheaval leads to a
euphoria, or even a feeling of rebirth, and is a necessary condition to developing a new,
nonracist White identity.
6. Autonomy status. Increasing awareness of one's own Whiteness, reduced feelings of
guilt, acceptance of one's role in perpetuating racism, and renewed determination to
abandon White entitlement lead to an autonomy status. The person is knowledgeable
about racial, ethnic, and cultural differences; values diversity; and is no longer fearful,
intimidated, or uncomfortable with the experiential reality of race. Development of a
nonracist White identity becomes increasingly strong. Indeed, the person feels
comfortable with his or her nonracist White identity, does not personalize attacks on
White supremacy, and can explore the issues of racism and personal responsibility
without defensiveness. A person with this status “walks the talk” and actively values and
seeks out interracial experiences.
Helms's model is by far the most widely cited, researched, and applied of all the White racial
identity formulations. It is not, however, without its detractors. In an article critical of the
Helms model (and of most “stage” models of White racial identity development), Rowe,
Bennett, and Atkinson (1994) raised objections over the model's basis in racial/ethnic
minority identity development models that may not apply to White identity and the
unsupported conceptual accuracy of putting forth the model as linear developmental via
stages, among other things. Finally, Rowe (2006) attacked the Helms model because it is
based upon the White Racial Identity Attitude Scale (Helms & Carter, 1990), which he labels
as “pseudoscience” because he asserts that the psychometric properties are not supported by
the empirical literature. In subsequent writings, Helms (1994) disclaimed the Rowe (Rowe &
Atkinson, 1995; Rowe et al., 1994) characterization of her model.
Select this link to open an interactive version of Chapter 12 text.
Video 12.2: White Identity Development
White identity development can be incredibly uncomfortable to process. Clinicians need to do
their own internal inventory and work through their own developmental process in order to be
the most effective in working with clients of color.
THE PROCESS OF WHITE RACIAL IDENTITY DEVELOPMENT: A
DESCRIPTIVE MODEL
Although there are differences in the models, it appears important for Whites to view their
developmental history in order to gain a sense of their past, present, and future as they
struggle with racial identity development. In our work with White trainees and clinicians, we
have observed some very important changes through which they seem to move as they work
toward multicultural competence (Sue, 2011). We have been impressed with how Whites
seem to go through parallel racial/cultural identity transformations. This is especially true if
we accept the fact that Whites are as much victims of societal forces (i.e., they are socialized
into racist attitudes and beliefs) as are their counterparts (Sue, 2003). No child is born
wanting to be a racist! Yet, White people do benefit from the dominant–subordinate
relationship in our society. It is this factor that Whites need to confront in an open and honest
manner.
Using the formulation of our past work (Sue & Sue, 1990), we propose a seven‐step process
that integrates many characteristics from the other formulations. Furthermore, we make some
basic assumptions with respect to those models:
1. Racism is an integral part of U.S. life, and it permeates all aspects of our culture and
institutions (ethnocentric monoculturalism).
2. Whites are socialized into U.S. society, and therefore inherit all its biases, stereotypes,
and racist attitudes, beliefs, and behaviors.
3. How Whites perceive themselves as racial beings follows an identifiable sequence that
can occur in a linear or nonlinear fashion.
4. The status of White racial identity development in any multicultural encounter affects the
process and outcome of interracial relationships.
5. The most desirable outcome is one in which the White person not only accepts his or her
Whiteness but also defines it in a nonracist and antiracist manner.
Seven‐Step Process
The seven phases of white racial identity development and their implications for White
Americans are described in this section. We encourage Whites to use this information to
explore themselves as racial/cultural beings and to think about their implications for work
with culturally diverse clients.
1. Naiveté phase. This phase is relatively neutral with respect to racial/cultural differences.
Its length is brief and is marked by a naive curiosity about race. As mentioned
previously, racial awareness and burgeoning social meanings are absent or minimal, and
the young child is generally innocent, open, and spontaneous regarding racial
differences. Between the ages of three and five, however, the young White child begins
to associate positive ethnocentric meanings to his or her own group and negative ones to
others. The child is bombarded by misinformation through the educational channels,
mass media, and significant others in his or her life, and a sense of the superiority of
Whiteness and the inferiority of all other groups and their heritage is instilled. The
following passage describes one of the insidious processes of socialization that leads to
propelling the child into the conformity stage:
It was a late summer afternoon. A group of White neighborhood mothers,
obviously friends, had brought their four‐ and five‐year‐olds to the
local McDonald's for a snack and to play on the swings and slides
provided by the restaurant. They were all seated at a table watching their
sons and daughters run about the play area. In one corner of the yard sat
a small Black child pushing a red truck along the grass. One of the White
girls from the group approached the Black boy and they started a
conversation. During that instant, the mother of the girl exchanged quick
glances with the other mothers, who nodded knowingly. She quickly rose
from the table, walked over to the two, spoke to her daughter, and gently
pulled her away to join her previous playmates. Within minutes, however,
the girl again approached the Black boy and both began to play with the
truck. At that point, all the mothers rose from the table and loudly
exclaimed to their children, “It's time to go now!”
(Taken from Sue, 2003, pp. 89–90)
2. Conformity phase. The White person's attitudes and beliefs in this phase are very
ethnocentric. There is minimal awareness of the self as a racial being and a strong belief
in the universality of values and norms governing behavior. The White person possesses
limited accurate knowledge of other ethnic groups, but he or she is likely to rely on
social stereotypes as the main source of information. Consciously or unconsciously, the
White person believes that White culture is the most highly developed and that all others
are primitive or inferior. The conformity phase is marked by contradictory and often
compartmentalized attitudes, beliefs, and behaviors. A person may believe
simultaneously that he or she is not racist but that minority inferiority justifies
discriminatory and inferior treatment, and that minority persons are different and deviant
but that “people are people” and differences are unimportant. As with their marginalized
counterparts at this phase, the primary mechanism operating here is one of denial and
compartmentalization. For example, many Whites deny that they belong to a race that
allows them to avoid personal responsibility for perpetuating a racist system. Like a fish
in water, Whites either have difficulty seeing or are unable to see the invisible veil of
cultural assumptions, biases, and prejudices that guide their perceptions and actions.
They tend to believe that White EuroAmerican culture is superior and that other cultures
are primitive, inferior, less developed, or lower on the scale of evolution.
It is important to note that many Whites in this phase of development are
unaware of these beliefs and operate as if they are universally shared by
others. They believe that differences are unimportant and that “people are
people,” “we are all the same under the skin,” “we should treat everyone the
same,” “problems wouldn't exist if minorities would only assimilate,” and
discrimination and prejudice are something that others do. The helping
professional with this perspective professes color‐blindness, views
counseling/therapy theories as universally applicable, and does not question
the relevance of such theories to culturally different groups. The primary
mechanism used in encapsulation is denial—denial that people are different,
denial that discrimination exists, and denial of one's own prejudices. Instead,
the locus of the problem is seen to reside in marginalized groups. Socially
devalued groups would not encounter problems if they would only assimilate
and acculturate (melting pot), value education, or work harder.
3. Dissonance phase. Movement into the dissonance phase occurs when the White person
is forced to deal with the inconsistencies that have been compartmentalized or
encounters information/experiences at odds with denial. In most cases, individuals are
forced to acknowledge Whiteness at some level, to examine their own cultural values,
and to see the conflict between upholding humanistic nonracist values and their
contradictory behavior. For example, a person who consciously believes that all people
are created equal and that he or she treats everyone the same might suddenly experience
reservations about having African Americans move next door or having his or her child
involved in an interracial relationship. These more personal experiences bring the
individual face to face with his or her own prejudices and biases. In this situation,
thoughts that “I am not prejudiced,” “I treat everyone the same regardless of race, creed,
or color,” and “I do not discriminate” collide with the denial system. Additionally, some
major event (e.g., the assassination of Martin Luther King Jr.) may force the person to
realize that racism is alive and well in the United States.
The increasing realization that one is biased and that EuroAmerican society
does play a part in oppressing minority groups is an unpleasant one.
Dissonance may result in feelings of guilt, shame, anger, and depression.
Rationalizations may be used to exonerate one's own inactivity in combating
perceived injustice or personal feelings of prejudice; for example, “I'm only
one person—what can I do?” or “Everyone is prejudiced, even minorities.” As
these conflicts ensue, the White person may retreat into the protective confines
of White culture (encapsulation of the conformity phase) or move
progressively toward insight and revelation (resistance and immersion phase).
Whether a person regresses is related to the strengths of the positive forces
pushing the individual forward (support for challenging racism) and the
negative forces pushing them backward (fear of some loss) (Sue, 2011; Todd
& Abrams, 2011). For example, challenging the prevailing beliefs of the times
may mean risking ostracism from White relatives, friends, neighbors, and
colleagues. Regardless of the choice, there are many uncomfortable feelings of
guilt, shame, anger, and depression related to the realization of inconsistencies
in one's belief systems. Guilt and shame are most likely related to the
recognition of the White person's role in perpetuating racism in the past. Guilt
may also result from the person's being afraid to speak out on certain issues or
to take responsibility for his or her part in a current situation. For example, the
person might witness an act of racism, hear a racist comment, or be given
preferential treatment over a minority person but decide not to say anything for
fear of violating racist White norms. Many White people rationalize their
behaviors by believing that they are powerless to make changes. Additionally,
there is a tendency to retreat into White culture. If others (which may include
some family and friends) are more accepting, forward movement is more
likely.
4. Resistance and immersion phase. The White person who progresses to this phase will
begin to question and challenge his or her own racism. For the first time, the person
begins to realize what racism is all about, and his or her eyes are suddenly open. Racism
is seen everywhere (e.g., advertising, television, educational materials, interpersonal
interactions). This phase of development is marked by a major questioning of one's own
racism and that of others in society. In addition, increasing awareness of how racism
operates and its pervasiveness in U.S. culture and institutions is the major hallmark of
this level. It is as if the person awakens to the realities of oppression; sees how
educational materials, the mass media, advertising, and other elements portray and
perpetuate stereotypes; and recognizes how being White grants certain advantages
denied to various minority groups.
There is likely to be considerable anger at family and friends, institutions, and
larger societal values, which are seen as having sold the person a false bill of
goods (democratic ideals) that were never practiced. Guilt is also felt for
having been a part of the oppressive system. Strangely enough, the person is
likely to undergo a form of racial self‐hatred at this phase. Negative feelings
about being White are present, and the accompanying feelings of guilt, shame,
and anger toward the self and other Whites may develop. The White liberal
syndrome may develop and be manifested in two complementary styles: the
paternalistic protector role or the overidentification with another minority
group (Helms, 1984; Ponterotto, 1988). In the former, the White person may
devote his or her energies in an almost paternalistic attempt to protect
minorities from abuse. In the latter, he or she may actually want to identify
with a particular minority group (e.g., Asian, Black) in order to escape his or
her own Whiteness. The White person will soon discover, however, that these
roles are not appreciated by minority groups and will experience rejection.
Again, he or she may resolve this dilemma by moving back into the protective
confines of White culture (conformity phase), experience conflict
(dissonance), or move directly to the introspective phase.
5. Introspective phase. This phase is most likely a compromise of having swung from an
extreme of unconditional acceptance of White identity to a rejection of Whiteness. It is a
state of relative quiescence, introspection, and reformulation of what it means to be
White. The person realizes and no longer denies that he or she has participated in
oppression and benefited from White privilege and that racism is an integral part of U.S.
society. However, individuals at this phase become less motivated by guilt and
defensiveness, accept their Whiteness, and seek to redefine their own identity and that of
their social group. This acceptance does not mean a less active role in combating
oppression. The process may involve addressing the questions, “What does it mean to be
White?”, “Who am I in relation to my Whiteness?”, and “Who am I as a racial/cultural
being?”
The affective elements may be existential in nature and involve feelings of
disconnectedness, isolation, confusion, and loss. In other words, the person
knows that he or she will never fully understand the minority experience but
feels disconnected from the EuroAmerican group as well. In some ways, the
introspective phase is similar in dynamics to the dissonance phase, in that both
represent a transition from one perspective to another. The process used to
answer the previous questions and to deal with the ensuing feelings may
involve a searching, observing, and questioning attitude. Answers to these
questions involve dialoging and observing one's own social group, and
actively creating and experiencing interactions with various minority group
members.
6. Integrative awareness phase. Reaching this level of development is most characterized
as (a) understanding the self as a racial/cultural being, (b) being aware of sociopolitical
influences regarding racism, (c) appreciating racial/cultural diversity, and (d) becoming
more committed toward eradicating oppression. A nonracist White EuroAmerican
identity is formed, emerges, and becomes internalized. The person values
multiculturalism, is comfortable around members of culturally different groups, and
feels a strong connectedness with members of many groups. Most important, perhaps, is
the inner sense of security and strength that needs to develop in order to function in a
society that is only marginally accepting of integrative, aware White persons.
7. Commitment to antiracist action phase. Someone once stated that the ultimate White
privilege is the ability to acknowledge one's privilege but do nothing about it. This phase
is most characterized by social action. There is likely to be a consequent change in
behavior and an increased commitment toward eradicating oppression. Seeing “wrong”
and actively working to “right” it requires moral fortitude and direct action. Objecting to
racist jokes; trying to educate family, friends, neighbors, and coworkers about racial
issues; and taking direct action to eradicate racism in school and the workplace and in
social policy (often in direct conflict with other Whites) are examples of actions taken by
individuals who achieve this status. Movement into this phase can be a lonely journey
for Whites, because they are oftentimes isolated by family, friends, and colleagues who
do not understand their changed worldview. Strong pressures in society to not rock the
boat, threats by family members that they will disown the individual, avoidance by
colleagues, and threats of being labeled a troublemaker or not being promoted at work
may all push the White person back to an earlier phase of development. To maintain a
nonracist identity requires Whites to become increasingly immunized to social pressures
for conformance and to begin forming alliances with persons of color or other liberated
Whites, who become a second family to them. As can be seen, the struggle against
individual, institutional, and societal racism is a monumental task in this society.
Video 12.3: Utilizing Your Own Development
White individuals go through a development process just like other groups and cultures. Once
you are able to understand where you are developmentally, you can be more intentional about
moving along the process, but also empathize with clients as they progress through their own
identity development.
DEVELOPING A NONRACIST AND ANTIRACIST WHITE IDENTITY
I sometimes visualize the ongoing cycle of racism as a moving walkway at the airport.
Active racist behavior is equivalent to walking fast on the conveyor belt. The person
engaged in active racist behavior has identified with the ideology of White supremacy
and is moving with it. Passive racist behavior is equivalent to standing still on the
walkway. No overt effort is being made, but the conveyor belt moves the bystanders
along to the same destination as those who are actively walking. Some of the bystanders
may feel the motion of the conveyor belt, see the active racists ahead of them, and
choose to turn around, unwilling to go to the same destination as the White
supremacists. But unless they are walking actively in the opposite direction at a speed
faster than the conveyor belt—unless they are actively antiracist—they will find
themselves carried along with the others.
(Tatum, 1997, pp. 11–12)
What does this metaphor of racism tell you about the difference between active and passive
racism? What is the “destination” of the walkway? If it represents our society, can you
describe what that destination looks like? What does the conveyor belt symbolize? Are you
on the conveyor belt? Which direction are you traveling? Do you even feel the movement of
the belt? What would it take for you to reverse directions? More importantly, how can you
stop the movement of the conveyor belt? What changes would need to occur for you at the
individual level to reverse directions? What changes would need to happen at the institutional
and societal levels to stop or reverse the direction of the conveyor belt?
As repeatedly emphasized in earlier chapters, White supremacy must be seen through a larger
prism of individual, institutional, and societal racism. All these elements conspire in such a
manner as to avoid making the “invisible” visible, and thus directly or indirectly discourage
honest racial dialogue and self‐exploration.
First, the walkway metaphor is a strong and powerful statement of the continuous and
insidious nature of racism; it is ever‐present, dynamic, and oftentimes invisible as it takes us
on a journey to White supremacist notions, attitudes, beliefs, and behaviors. The visible
actions of White supremacists moving quickly on the belt represent the overt racism that
we're aware of; these forms we consciously condemn. The conveyor belt represents the
invisible forces of society or the biased institutional policies, practices, and structures that
control our everyday lives. From the moment of birth, we are placed on the conveyor belt,
culturally conditioned, and socialized to believe that we are headed in “the right direction.”
For many White people, the movement of the belt is barely noticeable, and its movement
remains hidden from conscious awareness. This allows White people to remain naive and
innocent about the harm their inaction has on people of color.
Second, as indicated by Tatum (1997), one need not be actively racist in order to be racist.
The pace at which one walks on the conveyor belt determines the degree to which one
consciously or unconsciously harbors White supremacist notions: (a) “active racists” who are
aware and deliberate in beliefs and actions move quickly, (b) unintentional racists, unaware
of their biases and the direction they are taking, stroll slowly, and (c) “passive racists” choose
not to walk at all. Despite this, passive racists are nevertheless being moved in a direction that
allows for racism to thrive. On a personal level, despite beliefs of justice, equity, and fairness,
inaction on the walkway ultimately means that these individuals are also responsible for the
oppression of others.
Third, most people of color are desperately trying to move or run in the opposite direction.
The voices of people of color are filled with attempts to make well‐intentioned Whites
aware of the direction they are taking and of the harm they are inflicting on diverse others.
But they are hindered by many obstacles: well‐intentioned White Americans who tell them
they are going the wrong way and don't believe them; institutional policies and practices that
put obstacles in their retreating path (institutional racism); and punishment from society for
“not obeying the traffic rules”—a one‐way street of bias and bigotry.
Fourth, despite limited success in battling the constant forces of racism, people of color are
also slowly but surely being swept in a dangerous direction that has multiple implications for
their psychological health, physical well‐being, and standard of living. Walking at a fast
pace or running in the opposite direction is a never‐ending activities that is exhausting and
energy‐depleting. Worse yet, they are being trampled by the large numbers of well‐
intentioned White Americans moving in the opposite direction. Giving up or ultimately being
swept to the end of the walkway means a life of oppression and subordination.
Last, the questions being posed to trainees are challenging. How do we motivate White
Americans to (a) notice the subtle movement of the walkway (making the invisible visible),
(b) discern the ominous direction it is taking (White racial supremacy), (c) begin to move in
the opposite direction (antiracism), and (d) stop the conveyor belt or reverse its direction
(institutional and societal change)? As indicated in the sections on White racial identity
development, becoming nonracist means engaging in soul searching, individual change, and
working on the self; becoming antiracist, however, means taking personal action to end
external racism that exists systemically and in the actions of others.
White Antiracist Identifications
Tatum (2007) articulated a vision of the roles occupied by White individuals who have made
their antiracist commitments and actions central to their identities:
It is possible to claim both one's Whiteness as a part of who one is and of one's daily
experience, and the identity of being what I like to call a “White ally”: namely, a White
person who understands that it is possible to use one's privilege to create more equitable
systems; that there are White people throughout history who have done exactly that; and
that one can align oneself with that history. That is the identity story that we have to
reflect to White children, and help them see themselves in it, in order to continue racial
progress in our society.
(p. 37)
This term, White ally, has increasingly gained currency as antiracist White Americans have
sought to take a stand against racism and to align themselves with social movements such as
Black Lives Matter (Griffin, 2016). White alliance has professional relevance as well as
individual implications. Like members of every profession, White counselors must consider
the ways that their work is influenced by the unearned privilege that has accompanied their
skin color. White counselors who identify as White allies also accept accountability for
“work[ing] in solidarity with their colleagues of color to conduct culturally responsive
professional practice, research, training, and institutional transformation” (Spanierman &
Smith, 2017, p. 607).
The notion of White alliance has also been critiqued (Mizock & Page, 2016; Owens, 2017), in
that even the actions of self‐described allies can be undermined by the entitlement and blind
spots that accompany White privilege. The resulting pitfalls for White allies include short‐
term involvement, the expression of antiracist commitments only when convenient, and
engaging in recognition‐seeking for one's antiracist activities. At times, White antiracists
can be observed to enact their privilege by taking over meetings where racism is the topic,
rather than working collaboratively with or taking direction from their colleagues of color. In
addition, the efforts of would‐be allies can be compromised by a paternalistic “White
savior” stance.
The notion of an ally may promote a condescending narrative of allies as “rescuers” to
the “helplessly oppressed.” This narrative also reinforces problematic emotions of pity
for a marginalized group … Along with pity comes sympathy in the role of a “heroic
ally.” While sympathy has been found to be important to collective action, this role
positions the ally on the sidelines instead of participating fully in social change …
Furthermore, identification with an advantaged group identity may reify inferior–
superior statuses associated with it … such as hero to a victim.
(Mizock & Page, 2016, p. 24)
These potential pitfalls do not negate the value of the authentic soul‐searching and
commitment that motivate White antiracists to identify themselves as allies. They do,
however, underscore that one's development as a White ally is a lifelong endeavor (Sue,
2017).
Principles of Prejudice Reduction
Although White racial identity development models tell us much about the characteristics
most likely to be exhibited by individuals as they progress along this journey, they are very
weak in giving guidance about how to develop a nonracist White identity (Helms, 2015).
Possible answers seem to lie in the social‐psychological literature about the basic principles
or conditions needed to reduce prejudice through intergroup contact first formulated by
Gordon Allport (1954) in his classic book, The Nature of Prejudice. His work has been
refined and expanded by other researchers and scholars (Aboud, 1988; Amir, 1969; Cook,
1962; Gaertner, Rust, Dovidio, Bachman, & Anastasio, 1994; Jones, 1997). Sue (2003) has
summarized these findings into the basic principles of prejudice reduction: (a) having
intimate and close contact with others, (b) engaging in cooperation rather than competition on
common tasks, (c) sharing mutual goals, (d) exchanging accurate information rather than
stereotypes, (e) sharing an equal status relationship, (f) enjoying support for prejudice
reduction by authorities and leaders, and (g) feeling a sense of connection and belonging with
one another. To this, we might add the contributions of White racial identity development
theorists, who have indicated the importance of understanding oneself as a racial/cultural
being. It has been found, for example, that a person's level of White racial awareness is
predictive of his or her level of racism (Pope‐Davis & Ottavi, 1994; Wang et al., 2003); the
less aware participants in research projects were of their White racial identity, the more likely
they were to exhibit increased levels of racism.
The seven basic principles we provided in the previous section arose primarily through
studies of how to reduce intergroup conflict and hostility, but several seem consistent with
reducing personal prejudice through experiential learning and the acquisition of accurate
information about other groups. Translating these principles into roles and activities for
personal development has been made possible by recommendations from the APA
Presidential Task Force on Preventing Discrimination and Promoting Diversity (2012), the
President's Initiative on Race (1998, 1999), educators and trainers (Ponterotto et al., 2006;
Young & Davis‐Russell, 2002), and studies on difficult racial dialogues (Sue, Lin, Torino,
Capodilupo, & Rivera, 2009; Sue, Rivera, Capodilupo, Lin, & Torino, 2010).
Sue (2003) outlines five basic learning situations and activities, or principles, most likely to
enhance change in developing a nonracist White identity.
Principle 1: Learn About People of Color From Sources Within the Group
You must experience and learn from as many sources as possible (not just the media or
what your neighbor may say) in order to check out the validity of your assumptions and
understanding.
If you want to understand racism, White people may not be the most insightful or
accurate sources. Acquiring information from persons of color allows you to understand
the thoughts, hopes, fears, and aspirations of this group. It also acts as a counterbalance
to the worldview expressed by White society about minority groups.
Principle 2: Learn From Healthy and Strong People of the Culture
A balanced picture of a particular racial/ethnic group requires that you spend time with
healthy and strong people of that culture. The mass media and our educational texts
(written from the perspectives of EuroAmericans) frequently portray minority groups as
uncivilized or pathological, or as criminals or delinquents.
You must make an effort to fight such negative conditioning and ask yourself what are
the desirable aspects of the culture, the history, and the people. This can come about
only if you have contact with healthy representatives of that group.
If you seldom spend much intimate time with persons of color, you are likely to believe
the societal projection of minorities as being law breakers and unintelligent, prone to
violence, unmotivated, and uninterested in relating to the larger society.
Frequent minority‐owned businesses, and get to know the proprietors.
Attend services at a variety of churches, synagogues, temples, and other places of
worship to learn about different faiths and to meet religious leaders.
Invite colleagues, coworkers, neighbors, or students of color to your home for dinner or
a holiday.
Live in an integrated or culturally diverse neighborhood, and attend neighborhood
organizational meetings and attend/throw block parties.
Form a community organization on valuing diversity, and invite local artists, authors,
entertainers, politicians, and leaders of color to address your group.
Attend street fairs, educational forums, and events put on by the community.
Principle 3: Learn From Experiential Reality
Although listening to readings, attending theater, and going to museums are helpful in
increasing understanding, you must supplement your factual understanding with the
experiential reality of the groups you hope to understand. These experiences must be
carefully planned if they are to be successful, however.
It may be helpful to identify a cultural guide: someone from the culture who is willing to
help you understand his or her group; someone willing to introduce you to new
experiences; someone willing to help you process your thoughts, feelings, and behaviors.
This allows you to more easily obtain valid information on issues of race and racism.
Principle 4: Learn From Constant Vigilance of Your Biases and Fears
Your life must become a “have to” in being constantly vigilant to manifestations of bias
in both yourself and the people around you.
Learn how to ask sensitive racial questions of your minority friends, associates, and
acquaintances. Persons subjected to racism seldom get a chance to talk about it with a
nondefensive and nonguilty person from the majority group.
Most minority individuals are more than willing to respond, to enlighten, and to share if
they sense that your questions and concerns are sincere and motivated by a desire to
learn and serve the group.
Principle 5: Learn From Being Committed to Personal Action Against Racism
Dealing with racism means a personal commitment to action. It means interrupting other
White Americans when they make racist remarks, tell racist jokes, or engage in racist
actions, even if this is embarrassing or frightening.
It means noticing the possibility for direct action against bias and discrimination in your
everyday life: in the family, at work, and in the community.
It means taking initiative to make sure that minority candidates are fairly considered in
your place of employment, advocating to your children's teachers to include
multicultural material in the curriculum, volunteering in community organizations to
have them consider multicultural issues, and contributing to and working for campaigns
of political candidates who will advocate for social justice.
The journey to developing a White nonracist identity is not an easy path to travel.
Remember, racial identity and cultural competence are intimately linked to one another.
Becoming a culturally competent helping professional involves more than “book
learning”; it requires both experiential learning and taking personal action (Atkins,
Fitzpatrick, Poolokasingham, Lebeau, & Spanierman, 2017). Are you ready for the
challenge?
REFLECTION AND DISCUSSION QUESTIONS
1. Do these suggestions and strategies make sense to you? Are there others that come to
mind?
2. What would make it difficult for you to personally implement these suggestions? What
barriers stand in the way? For example, what would make it difficult for you to interrupt
a stranger or even a family member when a racist or sexist joke is made?
3. Have you ever been in a situation where you were the only White person in an activity
or event full of Black, Asian, or Latinx people? What feelings did you have? How did
you think? Were you uncomfortable or fearful?
4. What would you need in the way of support or personal moral courage to move toward
developing a White nonracist identity?
IMPLICATIONS FOR CLINICAL PRACTICE
1. Ultimately, the effectiveness of White therapists is related to their ability to overcome
sociocultural conditioning and to make their Whiteness visible.
2. Accept the fact that racism is a basic and integral part of U.S. life and permeates all
aspects of our culture and institutions. Know that as a White person, you are not
immune.
3. Understand that the level of White racial identity development in a cross‐cultural
encounter (e.g., working with minorities, responding to multicultural training) affects the
process and outcome of an interracial relationship (including counseling/therapy).
4. Work on accepting your own Whiteness, but define it in a nondefensive, nonracist, and
antiracist manner.
5. Spend time with healthy and strong people from another culture or racial group.
6. Know that becoming culturally aware and competent comes through lived experience
and reality.
7. Attend cultural events, meetings, and activities led by minority communities. This
allows you to hear from church leaders, to attend community celebrations, and to
participate in open forums so that you may sense the strengths of the community,
observe leadership in action, personalize your understanding, and develop new social
relationships.
8. When around persons of color, pay attention to feelings, thoughts, and assumptions that
you have when race‐related situations present themselves.
9. Dealing with racism means a personal commitment to action.
Video 12.4: Healthy Identity Development in White Clinicians
The process of White identity development is just as important to clinicians as understanding
the developmental process of clients-of-color. In doing so, clinicians free themselves to
become the best version of themselves, one that is based in a holistic self-understanding.
Video Lecture: White Racial Identity Development
Video Lecture: What Does It Mean to be White? The Invisible Whiteness of Being
SUMMARY
“What does it mean to be White?” is often an uncomfortable and perplexing question for
White Americans. Exploring the basis of this discomfort and its meaning is important for
cultural competence in mental health practice. Being a White person in this society means
chronic exposure to ethnocentric monoculturalism as manifested in White supremacy.
Research suggests that it is nearly impossible for anyone to avoid inheriting the racial biases,
prejudices, misinformation, deficit portrayals, and stereotypes of their forebears. If White
helping professionals are ever able to become effective multicultural counselors or therapists,
they must free themselves from the cultural conditioning of their past and move toward the
development of a nonracist and antiracist White identity.
White racial identity development models have been found to be helpful in describing how
majority group members go through a process of racial awakening that has direct meaning to
multicultural counseling. Two of the most influential models are those presented by Rita
Hardiman and Janet Helms. It has been found that the level of White racial identity awareness
is predictive of racism and of internal and interpersonal characteristics. The less aware
subjects studied were of their White identity, the more likely they were to exhibit higher
levels of racism, while the greater their White identity development, the greater their levels of
multicultural counseling competence, the higher their positive opinions toward diverse
groups, and the better their ability to form therapeutic alliances with clients of color.
A descriptive model of White racial identity development identifies a seven‐phase process
by which Whites become increasingly aware of themselves as racial/cultural beings: (a)
naiveté, (b) conformity, (c) dissonance, (d) resistance and immersion, (e) introspective, (f)
integrative awareness, and (g) commitment to antiracist action. Becoming nonracist means
engaging in soul searching, individual change, and working on the self; becoming antiracist,
however, means taking personal action to end external racism that exists systemically and in
the actions of others. Five basic principles are provided to facilitate racial/cultural awareness:
learn (a) from the groups you hope to understand, (b) from healthy and strong people of the
culture, (c) from experiential reality, (d) from constant vigilance of fears and biases, and (e)
from being committed to anti‐bias action.
GLOSSARY TERMS
Antiracist White identity
Commitment to antiracist action phase
Conformity phase
Dissonance phase
Ego statuses
Hardiman White racial identity development
Helms White racial identity development
Information processing strategies
Integrative awareness phase
Introspective phase
Naiveté phase
Nonracist White identity
Resistance and immersion phase
Unintentional racism
White privilege
White racial identity development
White racial identity development descriptive model
White supremacy
Whiteness
Video 12.5: Counseling Session Analysis
Analysis of counseling session by Drs. Derald Wing Sue and Joel Filmore.
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SECTION TWO
Multicultural Counseling and Specific
Populations
While Section One addressed common principles, practices, and issues of multicultural
counseling and therapy that are often applicable across groups, this section is divided into
four parts that recognize the unique challenges and group differences between socially
marginalized groups in our society. Section Two was created for several reasons.
First, we recognize that while issues of culture‐conflict, prejudice, and discrimination
affect almost all socially devalued groups in our society, the histories and the unique
challenges confronting people of color, for example, may differ substantially from those
confronting women, those who live in poverty, or religious minorities.
Second, we recognize that “multiculturalism,” “diversity,” and “multicultural counseling
competence” are broad terms that include race, gender, social class, religious orientation,
sexual orientation, and many other sociodemographic groups in our society. To not
acknowledge this fact is to render certain groups invisible, thereby invalidating their
existence as unique.
Third, numerous instructors continue to find the coverage of specific populations helpful
to their students. The extensive coverage in Section Two allows instructors freedom to
use all of the chapters contained within it or to selectively choose those that fit their
course requirements.
Last, but importantly, we have attempted to provide a guideline for how to approach the
use of population‐specific chapters through an open and flexible assessment process
that avoids stereotypical and rigid therapeutic applications (see Part V).
Part V: Understanding Specific Populations
Part VI: Counseling and Therapy with Racial/Ethnic Minority Group Populations
Part VII: Counseling and Special Circumstances Involving Racial/Ethnic
Populations
Part VIII: Counseling and Therapy with Other Multicultural Populations
13
Culturally Competent Assessment
Chapter Objectives
1. 1. Understand the many variables that influence assessment, diagnosis, and case
conceptualization.
2. 2. Develop awareness of the dangers of stereotyping and the importance of
appreciating the individuality of each client.
3. 3. Learn how cultural competence and responsiveness prevent diagnostic errors.
4. 4. Understand contextual and collaborative assessment.
5. 5. Understand Diagnostic and Statistical Manual of Mental Disorders (DSM‐5)
cultural formulations.
6. 6. Learn how to infuse cultural competence and responsiveness into standard
clinical assessments.
I approach people as people no matter their ethnic background.
(Common refrain heard among therapists and trainees)
A couple walked out after the first few minutes. I had sensed their mistrust and anger
and talked more than usual, immediately addressing our racial difference. They stormed
out, stating that I was talking too much and not listening.
(Maxie, Arnold, & Stephenson, 2006, p. 92)
Accurate assessment, diagnosis, and case conceptualization—key prerequisites to the
provision of appropriate treatment—are dependent upon the characteristics, values, and
worldviews of both the therapist and the client (American Psychological Association, 2006,
2017). Some clinicians choose not to consider race, ethnicity, and other social identities when
working with clients, as illustrated in the first quote in the epigraph, and some clinicians'
racial biases and/or discomfort get in the way of them making genuine connections with
clients, as evident in the second. In general, though, most therapists today recognize that
client variables, such as socioeconomic status, gender, and racial or cultural background, can
significantly affect assessment, diagnosis, and conceptualization. However, we often forget
that as clinicians, we are not “objective” observers of our clients. Instead, we each have our
own set of beliefs, values, and theoretical assumptions (e.g., the degree we think social
identities shape people's lives). To reduce error, a mental health professional must be aware
of potential biases that can affect clinical judgment, including the influence of stereotypes
(i.e., generalizations based on limited or inaccurate information). Unfortunately, our current
methods of assessment and diagnosis often do not adequately consider these factors,
especially with respect to therapist variables. Additionally, many of our instruments and
processes for assessment and diagnosis do not address client variables in a meaningful
manner.
If we are to follow best‐practice guidelines and the ethical standards of our profession, we
must consider broad background factors, including the worldview of each client. How can
this be accomplished? First and foremost, it is critical that we operate from the awareness that
an understanding of and openness toward our clients' beliefs, expectations, and experiences is
an essential aspect of the assessment and case conceptualization process. We believe that
culturally responsive assessment occurs through a combination of evidence‐based
guidelines for assessment and a cultural competency framework.
In this chapter, we will cover: (a) the impact of therapist variables on assessment and
diagnosis, emphasizing the dangers of stereotyping; (b) ways in which culturally competent
practices can reduce diagnostic errors; (c) contextual and collaborative assessment; and (d)
ideas for infusing cultural competence into standard intake and assessment procedures.
Careful consideration of these factors when using evidence‐based guidelines to conduct
assessment will ensure that clinicians form an accurate and complete picture of the problems
and issues facing each client. We will demonstrate how culturally responsive assessment
should be conducted—in a manner that considers the unique background, values, and beliefs
of each client. We hope that as you proceed through the final chapters of this book—chapters
describing general characteristics and special challenges faced by various diverse populations
—you will remember that we are providing this information so you will have some
knowledge of the specific research and the sociopolitical and cultural factors that might be
pertinent to a client or family from the population being discussed. However, it is critical that
when counseling diverse clientele, you actively work to avoid succumbing to stereotypes (i.e.,
basing your opinions of the client on limited information or prior assumptions). Instead, your
task is to develop an in‐depth understanding of each client, taking into consideration their
unique personal background and worldview. By doing this, you will be in a position to
develop an individually tailored treatment plan that effectively addresses presenting problems
in a culturally sensitive manner.
Video 13.0: Introduction
Introduction to counseling session by Dr. Joel Filmore.
THERAPIST VARIABLES AFFECTING DIAGNOSIS
Assessment is best conceptualized as a two‐way street, influenced by both client and
therapist variables. Because humans filter observations through their own set of values and
beliefs, we begin our discussion by focusing on therapist self‐assessment.
A treatment team observing a clinical interview erupted in laughter when the foreign‐
born psychiatric resident attempted to find out what caused or precipitated the client's
problem. In poor and halting English, the resident asked, “How brought you to the
hospital?” The patient responded, “I came by car.”
(Chambliss, 2000, p. 186)
Later, during the case conference, the psychiatric resident attributed the patient's response to
concrete thinking, a characteristic sometimes displayed by people with schizophrenia. The
rest of the treatment team, however, believed the response was due to a poorly worded
question. This example illustrates what can occur when therapists focus solely on the client
without considering the impact of therapist variables. Personal characteristics, attitudes, and
beliefs can (and do) influence how assessment is conducted and what is assessed, as well as
interpretations of clinical data. Counselors and other mental health professionals are often
unaware of how strongly personal beliefs can affect clinical judgment.
In one study, 108 psychotherapists read an intake report involving a male client whose
sexuality was revealed through references to his previous and present partners; all clinical
data were identical with the exception of references to sexual orientation. Details suggesting
heterosexual or same‐sex orientation had little impact on clinical ratings; however,
therapists given data suggesting the client was bisexual were more likely to “detect”
emotional disturbance. The researchers concluded that these differing diagnostic perceptions
were the result of stereotypes of bisexual men being “confused and conflicted” (Mohr,
Weiner, Chopp, & Wong, 2009).
In conducting culturally responsive assessment, we must not only be aware of the influence
of stereotypes but also be alert for common diagnostic errors, such as the following:
Confirmatory strategy. Searching for evidence or information that supports one's
hypothesis and ignoring data that are inconsistent with this perspective. When working
with clients, mental health professionals might search for information that confirms
beliefs based on their worldviews or theoretical orientation (Osmo & Rosen, 2002). In a
similar manner, our views or stereotypes of the characteristics and values of ethnic and
other diverse groups can act as blinders when working with clients from these groups.
Counselors can combat this type of error by working cooperatively with clients to
understand and interpret the presenting problem. Diagnostic accuracy is increased when
clinicians test any hypotheses they formulate with the client. When determining whether
these possible interpretations resonate with the client, it is critical that the therapist be
open to both confirmatory and disconfirmatory information.
Attribution error. Placing an undue emphasis on internal causes regarding a client's
problem. For example, a therapist might interpret a problem as stemming from a
personal characteristic of the client rather than considering environmental or
sociocultural explanations such as poverty, discrimination, or oppression. Attribution
error can be reduced by performing a thorough assessment that includes consideration of
sociocultural and environmental factors and testing hypotheses regarding extrapsychic
(i.e., residing outside the person) as well as intrapsychic (residing within the person)
influences.
Judgmental heuristics. Commonly used quick‐decision rules. These can be problematic
because they short‐circuit our ability to engage in self‐correction. For example, if we
quickly identify our client as “defensive” or “overreactive,” these characterizations will
reduce our attempt to gather additional or contradictory information. In one study
(Stewart, 2004), 300 clinicians received identical vignettes regarding hypothetical
clients, with the only difference being the clients' stated birth order. Birth order
influenced the judgment of the clinicians, including the expected prognosis for the client,
even though there is little research support for personality differences associated with
birth order. These kinds of beliefs or spontaneous associations occur automatically and
need to be identified and addressed. Therapists can reduce this tendency by
acknowledging the existence of judgmental heuristics, questioning the basis for quick
decisions, assessing additional factors, and evaluating the accuracy of opinions about
clients.
Diagnostic overshadowing. Providing inadequate treatment of the client's problem
because one's attention is diverted to a more prominent characteristic. For example,
individuals who are gay or lesbian can have a number of psychological issues that have
nothing to do with their sexual orientation. In diagnostic overshadowing, a therapist
might perceive the presenting problem as related to conflicts over sexual orientation and
fail to address other critical issues. Other such prominent characteristics are race,
religious affiliation, and visible disabilities.
We must be aware of our beliefs and values as we work with clients and their specific
presenting problems. We are all susceptible to making errors in clinical judgment during
assessment; therefore, it is important to adopt a tentative stance and test out our observations.
Those who remember that errors in judgment are possible can reduce their effect by using a
self‐corrective model. In the next section, for example, we discuss why it is important to
consider whether the current focus on cultural competence may, in fact, be creating new
sources of errors—errors resulting from applying cultural information in a stereotypic,
“one‐size‐fits‐all” manner.
Video 13.1: Assessment and Diagnosis
Assessing clients of color requires more than simply handing them a form to fill out. Because
most formal assessments are normed on majority populations, it's important to utilize
informal assessments also in order to gather a clearer picture of clients.
CULTURAL COMPETENCE AND PREVENTING DIAGNOSTIC
ERRORS
I guess her being a Jewish woman and my being a Black man made it a little difficult …
she didn't have first‐hand knowledge of that community. She only had second‐hand
knowledge, which she read, or what I told her, or what she heard. It was difficult for her
to truly understand what I was talking about and the true level of value that I thought
that it deserved.
(Chang & Berk, 2009, p. 528)
You shouldn't expect a lot of African American clients to be in touch with their feelings
and do some real intrapsychic work. Sometimes you have to be more directive and
problem‐focused in dealing with Black people.
(Constantine & Sue, 2007, p. 146)
Given the growing multicultural nature of the U.S. population, all mental health organizations
now promote cultural competence and the ability to work effectively with diverse clients. But
is it possible that this focus on cultural differences is creating unintended consequences? Is
the emphasis on understanding cultural factors leading to problems such as stereotyping or
the blind application of cultural information? The two quotes at the start of this section
illustrate the problems that can occur when general cultural information is applied to clients
without assessing for individual differences. Surprisingly, in the second case, the speaker was
a supervisor giving stereotype‐based advice to her supervisee.
Multicultural awareness can, in fact, lead to diagnostic overshadowing if a clinician's
attention to race or other diversity characteristics results in neglect of important aspects of the
client (Vontress & Jackson, 2004). This tendency is increased in workshops and classes that
focus primarily on the memorization of cultural information (Kissinger, 2014). As clinicians
working with diverse populations, we need to consider all aspects of each client's life and not
automatically assume that presenting problems are based on racial or diversity issues. In fact,
it would be irresponsible for a clinician to focus on a client's diversity or environmental
stressors when there are other significant concerns (Weinrach & Thomas, 2004).
Some mental health professionals have argued that the emphasis on culture and the
development of culture‐specific approaches have led to fragmentation, confusion, and
controversy in the field of counseling and psychotherapy. Diversity training has been accused
of producing “professionally sanctioned stereotyping,” in which the therapist gives primary
consideration to cultural attributes rather than focusing on understanding the uniqueness and
life circumstances of the individual client (Freitag, Ottens, & Gross, 1999; Sue & Sue, 2013).
Although it is important to understand group‐specific differences, it is equally critical that
we avoid a “cookbook” approach, in which the characteristics of different groups are
memorized and applied to all clients who belong to a specific group (Lee, 2006).
Do guidelines for increasing cultural competence (e.g., increasing knowledge about different
cultural groups and developing multicultural clinical skills) contribute to assessment errors,
such as confirmatory bias, diagnostic overshadowing, and stereotyping? These errors
certainly can happen, and are most likely to occur when clinicians fail to use self‐correcting
strategies or fail to consider the individuality of each client. It is our belief that effective
culturally relevant assessment can, in fact, minimize the dangers of stereotyping or of placing
inordinate weight on race or other diversity issues.
Cultural Self‐Awareness
Self‐awareness is important with respect to both cultural competency and evidence‐based
practice (EBP). Therapists may be unaware that stereotypes are affecting their views and/or
responses to clients or that differences between themselves and their clients are affecting the
therapeutic process. For example, studies have found that mental health professionals may
pathologize clients who display nontraditional gender role behavior (Seem & Johnson, 1998)
and may rate female clients as less competent than males (Danzinger & Welfel, 2000).
Such judgments (or inferential errors) constitute deviations from cultural competence and the
EBP model of self‐reflection and awareness regarding the impact of one's values and
beliefs. Identifying one's biases or taking the time to self‐reflect can help reduce such errors.
Questions such as, “Which of my identities allow me to experience privilege?”, “Which
identities expose me to oppression?”, and “How do I feel about these experiences?” can help
clinicians reflect on how their own backgrounds and experiences have shaped their
worldviews (Singh & Chun, 2010, p. 36).
Further, we need to develop an awareness of our assessment processes and identify our
values, theoretical orientations, and beliefs about different groups whose social, cultural, or
ethnic backgrounds differ from our own. We might ask such questions as, “Do I hold
assumptions about gender roles, sexual orientation, older individuals, political philosophy, or
‘healthy’ family structure that may influence my clinical judgment?” and “Do I hold certain
stereotypes or impressions of the client or the cultural groups to which the client belongs?”.
Such self‐assessment is a necessary step in working with clients who differ from us and is
an important component of counselor competence (Ridley, Mollen, & Kelly, 2011).
Cultural Knowledge
The knowledge component of cultural competence involves the awareness of different
worldviews (e.g., that the majority of cultures in the world have a collectivistic and
interdependent orientation; that the structure of some families is hierarchical in nature). Such
knowledge is crucial in working with ethnic minority populations. For example, cultural
knowledge is useful in helping counselors understand potential family patterns among
different ethnic minority populations; such information can be particularly helpful when
patterns differ from the family and relationship structure typical of White American families.
However, these descriptions are “modal” cultural characteristics and may or may not be
applicable to a particular client. Knowledge also involves the awareness that significant
within‐group differences can exist—individuals can vary, for example, in degree of
acculturation, level of identification with cultural values, and unique personal experiences.
Cultural information should not be applied rigidly; it is necessary to determine the degree of
fit between the general cultural information described in the special population chapters in
this book and the individual client in front of us. Gone (2009), for example, points out that it
is not enough to know that a client is American Indian; you need to ask, “What kind of Indian
are you?” In other words, you need to learn what tribe the client is affiliated with (if any), the
nature of their connection with the tribe, and, if the client is closely connected, the particular
values and practices of the tribal culture. Among ethnic minorities, within‐ and between‐
group differences are quite large—some individuals and families are quite acculturated, while
others retain a more traditional cultural orientation. Cultural differences, such as the degree of
assimilation, socioeconomic background, family experiences, and educational level, affect
each individual in a unique manner. Additionally, one's intersecting identities influence one's
lived experiences. For example, a bisexual first‐generation Mexican American woman's
experience with depression is most likely shaped through the interconnection of sexual
orientation, gender, generation status, and ethnic‐culture.
Knowledge of cultural values and potential identity‐related experiences associated with
specific groups can help us generate hypotheses about the manner in which a client (or family
members) might view a disorder or presenting concern. However, the accuracy of such
cultural hypotheses must be assessed for each client. Thus, it is critical that we communicate
with the client in order to confirm or disconfirm any hypotheses generated from our cultural
“knowledge.” Cultural “knowledge” requires not only that we be open to the worldviews of
others, but that we take care to remember that every client has a unique life story.
Culturally Responsive or Multicultural Skills
Cultural responsiveness requires that counselors effectively apply a variety of helping skills
when forming a therapeutic alliance. As discussed in Chapter 9 on Multicultural Evidence‐
Based Practice, it is important to individualize the choice of helping skills and avoid a blind
application of techniques to all situations and all populations. Our manner of developing an
effective therapeutic bond will differ from individual to individual and perhaps from ethnic
group to ethnic group. It is important to individualize relationship skills and to consistently
evaluate the effectiveness of our verbal and nonverbal interactions with the client. As
discussed later in this chapter, culturally responsive or multicultural skills incorporate the
entire therapy process from case conceptualization to treatment intervention. Applying
cultural awareness and knowledge in the clinical assessment process—where the clinician
listens deeply to and encourages client collaboration in understanding the presenting concern
—is one way to demonstrate multicultural skills.
In summary, errors in assessment can occur because of biases, mistakes in thinking, and
stereotypes held by the clinician. In the past, assessment practices focused only on the client;
potential counselor biases or inaccurate assumptions were not taken into consideration. It is
now clear that effective assessment requires that therapist characteristics also be considered.
Do cultural competency guidelines contribute to stereotypes? Some mental health
practitioners believe that they do. However, we would argue precisely the opposite: if used
appropriately, cultural competency and EBP guidelines that focus on awareness of one's
values and biases, appropriate use of cultural knowledge, and the value of understanding the
unique background and experience of each client help prevent stereotyping.
Video 13.2: Culturally Competent Assessment
A focus on client culture can go a long way in preventing errors in diagnosis. Clients-of-color
are often misdiagnosed or over diagnosed based on similar behaviors to their White
counterparts. Understanding clients through an informal lens can adjust for assessment error.
CONTEXTUAL AND COLLABORATIVE ASSESSMENT
Self‐awareness is an important first step in reducing errors in multicultural assessment.
However, this is only one part of the equation. Only through close collaboration with the
client can we accurately identify the specific issues involved in the presenting problem and
eliminate the blind application of cultural knowledge. This is best accomplished with a
collaborative approach, in which clients are given opportunities to share their beliefs,
perspectives, and expectations, as well as their explanations of problems. If a client's belief
about the presenting problem differs from that of the therapist, treatment based only on the
therapist's views is likely to be ineffective. In this section, we share some approaches a
therapist might use to introduce the assessment and case conceptualization process in a way
that facilitates dialogue and a collaborative relationship.
What we are going to do today is gather information about you and the problem that
brings you in for counseling. In doing so, I'll need your help. In therapy we'll work
together to decide what concerns to address and what solutions you feel comfortable
with. Some of the questions I ask may seem very personal, but they are necessary to get
a clear picture of what may be going on in your life. As I mentioned before, everything
that we discuss is confidential, with the exceptions that we already went over. I will also
ask about your family and other relationships and about your values and beliefs, since
they might be related to your concerns or might help us decide the best strategies to use
in therapy. Sometimes our difficulties are not just due to personal issues but are also due
to expectations from our parents, friends, or society. The questions I'll be asking will
help us put together a more complete picture of what might be happening with you and
what might be causing the symptoms you came here to address. When we get to that
point, we can talk together to see if my ideas about what might be going on seem to be
on the right track. If there are any important issues I don't bring up, please be sure to let
me know. Do you have any questions before we begin?
Assessment and diagnosis are critical elements in the process of devising a treatment plan. An
introduction such as the one just presented helps set the stage for a collaborative and
contextual intake interview. Clients are informed that family, environmental, and social‐
cultural influences will be explored. With notable exceptions such as the Cultural
Formulation Interview (CFI) (Lewis‐Fernández, Aggarwal, Hinton, Hinton, & Kirmayer,
2016), many clinical assessments and interviews do not consider these factors. To remedy
this shortcoming, we stress the importance of both the collaborative approach, in which the
client and the therapist work together to construct an accurate definition of the problem, and
the contextual viewpoint, which acknowledges that both the client and the therapist are
embedded in systems such as family, work, and culture. These perspectives are gaining
support within various mental health professions. For example, ethical principles regarding
informed consent about therapy emphasize the need to give clients the information necessary
to make sound decisions and, thus, be collaborators in the therapy process (Behnke, 2004).
The importance of collaboration was also stressed in the report of the President's New
Freedom Commission on Mental Health (2003), in which clients are described as
“consumers” and “partners” in the planning, selection, and evaluation of services. As we have
already discussed, contextualism is also important—recognizing that both therapist and client
operate from their own experiences and worldviews. Just as clients may have socialization
experiences or experiences with prejudice or discrimination that play a role in their presenting
concerns, so might therapists hold worldviews or have had experiences that influence their
perceptions of the client or the client's issues.
Collaborative Conceptualization Model
CASE STUDY
ERICA
Erica is a biracial (North American father and Korean mother) college student who was
raised in Korea. She sought counseling to relieve feelings of loneliness and anxiety at
the university. Erica speaks unaccented fluent English and considers herself bicultural.
When asked to describe her background and her current problem, she was reluctant to
give much information. The counselor entertained the possibility that cultural constraints
might be involved in Erica's difficulty to talk about mental health issues and inquired
about how she would describe her problems in a Korean setting. Erica responded that in
Korea people did not convey their problems to others; it would be considered selfish and
self‐centered. With Erica's help, the problem was conceptualized as a conflict between
Korean norms and values and those of the United States. Erica's roommates believed she
was too “passive and meek” and encouraged her to be more assertive. Erica explained
that in Korea people were “tuned into” her needs, so she did not need to directly
verbalize them. Erica began to realize that her social anxiety and loneliness were related
to differing cultural expectations and concluded that she would need to learn new ways
of communicating. (Seeley, 2004)
The preceding example illustrates the importance of collaborative assessment and the value
of obtaining clients' input regarding social and cultural elements that may be associated with
their presenting problems. In what ways did Erica's counselor encourage collaboration? What
were the outcomes of these efforts?
Gambrill (2005) has identified ways in which therapists can enhance the accuracy and
effectiveness of assessment, conceptualization, and treatment planning. First, as we have
emphasized previously, therapists need to be aware of the impact of their own values,
worldviews, and beliefs on their practice. Similarly, clients' unique characteristics, values,
and circumstances should always be considered. Additionally, clients should be encouraged
to actively participate in the assessment and conceptualization process. In other words, case
conceptualization—as well as assessment—is best done in a collaborative manner, in which
therapist self‐awareness, client involvement, and the scientific method are all utilized. With
this approach, the therapist and the client can choose intervention strategies that involve the
integration of high‐quality research, clinical expertise, and client input.
Principles of Collaborative Conceptualization
Collaborative conceptualization (modified from Spengler, Strohmer, Dixon, & Shivy, 1995
to include client involvement) consists of the following steps:
1. Use both clinician skill and client perspective to understand the problem. Clinical
expertise is essential in assessment, developing hypotheses, eliciting client participation,
and guiding conceptualization. Therapists bring experience, knowledge, and clinical skill
to this process; clients bring an understanding of their own background and their
perspective on the problem. Therapists should be aware of their own values, biases,
preferences, and theoretical assumptions and how these factors might influence their
work with clients.
2. Collaborate and jointly define the problem. Within this framework, the clinician and the
client, either jointly or independently, formulate conceptualizations of the problem. A
joint process generally leads to more accurate conceptualization (e.g., “Erica, can you
tell me if you experienced these feelings when you were living in Korea?”, “How did
your family or community make meaning of your feelings?”). In cases where definitions
of the problem differ, these differences are discussed, and the agreed‐upon aspects of
the problem can receive primary focus. In some cases, the therapist can reframe the
client's conceptualization in a manner that results in mutual agreement.
3. Jointly formulate a hypothesis regarding the cause of the problem. The therapist can
tentatively address possibilities concerning what is causing or maintaining the problem
with questions such as, “Could the problems you are having feeling lonely and anxious
be related to your relatively new life on a university campus in the United States?”, “Are
your feelings related to cultural differences between you and your roommate and other
students on campus?”, “Do you think your experiences are related to cultural and value
differences between the United States and Korea?”, and “You mentioned before that you
get really down on yourself when you feel you aren't living up to your parents'
expectations. Do you think that might have anything to do with how you've been feeling
lately?”. When perceptions or explanations of the problem differ, these differences can
be acknowledged and an attempt can be made to identify and focus on similarities.
4. Jointly develop ways to confirm or disconfirm the hypothesis on the problem, continuing
to consider alternative hypotheses. The therapist might say, “If your anxiety and
loneliness are due, in part, to a conflict between the United States and Korean cultural
values and practices, how would we determine if this is the case?”, “How can we figure
out if your parents' wanting you to get all A's in college is part of what is going on?”, or
“What else might be involved in your feeling anxious? What about feeling lonely? Do
they always occur together?”.
5. Test out the hypothesis using both the client and the therapist as evaluators. The
therapist might ask, “You learned new ways of communicating—did that reduce your
anxious feelings or your sense of loneliness?”, “Did you make other changes sense our
last session? What were they? Do you think those changes reduced your feelings of
anxiety and loneliness?”, or “Did anything in your environment change sense our last
session?”
6. If the conceptualization appears to be valid, develop a treatment plan. The therapist
might say, “You mentioned you felt better when you spent some time with new friends
who were also from Korea. It sounds to me like you confirmed your hypothesis that your
loneliness was related to not feeling connected to people on campus. You noticed that
there was little change in your mood when you practiced more direct communications
with other students. Let's talk about how that important information can be used when
we decide how to best treat your anxiety.”
7. If the hypothesis is not borne out, jointly collect additional data and formulate new,
testable hypotheses. The therapist might say, “It's good we checked out the idea that
there is a connection between your mood and adopting more direct communications.
You mentioned that when you practiced being more direct with your peers, you felt even
more anxious. Can I ask you to share some of the thoughts that were going through your
head when you were practicing these new communication skills?”
We believe it is of critical importance to go through a collaborative process such as this;
therapist and client can adopt a scientific framework as they work to conceptualize the
problem and then have an equal voice in evaluating the problem definition. Unless there is
substantial agreement on the definition of a problem, therapeutic progress is likely to be less
than optimal.
There is a movement away from relying on “practitioners' ideology” or preferences for
treatment options to interventions that have received research support (Edmond, Megivern,
Williams, Rochman, & Howard, 2006). As mentioned in our discussion of EBP in Chapter 9,
we believe that intervention strategies should align with facilitating qualities possessed by
therapists (empathy, warmth, and genuineness), client characteristics (motivation, personality,
and support systems), and research‐based therapeutic techniques. Interventions should not
be rigidly applied, but instead should be modified according to client characteristics and
feedback. Consensus between therapist and client regarding the course of therapy strengthens
the therapeutic relationship. In addition, using a collaborative approach allows clients to
develop confidence that the therapist understands their issues and is using methods that are
likely to achieve desired goals. Thus, collaboration improves treatment outcome by
enhancing clients' hope and optimism.
Video 13.3: The Context of Assessment
Focusing on systemic issues such as environment can greatly increase and improve the
validity of both formal and informal assessments. Understanding how systems within the
client's sphere of existence impacts them can make assessments more reliable.
INFUSING CULTURAL RELEVANCE INTO STANDARD CLINICAL
ASSESSMENTS
Increasingly, interview forms and diagnostic systems are beginning to place greater emphasis
on collaboration or contextualism. Good clinical assessments incorporate the client
understanding of the presenting concern or disorder, an extensive exploration of their trauma
history (e.g., individual, gender, racial‐ethnic, cultural or historical, etc.) and strengths, as
well as an explicit exploration of their multiple identities and the contexts in which they live
(Comas‐Diaz, 2012).
Cultural Formulation Interview
I got to voice my opinion … what's on my mind, what's in my heart … It was beautiful …
It was freeing, a weight lifted off my shoulder
(Muralidharan et al., 2017, p. 40)
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5)
(American Psychiatric Association, 2013) acknowledges the importance of cultural influences
on diagnoses such as culture‐related and gender‐related issues for each mental disorder.
For effective assessment, determining the cultural context of the illness is “essential.” The
CFI includes an overall cultural assessment that takes into account the cultural identity of the
individual; cultural conceptualizations of distress, psychosocial stressors, and cultural
features of vulnerability and resilience; and cultural differences between the individual and
the clinician. It consists of 16 questions “that clinicians may use to obtain information during
a mental health assessment about the impact of culture on key aspects of an individual's
clinical presentation and care” (American Psychiatric Association, 2013, p. 750). Similar
mental health cultural assessment forms are available online (Transcultural Mental Health
Centre, 2015). Muralidharan et al. (2017) conducted debriefing interviews with racial and
ethnic minority veterans with psychotic disorders after they participated in a CFI. Much like
the participant quoted at the beginning of this section, they all reported positive therapy
engagement. Although DSM‐5 has expanded the emphasis on the importance of cultural
factors in assessment, most standard intake forms only provide cursory assessment of cultural
influences.
Therapists who recognize and value the importance of a collaborative and contextual
approach may decide to make modifications in standard assessment intake forms. We will
suggest ways in which consideration of cultural and environmental factors can be included in
or added to standard intake interviews.
Culturally Sensitive Intake Interview
Nearly everyone in the mental health field conducts diagnostic intake interviews during the
first sessions. Typically, the client is informed that the assessment session is not a therapy
session but rather a time to gather information in order for the therapist to get to know them
and to more fully understand their concerns. The specific relationship‐building skills
addressed in Chapter 9 are extremely important in the context of assessment. For example, it
is important that the clinician ask questions and respond to answers in a supportive and
empathetic manner.
Intake forms generally include questions concerning client demographic information, the
presenting problem, the history of the problem, previous therapy, psychosocial history,
educational and occupational experiences, family and social supports, medical and
medication history, and risk assessment. Many standard intake questions are focused
primarily on the individual, with little consideration of situational, family, sociocultural, or
environmental issues. We realize that it is difficult to modify the standard intake forms used
by clinics and other mental health agencies, but consideration can be given to these
contextual factors when gathering data or making a diagnosis. This section presents the
common areas of inquiry found in standard diagnostic evaluations and the rationale for each
(Rivas‐Vazquez, Blais, Rey, & Rivas‐Vazquez, 2001), together with suggestions for
specific contextual queries that can be used to supplement them when working with ethnic
minorities and other diverse populations.
Identifying information. Asking about the reason for seeking counseling allows the
therapist to gain an immediate sense of the client and his or her problem. Other
information gathered includes age, gender, ethnicity, marital status, and referral source.
It is also important to inquire about cultural groups to which the client feels connected.
Clinicians should consider whether other areas of diversity, such as religion, sexual
orientation, age, gender, or disability, are important in understanding the client or any of
the difficulties he or she is facing. For ethnic minorities or immigrants, clinicians can
inquire about the degree of acculturation or adherence to traditional values. When
relevant, ask about the primary language used in the home or the degree of language
proficiency of the client or family members. Determine whether an interpreter is needed.
(It is important not to rely on family members to translate when assessing clinical
matters.)
Presenting problem. To understand the source of distress in the client's own words,
obtain his or her perception of the problem and assess the degree of insight he or she has
regarding the problem and its chronicity. Some questions you can consider include:
What is the client's explanation for his or her symptoms? Does it involve somatic,
spiritual, or culture‐specific causes? Among all groups potentially affected by
disadvantage, prejudice, or oppression, does the client's own explanation involve
internalized causes (e.g., internalized heterosexism among gay males or lesbians, or
self‐blame in a victim of a sexual assault) rather than external, social, or cultural
factors? What does the client perceive are possible solutions to the problem?
History of the presenting problem. To assist with diagnostic formulation, it is helpful to
have a chronological account of and perceived reasons for the problem. It is also
important to determine levels of functioning prior to the problem and since it has
developed, and to explore social and environmental influences. When did the problem
first occur, and what was going on when this happened? Has the client had similar
problems before? How was the client functioning before the problem occurred? What
changes have happened since the advent of the problem? Are there any family issues,
value conflicts, or societal issues involving such factors as gender, ability, class,
ethnicity, or sexual orientation that may be related to the problem?
Psychosocial history. Clinicians can benefit from understanding the client's perceptions
of past and current functioning in different areas of living, as well as early socialization
and life experiences, including expectations, values, and beliefs from the family that
may play a role in the presenting problem. How does the client describe his or her level
of social, academic, or family functioning during childhood and adolescence? Were
there any traumas during this period? Were there any past social experiences or
problems with the family or community that may be related to the current problem?
McAuliffe and Eriksen (1999) describe some questions that can be used, when
appropriate, to assess social background, values, and beliefs: “How has your gender role
or social class influenced your expectations and life plans?”, “Do religious or spiritual
beliefs play a role in your life?”, “How would you describe your ethnic heritage; how
has it affected your life?”, “Within your family, what was considered to be appropriate
behavior in childhood and adolescence, and as an adult?”, “How does your family
respond to differences in beliefs about gender, acculturation, and other diversity
issues?”, and “What changes would you make in the way your family functions?”.
Abuse and trauma history. Despite the potential importance of determining if the client
is facing any harmful or dangerous situations, many mental health professionals do not
routinely inquire about abuse histories, even in populations known to be at increased risk
of abuse. In one study, even when the intake form included a section on abuse, less than
one‐third of those conducting intake interviews inquired about this topic (Young,
Read, Barker‐Collo, & Harrison, 2001). It is extremely important to address this issue,
since background information such as a history of sexual or physical abuse can have
important implications for diagnosis, treatment, and safety planning. The following
questions involve domestic violence for women (Stevens, 2003, p. 6) but can and should
be expanded for use with other groups, including men and older adults:
Have you ever been touched in a way that made you feel uncomfortable? Have you
ever been forced or pressured to have sex?
Do you feel you have control over your social and sexual relationships? Have you
ever been threatened by a (caretaker, relative, partner)?
Have you ever been hit, punched, or beaten by a (caretaker, relative, or partner)?
Do you feel safe where you live?
Have you ever been scared to go home? Are you scared now?
If, during the intake process, a client discloses a history of having been abused
and there are no current safety issues, the therapist can briefly and
empathetically respond to the disclosure and return to the issue at a later time
in the conceptualization or therapy process. Of course, developing a safety
plan and obtaining social and law enforcement support may be necessary when
a client discloses current abuse issues. Other forms of abuse and trauma should
also be assessed. For example, Carter and Sant‐Barket (2015) developed a
clinical assessment protocol using the Race‐Based Traumatic Stress
Symptom Scale.
Strengths. It is important to identify culturally relevant strengths, such as pride in one's
identity or culture, religious or spiritual beliefs, cultural knowledge and living skills
(e.g., hunting, fishing, folk medicine), family and community supports, and resiliency in
dealing with discrimination and prejudice (Hays, 2009). The focus on strengths often
helps put a problem in context and defines support systems or positive individual or
cultural characteristics that can be activated in the treatment process. This is especially
important for ethnic group members and individuals of diverse populations subjected to
negative stereotypes. What are some attributes they are proud of? How have they
successfully handled problems in the past? What are some strengths of the client's family
or community? What are sources of pride, such as school or work performance,
parenting, or connection with the community? How can these strengths be used as part
of the treatment plan? Using the client's strengths has been found to lower depression
and increase happiness (Gander, Proyer, Ruch, & Wyss, 2013).
Medical history. It is important to determine whether there are medical or physical
conditions or limitations that may be related to the psychological problem and that
should be taken into consideration when planning treatment. Is the client currently
taking any medications, or using herbal substances or other forms of folk medicine? Has
the client had any major illnesses or physical problems that might have affected his or
her psychological state? How does the client perceive these conditions? Is the client
engaging in appropriate self‐care? If there is some type of physical limitation or
disability, how has this influenced daily living? How have family members, friends, or
society responded to this condition?
Substance abuse history. Although substance use can affect diagnosis and treatment, this
potential concern is often underemphasized in clinical assessment. Because substance
use issues are common, it is important to ask about drug and alcohol use. What is the
client's current and past use of alcohol, prescription medications, and illegal substances,
including age of use, duration, and intensity? If the client drinks alcohol, how much is
consumed? Do the client or their family members have concerns about the client's
substance use? Has drinking or other substance use ever affected the client's social or
occupational functioning? What are the alcohol‐ and substance‐use patterns of family
members and close friends?
Risk of harm to self or others. Even if clients do not share information about suicidal or
violent thoughts, it is important to consider the potential for self‐harm and harm to
others. What is the client's current emotional state? Are there strong feelings of anger,
hopelessness, or depression? Is the client expressing intent to harm him‐ or herself?
Does there appear to be the potential to harm others? Have there been previous situations
involving dangerous thoughts or behaviors? Asking a client a simple question such as,
“How likely is it that you will hurt yourself?”, may yield accurate self‐predictions of
future self‐harm (Peterson, Skeem, & Manchak, 2011).
Diversity‐Focused Assessment
Diversity considerations can easily be infused into the intake process. Such questions can
help the therapist understand the client's perspective on various issues. Questions that might
provide a more comprehensive account of the client's perspective include (Dowdy, 2000):
How can I help you? This addresses the reason for the visit and client expectations
regarding therapy. Clients can have different ideas of what they want to achieve. Unclear
or divergent expectations between client and therapist can hamper therapy.
What do you think is causing your problem? This helps the therapist to understand the
client's perception of the factors involved. In some cases, the client will not have an
answer or may present an implausible explanation. The task of the therapist is to help the
client examine different areas that might relate to the problem, including interpersonal,
social, and cultural influences. However, one must be careful not to impose an
“explanation” on the client.
Why do you think this is happening to you? This question taps into the issue of causality
and possible spiritual or cultural explanations for the problem. Some clients may believe
the problem is due to fate or is a punishment for “bad behavior.” If this question does not
elicit a direct answer or if you want to obtain a broader perspective, you can inquire,
“What does your mother (husband, family members, friends) believe is happening to
you?”
What have you done to treat this condition? Where else have you sought treatment?
These questions can lead to a discussion of previous interventions, the possible use of
home remedies, and the client's evaluation of the usefulness of these treatments.
Responses can also provide information about previous providers of treatment and the
client's perceptions of prior treatment.
How has this condition affected your life? This question helps identify individual,
interpersonal, health, and social issues related to the problem. Again, if the response is
limited, the clinician can inquire about each of these specific areas.
IMPLICATIONS FOR CLINICAL PRACTICE
Although there is increased focus on cultural relevance in assessment, difficulties in
effective implementation of culturally competent practices are prevalent. Hansen et al.
(2006) conducted a random‐sample survey of 149 clinicians regarding the importance
of multicultural competencies and, more pertinently, whether they practiced these
recommendations. Although the participants rated competencies such as “Using DSM
Cultural Formulations,” “Preparing a Cultural Formulation,” “Using Racially/Ethnically
Sensitive Data‐Gathering Techniques,” and “Evaluating One's Own Multicultural
Competence” as very important, they were unlikely to actually use these competencies
in their practice.
What accounts for this discrepancy between the ratings of importance of multicultural
competencies and the actual use of recommended practices? We believe that a
contributing factor is the continued reliance on counseling and psychotherapy practices
that were developed without consideration of diversity issues or the impact of therapist
qualities on assessment and conceptualization. Many intake interviews and clinical
assessments continue to reflect the view that a disorder resides in the individual. Until
assessment questionnaires systematically include specific questions such as those
discussed in this chapter, cultural competency will receive only lip service.
Knowledge of cultural variables and sociopolitical influences affecting members of
different groups can sensitize therapists to possible cultural, social, and environmental
influences on individual clients. As you read the remaining chapters, which deal with a
variety of specific populations, we hope you do not see the information as an end in
itself, but rather as a means to assist you to create hypotheses when working
collaboratively with clients in the assessment and conceptualization process. As we
advise repeatedly throughout the chapters themselves, it is important not to stereotype
clients or to overgeneralize based on the information presented. Inappropriate reliance
on cultural information can lead to misdiagnosis and mistaken treatment
recommendations, such as seeking treatment with a folk healer. Such problems can be
minimized by combining cultural and traditional psychiatric or psychological
assessments (Paniagua, 2013).
In the following chapters on diverse populations, we present their various characteristics
and strengths, specific challenges of working with them, and the implications of these
factors for clinical practice. It is our hope that you will refer back to this chapter for
guidance as you strive to implement culturally competent practices with clients from
these specific populations.
SUMMARY
Accurate assessment, diagnosis, and case conceptualization are essential for the provision of
culturally appropriate treatment. Most clinicians recognize the importance of their clients'
socioeconomic status, gender, and racial/cultural background. However, they often forget that
their own beliefs, values, theoretical assumptions, and other biases can affect their clinical
judgment. Contextual and collaborative assessment, which infuses cultural factors into
standard intake and assessment procedures and takes into consideration the client's unique
personal and cultural background, can reduce diagnostic errors.
Assessment is influenced by both client and therapist variables. Clinicians should be aware of
the influence of stereotypes, and remain alert for common diagnostic errors. Such errors
include: (a) confirmatory strategy—searching only for evidence or information supporting
one's hypothesis; (b) attribution errors—holding a different perspective on the problem from
that of the client; (c) judgmental heuristics—using quick‐decision labels or automatic
associations; and (d) diagnostic overshadowing—minimizing the client's actual problem by
attending primarily to other prominent characteristics such as age, ethnicity, or sexual
orientation as causal factors. We are all susceptible to making errors, and it is important to
adopt a tentative stance and test out our observations.
Culturally responsive assessment involves self‐awareness, knowledge of culturally diverse
groups, specific clinical skills, and the ability to intervene at the individual, group,
institutional, and societal levels. This process works best with a contextual and collaborative
approach, acknowledging that both the client and the therapist are embedded in systems such
as family, work, and culture and working with the client to develop an accurate definition of
the problem, appropriate goals, and effective interventions. Steps involved in collaborative
assessment include: (a) using both clinician skill and client perspective to understand the
problem; (b) jointly defining the problem; (c) working together to formulate and evaluate a
hypothesis on the cause of the problem; (d) confirming or disconfirming the hypothesis; and
(e) developing a treatment plan.
Standard clinical assessment forms need to account for the cultural identity of the client,
cultural conceptualizations of distress and appropriate treatment, psychosocial stressors, and
any cultural differences between the client and the clinician. These diversity considerations
can easily be infused into the intake process.
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PART VI
Counseling and Therapy with Racial/Ethnic
Minority Group Populations
Chapter 14 Counseling African Americans
Chapter 15 Counseling American Indians/Native Americans and Alaska Natives
Chapter 16 Counseling Asian Americans and Pacific Islanders
Chapter 17 Counseling Latinx Populations
Chapter 18 Counseling Multiracial Populations
14
Counseling African Americans
Chapter Objectives
1. 1. Learn the demographics and characteristics of African Americans.
2. 2. Identify counseling implications of the information provided for African
Americans.
3. 3. Provide examples of strengths that are associated with African Americans.
4. 4. Know the special challenges faced by African Americans.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with African Americans.
During a routine traffic stop in a suburb of St. Paul, Minnesota Philando Castile was
shot seven times and killed by police officer, Jeronimo Yanez. Castile's girlfriend and
her daughter were in the car at the time of the death. Neither Castile nor his girlfriend
committed a crime, yet his girlfriend was handcuffed and placed in a squad car shortly
after the killing. Yanez was found not guilty for the killing even though the crime was
ruled a homicide and large portions of the incident were captured on video.
(Ellis & Kirkos, 2017)
The Department of Justice and the U.S. Attorney's Office investigated the Chicago
Police (CPD) in the aftermath of the fatal shooting of Black teenager Laquan McDonald
by Officer Jason Van Dyne. The agencies concluded that “CPD officers engage in a
pattern or practice of using force, including deadly force, that is unreasonable.” Officer
Van Dyke was eventually found guilty of second degree murder.
(U.S. Department of Justice Civil Rights Division & U.S. Attorney's Office Northern District of Illinois, 2017, p.
5)
The African American community has consistently named police violence directed at
their communities as a social problem and demanded justice and reform. The movement
for Black lives reflects the most recent efforts. The current movement was initially
sparked by three Black women's—Alicia Garza, Patrisse Cullors, and Opal Tometi—call
to action with the use of hash #BlackLivesMatter.
(McLaughlin, 2016)
In a study of women scientists working in the fields of science, technology, engineering,
and math, nearly half of African American women scientists had experienced being
mistakenly identified as custodial or administrative staff as compared to one‐third of
white women scientists. African American women attributed the incidents as because of
their race while white women believed that it was because of their gender.
(Williams, Phillips, & Hall, 2014)
African Americans have a history of advocating for justice and democracy. In the close
2017 Alabama senate race between Roy Moore (someone accused of sexual misconduct
with underage girls and who espoused racist, sexist, homophobic sentiments) and Doug
Jones (U.S. Attorney who prosecuted KKK members responsible for the church bombing
killing 4 Black girls), African Americans were largely responsible for Moore's defeat.
There was a high voter turn out, with 96% of African Americans voting for Jones (98%
of women and 94% of men).
(Bowerman, 2017)
The preceding scenarios illustrate the social conditions facing many African Americans and
the community's resilience and contributions to U.S. society. The African American
population was 46.3 million in 2015, representing about 13% of the total population (U.S.
Census Bureau, 2017). Overall, African Americans' economic health is significantly less
stable than that of the general U.S. population. For example, the poverty rate for African
Americans remains nearly twice as high as that of all households (25.4% versus 14.7%) (U.S.
Census Bureau, 2017), and the unemployment rate is over twice that of White Americans
(9.5% versus 4.6%) (U.S. Department of Labor, 2015). There is also a wealth gap, with
Whites having a net worth 13 times greater than African Americans (Pew Research Center,
2016). Of African American men, 38% are experiencing downward mobility out of the
middle class, compared with 21% of White men (Acs, 2011). Further, infant mortality for
Blacks is over twice that of Whites (Centers for Disease Control, 2013), and the lifespan of
African Americans is 5–6 years shorter than that of White Americans. Although African
Americans make up only 13% of the U.S. population, 40% of those incarcerated are Black,
while Whites, who make up 64% of the population, account for only 39% of those in prison
(Hagler, 2015). African American women are also more likely to be arrested than Latinas or
White women (Brame, Bushway, Paternoster, & Turner, 2014).
Although these statistics are grim, much of the literature is based on the economically
disadvantaged rather than on other segments of the African American population (Holmes &
Morin, 2006). This focus on those living in poverty masks the great diversity that exists
among African Americans and the significant variance in socioeconomic status, educational
level, cultural identity, family structure, and reactions to racism. For example, 38% of
African American households are middle income and 12% are upper income, compared with
44% and 26% of White households, respectively (Parlapiano, Gebeloff, & Carter, 2015).
Many middle‐ and upper‐class African Americans embrace the values of the dominant
society, believe that advances can be made through hard work, feel that race has a relative
rather than a pervasive influence on their lives, and take pride in their heritage. As Hugh
Price, former president of the National Urban League, observed, “This country is filled with
highly successful Black men who are leading balanced, stable, productive lives working all
over the labor market” (Holmes & Morin, 2006, p. 1). However, even among this group of
successful African American men earning $75,000 a year or more, six in ten reported being
victims of racism and having someone close to them murdered or incarcerated.
CHARACTERISTICS AND STRENGTHS
In the following sections, we consider the characteristics, values, and strengths of African
Americans and their implications in treatment. African Americans are becoming increasingly
heterogeneous in terms of ethnic and racial identity, social class, educational level, and
political orientation, so it is important to remember that the following are generalizations;
their applicability needs to be assessed for each client.
Racial and Ethnic Identity
Racial identity attitudes play a role in African Americans' mental and physical health. Cross'
(1991, 1995) nigrescence model, as outlined in Chapter 11, describes movement from a
raceless identity to a positive, internalized Black identity. Cross identifies the statuses of
preencounter, encounter, immersion‐emersion, and internalization. These statuses are
associated with differences in perspective regarding the self and relationships with others,
including the acceptance of White standards and deprecation of Black culture and an
appreciation of both Black culture and aspects of the White culture. An individual's level of
racial identity affects awareness of and willingness to discuss racial issues or racism
(Forsyth, Hall, & Carter, 2015).
Implications
African Americans who have attitudes and behaviors consistent with the preencounter level
are less likely to report racial discrimination, whereas those in the immersion stage tend to be
least satisfied with societal conditions. African Americans with the greatest internalization of
Black‐multicultural racial identity report the highest psychological adjustment (Telesford,
Mendoza‐Denton, & Worrell, 2013). African American preferences for counselor ethnicity
are often related to their current stage of racial identity. Parham and Helms (1981) found that
African Americans with higher preencounter attitudes preferred a White counselor, whereas
those in later stages preferred an African American counselor. In a study involving 128 Black
college students, over 75% had no preference regarding the race of the counselor for issues
such as depression, anxiety, drug or alcohol problems, meeting new people, overcoming
loneliness, and dealing with anger. However, 50% indicated preference for a Black counselor
for racial issues and problems with personal relationships. Elevated cultural mistrust and
strong internalized Afrocentric attitudes were associated with a stronger preference for a
Black counselor (Townes, Chavez‐Korell, & Cunningham, 2009).
Often, the most important counselor characteristic for African Americans is the cultural
sensitivity of the counselor. Culturally sensitive counselors (those who acknowledge the
possibility that race or culture might play a role in a client's problem) are seen as more
competent than culture‐ or color‐blind counselors (those who do not assess for
environmental issues such as racial prejudice) (Gushue, Walker, & Brewster, 2017; Want,
Parham, Baker, & Sherman, 2004). Among a group of working‐class African American
clients, the degree of therapeutic alliance with White counselors was affected not only by the
client's racial identity attitudes but also by similarities in gender, age, attitudes, and beliefs.
Additionally, clients facing issues related to parenting, drug use, or anxiety looked for
therapists with understanding of these specific issues (Ward, 2005).
Family Structure
African American family structure is complicated and consists of the nuclear and the
extended family. Blood relatives and fictive kin (close family friends) play important roles in
promoting the health and well‐being of the family unit. In terms of traditional indicators of
family, about 45% of African American households are headed by married couples (U.S.
Census Bureau, 2017). Although there has been a significant decline in nonmarital births in
the United States across racial and ethnic groups, African Americans have the highest birth
rate among nonmarried women, at 69.8% (Centers for Disease Control, 2018). African
American children are more likely to live in a household with a grandparent present (5.6%)
compared to White American children (2.6%) (U.S. Census Bureau, 2016). Given the varied
structure of African American families, it is important to take into account kinship bonds with
extended family and friends, as illustrated in the following case study.
CASE STUDY
JOHNNY
A mother, Mrs. J., brought her 13‐year‐old son Johnny in for counseling due to
recent behavioral problems at home and in school. After asking, “Who is living in the
home?” the therapist learned that Johnny lived with his mom, a stepfather, and five
brothers and sisters. Also, the mother's sister, Mary, and three children had been staying
with the family while their apartment was repaired. The mother also had a daughter
living with an aunt in another state. The aunt was helping the daughter raise her child.
When asked, “Who helps you out?” Mrs. J. responded that her mother sometimes helps
watch the children but that, more frequently, a neighbor (who has children of a similar
age) watches the younger children when Mrs. J. works during school hours.
Further questioning revealed that Johnny's problem developed soon after his aunt and
cousins moved in. Before this, Johnny had been his mother's primary helper and took
charge of the children until the stepfather returned home from work. The changes in the
family structure that occurred when the sister and her children arrived were stressful for
Johnny. Family treatment included Mrs. J. and her children, the stepfather, Mary and her
children, and Mrs. J.'s mother. Pressures on Johnny were discussed, and alternatives
were considered. Mrs. J.'s mother agreed to invite Mary and her children to come live
with her temporarily. To deal with these additional disruptions in the family, follow‐up
meetings focused on clarifying roles in the family system. Johnny once again assumed
the role of helping his mother and stepfather watch the younger children. Within a
period of months, his behavioral problems at home and in school disappeared.
Implications
Because of the possibility of the complexity of the family arrangements, questions should be
directed toward clarifying who is living in the home and who helps with childcare. Therapists
should work to strengthen and increase functionality of the existing family structure rather
than attempt to change it. One of the strengths of the African American family is that men,
women, and children are allowed to adopt multiple roles within the family. For example, as in
the case of Johnny, older children might adopt a caretaking role, and friends or grandparents
might help raise children. In such cases, therapy might focus on enhancing the working
alliance among caregivers (Muroff, 2007).
A counselor's reaction to a client's family structure may be affected by a Eurocentric,
nuclear‐family orientation. Similarly, many assessment forms and evaluation processes are
based on a middle‐class European American perspective of what constitutes a family. For
family therapy to be successful, counselors must first identify their own set of beliefs and
values regarding appropriate roles and communication patterns within a family and take care
not to impose these beliefs on other families. Similarly, it is helpful to move away from a
deficit model to an asset or strengths perspective when evaluating families (Rockymore,
2008). For example, a supportive parenting style that includes warmth, communication, and
consistent discipline appears to be protective against drug use by African American youth
(Gibbons et al., 2010). However, physical discipline or critical comments, unless unduly
harsh, should not necessarily be viewed negatively; each situation should be assessed
individually. Culturally sensitive parent education programs designed for African Americans
focus on different types of discipline, single parenting, and strategies for dealing with culture
conflicts and responding to racism. In working with African American families living in high
concentrations of poverty, the counselor may need to assume various roles, including
advocate, case manager, problem solver, and facilitating mentor, and to help the family
navigate community systems, including the educational or judicial system.
Spiritual and Religious Values
CASE STUDY
Dee
Dee is a 42‐year‐old African American woman recently divorced after 20 years of
marriage and raising two children with little support from her ex‐husband. She
presented with depressive‐like symptoms—feelings of loneliness, lack of energy, lack
of appetite, and crying spells … Although part of the treatment focused on traditional
psychological interventions, such as cognitive restructuring, expression of feelings, and
changing behaviors, D.'s treatment also included participation in two church‐related
programs, including the women's ministry, a program that provides social and emotional
support. Treatment also included participation in “The Mother to Son Program,” a
program targeting single mothers parenting African American boys. This program
provides support for mothers and mentoring relationships for their sons. (Queener &
Martin, 2001, p. 120)
Implications
Religion and spirituality are important to many African Americans, like Dee, and serve as a
protective factor in response to stressors; church participation provides comfort, economic
support, and opportunities for self‐expression, leadership, and community involvement.
Over 75% of African Americans state that religion is very important to them and rely on
religious and spiritual communities to deal with mental health issues (Avent & Cashwell,
2015). Among a sample of low‐income African American children, those whose parents
regularly attended church had fewer problems (Christian & Barbarin, 2001). Support systems
connected with the church (including friends and club involvement) were found to promote
resilience in African American undergraduates exposed to racial microaggressions (Watkins,
Labarrie, & Appio, 2010). The African American church often functions as a religious, social,
and political hub, facilitating social events that serve to foster a sense of “peoplehood”
(Boyd‐Franklin, 2010).
If a client is heavily involved in church activities or has strong religious beliefs, the counselor
might consider enlisting church leaders to help them (or their family) deal with social and
economic stressors or conflicts involving the family, school, or community. Church personnel
are often aware of the family dynamics and living conditions of parishioners. In addition,
churches often sponsor parenting programs or activities that enrich family life.
Educational Characteristics
CASE STUDY
JACKIE
Jackie, a 10‐year‐old African American girl, came in with her mother presenting with
anger problems, low mood, suicidal thoughts, and family discord. She had always been a
stellar student, but her grades had begun to fall from straight As to Bs and Cs. Jackie
notes that “she is not smart enough to keep up with the other kids.”
(Muroff, 2007, p. 131)
Implications
African American parents, acutely aware of obstacles produced by racism and economic
conditions, often encourage their children to develop career and educational goals at an early
age. In one study of 1,225 school‐aged African American males (6th to 10th graders), 62%
aspired to go to college, similar to rates for White male students. Black males with plans to
attend college frequently reported positive feelings about their school and teachers (Toldson,
Braithwaite, & Rentie, 2009). Although gains have been made, the gap in high school
graduation between African American and White children persists. In the 2014–2015 school
year, the adjusted cohort graduation rate for African Americans was 75%, compared to 88%
for White Americans (NCES, 2017). Similarly, more and more Black Americans are going to
college, but they have different college experiences and graduation rates compared to their
White counterparts. Black students are much more likely to attend a 2‐year institution or go
to college part time and less likely to graduate from a 4‐year institution in 6 years
(Casselman, 2014); about 20.6% of Black students who entered college in 2009 earned their
degree, compared to 44.2% of White students (NCES, 2017).
The educational environment is often negative for African American youth. They are two to
five times more likely to be suspended from school, and often receive harsher consequences
than their White peers (Rudd, 2014). School personnel often hold stereotypes of African
American parents as being neglectful or incompetent and blame children's problems on a lack
of parental support for schooling. As one teacher stated, “The parents are the problem! They
[the African American children] have absolutely no social skills, such as not knowing how to
walk, sit in a chair, … it's cultural” (Harry, Klingner, & Hart, 2005, p. 105); but when
researchers visited the homes of parents who were criticized, they often observed parental
love, effective parenting skills, and family support for education.
When working with African American school‐age youth around academic performance, it is
thus important to consider the ways in which teacher low expectations and school policies
and practices may inadvertently discriminate against Black youth. A lot of national attention
has rightly focused on Black boys' experiences in schools. Unfortunately, the experiences of
Black girls, like Jackie, have been left out of this discourse. Black girls are being
marginalized in the classroom, and in some instances pushed out of school altogether (Morris,
2016). In addition to significant racial disparities in expulsion rates, Black girls experience
vulnerabilities that undermine their school attendance and educational opportunities. They
receive less attention than their male counterparts, and schools often do not intervene in
situations of sexual harassment; additionally, Black girls report feeling uncomfortable with
security protocols at schools (Crenshaw, Oce, & Nanda, 2015). Psychological interventions
should consider the contexts in which youth operate and identify individual and system‐
level changes.
African American Youth
CASE STUDY
MICHAEL
Michael is a 19‐year‐old African American man brought to counseling by his aunt,
Gloria, with whom he has lived for the past 2 years. Gloria is concerned about Michael's
future … Although Michael graduated from high school and is employed part‐time at a
fast‐food restaurant, he is frustrated with this work and confused about his future. He
believes that Black men “don't get a fair shake” in life and is discouraged about his
prospects about getting ahead … Michael's aunt … is concerned that Michael's peers are
involved in gangs and illegal activities. She thinks the rap music he listens to is
beginning to fill his head with hate and anger … Michael's major issues center around a
need to develop a positive identity as an African American man and discover his place in
the world.
(Frame & Williams, 1996, p. 22)
Frame and Williams (1996) suggested several strategies for working with African American
youth such as Michael. The first is based on the African tradition of storytelling and involves
the use of metaphors. In response to statements like, “Black men don't get a fair shake,”
counselors can encourage clients to identify family phrases or Biblical stories that instill
hope. Additionally, the writings of prominent African Americans can be used to generate
metaphors. To assist Michael with his struggle to overcome societal barriers, he could be
encouraged to envision himself as a crusader for human rights as a socially appropriate way
of directing his anger. The counselor could also engage Michael in discussions about rap
music; issues addressed in the lyrics could be explored, as well as healthy outlets for feelings
of anger or despair. Family and community support for Michael could be generated by
including extended family, the pastor, teachers, and other important individuals in Michael's
life and encouraging them to discuss their own struggles and search for identity. Use of
techniques such as these, derived from African American experiences, can lead to personal
empowerment.
In counseling African American girls, issues involving racial, gender, and racial‐gender
identity should be explored. Counselors can help African American girls and women
counteract negative images associated with being Black and being female. Enhancing their
internal strength by developing their pride and dignity in Black womanhood can serve as a
buffer to racism and sexism, can prevent the incorporation of negative images into their belief
systems (Owens, Stewart, & Bryant, 2011), and can improve their psychological well‐being
(Lewis, Williams, Peppers, & Gadson, 2017).
Cultural Strengths
Protective factors and strengths among African Americans include positive ethnic identity or
racial pride; resourcefulness and coping skills to deal with societal issues; familial, extended
kin, and community support systems; flexible family roles; achievement orientation; and
spiritual beliefs and practices (Kaslow et al., 2010; LaTaillade, 2006). Family and religious
protective factors have been hypothesized to account for findings that African Americans
have lower levels of heavy and binge drinking than any other ethnic group, with the exception
of Asian Americans (Substance Abuse and Mental Health Services Administration, 2013).
Additionally, African American adolescents have low rates of substance use compared to
Whites and other ethnic groups (Johnston, O'Malley, Miech, Bachman, & Schulenberg,
2014).
The African American family structure has many advantages. Among families headed by
females, the rearing of children is often undertaken by a large number of relatives, older
children, and close friends. For many, the extended family network provides emotional and
economic support. African American families are characterized by flexibility in family roles,
strong kinship bonds, a strong work and achievement ethic, and a strong religious orientation
(McCollum, 1997; Rockymore, 2008). Kinship support diminishes risks of internalizing or
externalizing problem behaviors in children and can ameliorate conditions such as poor
parenting (Taylor, Larsen‐Rife, Conger, Widaman, & Cutrona, 2010). Among low‐income
single mothers, many display substantial parenting involvement and emphasize achievement,
self‐respect, and racial pride with their children.
Despite the challenges of racism and prejudice, many African American families have been
able to instill positive self‐esteem in their children by means of role flexibility. African
American men and women value behaviors such as assertiveness. Compared to White
American families, African American men are more accepting of women's work roles and are
more willing to share in the family responsibilities traditionally assigned to women. Many
women demonstrate a “Strong Black Woman” image that includes pride in racial identity,
self‐reliance, and capability in handling challenges—all while nurturing the family.
Although self‐efficacy can be a strength, excessive investment in meeting the expectations
of such a role can lead to emotional suppression and increased vulnerability to stress
(Donovan & West, 2015; Harrington, Crowther, & Shipherd, 2010).
SPECIFIC CHALLENGES
In the following sections, we consider challenges often faced by African Americans and
consider their implications in treatment.
Racism and Discrimination
Racism and discrimination are significant concerns within the African American community.
As former President Obama observed during his eulogy for Rev. Clementa Pinckney and
eight of his congregants who were shot to death by a White supremacist, racial bias can be
evident or may occur without realization, such as “the subtle impulse to call Johnny back for
a job interview—but not Jamal” (Moser, 2015). A study by Bertrand and Mullainathan (2004)
found that résumés with either African American or White‐sounding names (Lakisha and
Jamal versus Emily and Greg) sent to help‐wanted ads received a differential response. The
“White” names received 50% more calls for interviews.
African Americans perceive both subtle and direct forms of racism in the United States.
Whereas a little over half of Whites (53%) believe Blacks have equal societal opportunities,
88% of Blacks believe more change is necessary (Pew Research Center, 2016). Due in part to
the deaths of unarmed Black people at the hands of the police, 84% of Americans believe that
Blacks are treated unfairly by police (Pew Research Center, 2016). A movement for Black
lives has arisen to take a stand against police brutality and the anti‐Black racism in society.
In response to the tragedy involving Sandra Bland, whose stop for changing lanes without
signaling resulted in a sequence of events that ended with her death, U.S. Attorney General
Loretta Lynch remarked,
I think that it highlights the concern of many in the Black community that a routine stop
for many of the members of the Black community is not handled with the same
professionalism and courtesy that other people may get from the police.
(Glum, 2015)
The specific Black Lives Matter movement points out that Black people are singled out and
“intentionally left powerless at the hands of the state … and are deprived of basic human
rights and dignity” (Black Lives Matter, 2015). This movement is gaining strength nationally
and challenging instances of racism against African Americans.
Consciously or unconsciously, many people associate African Americans with crime and
favor harsher punishments for African Americans. The media perpetuates the perception of
African Americans as criminals. A recent study found that Black families were significantly
more likely to be portrayed by various media outlets as dependent, dysfunctional, and
criminal than were White families (Dixon, 2017); for example, although African Americans
constitute about 27% of those arrested and charged with a crime, they make up 37% of news
stories about those who have committed crimes. It is no surprise that individuals internalize
these ubiquitous messages. In research studies, Whites, when primed to think about crime,
focused their attention on Black rather than White faces and were more likely to identify
blurry images as weapons when exposed to Black faces. When Whites read descriptions of a
juvenile offender convicted of rape, they supported harsher sentences when he was described
as Black (Weir, 2014). In a study involving African American defendants who were
convicted of killing White victims, Eberhardt, Davies, Purdie‐Vaughns, & Johnson (2006)
found that defendants with darker skin and broader noses were twice as likely to receive the
death penalty compared to those who looked less stereotypically Black. Similarly, Viglione,
Hannon, and DeFina (2011) found that African American women with lighter skin received
shorter sentences than those with darker skin who committed similar crimes.
Youth with an incarcerated parent have increased risk of poverty, school failure, emotional
distress, criminal activity, and drug use. This effect can further exacerbate the cycle of racial
inequality, substance abuse, and imprisonment (Roettger, Swisher, Kuhl, & Chavez, 2011).
The experience of perceived racial discrimination is associated with decreased levels of
self‐esteem and life satisfaction and increased depressive symptoms in African American
and Caribbean Black youth (Seaton, Caldwell, Sellers, & Jackson, 2011). Some African
American adolescents report drug use as a way of coping with feelings of anger in reaction to
racial discrimination (Gibbons et al., 2010).
African American parents differ in the ways in which they address racism with their children.
Some address racism and prejudice directly and help their children to develop a strong Black
identity, whereas others consider race to be of minor importance, ignore the topic of race, and
focus on human values or discuss the issue only if it is brought up by their children. Racial
socialization can help buffer the negative effects of racism and discrimination (Lee & Ahn,
2013). In homes where race is not discussed, children have fewer opportunities to develop
coping strategies when faced with discrimination. Similarly, protective factors for African
American youth include a parental focus on increasing positive feelings about self and
enhancing a sense of pride in one's culture (Belgrave, Chase‐Vaughn, Gray, Addison, &
Cherry, 2000). Messages of cultural pride from parents are associated with the development
of positive ethnic identity, self‐esteem, and socioemotional competence in African
American children (Rodriguez, McKay, & Bannon, 2008). Therapists may decide to discuss
the positive benefits of racial socialization with African American parents. The American
Psychological Association's RESilience initiative has produced several resources to help
therapists and parents uplift “youth through healthy communication about race” (American
Psychological Association, n.d.).
Implications
Since the mental health environment is a microcosm of the larger society, mental health
professionals need to identify their own racial attitudes and be ready to address mistrust from
African American clients concerned about being viewed through the lens of a stereotype
(Jordan, Lovett, & Sweeton, 2012). Therapists should carefully assess both the problems
confronting a client and the client's response to the problem situation, including the way he or
she usually deals with racism, with the understanding that the expression of racism may differ
depending on the person's gender, class position, sexual orientation, and religion.
Jones (1985) described four interactive factors that should be considered in working with
African American clients (see Figure 14.1). The first is racial oppression. Most African
Americans have faced racism, and the possibility that this factor plays a role in the presenting
problem should be examined. Other interactive factors described by Jones include the
possible influence of African American culture and traditions on the client's behavior, the
degree to which the client has adopted majority culture values, and the client's personal
experiences. Individual experiences with racial oppression can vary significantly among
African Americans. The task of the therapist is to help the client understand the effects of
such experiences and allow this understanding to guide conscious, growth‐producing
choices.
IMPLICATIONS FOR CLINICAL PRACTICE
The first therapy sessions are crucial in determining whether a client will return. African
Americans have a high rate of therapy termination (Fortuna, Alegria, & Gao, 2010).
Termination often reflects a counselor's inability to establish an effective therapeutic
alliance. Prior experiences may render issues of trust very important. The counselor can
deal with these issues by discussing them directly and by being open, authentic, and
empathetic. Clients often make a decision regarding continuation of therapy based on
their personal evaluation of the counselor. As one African American client stated, “I am
assessing to see if that person [counselor] is willing to go that extra mile and speak my
language and talk about my Blackness” (Ward, 2005, p. 475). Counselors may need to
have a broader role and more flexible style, including being more direct, serving in an
educative function, and helping the client deal with agencies or with issues involving
health and employment. Although the order of these elements can be modified and some
can be omitted, these steps may be helpful to the counselor and the client:
1. Understand that power and privilege can affect counseling. During the first session, it
may be beneficial to bring up the reaction of the client to the session. Makes statements
such as, “Sometimes clients feel uncomfortable working with a counselor of a different
race. Would this be a problem for you?” Or, when the counselor is Black, “Clients have
different responses to the race of their counselor, what does it mean to you to have a
counselor who is also Black?” Be open if the client discusses any experiences with
racism or discrimination, or if they indicate that race does not matter.
2. Recognize that there is great diversity among African Americans. Assess the clients'
values and preferences by identifying their expectations and worldview and what they
believe counseling entails. Explore their feelings about counseling. Determine how they
view the problem and possible solutions.
3. If clients are there involuntarily, discuss how counseling can be made useful for them.
Explain your relationship with the referring agency and the limits of confidentiality.
4. Assess the positive assets of the client, such as personal strengths, family (including
relatives and nonrelated friends), and available community resources (including the
church).
5. Help the client define goals and appropriate means of attaining them. Assess ways in
which the client, family members, and friends have handled similar problems
successfully.
6. After the therapeutic alliance has been formed, collaboratively determine interventions.
Consider culturally adapted evidence‐based therapies that have been found to be
effective with African Americans. Problem‐solving and time‐limited approaches may
be most acceptable. Analysis of the client's racial identity and family can be helpful in
deciding if alternative treatment modes and approaches might be beneficial.
7. Determine any external factors that might be related to the presenting problem.
Determine whether and how the client has responded to discrimination and racism, in
both unhealthy and healthy ways. Do not dismiss issues of racism as “just an excuse”;
instead, help the client address issues of discrimination and identify productive means of
dealing with such problems.
8. Examine issues around racial identity, taking into account that many clients at the
preencounter stage will not believe that race is an important factor. For some, increased
Afrocentric identification will be important in establishing a positive self‐identity. In
these cases, elements of African/African American culture can be incorporated in
counseling through readings, movies, music, and discussions of prominent African
Americans.
FIGURE 14.1 The Interaction of Four Sets of Factors in the Jones Model
Source: Jones, A. C. (1985). Psychological functioning in Black presenting Americans: A conceptual problem guide
for use in psychotherapy. Psychotherapy, 22, 367. Copyright 1982 Psychotherapy. Reprinted with permission
Select this link to open an interactive version of Figure 14.1
Video Lecture: Culturally Competent Counseling: Innovative Approaches to Counseling
African Descent People by Thomas Parham
SUMMARY
African Americans represent approximately 13% of the U.S. population. On nearly all
measures of education, employment, earnings, and psychological and physical health, they
experience a standard of living much below their White counterparts. Individual, institutional,
and cultural racism accounts for many of these disparities. The life experience of African
Americans affects the manifestation of mental disorders and the therapeutic process. To work
effectively with African American clients, therapists must be knowledgeable of their
characteristics and strengths. Ethnic and racial identity, family structure, spiritual and
religious values, education characteristics, and the experiences of Black youths all suggest
important dimensions to consider in counseling African Americans. An important aspect of
cultural competency with African Americans is the recognition of protective factors and the
strengths that have allowed them to survive in an intolerant society. Eight clinical
implications for counselor practice are identified.
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15
Counseling American Indians/Native Americans and Alaska
Natives
Chapter Objectives
1. 1. Learn the demographics and characteristics of American Indians and Alaska
Natives.
2. 2. Identify counseling implications of the information provided for American
Indians and Alaska Natives.
3. 3. Provide examples of strengths that are associated with American Indians and
Alaska Natives.
4. 4. Know the special challenges faced by American Indians and Alaska Natives.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with American Indians and Alaska Natives.
Many American Indian children were forced to attend boarding schools far away from
their homes in which they were compelled to adopt European American culture.
Although attendance at such schools for the most part ended in the late 1960s, we still
see remnants of intolerant attitudes among teachers. Mirranda Washinawatock was
publicly ridiculed and punished for speaking her native Menominee at her Catholic
school. This was particularly hurtful to many of the older tribe members who remember
being beaten for speaking their language, which sadly accounts for some of the loss of
the language now.
(Black, 2012)
For nearly two years, the Energy Transfer Partners worked to receive federal approval
to build pipeline to carry crude oil from North Dakota to Iowa, passing through
Standing Rock Sioux land. American Indians from across the country, joined their Sioux
brothers and sisters to protest the construction of the pipeline because of the desecration
of sacred land and the likelihood that the water and soil in the affected areas would
become polluted. Among President Donald Trump's first actions in office in January
2017 was to issue a Presidential Memorandum approving the construction of the
pipeline. And, as anticipated there were leaks within a few months of operation.
(Smith & Bosman, 2017)
In 2014, the city of Eureka, California, drafted an apology to the Wiyot tribe for the
1860 massacre on Indian Island, during which 200 sleeping Wiyot, including women
and children, were slaughtered. The City Council removed the apology part of the letter
for fear of opening itself up to liability and substituted language acknowledging that the
Wiyot people had been massacred but not stating who was responsible.
(Lee, 2015)
The American Indian/Alaska Native (AI/AN) population is about 5.4 million people,
representing nearly 2% of the U.S. population. AI/AN form a highly heterogeneous group
composed of 566 distinct tribes, with about 170 languages (U.S. Census Bureau, 2015). In
fact, over a quarter (26.8%) of AI/AN people speak another language other than English in
the home. About 22% of American Indians live on reservations, whereas 60% reside in
metropolitan areas (Office of Minority Health, 2012). The high school graduation gap has
narrowed over the years: 82.4% of AI/AN have graduated high school, compared to 86.9% in
the general U.S. population (U.S. Census Bureau, 2015). American Indians have the highest
national poverty rate, 28.3%, with income only 69% of the mean income of all households
(U.S. Census Bureau, 2015). AI/AN differ in their degree of acculturation. Although most do
not live on reservations or with their tribes, many are returning because of casino jobs or a
more nurturing environment. One man who returned described his need for a more “friendly
place, friendly face, and friendly greetings” (Shukovsky, 2001, p. A1).
What constitutes an Indian is often an area of controversy. The U.S. Census depends on
self‐report of racial identity. Congress has formulated a legal definition: An individual must
have an Indian blood quantum of at least 25% to be considered an Indian. This definition has
caused problems both within and outside the Indian community. Some tribes have developed
their own criteria and specify either tribal enrollment or blood quantum levels. Tribal
definitions typically allow inclusion of the 60% of American Indians who have mixed
heritage, including Black, White, and Latinx backgrounds (Trimble, Fleming, Beauvais, &
Jumper‐Thurman, 1996).
Because AI/AN make up such a small percentage of the U.S. population, they are relatively
“invisible,” which makes information about them susceptible to stereotypes. This is one of
the reasons many oppose the use of Indian‐themed mascots and logos. American Indians
want the ability to define themselves and are aware of the harmful effects of stereotyped
portrayals (Jacobs, 2014). American Indian high school and college students who viewed
these types of images reported higher levels of depression, lower self‐esteem, and decreased
feelings of community worth (Fryberg, Markus, Oyserman, & Stone, 2008). In examining
online responses to this controversy, Steinfeldt et al. (2010) found hostile and racially
offensive attitudes from mostly White respondents: “If the nickname is taken away, we
should take away Indian educational programming and funding” and “We are being
victimized by reverse racism and PC society.”
Health statistics reveal significant disparities. The death rate by any cause is nearly 50%
higher for AI/AN persons than for White individuals (Espey et al., 2014). AI/AN individuals
have death rates for unintentional injuries due to motor vehicle traffic crashes, poisoning, and
falls that are 1.4 to 3.0 times higher than among Whites (Murphy et al., 2014). Injuries and
violence account for 75% of all deaths for AI/AN between the ages of 1 and 19. These
populations also suffer disproportionately from depression, anxiety, and substance abuse
(Office of Minority Health, 2012). Among Native American women at a private care facility
in New Mexico, 21% reported mood disorders, 47% had an anxiety disorder, and 14% had
alcohol dependence or abuse issues. These rates are 2.0 to 2.5 times higher than found in the
general population (Duran et al., 2004).
CHARACTERISTICS AND STRENGTHS
In the following sections, we discuss the characteristics, values, and strengths of AI/AN
populations and consider their implications in treatment. Remember that these are
generalizations and that their applicability needs to be assessed for particular clients and their
families.
Tribal Social Structure
For the many American Indians living both on and off reservations, the tribe is of
fundamental importance. The tribe and the reservation, an interdependent system, provide
Native Americans with a sense of belonging and security. Tribal connections are significant
because individuals see themselves as an extension of their tribe. Status is achieved, and
rewards gained, by adherence to tribal structure. American Indians judge themselves in terms
of whether their behaviors are of benefit to the tribe. Personal accomplishments are honored
and supported if they serve to benefit the tribe.
Implications
Interventions and decision‐making with AI/AN individuals should take into account the
importance placed on tribal relationships. In a study of 401 AI/AN youth (half tribal‐based
and half urban‐based), urban‐based youth were more likely to identify personal, familial,
and environmental strengths than were tribal‐based youth, whereas the latter identified more
tribal strengths (Stiffman et al., 2007). The tribe is very important for many Indians, even
those who do not reside on a reservation. Many use the word here to describe the reservation
and the word there to describe everything that is outside. The reservation is a place to
conduct ceremonies and social events and to maintain cultural identity. American Indians
who leave the reservation to seek greater opportunities sometimes report losing their sense of
personal identity (Lone‐Knapp, 2000).
Family Structure
It is difficult to describe “the Indian family.” It varies from the matriarchal structures seen in
the Navajo, where women govern the family, to patriarchal structures, in which men are the
primary authority figures. Some generalizations can be made, however. A high fertility rate
and strong roles for women are commonly seen. For most tribes, the extended family is the
basic unit. Children are often partially raised by relatives, such as aunts, uncles, and
grandparents, who live in separate households (Garrett, 2006).
Implications
The concept of the extended family is often misunderstood by those in the majority culture
who operate under the concept of the nuclear family. Misinterpretations are possible if a
counselor believes that parents should raise and be responsible for their own children. The
extended family often includes distant relatives and even friends. It is not unusual for children
to stay in multiple households. In work with children, counselors should determine the roles
of various family members, so that interventions can include appropriate individuals. The
emphasis on collectivism is strong. If the goals or techniques of therapy lead to discord within
the family or tribe, they will not be effective. Interventions may need to include the input of
family, relatives, friends, elders, or tribal leaders.
Cultural and Spiritual Values
Because of the great diversity and variation among American Indians, it is difficult to
describe a set of values that encompasses all groups. However, certain generalizations can be
made regarding common values (Garrett & Portman, 2011; Jumper‐Reeves, Dustman,
Harthun, Kulis, & Brown, 2014).
1. Sharing. Honor and respect are gained by sharing and giving, in contrast with the
dominant U.S. culture, where status is gained by the accumulation of material goods.
Implications: Once enough money is earned, youth and adults may stop working
and spend time and energy in ceremonial activities. The accumulation of wealth is
not a high priority but is a means to enjoy the present. Interventions targeting
alcohol or drug use should take into consideration the emphasis on sharing.
2. Cooperation. Having a harmonious relationship is important and the tribe and the family
take precedence over the individual. Children are often sensitive to the opinions and
attitudes of their peers and may actively avoid disagreements or contradictions. Most do
not like to be singled out and made to perform in school unless the whole group benefits.
Implications: Instead of going to work or school, children or adults may prioritize
assisting a family member needing help. Children may be seen as unmotivated in
school because of their reluctance to compete with peers.
3. Noninterference. It is important not to interfere with others and to observe rather than
react impulsively. Rights of others are respected. This belief in noninterference extends
to parenting style.
Implications: Culture significantly shapes parent–child relationships. AI/AN are
more indulgent and less punitive than parents from other ethnic groups (BigFoot &
Funderburk, 2010). EuroAmerican parenting styles may conflict with American
Indian values. One culturally sensitive parent education program developed for this
population included: (a) use of the oral tradition of storytelling to teach lessons to
children; (b) an understanding of the spiritual nature of child rearing and the
spiritual value of children; and (c) use of the extended family in child rearing. The
eight‐session program included social time for parents and children before each
session, including storytelling and a potluck meal. The program applied traditional
teaching methods, such as nurturing, use of nature to teach lessons, and use of
harmony as a guiding principle for family life (Gorman & Balter, 1997).
4. Time orientation. There is a greater focus on the present than on the future. Ideas of
punctuality or planning for the future may be less important. Life is to be lived in the
here and now.
Implications: Tasks may be approached from a logical perspective rather than
according to deadlines. In contrast, the U.S. majority culture values delay of
gratification and planning for future goals. In working with these issues, the
counselor should acknowledge such value differences and help the individual or
family develop strategies to negotiate value conflicts.
5. Spirituality. The spirit, mind, and body are all interconnected. Illness involves
disharmony between these elements. Positive emotions can be curative; healing can take
place through events such as talking to an old friend on the phone or watching children
play (Garrett & Wilbur, 1999).
Implications: Traditional curative approaches attempt to restore spirit–mind–body
harmony. The sweat lodge and vision quest are often used to reestablish
connections between the mind, body, and spirit. To treat a problem successfully, all
of these elements may need to be considered and addressed. Counselors can help
clients identify factors involved in disharmony, determine curative events,
behaviors, and feelings, and use client‐generated solutions to create balance.
6. Nonverbal communication. Learning occurs by listening rather than talking. Families
tend to ask few direct questions. Direct eye contact with an elder may be seen as a sign
of disrespect.
Implications: Differences in nonverbal communication can lead to
misunderstandings. For example, counselors may view lack of eye contact or direct
communication as a sign of disrespect. It is important to determine whether specific
behaviors are due to cultural values or are actual problems.
Cultural Strengths
AI/AN populations had to endure genocide and assimilation efforts and were able to do so
because of cultural values and strengths such as spirituality, respect for traditional values and
ceremonies, extended family networks, allegiance to the family, community, and tribe,
wisdom of the elders, respect for the environment and the land, connection to the past,
adaptability, and the promotion of such themes as belonging, mastery, independence, and
generosity (American Psychiatric Association, 2014; Gilgun, 2002). The values of listening
and observing rather than reacting can enhance communication and decrease conflict.
Spiritual and traditional practices also act as a protective factor (Garroutte, Goldberg, Beals,
Herrell, & Manson, 2003). The respect shown for the environment and the interconnection
between humans and the environment is something that can be emulated by all cultures.
Additionally, the focus on the present is increasingly recognized as an asset, particularly
among those who incorporate mindfulness activities into clinical practice (Chiesa & Serretti,
2011).
SPECIFIC CHALLENGES
In the following sections, we describe the challenges often faced by AI/AN populations and
consider their implications in treatment.
Historical and Sociopolitical Background
In North America, wars and diseases that resulted from contact with Europeans decimated the
AI/AN population; by the end of the eighteenth century, only about 10% of the original
population remained. Additionally, the tribes suffered massive loss of their land. Their
experience in America is not comparable to that of any other ethnic group. In contrast to
immigrants, who arrived with few resources and struggled to gain equality, AI/AN originally
had resources. However, their land and status were severely eroded by imperial, colonial, and
then federal and state policies (Johnson et al., 1995). For years, extermination and seizure of
lands seemed to be the primary governmental policy toward Indians.
In the 1830s, more than 125,000 people from different tribes were forced from their homes in
many different states to a reservation in Oklahoma. The move was traumatic for their
families and, in many cases, disrupted their cultural traditions. Assaults against their culture
also occurred in the form of attempts to “civilize” them. Children were removed from their
families and placed in English‐speaking boarding schools. They were not allowed to speak
their own language and were forced to spend eight continuous years away from their families
and tribes. Children were also removed from their homes and placed with non‐Indian
families until the Indian Child Welfare Act of 1978 prohibited these practices (Johnson et al.,
1995). However, during the 1998 congressional hearings regarding possible amendments to
the Indian Child Welfare Act, statistics were cited indicating that over 90% of American
Indian children were still being placed by state courts and child welfare workers into non‐
Indian homes (Congressional Record, 1997). Although amendments to the original act
dramatically reduced this type of placement, the National Indian Child Welfare Association
(2014) and other advocacy organizations recently asked the Department of Justice to
investigate Indian Child Welfare Act violations.
These disruptive events had a tremendous negative impact on family and tribal cohesion and
prevented the transmission of cultural values from parents to children. Some professionals
believe that the experiences of colonization, coercive assimilation experiences in boarding
schools, and the widespread loss of indigenous languages and customs may result in
“historical trauma,” in which the distress and dysfunction experienced by an individual can be
passed down intergenerationally (Gone, 2014). Individuals may have unresolved grief—“soul
wounds”—that lead to behavioral dysfunction and substance abuse. The following case study
illustrates some of the disruptions caused by a boarding school experience.
CASE STUDY
MARY
Mary was born on the reservation. She was sent away to school when she was 12 and
did not return to the reservation until she was 20. By the time she returned, her mother
had died from pneumonia. She didn't remember her father, the medicine man of the
tribe, very well. Shortly after she returned, she became pregnant by a non‐Indian man
she met at a bar. Mary's father … looked forward to teaching and leaving to his
grandson, John, the ways of the medicine man … John felt his grandfather was out of
step with the twentieth century … Mary … could not validate the grandfather's way of
life … [because] she remembered having difficulty fitting in when she returned to the
reservation … In response to the growing distance between her father and her son, she
became more and more depressed and began to drink heavily. (Sage, 1997, p. 48)
In the past, the tribe, through the extended family, was responsible for the education and
training of children. The sense of tribal identity developed through this tradition was
significantly eroded by governmental policies. In addition, even recent history is full of
broken treaties, the seizure or misuse of Indian land, and battles led by local or federal
officials to remove or severely limit fishing and hunting rights. Thus, AI/AN are often
suspicious of the motives of the majority culture; many expect that they will not be treated
fairly by non‐Indians (Cruz & Spence, 2005).
Implications
When working with children and families, it is important to consider the historical
sociopolitical relationship between AI/AN and the local, state, and federal government. The
counselor should understand not only the national history of oppression but also local issues
and specific tribal history.
The historic disruption of families resulting in the Indian Child Welfare Act has important
implications for how AI/AN might view child protective services or respond to runaway
youth. Currently, decisions regarding the placement of their children are held in tribal courts.
Testimony from expert witnesses familiar with the specific tribal or cultural group must be
obtained before children can be removed from their homes. Additionally, if children are
removed from their parents, residence with extended family members, other tribal members,
or other AI/AN families is given primary consideration.
Educational Concerns
Educational gaps between AI/AN youth and White youth persist (National Conference of
State Legislators, 2008). Native children appear to do well during the first few years of
school. However, by the fourth grade, a pattern of academic decline, disengagement, and
truancy develops; a significant drop in achievement motivation often occurs in middle school.
Although some have argued that traditional cultural values and beliefs are incompatible with
those of the educational system, there is increasing support for the view that perceived
barriers to mobility are the culprit behind reduced academic performance. In other words,
academic success is not perceived as leading to rewards or success. Others argue that
structural issues within the school, including limited resources, a lack of teacher preparation
or cultural sensitivity, and racial discrimination, are in fact pushing AI/AN youth out of
traditional school settings (Johnston‐Goodstar & VeLure Roholt, 2017). In addition, some
of youth from low‐income communities see that jobs are available in casinos or on the
reservation, which can provide them with opportunities to contribute financially to their
families. This makes it difficult for them to see the value in pursuing a “White man's
education.”
Implications
The blame for school failure has generally been placed on the individual rather than on the
school environment. However, many youths who leave school report feeling “pushed out”
and express mistrust of teachers, who represent the same White community that has
historically exerted control over the economic, social, and religious lives of American Indians
(Deyhle & Swisher, 1999). At a systems level, positive changes could occur if public schools
and institutions of higher education were to (a) recognize the sociocultural history of AI/AN
and acknowledge their perceptions of schools as a potentially hostile environment and (b)
increase efforts to accommodate some of the social and cultural differences of the students,
including by adapting curricula to reflect their cultural background (Reyhner, 2002). The
perceived lack of reward for academic achievement also needs to be addressed. Schools must
help students bridge the two worlds of AI/AN and White cultures. Some tribes have given up
on the public school system and have developed their own learning centers and community
colleges.
The AlterNative Education Program was created to interest American Indians in
postsecondary education. It recruits indigenous students and alumni at Columbia University
to travel to reservations in New Mexico and teach high school‐aged youth about their
identity and past. The program covers areas such as oppression, stereotypes, and colonialism,
focuses on identity building, and encourages higher education. Responses from the
participants have been quite positive and have resulted in increased interest in college
enrollment (Aronowitz, 2014).
Acculturation Conflicts
I don't know the meaning of the symbols of our culture. Instead, I know the symbols of
the Catholic faith.
(Gone, 2009, p. 757)
I didn't know we had herbs and plants that grew here, that are medicine and vitamins. I
didn't know we had that until they [the elders] brought it up.
(Goodkind, Gorman, Hess, Parker, & Hough, 2015, p. 495)
…some people are more spiritual‐tradition based than others. Some are more
modernized, too, and have lost touch with some of that kind of stuff; it varies.
(Flynn, Olson, & Yellig, 2014, p. 285)
Not only do AI/AN children and adolescents face the same developmental issues as other
youth, but they also may experience conflict over exposure to two very different cultures, a
factor that may result in failure to develop a positive self‐image or strong ethnic identity
(Garrett & Portman, 2011). Many youth are caught between the expectations of their parents
that they will maintain traditional values and the necessity to adapt to the majority culture
(Rieckmann, Wadsworth, & Deyhle, 2004). In one study of adolescents, the most serious
problems identified involved ethnic identity, family relationships, grades, and concerns about
the future. One‐third of the girls surveyed reported feeling they did not want to live (Bee‐
Gates, Howard‐Pitney, LaFromboise, & Rowe, 1996).
Some AI/AN are acculturated and hold the values of the larger society. The degree to which a
client identifies with the native culture or is acculturated to the dominant U.S. culture should
always be considered. Garrett and Pichette (2000) have formulated five levels of cultural
orientation:
1. Traditional. The individual may speak little English and practice traditional tribal
customs and methods of worship.
2. Marginal. The individual may be bilingual but has lost touch with his or her cultural
heritage, yet is not fully accepted in mainstream society.
3. Bicultural. The individual is conversant with both sets of values and can communicate in
a variety of contexts.
4. Assimilated. The individual embraces only the mainstream culture's values, behaviors,
and expectations.
5. Pantraditional. The individual has been exposed to and adopted mainstream values but
is making a conscious effort to return to the “old ways.”
Implications
Counselors need to discuss the client's tribal affiliation (if any), languages spoken, self‐
identity, and residential background, and find out whether there is a current relationship to a
tribe or tribal culture (Garrett & Pichette, 2000). The therapeutic process and goals
appropriate for someone living on a rural reservation may be very different from those
appropriate for an urbanized American Indian who retains few traditional beliefs. Individuals
with a traditional orientation may be unfamiliar with expectations of the dominant culture and
may want to develop the skills and resources to deal with mainstream society. In contrast,
assimilated or marginal American Indians may want to examine self‐identity conflicts and
may face issues such as (a) lack of pride in or denial of their heritage, (b) pressure to adopt
majority cultural values, (c) guilt over not knowing or participating in the cultural customs or
events, (d) negative views regarding their group, and (e) a lack of an extended support or
belief system. It may be healthiest to have a bicultural orientation that allows the individual to
live in both worlds. This perspective appears to confer strength and resiliency in American
Indians (Flynn et al., 2014).
The client's level of acculturation should also be a factor that guides the therapist's selection
of therapeutic interventions. For example, acculturated and bicultural AI/AN have found
success with all components of cognitive behavioral therapy (CBT), whereas those who are
traditionally oriented are responsive to the short‐term focus, activity schedule, and
homework assignments in CBT but have difficulty with the underlying theoretical
assumptions regarding the association between thoughts and emotional symptoms (Jackson,
Schmutzer, Wenzel, & Tyler, 2006). In these cases, modified explanations for CBT may be
useful.
Alcohol and Substance Abuse
It's a good thing that I'm away from home and even though [my family] miss[es] me and
I miss them … I can understand … being away from home, it just is such a big relief for
them and for me … because of all the alcoholism, the drug usage … the drama and
gossiping. It just seems so depressing for them and then for me as well.
(Flynn et al., 2014, p. 286)
Substance abuse is a significant concern among some AI/AN, particularly those living on a
reservation or in a high‐poverty neighborhood. Although rates of alcohol use vary across
tribes and regions, AI/AN have the highest weekly alcohol consumption of any ethnic group
(Chartier & Caetano, 2010). As with the college student quoted by Flynn et al. (2014), some
youth are exposed to the effects of alcohol use and abuse early in life. However, it must be
remembered that there is variability in alcohol‐use patterns between specific subgroups; for
example, Southwest Indians, especially females, have low rates of alcohol consumption
(Chartier & Caetano, 2010).
A variety of explanations have been put forth for the high levels of alcohol abuse. Although
drinking alcoholic beverages may initially have been incorporated into cultural practices as an
activity of sharing, giving, and togetherness (Swinomish Tribal Mental Health Project, 1991),
heavy alcohol use is associated with other factors, such as feelings of historical loss in terms
of language, land, and traditions (see Cromer, Gray, Vasquez, & Freyd, 2018). Further, living
in extreme poverty with little access to jobs with a living wage can lead some to turn to
alcohol or other substances to dull the pain.
Implications
Successful drug treatment programs have incorporated appropriate cultural elements. Because
peers often support substance use, prevention and interventions should involve not only the
individual but also the community and family, including siblings, cousins, and friends
(Boyd‐Ball, Véronneau, Dishion, & Kavanagh, 2014). One tribal community reduced its
alcoholism rate from 95% to 5% in 10 years by addressing some of the pain of historical loss
through revitalizing traditional culture and taking a strong community stance against alcohol
abuse (Thomason, 2000). Many tribes have developed similar programs to deal with
alcohol‐ and drug‐abuse issues. Programs have the greatest chance of promoting health
when they incorporate cultural strengths, evidence‐based strategies, and traditional tribal
practices such as talking circles and ceremonies (Jumper‐Reeves et al., 2014).
Domestic Violence
The rate of domestic violence, along with physical and sexual assault, is quite high in many
native communities. Statistics indicate that AI/AN women experience domestic violence and
physical assault at much higher rates than women of other ethnicities (Peters, Straits, &
Gauthier, 2015). Native women often experience sexual and physical abuse early in life;
abuse is especially high among lesbian and bisexual women (D'Oro, 2010). The high
incidence of domestic violence may result from changes in traditional roles for men and
women, as well as substance abuse and stressors associated with social and economic
marginalization. There is an intergenerational pattern of violence in many families in which
individuals who witnessed family or domestic violence become aggressive with their own
partners (Myhra & Wieling, 2014). Thus, the cycle of violence is perpetuated.
Implications
During counseling, it may be difficult to determine whether domestic violence is occurring
within a family or couple. Native American women who are abused may remain silent
because of cultural barriers, a high level of distrust of White‐dominated agencies, fear of
familial alienation, and the historical failure of state and tribal agencies to protect women
from domestic crimes (Wahab & Olson, 2004). Jurisdictional struggles between state and
tribal authorities can also result in a lack of help for women. Many tribes acknowledge the
problem of family violence and have developed community‐based domestic violence
interventions using strategies from the Indian cultural perspective (Hamby, 2000). When
working with a domestic‐violence issue with a Native American woman, tribal issues, tribal
programs, and family support options should be identified.
Suicide
At the Montana Indian Reservation, sixteen‐year‐old Franci Jackson considered
hanging herself with a rope when she felt she couldn't take any more bullying at school.
But then she changed her mind. “I thought of my mom and dad and how much they love
me. And if I leave, what would they do without me? But most kids don't think,” she said
in tears. Six American Indian students living in her area had killed themselves in the
previous year with another 20 attempting suicide.
(Associated Press, 2011)
Suicide rates have reached epidemic proportions among AI/AN. For individuals between the
ages of 15 and 34 years, the suicide rate is about 250% higher than in the general population,
and suicide is the second leading cause of death among those aged 15 to 34 years (CDC,
2013). Among a sample of 122 middle school children living on a North Plains reservation,
20% had made a nonfatal suicide attempt, and of this group, nearly half had attempted suicide
two or more times (LaFromboise, Medoff, Harris, & Lee, 2007). Death rates from suicide are
highest among AI/AN populations in Alaska and in the Northern Plain states (Herne,
Bartholomew, & Weahkee, 2014). The high incidence of suicide is associated with alcohol
abuse, poverty, boredom, family stress, and historical loss or disconnection from one's
culture and community (Gray & McCullagh, 2014).
Implications
There are many societal and economic issues facing AI/AN. For those who live on a
reservation or identify with a tribe, community activities sometimes focus on reducing
suicidal ideation and promoting resilience in youth. Effective programs need to be culturally
consistent. For example, many Indians believe that mental health issues are a result of
unbalanced spiritual relationships (Limb & Hodge, 2010). In traditional belief systems, there
is not only a seen world but also an unseen world. Events that disrupt the unseen world
disturb the harmony in the seen world. Therefore, if intervention focuses only on the seen
world, change will likely not occur (Cruz & Spence, 2005).
A promising culturally tailored suicide intervention program was implemented by
LaFromboise and Howard‐Pitney (1995) at the request of the Zuni Tribal High School.
Scores on a suicide probability measure indicated that 81% of the students were in the
moderate‐to‐severe risk range. Of the participants, 18% reported having attempted suicide,
and 40% reported knowing of a relative or friend who had committed suicide. The program
included role‐playing, building self‐esteem, identifying emotions and stressors,
recognizing and eliminating negative thoughts or emotions, receiving information on suicide
and intervention strategies, and setting personal and community goals. The program was
effective in reducing feelings of hopelessness and suicidal probability ratings. Intervention
programs may need to be developed based on the needs of individual tribes. For example,
although among the Pueblo suicidal ideation was associated with the suicidal behavior of
friends, for adolescents from Northern Plain tribes the most significant factors were low
self‐esteem and depression (LaFromboise, 2006).
IMPLICATIONS FOR CLINICAL PRACTICE
1. Explore the client's ethnic identity, tribal affiliation, and adherence to cultural values.
Also, discuss family members' association with a tribe or reservation and the importance
of rituals or ceremonies in healing. In addition, determine the appropriateness of a mind–
body–spirit emphasis. Keep in mind that many American Indians adhere completely to
mainstream values, whereas others, especially those living on or near reservations, may
hold traditional values (Peters et al., 2015).
2. Understand the extensive history of colonization, genocide, and social injustice
experienced by AI/AN and learn about local issues associated with the client's tribe or
reservation. Become familiar with key books in the field, including Native American
Post‐Colonial Psychology and Healing the Soul Wound.
3. Don't fall into the trap of viewing AI/AN as a group of peoples who only existed in the
past or who have been beaten down by oppression. Appreciate the rich diversity among
AI/AN in the present and understand the resiliency and hope across generations.
4. Learn about the client using a client‐centered listening style, and when appropriate use
self‐disclosure and provide the client with the opportunity to identify the focus of the
session (Flynn et al., 2014; Thomason, 2011).
5. Assess the problem from the perspective of the individual, family, extended family, and,
if appropriate, the tribal community; attempt to determine the role of cultural and
experiential factors and whether the client has seen a traditional healer.
6. If necessary, address basic needs such as problems involving food, shelter, childcare,
and employment. Identify possible resources, such as Indian Health Services or tribal
programs.
7. Identify possible environmental contributors to problems, such as racism, discrimination,
poverty, and acculturation conflicts; consider how knowledge of these factors can help
reduce self‐blame.
8. Help children and adolescents determine whether cultural values or an unreceptive
environment contribute to their problem. Strategize different ways of dealing with these
conflicts. For some, strengthening their sense of cultural identity can be helpful.
9. Help determine concrete goals that incorporate cultural, family, extended family, and
community perspectives.
10. Determine whether child‐rearing practices are consistent with traditional methods and
how they may conflict with mainstream methods.
11. In family interventions, identify extended family members, determine their roles, and,
when appropriate, request their assistance.
12. Generate possible solutions with the client and consider the possible consequences of
change from individual, family, and community perspectives. When appropriate, include
strategies that may involve cultural elements and that focus on holistic factors (mind,
body, spirit).
Video Lecture: Overcoming Personal Racism: What Can I Do?
SUMMARY
American Indians/Native Americans and Alaska Natives make up such a small percentage of
the U.S. population that they are relatively “invisible.” Life‐expectancy and mental/physical
health disparities, however, are among the worst for this population. Their experience in
America is not comparable to that of any other ethnic group. In contrast to immigrants, who
arrived with few resources and struggled to gain equality, they originally had resources,
which were severely eroded or destroyed by imperial, colonial, and federal and state policies.
Alcohol and substance abuse, domestic violence, and suicide are among the most pressing
behavioral health issues facing this population. In work with AI/AN, counselors need to
understand how the values of sharing, cooperation, noninterference, time orientation,
spirituality, and nonverbal communication are relevant to mental health practice. Twelve
clinical implications for counselor practice are identified.
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Note
“American Indian” and “Native American” are used interchangeably in this chapter.
16
Counseling Asian Americans and Pacific Islanders
Chapter Objectives
1. 1. Learn the demographics and characteristics of Asian Americans and Pacific
Islanders.
2. 2. Identify counseling implications of the information provided for Asian
Americans and Pacific Islanders.
3. 3. Provide examples of strengths associated with Asian Americans and Pacific
Islanders.
4. 4. Know the special challenges faced by Asian Americans and Pacific Islanders.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with Asian Americans and Pacific Islanders.
[I]n many [Asian] societies people who suffer from major depression do not complain
primarily of sadness. The symptoms that stand out for those people may be changes in
appetite, headaches, backaches, stomachaches, insomnia, or fatigue. Such symptoms
and complaints would take people suffering from depression to their primary care
doctor, and they may be less likely to be diagnosed with a mental disorder.
(Kalibatseva & Leong, 2011, p. 3)
Calling Asian Indians the new “model minority” isn't a compliment. It's an attempt to fit
them into a box for political purposes … The phase “model minority” inherently pits
one minority group against others … After all, if one community is the “model,” then the
others are problematic and less desirable.
(Srivastava, 2009, p. 1)
“It's not enough to have Asian Americans and Pacific Islanders on just a handful of
shows … Shows set in diverse cities like New York and Los Angeles should not be
completely white” [Nancy Wang Yeun]—but according to TV, they are … “As much as
we may want to dismiss TV as simple entertainment, it undeniably contributes to our
cultural landscape and our understanding of the world … What does it mean when
[Asian Americans and Pacific Islanders] are missing or tokenized in this landscape? It
reinforces the idea that we don't belong” [Jenny J. Lee].
(Ramos, 2017)
The Asian American population is growing rapidly, and as of 2013, was close to 18 million,
representing 5.3% of the total population. Native Hawaiian and other Pacific Islanders
number 1.2 million and make up 0.4% of the total population (U.S. Census Bureau, 2015).
The largest Asian groups in the United States include
over 4 million Chinese,
3.4 million Filipinos,
3.2 million Asian Indians,
1.7 million Vietnamese,
1.7 million Koreans, and
1.3 million Japanese. (U.S. Census Bureau, 2012)
Nearly three‐quarters of Asian American adults were born abroad and about two‐thirds
speak a language other than English at home; approximately half do not speak English “very
well.” Between‐group differences within the Asian American population are quite large,
since the population comprises at least 40 distinct subgroups that differ in language, religion,
and values. Counselors should not assume that Asian Americans are all the same. Individuals
diverge on variables such as ethnicity, culture, migration and relocation experiences, degree
of assimilation or acculturation, identification with the home country, facility in their native
language and in English, family composition, educational background, religion, and sexual
orientation (Nadal, Escobar, Prado, David, & Haynes, 2012).
CHARACTERISTICS AND STRENGTHS
In the following section, we present some of the cultural values, behavioral characteristics,
and expectations that Asian Americans might have about therapy and consider the
implications of these factors in treatment. The level of accuracy of these group
generalizations for each individual client or family must be determined by the therapist.
Asian Americans: A Success Story?
The contemporary image of Asian Americans is that of a highly successful minority that has
“made it” in society. Indeed, a close analysis of census data (U.S. Census Bureau, 2016)
seems to support this contention. Of those over the age of 25, over half of Asian Americans
and Pacific Islanders have a bachelor's degree, versus a little over 30% of their White
counterparts; 21.4% have an advanced degree, compared with 12.1% of Whites (U.S. Census
Bureau, 2016). Words such as intelligent, hardworking, enterprising, and disciplined are
frequently applied to this population (Lim, 2014). The median income of Asian American
families was $77,166 in 2013, as compared with $56,516 for the U.S. population as a whole
(U.S. Census Bureau, 2013).
However, a closer analysis of the status of Asian Americans reveals a somewhat different
story. First, in terms of economics, references to the higher median income of Asian
Americans do not take into account (a) the higher percentage of Asian American families
having more than one wage earner, (b) between‐group differences in education and income,
and (c) a higher prevalence of poverty despite the higher median income (11.4% for Asian
Americans and 17.6% for Pacific Islanders, versus 9.4% for non‐Hispanic Whites) (U.S.
Census Bureau, 2013). Rates of poverty are particularly high among Hmong, Guamanian,
Indonesian, and Cambodian immigrants (Ramakrishnan & Ahmad, 2014).
Second, in the area of education, Asian Americans show a disparate picture of extraordinarily
high educational attainment among a few and a large, undereducated mass. Among
Bhutanese, over 60% adults have not completed high school. Fewer than 17% of Tongan,
Cambodian, Laotian, Hmong and Pacific Islander adults have a bachelor's degree (Shah &
Ramakrishnan, 2017). When averaged out, this bimodal distribution indicates how misleading
statistics can be.
Third, there is now widespread recognition that Chinatowns, Manilatowns, and Japantowns in
San Francisco and New York represent ghetto areas with prevalent unemployment, poverty,
health problems, and juvenile delinquency. People outside these communities seldom see the
deplorable social conditions that exist behind the bright neon lights, restaurants, and quaint
shops.
Fourth, although Asian Americans underutilize mental health services, it is unclear if this is
due to low rates of socioemotional difficulties or to cultural values inhibiting self‐referral
(Zane & Ku, 2014). It is possible that a large portion of the mental illness, adjustment
problems, and juvenile delinquency among Asians is hidden. The discrepancy between
official and real rates of adjustment difficulties may be due to cultural factors, such as the
shame and disgrace associated with admitting to emotional problems, the handling of
problems within the family rather than relying on outside resources, and the manner of
symptom formation, such as a low prevalence of acting‐out disorders.
Fifth, Asian Americans have been exposed to discrimination and racism throughout history
and continue to face anti‐Asian sentiments. Even fourth‐ and fifth‐generation Asian
Americans are sometimes identified as “foreign” (Tsuda, 2014). In a daily diary study of
Asian Americans, 78% reported experiencing at least one racial microaggression during a
two‐week period, and often more, including being ignored at restaurants, being told
inappropriate jokes, and being teased for not using Western utensils (Ong, Burrow, Fuller‐
Rowell, Ja, & Sue, 2013). Perceived racial microaggressions and discrimination are
associated with higher psychological distress, anxiety, depression, and somatic symptoms
(Ong et al., 2013).
It is important for those who work with Asian Americans to look behind the success myth and
to understand the historical and current experiences of Asians in America. The matter is even
more pressing for counselors when we realize that Asian Americans underutilize counseling
and other mental health facilities. The approach of this chapter is twofold. First, we attempt to
indicate how the interplay of social and cultural forces has served to shape and define the
lifestyle of recent immigrants/refugees and American‐born Asians. Second, we explore how
an understanding of Asian American values and social experiences suggests a need for
modifications in counseling and psychotherapeutic practices when working with some
members of this population.
CASE STUDY
KATHERINE
Growing up in a traditional Asian household, there were a handful of subjects I
knew never to broach: Academic failure, acting more “American,” sex and mental
illness …
I … fumbled the words to tell my parents about [being depressed] and the avenues
of treatment I had researched. Their response was dismissive, but not—as I later
understood—in a neglectful vein. When I mentioned the possibility of medication,
they became angry—the world that had shaped them was neither nurturing nor
particularly nuanced. As Chinese immigrants, they lived shoulder‐to‐shoulder
with poverty and near‐starvation. Their experiences were reinforced by an
ironclad culture that encouraged stoic endurance and regarded mental illness as a
weakness of character, a shame borne not only by the individual, but by the entire
family. And here was their daughter, who lived in a manicured middle‐class
suburban home and always went to bed with a full belly, complaining she felt
depressed.
“It's not real. Get over it” was the gist of their advice. Then and now, to our
detriment, I'm certain many Asian‐American kids have heard the same thing.
So I tried. In high school, I became the poster‐child for a “high‐functioning
depressive,” as the terminology goes. I maintained a 4.0 GPA, won national
writing awards and earned admission to an Ivy League university—things my
parents wanted for my future. This made me a role model for the younger students
in our community. I was even asked for lifestyle tips on how to succeed in school.
Parents pointed at me and said to their children, “You should be more like her.”
But the depression persisted, stubborn and malicious, leaching my motivation and
compelling me to seek relief in terrible things. After school, I'd shut myself in my
room and cut myself until I could no longer stand the pain.
(Xie, 2016)
Collectivistic Orientation
Katherine's parents' initial response to her sharing her experiences with depression reflects
their cultural socialization. As Chinese immigrants, they view depression as a weakness with
the potential to bring shame to the family. With this more collectivistic orientation comes the
expectation that children will strive for family goals and not engage in behaviors that might
bring dishonor to the family. More traditional Asian American parents tend to show little
interest in children's viewpoints regarding family matters, for instance whether or not
Katherine should seek treatment. Asian American adolescents are often expected to assist,
support, and respect their families, even when exposed to a society that emphasizes
adolescent autonomy and independence (Fuligni et al., 1999).
Whereas EuroAmerican parents rated being “self‐directed” as the most important attribute
in children's social competence, Japanese American parents chose “behaves well” (O'Reilly,
Tokuno, & Ebata, 1986). Chinese American parents also believed that politeness and
calmness are important childhood characteristics (Jose, Huntsinger, & Liaw, 2004). Asian
American families do differ, however, in the degree to which they embrace collectivistic
values and in their flexibility in applying these values. For example, Katherine was
hospitalized because of concerns she would hurt herself shortly before graduating high
school. When she returned home, her parents began to learn more about depression and were
open to her seeking help outside of the family.
Implications
Because of a possible collectivistic orientation, it is important to consider the family and
community context during assessment and problem definition. A therapist should be open to
different family orientations and should avoid automatically considering interdependence as a
sign of enmeshment. After doing a client‐centered analysis of the problem, counselors can
ask, “How does your family see the problem?” For traditionally oriented Asian Americans, a
focus on individual client needs and wishes may run counter to the values of collectivism.
Goals and treatment approaches may need to include a family focus, such as asking “How
important is it for you to consult your family before deciding how to deal with the problem?”
or “How would achieving your goals affect you, your family, friends, and social
community?”. Questions such as these allow the therapist to assess the degree of collectivism
in the family. Acculturated Asian Americans with an individualistic orientation can often
benefit from traditional counseling approaches, but family issues should also be considered,
since acculturation conflicts are common, as in Katherine's case.
Hierarchical Relationships
Traditional Asian American families tend to be hierarchical and patriarchal in structure, with
males and older individuals occupying a higher status (Kim, 2011). Communication flows
downward from parents to children; children are expected to defer to their elders as a matter
of obligation and duty (Lau, Fung, & Yung, 2010). Sons are expected to carry on the family
name and tradition. Even when they marry, their primary allegiance is to the parents.
Between‐group differences do exist. Japanese Americans are the most acculturated. The
majority are third‐ or fourth‐generation Americans. Filipino American families tend to be
more egalitarian, whereas Korean, Southeast Asian, and Chinese American families tend to
be more patriarchal and traditional in orientation (Blair & Qian, 1998). Modern Chinese
societies are moving toward more egalitarian relationships between husband and wife and
between parents and children (Chen, 2009), as we can see in some of this change in
Katherine's family over the years.
Implications
Clients should be aware that Asian Americans may respond to the counselor as an authority
figure, be reluctant to express true feelings and concerns, and say what they think the mental
health professional wants to hear (Son & Ellis, 2013). In family therapy, it is important to
determine the family structure and communication pattern. Does it appear to be egalitarian or
hierarchical? If the structure is not clear, addressing the father first and then the mother may
be most productive.
If English is a problem, use an interpreter. Having children interpret for the parents can be
counterproductive because it upsets the hierarchical structure. For very traditionally oriented
families, having communication between family members directed to the therapist may be
more congruent with cultural values than having family members address one another. It is
also important to assess possible status changes within the family. It is not uncommon among
Asian immigrants for women to retain their occupational status while men are either
underemployed or unemployed. Such loss of male status may result in family conflict,
particularly if males attempt to maintain their status by becoming even more authoritarian. In
such cases, it may be helpful to cast societal factors as the problem that needs to be
addressed.
Parenting Styles
As with Katherine's parents, Asian American parenting styles tend to be more authoritarian
and directive than those in EuroAmerican families (Kim, 2011), although a relaxed style is
often used with children younger than six or seven (Jose et al., 2004). For example, Chinese
parenting is based on the concepts of chiao shun (to train) and guan (to govern and to love)
(Russell, Crockett, & Chao, 2010). Shame, the induction of guilt, and love withdrawal are
often used to control and train children (Lau, Fung, Wang, & Kang, 2009). When Katherine
returned home from her hospitalization, she and her parents worked through what she
described as “resentful, agonized silence” that had gone on for years within the family.
Problem behavior in children in some families is viewed as a lack of discipline. While praise
is frequently used in the majority culture to reinforce desired behaviors, many Asian families
consider instruction to be the main parenting strategy (Paiva, 2008). As one parent stated, “I
don't understand why I should reward things they should already be doing. Studying hard is a
normal responsibility. Listening to parents is a must. Why should they feel proud when they
are merely meeting a basic obligation?” (Lau et al., 2010, p. 887). However, differences in
parenting style between Asian American groups have been found. Japanese and Filipino
American families tend to have the most egalitarian relationships, whereas Korean, Chinese,
and Southeast Asian Americans are more authoritarian (Blair & Qian, 1998).
Implications
Egalitarian or Western‐style parent‐effectiveness training strategies may run counter to
traditional child‐rearing patterns. Traditional Asian American families exposed to Western
techniques or styles may feel that their parenting skills are being criticized. Instead of
attempting to establish egalitarian relationships, the therapist can focus on identifying
different aspects of parenting, such as teaching and modeling. They can then help refocus on
the more positive aspects of Asian child‐rearing strategies, framing the change as helping
the children with problems rather than as altering traditional parenting. It is also important to
commiserate with parents regarding the difficulties they encounter raising children in a
society with different cultural standards (Lau, 2012).
Emotionality
Strong emotional displays, especially in public, are considered signs of immaturity or a lack
of self‐control; control of emotions is considered a sign of strength (Kim, 2011). Thus,
some Asian Americans, especially those who are less acculturated into the United States, may
be hesitant to discuss or openly display emotions. Instead, care and concern are shown by
attending to the physical needs of family members. Fathers frequently maintain an
authoritative and distant role and are not generally emotionally demonstrative or involved
with children. Their role is to provide for the economic and physical needs of the family.
Mothers in general are more responsive to the children but use less nurturance and more
verbal and physical punishment than do EuroAmerican mothers (Kelly & Tseng, 1992).
However, mothers are expected to meet the emotional needs of the children and often serve as
the intermediary between them and the father. When children are exposed to more open
displays from Western society, they may begin to question the comparative lack of emotion
displayed by their parents.
Implications
Counseling techniques that focus directly on emotions may be uncomfortable and produce
shame for traditional Asian Americans. Emotional behavior can be recognized in a more
indirect manner. For example, if a client shows discomfort, the therapist could respond by
saying either “You look uncomfortable” or “This situation would make someone
uncomfortable.” In both cases, the discomfort would be recognized. We have found that
many Asian Americans are more responsive to the second, more indirect acknowledgment of
emotions. Feelings of shame or embarrassment may interfere with self‐disclosure and need
to be addressed in counseling. The process may be facilitated by affirming that the sharing of
personal information, although it may be uncomfortable, is a natural process in therapy (Zane
& Ku, 2014). It is also helpful to focus on behaviors more than emotions and to identify how
family members are meeting each other's needs. Among traditional Asian American couples,
care and concern may be demonstrated by taking care of the physical needs of the partner
rather than by verbally expressing concern. Western therapies that emphasize verbal and
emotional expressiveness may not be appropriate in work with traditional Asian couples or
bicultural families such as Katherine's, in which she was more acculturated than her parents.
Holistic View on Mind and Body
Katherine's “weighty periods of apathy and sadness” are similar to the way many high school
girls in the United States experience depression. However, more traditional Asian Americans
may not experience depression in the same way. Instead of feeling sad, someone might talk
about not being able to sleep or having headaches, stomachaches, or other somatic symptoms.
The somatic complaints reflect a more customary Asian American understanding of the
mind–body connection. In many Asian ethnic groups, physical complaints are a common and
culturally accepted means of expressing psychological and emotional stress. It is believed that
physical problems cause emotional disturbances and that symptoms will disappear once the
physical illness is treated. Instead of mentioning anxiety or depression, Asian clients may
mention headaches, fatigue, restlessness, and disturbances in sleep and appetite (Wong, Tran,
Kim, Kerne, & Calfa, 2010). Even psychotic patients typically focus on somatic complaints
and seek treatment for these physical ailments (Nguyen, 1985).
Implications
Treat somatic complaints as real problems. Inquire about medications or other treatments that
are being used to treat the symptoms. To address possible psychological factors, ask
questions such as, “Dealing with headaches and dizziness can be quite troublesome; how are
these affecting your mood or relationships with others?” This approach both legitimizes the
physical complaints and allows an indirect means of assessing psychosocial factors. It is
beneficial to develop an approach that deals with both somatic complaints and the
consequences of being “ill.”
Academic and Occupational Goal Orientation
There is great pressure for children to succeed academically and to have a successful career,
since both are indicative of a successful upbringing. In Katherine's narrative, she talked about
excelling in high school and in some respects surpassing her parents' high academic
expectations. Katherine is not an anomaly. As a group, Asian Americans perform better
academically than do their EuroAmerican counterparts. Although Asian American students
have high levels of academic achievement, they also have more fear of academic failure and
spend twice as much time each week studying as their non‐Asian peers (Eaton & Dembo,
1997). Their achievement often comes with a price. Similar to Katherine, Asian American
adolescents report feeling isolated, depressed, and anxious, and report little praise for their
accomplishments from their parents (Lorenzo, Pakiz, Reinherz, & Frost, 1995). Asian
American parents often have specific career goals in mind for their children (generally in
technical fields or the hard sciences). Because choice of vocation may reflect parental
expectations rather than personal talent, Asian college students are sometimes uncertain about
realistic career options (Lucas & Berkel, 2005). Deviations from either academic excellence
or “appropriate” career choices can produce conflict with family members.
Implications
Counselors can inquire about and discuss conflicts between parental academic or career goals
and the client's strengths, interests, and desires. When working with parents, counselors can
encourage the recognition of all positive behaviors and contributions made by their children,
rather than just academic performance. For career or occupational conflicts, counselors can
acknowledge the importance parents place on their children achieving success, while
indicating that there are many career options that can be considered. Differences of opinion
can be presented as a culture conflict. The counselor can help the client brainstorm ways to
present other possibilities to their parents. Because Asian American students often lack clarity
regarding vocational interests, they may need additional career‐counseling assistance (Lucas
& Berkel, 2005).
Cultural Strengths
Asian Americans' cultural values can provide resiliency and strength. The family orientation
allows members to achieve honor by demonstrating respect for parents and elders and
supporting siblings in their endeavors. These customs produce a collective support system
that can shield the individual and family from sources of stress. Because the achievements
and success of an individual are considered a source of pride for the family rather than the
individual, group harmony is primary. Enculturation or identification with one's racial and
ethnic background can serve as a buffer against prejudice, discrimination, and family
conflicts (Hwang, Woods, & Fujimoto, 2010; Kim, 2011). For Korean American adolescents,
ethnic identity pride is positively related to self‐esteem, especially when there is strong
parental support (Chang, Han, Lee, & Qin, 2015).
Pacific Islanders have faced a history of colonization and oppression. Despite these
challenges and obstacles, cultural strengths such as collectivity, harmony in family
relationships, and respect for elders have been an important source of resilience. Pacific
Islanders can rely on the community and family during times of stress (Vakalahi, 2009).
Korean American college students were found to have strong cognitive flexibility. In dealing
with conflicts with parents, these individuals used creative means to prevent or resolve
problems in a way that accommodated traditional cultural expectations and their own
personal needs (Ahn, Kim, & Park, 2008).
SPECIFIC CHALLENGES
In the following sections, we describe the challenges often faced by Asian Americans and
consider their implications in treatment.
Racial Identity Issues
White privilege was a concept I was unaware of, even though it was intricately woven
into the fabric of my life. If someone had asked me then, I would probably have said that
I have not experienced racism, and I did not feel oppressed in any way. This is not to say
I had not experienced racism. I just never thought of those encounters as racism
because, most of the times, they were subtle. I reacted to racial microaggressions with
confusion, fear, and frustration, although I never understood my emotions.
(Lo, 2010, p. 26)
As Asian Americans are progressively exposed to the standards, norms, and values of the
wider U.S. society, the result is increasing assimilation and acculturation. Bombarded on all
sides by peers, schools, and the mass media, which uphold Western standards, Asian
Americans are frequently placed in situations of extreme culture conflict and experience
distress regarding their behavioral and physical differences (Kim, 2011). Asian American
college women report lower self‐esteem and less satisfaction with their racially defined
features than do their Caucasian counterparts (Mintz & Kashubeck, 1999). C.‐R. Lee (1995)
describes his experiences as “straddling two worlds and at home in neither” and tells how he
felt alienated from both American and Korean cultures. As with other adolescents, those of
Asian American descent also struggle with the question of “Who am I?” In the preceding
case, Lo talks about struggling with his racial identity. For Lo, three intersecting racial–
ethnic–cultural identity processes are at play: (a) what it means to be racialized in the United
States as an Asian American (i.e., racial identity); (b) how important or salient his Korean
American identity is to him (i.e., ethnic identity); and (c) to what extent he is acculturated
into the cultural values and practices of the United States and to what extent he is
enculturated into the cultural values and practices of his Korean heritage.
Implications
Although identity issues can be a problem for some Asian Americans, others believe that
ethnic identity is not salient or important. Assessing the ethnic self‐identity of clients is
important, because it can affect how we conceptualize the presenting problems and how we
choose the techniques to be used in therapy. Those who adhere to Asian values have a more
negative view toward seeking counseling (Kim, 2007). Acculturated Asian American college
students hold beliefs similar to those of counselors, whereas less acculturated students do not
(Mallinckrodt, Shigeoka, & Suzuki, 2005). Acculturated Asian clients who have lower levels
of enculturation into their home culture are generally receptive to Western styles of
counseling and may not want reminders of their ethnicity. Traditionally identified Asians are
more likely to be recent immigrants who retain strong cultural values and are more responsive
to a culturally adapted counseling approach. Bicultural Asian Americans adhere to some
traditional values, while also incorporating many Western values. Being bicultural is
associated with greater physical and mental health (Jang, Park, Chiriboga, & Kim, 2017).
Programs that help Asian American youth develop social awareness about ethnic identity
issues and societal imbalance in power are associated with increased pride, self‐efficacy,
racial and ethnic esteem, and increased interest in contributing to societal change (Suyemoto,
Day, & Schwartz, 2015).
Acculturation Conflicts
Children of Asian descent who are exposed to different cultural standards often attribute their
psychological distress to their parents' backgrounds and different values. The issue of not
quite fitting in with their peers yet being considered “too Americanized” by their parents is
common. Parent–child conflicts are among the most common presenting problems for Asian
American college students seeking counseling (Lee, Su, & Yoshida, 2005) and are often
related to dating and marriage issues (Ahn et al., 2008). Chinese immigrant mothers report a
larger acculturation gap with sons than with daughters (Buki, Ma, Strom, & Strom, 2003).
The larger the acculturation gap between parents and children, the greater the number of
family problems. Parents may complain, “My children have lost their cultural heritage”
(Hwang et al., 2010). The inability to resolve differences in acculturation results in
misunderstandings, miscommunication, and conflict (Lee, Choe, Kim, & Ngo, 2000). Parents
may feel at a loss in terms of how to deal with their children. Some respond by becoming
more rigid.
Implications
To prevent negative interpersonal exchanges between parents and their children, therapists
can reframe problems as resulting from acculturation conflicts. In this way, both the parents
and the children can discuss cultural standards and the expectations from larger society.
Although family therapy would seem to be the ideal medium in which to deal with problems
for Asian Americans, certain difficulties exist. Most therapy models are based on
EuroAmerican perspectives of egalitarian relationships and require verbal and emotional
expressiveness. Some models assume that a problem in a family member is reflective of
dysfunction between family members. In addition, the use of direct communication between
child and parents, confrontational strategies, or nonverbal techniques such as “sculpting” may
be an affront to the parents.
Assess the structure of the Asian American family. Is it hierarchical or more egalitarian?
What is its perception of healthy family functioning? How are decisions made? How do
family members show respect for each other and contribute to the family? Focus on the
positive aspects of the family and reframe conflicts to reduce confrontation. Expand systems
theory to include societal factors such as prejudice, discrimination, poverty, and conflicting
cultural values. Issues revolving around the pressures of being an Asian American family in
U.S. society need to be investigated. Describe the session as a solution‐oriented one and
explain that family problems are not uncommon. As much as possible, allow sensitive
communications between family members to come through the therapist. The therapist can
function as a culture broker in helping the family negotiate conflicts with the larger society.
Expectations Regarding Counseling
Because psychotherapy may be a foreign concept for some Asian Americans, it is important
to carefully explain the nature of the assessment and treatment process and the necessity of
obtaining personal information and insight into family dynamics. Asian American clients may
expect concrete goals and strategies focused on solutions. Even acculturated Asian American
college students prefer counselors to serve as direct helpers offering advice, consultation, and
the facilitation of family and community support systems (Atkinson, Kim, & Caldwell, 1998).
Mental health professionals must be careful not to impose techniques or strategies.
Counselors often believe that they should adopt an authoritarian or highly directive stance
with Asian American clients. What many Asian American clients expect is that the counselor
will take an active role in structuring the session and outlining expectations for client
participation in the counseling process. It can be helpful for the therapist to accept the role of
being the expert regarding therapy, while the client is given the role of expert regarding his or
her life. In this way, clients can assist the therapist by facilitating understanding of key issues
and possible means of approaching the problem (Chen & Davenport, 2005).
Implications
Carefully describe the client's role in the therapy process, indicating that problems can be
individual, relational, or environmental, or a combination thereof, and that you will perform
an assessment of each of these areas. Introduce the concept of co‐construction—that
effective counseling involves the client and the counselor working together to identify
problems and solutions. The therapist might explain, “In counseling, we try to understand the
problem as it affects you, your family, friends, and community, so I will ask you questions
about these different areas. With your help, we will also consider possible solutions that you
can try out.” Co‐construction reduces the chance that the therapist will impose his or her
worldview on the client.
The counselor should direct therapy sessions but should ensure full participation from clients
in developing goals and intervention strategies. Suggestions can be given and different
options presented for consideration by the client. Clients can also be encouraged to suggest
their own solutions and then select the option that they believe will be the most useful in
dealing with the problem. The opportunity for Asian American clients to try interventions on
their own promotes the cultural value of self‐sufficiency. The consequences for any actions
taken should be considered, not only for the individual client, but also for the family. The
client's perspective is also important in determining what needs to be done if cultural or
family issues are involved.
Therapy should be time limited, should focus on concrete resolution of problems, and should
deal with the present or immediate future. Cognitive‐behavioral and other solution‐
focused strategies are useful in working with Asian Americans (Chen & Davenport, 2005).
However, as with other Eurocentric approaches, these approaches may need to be altered
because the focus is on the individual, whereas the unit of treatment for Asian Americans
may be the family, community, or society. Cognitive‐behavioral approaches can be
modified to incorporate a collectivistic rather than an individualistic perspective. For
example, assertiveness training can be altered for Asian clients by first considering possible
cultural and social factors that may affect assertiveness (e.g., minority status or personal
values such as modesty) and then identifying, together with the client, situations where
assertiveness might be functional, such as in class or when seeking employment, and those
where a traditional cultural style might be more appropriate (e.g., with parents or other
elders). Additionally, possible cultural or societal influences that affect social anxiety or
assertiveness can be discussed. Finally, the client can practice role‐playing to increase
assertiveness in specific situations. This concrete alteration of a cognitive‐behavioral
approach considers cultural factors and allows the client to establish self‐efficacy.
Racism and Discrimination
At every chapter of my life, I have been made to feel like the other. So much so that I
have conditioned myself to feel most comfortable when I am standing alone as the sole
Asian. Despite growing up in a Chinese family, my world is saturated by so many more
white perspectives that I once assumed that they were the standard.
(Tam, 2013)
The preceding narrative comes from a blog post by journalist Ruth Tam. Tam discusses her
understanding of #NotYourAsianSidekick, a term coined by writer Suey Park to characterize
the intersection between patriarchy and racism that Asian women experience in the United
States and abroad. Tam captures the ubiquity of Whiteness. At points in her life, she
internalized how White people saw her based on their racial stereotypes. Asian Americans
continue to face racial stereotyping along with racism and discrimination, the form of which
may depend on their gender. These everyday experiences, whether acknowledged or not,
impact Asian Americans' health and well‐being (Lee & Ahn, 2011).
Experience with discrimination in foreign‐born and U.S.‐born Asian American college
students was related not only to depression but also to intergenerational conflicts, especially
with the mother, probably because she is the person with whom family members primarily
interact in navigating social problems (Chang, Chen, & Cha, 2015). Southeast Asian refugees
who experienced racial discrimination reported high rates of depression (Noh, Beiser, Kaspar,
Hou, & Rummens, 1999).
Implications
A therapist must assess the effects of possible environmental factors, such as racism, on
mental health issues in Asian Americans and help ensure that they not internalize issues based
on discriminatory practices. Instead, the focus should be on how to deal with racism and on
possible efforts to change the environment. If a problem occurs in school, the therapist can
help assess the school's social receptivity to Asian students. The same can be done with
discriminatory practices at a client's place of employment. Intervention may have to occur at
a systems level, with the therapist serving in the role of advocate for the client.
IMPLICATIONS FOR CLINICAL PRACTICE
[A] one‐size‐fits‐all approach to clinical work with Asian Americans is
potentially problematic. Instead, it is important for clinicians to identify within‐
group differences among their Asian American clients based on their mental illness,
lay beliefs, and level of enculturation.
(Wong et al., 2010, p. 328)
There is a range of acceptable practices in working with Asian American clients.
Qualities such as attitudinal similarity between the counselor and the client and
agreement on the cause and treatment of a disorder are more important than racial match
in promoting counselor credibility and a strong therapeutic alliance (Meyer, Zane, &
Cho, 2011). Asian Americans view counselors who demonstrate multicultural
competence by addressing their cultural beliefs as more competent (Wang & Kim,
2010). Helping Asian American clients formulate culturally acceptable strategies can
improve their problem‐solving abilities and facilitate the development of skills for
successful interactions within the larger society, including balancing conflicting values.
Many of the counseling skills learned in current mental health programs, such as
cognitive behavioral therapy (CBT), can be effective, especially if modifications are
made for less acculturated clients (Lau, Chan, Li, & Au, 2010). Considerations in
working with Asian American clients include the following:
1. Be aware of cultural differences between the therapist and the client in the areas of
counseling, appropriate goals, and process. Use strategies appropriate to the
collectivistic, hierarchical, and patriarchal orientation of Asian Americans, when needed.
2. Build rapport by discussing confidentiality and explaining the client role, including the
process of co‐constructing the problem definition and solutions.
3. Identify and incorporate the client's beliefs about the etiology and appropriate treatment
regarding the disorder.
4. Assess not just from an individual perspective but including family, community, and
societal influences on the problem. Discover the client's worldview, degree of
acculturation, and ethnic identity. Explore whether the client's experiences with
acculturation and ethnic identity are influenced by gender or other social identity.
5. Conduct a positive assets search. What strengths, skills, problem‐solving abilities, and
social supports are available to the client or their family? How have problems been
successfully solved in the past?
6. Consider or reframe the problem, when possible, as one involving issues of culture
conflict or acculturation.
7. Determine whether somatic complaints are involved, and assess their influence on mood
and relationships. Discuss somatic as well as psychological issues.
8. Take an active role, but allow the client to choose and evaluate suggested interventions.
Asian American clients may prefer an immediate resolution to a problem to an in‐
depth exploration.
9. If appropriate, use problem‐focused, time‐limited approaches that have been
modified to incorporate possible cultural factors.
10. Discuss strategies you have used in the past to solve problems similar to those faced by
the client.
11. With family therapy, be aware that Western‐based theories and techniques may not be
appropriate for Asian families. Determine the structure and communication patterns
among the family members. It may be helpful to address the father first and to initially
have statements by family members directed to the therapist. Focus on positive aspects
of parenting, such as modeling and teaching.
12. In couples counseling, assess for societal or acculturation conflicts, and determine the
couple's perspective on what an improved relationship would look like. Problems often
occur when there are differences in acculturation between the partners. Determine the
ways that caring, support, and affection are shown, including in providing for economic
needs.
13. With Asian children and adolescents, common problems involve acculturation conflicts
with parents, feeling guilty or stressed over poor academic performance, negative self‐
image or identity issues, and struggles between interdependence and independence.
14. Consider the need to act as an advocate or to engage in systems‐level intervention in
cases of institutional racism or discrimination.
Video Lecture: Culturally Competent Counseling: Innovative Approaches to Counseling
Asian Americans by Fred Leong
SUMMARY
Asian Americans and Pacific Islanders make up nearly 6% of the U.S. population, but
comprise 40 distinct subgroups, each with its own language, religion, and customs. The
counselor should not assume that these groups are all the same. Asian Americans are often
seen as a model minority, which masks the historical and continuing prejudice and
discrimination directed toward them. Counselors working with Asian Americans and Pacific
Islanders must be cognizant of major cultural differences such as collectivism, hierarchical
relationships, parenting styles, emotionality, holistic orientation, and academic/occupational
goal orientations that contrast with EuroAmerican characteristics. A failure to acknowledge
these differences may lead to inappropriate and ineffective treatments. Further, it is important
to understand and work with the strengths of the group, and to be knowledgeable about racial
identity development, acculturation conflicts, and the different expectations Asian Americans
may have of counseling. Fourteen clinical implications for counselor practice are identified.
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17
Counseling Latinx Populations
Chapter Objectives
1. 1. Learn the demographics and characteristics of Latinx individuals.
2. 2. Identify counseling implications of the information provided for Latinx
individuals.
3. 3. Provide examples of strengths that are associated with Latinx individuals.
4. 4. Know the special challenges faced by Latinx individuals.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with Latinx individuals.
I need to hear it, see it, sound it out for a while. I do think that it is incredibly important
to experiment with language as we change as a country. So [Latinx] does make sense,
because our community is changing. We are talking about gender issues, we are talking
about LGBT issues, and we are looking for terms that explain and help us understand
our experience in this country.
(Daisy Hernandez, quoted in Reyes, 2016)
When Mexico sends its people, they're not sending their best. They're not sending you.
They're sending people that have lots of problems, and they're bringing those problems
with us. They're bringing drugs. They're bringing crime. They're rapists. And some, I
assume, are good people.
(Donald Trump on the presidential campaign trail in 2015)
In part because of the anti‐immigrant and anti‐Latinx sentiments espoused by
political leaders in the U.S., we see an increase in experiences with racism. According to
a Pew Research Center poll, over half (52%) of “Hispanics” report experiencing racial
or ethnic discrimination in their lifetime; this number jumps to nearly two‐thirds (65%)
if we only focus on younger adults from 18 to 29.
(Krogstad & Lopez, 2016)
I grew up believing in the American dream and I worked hard to earn my place in the
country that nurtured and educated me. Like the thousands of other undocumented
students and graduates across America, I am looking for one thing, and one thing only:
the opportunity to give back to my community, my state, and the country that is my
home, the United States.
(Maria Gomez, quoted in Durbin, 2018)
In this chapter, we use the gender‐inclusive term “Latinx” in reference to individuals living
in the United States with ancestry from Spanish‐speaking (e.g., Mexico, Puerto Rico, Cuba,
Dominican Republic) and non‐Spanish‐speaking (e.g., Brazil, French Guiana, Suriname)
South and Central American countries. However, people vary in preference for the terms used
for pan‐ethnic self‐identification; some prefer the gendered terms “Latina” and “Latino,”
some prefer the term “Hispanic,” and some prefer more specific ethnic terms such as
“Chicana,” “Puerto Rican,” and “Brazilian.” The U.S. Census uses the term Hispanic as an
ethnic descriptor rather than the term Latina/o or Latinx (pronounced La‐teen‐ex).
Throughout Latin America, the immigration of European and Asian populations, the forced
displacement of people from Africa, and the subsequent mixture with indigenous groups has
resulted in a wide range of phenotypes. Thus, the physical traits of Latinx vary greatly, and
include characteristics of indigenous groups, Africans, Asians, and light‐skinned Europeans.
About a quarter of Latinx individuals identify as Afro‐Latino and about a quarter identify as
indigenous (Krogstad & Lopez, 2016). Although the growth of the Latinx population has
slowed since about 2007, Latinx individuals are currently the largest minority group in the
United States, making up 17.6% of the total U.S. population; among them, 63% are of
Mexican origin, 9.5% are from Puerto Rico or of Puerto Rican descent, and nearly 4% have
either Cuban or Salvadorian ancestry, while others have their origins in the Dominican
Republic (3.3%), Guatemala (2.5%), or another Central or South American country (U.S.
Census Bureau, 2017).
With the exception of American Indians, more Latinx individuals have ancestors belonging to
the original lands of the Americas than in any other racial or pan‐ethnic group. Thus, it
seems odd to talk about Latinx individuals, particularly those from Mexico, as immigrants in
the United States. Having said that, a little over a third of Latinx individuals are immigrants
(U.S. Census Bureau, 2017), and nearly half (45%) of all immigrants are of Hispanic origin
(Zong, Batalova, & Hallock, 2018). It is not surprising then that nearly half of all Latinx
adults express concern that they, a family member, or a close friend will be deported (Lopez,
Taylor, Funk, & Gonzalez‐Barrera, 2013). Those who are undocumented occupy the lowest
rung of the labor pool and are often taken advantage of because they have no legal status.
Although Latinx groups share many characteristics, there are many between‐group and
within‐group differences. Many are strongly oriented toward their ethnic group, whereas
others are quite acculturated to mainstream values. About three‐fourths of U.S.‐born
Latinx individuals are third‐generation or higher, with many descended from the large wave
of Latin Americans who began immigrating in the 1960s. In certain states and cities, they
make up a substantial percentage of the population. Mexican Americans are the dominant
Latinx group in metropolitan areas throughout the United States, especially in California and
Texas. Most Puerto Ricans reside in the Northeast, and most Cubans live in Florida (Lopez &
Dockterman, 2011). There are a number of wealth and health disparities. The median income
of Latinx families ($47,675) is about 80% of the U.S. median family income ($59,039), with
nearly one in five Latinx individuals living in poverty; in 2016, about 16% of Latinx
individuals did not have health insurance (U.S. Census Bureau, 2017).
CHARACTERISTICS AND STRENGTHS
In the following sections we describe the characteristics, values, and strengths of Latinx
individuals and consider their implications in treatment. These are generalizations and their
applicability needs to be assessed for each client or family.
Cultural Values and Characteristics
The development and maintenance of interpersonal relationships are central in Latin
American cultures (Kuhlberg, Pena, & Zayas, 2010). There is typically deep respect and
affection among a large network of family and friends. Family unity, respect, and tradition
(familismo) are an important aspect of life. Cooperation among family members is stressed.
For many, the extended family includes not only relatives but also close friends and
godparents (padrinos). Each member in the traditional family has a role: mother (caregiver),
father (provider), children (obedient), grandparents (wise council), and godparents (resource)
(Lopez‐Baez, 2006).
Implications
Familismo refers not only to family cohesiveness and interdependence but also to loyalty and
placing the needs of close friends and family members before personal needs (Baumann,
Kuhlberg, & Zayas, 2010). Counselors can inquire about clients' connectedness with
extended and nuclear family members and the value placed on familismo. Because of these
strong familial and social relationships, Latinx individuals often wait until resources from
extended family and close friends are exhausted before seeking help. Even in cases of severe
mental illness, many delay obtaining assistance (Kouyoumdjian, Zamboanga, & Hansen,
2003).
Although familismo is a source of resilience for many Latinx families, emotional involvement
and obligations with numerous family and friends can function as a source of stress,
particularly when decisions are made that affect the individual negatively (Aguilera, Garza, &
Muñoz, 2010). Problem definition may need to incorporate the perspectives of both nuclear
and extended family members, and solutions may need to bridge cultural expectations and
societal demands. Additionally, family responsibilities sometimes take precedence over
outside concerns, such as school attendance or work obligations. For example, older children
may be kept home to care for ill siblings, attend family functions, or work (Headden, 1997).
Under these circumstances, problematic behaviors (i.e., absenteeism) can be addressed by
framing them as a conflict between cultural and societal expectations.
Family Structure
Traditionally oriented families are hierarchical in form, with special authority given to
parents, older family members, and males. Within this type of family structure, sex roles are
clearly delineated. The father is typically the primary authority figure. Children are expected
to be obedient and are typically not involved in family decisions.
Parents reciprocate by providing for children through young adulthood and even after
marriage. This type of reciprocal relationship is a lifelong expectation and is the cornerstone
of familism. Older children are expected to care for and protect their younger siblings; older
sisters often function as surrogate mothers. Although changing gender norms are affecting the
boundaries of traditional family roles, the saliency of family as a core value and the
importance of family connectedness remain central.
Implications
Assessment of family structure should consider the ways that decisions are made within the
family unit. Conflicts among family members often involve differences in acculturation and
conflicting views of roles and expectations for family members, as well as clashes between
cultural values and mainstream societal expectations on the parts of parents and their children
(Baumann et al., 2010). In less acculturated families, counselors may find success by helping
family members reframe these issues as responses to acculturation stress; they can then
negotiate conflicting cultural norms and values. Counselors can help clients consider ways in
which they can demonstrate their allegiance to the family without significantly compromising
their own acculturation. One such approach is demonstrated in the following case:
During family therapy, a Puerto Rican mother indicated to her son, “You don't care for
me anymore. You used to come by every Sunday and bring the children. You used to
respect me and teach your children respect. Now you go out and work, you say, always
doing this or that. I don't know what spirit [que diablo] has taken over you.”
(Inclan, 1985, p. 332)
In response, the son explained that he was sacrificing and working hard because he wanted to
be a successful provider and someone of whom his children could be proud. The son has
adopted future‐oriented, mainstream U.S. values, stressing hard work and individual
achievement. The mother was disappointed because she believed her son should spend time
with her, encourage the family to gather together, and prioritize the family over individual
desires. This clash in values was at the root of the problem.
In working with this family, the therapist provided alternative ways of viewing the conflict.
He explained how our views are shaped by the values that we hold. He asked the mother
about her socialization and early childhood values. The son expressed how difficult it was to
lose his parents' respect, but also his belief that he needed to work hard and focus on the
future in order to succeed in the United States. The therapist pointed out that different
adaptive styles may be necessary for different situations and that what “works best” may be
dependent on the social context. Both mother and son acknowledged that they demonstrate
love and affection in different ways. As a result of the sessions, mother and son better
understood the nature of their conflicts and were able to improve their relationship.
Gender Role Expectations
Latinx individuals often experience conflicts over gender roles. In traditional culture, men are
expected to be strong, dominant, and the provider for the family (machismo), whereas women
are expected to maintain harmony and nurture spiritual life within the family, and to be
modest, virtuous, and subordinate to others (marianismo) (Piña‐Watson, Castillo, Jung,
Ojeda, & Castillo‐Reyes et al., 2014). Within a traditional family structure, the father
expects family members to be obedient. Areas of possible gender role conflict for men
(especially among immigrants) include the following (Avila & Avila, 1995; Constantine,
Gloria, & Baron, 2006):
1. Lack of confidence in areas of authority. Latino men may lack confidence interacting
with agencies and individuals outside of the family; this can result in feelings of
inadequacy and concern about diminished authority, especially if the wife or children are
more fluent in English.
2. Feelings of isolation and depression because of the need to be strong. Talking about
concerns or stressors may be seen as a sign of weakness. This difficulty discussing
feelings can produce isolation and anger or depression.
3. Conflicts over the need to be consistent in one's role. As ambiguity and stress increase,
there may be more rigid adherence to traditional roles.
For women, conflicts may involve (a) expectations associated with traditional roles, (b)
anxiety or depression over not being able to live up to these standards, and (c) an inability to
express feelings of anger (Lopez‐Baez, 2006). Latina immigrants are often socialized to feel
inferior and to expect suffering or martyrdom. However, given the economic, political, and
social climate of the United States, women may be asked to assume greater responsibility to
provide financially for the family. For Latinx immigrant families, language skills and
familiarity with U.S. culture may further disrupt traditional gender and other family roles.
There is a shift in power dynamics within the family when children are placed in the role of
language brokers, creating generational stress between parents and children. While the
rupture affects all family members, it may be especially difficult for fathers, who
understandably may feel as though their authority and ability to provide for their family are
being called into question. With parents' increased acculturation to dominant U.S. norms,
such views may shift. Certain gender roles may change more than others over time. Some
women may be very modern in their views regarding education and employment but remain
traditional in the area of sexual behavior and personal relationships. Others remain very
traditional in all areas. Cultural differences between partners are associated with strained
marital relationships, while couples with cultural similarity have a more positive marital
experience (Cruz et al., 2014).
Implications
Therapists should explore the client's degree of adherence to traditional gender norms, as well
as the gender role views among family members. It is important to consider the potential
impact of acculturation on marital relationships, particularly when women function
independently in the work setting or when dealing with schools and other agencies. For both
men and women, role conflict is likely to occur if the man is unemployed, if the woman is
employed, or both.
When dealing with gender role conflicts, counselors who believe in equal relationships must
be careful not to impose their views on clients. Instead, if a Latina client desires greater
independence, the counselor can help her consider the consequences of change, including
potential problems within her family and community, and work to help her achieve her goal
within a cultural framework. It is helpful to frame conflicts in gender roles as an external
issue involving differing expectations between cultural and mainstream U.S. values and to
encourage problem solving to deal with the different sets of expectations.
Spiritual and Religious Values
Mrs. Lopez, age 70, and her 30‐year‐old daughter sought counseling because they
had a very conflictual relationship … The mother was not accustomed to a counseling
format … At a pivotal point in one session, she found talking about emotional themes
overwhelming and embarrassing … In order to reengage her, the counselor asked what
resources she used when she and her daughter quarreled. She … prayed to Our Lady of
Guadalupe.
(Zuniga, 1997, p. 149)
The therapist subsequently employed a culturally adapted strategy of having Mrs. Lopez use
prayer and spiritual guidance to understand her daughter and to find solutions to their
conflicts. This use of a cultural perspective allowed the sessions to continue. Religion (often,
but not always, Catholicism) is important to many Latinx individuals, although less so among
younger individuals (Pew Research Center, 2014). Prayers requesting guidance from patron
saints can be a source of comfort in times of stress. It is not uncommon for Latinx youth and
adults to express a certain level of fatalism or the belief that life experiences are determined
by fate; like many cultural phenomena, fatalism is complex and consists of several
dimensions, including luck and destiny. It seems that a sense of fate or predeterminism is
related to lower health outcomes primarily for people who also adopt a higher pessimistic
outlook (Piña‐Watson & Abraído‐Lanza, 2017).
Some Latinx individuals believe that good and evil spirits affect mental health problems
(espiritismo). When they attribute their difficulties to the spirit world, they often turn to
indigenous healing practices for relief. The rituals, prayers, communication with the spirits,
and herbal remedies are culturally sanctioned methods of addressing the root cause of distress
(Comas‐Diaz, 2012).
Implications
During assessment, it is important to consider religious or spiritual beliefs and to explore the
spiritual meanings of presenting problems. If there is a strong belief that fate accounts for the
current situation, instead of attempting to change this view, the therapist can acknowledge it
and help the individual or family determine the most adaptive response to the situation. The
therapist might say, “Given that the situation is unchangeable, how can you and your family
deal with this?” with the aim of helping the client develop problem‐solving skills within
certain parameters. It may be important to also tease out whether the person's understanding
of the presenting concern represents a predetermined belief, such as “This is meant to happen
to me,” or whether it is a more pessimistic worldview of their own worthiness, such as “I am
meant to suffer in life.” The latter has the most negative impact on psychological health
(Piña‐Watson & Abraído‐Lanza, 2017).
A strong reliance on religion can be a resource (e.g., evoking God's support through prayer to
facilitate problem solving). Fatalism can be countered by stressing “Ayu‐ date, que Dios te
ayudara,” which is the equivalent of “God helps those who help themselves” (Organista,
2000). Indigenous healing practices can also be incorporated into the therapeutic process. We
would not expect a Western‐trained therapist to perform traditional healing rituals; instead,
it makes sense to work with a culturally sanctioned shaman or espiritista in treatment
planning.
Educational Characteristics
The statement in my microaggression project was “Are you legal?” That's because in
my freshman year [of high school], I remember some people asking me those kinds of
questions. And I am a pretty calm guy. I don't get offended by almost anything. I take
almost everything just as a joke. But that specific statement kind of hurt me at that time.
(Manning, 2016)
Many Latinx high school students experience racial discrimination and microaggressions by
teachers and fellow students. Unfortunately, these experiences cause students to feel less
connected to school, which in turn leads to absenteeism and lower grades (Benner & Graham,
2011). Similar to their American Indian and Black peers, some Latinx students feel pushed
out of the school system altogether. Latinx students have significantly lower public high
school graduation rates compared to their White peers: 78% compared to 88% in 2014–2015
(National Center for Educational Statistics, 2017). The good news is that the gap has
narrowed over the past decade.
This upward trend reflects the high value many Latinx youth place on education and their
optimism about the future and performing better in school (Pew Research Center, 2009). Not
surprisingly, then, college attendance is also increasing among Latinx young people: 18%
were in college in 2013, versus 12% in 2009. Although there is improvement, Latinx young
adults continue to lag substantially behind White youth in obtaining a bachelor's degree (9%
versus 69%) (Fry, 2014).
Implications
Clinicians must assess not only intrapsychic issues but also the degree to which external
conditions are involved in mental health issues. Thus, it is important to be sensitive to
sociopolitical issues (e.g., anti‐immigrant sentiments) and client experiences with
disenfranchisement and discrimination. For example, highly educated Latinx adults report
demoralizing situations in which their academic success is questioned or they are assumed to
be less qualified than they actually are (Rivera, Forquer, & Rangel, 2010).
When working with school‐aged youth, counselors should assess whether contextual factors
within the school environment are contributing in some part to students' psychological or
behavioral distress. Assessment areas might include broader cultural domains such as the
level of acculturation and enculturation of the youth and their parent(s), the
socioeconomic/financial health of the family, individual/family/community trauma, and
cultural protective factors, in addition to the more specific school environment. Given that
youth's experiences are shaped by who they are as individuals as well as their race, gender,
and sexual orientation and their interactions, it is important to ask them directly about
potential bullying or mistreatment because of their various identities. Counselors should be
prepared to work with students to cope with painful racial microaggressions such as the one
described at the beginning of this section, as well as to intervene more systemically within the
schools to address the culture of racial intolerance.
Cultural Strengths
Educationally, we're there for each other. Emotionally, we're there for each other. There
is also a sibling sort of rivalry. You want to do better, compete with each other, pick
each other up. If one does good in math, we're all inspired to do good. The group is like
a giant family. Yeah, we have our arguments, but they don't last long. We'll argue and
then someone will kick you like to say, “I'm sorry,” and then you move on
(Matos, 2015, p. 445)
The preceding quote is an excerpt from a qualitative study of the challenges and protective
factors Latinx experience negotiating college environments (Matos, 2015). Findings from the
study illustrate a number of the cultural strengths within Latinx communities, including a
strong work ethic and valuing a sense of emotional and physical connection to others
(Adames & Chavez‐Dueñas, 2016). Most Latinx children grow up in two‐parent families,
often supported by a strong kinship system. Familismo and the related sense of connectedness
and loyalty among immediate and extended family can be a source of significant social and
emotional support for individuals and families (Kuhlberg et al., 2010). Traditional Latinx
values place a great deal of emphasis on creating a harmonious atmosphere and accord within
the family system. Personalismo refers to a personalized communication style that is
characterized by interactions that are respectful, interdependent, and cooperative. Simpatico
refers to the relational style displayed by many Latinx individuals—a style emphasizing
social harmony and a gracious, hospitable, and personable atmosphere (Holloway, Waldrip,
& Ickes, 2009). Cultural identity and values can serve as a protective asset against stress by
promoting a sense of belonging (Ai, Aisenberg, Weiss, & Salazar, 2014), while a strong
system of spiritual and religious beliefs can be nurtured as a source of strength when dealing
with personal or family issues.
SPECIFIC CHALLENGES
In the following sections, we consider challenges often faced by Latinx individuals and
reflect on their implications in treatment.
Stigma Associated with Mental Illness
Depressive symptoms are common among Latinas, with 53% reporting moderate to severe
symptoms versus 37% of White women (Diaz‐Martinez, Interian, & Waters, 2010).
Mexican American males and Puerto Ricans of both genders have high rates of weekly
alcohol consumption and binge‐drinking; additionally, alcoholism among these groups is
more likely to be chronic (Chartier & Caetano, 2010). Statistics such as these confirm the
need for mental health support. However, the cultural stigma associated with mental illness,
including fear that psychiatric medications can cause addiction, results in reluctance to seek
treatment. Latinx immigrants are also more likely than members of the majority culture to
fear embarrassment or social discrimination from family, friends, and employers if they
acknowledge psychological distress, and are more likely to express psychological distress via
somatic symptoms.
“When Latinos think of mental illness, they just think one thing: loco,” says Clara Morato,
whose son, Rafaelo, was diagnosed with bipolar disorder at age 18 (Dichoso, 2010, p. 1).
Machismo may also be a barrier to seeking treatment, owing to concerns about lost time from
work (Vega, Rodriguez, & Ang, 2010). Additionally, Latinx individuals underutilize
resources for their children. Although most young children are citizens, one or both parents
may be undocumented and, therefore, reluctant to seek assistance (Capps, Fix, Ost,
Reardon‐Anderson, & Passel, 2005). Some Latinx individuals are afraid to sign up for
insurance over concern that their undocumented family members will get discovered, and
deported. This results in the inability to pay for mental health treatment (Dembosky, 2014).
Implications
Clinicians can anticipate and help counteract the stigma associated with mental illness by
taking the time to build rapport and provide psychoeducation about therapeutic approaches
(Vega et al., 2010). Comas‐Diaz (2012), a Puerto Rican multicultural therapist, advocates
exploring the client's heritage, history of cultural translocation, and views about counseling
early in therapy and encourages a flexible therapeutic style that might include roles familiar
to the client, such as healer, advisor, coach, teacher, guide, advocate, consultant, and mentor.
Developing a culturally relevant therapeutic alliance, providing psychoeducation about how
treatment is conducted and how goals are developed in a collaborative manner, and using a
flexible, culture‐centered approach can help clients overcome their fear of the stigma
associated with seeking help and their reluctance to participate openly in treatment.
Acculturation Conflicts
As with many ethnic minority groups, Latinx individuals are frequently faced with societal
values distinctly different from their own. Additionally, the severing of ties to family and
friends, the loss of supportive resources, language inadequacy, unemployment, and culture
conflict all function as stressors for recent immigrants. Some maintain their traditional
orientation, whereas others assimilate and exchange their native cultural practices and values
for those of the host culture. Differences in acculturation between family members can
produce stress within the family unit, as seen in the following case.
Juan, a 46‐year‐old Latino, was born in Mexico and has lived in the United States for
10 years. He works as a cook, has been married for over 20 years, and has five children.
Juan has frequent conflicts with his wife and children, believing that they want freedom
from him and that they have become too “Americanized.” He strongly believes in the
cultural values of familismo (family connectedness), machismo (being head of the
family, with responsibility for providing for the family), and respecto (respect) from his
children. As husband and father, he believes that he should set the rules in the family
and that his wife and children should respect his rules. Juan often feels stressed, angry,
hopeless, and depressed and has had suicidal thoughts and thoughts of hurting his wife.
When angry, he resorts to threats and physical violence.
(Santiago‐Rivera, Kanter, Benson, Derose, Illes, & Reyes, 2008)
Juan's therapist recognized that traditional cognitive behavioral therapy (CBT, an evidence‐
based treatment for depression) might not adequately address the environmental stressors,
acculturation conflicts, and feelings of isolation and powerlessness Juan was experiencing.
Instead, he modified another evidence‐based treatment (behavioral activation therapy). He
encouraged Juan to participate in free or low‐cost activities such as attending church
services with his wife and children, thus enhancing family relationships and building social
networks within the community. Differences between Juan's upbringing in Mexico and the
American culture faced by his children were also discussed in therapy, increasing Juan's
understanding of the issues faced by his wife and children. At the end of therapy, Juan was no
longer depressed and reported improved relationships with his wife and children (Santiago‐
Rivera et al., 2008).
Those who completely reject or accept the values of the host culture appear to experience
greater stress than those who partially accept them (Miville, Koonce, Darlington, & Whitlock,
2000). Miranda and Umhoefer (1998a, 1998b) found that both highly and minimally
acculturated Mexican Americans scored high on social dysfunction, alcohol consumption,
and acculturative stress. They concluded that a bicultural orientation (i.e., maintaining some
components of the native culture while incorporating practices and beliefs of the host culture)
may be the “healthiest” resolution for acculturation; those with bicultural values are able to
accept and negotiate aspects of both cultures. Some of the issues involved in acculturation
conflict are evident in the following case.
A Latino teenager, Mike, was having difficulty knowing “who he was” or what group he
belonged with. His parents had given him an Anglo name to ensure his success in
American society. They only spoke to him in English because they were fearful that he
might have an accent. During his childhood, he felt estranged from his relatives because
his grandparents, aunts, and uncles could speak only Spanish. At school, he did not fit in
with his non‐Latino peers, but also felt different from the Mexican American students
who would ask him why he was unable to speak Spanish. Mike's confusion over his
ethnic identity resulted in significant distress.
(Avila & Avila, 1995)
During their early teen years, Latinx youth may begin to have questions about their identity
and question whether they should adhere to mainstream or traditional values. The
representation of Latinx individuals on English‐language channels often involves characters
who behave criminally or are violent. The mixed heritage of many Latinx Americans raises
additional identity questions. Should those of Mexican heritage call themselves “Mexican,”
“American,” “Mexican American,” “Chicano,” “Latina/o,” or “Hispanic”? What about those
with indigenous, Asian, or African ancestry? An ethnic identity provides a sense of belonging
and group membership. Many Latinx youngsters undergo the process of searching for an
identity. This struggle, in combination with acculturative stresses, may contribute to problems
such as substance abuse, aggressive behavior, delinquency, low self‐esteem, and an
increased risk for suicide (Smokowski, Rose, & Bacallao, 2010). Retention of one's culture
may be related to positive mental health. Mexican American students who maintained their
ethnic identity and heritage had higher levels of self‐esteem and life satisfaction. Cultural
retention may help prevent problem behaviors (Navarro, Ojeda, Schwartz, Piña‐Watson, &
Luna, 2014).
Implications
The client's degree of acculturation has important implications for treatment, especially
during initial therapy sessions, and can influence both perceptions of and responses to
counseling. For example, individuals with minimal acculturation may have difficulty being
open and self‐disclosing or discussing their issues in depth and may believe that counseling
will take only one session (Dittmann, 2005). Acculturation can be assessed by inquiring about
the client's background, generational status, residential history, reasons for immigration (if
applicable), primary language, religious orientation and strength of religious beliefs, extent of
support from extended family, and other factors related to acculturation. The therapist needs
to determine the client's degree of adherence both to traditional values and to those of the
dominant U.S. culture. The therapeutic alliance can be enhanced by inviting the client to
share their story and then listening deeply and empathically (Comas‐Diaz, 2012).
Ethnic identity issues should be recognized and incorporated during assessment and treatment
of youth and adults. Conflicts between mainstream values and ethnic group values can be
discussed, and clients can help brainstorm methods for bridging these differences. It should
be stressed that ethnic identity is part of the normal development process. In many cases, a
bicultural perspective may be the most functional, since such a perspective does not involve
the wholesale rejection of either culture.
Counselors should also inquire about potential acculturation conflicts, including their impact
on client symptoms or family conflicts. Although values such as familismo can be a source of
strength for youth, distress may feel unbearable when there is parent–child discord
(Hernandez, Garcia, & Flynn, 2010). Identification with core cultural values appears to serve
as a protective factor against risky behavior such as substance abuse and to serve as a source
of strength for children and adolescents (Dettlaff & Johnson, 2011). Counselors can help
youth explore and retain their cultural values and ethnic identity to bolster self‐esteem and
life satisfaction (Ai et al., 2014).
Research attempting to identify the risk factors accounting for the high incidence of suicide
attempts among Latinas, particularly among girls whose mothers place high value on
familismo, suggests that although familismo can be a protective factor with respect to
emotional and behavioral health, conflicts that result from adolescent strivings for autonomy
and subsequent parent–child discord can be a risk factor, particularly for those accustomed to
close parent–child relationships and harmony in the family unit (Kuhlberg et al., 2010).
Adolescents may question family obligations and parental rules and desire input into
decisions. Such behavior may be viewed as disrespectful by parents and extended family.
Larger societal factors such as immigration policies, discrimination, and concerns about
family separation also serve as risk factors (Romero, Edwards, Bauman, & Ritter, 2014).
Females may feel overprotected by parents and question their rules or expectations, such as
that the daughter will stay at home to care for others and be monitored on dates or forbidden
to date; such acculturation conflict may be particularly distressing to girls, since gender
socialization for females emphasizes their role in maintaining harmonious relationships.
Mother–daughter conflicts are exacerbated when the family orientation is traditional and the
daughter has a high mainstream cultural involvement (Derlan, Umaña‐Taylor, Toomey,
Updegraff, & Jahromi, 2015). Both biculturalism and familismo are related to higher self‐
esteem and greater flexibility in negotiating both cultures among Latinx adolescents
(Smokowski et al., 2010). Effective interventions for parent–child conflict include enhancing
bicultural understanding and promoting adaptive interpersonal behaviors (e.g., improved
communication, increased parental affection, and emotional connection) (Kuhlberg et al.,
2010).
Linguistic Issues
Considerable evidence suggests that assessment results can be influenced by linguistic
differences or misunderstandings. Assessments should always be conducted in the primary
language of the client and interpreted within a sociocultural context.
Implications
It is essential that clinicians consider the validity of tests for Latinx clients and the influence
of cultural or social factors, as well as language barriers, discrimination, immigration stress,
and poverty. Because of the lack of bilingual counselors, problems in diagnosis can occur
with clients who are not proficient in English. For example, Marcos (1973) reported that
Mexican American clients were considered to have greater psychopathology when
interviewed in English than when interviewed in Spanish. If an interpreter is used, this may
present its own difficulties in the counseling process, such as distortions in communication.
IMPLICATIONS FOR CLINICAL PRACTICE
Several writers (Bean, Perry, & Bedell, 2001; Paniagua, 1994; Velasquez et al., 1997)
have made suggestions about initial counseling sessions with Latinx clients.
1. Assess the acculturation level of the client and family members and modify your
interactions and assessment accordingly.
2. It is important to engage in a respectful, warm, and mutual introduction with the client.
Less acculturated clients may expect a more formal relationship and see the counselor as
an authority figure. Paniagua (1994) recommends interviewing the father for a few
minutes during the beginning of the first session, showing recognition of the father's
authority and sensitivity to cultural factors in counseling.
3. Determine whether a translator is needed. Determine if a Spanish‐speaking therapist is
available, if preferred.
4. Give a brief description of what counseling is and the role of each participant. Such
information is particularly important for less acculturated clients, who may expect to
meet for only one or two sessions or expect to have medication prescribed.
5. Explain the notion of confidentiality. Even immigrants with legal status have inquired
about whether the information shared during counseling will “end up in the hands of the
Border Patrol or other immigration authorities” (Velasquez et al., 1997, p. 112).
Immigrant families may also be uncertain about the limits of confidentiality, especially
as it applies to child abuse or neglect issues. Physical discipline is used in some families.
Parents may be fearful about how their child‐rearing practices will be perceived.
6. Have clients state in their own words the problem as they see it. Determine the possible
influence of religious or spiritual beliefs. Use paraphrasing to summarize and clarify the
problem.
7. Consider whether there are cultural or societal aspects to the problem. What are the
impacts of racism, poverty, and acculturative stress?
8. Determine the positive assets and resources available to the client and his or her family.
Have they, other family members, or friends successfully dealt with similar problems?
9. Help the client prioritize the problems and decide on the goals and expectations for
therapy.
10. Discuss possible negative consequences of achieving the indicated goals for the client
and the family.
11. Discuss the possible participation of family members in therapy. Within the family,
determine the hierarchical structure, as well as the degree of acculturation of the
different members.
12. Assess possible problems from external sources, such as the need for food, shelter, or
employment, or stressful interactions with agencies/systems based on race, gender,
status, and the like. Provide necessary assistance in developing and maintaining
environmental supports.
13. Explain the treatment to be used, why it was selected, and how it will help achieve the
goals (culturally adapted evidence‐based therapies should be considered). Consistently
evaluate the client's or family's response to the therapeutic approach chosen.
14. With the client's input, determine a mutually agreeable length of treatment. It is better to
offer time‐limited, solution‐based therapies.
15. Remember that personalismo is a basic cultural value for many Latinx. Although initial
meetings may be quite formal, once trust has developed, clients may develop a close
personal bond with the counselor, treat the counselor as a close friend or family member,
and give gifts or extend invitations to family functions. These behaviors are culturally
based and not evidence of dependency or a lack of boundaries.
16. When there are acculturation conflicts, have clients identify external demands rather
than merely focus on intrapsychic or relational issues.
Video Lecture: Culturally Competent Counseling: Innovative Approaches to Counseling
Latina/o People
SUMMARY
The gender‐inclusive term “Latinx” refers to a diverse group of people whose countries of
origin include Mexico, Puerto Rico, Cuba, and other Caribbean and Central and South
American countries. As with other groups of color, their standard of living is far below that of
their White counterparts and they have been subjected to continual racism and bias.
Understanding the major differences in the family structures (familismo), gender role
expectations (machismo and marianismo), spiritual and religious values, educational
characteristics, and cultural strengths of this group is important in informing culturally
responsive practice. Counselors must anticipate specific challenges they face, such as mental
illness stigma, acculturation conflicts, and linguistic issues in addition to the larger social
policies and practices. Sixteen clinical implications for counselor practice are identified.
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18
Counseling Multiracial Populations
Chapter Objectives
1. 1. Learn the demographics and characteristics of individuals of multiracial descent.
2. 2. Identify counseling implications of the information provided for multiracial
individuals.
3. 3. Provide examples of strengths that are associated with multiracial individuals.
4. 4. Know the special challenges faced by multiracial individuals.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with multiracial individuals.
When people try to get to know you, it's as if you're being demeaned to some sub‐
human creature. You always feel pressured to explain your ethnicity … you just feel like
some wax model in a museum exhibit. People gaze upon you either in wonder or
confusion. Their reactions are predictably insensitive and inconsiderate. “Um, what are
you?” they ask, overwhelmed with curiosity.
(Harvard, 2013)
Her maternal grandparents raised Lisa as White in a small Midwestern farming
community. Growing up, she sometimes felt different than her peers, but she didn't know
why. She noticed her skin would tan easily in the summer and her hair was curlier than
most of her friends'. Lisa began questioning her assumed White identity when she moved
to the South as a teenager. People teased her and called her the N‐word. Confused,
she turned to her grandparents. That is when she learned her biological father was
Black. In college, Lisa began to identify as Black‐biracial. She took Black Studies
courses, and dated and eventually married a Black man.
(Author's own case vignette)
People of mixed‐race heritage are often ignored, neglected, and considered nonexistent in
educational materials, media portrayals, and psychological literature (Bailey, 2013).
Multiracial individuals are also faced with the “What are you?” question. For years,
multiracial individuals have fought for the right to identify themselves as belonging to more
than one racial group on official documents; these efforts were largely spearheaded by White
mothers of multiracial children (Makalani, 2009). Our society, however, is one that tends to
force people to choose one racial identity over another. Lisa received counseling to unlearn
her early racial socialization as she explored the personal meaning of her African
Americanness. She admitted holding some of the same negative beliefs about Black people as
her peers; she made fun of Black people and thought herself somewhat superior in subtle and
unquestioned ways. By raising her White, Lisa's grandparents forced her to choose one
identity while actively denying her knowledge of another. There are countless everyday
examples of the ways in which others ignore or deny the complexity of one's racial identity.
One multiracial psychology intern (Japanese mother and Irish father) working in a Black
community was asked by his supervisor how his clients felt about working with a “White”
psychologist. When the supervisor noticed the confusion on the intern's face, he stated, “I
know you are Asian but you look White” (Murphy‐Shigematsu, 2010). The intern
considered the supervisor's reaction to him to be a microaggression and felt it interfered with
their working relationship.
Identity formation among multiracial people is complicated and is shaped by one's phenotype,
racial socialization in the home, and the neighborhood/environment in which one is raised. As
with other types of social identities, multiracial people negotiate between their self‐identity
and the identities imposed by others. Unfortunately, mental health professionals often receive
little training in working with multiracial clients. In fact, counselors may have conscious and
unconscious attitudes, biases, and stereotypes similar to those of the layperson regarding race
mixing (miscegenation) and “racial contamination.” Acceptance of interracial marriages and
multiracial children has increased over the years. In a recent Pew Research Center report,
nearly 4 out of 10 believed that interracial marriage was positive and only about 1 in 10
opposed the idea of a relative marrying someone of another race (Bialik, 2017). Race matters,
however: the figure jumped to 14% when non‐Blacks were asked about a relative marrying
someone who was Black.
In more ways than one, the 2000 U.S. Census set in motion a complex psychological and
political debate when, for the first time, it allowed people to check more than one box for
their racial identities and to be counted as multiracial (Nittle, 2011). Proponents of the change
have argued that it is unfair to force multiracial people to choose only one identity because
such practices (a) deny racial realities, (b) undermine pride in being multiracial, and (c)
ignore important personal information (e.g., the medical advantages of knowing one's racial
heritage). Custom, history, and prejudices continue to affect perceptions of those who are
multiracial, however. Additionally, many civil rights organizations, including the National
Association for the Advancement of Colored People (NAACP), believe that multiracial
categorization will dilute the strength of their constituencies. Because census numbers on race
and ethnicity figure into sociopolitical calculations involving antidiscrimination laws,
dispersal of funds for minority programs may also be adversely affected. Persons of mixed
racial heritage negotiate this space when constructing personal and political identities. For
example, someone like Lisa might identify as Black‐biracial both to acknowledge the
sociopolitical aspect of their Black identity and to honor their personal biracial identity.
CHARACTERISTICS AND STRENGTHS
In the following sections, we consider the history and characteristics of multiracialism in the
United States, the strengths of multiracial individuals, and their implications for treatment.
These are generalizations, and their applicability needs to be assessed for each client or
family.
Multiracialism in the United States
Mental health professionals can increase their understanding of multiracialism and related
issues by increasing awareness of facts such as the following (Frey, 2014; U.S. Census
Bureau, 2010):
The biracial baby boom in the United States started in 1967, when the last laws against
race mixing (antimiscegenation) were repealed. As a result, there was a rapid increase in
interracial marriage and a subsequent rise in the number of multiracial children in the
United States. In 2013, 12% of heterosexual newlyweds were interracial couples, with
nearly 6 out of 10 American Indians marrying someone of another race (Wang, 2015). In
2015, nearly 3 out of 10 Latinx (29%) and Asian (27%) new marriages were interracial
—considerably greater than for Black (18%) and White (11%) new marriages (Bialik,
2017). The most common interracial pairings during this time period were Latinx–White
(42%), Asian–White (15%), multiracial–White (12%), Black–White (11%), American
Indian–White (3%), and various other minority/minority couplings.
It is estimated that multiracial people make up 2.4% of the national population, or more
than 7.5 million people. The percentage of multiracial people is as high as 6.9% if one
takes into account the racial background of people's parents and grandparents (Pew
Research Center, 2015). The numbers of multiracial people in the United States is
growing rapidly by any calculation. About 14% of infants in 2015 were multiracial, with
42% having one Latinx parent and one White parent, 22% having one multiracial and
one White parent, 14% having one Asian and one White parent, and 10% having one
Black and one White parent.
Implications
These statistics hide how multiracial people live their daily lives; they do not capture how
identity is performed and understood and they do not shed light on how some multiracial
people feel coerced into adopting a monoracial identity. The reality is that the offspring of a
Black–White union is often considered Black by our society. Why not White? Why is it easy
for us to accept the notion that children of certain interracial unions (e.g., Asian–White,
American Indian–White) are multiracial when we cannot do the same for combinations that
involve Black Americans? Why do some people of mixed‐race heritage choose to identify
themselves with only one race? Are certain interracial relationships more acceptable than
others? Why? What accounts for the fact that Asian American women and Latinas are more
likely than their male counterparts to marry outside of their ethnic group?
Mental health professionals who work with multiracial clients need to understand the
implications of these questions if they are to be effective in their work with racially mixed
clients. They need to examine their own attitudes toward interracial couples and multiracial
children. In our journey to understand the implications of the issues confronting multiracial
individuals, we concentrate on several themes that have been identified as important in
working with this population.
The “One Drop of Blood” Rule
Alvin Poussaint, an African American Harvard psychiatrist, stood before a packed audience
and posed a pointed question: “Do you know how powerful Black blood is?” After an
awkward silence, he answered: “It is so powerful that one tiny drop will contaminate the
entire bloodstream of a White person!” What Poussaint was referring to is called
hypodescent, or the One Drop Rule, a class‐based social system that maintains the myth of
monoracialism by assigning a person of mixed racial heritage to the least desirable racial
status. This system was institutionalized by an 1894 Supreme Court decision (Plessy v.
Ferguson) that determined that a person who was seven‐eighths White and one‐eighth
Black and “maintained that he did not look Negro” was nonetheless to be classified as Negro
(Davis, 1991).
In essence, the hypodescent concept stemmed from a variety of self‐serving motives.
Initially, it was an attempt by White European immigrants to maintain racial purity and
superiority by passing laws against interracial marriages (antimiscegenation laws), primarily
directed at Blacks and American Indians. As early as the 1660s, laws were passed making it a
crime for “Negro slaves” to marry “free‐born English women” (Wehrly, Kenney, &
Kenney, 1999). Hypodescent thinking and laws not only maintained racial “purity” but also
generated additional property for slave owners and accommodated the sexual abuse of
African women. Africans were purchased as slave laborers; the more slaves an owner
possessed, the greater his wealth and access to free labor. Thus, economically, it was
beneficial to classify the offspring of a Black–White union—often the result of a rape—as
“Negro” because it increased the owner's wealth. Also, the prevalent beliefs of the time were
that “Negroes and Indians” were subhuman, uncivilized, lower in intellect, and impulsively
childlike. One drop of Black blood in a person would make him or her contaminated and
Black.
The rule of hypodescent applies to other racial and ethnic minority groups as well, but it
appears to predominate with African Americans. Although groups of color are often averse to
discussing social desirability differences between them, conventional wisdom and some data
suggest that African Americans are often considered less desirable than their Asian American
counterparts (Jackson et al., 1996), although Asian Americans are still considered
significantly less desirable than Whites. It also appears that the intersection of one's race and
gender affects how one is perceived by society. For example, images of Asian American
women are much more favorable (e.g., petite, exotic, and sexually pleasing) than those of
their male counterparts (e.g., passive, inhibited, and unattractive; Sue, 2005). Because of
racial‐gender prejudice, Black women are perceived as masculine and thus as undesirable
dating partners (Schug, Alt, Lu, Gosin, & Fay, 2017).
These biases help explain why interracial marriages between Asian American women and
European American men occur more frequently than marriages between Black women and
White men, and why mixed‐race children of the former union are more likely to be
considered multiracial, whereas those of the latter are more likely to be considered Black
(Jackman, Wagner, & Johnson, 2001). These double standards not only lead to hard feelings
and resentments between African Americans and Asian Americans but also create friction
among men and women within specific racial or ethnic minority groups. It is important to
understand that such antagonism between racial and ethnic minority groups and between men
and women originates from larger biased sociopolitical processes.
Implications
Many multiracial individuals find that society imposes a racial identity upon them. Such
identities are often influenced not only by their phenotype and racial heritage, but also by the
societal status associated with their particular background (Moss & Davis, 2008). In fact,
individuals of mixed‐racial heritage are generally considered to have “lower status”
compared to European Americans. Multiracial children, when asked their heritage, have been
found to answer one way internally and another way externally (Cross, 1991). The external
answer may be an attempt to fit in, to not violate the expectations of the questioner, or to take
the path of least resistance.
For example, answering that one is biracial is often not satisfactory to a questioner and is
likely to result in further probing. Unable to identify their conflicts and feelings about being
multiracial and about the frequent questions about their identity, children often settle for the
answer most likely to end the questions, responding by giving the “most acceptable”
monoracial identity, which may be at odds with their self‐definition. A number of
contextual factors influence how multiracial people self‐identify when they become adults.
Research with over 37,000 multiracial adults suggests that income, educational level, and
where one lives consistently influence how one chooses to label oneself (Davenport, 2016).
People who have incomes of over $100,000 have a greater chance of self‐labeling as White
compared to identifying as Asian, Black, or Latinx; the opposite is the case for people who
live in the Midwest, where there is a preference for identifying with one's racial minority
identity. Interestingly, Asian–White and Black–White individuals with a college degree also
prefer minority self‐identification. The main point here is for counselors to resist the urge to
label a client's race and instead to explore not only how the client identifies, but what their
identification means to them and their life story.
Strengths
Although a multicultural identity can result in challenges, many cite advantages, such as
having access to and support from several cultural communities (Sanchez, Shih, & Garcia,
2009). Multiracial individuals who have multiple‐racial‐identity integration appear to
have higher levels of psychological adjustment (Jackson, Yoo, Guevarra, & Harrington,
2012). Other advantages include the ability to see issues from a variety of perspectives
(Cheng & Lee, 2009). Those who have an integrated multiple racial identity have lower stress
levels and feelings of alienation compared to those who are in conflict about their racial
identity (Binning, Unzueta, Huo, & Molina, 2009). When adolescents were asked what they
perceived were advantages to being multiracial, they mentioned three things in particular:
having greater opportunities for international travel, being comfortable with people from
different racial backgrounds, and being intriguing to others (Bosquet & Sarinana, 2014).
In the present day, there is much greater acceptance of interracial marriage, especially among
young adults (Pew Research Center, 2015). Multiracial individuals are quite visible on
television, in movies, and in advertising. Support groups have arisen. For example, Michelle
Lopez‐Mullin (now Watson), past president of her university's Multiracial and Biracial
Student Association, has one parent who is Chinese and Peruvian and one who is White and
American Indian, and finds pride in her identity (Saulny, 2011). Instead of feeling
marginalized, many multiracial individuals possess enhanced cultural competence and feel
comfortable in more than one cultural setting. They may be able to “borrow from their
various racial backgrounds, culling out strengths specific to these cultures, and using them to
support their well‐being” (Pedrotti, Edwards, & Lopez, 2008, p. 199). And, as in the case of
Lopez‐Mullin, pride may develop through membership in different cultural groups. In a
SPECIFIC CHALLENGES
In the following sections, we consider challenges often faced by multiracial populations and
consider their implications for treatment. Remember that these are generalizations and that
their applicability needs to be assessed for each client.
Racial/Ethnic Ambiguity: “What Are You?”
My sister and I are half black, a quarter white, and a quarter Indian with British
accents, and everyone we meet seems eager to immediately “place” us into neat boxes.
It's human nature to be curious about people's backgrounds, and trying to solve the
“puzzle” of a multiracial person is understandably interesting. But being the puzzle that
people want to solve isn't always great.
(Bahadur, 2015)
Racial/ethnic ambiguity occurs when people are not easily able to distinguish the monoracial
category of a multiracial individual from phenotypic characteristics. Phenotypic traits play a
major role in how people perceive others. If African American traits are apparent, the One
Drop Rule will automatically classify a person as Black, regardless of how they self‐
identify; the observer might think, “She says she's mixed, but she is really Black” (Bean &
Lee, 2009). For multiracial individuals with ambiguous features, the “What are you?”
question becomes a constant dilemma.
The “What are you?” question requires an individual to justify his or her existence in a world
rigidly built on the concepts of racial purity and monoracialism. This is reinforced by a
multiracial person's attempts to answer such a question by discerning the motives of the
interrogator: “Why is the person asking?” “Does it really matter?” “Are they really interested
in the answer, or am I going to violate their expectations?” “Do they see me as an oddity?” If
the person answers “American,” this will only lead to further inquiry. If the answer is
“mixed,” the interrogator will query further: “What ethnicity are you?” If the answer is “part
White and Black,” other questions follow: “Who are your parents?” “Which is Black?” “Why
did they marry?” The multiracial person begins to feel picked apart and fragmented by such
questioning about his or her racial background (Root, 1990). The problem with giving an
answer is that it is often “not good enough.”
The communication from our society is quite clear: “There is something different about you.”
We cannot stress enough the frequency with which multiracial persons face a barrage of
questions about their racial identities, from childhood to adulthood (Houston, 1997). The
inquisition can result in invalidation, conflicting loyalties to the racial/ethnic identities of
parents, internal trauma, and confused identity development.
Implications
Multiracial children often feel quite isolated and may find little support, even from their
parents. This is especially true for monoracial parents, who themselves are not multiracial.
How, for example, does a White woman married to a Black man raise her child? White?
Black? Mixed? Parents of interracial marriages may fail to understand the challenges
encountered by their children, gloss over differences, or raise the children as if they were
monoracial. The children may, therefore, lack role models and experience loneliness. Even
being a multiracial parent may not result in greater empathy for or understanding of the
unique challenges faced by multiracial children, especially if the parent (themself the victim
of a monoracial system) has not adequately resolved their own identity conflicts. Therapists
can help interracial couples prepare their children for questions about their racial heritage.
Children are more likely to develop positive multiracial identities if their parents have
modeled strong ethnic identities (Stepney, Sanchez, & Handy, 2015).
Racial Identity Invalidation
Being forced into a side is an all too familiar situation for me and other biracial people I
have spoken to. I have found myself many times being classified as Asian because I have
predominantly Asian features and therefore do not seem “white enough.” Similarly, I
am often classified as white because I do not have enough Asian characteristics. [My
friend said it best] “You're constantly trying to find a home, somewhere you ‘belong.’”
(Sim, 2017)
A number of multiracial individuals experience racial identity invalidation; people try to fit
them into a monoracial box based on the way they look or how they behave (Franco &
O'Brien, 2017). It is hurtful when people deny an aspect of one's identity, especially when the
rejection comes from someone of the “minority” (Franco & Franco, 2016). A person who is
Asian, White European, American Indian, and African may not be completely accepted by
any of these groups. It is not uncommon for people to be told they are “not enough,” as in
“you are not Asian enough” or “Black enough.” Multiracial people may thus encounter
prejudice and discrimination from all sides (Sanchez et al., 2009). Experiencing racial
identity invalidation is related to greater racial identity challenges such as not feeling like one
belongs to any racial group; these challenges are in turn related to having more depressive
symptoms (Franco & O'Brien, 2017).
In Chapter 11, we spent considerable time discussing racial–ethnic–cultural identity attitudes
among minority group members. Criticisms leveled at these theories include the following:
(a) they were developed from a monoracial perspective rather than a multiracial one; (b) they
falsely assume that multiracial individuals will be accepted by their parent culture or cultures;
and (c) their linear nature is inadequate to describe the complexity of the many possible
multiracial resolutions (Kerwin & Ponterotto, 1995; Root, 1996). The experiences and
attitudes of multiracial individuals differ significantly depending on the races that make up
their background and how the world sees them.
Compounding the difficulty with the application of monoracial identity theory to multiracial
individuals is that 61% of those with a mixed racial background do not consider themselves
to be multiracial (Pew Research Center, 2015). Reasons why individuals do not identify as
multiracial include (respondents could have more than one reason):
They look like one race (47%).
They were raised as one race (47%).
They closely identify with a single race (39%).
They never knew the family member or ancestor who was a different race (34%).
Another problem for racial–ethnic–cultural identity theories is that the identity for many
multiracial individuals is fluid. About 30% of multiracial adults indicate that the way they
view their race has changed over time. Natasha Sim (2017) comments on her “ever‐
changing” racial identity in her blog post, quoted at the start of this section. Some who
originally thought of themselves as only one race now consider themselves multiracial, and
others who thought of themselves as multiracial now view themselves as one race (Pew
Research Center, 2015). These factors raise questions about the applicability of monoracial
identity theories to multiracial Americans.
Many multiracial individuals confront the process of resolving racial identity invalidation
and developing a healthy identity throughout their lives. Root (1998) describes four possible
identity resolutions.
1. The multiracial individual accepts the identity assigned by society. For example, the
child of a Black–Japanese union is likely to be considered Black by friends, peers, and
family. Root believes that this can be a positive choice if the person is satisfied with the
identity, receives family support, and is active rather than passive in evidencing the
identity. The individual in this situation, however, may have a very fluid identity that
changes radically in different situations. If they travel or move to another community or
region, for example, their assigned racial identity might become Japanese or even mixed.
2. The multiracial individual chooses to identify with both groups. “I think a lot of us are
chameleons. We can sit in a group of White people and feel different, but still fit in …
But we can turn around and sit in a group of Black people, even though we are not Black
in the same way” (Miville, Constantine, Baysden, & So‐Lloyd, 2005, p. 512). In this
case, the person is able to shift from one identity (White American) when with one
group to another identity (African American) when with a different group. This method
of adaptation is healthy as long as the individual views the ability to move in two worlds
as positive, does not lose their sense of self‐integrity, and can relate well to positive
aspects of both identities and cultures.
3. The multiracial individual decides to choose a single racial identity in an active manner.
Although this may appear similar to the first option, it differs in two ways: (a) it is the
individual, not society, who makes the choice of racial group identity; and (b) the
identity is less prone to shifting when the situational context changes. Actively choosing
a single racial identity can be a positive option when the individual does not deny his or
her other racial heritage and when the group with whom the individual chooses to
identify does not marginalize him or her.
4. The multiracial individual chooses to identify with a mixed‐race heritage or
multiracial identity. “I think it [being multiracial] has made me expertly cued to cultural
cues. Kind of as an observer, I'm always trying to learn, ‘ok, what's going on here, how
does one act here, and what are the cultural norms’” (Suyemoto, 2004, p. 216). In fact,
bicultural/biracial or multicultural/multiracial identification rather than identification
with only one race is increasing in frequency (Brunsma, 2005; Suzuki‐Crumly &
Hyers, 2004). A multicultural identity allows equal valuing of all aspects of one's racial–
ethnic–cultural heritage, the ability to relate to all groups, and feelings of being well
integrated.
Implications
In therapy with multiracial individuals, the stress associated with feeling their racial identity
is not validated can sometimes come to the surface. The type of conflict and resolution may
differ depending on the client's gender, the composition of their multiracial combination, and
other group identity factors, such as socioeconomic status, age, and sexual orientation. Also,
identities may shift, with the degree of fluidity displayed depending on the situational
context. It is possible, as suggested by Root, that there may be more than one identity
resolution that can lead to healthy adjustment.
However, it should not be assumed that a client's racial identity is the source of their problem.
If experiences with racial identity invalidation are producing distress, positive resolution can
occur with any of the choices discussed. Therapists should be aware that a growing number of
multiracial individuals are choosing “multiracial” as their ethnic identity. This choice should
not be considered pathological and interpreted as confusion or an inability to commit to an
integrated identity (Suyemoto, 2004). Therapists should also recognize that the issue at hand
may be less about identity resolution and more about acknowledging the hurt, pain, and
isolation the individual feels because of the daily invalidations they are experiencing.
Intermarriage, Stereotypes, and Myths
Although national surveys indicate that people are much more accepting of interracial
marriages then they were a decade ago, the reactions of some people to seeing images of
couples from different races tell a different story. A minority of Americans still vigorously
oppose such unions. The reaction to a Cheerios ad involving a mixed racial girl with a White
mother and an African American father exemplifies this point. So many racist reactions were
posted on YouTube in response to the ad that the comments section was disabled (Stump,
2013). There is considerable evidence that myths and stereotypes associated with multiracial
individuals and interracial couples have involved attempts to prevent the mixing of races
through the stigmatization of such mixture (Wehrly et al., 1999). African American males are
often stereotyped as lazy, violent, and poor fathers, and African American women as
aggressive, hostile, and undesirable. History is replete with incidents reflecting society's
hostility and antagonism toward African Americans.
Unfortunately, sociopsychological research on this topic has often perpetuated and reinforced
inaccurate beliefs about race mixing and mixed‐race people. Even now, some individuals
still view interracial relationships as an oddity. When an interracial couple is asked, “So, how
did the two of you meet?” the inquiry may not be due to pure curiosity but instead reflect the
question: “How did you two end up together?” (Goff, 2014). Members of a minority group in
mixed‐race relationships are too often seen as trying to elevate themselves socially,
economically, and psychologically.
Implications
In general, early myths about mixed marriages implied that these unions were the result of
unhealthy motives by the partners and that multiracial offspring were doomed to suffer
deficiencies and pathologies. These assumptions, and the early studies of mixed‐race
individuals, were problematic. First, if partners in mixed marriages or partnerships and their
multiracial offspring experienced identity issues, conflicts, and psychological problems, it is
likely that these difficulties were the result of an intolerant and hostile society. In other
words, they would have resulted from bias, discrimination, and racism, rather than from
anything inherent in the marriage or the “unhealthy” qualities of those involved. Second, we
already know that research is influenced by and reflects societal views. It seems likely,
therefore, that early researchers most likely asked questions and designed studies with a focus
on identifying pathology rather than looking at the healthy and functional traits of the group.
Third, in the case of interracial marriages, current research suggests that they are based on the
same ingredients as other unions: love, companionship, and compatible interests and values
(Rosenblatt, Karis, & Powell, 1995).
Discrimination and Racism
Multiracial individuals have also been subjected to instances of racism and discrimination.
About 55% have been exposed to racial slurs or jokes. The degree of reported exposure varies
according to the specific races that are part of an individual's racial background. Although
40% of mixed‐race adults with an African American background said they were unfairly
stopped by police, only 15% of White and American Indian adults, and 6% of biracial White
and Asian individuals, reported the same experience. A similar pattern was found for other
forms of racial discrimination. In fact, the exposure to racism and discrimination of mixed‐
race adults was similar to that reported by single‐race individuals of a specific race. Biracial
individuals with an African American background reported the same level of discrimination
as single‐race African Americans, while mixed‐race adults with an Asian background
reported discrimination at the same level as single‐race Asians (Pew Research Center,
2015). Although being multiracial does not itself lead to emotional problems, societal
reaction to race mixture can introduce stressors. Issues of racial identity and racial
discrimination among multiracial adolescents have been associated with substance abuse and
other problem behaviors (Choi, Harachi, Gillmore, & Catalano, 2006).
Implications
It is important to understand that research has identified beneficial sociopsychological traits
associated with a multiracial heritage, including an increased sense of uniqueness, greater
variety in one's life, greater tolerance and understanding of people, a greater ability to deal
with racism, and a greater ability to interact and build alliances with diverse people and
groups (Sanchez et al., 2009; Saulny, 2011).
A Multiracial Bill of Rights
Countless numbers of times I have fragmented and fractionalized myself in order to
make the other more comfortable in deciphering my behavior, my words, my loyalties,
my choice of friends, my appearance, my parents, and so on. And given my multiethnic
history, it was hard to keep track of all the fractions, to make them add up to one whole.
It took me over 30 years to realize that fragmenting myself seldom served a purpose
other than to preserve the delusions this country has created around race. Reciting the
fractions to the other was the ultimate act of buying into the mechanics of racism in this
country.
(Root, 1996, pp. 4–5)
These words were written by Maria Root, a leading psychologist in the field of multiracial
identity and development, who expressed concerns about the way in which society has
historically relegated multiracial persons to deviant status or ignored their existence because
they do not fit into a monoracial classification. In her personal and professional journey, Root
(1996) developed a Bill of Rights for Racially Mixed People that asserts their right not to
justify their existence or ethnic legitimacy, their right to self‐identity rather than assume the
identity expected by others, and their right to identify with more than one group of people.
Implications
Root's assertions have major implications for mental health providers, because they challenge
our notions of a monoracial classification system, reorient our thoughts about the many
myths of multiracial persons, make us aware of the systemic construction and rationalizations
of race, warn us about the dangers of fractionating identities, and advocate freedom of choice
for the multiracial individual.
IMPLICATIONS FOR CLINICAL PRACTICE
Although monoracial minority group members experience many of the issues faced by
multiracial individuals, the latter, in addition to dealing with racism, are likely to
experience unique stressors related to their multiple racial/ethnic identities. For example,
most monoracial minorities find their own groups receptive and supportive of them.
Multiracial individuals may be placed in the awkward situation of not being fully
accepted by any group. Likewise, monoracial minority group children can expect
psychological and emotional support from their parents—the parents share common
experiences with their children, can act as mentors, and relate to the experiences their
children encounter with respect to minority status. However, multiracial children are
likely to have monoracial parents who do not understand the challenges facing them
(Townsend, Markus, & Bergsieker, 2009). Common problems for multiracial youth and
adults include communication difficulties with their parents about racial identity issues,
reactions of peers and society to their identity, and pressure to assume a monoracial
identity (Jolivette & Gutierrez‐Mock, 2008). The following are guidelines for working
with multiracial clients.
1. Become aware of your own stereotypes and preconceptions regarding interracial
relationships and marriages. When you see a racially mixed couple, do you pay extra
attention to them? What thoughts and images do you have? Awareness of your own
biases will help you avoid imposing them upon your clients.
2. When working with any client, do not assume their racial background or personal racial
identity. Allowing multiracial people to self‐define and share their racial story or
stories can combat a history of racial identity invalidation. This means being cautious
about the “What are you?” question. It is important to emphasize the positive qualities of
the total person rather than seeing them as a collection of parts.
3. Remember that being a multiracial person can mean coping with isolation resulting from
external factors related to prejudice. Hence, mixed‐race persons can experience
forced‐choice situations and strong feelings of loneliness, rejection, anger, and
guilt/shame as a result of not fully integrating all aspects of their racial heritage.
4. Identify the strengths associated with a multicultural identity and the resources available
to the client, rather than focusing only on challenges.
5. With mixed‐race clients, emphasize the freedom to choose one's identity. There is no
one identity suitable for everyone. It is important to note that identities are often
changing and fluid rather than fixed.
6. Remain open to exploring the forces of oppression and racism related to the client's
experience as a multiracial person. The counselor can empower clients to take an active
part in formulating their identities.
7. Recognize that family counseling may be especially valuable in working with mixed‐
race clients, especially if they are children. Frequently, parents (especially those who are
monoracial) are unaware of the unique challenges related to their child's multiracial
journey. Interracial couples should also be assessed to see if differing cultural values and
expectations may be impacting their children in a negative manner. Parents can be taught
to empower their children to explore the meaning of their racial identity, without
labeling it for them.
8. When working with multiracial clients, ensure that you possess basic knowledge of the
history and issues related to hypodescent thinking (the One Drop Rule), ambiguity (the
“What are you?” question), and marginality. The knowledge cannot be superficial, but
must entail a historical, political, social, and psychological understanding of the
treatment of race, racism, and monoracialism in U.S. society. In essence, these four
dynamics form the context within which the multiracial individual operates on a
continuing basis.
9. Remember that many multicultural individuals are proud of their identity or have
resolved their identity in a healthy manner and that their multiracial identity is not a
factor in their presenting problem.
10. Educational institutions should provide support services for multiracial students and
opportunities to increase awareness and understanding of multiracial issues in the
curriculum (Ingram, Chaudhary, & Jones, 2014).
SUMMARY
Multiracial people are often ignored, neglected, and considered nonexistent in educational
materials, media portrayals, and psychological literature. Multiracial individuals are faced
with “What are you?” questions because society and even groups of color see race as
monoracial. Others may invalidate their racial identity, which can lead to a discrepancy
between their own self‐identity and that imposed by others. Mental health professionals
often receive little training in working with multiracial clients who are distressed or confused
by having monoracial categories imposed upon them. To work effectively with multiracial
individuals, the therapist must understand multiracial identity and its unique strengths and
challenges, including the stereotypes and myths associated with being multiracial and
concepts such as hypodescent. Many mixed‐race individuals do not identify as being
multiracial, and for others, identity may shift over time. There are different routes to a
healthy multiracial identity. Ten clinical implications for counselor practice are identified.
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19
Counseling Arab Americans and Muslim Americans
Chapter Objectives
1. 1. Learn the demographics and characteristics of Arab Americans and Muslim
Americans.
2. 2. Understand the differences between these two populations
3. 3. Identify counseling implications of the information provided for Arab Americans
and Muslim Americans.
4. 4. Provide examples of strengths that are associated with Arab Americans and
Muslim Americans.
5. 5. Know the special challenges faced by Arab Americans and Muslim Americans.
6. 6. Understand how the implications for clinical practice can guide assessment and
therapy with Arab Americans and Muslim Americans.
Most people are really scared … there's this feeling of the walls closing in. I'll say me
personally, I was really overwhelmed this weekend when everything happened at JFK
[airport], when the Iraqi interpreters who worked with the U.S. military were being
detained. It is this feeling of, what is happening right now? Where is this Muslim ban
going?
(H. Hoghul, as interviewed on CNN; Media Matters, 2017)
Democrats were forced to defend their appointment of Rep. Andre Carson of Indiana, a
Muslim, to the House Intelligence Committee after anti‐Muslim protests erupted on
Twitter and other social media with complaints that exposing American secrets to
Carson could be dangerous.
(Associated Press, 2015)
Nineteen year old Yusor Mohammed, a Muslim, felt like a “proud and blessed”
American who fit in. “That's the beautiful thing here, is it doesn't matter where you
come from … But here we're all one.” She, her 23‐year‐old husband Deah Shaddy
Barakat, and her 19‐year‐old sister Razan Mohammad Abu‐Salha were later shot
to death by an angry neighbor.
(Botelho & Davis, 2015)
In this chapter, we discuss some of the characteristics, values, and challenges of the Arab and
Muslim American community and consider their implications for treatment. Remember that
this overview provides generalizations about a diverse community of people, and that the
applicability of this general commentary always needs to be assessed with regard to the
individual client.
CHARACTERISTICS AND STRENGTHS
Arab Americans
Arabs are individuals who originate from countries located in the Middle East and North
Africa and whose primary language is Arabic. Arabs began immigrating to the United States
in the late 1800s. Arab Americans, descending from about 20 different countries, are
heterogeneous in terms of race, religion, and political ideology. The majority of Arab
Americans are native‐born U.S. citizens.
Arab Americans can have African, Asian, or European ancestry. Approximately 56% of Arab
Americans trace their ancestry to Lebanon, while 14% are from Syria, 11% from Egypt, 9%
from Palestine, 4% from Jordan, 2% from Iraq, and 4% from other countries (El‐Badry,
2006). Although the populations of Arabic‐speaking countries include large numbers of
Muslims, only about one‐quarter of Arab Americans are Muslims (Jackson & Nassar‐
McMillan, 2006).
Because of categorization systems used in the U.S. Census, it is difficult to determine the
precise size of the Arab American population. The U.S. Census estimates that there are 1.8
million Arab Americans. However, the Arab American Institute believes the U.S. Census
severely underestimates the number in the group and that there are actually 3,665,789 Arab
Americans, with 94% living in metropolitan areas such as Los Angeles, Detroit, New York,
Chicago, and Washington, DC (Arab American Institute, 2012). The count of Americans of
Middle Eastern and North African (MENA) descent—a group that includes Arab Americans
—could soon become much clearer: in 2017, the United States Census Bureau recommended
adding that category to the 2020 U.S. Census (U.S. Census Bureau, 2017).
The majority of Arab American immigrants arrived in the United States in two major waves
(Nassar‐McMillan & Hakim‐Larson, 2003; Suleiman, 1999). The first lasted from 1875
until World War II and primarily involved Arab Christians from Lebanon and Syria who
immigrated for economic reasons. The second wave began after World War II and included
Palestinians, Iraqis, and Syrians, who left in order to escape the Arab–Israeli conflicts and
civil war. This latter group included larger numbers of Muslims. The aftermath of the
September 11 attacks initially reduced Arab immigration, yet by 2005, the number of
immigrants from Muslim countries such as Egypt, Pakistan, and Morocco had increased again
(Elliott, 2006). Recent years have seen another fluctuation, however, as the number of
Muslim refugees and immigrants from majority Muslim countries to the United States
appeared to fall again in 2018 (Connor & Krogstad, 2018).
In comparison with the U.S. population as a whole, Arab Americans are more likely to be
married (61% versus 54%), male (57% versus 49%), young, and highly educated (46% have a
bachelor's degree, versus 28% of the total adult population) (Arab American Institute, 2012).
Sixty‐nine percent indicate they speak a language other than English at home, but 65%
speak English “very well.” The majority work as executives, professionals, and office and
sales staff. Forty‐two percent work in management positions. Arab American income is
higher than the national median income ($59,012 versus $52,029) (Arab American Institute,
2012). However, the poverty rate is also higher (17% versus 12%; U.S. Census Bureau,
2005). Arab Americans participate in a variety of religions. More than 33% are Roman
Catholic, 25% are Muslim, 18% are Eastern Orthodox, 10% are Protestant, and 13% report
other religion or no affiliation (Arab American Institute, 2003).
Muslim Americans
It is estimated that over 3 million Muslims—followers of Islam—are currently living in the
United States. Islam is one of the fastest‐growing religions in the country, with
approximately one‐fourth of U.S. Muslims being converts to the faith (U.S. Department of
State, 2002). Within Islam, there are two major sects: Sunni and Shiite. The Sunnis are the
larger group, accounting for approximately 90% of Muslims worldwide. The remaining 10%
are Shiites. Although many conflate Muslims with Arabs, most Muslims do not descend from
Arabic‐speaking countries (DeSilver & Masci, 2017). The percentage of Muslims currently
found in different regions of the world is estimated as follows: Asia‐Pasific, 61.7%; Middle
East–North Africa, 19.8%; Sub‐Saharan Africa, 15.5%; Europe, 2.7%; and Americas, 0.3%
(DeSilver & Masci, 2017). The majority of U.S. Muslim adults (58%) are first‐generation
Americans who were born in another country, while approximately 18% were born in the
United States and have at least one parent who emigrated from abroad. About a quarter (24%)
of American Muslims are U.S. natives whose parents were born in the United States (Pew
Research Center, 2017).
First‐generation Muslim Americans come from a wide range of countries around the world.
About 25% are immigrants from the Middle East or North Africa, while about 35% come
from South Asian nations. Others came to the United States from sub‐Saharan Africa (9%),
European countries (4%), and Iran (11%). In the United States, 41% of Muslim Americans
report their race as White, 20% as Black, 28% as Asian, 8% as Hispanic, and 3% as other or
mixed race (Pew Research Center, 2017). The Muslim American population is much younger
than the non‐Muslim population—35% of adult Muslims are between the ages of 18 and 29,
versus 21% of other adults in the United States (Pew Research Center, 2017). The largest
proportions of Muslim Americans describe themselves as being politically moderate, highly
religious, and committed to “American dream” beliefs – that people who work hard can get
ahead (Pew Research Center, 2017).
Cultural and Religious Values
The lives of many observant Muslims are governed by Islamic laws derived from the Qur'an,
which deals with social issues, family life, economics and business, sexuality, and other
aspects of life. Muslims consider the Qur'an to be the literal word of God; the name of their
religion means “submission to God.” Adherence to Islam is demonstrated by individual
accountability and a declaration of faith (“There is no god but God and Muhammad is his
messenger”). Muslims engage in the ritual of prayer five times a day and annually fast during
daylight hours throughout the holy month of Ramadan—a time for inner reflection, devotion
to God, and spiritual renewal. Almsgiving and a pilgrimage to Mecca are additional signs of
devotion (Nobles & Sciarra, 2000). Some Muslim women, particularly those of Arab descent,
wear traditional clothing because of the Islamic teachings of modesty.
Family Structure and Values
Family structure and values of Arab Americans and Muslim Americans differ widely,
depending on the specific country of origin and acculturation level. An Arab American
engineer living in San Francisco made the following observation: “American values are, by
and large, very consistent with Islamic values, with a focus on family, faith, hard work, and
an obligation to better self and society” (U.S. Department of State, 2002, p. 1).
Some generalizations can be made about the values of many Arab Americans. Hospitality is
considered an important aspect of interpersonal interactions (Nobles & Sciarra, 2000). Family
obligations and interdependence among members are very important. This group orientation
can result in pressure for conformity and high expectations for children. Parents expect to
remain part of their children's lives for as long as possible. In traditional Arab American
families, there is a strong sense of a community and an identity that revolves around culture
and God. The family structure tends to be patriarchal, with the men being the authority and
head of the family. Women are responsible for raising the children and instilling cultural
values in the offspring. In general, boys are advised by older males, and girls are advised by
older females. The maintenance of traditional gender roles has resulted in lower employment
levels for even highly educated Arab women (Al Harahsheh, 2011).
Arab culture tends to be collectivistic, so that the success or failure of an individual reflects
on the entire family. This personal responsibility for social behavior sometimes leads to stress
and anxiety. Arab college students appear to have higher than expected rates of social
anxiety, which may result from internalized norms of social responsibility for their conduct
(Iancu et al., 2011). Personal problems are often disclosed only to close family or friends.
Opposite‐sex discussions with other than a family member may be problematic (Jackson &
Nassar‐McMillan, 2006). Seeking treatment for emotional problems may be considered
shameful, so outside help is likely to be sought only as a last resort (e.g., Heath, Vogel, &
Al‐Darmaki, 2016).
In traditionally oriented Muslim families, the oldest son is prepared to become the head of the
extended family. Family roles are complementary, with men serving as provider and head of
the family and women maintaining the home and rearing children. Mothers are likely to
behave affectionately toward their children, whereas fathers may be aloof, generating both
fear and respect (Dwairy, 2008). Many Muslim women avoid physical contact with
nonrelated males, such as shaking hands or hugging (Tummala‐Narra & Claudius, 2013).
However, wide variation exists. Some Muslim American women shake hands with men,
support gay marriage, and consider themselves devout even though they do not wear a hijab
or head covering (Lawrence, 2014). Contrary to public opinion, U.S. women who have
converted to Islam do not consider themselves to be “brainwashed” or as having forfeited
their “free will” (Aleccia, 2013).
Implications
Counselors should be aware that traditional Arab American and Muslim American families
tend to be hierarchical, with men considered to be the head of the family. Although Western
media often portrays women as powerless victims of emotional and physical abuse, in most
Arab and Muslim families, women are treated with honor and respect (Ibrahim & Dykeman,
2011). Problems can occur with acculturation conflicts involving the struggle between
adhering to traditional familial patterns (culturally collective support) and seeking individual
fulfillment.
Cultural Strengths
Arab Americans and Muslim Americans tend to be collectivistic rather than individualistic in
orientation. Family and community supports can be protective factors in dealing with
prejudice and discrimination from the larger society. Family resources can be brought to bear
on personal issues and problems. Newer immigrants often receive support and acceptance
within Arab communities. Arab Americans have high levels of educational and economic
success, partially due to their ability to acculturate and assimilate quickly (Nassar‐
McMillan, 2011). Similarly, being part of a religious community can provide guidance in
dealing with problems and issues. Being a Muslim can provide not only religious beliefs but
also a code of behavior that encompasses cultural, racial, gender, and familial considerations.
SPECIFIC CHALLENGES
In the following sections, we discuss the challenges often faced by Arab Americans and
Muslim Americans and consider their implications in treatment.
Stereotypes, Racism, and Discrimination
When an Indian American, Nina Davuluri, won the Miss America crown, social media
responses included: “Congratulations Al‐Qaeda. Our Miss America is one of you,”
“So miss america is a terrorist,” and “How the f—k does a foreigner win miss America?
She is a Arab! #idiots.”
(Golgowski, 2013)
Rita Zaweidah, the co‐founder of the Arab American Community Coalition of
Washington State explains, “When somebody is picked up or arrested or they've done
something, they don't just mention that it is a male that was picked up. It's a Muslim
male. You never see them saying a Christian male or an Irish male or an English male
or female or whatever else. But for some reason when it's anything regarding the Middle
East, the religion is the first word somewhere in that sentence.”
(Zaki, 2011)
In recent decades, Muslims and “Arab‐appearing” individuals have been subjected to
increased discrimination and attacks. Although Arab Americans and Muslim Americans have
always encountered prejudice and discrimination, negative behavior directed toward these
groups accelerated following the September 11, 2001, attacks, the Boston marathon bombings
in 2013, and the murders of staff members at the offices of the Charlie Hebdo magazine in
France in 2015. Hate crimes against Muslims are now second only to those perpetrated
against Jewish Americans (Federal Bureau of Investigation, 2010).
Arabs, Arab Americans, and Muslims are often stereotyped in movies as sheiks, barbarians,
or terrorists (Nassar‐McMillan, Lambert, & Hakim‐Larson, 2011). Arabs are so
commonly stereotyped as being violent or terrorists that, in one study, individuals who played
a terrorist‐themed video game showed an increase in negative attitudes toward Arabs—even
though the game involved Russian characters. This finding clearly demonstrates a “strong
associative link” between Arabs and terrorism (Saleem & Craig, 2013).
Further, Islam's portrayal as a violent religion is widespread in American popular culture,
fueling anti‐Muslim bigotry and microaggressions (Husain & Howard, 2017). In fact, in
2006, Pope Benedict XVI created a storm of protests from the Muslim world when he read a
quote from a fourteenth‐century emperor: “Show me just what Muhammad brought that was
new, and there you will find only evil and inhuman, such as his command to spread by the
sword the faith he preached.” The pope later professed “total and profound respect for all
Muslims” and said he was trying to make the point that religion and violence do not go
together. Nonetheless, followers of Islam were deeply hurt by his statement.
The September 11 attacks and the Boston Marathon bombings both had a profound impact on
how Arab Americans and Muslim Americans were viewed in the United States. The vast
majority of Arab Americans and Muslim Americans were angered, upset, and dismayed by
the terrorist attacks, as were all Americans, and many supported retaliation against the
countries supporting the terrorists (Zogby, 2001). At the same time, they were aware of the
increased negative response by the public to Muslims and those of Arab descent as hate
crimes increased and thousands of Arab American and Muslim American males were
subjected to deportation hearings, airline passenger profiling, vandalism, physical violence,
and increased discrimination (Haq, 2013; Moradi & Hasan, 2004).
Unfortunately, many of their fears regarding discrimination were realized. In a report
covering incidents involving Arab Americans occurring between September 11, 2001 and
October 11, 2002, the following facts were reported:
More than 700 violent incidents were directed at Arab Americans or those perceived to
be Arab Americans or Muslims during the first 9 weeks after the September 11 attacks.
More than 800 cases of employment discrimination against Arab Americans occurred.
More than 80 cases of illegal or discriminatory removal from aircrafts after boarding
occurred (removal based on perceived ethnicity).
Thousands of Arab men were required to submit to a “voluntary interview” by
government officials.
Numerous instances of denial of services and housing occurred (American‐Arab
Anti‐Discrimination Committee, 2003).
Behavioral changes resulted from the scrutiny given to Arab Americans and Muslims. Among
Muslim Americans who worship at a mosque, nearly 100% reported being called a profane
name in public, being profiled at airports, or having been visited by authorities. Because of
the harassment and resulting fear, some stopped attending prayer services (Sahagun, 2006).
Muslim American women face added stressors, since their traditional garments are clearly
identifiable (Winerman, 2006). Although more than 15 years has passed since the September
11 attacks, Arab Americans and Muslim Americans remain wary. Their concerns may be
warranted. Results from a recent poll indicate that 46% of Americans believe that Islam is
more likely than other religions to encourage violence among believers (Pew Research
Center, 2015).
In keeping with these trends, Executive Order 13769—more commonly known as the Muslim
ban—was issued by President Donald Trump on January 27, 2017 (Leung, Langmaid, &
Hackney, 2017). This order banned U.S. entry by residents of Iran, Iraq, Libya, Somalia,
Sudan, Syria, and Yemen, all nations with Muslim majority populations. As border officials
initiated enforcement of the order at American airports that evening, hundreds of travelers
were detained or sent back to their countries, even as U.S. citizens and attorneys assembled in
protest. By February 4, the resulting legal challenges to the constitutionality of the order
resulted in a cessation of its enforcement, although some provisions were later reinstated (de
Vogue, 2017).
The vast majority of Muslim Americans reject extremism and express concern over its rise
both in the United States and in other countries. Half believe that it has become more difficult
to be Muslim in the United States in recent years due to challenges such as discrimination,
stereotyping, and negative media portrayals (Pew Research Center, 2017). At 66%, Muslim
Americans are even more likely than other Americans (at 49%) to say that they are very
concerned about global extremism in the name of Islam, and three‐quarters say that there is
little or no support for extremism within the U.S. Muslim community (Pew Research Center,
2017). Muslim groups started a “Respond with Love” campaign to raise funds to help rebuild
six predominantly Black churches that were damaged by fire during a 2‐week period in
2015, in what may have been cases of arson, and to “stand against hate.” Regardless of the
cause of the fires, the group wanted to demonstrate with “our African American brothers and
sisters” against “institutionalized racism and racist violence” (Bever, 2015).
Americans' attitudes toward Muslims and Arabs are negative in many ways, with Republicans
and White evangelicals reporting the greatest reservations. A quarter of Americans believe
that half or more of Muslims are anti‐American, and 50% of Americans do not see Islam as
part of mainstream society. At the same time, the percentage of Americans who associate
Islam with violence declined from 50% in 2014 to 41% in 2016 (Pew Research Center,
2017). Similarly, the favorable opinion of Arabs dropped from 43% in 2010 to 32% in 2014.
Further, 42% of Americans indicated support for law‐enforcement profiling of Arab
Americans and Muslim Americans (Wisniewski, 2014).
Implications
Because many Americans have negative views of Arab Americans and Muslim Americans,
mental health professionals should examine their own attitudes toward these groups.
Have you been influenced by the negative stereotypes of individuals from these groups?
Would you feel less safe during air travel with Arab‐looking passengers or if you
noticed a fellow passenger carrying a Qur'an? What would your reaction be if a client
came in wearing traditional clothing?
It is important to realize that Arab Americans, especially those who appear to be from an
Arab country or who are Muslim, are bombarded by negative stereotypes, prejudice, and
discrimination.
Mental health professionals should ask about discriminatory actions directed toward
clients and be willing to explore these experiences and help seek solutions.
Therapists should be informed regarding antidiscrimination policies, should be able to
provide clients with information about recourses for discriminatory actions, and should
support client efforts to challenge discrimination. If clients are encountering job or
housing discrimination, the therapist can discuss their legal rights and assist them in
taking appropriate actions, such as reporting hate crimes to the police.
The website for the American‐Arab Anti‐Discrimination Committee (ADC) offers
legal resources and information on addressing discrimination in these and other areas.
Acculturation Conflicts
A 14‐year‐old Middle Eastern Muslim boy was suspended from school for the use of
alcohol and skipping school. He had been receiving good grades and had no previous
behavioral problems. His problems stemmed from acculturation conflicts and the stigma
associated with the 9/11 terrorist attacks.
(Measham, Guzder, Rousseau, & Nadeau, 2010)
Elkugia, who was born in Libya, was voted homecoming queen for her high school.
While playing basketball for her high school team, she wears a headscarf, a long jersey,
and athletic pants instead of shorts. Her clothing reflects her Muslim faith and is a
“form of modesty.”
(Iwasaki, 2006)
As with many groups that face discrimination and prejudice, some Arab Americans and
Muslim Americans do not spontaneously announce their religion or ethnic background, and
some have changed their names to be more “American‐sounding.” Although some Arab
Americans are bicultural and accept both their Arab and their American identities (Nobles &
Sciarra, 2000), others try to disguise their religious and ethnic identities by wearing
American‐style clothing. Many have completely assimilated, especially those from the first
wave of Arab American immigration, who were primarily Christian. Immigrant Muslims, on
the other hand, may be struggling with the challenges of maintaining their traditional
practices within an American context (Podikunju‐Hussain, 2006). Muslim women may wear
the hijab as a sign of modesty, and the resulting ethnic visibility can increase the stereotyping
and stigmatization that these women experience (Everett et al., 2015). Traditionally oriented
Arab and Muslim Americans may avoid certain aspects of American society, preferring to
maintain contact with individuals from their own religious group or country of origin. The
September 11 attacks appear to have strengthened the ethnic identity of many Arab
Americans, with 88% of those polled after the attacks responding that they were proud of
their heritage and 84% indicating that their ethnic heritage was important in defining their
identity. More than 80% said that securing Palestinian rights was personally important to
them (Zogby, 2001).
Implications
Because culture, values, and religion can differ significantly within the Arab American and
Muslim American communities, therapists need to determine the background and beliefs of
each client or family, rather than responding in a stereotypical manner. Some individuals may
be highly acculturated or assimilated, whereas others may adhere strongly to traditional
cultural and religious standards; this is especially true for Arab Americans who are Muslims.
Generational acculturation conflicts are common, with children acculturating more quickly
than parents. This may be especially problematic for traditionally oriented Arab Americans
who adhere to a hierarchical family structure in which children are expected to “behave
appropriately.”
IMPLICATIONS FOR CLINICAL PRACTICE
Arab Americans are a very diverse group in terms of religion, culture, country of origin,
and degree of acculturation. There is similar diversity within the Muslim community.
Recent Muslim immigrants are likely to adhere more strictly to Islamic principles,
whereas those who have lived in the United States for much of their lives are more likely
to have a moderate perspective (Ibrahim & Dykeman, 2011). In general, non‐Arab and
non‐Muslim Americans possess little knowledge about these groups and have often
been exposed to misinformation. Because of this, many view the actions of extremist
Islamic groups as representing the views of all Arab Americans and Muslim Americans.
As mental health workers, we need to understand Arab culture and Muslim beliefs.
The following are recommendations for working with Arab American and Muslim
American clients (Podikunju‐Hussain, 2006; Ibrahim & Dykeman, 2011):
1. Identify your attitudes about Arab Americans and Muslim Americans.
2. Recognize that many face discrimination and violence because of their Arab background
or their religious beliefs.
3. Be ready to help those who have been discriminated against in seeking legal recourse.
4. Cross‐gender counselor pairing may be problematic with Arab or Muslim clients.
Inquire if the gender of the therapist is a factor to be considered.
5. Recognize that Arab Americans and Muslim Americans are diverse groups. Recent
immigrants are more likely to hold stronger traditional values and beliefs. Collaborate
with each client or family to gain an understanding of their lifestyle and beliefs,
including their religion and the importance of religion in their lives. Religion may not be
a factor in the presenting problem.
6. Determine the structure of the family through questions and observation. With
traditional families, try addressing the husband or male first. Traditional families may
appear highly interdependent, a common cultural characteristic. Determine if
acculturation conflicts are producing stress within the family.
7. Be careful of self‐disclosures that may be interpreted as weakness. Positive self‐
disclosures may enhance the therapeutic alliance.
8. In traditionally oriented Arab Americans families, there may be reluctance to share
family issues or to express negative feelings with a therapist, especially by men (Heath,
Vogel, & Al‐Darmaki, 2016).
9. There may be greater acceptance to holistic approaches that incorporate family members
and the religious or social community, especially with clients who hold traditional
values.
10. Be open to exploring spiritual beliefs and the use of prayer or fasting to reduce distress.
Alternative explanations and expressions of psychological distress should be accepted
without the imposition of a Western worldview. Counselors should be open to talking
about religion and drawing on religious coping strategies. Islam encourages self‐
responsibility in actions and alternatives to negative thoughts. Identifying the client's
views regarding Islam may be useful in adapting therapy (Ebrahimi, Neshatdoost,
Mousavi, Asadollahi, & Nasiri, 2013; Meer & Mir, 2014).
11. Cognitive behavioral strategies may be productive for Muslims if distressing thoughts
are modified in accordance with Islamic beliefs (Khodayarifard & McClenon, 2011).
Video Lecture: The Psychology of Racism: Where Have We Gone Wrong?
SUMMARY
Arab Americans are descendants from countries located in the Middle East and North Africa
and are heterogeneous in terms of race, religion, and political ideology. The majority of Arab
Americans are native‐born U.S. citizens. Muslims are followers of Islam, one of the
fastest‐growing religions in the United States. Most Muslims do not descend from Arabic‐
speaking countries. Effective work with these populations requires knowledge of cultural and
religious dictates, especially Islamic laws derived from the Qur'an, which deals with social
issues, family life, economics and business, sexuality, and other aspects of life. Collectivism,
hierarchical family structure, and patriarchy are important cultural values in Arab American
and Muslim American populations. The increase of prejudice and discrimination toward these
groups accelerated following the September 11, 2001 terrorist attacks. Hate crimes against
Muslims are now second only to those perpetrated against Jewish Americans. Eleven clinical
implications for counselor practice are identified.
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20
Counseling Immigrants and Refugees
Chapter Objectives
1. 1. Learn the demographics and characteristics of immigrants and refugees.
2. 2. Identify counseling implications of the information provided for immigrants and
refugees.
3. 3. Provide examples of strengths that are associated with immigrants and refugees.
4. 4. Know the special challenges faced by immigrants and refugees.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with immigrants and refugees.
In responding to President Donald Trump's controversial statements about immigrants
from Haiti and African countries, United Nations human rights spokesman Rupert
Colville said in a briefing in Geneva “There is no other word one can use but ‘racist.’
You cannot dismiss entire countries and continents as ‘shitholes,’ whose entire
populations, who are not white, are therefore not welcome.”
(O'Keefe & Gearan, 2018)
Jean Yannick Diouf's story is among the nearly 70 narratives Illinois Senator Dick
Durbin collected from dreamers (individuals brought to the U.S. at an early age without
documentation). “When Yannick was 8, his father, a diplomat from the African country
of Senegal, brought his family to the United States. Unfortunately, Yannick's parents
separated, and Yannick's father returned to Senegal, leaving Yannick and the rest of the
family behind. Yannick didn't realize it at the time, but when his father left the United
States, Yannick lost his legal status to live in this country. Yannick—an honors student
and community leader who is currently studying business management at the University
of Maryland, College Park—told me that, to him, ‘DACA means dignity. More than
making money, having a job gives us dignity and self‐respect. I want to work for what I
have. I don't look to anyone for pity. People should judge me based on what I do and
what I stand for, not based on status. I want to be given a chance to prove that not only
am I a functioning member of society, I am here to serve and share my talents with those
in my community’.”
(Durbin, 2018)
Abrahim Mosavi, a national of Iran and resident of the United States for more than
three decades, applied to naturalize in 2000. Although he is eligible to become a citizen,
he has waited thirteen years for a final decision on his application. “No one can tell me
why I should have to wait so long,” said Mr. Mosavi.
(ACLU, 2013)
The international‐born population in the United States (including undocumented
immigrants) was 41.3 million in July 2013; nearly one out of every six adults living in the
United States was born abroad (Zeigler & Camarota, 2014). Approximately 12 million are
from Mexico, 10.5 million from East and South Asia, 4 million from the Caribbean, 3.2
million from Central America, 3 million from South America, 1.6 million from the Middle
East, and about 7.5 million from other countries. Mexican immigrants made up about 28% of
all U.S. immigrants, and Asians are currently the fastest‐growing group of immigrants in the
United States (Pew Research Center, 2014). Immigration from Mexico slowed considerably
after the economic downturn in the U.S. economy in 2009; in fact, over 1 million Mexican
immigrants have returned to their country of origin since that time.
About 11.4 million immigrants are unauthorized, having entered the United States without
inspection or overstayed their temporary stay; approximately 60% of undocumented
immigrants have been here for more than a decade (Baker & Rytina, 2013). Of the
unauthorized immigrants in the United States, an estimated 5,850,000 are from Mexico,
1,700,000 from Central America, 1,400,000 from Asia, 600,000 from Europe and Canada,
550,000 from the Caribbean, 400,000 from the Middle East or Africa, and 190,000 from
South America (Pew Research Center, 2014).
The reasons for migration include escape from poverty, seeking a higher quality of life, and
political unrest (Negy, Schwartz, & Reig‐Ferrer, 2009). Many immigrants, particularly
those from undeveloped countries and those who are undocumented, earn extremely low
wages. Approximately 23% of immigrants and their U.S.‐born children live in poverty
(Camarota, 2012). About 60% of farm workers, who help pick billions of dollars of
agricultural products, are undocumented immigrants. Nearly 25% of workers who butcher
meat, poultry, and fish are undocumented, including many women. Most undocumented
immigrants subsist on poverty‐level wages and are exposed to exploitation and abuse in the
workplace. A high percentage of women working in these food industries are subject to
sexual abuse (Southern Poverty Law Center, 2010).
Since 2012, there has been a surge of unaccompanied immigrant children, primarily from
Central American countries such as Guatemala, Honduras, and El Salvador; many of these
children have come to the United States to escape the escalating gang violence in their home
countries (young children and teens are forced to join gangs; if they refuse, they and their
families are subjected to violent retribution). While border patrol agents can quickly deport
children from Mexico, those from Central American countries are given full court
proceedings (Lind, 2014). This is creating a backlog of immigration cases. Other countries,
such as Mexico, Panama, Nicaragua, and Belize, are also inundated with Central Americans
seeking asylum (Restrepo & Garcia, 2014).
There is a wide range of educational levels among adult immigrants, with nearly one‐third
having a college degree (U.S. Census Bureau, 2012). New immigrants are better educated
than the U.S. population as a whole: about four out of ten immigrants coming to the United
States between 2007 and 2013 had earned at least a bachelor's degree (Fry, 2015). Immigrants
make up nearly 28% of physicians, 31% of computer programmers, and 47% of medical
scientists. East Asians and Nigerians are the most highly educated immigrants in U.S. history,
with more than 60% having at least a bachelor's degree (Pew Research Center, 2014;
TADIAS, 2014). In contrast, about one‐third of U.S. adult immigrants as a whole have not
completed high school (compared with 12.5% of the total adult population) (U.S. Census
Bureau, 2012). Among the immigrant secondary school population, the high school dropout
rate was 21% in 2009—significantly higher than the national average. Although immigrants
make up 10% of high school students, they account for 27% of high school dropouts (Child
Trends, 2014). In general, children of immigrant families have high rates of poverty (35%)
(Wight, Chau, & Aratani, 2011).
According to the Department of Homeland Security, only about 39% of undocumented
immigrants currently in the United States arrived after the year 2000. Most undocumented
immigrants are well integrated into society, and many have children born in the United States
—children whose dominant language is English and who have never visited their parents'
homeland. Having established their lives in the United States and having children who only
know life in the United States are powerful reasons for these immigrants to want to remain in
the country. The work of these undocumented immigrants is indispensable in areas such as
agriculture, construction, childcare, and the restaurant and hotel industry (Marrero, 2011).
Despite the belief that immigrants are a drain on society, they are no more likely to use social
services than are native‐born Americans. In fact, the belief that unauthorized immigrants are
a financial burden on society ignores the fact that they pay billions of dollars in taxes each
year, and nearly half of the adults who have been in the United States for more than 10 years
are homeowners (CAP Immigration Team, 2014). Meanwhile, although incidents such as the
shooting of a young woman in San Francisco in 2015 by an undocumented Mexican raise
fears about crime regarding this population, studies have found that immigrants have a much
lower rate of crime and are less likely to be behind bars than are native‐born individuals.
These findings apply “for both legal immigrants and the unauthorized regardless of their
country of origin or level of education” (Ewing, Martínez, & Rumbaut, 2015). Fear regarding
immigrants, especially those who are undocumented, may be a product of negative
stereotyping or inordinate attention to the criminal acts of a few.
CHARACTERISTICS AND STRENGTHS
In the following sections we describe the historical, sociopolitical, cultural, and gender
characteristics of immigrants, implications for treatment, and the strengths often seen among
those who emigrate. Remember that these are generalizations and their applicability needs to
be assessed for each client.
Historical and Sociopolitical Factors
The twin 12‐year‐old Duarte sisters watched in horror as their parents were
accosted and taken away by U.S. Immigration Customs Enforcement (ICE) agents
outside of their California home. They were born in the U.S. years after their parents
immigrated to the country from Mexico. The sisters and their two older brothers are now
trying to piece back together their family and their lives.
(Keierleber, 2017)
The election of Donald Trump as president of the United States shifted recent immigration
policies and public discourse. During the 2016 election season, the Southern Poverty Law
Center administered a national survey to approximately 2,000 K–12 teachers. Key findings
from the survey include:
More than two‐thirds of teachers reported that students—mainly immigrants, children
of immigrants, and Muslims—had expressed concerns or fears about what might happen
to them or their families after the election.
More than half had seen an increase in uncivil political discourse.
More than one‐third had observed an increase in anti‐Muslim or anti‐immigrant
sentiment. (Costello, 2016, p. 4)
It seems the children's concerns and fears have to a large degree been realized.
The Trump administration's approach to immigration is part of a larger history of unfair and
exclusionary laws restricting the immigration of non‐White people to the United States.
Until 1952, only White persons were allowed to become naturalized citizens. With the
Immigration Act of 1965, people from any nation were finally allowed to apply for
citizenship. In part, the U.S. civil rights movement facilitated this change. Even now,
however, under a little‐known federal program, the Controlled Application Review and
Resolution Program (CARRP), the government excludes many applicants for citizenship or
work visas from Arab, Middle Eastern, Muslim, and South Asian communities by delaying
and denying their applications. According to the American Civil Liberties Union (ACLU)
(2013), it does so by “relying on extraordinarily overbroad criteria that treat religious
practices, national origin, and innocuous associations and activities as national security
concerns.” Thus, individuals from these countries and religious backgrounds do not appear to
have the same opportunities as other immigrant groups to work or gain citizenship in the
United States.
During his first year as president, Donald Trump signed seven executive orders to change
immigration policies, most designed to restrict immigration from non‐White countries or to
arrest immigrants and/or remove them to their country of origin (Pierce & Selee, 2017).
Among the executive orders include:
1. Canceling Deferred Action for Childhood Arrivals (DACA). In 2012, President Obama
took executive action authorizing DACA, which provided temporary deportation
protection for more than 500,000 unauthorized young immigrants and allowed them to
apply for work permits; these young adults, called “dreamers,” were brought to the
United States as children without proper documentation. In November 2014, Obama
extended DACA to provide deportation relief and work permit eligibility for another 4.7
million undocumented immigrants who had lived in the United States for at least 5 years
and whose children were citizens or legal permanent residents. These actions provided
deportation protection for about 5.5 million undocumented immigrants, while about 6
million others did not qualify for temporary deportation relief under these programs
(Lind, 2015).
2. Ending Temporary Protected Status (TPS). TPS provided people fleeing war and natural
disasters special privileges to live and work in the United States. Approximately,
200,000 Salvadorans, 45,000 Haitians, and 2,500 Nicaraguans must return to their
country of origin by early 2019. Many of these people have been living in the United
States and contributing to U.S. society since 2001, and the earthquake in El Salvador.
3. Reducing refugee admissions to an all‐time low. Trump capped the refugee settlements
in the United States at 50,000 in 2017 and 45,000 in 2018, which is considerably lower
than the cap under the Obama administration (110,000).
Additionally, some states have passed laws that target immigrants. In some cases, election
officials at polling places are allowed to make inquiries of registered voters who appear to be
immigrants, such as, “Are you a native or a naturalized citizen?”, “Where were you born?”,
and “What official documentation do you possess to prove your citizenship?”. The voters are
then required to provide documentation and to declare, under oath, that they are the person
named therein.
These anti‐immigration policies continue to provoke fear and unease within immigrant
communities, as well as decrease the likelihood of immigrants reporting crimes or abuse. In
response to recently implemented state laws requiring schools to inquire about the
immigration status of students, federal officials have stated that school districts must “ensure
that any required documents would not unlawfully bar or discourage a student who is
undocumented or whose parents are undocumented from enrolling in or attending school.” In
other words, immigration status should not play a role in establishing residency within a
school district (Khadaroo, 2014).
Despite the rise in anti‐immigration policies and rhetoric, most Americans support
providing a pathway to citizenship for the dreamers and other immigrants. In a recent poll,
about 70% of Americans believed dreamers should be allowed to stay in the country legally
(Samuels, 2018) and a little over half believed immigration strengthens the United States.
There is a sizable number, however, who believe the United States should tighten its boarders
and restrict immigration. The argument is often made that undocumented immigrants violated
the law by not following immigration policy and that they are a drain on the social system.
Those on the other side of the debate counter that businesses have benefited from and
continue to rely on the work provided by undocumented workers, many of whom have lived
in the United States for decades, paying taxes and contributing to their communities.
Cultural and Acculturation Issues
Immigrants face the overwhelming task of learning about the workings of U.S. society.
Immigrants need to negotiate the educational system, acquire language proficiency, and seek
employment. They must adjust and adapt to new cultural customs within a completely
different society and navigate the mixed reception they receive from U.S. citizens. Placed in
unfamiliar settings, adjusting to climactic differences, and lacking community and social
support, many experience severe culture shock (Bemak & Chung, 2014). Feelings of
isolation, loneliness, disorientation, helplessness, anxiety, and depression often characterize
the immigration experience. The only sources of comfort and support may be a small circle of
relatives or friends, who also may be adjusting to a different way of life.
In families in which the degree of acculturation varies, the exposure to different values,
attitudes, and behavioral expectations can result in acculturation‐based problems. In
immigrant families, children and adolescents attend school and thus more quickly acculturate
and adapt to U.S. culture, whereas the parents and older family members tend to adhere to
traditional cultural values. Children may believe that their parents are unable to offer advice
or help with social problems. Parents may begin to feel that their children are abandoning
them and their cultural background. Parent–child acculturation discrepancies can lead to a
sense of alienation between family members. Immigrant families may seek therapy when
parent–child communication difficulties lead to intergenerational conflicts or produce
psychological symptoms in the child (APA Presidential Task Force on Immigration, 2013).
Implications
Counselors often need to take on multiple roles with clients who are recent immigrants,
including educator (providing information on services and education about their rights and
responsibilities) and advocate (helping negotiate the institutional structures of the health care,
education, and employment systems). In addition to traditional mental health services,
psychoeducational approaches are often required to assist immigrants to acquire (a) education
and training for themselves and their children; (b) knowledge of employment opportunities,
job search skills, and the ability to manage financial demands; (c) language proficiency to
ensure success in U.S. society; and (d) strategies to manage family relationship conflicts.
To effectively assist immigrants, it is important to understand the life circumstances of
immigrant groups, to have liaisons within the immigrant community, and to be familiar with
community resources aimed at helping immigrants adjust to a new world. When addressing
family problems around acculturation issues, it is often helpful to cast the exposure to
different values and expectations as the source of acculturation conflicts and help family
members problem‐solve methods of dealing with differing cultural expectations.
Gender Issues and Domestic Violence
Many immigrants come from countries in which there are gender inequities and spousal
abuse; women may be reluctant to seek help because of self‐blame, concern for their
children, or lack of knowledge about abuse protection laws (Ting & Panchanadeswaran,
2009). Reluctance to report partner abuse may also be influenced by economic dependence or
fear of retaliation (Quiroga & Flores‐Ortiz, 2000). Further, many immigrant women have
been socialized to sacrifice their own personal needs for the good of their husbands and
children. Such training leads to their ignoring or denying their own distress and prioritizing
family needs (Ro, 2002).
Male immigrants may face a loss of status and develop a sense of powerlessness. They may
have lost their assigned roles within the family and society as a whole and may be
unemployed or underemployed. Because women often find it easier to gain employment, the
resulting changes in the balance of power may increase the risk of domestic violence as men
attempt to reestablish their authority (Bemak & Chung, 2014).
Implications
As with other cases involving family violence, the following steps are recommended:
Assess the lethality of the situation. If there is a high degree of danger, develop a safety
plan. The client should know where she and her children can stay if she needs to leave
home. The therapist should help identify shelters or other resources available for the
particular immigrant group to which she belongs.
If the degree of violence is nonlethal and the client does not want to leave the home,
provide psychoeducational information on abusive relationships, the cycle of violence,
and legal recourse. Also provide crisis numbers or other contact information to use if the
violence escalates.
Convey an understanding of both the cultural and the situational obstacles the client
faces. Recognize that some women may define their role as the one who protects and
cares for everyone's welfare. Forming a strong therapeutic relationship is especially
important if no support is available from other family members or friends.
Attempt to expand support systems for the client, especially within her community.
Support groups and services are now available for a number of different immigrant
groups.
Strengths
The attributes from the various ethnic and cultural groups to which immigrants belong
strengthen the diversity of our nation. Immigrants have made positive social, political, and
cultural contributions to U.S. society for many generations. Immigrants often demonstrate
significant loyalty to the United States as their chosen homeland and have brought with them
both ingenuity and a strong work ethic. They have a “high level of engagement” in the labor
market and generally have good psychological and physical health (APA Presidential Task
Force on Immigration, 2013).
Many immigrants are from countries with a collectivistic orientation in which religion or
spiritual practices are important; they often serve as role models of interdependence and
cooperation with multiple extended family and community supports. The role of the family
and the strength of spiritual beliefs serve as core resources to make meaning of and help cope
with the stress associated with adapting to a completely new environment (Kira &
Tummala‐Narra, 2015). Immigrants are often supportive of each other and promote group
identification and acceptance of differences. These kinds of support can help ameliorate the
stressors involved in living in a new culture, especially a society that emphasizes the
individual.
SPECIFIC CHALLENGES
In the following sections, we consider challenges faced by immigrant individuals and
consider their implications for treatment. Remember that these are generalizations and that
their applicability needs to be assessed for each client.
Prejudice and Discrimination
Refugees who are forced to leave their countries because of persecution or war, are
often described in negative terms such as “waves” of refugees that threaten to flood the
country, “sponges off the welfare system,” “criminals,” “lacking in morals,”
“cockroaches” or “parasites.”
(Hamilton, Medianu, & Esses, 2013, p. 94)
The September 11, 2001, terrorist attacks had a dramatic impact on U.S. attitudes toward
immigrants and refugees. The new emphasis on preventing the entry of terrorists into the
United States resulted in not only Arab or Muslim Americans being viewed with suspicion,
but anyone who “appears foreign.” Immigrants became regarded as possible terrorists.
Following the trauma of September 11, the movement toward the legalization of
undocumented immigrants slowed, and there was a dramatic decline in the admission of
refugees (Frej, 2016). The anti‐immigration nativism movement, promoting the position
that only U.S. “natives” (understood to be people of European descent) belong in the United
States, is receiving greater support (Nassir, 2014). Similarly, the English‐only movement,
viewed by many immigrants and others as being exclusionary, is strengthening.
Although immigrants already use less than 50% of available health care resources as
compared with the average U.S. citizen (National Immigration Law Center, 2006), the
climate of fear has led to even further decreases in the utilization of medical or government
services by immigrants. While immigrants' children born in the United States are citizens,
many undocumented parents harbor great fear and anxiety about their own immigration status
or that of close family members. Parents or guardians who are undocumented are fearful of
registering their children for school or seeking medical attention..Other immigrants, even
those who are permanent legal residents, are afraid that seeking assistance might suggest an
inability to live here independently and increase their chances of being deported or of not
being granted citizenship.
Implications
Mental health professionals should be aware that immigrant clients or their families may see
the therapist as an arm of government. The therapist should also be aware of the rights and
exclusions associated with immigrant status (Bernstein, 2006):
Hospitals are required to provide emergency care to anyone in need, including
undocumented immigrants. Other treatments depend on local laws. Information
regarding other immigrant issues can be obtained from the National Immigration Law
Center.
Free community clinics exist that will treat individuals regardless of immigration status.
Immigrants can ask health care providers for interpreter services.
Most documented immigrants are not eligible to receive Medicaid, food stamps, or
social security benefits during their first 5 years in the United States or longer, regardless
of how much they have paid in taxes.
Undocumented immigrants face tremendous difficulties when seeking a higher
education. The imposition of out‐of‐state tuition fees effectively keeps them out of
college in most of the country. In support of higher education for these students, 18
states currently have provisions allowing for in‐state tuition rates for undocumented
students, and five (California, Minnesota, New Mexico, Texas, and Washington) allow
undocumented students to receive state financial aid. Three states (Arizona, Georgia, and
Indiana) prohibit in‐state tuition rates for undocumented students, and two (Alabama
and South Carolina) prohibit them from enrolling at any public postsecondary institution
(National Conference of State Legislatures, 2015).
Many advocacy agencies now encourage immigrant parents to have a detailed plan in
place in case they are deported, including granting power of attorney to someone who
can take custody of their children (O'Neill, 2012).
Barriers to Seeking Treatment
Multiple barriers exist for immigrants in their utilization of social and mental health services.
As mentioned earlier, immigrants utilize health care services much less than U.S. citizens.
Mental health providers need to understand how cultural, linguistic, and informational
barriers can affect immigrants.
In a survey of health care providers, several barriers to accessing services were identified:
Communication difficulties due to language differences. More than half of the providers
identified language barriers as the major source of difficulty in providing service. These
barriers affect critical areas, such as obtaining accurate information during assessment.
The providers also mentioned that it is difficult to obtain interpreter services, especially
given the diversity of dialects within some ethnic groups (Weisman et al., 2005).
Lack of knowledge of mainstream service delivery. Many immigrants lack knowledge
about how the health care system operates in the United States. Extra time is required
when providers try to explain clinic practices and paperwork. Often, apparent
noncompliance in following through with recommendations is due to poor understanding
of services.
Cultural factors. Many immigrant groups are hesitant to speak about “family issues” or
issues of personal concern because of the cultural importance of privacy (Chung &
Bemak, 2007). Women who have been abused by their husbands or sexually assaulted
may not talk about these issues because of cultural norms and shame, as well as over
fear of deportation. A stigma exists for many immigrants around seeking help for mental
health problems, and there may be fear that mental health issues will be blamed on the
family.
Lack of resources. Many immigrant families are living in poverty and may lack
transportation to go to the service location. In addition, they may not have time to attend
sessions, due to inflexible work schedules or the economic necessity of working as many
hours as possible.
Linguistic and Communication Issues
If immigrants are not fluent in English, the use of interpreters may be necessary. Many
therapists and interpreters are not aware of the dynamics involved when another individual
enters the therapy relationship. Most interpreters receive little or no training in working with
distressed or traumatized individuals, and they may experience uncontrollable feelings of
emotional distress when hearing traumatic stories, especially when their backgrounds are
similar to those of the clients (Miller, Zoe, Pazdirek, Caruth, & Lopez, 2005). For example,
one interpreter discovered that in order to protect herself from distressing feelings as she was
interpreting for traumatized clients, she became dismissive and casual when describing the
violent events. In another case, a therapist observed, “I had one interpreter start shaking. It
was too much for her … She just became incredibly upset and angry” (Miller et al., 2005, p.
34).
Therapists also report developing reactions to interpreters. Some think of interpreters as
“translation machines,” whose interpersonal qualities are unimportant. Eventually, however,
most realize that interpreters form part of a three‐person alliance. Initially, clients may
develop a stronger attachment to the interpreter than to the therapist. Because of this,
therapists need to deal with feelings of “being left out” and to accept that their relationships
with these clients might develop in a slower fashion. Therapists may also choose to use
interpreters as important cultural resources by obtaining their thoughts about issues discussed
in sessions. In general, therapists are appreciative of interpreters and do not perceive any
long‐term negative effects on the therapeutic progress. Sometimes, however, interpreters
interject their own opinions, intervene directly with clients, or question interventions because
they do not understand the therapeutic approach (Miller et al., 2005).
Implications
Both therapists and interpreters benefit from knowledge of best practices such as the
following (Searight & Searight, 2009; Yakushko, 2010):
Interpreters should receive brief training in specific mental disorders and the
interventions employed in therapy, particularly treatment of trauma, grief, and loss.
Because traumatic experiences discussed in therapy can affect interpreters, therapists
should discuss self‐care strategies for the interpreter, as well as ways of dealing with
exposure to traumatic reports.
Clients do not regard interpreters as translation machines. Therefore, interpreters should
be trained in the relationship skills that are needed in therapy. In the triadic relationship,
interpersonal skills such as empathy and congruence are necessary.
Therapists should also receive training on how to work effectively with interpreters and
become conversant with different models of interpreting. Some prefer simultaneous
translation, whereas others prefer delayed translation.
Therapists should be aware that, in many cases, the therapeutic alliance may form with the
interpreter first. Many therapists who have worked with interpreters understand that for
non‐English‐speaking clients, interpreters are the bridge between themselves and the
therapist, and are critical in assessment and the provision of therapy.
Counseling Refugees
Deng fled the civil war in Sudan and has been in the United States for the past 2 years.
He is 28 years old and spent 4 years in a refugee camp before coming to the United
States. He describes fleeing burning villages outside of Darfur and seeing many people
from his own family and community slaughtered, raped, and beaten. He remembers
running and hiding, being near starvation, drinking muddy water, avoiding crocodiles
and once a lion, and being alarmed when bombs dropped nearby … He wonders what
happened to his family and friends and feels guilty for having escaped.
(Chung & Bemak, 2007, p. 133)
Deng's escape from Sudan and the trauma he experienced are not uncommon for refugees.
The United States provides refugee status to persons who have been persecuted or have a
well‐founded fear of persecution. In contrast to other immigrants, who voluntarily left their
country of origin, refugees are individuals who fled their country in order to escape
persecution due to race, religion, nationality, political opinion, or membership in a particular
social group. Asylees, individuals who meet the criteria for refugee status, are either
physically present in the United States or at a point of entry when granted permission to
reside in the country. Any alien present in the United States or arriving at a port of entry may
seek asylum. Individuals granted asylum are authorized to work in the United States. In
addition, an asylee is eligible for certain public benefits, including employment assistance, a
social security card, and social services. Similar to refugees, asylum seekers have been
uprooted from their countries of origin, often after suffering years of persecution or torture
directed toward themselves, their family and friends, or even their entire community.
Predetermined allotments for specific geographical locations limit the number of refugees and
asylees accepted by the U.S. government; these limits change from year to year. In 2013, the
69,909 persons admitted to the United States as refugees were primarily from four countries:
Iraq (27.9%), Burma (23.3%), Bhutan (13.1%), and Somalia (10%). Additionally, 25,199
individuals from China (34%), Egypt (14%), Ethiopia (3.5%), Nepal (3.4%), and Syria
(3.2%) were granted asylum (Martin & Yankay, 2014). These numbers of both refugees and
those granted asylum in the United States have significantly decreased since the election of
President Donald Trump.
What characterizes the life experience of many refugees is their pre‐migration trauma,
which is often life‐threatening in nature. The impact of trauma is likely to be exacerbated by
the challenges of adjustment to a new world. Being displaced from their country of origin,
refugees often express concern about adapting to a new culture and country. Losing their
cultural identity is also a worry. Lacking a support or community group, refugees often feel
estranged and isolated. Many report feelings of homesickness and concerns over the breakup
of their family and the loss of community ties. There are often worries about the future,
difficulties communicating in English, and unemployment.
Refugees want their children to learn their native language and to maintain family and cultural
traditions. Many refugee parents are also especially concerned about the Americanization of
their children, given the U.S. societal emphasis on openness and individuality. Parents may
worry about the academic and social adjustment of their children and what they perceive to
be a lack of discipline in American society. Because of the limitations on available
employment, many have inflexible, low‐wage jobs that prevent them from adequately
supervising their children (Weine et al., 2006).
Effects of Past Persecution, Torture, or Trauma
Post‐traumatic stress disorder (PTSD) and elevated rates of mood and anxiety disorders are
frequent in the refugee population (Nickerson, Bryant, Silove, & Steel, 2011), including
nightmares and symptoms involving dissociation, intrusive thoughts, and hypervigilance
(Chung & Bemak, 2007). It is important to note, however, that the vast majority of refugees
are able to make a healthy transition to life in the United States. Although many of the
challenges faced by refugees are similar to those encountered by immigrants, differences do
exist. In general, refugees are under more stress compared to immigrants. Most immigrants
had time to prepare for their move to the United States, whereas for most refugees, the escape
was sudden and traumatic. Family members have often been left behind. With the exception
of some undocumented immigrants, who often have experienced robbery, beatings, and
sexual assault, refugees have typically been exposed to more trauma than other immigrants
(Bemak & Chung, 2014).
The pre‐migration experiences of many refugees include the atrocities of war, torture and
killing, sexual assault, incarceration, and a continuing threat of death. For example, Central
American refugees from El Salvador, Guatemala, Nicaragua, and Honduras report violent
experiences, such as witnessing beatings and killings, fearing for their own lives or those of
family members, being injured, or being victims of sexual assault. These Central American
refugees report feelings of isolation and exhibit high levels of mistrust with service providers
(Asner‐Self & Marotta, 2005). Refugees often experience emotional reactions related to the
destruction of their family and social networks, sometimes as a result of genocide. Many
report that memories of war intrude into their daily lives.
Implications
To see loved ones raped, beaten, and killed can have lasting, long‐term consequences. It
may be difficult to share such traumatic experiences with a therapist. In order to have a strong
therapeutic relationship with traumatized refugees, it is especially important to establish trust
and to recognize that the disclosure of traumatic experiences takes time. Questions not related
to violence, exposure to weapons, or other stressful incidents might allow for greater comfort
in revealing traumatic experiences and reduce feelings of fear, shame, and humiliation later
(Asner‐Self & Marotta, 2005).
It is important to consider the cultural perspective of refugees concerning mental and physical
disorders in order to determine how their views might be different from those of the dominant
culture. For example, in some countries, women victimized by sexual assault are shunned and
considered unfit for marriage. In addition, many immigrants take a somatic view of
psychological disorders and see mental disorders as resulting from physical problems. If a
client brings up somatic symptoms, the therapist can work first with these complaints. Also,
because there may be a lack of understanding of PTSD symptoms, therapists can help clients
understand why they occur. Symptoms can be framed as normal reactions to trauma that
anyone in their situation might develop. Therapists can reassure clients that the symptoms can
be treated and are not signs that they are “going crazy.”
Safety Issues and Coping with Loss
Refugees often come from politically unstable situations. In such cases, issues of safety are
salient and must be addressed. In the process of requesting refugee status, some clients may
have faced the adversarial experience of having to prove that they were persecuted. Because
of this, they may be reluctant to relate their experiences or seem fearful that they will not be
believed.
The loss of friends, family, and status is very troubling to refugees. They often feel guilty
about leaving other family members behind and may go through a bereavement process.
Many will not be able to resume their previous level of occupational and social functioning. It
is important to identify their perceptions about what is lost.
Implications
Therapists should discuss confidentiality and the reason for assessment early in the intake
process. Based on negative experiences with governmental powers in their homeland,
refugees may be concerned about providing information or may be worried that any
information they share will be used against them. Also, since problem behaviors or mental
difficulties may be seen as a source of shame for the individual or the family, knowing that
the information they provide will be confidential may offer some relief. It is helpful to
acknowledge the difficulty involved in sharing private information, providing reassurance
that it is necessary in order to develop the best solutions. To explore the possibility that
cultural constraints exist, the counselor might also say something like the following:
“Sometimes people in counseling believe that family issues should stay in the family. How do
you feel about this belief?”
To understand the loss experienced by refugees, it may be helpful to ask them to share their
migration stories as part of the assessment. This provides an understanding of their social and
occupational life prior to leaving their country of origin. Information regarding family life,
friends, and activities can be gathered by asking questions such as, “What was your life like
before coming to the United States?”, “What was family life like?”, “What kind of job or
family roles did you have?”, and “What was your community like?”. Therapists can also
inquire about experiences with transition from the client's homeland and any traumas
associated with this process: “What happened before, during, and after you left your
country?”, “What differences do you see between living in your country and living in
America?”, “What do you see as the advantages and disadvantages of living in either
country?” It is important to understand experiences with resettlement camps and find out
whether family members were separated. In addition, therapists should inquire about clients'
experiences with prejudice and discrimination in their homeland and since arriving in the
United States. This process gives a clearer picture of the perceived losses and experiences of
refugees (Weisman et al., 2005).
IMPLICATIONS FOR CLINICAL PRACTICE
Many immigrants hold cultural belief systems that are collectivistic. In contrast to the
individualistic Western worldview, they may consider interpersonal relationships and
social networks to be of paramount importance. Mental health systems that value
independence over interdependence, separate mental functioning from physical
functioning, attribute causation as internally located, and seek to explain events from a
Western empiricist approach can be at odds with the cultural belief systems of
immigrants and refugees. Counselors may inadvertently impose their belief systems on
these clients and communicate a disrespect for their worldview. Counselors should
perform a self‐assessment with respect to their own attitudes by asking themselves
questions such as, “How do I feel about immigrants and refugees coming to our
country?” and “What are my feelings about undocumented immigrants?” (Villalba,
2009). It is important for therapists to consider the following (Bemak & Chung, 2014;
Burnett & Thompson, 2005):
1. Remember that immigrants and refugees face multiple stressors, including the stress of
moving to and living in another country, learning another language, and negotiating new
social, economic, political, educational, and social systems. It is often a confusing and
frightening experience. Mental health providers who understand the complexities of this
situation can do much to reassure clients by demystifying the process.
2. Be aware that the client may have day‐to‐day stressors, such as limited resources, a
need for permanent shelter, lack of employment, or frustrating interactions with
agencies. Allow time to understand and to provide support related to these immediate
needs, or to help the client locate resources related to specific needs.
3. Do not assume that the client has an understanding of mental health services or
counseling. Give a description of what counseling is and the roles of therapist and client.
4. Inquire about the client's beliefs regarding the cause of their difficulties, listening for
sociopolitical, cultural, religious, or spiritual interpretations. Understanding and
validating clients' conceptualizations of presenting problems within their cultural matrix
is an important aspect of providing culturally relevant services.
5. Allow time for clients to share their backgrounds, their pre‐migration stories, and their
life experiences since immigrating.
6. Clearly describe the symptoms of mental disorders, outline various psychotherapeutic
approaches, and explain how chosen strategies will help the client make desired changes.
Modify evidence‐based therapies to include cultural beliefs.
7. Cultural adaptations include condensation of treatment sessions, review of concepts
covered, and modification of materials such as the inclusion of visual aids and of
culturally relevant metaphors, values, and proverbs (Ramos & Alegría, 2014).
8. Keep current regarding what is happening at the local, state, and federal level relative to
immigration and refugee issues, particularly the tone of the debate. As our review
indicates, sociopolitical conditions and public policy can have either positive or negative
effects on refugees' life experiences.
9. Families may be impacted by poverty, fear of immigration raids, parents working
multiple jobs, and a lack of an extended family network. In addition, acculturation
conflicts can occur. In some families, children have learned to threaten parents with
dialing 911 when physically disciplined (Leidy, Guerra, & Toro, 2010).
10. Mental health providers should consider offering services within the immigrant
community rather than outside of it. These services should be made culturally relevant
and partially staffed by members from the immigrant community.
11. Help undocumented immigrants have a plan in place for dealing with possible
deportation of family members and to secure advocacy resources that are available to
them.
12. In the course of assessment and diagnosis of mental disorders, take into account
environmental factors, language barriers, and potential exposure to discrimination and
hostility. When necessary, use skilled and knowledgeable interpreters.
13. Be knowledgeable about refugee experiences and the psychological strategies commonly
used to cope with stress. Understand that symptom manifestations may include post‐
traumatic stress and other mental disorders that arise from experiences of war,
imprisonment, persecution, rape, and torture. Symptoms might involve nightmares,
avoidance, hopelessness, or negative beliefs about the self and others.
14. Develop your own system of self‐care to decrease the effects of intense work with
clients with traumatic histories.
SUMMARY
Immigrants come to this country to escape poverty or political unrest, and to seek a better life.
Despite the belief that immigrants are dangerous or a drain on society, they are no more likely
to use social services and to commit crimes than native‐born Americans. Nevertheless,
many citizens are opposed to the number of immigrants entering the United States and are
against providing a path to citizenship for those who are undocumented. Refugees are those
forced to leave their countries in order to escape persecution due to race, religion, nationality,
political opinion, or membership in a particular social group. In addition to facing major
cultural differences and coping with a new environment, both groups have been subjected to
individual, institutional, and societal prejudice and discrimination. Clinicians need to be
attuned to linguistic and communication issues, pre‐migration trauma, and post‐traumatic
stress for refugees. Fourteen clinical implications for counselor practice are identified.
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21
Counseling Jewish Americans
Chapter Objectives
1. 1. Learn the demographics and characteristics of Jewish Americans.
2. 2. Identify counseling implications of the information provided for Jewish
Americans.
3. 3. Provide examples of strengths that are associated with Jewish Americans.
4. 4. Know the special challenges faced by Jewish Americans.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with Jewish Americans.
It hurts to watch the videos and hear the chants that were coming out of Charlottesville
on Saturday, August 12th [2017]. “Blood and soil! Jew will not replace US!” “Heil
Hitler!” “Blood and Soil” was a Nazi slogan that meant ethnicity was based solely on
blood descent and the territory a person maintained. “Blood and Soil” actually became
a Nazi policy in 1933, and farmers needed to produce an Aryan race certificate in order
to receive benefits under the law. “Why do people hate Jews, Mama?” my youngest
child asked, as we walked to school last spring.
(Goldman, 2017)
“Congress, the White House and Hollywood, Wall Street, are owned by the Zionists …
Everybody is in the pocket of the Israeli lobbies, which are funded by wealthy
supporters, including those from Hollywood. Same thing with the financial markets.”
Quote from Helen Thomas, former member of the White House press corps.
(Weiss, 2013)
Thirty percent believe that American Jews are more loyal to Israel than to America, and
26 percent believe that Jews are responsible for the death of Christ. Nineteen percent of
Americans believe Jews have too much power in the business world. One out of five
African Americans and more than a third of foreign‐born Hispanics hold anti‐Semitic
beliefs.
(Anti‐Defamation League, 2013)
Anti‐Semitism appears to be rearing its head across Europe yet again. The
perpetrators of the recent terror attacks in Paris and Copenhagen both targeted Jews …
Reports of anti‐Semitic incidents have risen in the U.K. as well as in France, where the
most European Jews live.
(Looft, 2015)
Jewish Americans constitute a diverse community with multifaceted ethnic backgrounds,
cultural identifications, and religious practices (Friedman, Friedlander, & Blustein, 2005). In
the following sections, we discuss some of the characteristics, values, and strengths of the
Jewish American community and consider their implications for treatment. Remember that
this overview provides generalizations about a diverse community of people, and that the
applicability of the generalizations always needs to be assessed with regard to individual
clients.
Jewish Americans include (a) people who practice Judaism and have a Jewish ethnic
background, (b) people who have converted to Judaism but do not have Jewish parents, and
(c) individuals with a Jewish ethnic background who do not practice Judaism but still
maintain their cultural identity and connection to their Jewish descent (Schlosser, 2006).
Although most Jewish Americans do not follow all Jewish religious traditions (approximately
40% indicate that religion plays a major role in their lives), many retain strong Jewish
connections by celebrating the major holy days of Yom Kippur, Hanukkah, and Passover.
Also, some regularly attend synagogue services and follow the tradition of keeping kosher
homes (food and preparation rules that adhere to religious dietary guidelines) (Younis, 2009).
Although Jewish individuals have experienced centuries of discrimination both within the
United States and throughout the world, they have received little attention in the multicultural
literature.
In the United States, approximately 4.2 million individuals are Jewish by religion, while
another 1.1 million are secular or cultural Jews, who report that they have no religion but
consider themselves to be Jewish (Pew Research Center, 2013). These individuals form the
largest Jewish community in the world outside of Israel (where there is a Jewish population
of 7.8 million); there are also large Jewish populations in Canada and Argentina. Most
American Jews (94%) identify their race as White (Pew Research Center, 2013).
The earliest Jews to arrive in the United States immigrated from Spain and Portugal. The
second group immigrated from Germany and Eastern Europe because of persecution or for
economic reasons. By World War I, 250,000 German‐speaking Jews had arrived in
America. Eastern European Jews came to America as a result of overpopulation, poverty, and
persecution. Between 1880 and 1942, more than 2 million Jews from Russia, Austria,
Hungary, and Romania entered the United States, forming the largest group of Jews in the
country (Zollman, 2006). Because of their historical and political background, Jewish
Americans are among the most liberal political groups in America, with about 70%
supporting the Democratic Party. In general, Jews describe themselves politically as “liberal”
or “very liberal.” However, one subgroup, the Orthodox Jews, are not as liberal, with half
describing themselves as politically conservative and supporting the Republican Party (Pew
Research Center, 2013).
Since 1990, the Jewish population in the United States has decreased from 5.5 to 4.2 million.
According to the Pew Research Center (2013), this population decline is due to aging (many
are older than 65, and younger individuals are more likely to identify themselves as having no
religion), falling birth rate, intermarriage (over one‐third of Jewish individuals who
intermarry do not raise their children to be Jewish), and assimilation. Approximately 52% of
Jewish women between the ages of 30 and 34 have not had any children, compared with 27%
of all American women; the fertility rate of Jewish women is below that needed to maintain
the population (Berkofsky, 2006). Adherence to Jewish traditions has also declined over time.
In terms of religiosity, two‐thirds of Jews do not belong to a synagogue, about a quarter do
not believe in God, and one‐third celebrate Christmas (Goldstein, 2013).
Approximately 85% of Jewish Americans were born in the United States, and almost all are
native English speakers. Some speak Hebrew, Yiddish, or the language of their country of
origin. Most of those born outside the United States are from the former Soviet Union. Jews
are a highly educated group, with 62% of those 18 and older possessing at least a bachelor's
degree, versus 22.4% of non‐Jews. Their income level and household wealth is much higher
than that of the total population (Chua & Rubenfeld, 2014). Most Jewish individuals consider
themselves to be a minority group and indicate that their heritage is “very” or “somewhat”
important to them. About half report “strong emotional ties” to Israel. Jewish Americans were
in the forefront of the civil rights movement in the 1960s. In fact, half of the White Freedom
Riders and civil rights attorneys involved in the movement were Jewish Americans. Jewish
Americans are well represented in all aspects of American society in terms of business,
education, politics, entertainment, and the arts.
CHARACTERISTICS AND STRENGTHS
In the next sections, we present some of the attributes, values, and strengths that are generally
characteristic of the Jewish community. This section will be followed by consideration of
some of the challenges faced by this group.
Spiritual and Religious Values
Judaism, with its belief in an omnipotent God who created humankind, was one of the earliest
monotheistic religions. According to Judaism, God established a covenant with the Jewish
people and revealed his commandments to them in the Torah, the holy book. The most
important commandments are the Ten Commandments. Individuals who wish to convert to
Judaism go through the process of (a) studying Judaism and the observance of the
commandments, (b) immersion in a ritual bath, and, for males, (c) circumcision (although
symbolic circumcision may be allowed by some sects).
One of the most important Jewish holidays is Yom Kippur, the Day of Atonement. It is a time
set aside to atone for sins during the past year. Rosh Hashanah, the start of the Jewish New
Year, is another High Holiday in Judaism. This holiday, celebrated 10 days before Yom
Kippur, represents the creation of the world or universe. Even those who are not religious
often attend synagogue services and spend time with family during these celebrations.
Within Judaism, the degree of adherence to religious tradition varies. Those who are
traditional (Orthodox Judaism) follow all Jewish traditions. Conservative Judaism also seeks
to preserve Jewish traditions and ceremonies but is more flexible in interpreting religious law.
Many others are adherents of the progressive movement (Reform Judaism), which advocates
the freedom of individuals to make choices about which traditions to follow (Altman, Inman,
Fine, Ritter, & Howard, 2010; Rich, 2011). About one‐third of U.S. Jews (35%) identify
with the Reform movement, 18% with the Conservative movement, and 10% with Orthodox
Judaism, including 6% who belong to Ultra‐Orthodox groups (which reject modern secular
society and believe they are the most religiously authentic Jews) and 3% who are Modern
Orthodox (follow traditional practices but engages with the secular world to expand their
spirituality). The remaining 37% do not identify with any particular Jewish denomination.
With the exception of Orthodox Jews (who are very religious), Jews are less religiously
committed than the U.S. public in general (Pew Research Center, 2013).
As previously noted, individuals need not actively practice Judaism in order to consider
themselves Jewish. Many who are nonreligious but of Jewish parentage or upbringing
identify as Jewish. About half who identify as Jewish adhere to Judaism, while many others
celebrate only some Jewish holidays, deeming such celebration a cultural rather than a
religious activity. These individuals consider themselves Jewish because of the commonality
of history, culture, and experiences.
Friedman et al. (2005) conducted interviews with 10 Jewish adults to understand their
perspective on their own identity. All participants indicated a fluidity of identity over the
years. One stated, “When I was a kid, it made me feel a little bit different in certain situations,
but now I would be very proud to be associated with Jewish people and to be Jewish. I would
say it has gotten stronger.” Another commented, “[I]t's the dips and valleys in my life … it is
pretty much a constant, but it does go up and down” (p. 79). Among the participants,
childhood experiences, such as participating in Jewish holiday traditions with family
members, eating in a kosher dining room, or engaging in discussions with parents about
Judaism, influenced their cultural identity. As adults, some expressed feelings of guilt
because they did not consistently practice religious customs. Some had a deep Jewish identity
but did not engage in Jewish rituals. However, most expressed pride about being Jewish.
From this phenomenological study, it appears that those who practice Judaism define Jewish
identity differently from those who are secular and do not engage in religious practices. For
many, Jewish identity revolves around common experiences and history, rather than religion.
Ethnic Identity
For many Jewish individuals, their identity is tied to historical events, such as the Holocaust
and the oppression historically faced by the Jewish people. Again, it can also involve cultural
traditions and ancestry, not just religious beliefs. There is no single Jewish identity. Instead,
there is a range of identities: from individuals who are proud of their Jewish heritage, to those
who have internalized anti‐Semitism and hide their Jewish background from others, to those
who feel confused and alienated from mainstream Jewish culture. While some do not publicly
self‐identify as Jewish, others are bicultural and take pride in both American and Jewish
identities.
Schlosser (2009b) believes that Jews go through the following stages of ethnic identity
development:
Lack of awareness of one's Jewish identity.
Gradual awareness of Jewish identity.
Comparison of Judaism with other religions, such as Christianity.
Development of a sense of Jewishness.
Counselors should recognize that American Jews may have identity concerns related to
anti‐Semitism, living under Christian privilege, the Holocaust, and the invisibility of
Judaism. Jews are highly diverse in regard to cultural and ethnic identity and adherence to
religious orthodoxy. The counselor should not assume that all Jewish clients see Jewish
identity or practice Judaism in the same manner (Schlosser, 2006).
Gender‐Related Considerations
Orthodox Jews adhere strictly to the tenets of Judaism, which offer a comprehensive guide to
living that includes rules and practices affecting one's entire life, such as what to do upon first
waking up, what foods are allowed or forbidden, what attire and grooming are appropriate,
what business practices should be followed, who to marry, and the proper way of observing
holidays and the Shabbat (Rich, 2011). Some of these characteristics may make Orthodox
Jews suspicious of therapy. Because of their strong faith in Judaism, they may be reluctant to
seek treatment, since that might imply that their religion has failed them or that they are
defective in some way. Orthodox Jewish communities tend to be very close‐knit, and the
stigma associated with seeking therapy may reduce a person's opportunities to establish social
relationships or find marriage (Schnall, 2006).
Although Jewish denominations arise from a traditionally patriarchal system, most Jewish
Americans have moved toward an egalitarian relationship between spouses. However, those
who are Orthodox are more likely to adhere to specific role divisions between males and
females. Within the Orthodox tradition, women have the responsibility of taking care of the
home, maintaining the health and happiness of the family, and nurturing the children.
Because it is men who interpret the laws of Judaism, women are subject to their husband's or
father's interpretations of what constitutes appropriate behavior. The roles in marital
relationships are seen to be complementary, with love and romance being less important than
the task of raising a family (Schnall, 2006). Orthodox Jews are typically more restrictive
about birth control and abortion than other Jewish Americans (Miller, Barton, Mazur, &
Lovinger, 2014), as well as less accepting of lesbian, gay, bisexual, transgender, and queer
(LGBTQ) identifications and relationships (Balkin, Watts, & Ali, 2014). Marital and family
conflicts may occur as women move toward less rigid role divisions (Blackman, 2010).
Cultural Strengths
Judaism is a guidebook on how to live your life and be a good person … I keep Kosher
because that's what I grew up with and it's something that is a comfort to me … My
grandma and all my relatives … died for their religion
(Altman et al., 2010, p. 167)
Judaism is more than just a religion. It is a culture with a set of traditions and historical
experiences that provides members with a sense of connection and commonality and with
feelings of acceptance (Schlosser, 2006). For some, the sociocultural connection is more
central to individual and family life than the religious aspects. Religious behavior and
traditions, such as lighting Shabbat candles, can be calming, since they remind individuals of
their history and their community (Altman et al., 2010). These aspects of Judaism serve as
protective factors against the discrimination and prejudice that Jews face. Among Orthodox
Jews, higher levels of religious beliefs are associated with positive mental health. This may
be due to emotional and spiritual support from having a personal relationship with God
(Rosmarin, Pirutinsky, Pargament, & Krumrei, 2009).
The majority of Americans hold American Jews in high regard, stressing their strong
religious faith, contributions to the cultural life of the country, and emphasis on the
importance of the family. Indeed, American Jews themselves are overwhelmingly proud to be
Jewish and have a strong sense of being part of the Jewish community. Other aspects that are
important to Jewish Americans' identity are leading an ethical life, working for justice and
equality, and having a good sense of humor. However, only 19% indicated that following
Jewish law was an essential part of being Jewish (Pew Research Center, 2013).
SPECIFIC CHALLENGES
In the following sections, we consider challenges often faced by those who are Jewish;
subsequently, we will consider their implications in the context of treatment.
Historical Background and Sociopolitical Challenges
David Duke spoke to a group of Holocaust deniers at a conference on the Holocaust
convened by Iran's president in 2006. During his speech, the former Imperial Wizard of
the Ku Klux Klan and Louisiana State Representative claimed that the Holocaust was a
hoax perpetrated by European Jews to justify the occupation of Palestine and the
creation of Israel.
(Fathi, 2006)
Since the Middle Ages, the Jewish people have experienced persecution, oppression, and
second‐class status, as well as being targeted for massacre or expulsion from their homes
(e.g., during the Christian Crusades, the Spanish Inquisition, the Holocaust [the Shoah], and
so on). For centuries, they have been stereotyped as hungry for wealth, power, and control,
and they have been scapegoated during periods of financial distress.
One older Jewish woman asked her therapist, “Have you heard of the Holocaust?”
(Hinrichsen, 2006, p. 30). The Holocaust represents an incredibly traumatic period in Jewish
history. During this period, Nazi Germans murdered approximately 6 million Jewish men,
women, and children. There were many more who survived inhumane treatment after being
imprisoned in forced‐labor and concentration camps. Their lives have been affected forever.
What constitutes Jewish identity is complex and highly personal. An important aspect is a
sense of shared cultural and historical experiences. Holocaust deniers—individuals who do
not acknowledge or who question the existence of the genocide that occurred during the
Holocaust—seek to invalidate the loss and suffering of Holocaust victims and their families,
and in so doing, strike at an important part of contemporary Jewish identity. It is distressing
when this tragic history is ignored or invalidated. It is also hurtful when our society
recognizes Christian holidays and religious expectations but ignores those of the Jewish faith.
A well‐known mental health practitioner and educator, Stephen Weinrach, was proud of his
Jewish identity and became an outspoken critic of the mental health organization to which he
belonged for being blind to the plight of Jewish Americans.
Issues that have concerned Jews have failed to resonate with the counseling profession,
including, for the most part, many of the most outspoken advocates for multicultural
counseling … The near universal failure of those committed to multicultural counseling
to rail against anti‐Semitism and embrace the notion of Jews as a culturally distinct
group represents the most painful wound of all.
(Weinrach, 2002, p. 310)
Weinrach (2002) made the following observations regarding the mental health profession:
Counseling associations ignore requests from Jewish members to reschedule meetings
when they conflict with Jewish holidays (e.g., the National Board for Certified
Counselors scheduled the National Counseling Exam on Yom Kippur, a day when work
is not permitted).
Texts on multicultural counseling often do not address Jewish Americans as a diverse
group. Only 8% of multicultural courses in American Psychological Association (APA)
doctoral programs in counseling covered Jews as a distinct cultural group (Priester et al.,
2008).
Few articles in counseling journals have involved Jewish Americans, and in some texts,
Jewish Americans have been portrayed in a stereotypic manner.
In our opinion, Weinrach has made some valid points. In writing this chapter, we found very
few articles on clinical issues involving Jewish Americans or their history of oppression,
although numerous articles were easily located for the other diverse groups covered in this
text. We must recognize the degree of prejudice and discrimination faced by Jewish
Americans and reexamine policies that may be insensitive to their concerns.
Prejudice and Discrimination
The two 17‐year‐old girls told of repeated acts of anti‐Semitic bullying—one girl
had money shoved into her mouth, another kept seeing swastikas pervasively in school
hallways and lockers … the Jewish students accused 35 students of anti‐Semitic
behaviors. They told of finding swastikas drawn on walls and lockers, sometime
accompanied by messages like “Die Jew,” of slurs like “Christ killer” and “disgusting
Jew” … and of being shoved, punched, taunted and humiliated and of experiencing bus
rides where classmates chanted “white power” and saluted Nazi‐style.
(Berger, 2015)
Because of the targeting and killing of Jewish people in Paris and Copenhagen and the
vandalism of hundreds of headstones at a cemetery in eastern France, Israeli Prime
Minister Binyamin Netanyahu has asked Jewish individuals in European countries to
migrate to Israel, saying “This wave of terror attacks can be expected to continue,
including anti‐Semitic and murderous attacks. We say to the Jews, to our brothers and
sisters, Israel is your home and that of every Jew. Israel is waiting for you with open
arms.”
(Politi, 2015)
Prejudice and discrimination against Jews are found all over the world. A survey of over 100
countries revealed that anti‐Semitic views and attitudes were held by 74% of the population
in the Middle East and North Africa, 34% in Eastern Europe, 24% in Western Europe, 23% in
Sub‐Saharan Africa, 22% in Asia, 19% in the Americas, and 14% in Oceania. The survey
also showed that 35% of the world's population had never heard of the Holocaust and that
among those who had, 32% believed it was either a myth or had been greatly exaggerated.
The most widely accepted anti‐Semitic stereotypes worldwide are “Jews are more loyal to
Israel than to this country/the countries they live in,” “Jews have too much power in the
business world,” and “Jews don't care about what happens to anyone but their own kind”
(ADL Global 100, 2013).
Jewish Americans have long been targets of discrimination and prejudice. That such
prejudice continues to this day is revealed in the astonishing statistic that of the 1,163 hate
crimes motivated by religious bias committed in the United States in 2013, the vast majority
(59.2%) were anti‐Semitic (followed by anti‐Islamic, at 14.2%) (Federal Bureau of
Investigation, 2013). Prejudicial reactions against Jews involve not only overt actions such as
vandalism, assaults, and direct displays of anti‐Semitism, but also negative attitudes and
beliefs. Such prejudice is revealed in personal statements such as that made by actor and
director Mel Gibson in 2006 that “Jews are responsible for all the wars in the world” (Gibson
has since apologized for his statement) and a complaint purportedly made by Judith Regan,
an editor at HarperCollins Publishers, that a “Jewish cabal” was against her—referring to
members of the publishing firm and their decision not to publish a controversial book by O. J.
Simpson that Ms. Regan had produced (Hall, 2006).
In a survey of Americans (Anti‐Defamation League, 2013), it was found that 14% of adults
held “hard‐core” anti‐Semitic beliefs. Many believed that Jewish Americans wield too
much power in business, the news media, and the movie and television industries. In a
national poll of American voters (Council for the National Interest, 2006), 39% believed that
the “Israeli lobby” was a key factor responsible for the United States confronting Iran and
going to war in Iraq. Among Jewish Americans, 77% disagreed with this view. Not
surprisingly, anti‐Semitic views toward American Jews often arise in conjunction with
negative reactions to Israeli actions in the Middle East (Cohen, Jussim, Harber, & Bhasin,
2009).
Although Jewish individuals have achieved great success, it is evident that they remain
targets of prejudice, discrimination, and even violence throughout the world. In the United
States, about 43% of Jewish Americans report facing “a lot of discrimination” and 15%
indicate that they have been called offensive names or have been snubbed socially because of
being Jewish (Pew Research Center, 2013). Jewish Americans have reported being
discriminated against at a rate similar to that reported by African Americans (Berkofsky,
2006; Goldberg, 2000).
Jewish undergraduates report experiencing microaggressions that involve suspicion from
others and accusations or expectations that they are greedy or overaffiliated with their group.
They also report that there is a lack of institutional cultural sensitivity for Jewish students
(Na, Kleiman, Poolokasingham, & Spanierman, 2014). Additional examples of
microaggressions against Jewish Americans include automatically assigning intelligence to
Jews, giving preference to Christians, showing a lack of recognition of Jews during
multicultural discussions, and assuming that Jews are wealthy and have control over U.S.
policy and decisions in Hollywood (Schlosser, 2009a).
IMPLICATIONS FOR CLINICAL PRACTICE
It is evident that Jewish Americans continue to face a great deal of prejudice, even with
the successes they have had in American society. For this reason, it is critical for
therapists to be aware of the prejudice and discrimination that Jewish American clients
may have experienced. A 78‐year‐old woman seeking treatment for depression asked
the counseling intern, “Are you Jewish?” (Hinrichsen, 2006, p. 30). When the intern
inquired about the question, the client stated that she had experienced discrimination
from non‐Jews and was uncertain whether the intern would understand her difficulties.
Anti‐Semitic attitudes within ethnic minority populations may be especially troubling
to those who are Jewish; that is, it can be especially hurtful when others who have
experienced oppression, prejudice, and discrimination behave in a discriminatory
manner toward Jews. There are several reasons for the anti‐Semitic attitudes of some
foreign‐born Hispanic immigrants and African Americans toward Jewish Americans.
First, many do not perceive Jews as a disadvantaged minority. Second, some may resent
the fact that the Jewish community has historically opposed affirmative action policies
and that its members are more likely to favor advancement based on merit (Shapiro,
2006).
Some Jewish groups may be hesitant about seeking counseling services. Among
Russian‐speaking Jewish immigrants to the United States, willingness to pursue
psychotherapy has been observed to be low, especially for men (Drob, Tasso, & Griffo,
2016). Orthodox Jews may be reluctant to engage in therapy because of issues such as
confidentiality and the concern that they will be asked to do things that are against their
religious beliefs. Moreover, the seeking of mental health services is frequently
stigmatized within the Orthodox community (Schnall et al., 2014).
Consulting with a rabbi on how to deal with issues such as confidentiality or how
Judaism might affect counseling could be useful. Therapists can also work jointly with
the client and the rabbi in defining the problem and developing interventions, so that
these components of therapy do not conflict with religious beliefs. The rabbi may be
helpful in developing culturally sensitive intervention strategies that incorporate
religious principles (Schnall, 2006).
In Jewish Issues in Multiculturalism: A Handbook for Educators and Clinicians,
Langman (1999) indicates it is difficult to use culturally appropriate interventions
because of the diversity of the Jewish culture. However, he does offer some guiding
principles of importance for mental health providers. First, it is very important to be
respectful of and knowledgeable about Jewish culture. Because most clinicians are from
a Christian background, the traditions, values, and religious rituals that are important to
Jewish Americans are often overlooked or dismissed. As we discussed in Chapter 6,
therapists might inadvertently commit microaggressions due to their lack of
understanding. For example, Langman describes a Jewish client who requested that an
appointment not be scheduled during Yom Kippur, to which the therapist responded,
“What? Do you need to pray or something?” The client felt humiliated, devalued,
ashamed, and unsupported.
Second, therapists should strive to understand the full spectrum of Jewish identities
within the Jewish population, including those of both religious and nonreligious Jews.
As already indicated, the therapist should have some knowledge of the history of anti‐
Semitism and its effects on identity, as well as the possible repercussions of internalized
anti‐Semitism. Langman (1999) discusses the latter as an insidious social conditioning
process that makes some Jewish Americans ashamed of their ethnic and religious
heritage. He views the sociopolitical process that defines Jewish differences as deviance
to be the culprit and encourages counselors not to “blame the victim.”
Third, as Langman makes clear, therapists need to be aware of any values, assumptions,
and biases of their own that may be detrimental to their Jewish clients. He cites research
that indicates that Jews are viewed as being “cold,” “hostile,” and “obstructive,” whereas
non‐Jews (White) are seen as being more “warm,” “friendly,” and “helpful.” He
encourages counselors to explore any feelings of negativism toward Jewish Americans,
Jewish culture, Judaism, and/or Israel.
Finally, although about two‐thirds of Jewish Americans are not associated with a
synagogue or have only slight connections to a Jewish congregation, it may be desirable
to consult with a rabbi when working with clients who are strongly religious,
particularly those who maintain Orthodox beliefs. In some cases, religious doubts or
issues about religiously prohibited behaviors or behaviors associated with guilt or shame
might be best addressed with guidance from religious leaders as part of the therapeutic
process. Such consultation is easier when the counselor has spent time cultivating
relationships with the Jewish community.
Counselors should also consider the following (Altman et al., 2010; Schlosser, Safran,
Suson, Dettle, & Dewey, 2013):
1. As members of mental health professions, we must be aware of policies or expectations
that do not take Jewish American concerns into consideration, such as scheduling
meetings or appointments on Jewish holidays.
2. We need to examine our attitudes and beliefs in regard to Jewish Americans. Are their
problems invisible to us? Is our failure to acknowledge the discrimination experienced
by Jewish people due to a Christian‐centered worldview, a lack of knowledge, or an
unconscious anti‐Semitism?
3. It is important to remember that Jewish Americans are the most targeted religious group
for hate crimes and discrimination. Because many Jewish Americans are well educated
and economically secure, we often do not understand that they may have experienced
discrimination or hate.
4. Jewish American mental health professionals should also feel free to bring up their
concerns when they are subjected to insensitivity or discrimination.
5. Jewish counselors should take care not to make assumptions about a client's Jewish
identity and issues based on the counselor's own sense of identity or beliefs regarding
Judaism (Schlosser, Safran, Suson, Dettle, & Dewey, 2013).
6. During assessment, it is helpful to ask clients about their sense of Jewish identity and
any life‐affirming values, beliefs, and cultural norms (Miller et al., 2014).
7. The degree of receptivity to counseling and therapy may vary according to the degree of
adherence to religious traditions. Orthodox versus non‐Orthodox Jews are more likely
to display treatment‐seeking stigma and prefer individual to group therapy (Baruch,
Kanter, Pirutinsky, Murphy, & Rosmain, 2014).
8. Among Orthodox Jews, women are expected to maintain the Jewish culture and raise
Jewish children. For those who deviate from these expectations (e.g., by being lesbian,
remaining single, or preferring a career to having children), conflicts may arise
(Ginsberg & Sinacore, 2013).
9. When working with Orthodox Jewish clients, determine how mental health issues are
defined within their religious and cultural framework and develop appropriate, culturally
adapted interventions based on this knowledge (Rosen, Rebeta, & Zalman Rothschild,
2014).
10. Although most Jewish Americans value psychotherapy and are receptive to traditional
forms of therapy, any concerns or issues regarding therapy should be addressed during
initial counseling sessions (Miller et al., 2014).
SUMMARY
Most Jewish individuals consider themselves to be members of a minority group and feel
their heritage is important to them. Within Judaism, the degree of adherence to religious
tradition varies from orthodoxy to progressive beliefs, practices, and decisions. Judaism is
more than just a religion. It is a culture with a set of traditions and historical experiences that
provide Jewish individuals with a sense of connection, commonality, and acceptance. As a
result, mental health providers need to understand the importance of Jewish identity. Jews
have suffered from anti‐Semitism in all parts of the world, and Jewish Americans have long
been targets of discrimination and prejudice. The Holocaust represents a deeply traumatic
period in Jewish history. The majority of hate crimes motivated by religious bias committed
in the United States have been anti‐Semitic. Cultural, gender, and identity differences also
have major implications for issues likely to arise in work with Jewish clients. Ten clinical
implications for counselor practice are identified.
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22
Counseling Individuals with Disabilities
Chapter Objectives
1. 1. Learn the demographics and characteristics of persons with disabilities.
2. 2. Know the different types of disabilities and the models and myths regarding
individuals with disabilities.
3. 3. Identify counseling implications of the information provided for persons with
disabilities.
4. 4. Recognize strengths that are associated with persons with disabilities.
5. 5. Know the special challenges faced by persons with disabilities.
6. 6. Understand best practices for assessment and therapy with persons with
disabilities.
I have experienced forced intimacy my entire life as a disabled child, youth and adult. I
am always expected to do the work of opening myself up for others' benefit, education,
curiosity or benevolent oppression.
(Mingus, 2017a)
Members of the deaf community view deafness not as a disability but as a difference in
human experience. Many have a positive attitude towards deafness and generally do not
consider it a condition that needs to be “fixed” and, therefore, may oppose
technological innovations such as cochlear implants.
(Konig, 2013)
A 77‐year‐old woman has been on kidney dialysis for 10 years; she also has seizures,
arthritis, and significant hearing loss. Communication with the social worker is not
going well due to the woman's impaired hearing. The daughter explains that her mother
has hearing aids but does not wear them because they hurt her ears. The social worker
directs all her questions to the daughter, leaving the mother wondering what is being
discussed.
(Desselle & Proctor, 2000)
People often lack understanding and do not know how to respond to people with disabilities.
Attitudes toward individuals with disabilities may be disdainful and dismissive, or overly
protective or sympathetic. In the third vignette, the social worker was talking to the daughter
as if the mother were not present. The daughter felt frustrated and responded,
You are not even trying to communicate with my mother … She can understand you if
you look at her and speak slowly and clearly … Imagine how you would feel if you and
your spouse went to the doctor to consult about a major surgery you were scheduled for
and the doctor directed the conversation only to your spouse as if you were not
intelligent enough to know what was being discussed.
(Desselle & Proctor, 2000, p. 277)
There are an estimated 56.7 million Americans with some level of disability (physical or
mental), of whom over half have a disability that severely affects daily functioning (Brault,
2012). Of the 72.3 million families in the United States, about 21 million have at least one
member with a disability. Rates of disability are higher among African Americans (22.2%)
and American Indian/Alaska Native groups (27%) compared with non‐Hispanic Whites
(16.2%) (Cornish, Gorgens, Olkin, Palomibi, & Abels, 2008). Because of traumatic brain
injuries incurred in the wars in Iraq and Afghanistan, the incidence of individuals with
physical disabilities is increasing (Terrio, Nelson, Betthauser, Harwood, & Brenner, 2011).
Women are more likely to experience a physical disability than men; further, women with a
physical disability are much more likely to experience depression than women in the general
population (Brown, 2014) and are at risk for abuse (Robinson‐Whelen et al., 2010). In
children, disability is more common in boys and in children from low‐income families
(Sullivan, 2009). Children with disabilities are more likely to be subjected to maltreatment,
including neglect; physical, sexual, or emotional abuse; and bullying (Jones et al., 2012;
Zablotsky, Bradshaw, Anderson, & Law, 2014).
Individuals with severe disability have high unemployment and poverty rates (U.S. Census
Bureau, 2010). As estimated by the Census Bureau's American Community Survey, only 32%
of those with disabilities are employed, versus 73% of those without (Office of Disability
Employment Policy, n.d.). Individuals with disabilities have significantly lower rates of
college completion compared to those without (Barber, 2012). Up to 90% of individuals with
psychiatric disabilities are unemployed—the highest unemployment of all disability groups
(Larson et al., 2011).
In the following sections, we offer background information about individuals with
disabilities, discuss the challenges often faced by these individuals, and consider their
implications in treatment. Remember that disabilities vary greatly in terms of severity as well
as the specific condition involved, and that people with disabilities constitute a diverse
community with multifaceted racial‐ethnic backgrounds, cultural identifications, and
religious practices. This overview, therefore, provides generalizations about a diverse group
of people, the applicability of which always needs to be assessed with regard to individual
clients.
CHARACTERISTICS AND STRENGTHS
In this section, we will consider the Americans with Disabilities Act (ADA), myths regarding
individuals with disabilities, models of disabilities, and characteristics and strengths
associated with this population.
The Americans with Disabilities Act (ADA)
The ADA, signed into law in 1990, prohibits discrimination against people with disabilities in
employment, transportation, public accommodation, communications, and governmental
activities and ensures that buildings, facilities, and transit vehicles are accessible and usable
by people with disabilities. Its passage was speeded up when hundreds of individuals with
disabilities demonstrated in front of the Capitol Building in Washington, D.C. To
demonstrate the barriers they faced, dozens left their wheelchairs and crawled up the 83 steps
to the building (Michaels, 2015).
The ADA defines disability as “a physical or mental impairment that substantially limits one
or more of the major life activities of such individual.” It protects individuals with intellectual
impairment, hearing or vision impairment, orthopedic conditions, learning disabilities, speech
impairment, HIV/AIDS, and other health or physical conditions. Psychiatric disorders
covered include major depression, bipolar disorder, panic and obsessive‐compulsive
disorders, some personality disorders, schizophrenia, and rehabilitation from drug addiction.
Under the ADA, employers are allowed to inquire about candidates' ability to perform the job
but not about their disability. Employers are not allowed to discriminate against an individual
with a disability during the person's employment or in regard to promotion if the individual is
otherwise qualified; similarly, employers cannot use tests that will cause individuals to be
screened out because of a disability. Additionally, employers are required to make reasonable
accommodations for people with disabilities.
Although the ADA has improved opportunities for employment by individuals with
disabilities, the law has been whittled away by court decisions that have supported businesses
rather than people with disabilities. For these reasons, the National Council on Disability has
indicated a need to “restore the original intent” of the ADA (American Association of People
with Disabilities, 2006).
Implications
Mental health professionals should keep abreast of federal and state disability laws, including
statutes affecting the rights of individuals with disabilities in school and work settings. It is
important for therapists to make sure that they do not provide unequal service or deny
treatment to clients with disabilities; if an individual requires treatment outside your area of
specialization, you can help facilitate a referral to a more qualified provider. Also, be alert for
criteria that may screen out or disadvantage clients with disabilities, such as requiring a
driver's license for payment by check. Policies, practices, and procedures in your office can
be modified to take into consideration those with disabilities, such as ensuring that service
animals are permitted in your building.
You may need to provide auxiliary aids and services, such as readers, sign‐language
interpreters, braille materials, large‐print materials, and videotapes or audiotapes to
facilitate communication with some clients. Evaluate your office for structural and
architectural barriers that prevent individuals from getting the services they need. Evaluate
the accessibility of your office, including the availability of ramps, parking spaces, reachable
elevator control buttons, and wide doorways.
Myths Regarding Individuals with Disabilities
There are many myths associated with people with disabilities (e.g., Center for Workplace
Preparation, n.d.; LSU Office of Disability Services, 2011; National Service Inclusion
Project, n.d.):
1. Most people with disabilities are in wheelchairs. Among the millions of people with
disabilities, a small proportion use wheelchairs, crutches, or walkers. Most have more
invisible disabilities, such as cardiovascular problems, arthritis and rheumatism, back
and spine problems, hearing impairment, asthma, epilepsy, neurodevelopmental
disorders (e.g., academic or intellectual impairment), and mental illness.
2. People with disabilities are a drain on the economy. It is true that many individuals of
working age with disabilities are not working. However, the majority of those who are
unemployed want to work. Discrimination often hampers their efforts to join the
workforce.
3. Employees with disabilities have a higher absentee rate than employees without
disabilities. Studies have found that employees with disabilities are not absent from
work more than nondisabled employees.
4. The greatest barriers to people with disabilities are physical ones. In actuality, negative
attitudes and stereotypes are the greatest impediments and the most difficult to change.
5. People with disabilities are brave and courageous. Individuals with disabilities react to
situations like anyone else does. They demonstrate a variety of emotional reactions in
adapting to their condition. Some adapt relatively quickly, whereas others have more
difficulty coping.
As mentioned previously, not all disabilities are apparent. Individuals with “invisible”
disabilities (e.g., many mental disorders or physical conditions such as traumatic brain injury)
may be responded to with frustration and resentment from friends, family members, and
employers. When an individual looks healthy, others may not believe they have a disability
and may blame them for the difficulties that they display. With a visible disability, prejudice
and discrimination can occur, but accommodations are more likely to be made.
With a less visible disabling condition, such as a traumatic brain injury, misattributions are
common (e.g., blaming difficulties in recovery on the individual's personality or
unwillingness to cooperate). There may also be unrealistic hopes for full recovery. Invisible
disabilities can be assessed by consulting with family and friends about the client's preinjury
behaviors, abilities, personality, and attitudes to determine whether there have been any
changes in these characteristics due to the injury. If this is the case, the counselor can educate
family members about the nature of the condition and explain how unrealistic expectations
sometimes develop with unobservable injuries (McClure, 2011).
Models of Disability
There are three models of disability, each influencing societal perceptions of disabling
conditions and possible treatment strategies (Artman & Daniels, 2010; Olkin, 1999). First, the
moral model focuses on the “defect” as representing some form of sin or moral lapse. The
disability may be perceived as a punishment or a test of faith. The individual or family
members may respond with feelings of shame and responsibility. In some cultures,
disabilities are believed to result from such factors as evil spirits, curses, or retribution from
unhappy ancestors. Second, the medical model regards disability as a defect or loss of
function that resides in the individual. Action is taken to cure or rehabilitate the condition. In
some cultural groups, intervention targets rebalancing mind–body disharmony. The medical
model has been responsible for many technological advances and treatments targeting a
variety of conditions. Additionally, this approach dismisses the notion that moral issues have
caused the disability. Third, the minority model views disability as an external problem
involving an environment that is filled with negative societal attitudes and that fails to
accommodate the needs of individuals with special needs. This perspective emphasizes the
oppression, prejudice, and discrimination encountered by individuals who are disabled—
experiences very similar to those of other minority groups.
Implications
Much research indicates that empowering individuals and caregivers increases life
satisfaction. Unfortunately, the stress and prejudice associated with disabilities increase the
risk for psychiatric or substance abuse problems (Turner, Lloyd, & Taylor, 2006). If mental
health issues appear to be related to the disability, it is important to identify the way the
disability is viewed by the client and by family members; such information may influence
problem definition and intervention strategies. If the disability is seen as a moral issue (e.g., a
test of faith), religious support may be an important component of the treatment process.
Goals might include reducing guilt, giving meaning to the experience, generating support
from the religious community, and developing problem‐solving approaches.
From the medical model perspective, the client or family members may want to focus on
improving the client's condition, using technology or other interventions to help “normalize”
functioning. Mental health professionals can not only help clients and family members obtain
technological resources but also enhance clients' independent living skills and advocate for
appropriate accommodations in school or work environments.
Incorporating perspectives from the minority model can be useful; counselors can emphasize
how societal attitudes play a large role in the problems faced by individuals with disabilities
and focus on environmental supports directed at maximizing the potential of the client. An
emphasis on self‐empowerment and self‐advocacy can help inoculate clients against
societal prejudices and discrimination and protect their self‐esteem.
Life Satisfaction
I should have picked up the pieces and made the adjustment, and not dwell on it … The
problem is the rest of the world is dwelling on it … this place won't hire you and this
company won't insure you and that potential lover won't look at you … So that reopens
the wound maybe twenty times a day and yet you're supposed to have made the
adjustment.
(Noonan et al., 2004, p. 72)
Because of an auto accident, Gary Talbot went from being an “able‐bodied man to
able‐bodied wheelchair user.” He evaluates his life this way: “I don't like the fact that
I can't walk down the street or go jogging or climb a hill or ride a bike. [But] there's so
much I can do and that I've been able to do that I just wouldn't change anything about
my life.”
(Rosenbaum, 2010)
Ratings of life satisfaction among individuals with disabilities tend to be lower than among
those without disabilities. However, this depends on the type of disability and the timing of
the rating. Some individuals adjust well, whereas others remain chronically distressed. In one
study of the life satisfaction of people with traumatic spinal cord injuries, 37% indicated they
were “very satisfied” and 31% “somewhat satisfied” with their lives. This compares to 50%
“very satisfied” and 40% “somewhat satisfied” among the general population. An interesting
aspect of the study was that those who perceived themselves as “in control” reported the
greatest satisfaction (Chase, Cornille, & English, 2000). Similarly, in a longitudinal study of
307 individuals who were “severely” handicapped, with a reduced capacity to work, life
satisfaction was reduced in the first year but rose to preinjury levels by the fourth year. Those
who were most likely to improve had the personality characteristic of “agreeableness,” an
attribute associated with the ability to access and cultivate social support. Thus, helping
clients develop or maximize social skills may enhance recovery (Boyce & Wood, 2011).
Having close social relationships and paid employment are also associated with increased life
satisfaction (Crompton, 2010). Individuals with disabilities often rate activities such as
communication, thinking, and relating socially as more important than being able to walk or
to dress oneself. Unfortunately, many health professionals display a negative attitude toward
disability. Only 18% of physicians and nurses imagined that they would be glad to be alive if
they had a high‐level spinal cord injury; in sharp contrast, 92% of those with this condition
reported satisfaction with their lives (Gerhart, Koziol‐McLain, Lowenstein, & Whiteneck,
1994).
Implications
Mental health and health care providers often underestimate the potential quality of life for
individuals with disabilities. They may accept signs of depression or suicidal thoughts as
normal because of their low expectations regarding life opportunities for this population. The
research seems to show that many individuals with disabilities feel satisfied with their lives
and that increasing their sense of control is important. Self‐efficacy can be enhanced by
encouraging as much personal control and decision making as possible. If depressive or
suicidal thoughts or wishes surface, they should be addressed. Some support the right of
individuals with disabilities to engage in assisted suicide. However, other organizations argue
that individuals with disabilities are an oppressed group and express concern that they may be
coerced to end their lives (Coleman, 2015).
Sexuality and Reproduction
In response to intrusive questions regarding her intimate experiences, poet Kelsey
Warren, who uses a wheelchair, replied “Cripple copulation may be slightly more
complicated, but it is always climactic.”
(Zeilinger, 2015)
Men and women with disabilities often express concerns over sexual functioning and
reproduction. They worry about their sexual attractiveness and how to relate to or find a
partner. Some may not know whether it is possible to have children or may have questions
about the genetic implications of procreating. Mental health professionals who are
uncomfortable with these topics may minimize or overlook these areas of concern.
Implications
Clearly, both clients and therapists need to be educated on these subjects as they relate to
specific disabilities. Many individuals who have a disability receive the societal message that
they should not be sexual or that they are sexually unattractive. This concern should be
addressed and assessed both individually and, where applicable, for couples. Therapists can
emphasize that sexual relationships are based on communication and emotional
responsiveness and can help individuals or couples develop new ways of achieving sexual
satisfaction. Prior perspectives regarding sexuality may have to be replaced with new ones.
Sexual pleasure is possible even with the loss of sensation in the genitals that occurs with
spinal cord injuries. Among men with spinal cord injuries, some are able to attain an erection
and ejaculate, although they may have to learn new forms of stimulation (Craig Hospital,
2015). Many women with spinal cord injuries are still capable of orgasms and sexual pleasure
from stimulation of the genitals or other parts of the body (Perrouin‐Verbe, Courtois,
Charvier, & Giuliano, 2013). Such injury also does not preclude the ability to become
pregnant or deliver a child.
Spirituality and Religiosity
Spirituality and religious beliefs can be a source of inner strength and support. One woman
with a disability wrote, “It sort of helps me to identify myself, thinking I am a woman created
by God and I am so precious and I am so loved and I have so much beauty inside of me”
(Nosek & Hughes, 2001, p. 23). Religion and spirituality (connection to a higher power) are
associated with increased life satisfaction and functional ability for individuals with traumatic
brain injuries (Waldron‐Perrine et al., 2011).
Implications
The mental health professional should determine the role, if any, that religious beliefs or
spirituality play in the life of a client with a disability. The spirituality of the woman in the
quoted example enhanced her sense of self. Such beliefs can be a source of support for clients
and their caregivers. Therapists can ask clients about their religious or spiritual beliefs and
how their beliefs help them confront challenges; they can then incorporate these beliefs into
treatment (Waldron‐Perrine et al., 2011). In some cases, individuals may believe that their
disability is a punishment from God or may blame God for not preventing the injury. These
issues should also be addressed and resolved. Therapists can consult with or refer to religious
leaders when working with clients who are attempting to come to terms with a disability.
Strengths
Many individuals with disabilities who have lived through natural disasters show
resiliency and adaptation. Instead of responding, “Where were they when we needed
them?” they were more likely to think, “What are my possibilities? What options do I
have?”
(Fox, White, Rooney, & Cahill, 2010, p. 237)
Because of the variety of disabilities and because individuals with disabilities can come from
any population, we will focus on personal characteristics that enhance daily living and
satisfaction with life. Individuals with traumatic brain injuries who feel a connection to a
higher power show greater life satisfaction and functional ability. Among those with spinal
cord injuries, coping strategies, hope, and optimism are associated with a higher quality of
life (Kortte, Gilbert, Gorman, & Wegener, 2010). Qualities such as creativity, resilience,
self‐control, self‐advocacy and the ability to make positive connections with others and
find meaning in life are strengths that can be tapped in the therapy process (Wehmeyer,
2014). Many individuals already possess these strengths; however, they can also be
developed or enhanced in counseling by focusing on changing the client's and the client's
significant others' perceptions of the disability. Outcome is enhanced by improving self‐
confidence and finding and developing ways to empower the client (Shallcross, 2011) and
encourage active decision making (Artman & Daniels, 2010).
For some, the development of a “disability identity” or a positive affirmation about the
disability may enhance self‐image. This might include association with the disability
community, confronting discrimination and prejudice, and advocacy to reduce constraints—
for example, by eliminating physical barriers that hamper access. Those with a disability
identity often adapt to and view their disability as a valuable experience rather than a
decrement. This perspective has been associated with lower distress levels among individuals
with multiple sclerosis (Bogart, 2015). Others can have a positive self‐identity even in the
absence of an emotional and social connection to the disability community. Counselors must
listen to what their clients need rather than force them into a specific direction in relation to
their disability (Dunn & Burcaw, 2013).
In general, finding meaning in one's experience is associated with better adjustment and
cognitive adaptation. Individuals facing a life‐changing disability benefit when they
embrace the opportunity to develop a new perspective on life, or view their changed life
circumstances as a signal to slow down or change their life for the better. In contrast, some
individuals do not search for meaning in their experiences, yet still make a good adjustment
to life. If a client is engaged in the search for meaning, the counselor can help with the
process. However, attempting to encourage such inquiry in a client who is not searching for
meaning may be counterproductive (Davis & Novoa, 2013).
SPECIFIC CHALLENGES
In the following sections, we consider challenges faced by individuals with disabilities and
their implications in treatment. Remember that these are generalizations and that their
applicability needs to be assessed for each client.
Prejudice and Discrimination
Ableism is an all‐too‐common discriminatory practice in which individuals without
disabilities are favored or given preferential treatment, with the implication that those with a
disability are somehow inferior (Keller & Galgay, 2010). Of course, people with disabilities
always have additional racial, ethnic, and gender‐related identities, and as a result, they may
experience ableist attitudes in concert with other forms of bias. In fact, the operations of
intersectionality in the lives of people with disabilities have not received extensive attention
from counseling researchers; a recent study found disability to be one of the two least studied
social identities within intersectional research (with the other being social class) (Shin et al.,
2017).
Additionally, individuals who have disabilities may be evaluated based on an insidious deficit
perspective (i.e., a belief that something is wrong with them). For example, employers believe
that individuals with physical disabilities are less competent than individuals without a
disability (Wang, Barron, & Hebl, 2010). Rohmer and Louvet (2009) make the point that
“visible disability can be considered a superordinate social category” (p. 76); that is,
disability appears to be a highly salient characteristic. For example, individuals with
observable physical disabilities are often referred to using language such as “confined to a
wheelchair” or “wheelchair bound” (Artman & Daniels, 2010).
Prejudicial terms such as retarded, lame, and crazy are also used without conscious
awareness of their impact on individuals with disabilities. Other reactions may be a result of
not understanding the nature of specific disabilities. For example, most people without
hearing loss do not understand that hearing aids can amplify all sounds, resulting in jumbled
hearing, which is why individuals with hearing impairment may choose not to wear them.
The public often has low expectations for individuals with disabilities and assumes that
disability in one area affects skills in other areas. Additionally, able‐bodied individuals
often do not consider the structural and psychological barriers that individuals with
disabilities have to face.
Implications
It is important for counselors to understand that individuals with disabilities are people first;
like members of any group, they may demonstrate a wide range of functional difficulties, as
well as varying accomplishments. Mental health professionals need to actively assist
individuals with disabilities to maximize their educational and employment opportunities.
Approximately 9% of students enrolled in postsecondary educational institutions have some
form of disability (Haller, 2006). Mental health professionals can prepare these students for
success at the college level by teaching them to be self‐advocates—encouraging them to
alert their professors to their disability status and request course accommodations, if needed.
The greatest prejudice may occur with hidden disabilities, such as psychiatric conditions. As
a person with schizophrenia stated, “I don't want to tell anybody, because people who aren't
ill, they do have a tendency sometimes to treat you different … We've got to disguise
ourselves a lot” (Goldberg, Killeen, & O'Day, 2005, p. 463). Educating employers and
workplace colleagues about specific conditions can sometimes allay fears (Law, 2011), as
well as address false stereotypes associated with disabilities (Mizrahi, 2014). Independence
for individuals with intellectual disabilities or severe mental health issues can be encouraged
by teaching them skills such as interviewing for jobs, managing money, doing laundry, and
performing other daily living tasks (Ericksen‐Radtke & Beale, 2001).
Mental health professionals need to recognize that they are also subject to disability prejudice
and address any discomfort they may have with disabilities. Several suggestions are helpful
(American Psychological Association, 2001; Landsberger & Diaz, 2010):
1. Instead of thinking about a “disabled person,” change the focus and use the phrase
“person living with a disability.” This emphasizes the individual rather than the
limitation.
2. Do not sensationalize disability by referring to the achievements of well‐known
individuals with disabilities as “superhuman” or “extraordinary.” Such references create
unfair expectations. Most individuals with disabilities have the same range of skills as
those without.
3. Avoid the use of phrases that evoke pity and conjure up a nonfunctional status, such as
“afflicted with,” “suffering from,” and “a victim of.”
4. Respond to individuals with a disability according to their skills, personality, and other
personal attributes, rather than their disability. Increase your understanding of an
individual's specific condition and related resources, but take care not to assume that the
disability is a primary concern.
See Table 22.1 for additional suggestions about working with clients with various disabilities.
TABLE 22.1 Things to Remember When Interacting with Individuals with Disabilities
Source: Adapted from United Cerebral Palsy (2001) and New York State Department of Health (2009).
1. People with physical disabilities:
Ask if assistance is required before providing it; if your offer is accepted, ask for
instructions on how to help and then follow them.
Do not use or move items such as wheelchairs, crutches, and canes without
permission. They are considered part of the individual's personal space. Address
the individual directly; it is important to attend to the client rather than to someone
who might have accompanied him or her.
Sit at eye level to facilitate comfort in communication.
Make certain there is easy access to your office.
2. People with vision loss:
Identify yourself and anyone else who is present when greeting the client. If the
individual does not extend a hand, offer a verbal welcome.
Offer the use of your arm to guide—rather than steer or push—the individual.
Give verbal instructions to facilitate navigation.
If a service dog is present, do not pet or play with it.
Ask about the individual's preference regarding presentation of information (e.g.,
large print, braille, audiotapes).
Let the individual know if you are moving about or if the conversation is to end.
Give verbal cues when offering a seat. Place the individual's hand on the back of
the chair and he or she will not need further help.
3. People who are deaf or hard of hearing:
Ask about the individual's preferred communication (some use American Sign
Language and identify culturally with the deaf community, whereas others may
prefer to communicate orally, read lips, or rely on residual hearing).
Address the individual directly, rather than a person accompanying them.
Realize that talking very loud may not enhance communication.
To get attention, call the person by name. If there is no response, lightly touch
them on the arm or shoulder.
Do not pretend to understand if you do not.
Use certified interpreters to facilitate communication; their role is to relay
information.
Try to avoid using family members as interpreters.
Make direct eye contact, and keep your face and mouth visible.
4. People with speech impediments:
Allow the individual to finish speaking before you speak.
Realize that communication may take longer, and plan accordingly. Do not rush.
Face the individual, and give full eye contact.
Address the individual directly.
Do not pretend to understand if you do not.
When appropriate, use yes‐or‐no questions.
Check with the individual, if needed, to ensure understanding.
Remember that a speech impediment does not mean the individual has
limited intelligence.
Select this link to open an interactive version of Table 22.1
Supports for Individuals with Disabilities
In the past, programs for persons with neurodevelopmental disabilities (e.g., autism,
intellectual impairment, learning disabilities) were limited to efforts at “rehabilitation” rather
than assistance in maximizing potential and developing independent living skills. There has
been gradual recognition that deficiencies in experiences and opportunities can significantly
limit an individual's development and that services are most effective when they enable
independence, self‐determination, and productive participation in society. To accomplish
this task, it is important to support students with disabilities in completing school and
learning job skills.
Many school‐to‐work transition programs, including those that provide students with
disabilities the opportunity to learn work‐related skills through local employment
opportunities, have shown promising results (e.g., see DC Partners in Transition at
www.dctransition.org). Some programs for individuals with moderate to severe intellectual or
physical disabilities provide prevocational orientations for both the family and the student.
Information on job preparation and job expectations is provided, followed by skills training
and then an internship in a local business, where employers give feedback on the individual's
performance. Such programs have been successful both in helping youth with disabilities
make the transition to employment or further education and in opening doors in the business
community. Mentors can also play an important role in helping college students with
disabilities achieve academic success. Many graduates attribute their academic success to
significant relationships with a faculty member or special services staff member (Barber,
2012).
With regard to educational settings themselves, college students with disabilities have been
found to report more distress related to academic performance than other students, as well as
higher rates of anxiety and suicidal ideation. Support personnel throughout campus
communities—including counselors, faculty, residence hall staff, and offices of disability
services—should coordinate their efforts to reach out to these students as early as possible in
their college careers (Coduti, Hayes, Locke, & Youn, 2016).
Implications
There has been a shift in the orientation of programs for people with disabilities from
remediation or “making them as normal as possible” to identifying and strengthening interests
and skills. Mental health professionals working with individuals with disabilities should be
aware of programs offering educational and employment assistance. For example, the
ParentCenterHub.org website is a repository of different resources for individuals with
disabilities, such as Organizations and Agencies in Your State, Employment, Postsecondary
Education, Recreation, Independent Living, Assistive Technology, and Disability Living
Online. Media such as Ability Magazine, Disability Scoop, e‐Bility, and New Mobility (a
magazine for active wheelchair users) also provide useful information and support for
individuals with disabilities. It is important for mental health professionals to be aware of the
ways current technology is enhancing quality of life and employment opportunities for many
individuals with disabilities. Vocational and support group information is easily accessible
via the Internet.
Counseling Issues with Individuals with Disabilities
I want to say unequivocally that disabled people are everywhere. We are one of the
largest oppressed groups on the planet. We are part of political movements, even if you
don't know or don't acknowledge that we are. No matter what community you're working
with, you are working with disabled people.
(Mingus, 2017b)
Helping professionals often display the same attitude as the general public toward individuals
with disabilities and may feel uncomfortable or experience guilt or pity when working with
this population. As when working with other oppressed groups, counselors must examine
their own views in regard to clients with disabilities and identify and question any prejudicial
assumptions. A client's disability should not be the sole focus of counseling. However,
environmental contributions to the problems a client is experiencing (e.g., frustrations with
architectural barriers or with negative stereotypes or prejudices) should be identified and
addressed in counseling.
Implications
As with all clients, comprehensive, nonbiased assessment is essential for those who have
disabilities. Kemp and Mallinckrodt (1996) point out some of the errors that can occur in
assessment and counseling relationships with individuals with disabilities. First, errors of
omission may be made. The counselor may fail to ask questions about critical aspects of the
client's life because they assume that the issue is unimportant due to the presence of the
disability. For example, sexuality and relationship issues may be ignored because of the belief
that the individual lacks the ability to pursue—or interest in pursuing—these intimacies.
Affective issues may also be avoided, because the counselor is uncomfortable addressing the
impact of the disability on the client. The counselor may display lowered expectations of the
client's capabilities.
Second, errors of commission may occur. In such cases, counselors make the unjustified
assumption that certain issues should be important because of the disability, when, in fact,
they are not important for the client. Further, a therapist might inaccurately assume that
personal problems faced by the client result from the disability. Career and academic
counseling may become a focus even when it is not what the client wants to discuss.
Therapists also make errors by not addressing the disability at all, encouraging dependency
and the “sick” role, or failing to confront countertransference issues (e.g., wanting to “rescue”
the client).
It is generally appropriate to ask a client about the disability, including any related concerns.
The therapist can also ask if there are ways that the disability is part of the presenting
problem. Such an approach allows the therapist to address the disability directly. In doing so,
it is important not to succumb to the “spread” phenomenon that often exists with disabilities:
believing that the disability encompasses unrelated aspects of the individual. If the disability
is of recent origin, factors such as coping strategies, recent challenges, the possibility of
self‐blame for the injury, and the amount of social support available can be assessed.
Family Counseling
Family caregivers now operate as integral parts of the health care system and provide services
that were once performed by professional health care providers. It is, therefore, important to
help reduce the impact of stressors on caregivers and other family members. Additionally,
emotional issues, such as distress, guilt, self‐punishment, and anger, may need to be
considered. Family members may feel angry about their caretaking responsibilities or
somehow feel responsible for the disabling condition (Resch et al., 2010).
Implications
Clients with a disability and their family members can work together to create positive
changes that enhance both client well‐being and family functioning. Among family
caregivers, attributes such as positive problem‐solving skills, positive problem orientation,
and coping strategies are associated with greater satisfaction for themselves and the
individual with the disability (Elliot, Shewchuk, & Richards, 1999). One effective approach
employed by caregivers is using problem‐solving strategies when encountering difficulties;
such caretakers learn to define the problem, generate and evaluate alternatives, implement
solutions, and assess outcomes. This approach helps increase self‐efficacy among family
members and improves their ability to cope with stress.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Identify your beliefs, assumptions, and attitudes about individuals with disabilities.
2. Understand the prejudice, discrimination, inconveniences, and barriers faced by
individuals with physical disabilities and the problems faced by individuals with
“invisible” disabilities.
3. Assess the impact of multiple sources of discrimination on ethnic minorities and other
diverse populations with disabilities (Dispenza, Varney, & Golubovic, 2017).
4. Redirect internalized self‐blame for the disability to societal attitudes.
5. Employ necessary modifications to enhance communication, and address the client
directly rather than through conversation with an accompanying individual.
6. Determine whether the disability is related to the presenting problem and, if so, identify
whether the client adheres to the moral model (disability results from a moral lapse),
medical model (disability is a physical limitation), or minority model (disability results
from societal failure to accommodate individual differences).
7. Determine whether the disability will influence assessment or treatment strategies. If this
is not an issue, continue with your usual methods of assessment and case
conceptualization.
8. If formal tests are employed, provide appropriate accommodations. Interpret the results
with care, since standardization does not take into account various physical disabilities.
9. Recognize that family members and other social supports are important.
When possible, include them in your assessment, case conceptualization,
goal formation, and selection of techniques, but try not to use family
members as interpreters for those with communication difficulties. Be
aware that family members may not fully understand psychiatric issues or
may be part of the problem (Ali, 2012).
10. Identify environmental changes or accommodations that may be needed, and assist the
client or family with the planning necessary to implement them.
11. Help family members reframe the problem so that family and client strengths can be
identified. Focus on and reinforce the positive attributes of the client and family
members.
12. Help both the client and family members develop self‐advocacy skills.
13. Realize that mental health professionals may need to serve as advocates or consultants to
initiate changes in academic and work settings.
14. Be aware of Web resources and provide links to disability‐related products such as
computer accessibility, clothing, augmentative communication devices, legal and
advocacy resources, job training, and educational resources.
Video Lecture: Can You Hold the Door for Me? Including Disability in Diversity by Rhoda
Olkin
SUMMARY
There are approximately 56.7 million Americans with some level of disability (physical or
mental); among this group, over half have a disability that severely affects daily functioning.
People often lack understanding and do not know how to respond to people with disabilities.
Attitudes vary from being disdainful and dismissive to being overly protective or
sympathetic. Ableism is an all too common discriminatory practice in which individuals
without disabilities are favored or given preferential treatment, thereby implying that those
with a disability are somehow inferior. The 1990 ADA extended the federal mandate of
nondiscrimination to individuals with disabilities and to state and local governments and the
private sector. Because of the number of myths and beliefs about those with disabilities,
counselors need to be informed in areas such as sexuality and reproduction, worker
capabilities, resource availability, and especially their own feelings of discomfort or bias
around those with disabilities. Fourteen clinical implications for counselor practice are
identified.
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23
Counseling LGBTQ Populations
Chapter Objectives
1. 1. Learn the demographics and issues faced by lesbian, gay, bisexual, transgender,
and queer (LGBTQ) individuals.
2. 2. Identify counseling implications of the information provided for LGBTQ
individuals.
3. 3. Recognize strengths that are associated with LGBTQ individuals.
4. 4. Know the special challenges faced by LGBTQ individuals.
5. 5. Understand how the implications for clinical practice can guide assessment and
therapy with LGBTQ individuals.
On June 26, 2015, The Supreme Court ruled 5–4 that same‐sex couples have the right
to marry. With the ruling, gay marriage became legal in all 50 states, affecting not only
the right to marry but also the right to be recognized as a spouse or parent on birth and
death certificates and other legal documents.
(Hurley, 2015)
A lone gunman opened fire at the Pulse nightclub in Orlando, Florida on June 22, 2016.
Almost 50 people were killed and another 58 injured in the predawn massacre. The
majority of the victims were Latinx gay individuals.
LGBT youth need support from their families—not derision. If you tell a child or
teenager they're not good enough, that they're worthless, that who they are is broken or
wrong, that's abuse.
(Valenti, 2015)
Zoey Tur, who was told that she would never work again in news if she transitioned to a
female, has been hired as a reporter for the “Inside Edition” television program.
Interestingly, she says the most difficult part of becoming a woman was the loss of “male
privilege.”
(Soopermexican, 2015)
In this chapter, we will discuss lesbian, gay, bisexual, transgender, and queer (LGBTQ)
Americans—individuals who have an affectional and/or sexual attraction to a person of the
same sex (gay men and lesbian women); individuals who have an affectional and/or sexual
attraction to members of both sexes (bisexual individuals); people whose gender
identification is inconsistent with the gender they were assigned at birth (transgender); and
people who identify as queer. The Q is sometimes also used to refer to individuals who are
questioning their sexuality.
About 3.5% of U.S. adults, or 9 million Americans, identify as lesbian, gay, or bisexual and
0.3% as transgender. In addition, about 19 million Americans have engaged in same‐sex
behaviors and around one‐fourth of the adult population acknowledges some same‐sex
attraction (Gates, 2011). Higher percentages for LGBTQ are reported among millennials
between the ages of 18 and 35. Of this group, 4% identified themselves as bisexual, 3% as
gay or lesbian, and 1% as transgender (Public Relations Research Institute, 2014).
The mood of the country reveals contradictory attitudes and actions toward sexual minorities.
Overall, there appears to be increased acceptance of LGBTQ individuals and their lifestyles.
In 1985, 89% of the public indicated that they would be upset if their child told them that he
or she was gay or lesbian; 9% would not be. To the same question in 2015, 39% responded
that they would be upset but 57% would not be. Also, in the same poll, 63% indicated that
“homosexuality should be accepted by society.” However, strong negative attitudes and
feelings toward gay people continue among older adults and White Evangelicals (Pew
Research Center, 2015).
Changes are also occurring in societal views regarding transgender individuals. Their issues
are also being discussed more openly, as represented by television shows with transgender
characters—such as “Transparent” and “Orange Is the New Black” (Leitsinger, 2015). When
receiving the Arthur Ashe Courage Award, Caitlin Jenner made a plea that people should be
respected and accepted, especially the “thousands of kids coming to terms with who they are”
(Melas, 2015). New York City is making it easier for transgender individuals to change the
sex listed on their birth certificates, even without undergoing sex‐change operations. This is
also true in Oregon, Washington, California, Iowa, Vermont, and Washington, D.C. (Wong,
2014). When he was in office, President Obama signed a memorandum indicating that
hospitals participating in Medicare or Medicaid programs “may not deny visitation privileges
on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or
disability,” and California Governor Jerry Brown signed a bill requiring schools to modify the
social studies curriculum to include the contributions of LGBTQ individuals (Lin, 2011).
As with many other areas of progress, these steps forward have been met with resistance and
retraction. The Trump administration issued several setbacks to LGBTQ rights in its first year
in office, including limiting protections for LGBTQ workers, rescinding past guidance on
transgender bathroom protection in public schools, and recommending a significant number
of judicial nominees with anti‐LGBTQ records (Lopez, 2018). In this chapter, we
contextualize the identity development and strengths of LGBTQ individuals within the
current social climate in the United States, as well as some of the major issues and challenges
facing sexual minorities, including the coming out process, societal misconceptions, and the
stress associated with ongoing prejudice and discrimination.
CHARACTERISTICS AND STRENGTHS
Schools and our society more generally vigorously reinforce gender norms and behaviors,
and those who do not adhere to these customs are often ridiculed and bullied. LGBTQ
individuals live in a heterosexual and cisgender society (i.e., a culture expecting “normative”
gender behavior) where they face the challenge of developing a healthy self‐identity in the
midst of societal norms that view their sexual orientation or gender identification as
“abnormal.” This disharmony can significantly affect the transition from childhood to
adolescence to adulthood, as well as family relationships and personal identity development.
In the following sections, we will consider the issues faced by LGBTQ individuals in these
areas, as well as the strengths found in this population.
Sexual and Gender Identity Awareness
Once LGBTQ individuals recognize heterosexual and transgender societal realities, the
discovery of being “different” can be agonizing. As one individual observed: “No matter how
open‐minded I believed my companion to be, the coming‐out conversation was always
excruciating. I was a sweaty, self‐conscious mess, having no idea what reaction I would
get” (Diehl, 2013). Awareness of sexual orientation for gay males and lesbians usually takes
place in the early teens, with sexual experiences and self‐identification typically occurring
during the mid‐teens and same‐sex relationships beginning during the late teens or early
20s (Pew Research Center, 2013). In a longitudinal study of 156 gay, lesbian, and bisexual
youth, 57% consistently self‐identified as gay/lesbian and 15% consistently identified as
bisexual, while 18% of bisexuals transitioned to gay/lesbian (Rosario, Schrimshaw, Hunter,
& Braun, 2006). Bisexual individuals are much less likely to say that sexual orientation is a
big part of who they are or to have come out to important people. They also report few
instances of discrimination (Parker, 2015).
Gender identity is an even more important aspect of one's total being. Transgender people
feel a marked incongruence between the gender with which they self‐identify and the
gender assigned to them based on their physical characteristics at birth. They often report
feeling “different” at an early age. Gender dysphoria, a mental health condition defined in the
Diagnostic and Statistical Manual of Mental Disorders (DSM‐5), occurs when there is
significant distress and impairment resulting from an incongruence between a person's gender
identity and assigned gender. One activist described gender dysphoria as “one of the greatest
agonies … when your anatomy doesn't match who you are inside” (Wright, 2001). Although
gender dysphoria is still considered a mental disorder (American Psychiatric Association,
2013), many transgender individuals are hoping that they can follow the successful path
taken by the gay and lesbian movement and eventually eliminate such classification.
Because transgender individuals have a longstanding conviction that nature somehow placed
them in the wrong body, they often wish to replace their physical sexual characteristics with
those of the appropriate gender. Therefore, sex reassignment surgery is frequently considered.
Such surgery has produced variable results; many females who undergo sexual reassignment
express satisfaction with the outcome, whereas males who change to female are less likely to
feel satisfied. This may be because adjusting to life as a man is easier than adjusting to life as
a woman, or perhaps because man‐to‐woman changes are more likely to produce negative
reactions (Lawrence, 2008).
Many LGBTQ individuals struggle with accepting their self‐identity, which they may
perceive to contrast with society's definition of what is healthy. The struggle for identity
involves one's internal perceptions, which likely contrast with external perceptions and the
assumptions made by others about one's sexual orientation. This process is particularly
complex for transgender individuals because their sexual orientation may be heterosexual,
same‐sex, or bisexual (Wester, McDonough, White, Vogel, & Taylor, 2010). Interrogating
and challenging the ways in which one has internalized heterosexism, homophobia, biphobia,
and/or transphobia is essential in the process of self‐acceptance and pride (Chaney, Filmore,
& Goodrich, 2011). A reduction of stress often occurs when an individual ceases struggling to
be “straight” and begins to establish a new identity, self‐concept, and understanding of what
constitutes an authentic and meaningful life. During this period, individuals (and members of
their families) often deal with issues of grief over letting go of the old, sometimes idealized,
identity (Adelson, 2012).
Implications
Adolescence and early adulthood is a time of exploration and experimentation. Heterosexual
activity does not mean one is a heterosexual, nor does same‐sex activity indicate
homosexuality. Many LGBTQ individuals describe feeling “different” from early childhood.
When they begin to acknowledge their sexual or transgender identity, they soon confront the
stigma associated with being gay, lesbian, bisexual, or transgender. Because of the
discrimination and prejudice they have faced or anticipate, it is important for mental health
professionals to take an affirming position that validates and helps normalize the individual's
identity. Often the stress and depression experienced by LGBTQ individuals is promulgated
by the cisgender and heterosexual nature of our society (Chaney et al., 2011).
Because of fear of the consequences of disclosure during their struggle with identity issues,
some LGBTQ youth (and adults) face this process alone, without the potential support and
nurturance of peers, parents, and other family members, or of others who have gone through
the same struggle. Many pretend to be straight or avoid discussing sexuality. Mental health
professionals can help LGBTQ individuals develop coping/survival skills, and expand their
environmental supports. Therapists should also work with others to address anti‐LGBTQ
bias and discrimination in schools, work places and other public spaces.
LGBTQ Youth
In many schools, discriminatory policies and practices exacerbate the sense of exclusion
students face … [T]eachers are made to fear adverse employment consequences for
identifying as LGBT or supporting LGBT students. Students in same‐sex relationships
are barred or discouraged from attending events as a couple, and transgender students
are denied access to facilities, classes, and extracurricular activities because of their
gender identity.
(Human Rights Watch, 2016a)
LGBTQ youth who are questioning their sexual orientation face a variety of stressors.
Discrimination and harassment in the school environment is common. In a large survey of
middle and high school students, over 80% of LGBTQ students reported experiencing
harassment at school in the past year, and about two‐thirds reported feeling unsafe because
of their sexual or gender orientation. Nearly 40% of LGBTQ students reported being
physically harassed, and over 18% had been physically assaulted in school because of their
sexual orientation. Further, 55% were exposed to cyberbullying through text messages,
emails, and postings on social networking sites. Safety concerns led one‐third of the
LGBTQ students surveyed to skip school (Kosciw, Greytak, Bartkiewicz, Boesen, & Palmer,
2012).
LGBTQ youth are more likely than their heterosexual peers to attempt suicide, especially
when they live in an unsupportive environment (Hatzenbuehler, 2011). Even higher rates of
suicide attempts are found among Black and Latinx LGBTQ youth (Meyer, Dietrich, &
Schwartz, 2008). LGBTQ youth also have increased risk for substance use and abuse
(McCabe, Hughes, Bostwick, West, & Boyd, 2009), especially when there is also a history of
childhood abuse or victimization (McCabe, Wilsnack, West, & Boyd, 2010).
Implications
As when working with adults, mental health professionals need to address the problems of
LGBTQ youth at both the systems and the individual levels. To improve the school
environment, professionals can advocate for inclusion of gay and transgender people in the
curriculum. They can also promote opportunities for social skill development relevant to
LGBTQ youth, provision of adequate social services, and a nondiscriminatory school
environment. About 20 states have antibullying laws prohibiting bullying on the bases of
sexual orientation or gender identity; a number of other states, however, have laws restricting
teachers and students from talking about LGBTQ issues within schools, including Alabama,
Arizona, Louisiana, Mississippi, Oklahoma, Texas, and Utah (Human Rights Watch, 2016b).
It is essential to encourage school personnel to consistently enforce policies that protect
LGBTQ youth from harassment and violence and to push for legislation protecting the rights
of LGBTQ youth. Programs promoting gay–straight alliances and antibullying policies
reduce not only harassment but also the risk of suicide (Hatzenbuehler, 2011; Poteat, 2017).
Support groups that allow LGBTQ students to discuss their concerns in a safe and
confidential environment are also important. LGBTQ youth need safe places to meet others
and to socialize. Community‐based supports such as hotlines, youth clubs, and such groups
as Parents, Families, and Friends of Gays and Lesbians (PFLAG), the Trevor Project, and
gay–straight alliances can be helpful. The Gender Spectrum provides resources in working
with children and youth with gender issues. Such organizations defuse possible harassment
and violence in schools and allow LGBTQ students to gain support and openly express their
sexual identities (Valenti, 2015).
On the individual level, bullying can lead to an internalization of negative attitudes by
LGBTQ youth and the development of dysfunctional shame‐focused coping strategies such
as social withdrawal, self‐criticism, and self‐harm. The counselor can help their clients to
realize that they are not responsible for the bullying and replace negative strategies and
cognitions with self‐affirmations and positive coping strategies (Greene, Britton, & Fitts,
2014).
LGBTQ Couples and Families
As opposition to gay marriage has eased over the past decade, the number of openly gay and
lesbian couples in the United States has nearly doubled, to about 650 000. Approximately one
out of five same‐sex couples is raising children (Yen, 2011). Upwards of 6 million children
and adults have an LGBTQ parent (Gates, 2013). Many LGBTQ couples and individuals
have a keen interest in becoming parents, and their legal right to adopt a child is now
supported by 63% of Americans, according to a Gallup Poll (Swift, 2014).
However, the right of gays and lesbians to adopt children has been challenged in many states.
Some religious agencies have gone so far as to discontinue adoption services to protest state
laws allowing gay men and lesbian women to adopt children (Stern, 2014). Many adoption
agencies still have discriminatory practices.
As one adoption worker observed, “I have seen a gay couple inquire about 30 children and
not get one answer back of interest in their home. That just would not happen and it does not
happen with the heterosexual couples we work with.” Even when gay and lesbian applicants
pass the required background checks, they still face the risk of being turned down if they do
not meet agency “standards” (Graham, 2013).
Are children raised by LGBTQ couples or individuals harmed in any way? Despite myths to
the contrary, children raised by same‐sex parents have no increased likelihood of gender or
sexual confusion or of developing a same‐sex sexual orientation (Patterson, 2013).
Research findings indicate that children raised by gay or lesbian parents are as mentally
healthy as children with heterosexual parents and that there is no reason to believe that a
heterosexual family structure is necessary for healthy child development. The relationships
within gay and lesbian households appear to be similar to those among heterosexual
individuals, although lesbian couples share a more egalitarian relationship than many
heterosexual couples (Riggle, Whitman, Olson, Rostosky, & Strong, 2008). In fact, children
raised by lesbian mothers perform better academically and have fewer behavioral problems
than their peers (Gartrell & Bos, 2010).
Implications
In addition to the typical relationship difficulties faced by heterosexual couples and families,
LGBTQ couples also face prejudice and discrimination from society. Conflicts sometimes
occur when individuals in LGBTQ relationships differ in terms of internalized
homophobia/biphobia/transphobia or the extent to which they are “out” to others in their
social, work, or family networks. For example, one member of the relationship may be
uncomfortable showing public displays of affection or may feel the need to hide the couple's
sexual orientation or their relationship.
In work with LGBTQ parents or in determining their suitability as adoptive parents, mental
health professionals should examine their own attitudes and beliefs about LGBTQ
individuals. The empirical data indicate that LGBTQ parenting styles and child‐rearing
practices do not differ significantly from those of their heterosexual counterparts. In addition
to normal developmental issues, children of LGBTQ parents may benefit from support when
explaining their nontraditional family to peers. Many hope that changes in school curricula
encouraging respect for diversity and diverse lifestyles will help with this challenge.
Strengths
Queer people of color not only survive experiences of oppression, they develop
resilience and coping skills in the process.
(Singh & Chun, 2010, p. 38)
Although LGBTQ people face discrimination, prejudice, and disadvantaged status in society,
many show considerable resilience in the face of adversity and effectively use such strategies
as maintaining hope and seeking social support (Singh, Hays, & Watson, 2011). Many cite
positive aspects of being a lesbian or a gay man, such as belonging to a supportive
community, being able to create families of choice, serving as positive role models, living
authentically, being involved in social justice and activism, and enjoying freedom from
gender‐specific roles (Orel & Fruhauf, 2014). The egalitarianism frequently seen in lesbian
couples not only promotes resilience in their children but also provides a positive model for
respectful interpersonal relationships (Bos & Gartrell, 2010).
SPECIFIC CHALLENGES
In the following sections, we discuss challenges faced by LGBTQ individuals and consider
their implications in treatment. Societal pressures and related struggles are reflected in the
higher incidence of substance abuse and of anxiety and depressive disorders within this
population. Gay youth are especially vulnerable because of pressures within the school and
peer environment and struggles with coming out to family members. Adults face issues
related to letting others know “who they really are,” as well as settling down with a partner,
getting married, and having children—things that heterosexual individuals take for granted.
Coming Out
Transgender teen Leelah Alcorn stepped in front of a semitrailer. In her suicide note,
she said her family did not accept her when she came out to them. Her mother
responded by stating that Leelah would never be a girl and that God doesn't make
mistakes; she continued to refer to Leelah by her male name, Josh.
(Helling, 2015)
I'm 14 and I wanted to share this story with you. So last night I came out to my dad. I
wasn't nervous as I knew he would be understanding. Since I was at dance I couldn't
speak to him face to face. So I sent him a text saying “I'm bisexual” and he replied with
“as long as you're doing the best in life as you can, who you're with doesn't matter. I
love you forever and always.” I was in tears when I saw this and I'm happy he knows
because I wouldn't have wanted to keep a secret from him.
(whenicameout.tumblr.com)
The process of maintaining secrets about sexual orientation or gender identity issues can
seriously affect relationships with friends and family. The decision to come out is extremely
difficult for many individuals, and is often influenced by the overwhelming sense of isolation
that they feel. Coming out to parents and friends can lead to rejection, anger, and grief.
Rejection is especially difficult for adolescents who are emotionally and financially
dependent on their family. For some, however, coming can lead to relief and acceptance.
There are data suggesting that when people decide to come out to their mother, it either
strengthens or does not change the relationship (Pew Research Center, 2013).
Coming out is an ongoing process for LGBTQ individuals—each time, they need to
determine with whom and when to disclose. During the initial stages of this process, self‐
esteem, life satisfaction, and happiness may decrease as the individual faces negative
reactions from others (Chaney et al., 2011). Bisexual individuals may encounter more
difficulty, since it is often assumed that they are “just going through a phase” or that they are
gay or lesbian but are unwilling to accept their sexual orientation (Schulman, 2014).
Coming out is often more difficult for ethnic minorities, who face the stigma of being
“multiple minorities.” Asian, Black, and Latinx gay and lesbian youth are more reluctant to
disclose their sexual orientation than are their White counterparts and are less likely to be
involved in gay‐related social activities (Adelson, 2012). Gay Mexican American men have
a greater degree of internalized homophobia, partly because of the cultural value of
machismo. In Latinx communities, there is strong negative reaction to gay men and frequent
use of slurs such as maricon (sissy) and joto (fag) (Estrada, Rigali‐Oiler, Arciniega, &
Tracey, 2011). Further, Latino men who are gay report racism, discomfort, and rejection from
the gay community, especially those with darker skin or more Indian features (Ibanez,
VanOss Marin, Flores, Millett, & Diaz, 2009).
Lindsey (2005), who is an African American, was asked to write a chapter on sexual diversity
for the 2005 edition of Our Bodies, Ourselves. She notes,
In the mainstream media, both gay and straight, coming out is portrayed in an extremely
idealized and simplistic way. The gay person, always white and middle class, decides he
or she is gay, tells families and friends, who might experience a little homophobia …
and ends up marching proudly down the main thoroughfare of a progressive major
metropolitan area.
(p. 186)
The experience of coming out is often different for people of color—they frequently face both
rejection from their communities and racism from the majority European American culture.
Among the working poor, it also means the possibility of losing their jobs. Transgender
individuals face additional challenges as friends, family, children, and coworkers adjust to
their change in gender and physical appearance (Budge, Tebbe, & Howard, 2010).
Implications
The decision of “when” and “with whom” to come out should be carefully considered.
Factors such as age, ethnicity, relationship status, and spiritual beliefs should be taken into
account (Chaney et al., 2011). To whom does the individual want to reveal the information?
What are the possible effects and consequences (both long‐ and short‐term) of self‐
disclosure, both for the individual and for the recipient of the information? What new sources
of support are available if negative reactions are encountered? If the individual is already in a
relationship, how will the disclosure affect his or her partner? In some cases, the client may
conclude that it is not yet a good time to disclose. If they do decide to come out, the counselor
can offer specific help and preparation in determining how this is best accomplished. Role‐
plays and the discussion of possible reactions can be practiced.
Clients needing support during the disclosure process may choose to disclose or pursue
follow‐up discussion during a counseling session. Disclosure to parents may provoke
feelings of both grief (e.g., loss of their visions of their child's future, including weddings and
grandchildren) and guilt (i.e., believing their parenting was responsible). Parents may need
support in dealing with the societal stigma of having an LGBTQ family member and may
benefit from receiving information and education about myths and stereotypes. If parents or
other family members are rejecting, the client must strengthen other sources of social support.
This may be particularly important for ethnic minorities, who can face additional culturally
based reactions. Prior to and during the coming out process, the counselor can help the client
deal with both external and internalized heterosexism and other societal beliefs that are at the
core of homophobia (Scott, 2011). Thus, rather than allowing clients to internalize self‐
blame, counselors can help them understand that it is societal prejudice that is the problem.
Prejudice, Discrimination, and Misconceptions
About one‐quarter of LGBT staff, faculty, and students reported experiencing
harassment … with transgender individuals receiving even higher levels of harassment
… About one‐third have considered leaving their institutions … 43% of transgender
students, faculty, and staff … feared for their physical safety.
(Rankin, Weber, Blumenfeld, & Frazer, 2010, p. 4)
We have alluded to the overwhelming prejudice and discrimination facing LGBTQ youth and
adults. Sexual assaults in adulthood have been reported by 12% of gay men and 13% of
bisexual men, compared to 2% of heterosexual men. Among women, the rates of sexual
assault were 16% for lesbians, 17% for bisexual women, and 8% for heterosexual women
(Balsam, Rothblum, & Beauchaine, 2005). A recent Pew Research Center (2013) study found
among LGBTQ adults:
58% have been subjected to slurs or jokes.
4 out of 10 were rejected by a family member or close friend after coming out.
3 out of 10 have been physically assaulted or threatened.
3 out of 10 felt unwelcome at a place of worship.
Nearly one‐quarter received poor service in a restaurant or other business.
Further, bisexual individuals sometimes experience hostility both from heterosexuals and
from the gay community (Brewster & Moradi, 2010). Mental distress is particularly
pronounced among bisexual women (Ward, Dahlhamer, Galinsky, & Joestl, 2014).
Transgender individuals face being viewed as mentally ill, delusional, or self‐destructive
not only by the public, but also by mental health workers (Mizock & Fleming, 2011).
In addition to openly antigay harassment, LGBTQ individuals often experience subtle
heterosexism, such as the common practice of equating the word gay with stupid or
automatically making the assumption that most people are heterosexual; practices such as
these create distress and feelings of denigration (Burn, Kadlec, & Rexer, 2005). LGBTQ
individuals face microaggressions that invalidate their sexual orientation, including the use of
language and terms that demonstrate heteronormality and heterosexual privilege (Smith,
Shin, & Officer, 2011). Perceived discrimination based on sexual orientation, especially
among those who keep silent about their experiences, increases the risk of depression
(McLaughlin, Hatzenbuehler, & Keyes, 2010).
It is likely that societal stressors such as prejudice and discrimination account for the finding
that LGBTQ youth report elevated rates of major depression, generalized anxiety disorder,
and substance abuse (Rienzo, Button, Sheu, & Li, 2006) and that LGBTQ adults are at higher
risk for substance‐ and alcohol‐related problems (Ward, Dahlhamer, Galinsky, & Joestl,
2014). Although gay men report high rates of major depression, lesbians appear to fare better
and report mental health equal to that of their heterosexual counterparts (DeAngelis, 2002).
A number of research studies reveal that bias continues to exist among mental health
professionals (Shelton & Delgado‐Romero, 2013). In one study, 97 counselors read a
fictitious intake report about a bisexual woman seeking counseling, with no indication that
the problem involved her sexual orientation. Instead, the problems given concerned her
career choice, troubles with her parents over independence, ending a two‐year relationship
with another woman, and troubles with her boyfriend. Hence, the issues involved were
boundaries with parents, career choice, and romantic relationships. Counselors with the most
negative attitude toward bisexuality believed her problems stemmed from her sexual
orientation and rated her lower in psychosocial functioning (Mohr, Israel, & Sedlacek, 2001).
It is not uncommon for therapists to engage in biased and inappropriate practices or to hold
beliefs that affect the therapeutic alliance with LGBTQ clients (Garnets, Hancock, Cochran,
Goodchilds, & Peplau, 1998; Shelton & Delgado‐Romero, 2013), including the following:
1. Assuming that a client is heterosexual, thereby making it harder to bring up issues
around sexual orientation.
2. Believing that same‐sex orientation is sinful or a form of mental illness.
3. Failing to understand that a client's emotional problems may result from experiences
with discrimination or internalization of society's view of homosexuality.
4. Focusing on sexual orientation when it is not relevant.
5. Attempting to have a client renounce or change their sexual orientation.
6. Lacking an understanding of identity development in lesbian women and gay men, or
viewing homosexuality solely as sexual activity.
7. Not understanding the impact of possible internalized negative societal pressures or
homophobia/biphobia/transphobia on identity development.
8. Underestimating the consequences of coming out for the client, and suggesting they
come out without careful discussion of the pros and cons of this disclosure.
9. Misunderstanding or underestimating the importance of intimate relationships for gay
men and lesbians. One therapist reportedly advised a lesbian couple who were having
problems in their relationship to not think of it as a permanent relationship and to
consider going to a gay bar to meet others.
10. Presuming that clients with a different sexual orientation cannot be good parents, and
automatically assuming that their children's problems are a result of their sexual
orientation.
11. Overidentifying with LGBTQ clients; offering excessive displays of acceptance or
“understanding.”
Implications
Although mental health organizations have acknowledged that homosexuality is not a mental
disorder, it is recognized that a “need for better education and training of mental health
practitioners” exists (Shelton & Delgado‐Romero, 2013). Heterosexist bias in therapy needs
to be acknowledged and changed. Fortunately, many mental health training programs have
made curricular changes to increase their emphasis both on the concerns and challenges of
LGBTQ individuals and on the positive characteristics and supportive relationships found in
these groups.
It is important for therapists to continue to examine possible stereotypes or negative attitudes
they may hold regarding LGBTQ clients and to monitor their behavior and interactions for
possible microaggressions. LGBTQ clients report perceiving counselors more positively and
feeling a greater willingness to disclose personal information, including sexual orientation,
when a counselor refrains from heterosexist language (e.g., using the term “partner” instead
of “boyfriend”/“girlfriend” or “husband”/“wife”). Workshops and training in the use of
nondiscriminatory intake forms and the identification of psychological and health issues
faced by many LGBTQ clients are helpful means of increasing health care providers'
effectiveness (Pachankis & Goldfried, 2013).
Aging
Kelly Glossip was accepted in a senior citizens home but turned it down, “I'm used to
being out, so the idea of going into senior housing in a straight environment is
horrifying … I know that I would have to go completely back in the closet.”
(Watkins, 2010, p. 1)
Because of anticipated or previous discrimination by health care providers, older LGBTQ
individuals underutilize health care. Their concerns appear to be justified.
In a recent study, heterosexual male and female nurses showed a strong preference for
heterosexual over lesbian and gay patients (Sabin, Riskind, & Nosek, 2015). Aging LGBTQ
individuals are fearful of having to go to retirement or assisted‐living communities, where
prejudice may exist. In interviews, residents of these communities assumed that people living
there were heterosexual and many expressed the view that it is “OK” to have LGBTQ
residents as long as they do not talk about their orientation (Clay, 2014). Unless attitudes
change, these types of problems will only increase, because nearly 1.5 million LGBTQ
individuals in the United States are older than age 65, and this number is expected to double
in 15 years (Movement Advancement Project, 2010). In addition, as with other segments of
U.S. society, ageism exists within gay and lesbian communities. All of these issues can
produce a great deal of concern among older LGBTQ adults as they confront declining health
and a diminishing social support system.
Implications
With older LGBTQ individuals, issues of coming out (or coming out again) may need to be
addressed as their needs for health care or social services increase. Counselors can assist
these clients to develop coping skills, expand their social support systems, and locate services
for older LGBTQ adults. Advocacy groups for this population are increasing in number. One
organization, Senior Action in a Gay Environment (SAGE), provides counseling, educational
and recreational activities, and discussion groups for older LGBTQ individuals. The Gay and
Lesbian Association of Retiring Persons (GLARP) operates retirement communities for
LGBTQ individuals and provides them with support and education on aging (Donahue &
McDonald, 2005). To promote a welcoming environment, some retirement communities use
marketing materials that show same‐sex couples and other indications of diversity.
In addition to these services, LGBTQ‐friendly teleconferences exist for homebound seniors.
Project Visibility, a training program for staff and administrators of nursing homes and
assisted‐living facilities, incorporates culturally competent practices that counter stereotypes
and foster compassionate care for older LGBTQ adults living in these facilities (Mellskog,
2011). Many organizations have added the transgender community to their mission
statements. The mental health professional needs to be aware of these resources and advocate
for laws that support LGBTQ partnership rights.
IMPLICATIONS FOR CLINICAL PRACTICE
1. Examine your own views regarding heterosexuality, and determine their impact on work
with LGBTQ clients. Understand heterosexual and cisgender privilege. A way to
personalize this perspective is to assume that some of your family, friends, or coworkers
may be LGBTQ.
2. Study appropriate practice guidelines and reports on therapy with LGBTQ individuals,
including the American Counseling Association's LGBTQ (ALGBTIC et al., 2013) and
transgender (2010) counseling competencies; the American Psychological Association's
LGB (American Psychological Association, 2011) and transgender and gender
nonconforming (American Psychological Association, 2015) guidelines for
psychotherapy; the Appropriate Therapeutic Responses to Sexual Orientation in the
American Psychological Association's Multicultural Competency in Geropsychology
(American Psychological Association, 2009a); the Report of the American
Psychological Association Task Force on Gender Identity and Gender Variance
(American Psychological Association, 2009b); and Adelson's (2012) Practice Parameter
on Gay, Lesbian, or Bisexual Orientation, Gender Nonconformity, and Gender
Discordance in Children and Adolescents.
3. Develop partnerships, consultation, or collaborative efforts with local and national
LGBTQ organizations.
4. Ensure that your intake forms, interview procedures, and language are free of
heterosexist bias and include a question on sexual behavior, attraction, or orientation;
include questions about gender identity and pronoun preference. Be aware that LGBTQ
clients may have specific concerns regarding confidentiality.
5. Do not assume that presenting problems are necessarily the result of sexual orientation
and gender identity. Typical presenting problems may include relationship difficulties,
self‐esteem issues, depression, and anxiety (Lyons, Bieschke, Dendy, Worthington, &
Georgemiller, 2010). Keep in mind that societal factors may play a role in these
problems.
6. Remember that mental health issues may result from stress due to prejudice and
discrimination; internalized homophobia/biphobia/transphobia; the coming out process;
a lack of family, peer, school, or community support; experiences of sexual
victimization or physical assault; suicidal ideation or attempts; and substance abuse.
Ethnic minority LGBTQ individuals may be dealing with rejection from their ethnic
communities as well as marginalization within the LGBTQ community.
7. Realize that LGBTQ couples may have problems similar to those of their heterosexual
counterparts but may also display unique concerns, such as differences in their degree of
comfort with public demonstrations of their relationship or reactions from their families
of origin.
8. Assess spiritual and religious needs. Many LGBTQ individuals have a strong religious
faith but they may encounter exclusion. Religious support is available. For example, for
individuals of the Christian faith, the Fellowship United Methodist Church accepts all
types of diversity and is open to gay congregation members. LGBTQ individuals who
have strong religious beliefs but who belong to a nonaffirming church can explore
different options, such as joining an affirming religious group, exploring more liberal
sects of their own religion, or developing their own definitions of what it means to be
gay or religious (Sherry, Adelman, Whilde, & Quick, 2010). It is much easier to adapt to
a different religious group than to change one's sexual orientation (Haldeman, 2010).
9. Because many LGBTQ clients have internalized the societal belief that they cannot have
long‐lasting relationships, access to materials that portray healthy and satisfying
long‐term LGBTQ relationships can help counteract these stereotypes.
10. Recognize that a large number of LGBTQ clients have been subjected to hate crimes as
well as microaggression. Depression, anger, post‐traumatic stress, and self‐blame
may result. These conditions need to be assessed and treated. It can be helpful to ask
questions such as, “Have you had incidences where you thought you were treated
differently because you are a sexual minority person?” (Kashubeck‐West, Szymanski,
& Meyer, 2008, p. 617).
11. For clients still dealing with internalized homophobia/biphobia/transphobia, it may help
to focus on assisting them to identify and replace heterosexist and cisgender messages
with positive affirming messages about their identity. Many LGBTQ individuals avoid
discrimination by assuming a heterosexual identity and avoiding the issue of sexuality
with others, whereas others are able to reveal their true identity. The consequences of
each of these reactions need to be considered from both individual and societal
perspectives.
12. A number of therapeutic strategies can be useful with internalized homophobia,
prejudice, and discrimination. Effective interventions may involve assisting clients to
identify and correct cognitive distortions, practice coping skills, or expand social
supports.
13. To increase awareness of internalized heterosexism, encourage LGBTQ clients who
have expressed concerns related to sexual orientation to talk about their coming out
experiences; thoughts and feelings about their sexuality; feelings of homophobia;
experiences with heterosexism in school, family, work, and religion; degree of
interactions with other LGBTQ individuals; and the availability of support
(Kashubeck‐West et al., 2008).
14. Systems‐level intervention is often needed in schools, employment situations, and
religious organizations. Diversity workshops can help organizations acquire accurate
information about sexual and gender diversity. Even with the Supreme Court decision
legalizing same‐sex marriage, counselors may need to be advocates for change and to
assist clients who are facing discriminatory action in regards to legal matters such as
adoptions.
15. Transgender individuals may need specific assistance making name changes, connecting
with local support groups, or locating medical professionals who provide hormones or
surgical options associated with a gender transition (Bess & Stabb, 2009).
16. Do not assume that coming out is the goal in all situations. Both counselor and client
should carefully consider consequences, especially for younger individuals, and develop
strategies to deal with possible negative reactions from family or friends.
SUMMARY
The acronym LGBTQ refers to individuals who have an affectional and/or sexual attraction to
persons of the same sex (gay men and lesbians) or to members of both sexes (bisexuals),
individuals whose gender identity is inconsistent with their assigned gender (transgender),
and individuals who self‐identify as queer. Overall, there appears to be increased societal
acceptance of LGBTQ individuals and their lifestyles, especially among the young. Despite
this change, prejudice, discrimination, and violence against sexual minorities continues.
Because of this fact, sexual identity issues and coming out are especially intense for
adolescents. Suicide attempts are high among LGBTQ adolescents and young adults.
Heterosexist bias in therapy needs to be acknowledged and changed. It is important for
therapists to continue to examine possible stereotypes or negative attitudes regarding LGBTQ
clients and to monitor their behavior and interactions for possible microaggressions. Sixteen
clinical implications for counselor practice are identified.
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75. Ward, B. W., Dahlhamer, J. M., Galinsky, A. M., & Joestl, S. S. (2014). Sexual
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78. Wong, C. M. (2014). New York's transgender residents will now be able to change birth
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79. Wright, K. (2001). To be poor and transgender. Progressive, 65, 21–24.
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technically‐arent/#.W4caDc5KgdU
24
Counseling Older Adults
Chapter Objectives
1. 1. Learn the demographics and characteristics of older adult clients.
2. 2. Identify counseling implications of the information provided for older adult
clients.
3. 3. Recognize strengths associated with older adult clients.
4. 4. Know the special challenges faced by older adult clients.
5. 5. Understand best practices in assessment and therapy with older adult clients.
I have lived by contributing to others, but when you retire, you can lose that feeling of
contributing value. Give us a chance to work with younger people as equals, and not be
directed by other people all the time!
(Participant in Smith, Shenk, Tran, Poon, Wahba, &Voegtli, 2017)
An examination of Facebook comments revealed that older adults are often “vilified”
and subjected to comments advocating that they be banned from public activities such as
driving and shopping; some Facebook users even proposed the execution of older
individuals.
(Levy, Chung, Bedford, & Navrazhina, 2014)
“[G]erontophobia” is harmful because we internalize it. Ageism has been described as
prejudice against one's future self. It tells us that age is our defining characteristic and
that, as midnight strikes on a milestone birthday, we will become nothing but old—
emptied of our passions, abilities and experience, infused instead with frailty and
decline.
(Karpf, 2015)
Individuals aged 65 and older currently constitute 16.2% of the U.S. population. This group is
growing, and is expected to constitute more than 20% of the population by 2030. During the
past decade, the age‐85‐and‐older group, the fastest‐growing segment of the adult
population, has increased by 38%. Because females live longer than males, at age 85 there are
only 39 men for every 100 women (Ortman, Velkoff, & Hogan, 2014). Because of the
“graying” of adults, definitions of “old” are changing. Most Baby Boomers define old as
being age 70 or older, although 25% believe that a person is not old until they reach the age
of 80 (Carroll, 2011).
We are an aging society, yet we are poorly prepared to handle our current aged population
and are certainly not equipped for the aging Baby Boomer generation. Information is lacking
on therapies and medications for older individuals. As a group, older adults are less likely to
receive new treatments for heart attacks or other illnesses, and older women are less likely to
receive radiation and chemotherapy after breast cancer surgery. This is surprising, since a
healthy person who is 65 years of age has an average life expectance of 19.3 more years (20.5
years for women and 17.9 years for men) (DHHS, 2014).
CHARACTERISTICS AND STRENGTHS
In the following sections, we consider the characteristics and strengths of older adults and the
associated treatment implications. Keep in mind that older adults constitute a diverse
community with multifaceted ethnic backgrounds, cultural identifications, and religious
practices. This overview, therefore, provides generalizations about a diverse group of people,
and its applicability always needs to be assessed with regard to individual clients.
Physical and Economic Health
She calls it “being sidelined.” Greta Hale, an 82‐year‐old grandmother of five, looks
forward to visiting her large family but often feels like an outsider when she does. On
holidays, she often sits alone while younger generations buzz about, preparing meals,
telling jokes, and engaging in lively debates. “My hearing is not so good anymore,” she
explains. Otherwise spry and healthy, Ms. Hale wants to participate but avoids doing so
because, she admits, “I don't always understand what people are saying. I think maybe
it's just easier for them to pretend I'm not there.” She considers this one of the more
difficult aspects of aging.
(Wallhagen, Pettengill, & Whiteside, 2006, p. 40)
Older adults often have physical impairments, such as hearing or vision loss or cardiovascular
disease (McDonnall, 2011). About 30% of adults between the ages of 65 and 74 have some
hearing impairment, and this increases to about half of those older than 75 (Wallhagen et al.,
2006). Up to 25% of older adults have insomnia or difficulty falling asleep (Silvertsen et al.,
2006). Ethnic minority older Americans tend to have more chronic, debilitating diseases, such
as diabetes and heart disease (Costantino, Malgady, & Primavera, 2009).
The majority of older individuals, however, are quite healthy and are able to live independent
lives requiring only minimal assistance. Only 3.3% of adults 65–74 years need help with
personal care from other persons; this percentage increases to 10.5% for those 75 and older
(CDC, 2015). In all age categories, women are more likely to need assistance than are men
(U.S. Census Bureau, 2005). The percentage of adults requiring nursing home care is only 1%
for those 65–74, 3% for those age 75–84, and 10% for those age 85 and older (DHHS, 2014).
Implications
When providing mental health services for older adults, counselors should consider the
possibility that some will have physical limitations. To ensure that the counseling
environment is appropriate for older clients, rooms should have adequate light and be free
from extraneous noise, as well as any limiting environmental barriers. If the client uses
eyeglasses or hearing aids, make sure these are present during the session. Because of the
frequency of physical illness (e.g., cardiovascular disease, hypertension), it is critical to work
with medical providers to rule out the possibility that physical conditions, medications, or
medication interactions are causing or contributing to emotional symptoms. Also, poverty,
unemployment, poor living conditions, discrimination, and lack of receptivity among health
care providers can significantly contribute to mental health concerns among older adults and
may need to be addressed.
Sexuality in Later Years
The topic of sexuality and the aging process is often given little consideration.
Underlying this neglect is the belief that sexuality should not be considered in the aged.
Stereotypes of older adults as being asexual are incorrect. Romantic relationships are
common in later life. In Internet personal ads, older men seek physical attractiveness
and younger women, while older women are more selective, seeking status and security.
(Alterovitz & Mendelsohn, 2009)
In our youth‐oriented society, older adults are not expected to be interested in sex. One
psychology intern remarked, “You never think the same about your older clients [or your
grandparents] after you have an 80‐year‐old woman telling you how much she enjoys oral
sex” (Zeiss, 2001, p. 1). Some consider sexual activity among older persons to be rare or even
inappropriate. However, sexual interest and activity continue well into the 80s and 90s for
many individuals. Among people 70 and older, 80% of men and 39% of women indicated
that a satisfying sexual relationship is an important part of the quality of life (Fisher, 2010). In
a study of over 3,000 older people, 53% between the ages of 65 and 74 were sexually active,
as were 26% between the ages of 75 and 85. In fact, a study found that while sexual
frequency among married couples decreased over time, it began to increase again in those
married for 50 years or more (Stroope, McFarland, & Uecker, 2015). Women reported
significantly less sexual activity than men; in part, this was due to a reduced likelihood of
having a spousal or intimate relationship, as well as sexual problems such as low desire,
difficulty with vaginal lubrication, and inability to reach orgasm. The most prevalent sexual
problem in older men was erectile dysfunction (Lindau et al., 2007).
Changes do occur in sexual functioning in both older men and older women. In men,
erections occur more slowly and require continuous stimulation, although they can be
maintained for longer periods without the need for ejaculation. The refractory period
increases, so that it may take a day or two for the man to become sexually responsive again.
Antihypertensive drugs, vascular diseases, and diabetes are common causes of impotence in
men. For women, aging is associated with a decline in estrogen, resulting in decreases in
vaginal lubrication. However, sexual responsiveness of the clitoris is similar to that of
younger women. Sexual activities remain important for older men and women. Medical and
psychological methods have been successful in treating sexual dysfunctions in older adults.
Age does not appear to be related to sexual satisfaction. In one survey involving 600 older
women, most respondents voiced positive reactions to their sexual experiences, such as
“Physical satisfaction is not the only aim of sex … It is the nearness of someone throughout
the lonely nights” and “I believe sex is a wonderful outlet for love and physical health and
worth trying to keep alive in advancing age … It makes one feel youthful and close to one's
mate and pleased to ‘still work’” (Johnson, 1995, p. A23).
Implications
Emotional stressors (retirement, caregiving, and lifestyle changes) and physical changes can
produce problems in sexual functioning. As with younger adults, therapists should remain
aware of possible sexual concerns. The mental health professional should determine the
reason for any difficulties, encouraging the client to consult with medical professionals when
appropriate. Many treatments and medications are now available to improve sexual
functioning in older adults. Knowledge of these advances is important for those counseling
this population.
Strengths
“There's an intimacy that comes later that is staggeringly wonderful,” she said. “You
can hold hands with this person you love and adore, and somehow it's just as passionate
as having sex at an earlier age. There is such a sense of connection and intimacy that
grows out of a long relationship, that touch carries with it the weight of so many
memories.”
(Hoffman, 2015)
The majority of older adults have good emotional stability and high levels of affective well‐
being. Although they may have less control over their environment, many show flexibility in
their ability to adjust to different situations. They also show greater facility in understanding
and managing emotions than younger individuals (Scheibe & Carstensen, 2010). Most older
adults are socially engaged and mentally alert. They also possess years of life and work
experience. Interestingly, more than half of the individuals selected to serve as chief
executive officers (CEOs) in Fortune 500 companies are over the age of 55 (Begley, 2010).
Many older adults, especially ethnic and minority group members, place a high value on
religious beliefs, a factor contributing to a sense of hope and optimism, meaning and purpose
in life, and better mental health (American Psychological Association, 2009). In recent
studies, older adults who believed they were resilient—had the ability to deal with stressors—
tended to display successful aging regardless of physical or cognitive impairments. The same
was true with those who rated themselves low on depression. Despite physical health status,
self‐ratings of successful aging were highly dependent on attitudinal qualities such as belief
in one's ability to cope with challenges (Jeste et al., 2013). Similarly, in a 16‐year
longitudinal study involving adults aged 70–100, most were satisfied with aging, felt younger
than their chronological age, and downgraded the importance of age‐related changes. Only
when they approached death did they become less satisfied with aging (Kotter‐Gruhn,
Kleinspehn‐Ammerlahn, Gerstorf, & Smith, 2009).
SPECIFIC CHALLENGES
In the following sections, we discuss challenges often faced by older populations and
consider their implications in treatment.
Prejudice and Discrimination
Old people are a pain in the [expletive deleted] as far as I'm concerned and they are a
burden on society. I hate everything about them, from their hair nets in the rain to their
white Velcro sneakers … they are senile, they complain about everything, they couldn't
hear a dumptruck.
(Levy et al., 2014, p. 173)
[Those who meet the] “stereotype of being depressed, cranky, irritable and obsessed
with their alimentary canal” constitute “no more than 10% of the older population …
The other 90% of the population isn't like that at all,” according to Paul Costa who has
studied aging for over 30 years.
(Tergesen, 2014)
Older individuals are subject to negative stereotypes and discrimination (Alterovitz &
Mendelsohn, 2009). Ageism, defined as negative attitudes toward the process of aging or
toward older individuals, is common in our society and around the world (North & Fiske,
2015). Older people always experience ageism at the intersections of other identities, such as
those associated with race, ethnicity, and gender, and the resulting manifestations of ageism
often differ. Older women, for example, are likely to be viewed negatively by society as a
whole, and many internalize ageist norms involving qualities such as beauty (Clarke, 2011).
In a review of negative attitudes toward older individuals, Palmore (2005) found that older
adults were thought to be inflexible in their thought processes; lacking in health, intelligence,
and alertness; and either lacking in sexual interest or, if they were sexually active, engaging
in activity inappropriate for their age. Older adults are also viewed as “all alike,” possessing
such characteristics as being rigid, sickly, dependent, and depressed (American Psychological
Association, 2009). Jokes about old age abound and are primarily negative in nature. The
entertainment industry, news broadcasts, and advertising media are dominated by younger
individuals. Information about older people is often presented by youthful reporters who may
not understand the experiences of older generations.
Implications
Ageism influences how both the general public and mental health professionals perceive older
persons. Negative stereotypes often result in older adults feeling invisible or less valued.
Many older individuals come to accept ageist views and suffer a loss of self‐esteem. In fact,
many internalize negative societal beliefs. Unfortunately, mental health professionals also
display age bias (Weiss, 2005), expressing reluctance to work with older adults, perceiving
this population as having a poorer prognosis, and viewing older people as less interesting,
more set in their ways, and less likely to benefit from therapy. Additionally, mental health
problems in older adults may be inaccurately attributed to aging. Such beliefs can limit
referrals for necessary services.
As always, therapists should be sensitive to intersectional considerations when working with
older adults, and should comprehensively assess for potential problems with discrimination
when working with those who have a disability, who come from a different ethnic or cultural
group to the therapist's own, or who are members of a sexual minority. Counselors can help
clients grapple with factors associated with ageism and find different sources of social
support. They can also actively work to change negative societal attitudes.
Mental Deterioration
Everyone knows that as we age, our minds and bodies decline—and life inevitably
becomes less satisfying and enjoyable. Everyone knows that cognitive decline is
inevitable. Everyone knows that as we get older, we become less productive at work.
(Tergesen, 2014)
A common view of older persons is that they are mentally incompetent. Although there is
some cognitive slowing associated with normal aging (e.g., periodic minor memory
difficulties, such as forgetting names or phone numbers or misplacing objects), the majority
of older adults do not demonstrate significant mental decline. In fact, most are still mentally
sharp and benefit from the store of knowledge they have acquired over a lifetime. Although
they may show decrements on cognitive tests, their performance is much better in real‐life
situations that incorporate their skills and prior experiences (Salthouse, 2012). Even when
cognitive slowing occurs, older adults often use various strategies to compensate for deficits
(Krendl, Heatherton, & Kensinger, 2009). Multitasking involving activities that compete for
attention (e.g., talking on a cell phone while crossing the street) becomes more difficult for
many older adults, although passive tasks are not affected (Neider et al., 2011). Similarly,
memory for perceptual information, highly practiced responses, and general knowledge holds
up well even when working memory is compromised (Craik, 2008).
Approximately one in seven adults aged 71 or older has dementia (i.e., memory impairment
and declining cognitive functioning), including the 5.2 million in this age group diagnosed
with Alzheimer's disease. Alzheimer's disease is now the fifth leading cause of death among
American adults aged 65 and older; the risk of Alzheimer's disease and other dementias
increases with age (Alzheimer's Association, 2014). Women usually live longer than men, so
they are more likely to develop dementia; among 65‐year‐olds, the lifetime risk of
developing dementia is approximately 11% for men and 19% for women (Gatz, 2007).
Implications
Older adults who report a cognitive decline should undergo assessment to determine if their
difficulties are associated with normal aging or due to pathological factors. For those with a
“normal” decline, reassurance and strategies to improve cognitive functioning can be useful
(American Psychological Association, 2014). Research has found that cognitive decline in
older adults can be delayed or reduced through lifestyle changes such as the use of cognitive
activities to stimulate the mind (e.g., chess, crossword puzzles, computer games, reading),
engaging in physical activity, and better nutrition. These lifestyle interventions appear to
improve neuroplasticity, increase neuronal connections in the brain, and increase cognitive
reserve (Williams & Kemper, 2010). Normal cognitive declines may be reversed with
specific training. In one study, older adults with declines in inductive reasoning or spatial
orientation were given a five‐hour training to improve these skills. Over two‐thirds
improved with the training, and 40% reached the same performance level in these areas as
they demonstrated 14 years previously. Such training may be useful for reversing specific
types of cognitive declines (Schaie, Willis, & Caskie, 2004).
For older adults demonstrating significant cognitive decline and for those suspected of having
a neurodegenerative condition such as Alzheimer's disease, the traditional mental status exam
can provide some indication of problem areas. However, a more frequently used assessment
is the Mini‐Mental State Examination (MMSE). This test takes about 5–10 minutes to
administer and has normative and validity data. It comprises 11 items that assess orientation,
attention and calculation, recall, language, and visual motor integrity.
Early detection of cognitive decline allows for treatment and advanced planning involving
legal matters or potential problems such as driving.
Other steps to take in evaluating cognitive changes include the following:
Obtain a self‐report from the client about possible changes in memory or other areas of
cognitive function.
Obtain reports from family members and friends regarding the client's cognitive
performance. Be especially alert to discrepancies.
Take a careful history of the onset and progression of the cognitive changes.
Coordinate with medical professionals who can assess for possible side effects of
medication or other physical conditions that may cause cognitive decline.
Assess for depression, since it can also result in dementia‐like performance or the
overreporting of cognitive problems. Remember that depression and dementia often
occur together.
Although dementia has a gradual progression, the effects of this condition can quickly affect
both the client and family members. In the early stages, memory problems are often the
primary concern. Delusions and hallucinations may develop as the dementia progresses.
Family members may not understand that individuals with dementia do not always recall
what they are told. They may become frustrated when the affected individual is forgetful or
needs extra assistance following through with tasks. Some may believe the behavior is willful
or may try to assume responsibility over all aspects of the older person's life, even when he or
she can perform effectively in some areas.
Self‐identity and autonomy are important to older adults, including those with dementia.
Adult children may infantilize or dominate a parent with a cognitive decline, assuming that
their actions are in the best interest of the parent but failing to take the parent's own
preferences or values into consideration. Elderspeak, such as “Are we ready for our bath?” or
“You want to take your medicine now, don't you?” (Williams, Kemper, & Hummert, 2005, p.
15), is often used with exaggerated intonation and elevated pitch, along with terms such as
“honey” or “good girl.” Elderspeak was found to be commonly used by one group of certified
nursing assistants when working with older adults with cognitive dysfunctions, especially
when other individuals were not around (Lombardi et al., 2014). Many older adults consider
elderspeak to be demeaning, and even those with severe dementia may react negatively to its
use by showing behavioral resistance (Williams, Herman, Gajewski, & Wilson, 2009).
Caregiving may be stressful and may increase conflict among family members. When
working with families that care for a relative with dementia, mental health professionals
should address the following:
1. The need for patience and understanding when working with individuals with dementia.
2. Potential stresses on family members and the need to enhance coping strategies,
including self‐care.
3. Education about specific neurological difficulties and their effects on cognition and
behavior; available treatments; and strategies for dealing with agitation, wandering, and
other safety issues.
4. The family dynamics as they relate to the caregiving situation, including the allocation
of caregiving responsibilities.
5. Strategies for effective communication among family members, possibly including
encouraging family members to avoid the use of elderspeak, oversimplification, and
unnecessary repetition of requests.
6. Financial and legal matters, such as power‐of‐attorney provisions.
Elder Abuse and Neglect
She raises her hands to her snow‐white hair in a gesture of frustrated bewilderment,
then slowly lowers them to cover eyes filling with tears. The woman, in her 70s, is trying
to explain how she wound up in a shelter that could well be where she spends the rest of
her life … She says she was usually ordered to “go to bed,” where she lay in a dark
room, upset, unable to sleep. A family member “just yelled at me all the time. Screamed
at me, cussed me out,” the woman says. “I don't know what happened. She just got tired
of me, I guess.”
(Sewell, 2013)
Maltreatment of older adults, including neglect and emotional, financial, physical, and sexual
abuse, is a significant public health concern. Many cases of abuse or neglect go undetected,
especially among those who are most vulnerable (e.g., individuals with dementia, depression,
or significant health concerns). Family circumstances most commonly associated with abuse
and neglect include (a) previous traumatic experiences and a pattern of violence in the family,
(b) stress (including marital stress) resulting from accommodating an older parent or relative
in the family home, (c) financial burdens, (d) overcrowded quarters, and (e) low levels of
social support (Acierno et al., 2010). It is also important to be alert for client self‐neglect
(e.g., unsafe driving, failure to eat or to take medications), another common concern that can
have serious consequences (Mosqueda & Dong, 2011).
Implications
It is essential that counselors be familiar with best practice guidelines for treating older adults
(American Psychological Association, 2014; Molinari, 2011) and the complex ethical and
legal issues pertaining to defining and reporting elder abuse and neglect, including self‐
neglect (Zeranski & Halgin, 2011). Counselors may see signs of bruising or malnutrition in
older clients or indications that they are suffering from emotional abuse. Assessment may be
difficult, since the client may have feelings of shame or dependency on the caregiver
(Horning, Wilkins, Dhanani, & Henriques, 2013). Several steps can be taken to reduce the
prevalence of elder abuse and neglect (American Psychological Association, 2001). First,
continued public education can bring the problem out in the open and increase awareness of
the risk factors for abuse. Second, respite care (e.g., family members, friends, or hired
workers helping with caregiving) can help reduce caregiver burnout. Third, increasing social
contact and support for caregivers can help keep stress more manageable. It may also be
possible to get assistance from religious or community organizations, as well as organizations
focused on particular medical conditions.
Substance Abuse
“I wouldn't get up in the morning,” she said. “I realized I was using alcohol to raise my
spirits. It raises your spirits for a little while, and then you become depressed … With
people dying around you, you feel more lonely and isolated.”
(Wren, 1998, p. 12)
Alcohol abuse can begin after a loss. Genevieve May, a psychiatrist, started abusing alcohol
after the death of her husband. Finding that this was not a solution, Dr. May entered the Betty
Ford Center and was successfully treated at age 83. There has been a dramatic increase in
substance abuse and the nonmedical use of prescription medications among older adults. It is
estimated that 11% of older adults abuse alcohol or prescription drugs; some of the misuse of
prescription drugs may involve misunderstanding of dosing instructions. Drugs that have
abuse potential include the benzodiazepines, opiates, and muscle relaxants. What is especially
problematic is that aging produces physiological changes that may increase the potency of
drugs and of their interactions. Because of this, the National Institute of Alcohol Abuse and
Alcoholism recommends that men 65 or older not have more than one drink daily, and a
maximum of two drinks on any occasion. Lower limits are recommended for women
(Bogunovic, 2012). The misuse of drugs can produce conditions resembling organic or
mental health conditions.
Between 1992 and 2008, the proportion of substance abuse treatment admissions involving
older Americans increased from 7.2 to 16.0% for heroin, from 2.9 to 11.4% for cocaine, from
0.7 to 3.5% for prescription medications, and from 0.6 to 2.9% for marijuana (Substance
Abuse and Mental Health Services Administration, 2010). About 20% of seniors take pain
medications several times per week; about 18% of these individuals abuse or become
addicted to these drugs (Lowry, 2013).
Implications
Older adults rarely seek treatment for substance abuse problems because of shame and
perhaps because they feel uncomfortable in programs that deal with “street” drugs, such as
heroin and cocaine. Late‐onset alcohol and drug abuse problems seem to be related to
stressors such as the death of a spouse, family member, or friend; retirement issues; family
conflicts; physical health problems; or financial concerns. Many of these stressors are typical
issues faced in later life. Early intervention to identify and provide support for these situations
can reduce substance abuse risk. As compared to younger substance abusers, older patients
respond better to more structured programs, more flexible rules concerning discharge, more
comprehensive assessment, and greater outpatient mental health aftercare (Moos, Mertens, &
Brennan, 1995). The U.S. Department of Health and Human Services (DHHS, 2005) has
published a comprehensive treatment manual for use by counselors that contains an
evidence‐based cognitive behavioral group treatment for substance abuse in older adults. It
includes modifications to therapy that incorporates physiological, cognitive, and social
changes that are characteristic of this population. The manual is helpful in providing specific
interventions in either a group or an individual format.
Social Isolation, Depression, and Suicide
Depression and social isolation are common complaints among older adults. Although
physical changes associated with aging (e.g., hearing or vision loss or cardiovascular disease)
can sometimes lead to depression (McDonnall, 2011), depression is not a normal
consequence of aging. Depression is more strongly associated with feelings of “being old”
than with actual age or health status (Rosenfeld, 2004). The rate of depression increases with
age for males, whereas in women it decreases after the age of 60. Stressful life changes, such
as the deaths of friends and relatives, increasing social isolation, or financial distress, can
increase the risk of depression. Social isolation is related not only to depression but also to
other mental health conditions and physical complaints; between 10 and 43% of older adults
living in the community report experiencing social isolation (Nicholson, 2012).
Among older men, the highest rates of depression are for those who never married (20.6%) or
who are separated or divorced (19.2%). The prevalence of depression among older women is
highest among those who are separated or divorced (23.1%) or widowed (15.4%). For males
and females with partners, depression is most common among those in stressful relationships
(St. John & Montgomery, 2009). Depression needs to be identified and treated, since it is also
seen as an independent risk factor for cardiovascular and cerebrovascular disease. Not only
does late‐life depression significantly affect older adults' physical health, but it can also
affect social connections and overall functioning, and increase the risk of suicide (Beyer,
2007).
Baby Boomers—those born in the 1950s and '60s—have shown a dramatic spike in suicides,
especially among Whites, Native Americans, and Alaskan men. This increase may be the
result of coming from a youth‐oriented and optimistic generation, and an associated
inability to deal with signs of aging or perceived lack of achievement (Bahrampour, 2013).
Suicide rates are exceptionally high among older men, with the risk increasing with
advancing age; White males aged 85 or older have the second highest suicide rate of any
group. It is unclear whether this group has less resilience and fewer coping strategies or
whether the high suicide rate is because life changes associated with advanced age (e.g., loss
of employment, physical changes, loss of control) are a greater stressor for men. Factors
associated with suicide include being separated, divorced, or alone; suffering depression;
having an anxiety disorder; having physical or medical problems; and dealing with family
conflict or loss of a relationship (American Foundation for Suicide Prevention, 2015).
Implications
It is important to avoid assuming that depression is a normal consequence of aging (American
Psychological Association, 2009). Interestingly, in a sample of 139 people over 100 years of
age, most were in good spirits even though they scored higher for depression than individuals
in their 60s (Scheetz, Martin, & Poon, 2012). However, in many cases, major depression
tends to be unrecognized in older adults and is a significant predictor of suicide. It is therefore
essential to assess for depression and suicidality when working with older adults. A popular
instrument for screening for depression is the Geriatric Depression Scale, which was
developed for older adults. It has age‐related norms and omits somatic symptoms that may
be associated with physical problems rather than depression.
Because depression often co‐occurs with physical illnesses, such as cardiovascular disease,
stroke, diabetes, and cancer, health providers often believe that the mood disturbance is a
normal consequence of these problems, so they are less likely to refer for mental health
treatment. Many older individuals who commit suicide have visited a primary care physician
very close to the event (45% within 1 week, 73% within 1 month) (Juurlink, Herrmann,
Szalai, Kopp, & Redelmeier, 2004). There is an urgent need to detect and adequately treat
depression in order to reduce suicide among older individuals.
Because of the deleterious effects of social isolation on older adults, early assessment and
intervention to prevent further isolation is important. Encouraging older adults to participate
in senior centers or other social activities in their community may decrease social isolation
(Nicholson, 2012). There is some evidence that the impact of loneliness and depression can
be counteracted by helping older adults focus on positive emotions such as happiness,
optimism, and resilience; in other words, happiness has been found to “undo” or negate the
negative effects of loneliness and depression in older adults (Newall, Chipperfield, Bailis, &
Stewart, 2013).
A number of biological and psychological treatments are effective in treating depression in
older adults. Approximately 80% of older adults with depression show improvement when
they are given appropriate treatment. Antidepressants such as certain selective serotonin
reuptake inhibitors (SSRIs) have comparatively few side effects and are more likely to be
continued—an important consideration, since rates of noncompliance with medication are
high among older adults (Cooper et al., 2005). Meta‐analyses of evidence‐based therapies,
such as cognitive behavioral therapy (CBT), dialectical behavior therapy, and interpersonal
therapy, indicate that these therapies are effective in reducing depression and dealing with
issues such as loss, transition, and cognitive decline in older individuals (Chand & Grossberg,
2013). Interpersonal therapy has been demonstrated to reduce suicidal ideation (Heisel,
Duberstein, Talbot, King, & Tu, 2009).
IMPLICATIONS FOR CLINICAL PRACTICE
Many older adults develop meaningful support systems in the community and have
positive contact with family members. Social contacts are important, and engaging in
either paid or volunteer work can enhance the self‐esteem and life satisfaction of older
individuals (Acquino, Russell, Cutrona, & Altmaier, 1996). Issues that older adults face
may include retirement and other changing roles; loss and illness of loved ones; more
limited financial resources; caretaking responsibilities; social isolation; health and
physical problems, including sensory impairment; and cultural devaluation of their
group by society (Corna, Wade, Streiner, & Cairney, 2009).
A number of therapy approaches, such as helping clients improve coping skills and
teaching them strategies to resolve interpersonal difficulties, can reduce depression in
older adults (Reynolds et al., 2014). CBT and interpersonal therapy are evidence‐based
therapies that can help older adults deal with issues of grief, role transition, interpersonal
conflict, and social skills deficit (Van Orden, Talbot, & King, 2012; Wyman‐Chick,
2013). Reducing loneliness or social isolation by increasing social opportunities and
developing positive emotions can be effective in improving the mental and physical life
of older adults. Finally, interventions that affirm older adults' ethnic and cultural
connections may enhance resilience and well‐being (e.g., Chavez‐Korell, Benson‐
Flórez, Delgado‐Rendón, & Farías, 2014).
Counseling can also significantly improve the quality of life for adults nearing their time
of death, or help them resolve late‐life issues. The American Counseling Association
includes end‐of‐life care provisions (quality of care, counselor competence, and
confidentiality) in its ethics code, and should be consulted when working with terminally
ill clients and their loved ones (Werth & Crow, 2009).
Following are some suggestions for offering mental health services to older adults
(American Psychological Association, 2014; Blando, 2014; Knight & McCallum, 1998;
Pennington, 2004):
1. Acquire specific knowledge and skills in counseling older adults, and critically evaluate
your own attitudes and beliefs regarding aging and older adults.
2. Remain knowledgeable about legal and ethical issues that arise when working with older
adults (e.g., competency issues).
3. Determine the reason for evaluation and the social factors affecting the problem, such as
recent losses, financial stressors, and family issues.
4. Show older adults respect, and give them as much autonomy as possible, regardless of
mental status or the issues involved. When communicating with older adults:
Give full attention to the individual.
Talk to, rather than about, the person.
Use respectful language (not elderspeak).
Treat the person as an adult.
Take the individual's concerns seriously.
5. Determine the older adult's view of the problem, belief system, stage‐of‐life issues,
educational background, and social and ethnic influences.
6. Assist in interpreting the impact of cultural issues, such as ethnic group membership,
gender, and sexual orientation, on the client's life and presenting problems.
7. Presume competence in older adult clients unless the contrary is obvious.
8. If necessary, reduce the pace of therapy to accommodate cognitive slowing.
9. Involve older adults in decisions as much as possible. If there are cognitive limitations, it
may be necessary to use legally recognized individuals to assist with decision‐making.
10. Use multiple assessments, and include relevant sources (client, family members,
significant others, and health care providers).
11. Determine the roles of family caregivers, educate them about emotional or
neurocognitive disorders, and help them develop strategies to reduce burnout.
12. When working with an older couple, help negotiate issues around time spent alone and
together (especially after retirement). Arguments over recreation are common. There is
often too much “couple time” and no “legitimate” reason for separateness.
13. Recognize that it is important to help individuals who are alone establish support
systems in the community.
14. Help older adults develop a sense of fulfillment in life by discussing the positive aspects
of their experiences. Success can be defined as having done one's best or having met and
survived challenges. A life review is often helpful.
15. Infections and medication side effects can be particularly troublesome for older adults. A
physical evaluation may be needed to determine whether mental symptoms have
physical causes.
16. Help adults very close to the end of their lives deal with their attachment to cherished
objects by having them decide how heirlooms, keepsakes, and photo albums will be
distributed and cared for.
SUMMARY
We are an aging society, and the older population has increased dramatically as the Baby
Boomers have retired and the average life span has increased. Yet, we are poorly prepared to
handle our current aged population, and information is lacking on therapies and medications
for older individuals. Physical changes and economic concerns become increasingly
important stressors in the life of this population. Counselors must become knowledgeable
about how aging affects cognitive functioning, sexuality, and social isolation as friends and
relatives pass away. Among older adults, special challenges present themselves: elder abuse
and neglect, substance abuse, depression, and suicide. One of the greatest challenges facing
this population is prejudice and discrimination directed at the elderly. Older individuals are
subjected to ageism, defined as negative attitudes toward the process of aging or toward older
individuals. Not only is less value placed on their lives, but they are often seen as a burden to
society. Sixteen clinical implications for counselor practice are identified.
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25
Counseling Individuals Living in Poverty
Chapter Objectives
1. 1. Learn the demographics associated with poverty.
2. 2. Identify counseling implications of the information provided regarding
impoverished clients.
3. 3. Recognize strengths associated with experiences involving poverty.
4. 4. Know the special challenges faced by impoverished clients.
5. 5. Understand best practices for working with impoverished clients.
We're people with lives and things in our lives that are affecting our health … Talking
about our mental health is not the same as someone who feels down sometimes. If you
don't have a roof over your head, if you don't have your electric bill paid, then how are
you going to take care of your mental health? There is not a traditional mental health
strategy that gets at that.
(Participant in the Reaching Out About Depression [ROAD] project, Goodman et al., 2007, p. 286)
At least 12 states have passed legislation requiring drug testing for certain people
receiving public assistance such as food stamps, public health care, and unemployment
benefits. This reinforces the view that the poor do not want jobs and as one legislator
argued “It reinforces the stigma that people who are in need, who are poor, are drug
users.”
(Laine, 2015)
[W]hen the therapist and client come from different class backgrounds, they do not
always view situations, family relationships, nor solutions from the same viewpoint … I
did not find that these therapists were particularly unsympathetic or knowingly unkind.
What I did find was that the therapists … were unaware of their own class values.
(Chalifoux, 1996, p. 32)
Poverty does not constitute a cultural designation in the true sense of the word, yet the
challenges and landmarks of life in poverty diverge enough from mainstream life to warrant
consideration by counseling professionals. The following sections offer an overview of the
circumstances facing individuals living in poverty and consider their implications in
treatment. Keep in mind that people living in poverty constitute a diverse community with
multifaceted racial‐ethnic backgrounds, cultural identifications, and religious practices. This
overview, therefore, provides generalizations about a diverse group of people, and its
applicability always needs to be assessed with regard to individual clients.
For counselors who come from middle‐class (and more affluent) backgrounds, it will be
important to learn about the everyday realities experienced by those living in poverty. Even
more crucial, however, is learning about the class‐related biases, attitudes, assumptions, and
procedures that are often embedded in the worldviews of people who hold social class
privilege, and the ways that these assumptions are manifested within psychological theory,
research, and practice. Without an awareness of the social, cultural, and interpersonal
discrimination that accompanies poverty, counselors may be unable to work effectively with
low‐income clients—and may even unintentionally contribute to their oppression.
These factors will be presented within the context of social class stratification theory (e.g.,
Beeghley, 2008). Many of us are not well acquainted with social class theory; we are much
more familiar with numerical calculations like socioeconomic status, and often think of
poverty only in terms of inadequate financial resources. Financial resources are indeed critical
to understanding life in poverty. A social class framework, however, positions poverty as
more than a lack of purchasing power. Rather, poverty involves being on the bottom‐most
rung in a hierarchical system of sociocultural power relations that goes beyond differences in
income. Within this hierarchy, social class oppression is called classism (Lott & Bullock,
2007), and it operates to limit access to many kinds of socially valued assets. As will be
described later, these assets include the availability of essential services and resources (e.g.,
education and health care), entrée to mainstream opportunities and experiences, cultural
inclusion/exclusion, and representation within our nation's system of participatory democracy
(Smith, 2010).
CHARACTERISTICS AND STRENGTHS
The U.S. Census Bureau estimated that the U.S. poverty rate was 12.7% in 2016, down from
13.5% in 2015 (Semega, Fontenot, & Kollar, 2017). The following trends and data illustrate
provide a demographic snapshot of U.S. poverty today:
In 2016, adults with no children were considered to be living in poverty if they had
$12,486 or less in annual income. An adult with a child fell below the poverty threshold
if he or she had less than $16,543 in income per year (Semega et al., 2017).
An overall decrease in poverty characterized most demographic groups. The only group
to experience an increase in its poverty rate was adults aged 65 and older (Semega et al.,
2017).
The poverty rate for Whites in 2016 was 11.0%, for African Americans it was twice that
at 22.0%, for Latinx people it was 19.4%, and for Asians it was 10.1% (Semega et al.,
2017). The highest U.S. poverty rates are found among American Indians, at 26.2%
(U.S. Census Bureau, 2017).
Children (at a poverty rate of 18.0%) continue to be the age group most likely to live in
poverty (Semega et al., 2017), and the U.S. child poverty rate is one of the highest in the
developed world (UNICEF, 2012).
Women are more likely to live in poverty than men. In 2016, 11.3% of males and 14.0%
of females were impoverished (Semega et al., 2017).
Globally, one of the distinguishing features of American poverty is that it takes place in
the wealthiest nation in the world. The United States continues to have one of the
world's most unequal income distributions. As measured by the Gini coefficient—a
statistic that reflects the disparity between the lowest and highest income levels in a
nation—and after adjusting for taxes, the United States has the highest level of
disposable‐income inequality among wealthy developed countries (Fisher &
Smeedling, 2016). This inequality has grown steadily over recent decades: in the 1970s,
the share of total income earned by the top 1% of families was less than 10%, but by the
end of 2012, it exceeded 20% (Saez & Zucman, 2014).
Similarly, the continuing escalation of wealth inequity in the United States is dramatic.
The top 0.1% of American families—a group comprising 160,000 families—by itself
owned 22% of all U.S. wealth in 2012, up from 7% in the late 1970s (Saez & Zucman,
2014).
These statements use the word poverty with reference to specific numerical criteria such as
the federal poverty threshold. Different branches of the U.S. government compute such
designations slightly differently, yet such calculations always underestimate the number of
families who are struggling economically. For example, according to the poverty threshold
given here, an adult with a child who is attempting to live on $16,544 per year would not be
counted among the poor. These statements also illustrate a significant characteristic of the
American social class structure: positions of lower socioeconomic power and access—that is,
life in poverty—intersect meaningfully with marginalization along other dimensions of
identity, such as race and gender.
Strengths
Presenting the strengths of people living in poverty is a somewhat self‐contradictory
undertaking. On the one hand, the question may seem to suggest that poor people are
somehow inherently different from the rest of us. However, research evidence supports the
opposite contention. Certainly, an individual can suffer a financial downturn for a variety of
personal reasons. Nevertheless, the fact that particular cultural groups are consistently
overrepresented among the poor supports the notion that poverty generally derives from
people's historical and sociopolitical contexts rather than from individual deficits (e.g., Belle,
1990; Carmon, 1985; Costello, Compton, Keeler, & Angold, 2003). Similarly, the elevated
levels of stress, deprivation, and physical wear‐and‐tear that are characteristically detected
among poor people would theoretically be expected to affect almost anyone who found
themselves constrained to survive life in poverty.
On the other hand, when people do survive poverty, they demonstrate strengths that are not
part of the stereotypical image that many people have of the poor. For example, Banyard
(2008) wrote of the patience, persistence, and determination of homeless women as they
struggled to make decent lives for their children—women who have often been stereotyped
with the classist, racist label welfare queen. The words of these homeless mothers illustrate
Banyard's characterization of them as not only surviving, but tenaciously creating survival
strategies, solving problems, and maintaining hope as they prioritize their children and their
roles as mothers.
[Y]ou have an allotted time to get out of the [shelter]. That's stressful, knowing that the
clock's ticking … You've worked all your life, and then you're stuck on welfare, and then
your children ask for things.
(p. 1)
We just, we think of it again, and think of another route. You know, like taking another
street. You know, it's not like you'll hit a highway … but it won't be a dead end street.
(p. 2)
You know, it's like I run this race, I fall down. I'm not just going to lay there. Even if I
lose, I'm going to get up and still try to make it to the finish line.
(p. 2)
Obviously, most of us would wish for a world in which mothers, fathers, and children did not
have to demonstrate their ability to survive homelessness. However, it is important to take
stock of the strengths that people in poverty demonstrate, as Banyard (2008) explained.
If we assume that women in poverty are lazy and unmotivated (common stereotypes), we
are likely to design policies that focus exclusively on giving them, as individuals,
penalties for not finding a job. If we, on the other hand, assume that many women
possess the desire to make a better life for themselves and their families, and listen to
their stories of how hard it is to feed and house a family on minimum wage or to find
affordable childcare, then we design policies which encourage work by supporting a
living wage and educational opportunities for low‐income workers and increasing
accessible, affordable childcare for their children.
(p. 2)
Most of us can readily recognize how a scarcity of the essential resources and services that
support life—healthy food, safe communities, good schools, adequate health care, a roof over
one's head—may lead in obvious ways to discomfort, distress, and crisis for poor families.
What may not be as obvious is the additional stress that results from institutional and cultural
classism. As is the case with other forms of oppression, classist attitudes often exist at an
unconscious level within the worldviews of well‐intentioned individuals, and may be
unintentionally perpetuated by counselors who are unaware of the implications of their
actions. Moreover, classism is always experienced at intersections with racial, ethnic, and
gender‐related identities, which means that poor people often experience classism in concert
with other forms of bias. It is worth mentioning that the operations of intersectionality in the
lives of people in poverty has not received extensive attention from counseling researchers; a
recent study found poverty to be the least studied social identity within intersectional research
(Shin et al., 2017). Understanding classism, therefore, is an essential component of
multiculturally competent practice. The following sections profile some examples of classist
discrimination.
SPECIFIC CHALLENGES
In this section, we consider the challenges faced by those living in poverty, such as their
invisibility, educational inequity, disparities in the judicial system, and health care inequities.
The Cultural Invisibility and Social Exclusion of the Poor
The American author and poet Dorothy Allison (1994), who was raised in poverty, observed,
“My family's life was not on television, not in books, not even in comic books” (p. 17), a
perception that has subsequently been borne out by the social psychological literature.
Bullock, Wyche, and Williams (2001) found that poor people rarely appear within televised
media representations, and when they do, they are often portrayed as lazy, promiscuous,
dysfunctional, and/or drug‐addicted. Similarly, the experiences of working‐class people
are largely without representation in popular culture, and there are few poor or working‐
class voices in the national discourse on public policy issues. When they are included, usually
with regard to specific topics such as organized labor, they are often presented in a negative
light.
Increasingly, the poor are being physically as well as metaphorically excluded from
mainstream cultural life. A report entitled “Homes Not Handcuffs” documented the rise in
civic ordinances that restrict the sharing of food, make it illegal to sit or sleep in public
spaces, and drive homeless people away from public areas, often resulting in the loss of their
personal documents, medications, and other property (National Law Center on Homelessness
and Poverty and National Coalition for the Homeless, 2009). Ehrenreich (2009) called this
trend “the criminalization of poverty” (p. 2).
Educational Inequities
In 2013, 51% of public school students were considered low income (qualifying for free
or reduced fee meals) as compared to 38% in 2000. As one educator warned “Without
improving the educational support that the nation provides its low income students—
students with the largest needs and usually with the least support—the trends of the last
decade will be prologue for a nation not at risk, but a nation in decline.”
(Southern Education Foundation, 2015, p. 4)
Although education is often promoted as a pathway out of poverty, American educational
disparities are such that the families with the greatest need are often relegated to the least
adequate educational resources. Further, children in poverty often do not have proper
nutrition, health insurance coverage, or necessary educational supplies.
The test score gap between affluent students and those from lower income families has
increased by 40% since the 1960s; 22% of those from lower income families do not graduate
from high school, as compared to 6% of those from higher income families (Annie E. Casey
Foundation, 2012). Jonathan Kozol (2006) has chronicled the interface of class, race, and
schooling in the United States in books like The Shame of the Nation, finding that children
who attend public schools in poor communities are more likely to be taught by poorly paid,
uncertified teachers, and to have fewer computers, fewer library books, fewer classes, fewer
extracurricular opportunities, and fewer teachers as compared with wealthier students.
According to “Losing Ground,” a report by the National Center for Public Policy and Higher
Education (2002), the relatively small number of students from low‐income families who
make it to college campuses will find that the costs of a college education have escalated at a
rate higher than both inflation and family income. As a result, the graduation rates of low‐
income students are reduced, while students from middle‐class and wealthy families
continue to attend college in record numbers.
Up to 40% of low‐income students who indicate that they will attend college fail to show up
in the fall. This phenomenon is called “summer melt.” Because they often lack role models
among family members and friends, these students are unfamiliar with the process of
completing paperwork for admission, financial assistance, housing, and class registration.
This is especially problematic when counselors are not available in the summer. Even after
financial packages receive preliminary approval, there is a need for documentation regarding
income and other resources. Unless assistance is available to help applicants respond to these
requests, prospective students may become confused and give up.
Implications
Low‐income students need assistance in navigating the application process for college
admittance and follow‐up support to ensure that enrollment proceeds successfully. Bridge
programs that facilitate the move from high school to college have been effective in reducing
summer melt attritions (Castleman & Page, 2014; Frey, 2014). Counselors play an important
role in assuring successful entry into college. In one case, the manager of a college housing
complex contacted a female student to inform her that she needed to immediately send in
$1,700 to cover her deposit and rent. Her mother contacted a transition counselor, who was
able to intervene until state financial assistance became available. Practical assistance such as
this is often necessary to help low‐income students navigate the complexities of the
educational system (Frey, 2014).
Poverty and Mental Illness
Living in poverty for any significant length of time increases all sorts of risk factors for
health and mental health problems. You are more stressed, worrying about money
constantly, and how you're going to pay the bills or have enough money to eat … If you
can still afford to live on your own, you will likely do so in a neighborhood more prone
to violence, exposing you to more trauma and risk for personal violence.
(Grohol, 2011)
Poverty is related to and often precedes the development of emotional problems such as
anxiety and depression (Hudson, 2005); it produces conditions conducive to the development
of mental health issues. Individuals who live in poverty face a number of stressors, such as
economic worries, discrimination, family conflict, inadequate housing, and frequent moves—
all of which may result in psychiatric symptoms, including heightened physiological reactions
to even minor anxiety‐inducing events (Wadsworth & Achenbach, 2005; Wadsworth &
Rienks, 2012). In addition, the living environment associated with poverty can increase the
risk of exposure to violence and trauma, resulting in high rates of stress disorders such as
post‐traumatic stress disorder (PTSD), and other problems such as aggression, delinquency,
substance abuse, and academic difficulties (Kearney, Wechsler, Kaur, & Lemos‐Miller,
2010).
Implications
Many individuals living in poverty do not seek treatment because of practical problems such
as limited transportation, inflexible work schedules, lack of health insurance, or other factors
that affect their access to mental health services. Counselors working with low‐income
clients should seek to develop a flexible schedule and style to meet the needs of individuals
who may not be able to attend weekly or 50‐minute sessions, address barriers that may
affect attendance, and increase the outreach component in providing therapy (Santiago,
Kaltman, & Miranda, 2013).
Environmental Injustice
Waste dumps, “dirty industries,” and other pollution‐producing operations are frequently
located in the urban and rural areas where poor people and people of color live. U.S.
Environmental Protection Agency (EPA) administrator Lisa Jackson called these
neighborhoods “hot spots of emissions, hot spots of contamination” as she discussed efforts
to address the resulting elevated risk of asthma and other pollution‐related conditions
(Eilperin, 2010, para. 17).
Disparities in the Judicial System
Mentioned regularly in media descriptions of legal proceedings, bail represents one of the
more overt forms of classist discrimination: the poor remain in prison cells while wealthier
people accused of the same crimes go home. Moreover, funding for legal aid services is
sufficient only to provide counsel to a small proportion of the Americans who need it, with
the result that millions of poor people are priced out of the U.S. civil legal process for the vast
majority of their legal concerns (Rhode, 2004). Reiman (2007) has argued that the criminal
justice system itself is deeply classist, in that it portrays crime as the misdeeds of the poor. In
other words, street crimes like burglary, theft, and selling drugs are the contents of the typical
police blotter and are detailed in national crime rate statistics. This practice serves to deflect
attention from the crimes that actually cause the most death, destruction, and suffering in our
country—crimes that derive from the actions of people with social class privilege: corporate
fraud, the creation of toxic pollutants, profiteering from unhealthy or unsafe products, and
risky high‐level financial ventures, for which the American public ends up bearing the
consequences.
Classism and the Minimum Wage
Without people working in minimum‐wage jobs, the lives of middle‐class and wealthy
Americans would come to a standstill. Our society relies upon the people who ring up our
purchases, work in childcare, change hospital beds, clean offices, and serve food; yet, the
citizens who perform these necessary jobs cannot earn enough money to lift their families
above the poverty line. The federal minimum wage of $7.25 per hour does not allow a full‐
time worker to lift his or her family of four out of poverty, a conclusion that emerges from
examining the cost of living around the country via Penn State's Living Wage Calculator.
This tool calculates the minimum cost of essential food, medical, housing, and transportation
requirements in almost every U.S. city and county, and is available online at
www.livingwage.geog.psu.edu. This observation goes hand‐in‐hand with a finding by the
National Coalition for the Homeless (2005): as many as 25% of people in U.S. homeless
shelters have jobs. The unlivable level of the federal minimum wage gives rise to inherent
ethical contradictions, suggesting that classist attitudes toward the poor may influence public
debate (or lack thereof) over this issue.
Health Care Inequities
The health disparities research is resoundingly clear: poor people face elevated rates of nearly
every sort of threat to survival, including heart disease, diabetes, exposure to toxins, cognitive
and physical functional decline, and homicide, among many other threats (e.g., Belle, Doucet,
Harris, Miller, & Tan, 2000; Scott, 2005). In the first quarter of 2014, the number of
Americans without health insurance dropped to 41 million, from 50 million in 2009 (Kaiser
Foundation, 2010; Tavernise, 2014). This decrease was primarily because of enrollment via
provisions of the Affordable Care Act. This trajectory appears to have reversed, however: the
number of Americans without health insurance rose by 3.2 million between 2016 and 2017,
which corresponded to an increase of 1.3 percentage points to 12.2% of the population
(Abulateb, 2018). The majority of the uninsured come from low‐income families, yet 61%
come from families where one or more members work full‐time. Not surprisingly, people
without access to medical care often have no choice but to allow preventable conditions to
escalate into serious ones, and to leave serious problems untreated. Correspondingly, a 2009
Harvard study found that nearly 45,000 U.S. deaths annually are associated with a lack of
health insurance (Wilper et al., 2009).
Negative Attitudes and Beliefs
Many states have passed laws restricting what food stamp recipients and people on
other food nutritional programs can buy including items such as crab or other shellfish,
energy drinks, soda, cookies, chips and steak (Kackley, 2015). Kansas politicians also
proposed a $25 withdrawal limit from ATMs by welfare recipients to “help” these
individuals manage their money better.
(Paulson, 2015)
My kids brought home a letter asking us to bring cookies or bars to a school potluck …
buying ingredients for making cookies is expensive, so we used our food stamps to buy
Oreos, self‐consciously explaining our dilemma to the store clerk … Make no mistake:
Forcing families to spend two‐thirds of their benefits on approved foods is not about
stemming growth in programs, teaching responsibility or curbing the extremely rare
instances of abuse. It is about shaming.
(Beyer, 2015)
The current laws restricting the “misuse” of government assistance to low‐income
individuals are based on negative characterizations that have little basis in truth. The small
amount of money that these families receive is spent on the necessities of life, not on buying
expensive foods. The proposed $25 cap on ATM withdrawals would cause welfare recipients
to spend more on fees and to travel more frequently to withdraw funds. Drug testing of
welfare applicants has incurred a cost of nearly 1 million dollars, and very few drug users
have been found. Although the national drug use rate is 9.4%, the rate of positive drug tests
for welfare applicants ranges from 0.002% to 8.3%. In fact, the positive drug rate for
applicants from all states but one is under 1% (Covert & Israel, 2015). These restrictive laws
only serve to strengthen negative stereotypes of lower‐income individuals, resulting in
shame and stigmatization.
By contrast, wealthy people can become national celebrities on the basis of their wealth
alone, with the media chronicling their everyday activities. Moreover, within popular culture,
intellectualism and critical thinking are largely presented as the exclusive province of more
affluent Americans. Although tax breaks for the wealthy contribute to the growing economic
gap between the top 1% and the rest of the population, such inequities receive only minor
criticism. Corporate welfare (grants, tax breaks, subsidies, and other special treatment for
corporations) cost taxpayers hundreds of billions of dollar a year (Bennett, 2015). As Brunari
(2014) writes, “The largest, wealthiest, most powerful organizations in the world are on the
public dole … Boeing receives $13 billion in government handouts and everyone yawns …
Where is the outrage?” By contrast, support for social programs for low‐income individuals
is carefully scrutinized, criticized, and considered a drain on society, and individuals using
these programs are described as irresponsible, drug addicts, spendthrifts, and lazy (Johnson,
2014; Lott & Saxon, 2002).
IMPLICATIONS FOR CLINICAL PRACTICE
Collectively, the manifestations of classism discussed in this chapter operate to create a
physically challenging, socially excluded life experience for men, women, and children
living in poverty. Like other forms of oppression, therefore, classism can undermine the
physical and emotional well‐being of people withstanding its impact. The social
exclusion of the poor was captured by psychologist Bernice Lott (2002), who described
the primary characteristic of classism as cognitive and behavioral distancing from the
poor. In particular, Lott linked this phenomenon to psychologists' lack of attention to
poverty, which is often apparent even in the context of their consideration of other
cultural issues. As a consequence, psychological theory, research, and practice tend to be
largely inaccessible by poor people and are not particularly relevant to their experiences
(Smith, 2010). In addition, counselors who offer services in poor communities may find
that their work is compromised by previously unexamined classist assumptions. Aponte
(1994), a family therapist who devoted his career to working with poor clients,
suggested that “therapy with the poor must have all the sophistication of the best
psychological therapies. It must also have the insight of the social scientist and the drive
of the community activist” (p. 9). The following suggestions can help guide counselors
in improving their skills in the context of poverty (Smith, 2005, 2009):
1. Supplement your knowledge of social class, poverty, and related issues. Although most
counselors do not receive training experiences focused on poverty, helpful resources
exist by which counselors, supervisors, and trainees can deepen their understanding of
social class, the circumstances faced by poor Americans, and the implications of both
for clinical work. Some useful starting points include the following:
Psychology and Economic Injustice (Lott & Bullock, 2007)
The Color of Wealth (Lui, Leondar‐Wright, Brewer, & Adamson, 2006)
Where We Stand: Class Matters (Hooks, 2000)
Report of the Task Force on Resources for the Inclusion of Social Class in
Psychology Curricula (American Psychological Association, 2008).
2. Increase your understanding and awareness of social class privilege. Many
counselors‐in‐training receive multicultural training experiences that facilitate their
awareness of ethnic‐ and race‐related identities; enhancing class awareness is an
analogous process, although it is seldom addressed as such. To aid counselors in this
effort, Liu, Pickett, and Ivey (2007) developed a list of self‐statements corresponding
to White middle‐class privilege, including “I can be assured that I have adequate
housing for myself and my family” and “My family can survive an illness of one or
more members” (p. 205). The authors also presented a case example to which counselors
can refer in applying class‐related considerations within counseling practice.
3. Learn about the everyday realities of life in poverty. Students in some professions (such
as social work) receive training that educates them about welfare procedures, housing
offices, food stamps, and other aspects of government bureaucracy; this training helps
prepare them to work with clients who have nowhere to turn for health services, shelter,
or childcare. Mental health counselors, who often lack this preparation, can find
themselves disoriented by the unfamiliar deprivations of life in a poor community.
Because such information is often locally specific and subject to change, city and state
government websites and Internet searches are a good way to learn about available
resources.
4. Learn to see the everyday signs of social class stratification and bias. Although social
class is not often discussed openly in the United States, the signs of its existence are all
around us if we begin to open our eyes to it. Sometimes these signs can be seen readily,
as in the aforementioned public fascination with the lives of wealthy people, or in
people's interest in wearing clothing that features corporate or designer logos. Others are
more subtle, such as those that are manifested through classist microaggressions (Smith
& Redington, 2010). These expressions of class‐based derogation are directly
analogous to microaggressions based on other marginalized identities (Sue et al., 2007).
Classist microaggressions include the use of class‐referenced words to indicate
favorable or unfavorable evaluations, such as describing an object or a person as classy
or high‐class in a complimentary fashion or describing it as low‐class or low‐rent to
discredit it. Other classist microaggressions illustrate specific intersections with other
identities. Hartigan (2005) discusses the meanings inherent in the name‐calling
directed toward poor White Americans, such as White trash, trailer trash, rednecks, and
hillbillies, whereas Rose (2008) analyzes a microaggression that derives from oppression
according to race, class, and gender: welfare queen.
5. Integrate a social justice framework within counseling practice. Many counselors who
go to work in poor communities will encounter bleak urban landscapes, crowded
schools, and crumbling housing developments. How are counselors to incorporate the
impact of such environmental and contextual dimensions within psychotherapeutic
practice, which often seems concerned primarily with an individual's emotional interior?
The application of a social justice model to counseling practice makes room within case
conceptualization and treatment design for counselors' analyses of the systemic aspects
and origins of client distress. Feminist and multicultural examinations of social justice
practice can be found within other chapters of this book, as well as in works by
Aldarondo (2007), Goodman et al. (2004), Miller and Stiver (1997), and Nelson and
Prilleltensky (2005).
6. Adopt a flexible approach to treatment. As multicultural psychologists have long
contended, the conventional roles and behaviors of psychological practice are at best
culture‐bound and at worst oppressive to clients from marginalized groups (Sue et al.,
1998). As mentioned, life in poverty can be vastly different from the middle‐class
existence portrayed in many counseling skills textbooks, and counselors must therefore
be willing to use their skills flexibly. Dumont (1992) wrote about his experience with
clients living in poverty, having come to practice in a community mental health center as
a psychoanalytically trained psychiatrist. Contending with the pathological social and
environmental forces—racism, pollution, involuntary unemployment, and malnutrition
—that predominated in his clients' lives, he concluded that “the 50‐minute hour of
passive attention, of pushing toward the past, of highlighting the shards of unconscious
material in free association, just does not work” (p. 6).
Along these lines, when counselors are willing to learn from community
members about the interventions that might be most useful, different
kinds of supplementary (or alternative) modalities can emerge. These
interventions might involve the development of new practices and
modalities in accordance with local needs, such as group discussions
offered as part of community gatherings, psychoeducational groups in
local classrooms, and collaborative events with homeless shelters (Smith,
2005; Smith, Chambers, & Bratini, 2009). Other modalities might involve
the formation of community partnerships that combine counseling
practice with peer counseling and local social justice advocacy (Goodman
et al., 2007). Participatory action research projects are also a means of
enhancing the well‐being of poor communities, in concert with social
justice activism (Smith & Romero, 2010).
7. Be willing to incorporate problem‐solving and resource identification within sessions
—but don't assume that this will be the focus of the work. People living in poverty are
often only a paycheck or an accident away from a health or housing crisis. Even in the
absence of crisis, they may be constrained to devote time and energy to such exigencies
as securing childcare and making food stamps last until the end of the month.
Counselors have indicated that they often feel that discussion of such issues is not
sufficiently “deep” and does not therefore qualify as the “real” work that they are there
to do (Schnitzer, 1996). Such a response bears traces of class bias in that it discounts as
superficial some of the most pressing realities of poor clients' lives. This bias can also
work in the other direction—middle‐class counselors can be so unsettled by their
clients' lack of resources that they assume that their psychological realities are oriented
entirely around securing them. The latter assumption undermines the therapeutic
encounter as well, in that it can hinder counselors from engaging poor clients in
exploring the same kinds of feelings, fears, hopes, and other emotional issues that clients
in any setting are likely to find important (Smith, 2005). It should go without saying that
many poor clients come to speak with counselors about precisely these issues. The
suggestion that emerges from this balancing act has much in common with good
multicultural counseling more generally: be accountable for understanding the unique
aspects of clients' sociocultural context and be open to addressing them, but do not
assume that this knowledge constitutes a “recipe” for working with them.
8. Incorporate an advocacy role into your work. Chen (2013) identified advocate as one of
the systems intervention roles in which counselors should be competent, and at no time
is that role more relevant than when working in the context of oppression. Moreover,
given that research has conclusively demonstrated the damage that poverty exacts upon
people's physical and emotional well‐being, advocating for the eradication of poverty
and the greater cultural inclusion of the poor is advocating for psychological well‐
being. Such advocacy can be expected to benefit a large portion of society, given that
over half of Americans are likely to spend at least a year below the poverty line at some
point during their lives (Hacker, 2006). Opportunities for advocacy include support for
broadened access to mental and physical health care for poor families, and participation
in the living wage movement, which seeks to raise the minimum wage to a level that
would allow workers to lift their families out of poverty.
SUMMARY
Poverty does not constitute a cultural designation in the true sense of the word, but the
challenges of a life in poverty are so different from mainstream life that it warrants
consideration by clinicians. Counselors are likely to come from middle‐class (or more
affluent) backgrounds and lack understanding about how the assumptions of mental health
and the process of counseling may be antagonistic and detrimental to their clients. Being
familiar with the demographics and the strengths of the poor is important for informed work.
The poor face many challenges in their lives: invisibility and social exclusion, educational
inequities, poverty‐related mental illness, disparities in the judicial system, wage and health
care inequities, and negative attitudes and beliefs about them. Eight clinical implications for
counselor practice are identified.
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26
Counseling Women
Chapter Objectives
1. 1. Review gender demographics and societal expectations affecting women.
2. 2. Identify counseling implications of the information provided.
3. 3. Recognize strengths that are associated with women.
4. 4. Know the special challenges faced by women.
5. 5. Understand how best practices can guide assessment and therapy with women.
For a long time, most women defined their own sexual harassment and assault in this
way: as something unspoken, something private, something to be ashamed of
acknowledging. Silence, although understandable, has its cost. A decade ago, I couldn't
have conceived of the fact that so many women had experienced sexual coercion or
intimidation; now, I'd be surprised if I could find a single one who hadn't. On Sunday
afternoon, the actress Alyssa Milano used her Twitter account to encourage women
who'd been sexually harassed or assaulted to tweet the words #MeToo. In the last 24
hours, a spokesperson from Twitter confirmed, the hashtag had been tweeted nearly half
a million times.
(Gilbert, 2017)
Microsoft CEO Satya Nadella stated during a conference on women and technology that
female employees should not ask for raises because it would be “good karma” not to do
so, that “the system” will compensate them over time, and that being patient for raises
was one of women's “superpowers.” He later admitted that he was “completely wrong.”
(Smith, 2014)
Nearly 40 million Americans provide unpaid care to an adult friend or relative, and of
those caregivers 60% are women, including 38% who report feeling highly stressed. The
typical caregiver in the United States is a 49‐year‐old female who balances a full‐
time job with at least 20 hours each week of helping an older or sick family member who
lives nearby.
(Gurnon, 2015)
There were 163,433,400 females in the United States in 2016, compared to 156,938,600
males (Kaiser Foundation, 2017). The ratio of women to men increases with age; among
those aged 85 or older, there are about twice as many women as men (U.S. Census Bureau,
2014). Although women constitute more than half of the population, we include them in the
special populations section because within the patriarchal nature of U.S. society, women have
been historically subjected to prejudice and discrimination as well as a disadvantaged status.
For centuries, governmental leadership and legal decision makers (e.g., the Supreme Court),
as well as religious leaders, have been primarily male—such power imbalances are deeply
ingrained in the social context of our society. Contemporarily, women continue to face
oppressive conditions and experience high levels of economic and psychological stress.
In this chapter, we focus on many feminist issues. Feminism, a frequently misunderstood
term, refers to efforts directed toward gender equality—equal economic, social, and political
rights and opportunities for women. Early feminists focused on voting and property rights,
whereas contemporary feminists advocate for reproductive rights; parental leave and quality
childcare; psychosocial safety for women (e.g., targeting domestic violence and sexual
assault); and ending wage disparity, sexist power structures, and other forms of
discrimination. Many feminists focus on the social forces that contribute to gender
oppression, as well as related socialization practices.
Feminist therapists believe that the patriarchal nature of U.S. society contributes to many of
the problems faced by women and that psychological symptoms are often the result of
women's subordinate status in society; feminist case conceptualizations incorporate the
intersection between multicultural influences and other forms of oppression. Interventions
based on a feminist perspective focus on goals such as empowerment, identifying personal
strengths, and discovering areas for self‐growth outside of traditional roles (Diaz‐
Martinez, Interian, & Waters, 2010).
CHARACTERISTICS AND STRENGTHS
In the following sections, we discuss issues faced by women—such as their prescribed roles
and socialization experiences—and their implications in treatment. We conclude with a
discussion of women's strengths. Keep in mind that women themselves are diverse, and have
multifaceted racial‐ethnic backgrounds, cultural identifications, and religious practices. This
overview, therefore, provides generalizations about a diverse group of people, and its
applicability always needs to be assessed with regard to individual clients.
Societal Roles and Expectations
Ongoing socialization experiences affect women's self‐perceptions. For example, the more
women are treated as sexual objects (e.g., subjected to sexualized evaluation such as erotic
gazes or overt visual inspection and related sexual comments), the more they feel devalued
and trivialized (Hill & Fischer, 2008). Such objectification is pervasive. Melissa Farley, a
clinical psychologist who conducted a study on the buying of sex (broadly defined as
purchases such as prostitution, pornography, phone sex, lap dances, etc.) found that it was
exceedingly difficult to locate men who do not participate in at least some of these activities.
She voices concern about the burgeoning demand for (and proliferation of) such products and
services, with the resultant dehumanization and commoditization of women (Bennetts, 2011).
Some are concerned that films that associate physical violence and pain with sex (such as
Fifty Shades of Grey) will result in the “erotic normalization of violence against women”
(Thistlethwaite, 2015).
There are ongoing concerns about the film industry's sexualization and marginalization of
females, even in family‐oriented films (Smith & Choueiti, 2011). The stereotyped standards
of beauty expressed through advertisements and the mass media also have a strong impact on
the health and self‐esteem of girls and women. The sexualization of young girls, sometimes
as early as the preschool years, is particularly troublesome (Machia & Lamb, 2009). When
females are exposed to stereotyped societal messages via toys (e.g., dolls), television, music
videos, song lyrics, magazines, and advertising, they begin to (a) believe that their primary
value comes from being attractive, (b) define themselves according to media‐influenced
body standards, and (c) see themselves as sexualized objects (American Psychological
Association, 2010; Moffitt & Szymanski, 2011).
Additionally, societal pressure for females to be thin leads to the internalization of an
unrealistic “thin ideal,” with resultant body dissatisfaction, disordered eating patterns, and
frequent dieting (Fallon, Harris, & Johnson, 2014; Hill & Fischer, 2008). In one sample of
4,745 middle and high school students, many more females than males were unhappy with
their bodies (42% of females versus 25% of males) and reported self‐esteem issues due to
body shape or weight (36% of females versus 24% of males) (Ackard, Fulkerson, &
Neumark‐Sztainer, 2007). The need to meet societal standards for thinness or beauty
becomes more intense when girls experience the physical changes associated with puberty.
Underweight models and digitally “enhanced” photos further convey unrealistic messages
about ideal body size and shape. Exposure to such photos is strongly associated with
increased depression, body dissatisfaction, and disordered eating in young women (Grabe,
Ward, & Hyde, 2008; Moffitt & Szymanski, 2011).
In addition to the focus on physical attributes, females are socialized to prioritize the needs of
others, taking on the role of nurturer and caregiver. They are influenced by beliefs that “good
mothers” should stay home with their children or be available if needed by their children
during work hours. Women often experience “role overload” and exhaustion due to
disproportionate responsibility for childcare, household chores, and care of elders. For
example, women are 2.5 times more likely than men to do housework, and among couples
with children, women spend nearly three times as much time on childcare as men (Bureau of
Labor Statistics, 2015). Such family responsibilities can affect women's employment status
and career commitment (Bertrand, Goldin, & Katz, 2010). Further, women are also more
likely to take on primary caretaking responsibilities for older or disabled family members
(National Alliance for Caregiving, 2009).
Implications
Interventions directed at challenging and changing the unrealistically thin female image
promoted by advertisers, magazines, and other mass media can help reduce body
dissatisfaction in females. Programs aimed at preventing or altering disturbed eating patterns
generally involve: (a) learning to develop a more positive attitude toward one's body; (b)
becoming aware of unhealthy societal messages of “what it means to be female” (e.g., girls
must be thin, pretty, and sexy); (c) understanding the consequences of internalized gender‐
related societal messages (e.g., distorted expectations and negative self‐statements); (d)
developing healthier eating and exercise habits; (e) increasing comfort in expressing feelings
to peers, family members, and significant others; (f) choosing appropriate self‐care
messages (e.g., “Being healthy is important, so I will eat and exercise appropriately”); (g)
developing plans to implement health‐based changes; and (h) identifying healthy strategies
to deal with stress and pressure (Richardson & Paxton, 2010).
Strengths
Women are acculturated to display affiliative qualities, such as sensitivity, nurturance,
kindness, and concern with relationships (dePillis & dePillis, 2008)—characteristics that are
often undervalued in our society. Such relationship strengths result in effective teamwork and
better rapport within family systems and within society. Women have a strong capacity for
developing and maintaining robust social support networks. Many women also demonstrate
skill at understanding how others are feeling, and responding accordingly; thus, they are
skilled at anticipating the emotional consequences of decisions. Women often show talent in
terms of creativity, problem solving, and mental flexibility, and are frequently guided by
strong values. A recent poll (Pew Research Center, 2015) revealed that Americans believe
women are just as creative and intelligent as men and that women are more honest, ethical,
compassionate, and organized, and better able to work out compromises compared to men.
Gender‐based characteristics such as emotional self‐regulation and an orientation to
relationships are assets in work settings (Raffaelli, Crocket, & Shen, 2005). Women
employees and leaders are more likely to display an open, consensus‐building, and collegial
approach to work; to encourage participation, teamwork, and cooperative efforts among
colleagues; and to share power (Caliper, 2005). These qualities are increasingly recognized as
important attributes in a work environment (Rosette & Tost, 2010). Women are also more
likely than men to display a transformational leadership style—an energetic, passionate
approach to projects and the ability to energize others to work toward clearly articulated goals
(Vinkenburg, vanEngen, Eagly, & Johannesen‐Schmidt, 2011).
SPECIFIC CHALLENGES
In the following sections, we consider the challenges often faced by women and consider
implications for treatment.
Discrimination, Harassment, and Victimization
Women continue to experience both sexism and gender‐based discrimination in social and
professional settings, with the vast majority of women reporting experiences with sexual
harassment, being disrespected due to their gender, or being subjected to sexist behavior by
strangers (Lord, 2010). Nearly two‐thirds of women believe that their gender faces
discrimination in today's society (Pew Research Center, 2015). As mentioned in our
discussion of microaggressions in Chapter 6, sexism can be overt (i.e., blatantly unequal and
unfair treatment), covert (i.e., unequal, harmful treatment conducted in a hidden manner, such
as gender‐biased hiring practices), or subtle (i.e., unequal treatment that is so normative that
it is unquestionably accepted). Women at the intersections of multiple marginalized identities,
such as lesbian, gay, bisexual, transgender, and queer (LGBTQ) women and women of color,
can face a particularly high degree of discrimination (Balsam, Molina, Beadnell, Simoni, &
Walters, 2011).
Sexual harassment (broadly defined as verbal or physical conduct of a sexual nature,
sometimes with explicit or implicit expectations that a woman submit to sexual requests)
continues to be quite prevalent in school and work environments. Intimidating, hostile, or
sexually offensive work environments (e.g., where sexually suggestive pictures are displayed
or sexual jokes are told) are also examples of sexual harassment. A national survey indicates
that sexual harassment in schools remains a significant concern—one that affects not only
girls' psychological well‐being, but also their learning (AAUW, 2011). Women feel
threatened and devalued by these unwanted sexual experiences (Smith, 2012). In a study
involving women working as servers in U.S. restaurants, it was found that sexual
objectification experiences can lead to depression and negative job satisfaction (Szymanski &
Feltman, 2015). The more women are treated as sexual objects (e.g., subjected to sexualized
evaluation such as erotic gazes or overt visual inspection and related sexual comments), the
more they feel devalued and trivialized. Although harassment can be extremely distressing
and can influence academic and work performance, many women are hesitant to report such
behavior.
Sexual and physical assault is also a significant concern for women. During their lifetime, an
estimated 31.5% of U.S. women are subjected to intimate‐partner violence, 19.3% are
raped, 43.9% suffer some other form of sexual violence, and 15.2% are the victims of
violence outside of the home. These statistics are higher among certain groups. It is estimated
that 32.3% of multiracial women, 27.5% of American Indian/Alaskan women, and 21.2% of
Black women have been raped at some point during their lifetime. Additionally, 65% of
multiracial women and 55% of American Indian/Alaska Native women have experienced
sexual violence other than rape (Breiding et al., 2014). Up to half of one sample of college
women reported experiencing some form of sexual aggression (Yeater, Treat, Viken, &
McFall, 2010). Finally, rates of violence against transgender women are disproportionately
high; it is estimated that the risk of becoming a homicide victim is 4.3 times greater in this
population than among women overall (Human Rights Campaign and Trans People of Color
Coalition, 2017).
Sexual victimization and intimate‐partner violence disproportionately affect women,
accounting for 27% of all violence experienced by females (U.S. Department of Commerce,
2011). Many women affected by intimate‐partner violence report significant ongoing
psychological distress (Zahnd, Aydin, Grant, & Holtby, 2011). Such abuse or harassment can
have long‐term effects, including chronic headaches, pelvic pain, gastrointestinal distress,
and other physical symptoms, as well as emotional symptoms such as anxiety, depression,
disordered eating, and post‐traumatic stress disorder (PTSD) (Chen et al., 2010; Steiger et
al., 2010).
Implications
Violence and sexual harassment against females can lead to a number of mental health
problems. It is important for counselors to ask about experiences with discrimination,
harassment, or gender‐based violence and to consider the effect of such events in case
conceptualization. Even among adolescents, screening should be performed for intimate‐
partner abuse, especially in cases where suicidal thoughts, use of drugs, or disordered eating
patterns exist.
The American Psychological Association (2007) recommends support for policy initiatives,
including legal and legislative reform addressing the issue of violence against women;
improved training for mental health workers so that they can recognize and treat those
affected by such violence; dissemination of information regarding violence against women to
churches, community groups, educational institutions, and the general public; and exploration
of psychoeducational and sociocultural interventions to change male objectification of
women. California and New York have passed a “yes means yes” law—legislation that
clearly conveys that consent to sexual activity requires an “an affirmative, conscious, and
voluntary agreement.” State‐supported colleges must adhere to this definition when
investigating sexual assaults (Garrido, 2014; McDermid, 2015).
Students and employees can benefit from knowing how to identify harassment and exactly
what steps to take if harassment occurs (e.g., request that the behavior stop; seek help from
parents, counselors, or administrative staff; record details of the event). Prevention strategies
targeting dating violence are sometimes implemented in high school and college settings
(Yeater et al., 2010). Similarly, strategies for assertively reacting to overt or covert sexism can
empower women who are confronted with offensive or discriminatory behaviors.
Additionally, therapists can help women who have been subjected to violence decrease self‐
blame (Szymanski & Feltman, 2014).
Educational Barriers
You never see someone that looks like me as a scientist. No matter how long I stay here.
When I walk through the campus, no one's ever gonna look at me and just think that I'm
a physicist … I guess the things that made other people find it hard to see me as a
scientist are making it hard for me to see myself as a scientist, too.
(Soffa Caldo, Chicana college senior, quoted in Ong, 2005, p. 593)
Although women make up 51% of the U.S. population, they are affected by implicit bias,
gender stereotyping, and discrimination and are thus underrepresented in positions of power.
Further, the National Coalition for Women and Girls in Education (2008) reports that girls
and women continue to be underrepresented in such areas as math and science, and female
students continue to receive less attention, encouragement, and praise than males. Teachers
are often unaware that they may be promoting sexism by providing differential responses to
male and female students (Frawley, 2005). In one study of third‐grade teachers who
believed they had a gender‐free style, it was found that boys were allowed to speak out of
turn, whereas girls were not; boys were less likely to be confronted when involved in
disagreements; and when girls spoke out of turn, they were reminded to raise their hands
(Garrahy, 2001).
Some progress has been made in promoting gender equality, but inequities continue. In many
cases, the culture of masculinity (including images of dominance and forcefulness) is deeply
entrenched in “masculine” fields of study within institutions of higher education (dePillis &
dePillis, 2008). Women face particular barriers in the fields of science, math, technology, and
engineering (Moss‐Racusin et al., 2015).
Implications
In the educational arena, mental health professionals can advocate for changes at the system
levels. Coursework for teachers can include demonstrations and discussion of responses that
may inadvertently convey gender‐restrictive messages. Attitudes and negative gender
stereotypes do affect performance (Johns, Schmader, & Martens, 2005). One study
investigating the influence of stereotype threat found that female engineering students who
interacted with men behaving in a sexist manner prior to taking an engineering test performed
more poorly than women exposed to a nonsexist male prior to the test. This effect was found
for engineering tests but not for English tests (i.e., an area not expected to be affected by
stereotype threat) (Logel et al., 2009).
Attitudes and expectations regarding stereotyped personality characteristics and appropriate
career choices need to be addressed in educational programs and with individual clients.
Small changes in the culture of mathematics, science, and engineering departments (e.g.,
hiring female faculty, providing mentoring systems for female staff and students, combating
negative stereotypes) can help attract women to these fields and maintain their interest,
enthusiasm, and sense of belonging (Hill, Corbett, & St. Rose, 2010).
Economic and Employment Barriers
Although women make up 55% of college students and account for a greater percentage of
associate, bachelor's, and master's degrees, women earn less than their male counterparts
across all racial groups. Hispanic women show the largest gap, making only 54% of the
earnings of White men (AAUW, 2014). This affects not only the women themselves, but also
the families they are supporting. The poverty rate for single mothers with children is 37%—
the highest of any demographic group in the United States. Women with a low income are
especially at risk for depression and domestic violence (Levy & O'Hara, 2010).
Many organizations continue to operate under a value system that emphasizes power and
control rather than relationship skills. Nontraditional career fields are often not hospitable to
women; thus, many women remain in “feminine” careers. Women are underrepresented not
only in fields such as science and engineering, but also in managerial and executive‐level
jobs—occupations associated with “masculine” qualities, such as being assertive and
independent and influencing others, rather than “feminine” qualities, such as sensitivity,
nurturance, kindness, and being concerned with relationships (dePillis & dePillis, 2008).
College women are also aware that when a woman behaves in a manner that is not considered
feminine, negative consequences may result. For example, if a woman displays a task‐
oriented style of leadership that violates the gender norm of modesty, she may be rated as
competent but at the expense of lower social attraction and likability ratings; men displaying
the same leadership style are rated high in both competence and likability (Rudman, 1998).
Women leaders often confront divergent expectations—they are expected to be assertive and
in control, but are simultaneously criticized for these same traits. Even successful
businesswomen report barriers to advancement on the corporate ladder, including the
following (Lyness & Thompson, 2000):
1. Women were made to feel that they somehow needed to change, that they were hired or
promoted due to “token‐hiring practices,” and that they were not a “good fit” for senior
management.
2. Male coworkers heightened cultural boundaries by emphasizing male camaraderie and
their differences from women, relying on a “good old boys network,” and withholding
from women information necessary for job performance.
3. Women executives received less frequent and less effective mentoring than their male
counterparts, including limited access to potential mentors, mentors unwilling to work
with them, and the misinterpretation of a mentorship request as a sexual invitation.
A study involving 610 women of different races working in the fields of science, technology,
engineering, and math (Williams, Phillips, & Hall, 2014) found the following forms of gender
bias that may contribute to the underrepresentation of women in nontraditional fields:
Prove it again. Two‐thirds of women indicated that they had to repeatedly demonstrate
a higher level of competence than their male colleagues. African American women were
most likely to experience this type of bias.
The tightrope. Over three‐quarters of women reported having to walk a fine line
between being seen as “too feminine” to be competent and as “too masculine” to be
likeable. Asian American women were much more likely to report a backlash from being
assertive, whereas African American women were given more “leeway” in behaving in a
“dominant” manner.
The maternal wall. Nearly two‐thirds of women with children faced the assumption
that motherhood would reduce their competence and commitment to work.
Tug of war. Women may also be biased against other women in these fields. Although
most reported that female colleagues supported one another, about half believed that
some women demonstrate considerable gender bias toward other women.
Sexual harassment. Over one‐third of women reported sexual harassment, with White
women being much more likely to be victims of this behavior.
Implications
Counselors can encourage continued education and job training for women working in
minimum‐wage jobs. Where needed, they can provide information on quality childcare and
assistance with locating food, clothing, and affordable housing. Counselors should consider
the worldview of women living in poverty and the web of stress with which low‐income
women contend. Therapists can use multicultural therapy models such as feminist relational
advocacy, a therapeutic approach focused on listening to women's narratives, recognizing the
role of oppression in creating emotional distress, recognizing strengths, and providing
advocacy as well as emotional and practical support (Goodman, Glenn, Bohlig, Banyard, &
Borges, 2009). When possible, mental health services should be provided in convenient
locations serviced by public transportation. Childcare and other on‐site programs for family
members can increase participation in the mental health system.
Mental health professionals should also help expand the career choices available to women.
In doing so, a comprehensive, skills‐based approach is most effective. One program for
college women (Sullivan & Mahalik, 2000) focused on increasing career self‐efficacy by
enhancing understanding of the impact of gender socialization on career choice and
development; learning about the career paths of successful women (e.g., reading about and
discussing women's unique career development and observing successful women and
interviewing them about their career decision‐making processes and insights); promoting
skills to manage anxiety through relaxation and adaptive self‐talk; and counteracting
internalized stereotypes by identifying and challenging self‐defeating thoughts.
Ageism and Women
The number of women aged 65 and older is expected to double by 2030, reaching 40 million
(U.S. Census Bureau, 2011). Given the emphasis on youth and beauty that exists in our
society, women face additional barriers as they age, including age discrimination at work
(Neumark, Burn, & Button, 2017); preferential treatment of younger females in stores,
restaurants, and other public establishments; reduced dating opportunities (e.g., men often
prefer to date younger women); and a sense of being “invisible” (Committee on Women in
Psychology, 1999). In addition, older women often confront changing roles (e.g., an “empty
nest,” loss of career, increased caretaking of aging family members, accommodation of a
partner's retirement). Responses to midlife changes such as menopause can be influenced by
both ageism and sexism, as well as by the cultural meanings ascribed to menopause (e.g.,
beliefs that sexual attractiveness and youthful qualities such as enthusiasm and energy are lost
at menopause).
Many women report that midlife transitions were not as stressful as they anticipated. Among
women between the ages of 40 and 59, nearly three‐fourths reported feeling “very happy”
or “happy.” Most were enjoying midlife because of increased independence, freedom from
worrying about what others think, freedom from parenting, and the ability to define their own
identity based on their own interests (McQuaide, 1998). Instead of being concerned about a
midlife crisis, aging, the empty nest syndrome, or menopause, many middle‐aged women
report going through a midlife review process, as well as having confidence, a strong sense of
identity, and a sense of power over their lives (Gibbs, 2005). These findings indicate that
transitions through midlife may be easier than was previously assumed. Different transition
experiences may occur for women experiencing the stress of poverty or caretaking
responsibilities.
Implications
It is important not to assume that all women experience a “midlife crisis” and to be aware that
women may differ significantly in how they experience life transitions. The life path of
women is quite variable. For example, some women are grandmothers in their late 30s or
early 40s; others delay childbearing until their 40s or never have children. Thus, women may
experience various midlife transitions at significantly different ages. The personal meanings
of and reactions to these events are different for each individual. Counselors can help women
negotiate the loss of prior roles by affirming new commitments in life and by assisting
women to develop the personal meaning of their life experiences through self‐exploration. It
is helpful to normalize feelings of anxiety or doubt associated with life transitions and to
reframe such experiences as opportunities for greater personal and spiritual development.
Depression
Depression is one of the most prevalent psychiatric disorders and a leading cause of
worldwide disability (Andrade et al., 2010). Women have a 70% greater lifetime risk of
experiencing a major depressive episode compared with men (Kessler, Chiu, Demler, &
Walters, 2005); various stressors, such as sexual abuse and unequal gender roles (Chen et al.,
2010; Vigod & Stewart, 2009), as well as perceived discrimination based on gender,
especially among those who do not talk to others about their experiences (McLaughlin,
Hatzenbuehler, & Keyes, 2010), contribute to the higher prevalence in this population. The
following three additional factors encountered by females are also linked with the
development of depression:
The presence of stress, especially acute stress and stress involving interpersonal
problems and the need to depend on others (Muscatell, Slavich, Monroe, & Gotlib,
2009).
Work environments that involve chronic stress and few decision‐making opportunities
—conditions experienced by many women in the workplace (Verboom et al., 2011).
Exposure to targeted rejection involving active, intentional social exclusion or rebuff
(Slavich, Way, Eisenberger, & Taylor, 2010).
Gender‐specific socialization practices can influence females' feelings of self‐worth.
Although males are socialized to value autonomy, self‐interest, and achievement‐oriented
goals, females are taught to value interdependent functioning and social goals such as
behaving in a caring or nurturing manner. The opinions of others, therefore, often influence
women's self‐perceptions. Women frequently try to maintain relationships at the cost of
their own needs and wishes. Failures in relationships are often viewed as personal failures,
compounding stress and affecting mood. Additionally, gender‐role expectations can
decrease women's sense of control over life situations and diminish their sense of personal
worth. Women are often affected by interpersonal stress, particularly stressors involving close
friends or family. Ruminating (i.e., repeatedly thinking about concerns or events) further
increases depressive symptoms among females (Hankin, 2009). Additionally, adolescent girls
experiencing depression are more likely to generate interpersonal stress, which can lead to
further ongoing depressive symptoms (Rudolph, Flynn, Abaied, Groot, & Thompson, 2009).
Women who are subject to stressors such as racism, ageism, and exposure to poverty have
increased vulnerability to depression. For example, among African American women,
everyday encounters with discrimination are linked with increases in depressive symptoms
(Wagner & Abbott, 2007). Community‐based focus‐group discussions involving African
American women with histories of violent victimization underscore the role of interpersonal
violence in the development of depression among these women (Nicolaidis et al., 2010).
Implications
In therapy, it is important to address the stressors faced by clients, identifying societal and
cultural factors as well as individual influences. Counselors should assess for environmental
factors, such as poverty, racism, economic conditions, and abusive relationships, as well as
specific experiences with overt, covert, or subtle sexism. Women often benefit from
psychoeducation regarding the power differential in society, unrealistic gender expectations,
and the impact of these expectations on mood. Identifying internalized stereotypes and related
self‐defeating thoughts and substituting more positive self‐statements can reduce
depression. Establishing strong social support networks and locating sources of assistance
with specific needs (e.g., financial, health, childcare) can help women who are experiencing
stressful life circumstances.
Evidence‐based therapies involving exposure to positive activities; facilitation of social
interactions; improved social, communication, and assertiveness skills; and identification of
role conflicts can help women decrease depressive symptoms and find relationships more
satisfying (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011; Levenson et al., 2010).
Similarly, learning strategies to alter negative, self‐critical thoughts and negative self‐
biases can reduce depressive symptoms (DeRubeis, Siegle, & Hollon, 2008). Using
mindfulness strategies involving calm awareness of present experiences, thoughts, and
feelings and developing an attitude of acceptance rather than being judgmental, evaluative, or
ruminative can disrupt the cycle of negative thinking (Gilbert & Christopher, 2010). Therapy
focused on improving interpersonal relationships and enhancing social support has been
helpful in decreasing depression in women affected by intimate‐partner violence (Zlotnick,
Capezza, & Parker, 2011).
Gender Bias in Therapy
It is important for counselors to recognize the sexist nature of our society and to be aware of
possible biases when working with female clients (Diaz‐Martinez et al., 2010). For
example, does the counselor believe there are certain attributes associated with a healthy
feminine identity? In past research, qualities such as being more submissive, emotional, and
relationship‐oriented were identified as positive qualities in women (Atkinson & Hackett,
1998). If counselors consciously or unconsciously adhere to these stereotypic societal
standards, they may convey blaming attitudes to clients during counseling (Notestine,
Murray, Borders, & Ackerman, 2017). For example, one study of family therapy sessions
revealed that counselors interrupted women more often than they interrupted men (Werner‐
Wilson, Price, Zimmerman, & Murphy, 1997). The therapists, unaware of their behavior,
were engaged in subtle sexism. Gender‐based microaggressions such as this are not only
destructive to the therapeutic alliance, but can also significantly affect a female client's sense
of empowerment (Owen, Tao, & Rodolfa, 2010).
Biases can also occur during diagnosis, especially for ethnic minority women (American
Psychological Association, 2007). Some researchers and clinicians contend that certain
personality disorders are based on exaggerated gender characteristics. Self‐dramatization
and exaggerated emotional expressions; intense fluctuations in mood, self‐image, and
interpersonal relationships; and reliance on others and the inability to assume responsibilities
are characteristics of histrionic, borderline, and dependent personality disorders, respectively.
Not surprisingly, women are much more likely to be diagnosed with these disorders.
Many psychological theories are gender‐biased. For example, the concepts of
“codependency” and “enmeshment,” descriptors more frequently applied to women, involve
behaviors such as devotion to home and relationships, connectedness, nurturance, and placing
the needs of the family over personal needs—behaviors that are strongly influenced by
cultural expectations and gender‐based socialization practices. Gender bias is also inherent
in family‐systems therapeutic models: these approaches generally fail to recognize the
effects of gender‐based power imbalance, including unequal distribution of power within
families. Also, disturbances are often interpreted as problems in the system rather than as
troubles due to stressors experienced by individual family members. Under this theoretical
conceptualization, women who are abused are seen as contributors to the system dysfunction.
IMPLICATIONS FOR CLINICAL PRACTICE
Both male and female counselors should self‐assess for possible sexist beliefs,
assumptions, or behaviors and take care not to limit client growth by fostering traditional
gender roles. Each female client should be provided the opportunity to choose the life
path that is best for her, despite societal gender expectations and political correctness.
Problems identified by female clients should be viewed within a societal context in
which devaluation of women is a common occurrence; gender‐based considerations
should be understood as integral aspects of problem conceptualization and treatment
planning. Guidelines for counselors working with female clients include the following
(American Psychological Association, 2007; Szymanski, Carr, & Moffitt, 2011):
1. Remain aware of potential biases in the diagnosis and treatment of women.
2. Recognize that many counseling theories and practices are male‐centered and may
require modifications when working with women. For example, cognitive‐behavioral
therapeutic approaches can be modified to include a focus on internalized societal
messages or unrealistic standards of beauty.
3. Possess up‐to‐date information regarding the biological, psychological, and
sociological issues that affect women, including a strong understanding of the
physiological and social implications of reproductive processes such as menstruation,
pregnancy (including unplanned pregnancy), birth, infertility and miscarriage, and
menopause.
4. Assess sociocultural factors to determine their role in the presenting problem. Consider
the influence of gender‐role socialization; overt, covert, and subtle sexism;
discrimination and harassment; and economic, educational, and employment barriers.
5. Help clients realize the impact of power imbalances, gender expectations, and societal
definitions of attractiveness on mental health.
6. Emphasize the unique strengths and talents that women bring to work and interpersonal
relationships, including the effectiveness of democratic, people‐oriented leadership
styles.
7. Help clients correct cultural misperceptions that men are superior in math, science, and
technology. Discuss women's achievements in leadership positions and in nontraditional
fields for women (e.g., science, math, technology, and engineering), as well as strategies
women have used to overcome barriers in these fields. Exposure to successful female
role models is important for both girls and women.
8. Encourage females to take challenging coursework in math and science and to recognize
that academic achievement is an ongoing, cumulative process.
9. Assess for the possible impact of abuse or trauma‐related experiences. If necessary,
help the client mobilize resources, such as support from friends and family, and develop
plans to leave (see Hays, 2013).
10. Clients may need assistance in developing financial independence and other supports
necessary to leave unhappy marriages or abusive relationships.
11. Do not allow traditional definitions of “good leadership” to mask the talents and
strengths women bring to the workplace. Systems‐level intervention may be needed to
create work environments that optimize the contributions of female leaders and
employees.
12. Counselors can educate women about how negative gender‐based stereotypes and
stereotype threat undermine women's confidence and lead to lower performance—such
knowledge can reduce the influence of negative stereotypes (Johns et al., 2005).
13. Be alert for signs of depression. Keep in mind that women tend to internalize problems
and that maternal depression can have a significant effect on children's behavior and
well‐being (Tully, Iacono, & McGue, 2008).
14. Encourage women to identify and address their own needs and to practice assertively
setting boundaries when confronted with unrealistic demands.
15. Be ready to take an advocacy role in initiating systems‐level changes as they relate to
sexism and sexual harassment.
16. Tailor the focus of treatment to encompass the additional concerns that are faced by
women with multiple marginalized identities, such as women of color (Bryant‐Davis &
Comas‐Díaz, 2016) and LGBTQ women (Singh, 2016).
SUMMARY
Women constitute over half the population of the United States, but because of the patriarchal
nature of society, they occupy a disadvantaged status. For centuries, governmental leadership
and legal decision makers, as well as religious leaders, have been primarily male—such
power imbalances are deeply ingrained in the social context of our society. Contemporarily,
women continue to face oppressive conditions and experience high levels of economic and
psychological stress. Effective work with female clients requires understanding gender‐
based societal pressures, sexual objectification, stereotyping, harassment, victimization,
discrimination, educational/employment barriers, depression, and ageism. Gender bias in
therapy is a reality. Feminism, a frequently misunderstood term, refers to efforts directed
toward gender equality—equal economic, social, and political rights and opportunities for
women. Feminist therapy represents a school of thought and action directed at addressing
these inequalities. Sixteen clinical implications for counselor practice are identified.
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Glossary
Ableism:
An all‐too‐common discriminatory practice in which individuals without
disabilities are favored or given preferential treatment, thereby implying that those
with a disability are somehow inferior
Abnormality:
A term used to describe a deviation from some standard or norm considered to be
desirable
Acculturation:
The process of internalizing the values, beliefs and traditions of the larger society
Activity dimension:
A reference to how different cultural groups lie in their action orientation from one
of “doing” and influencing the world, to one of “being” or living in harmony with
nature
Afrocentric:
An ideology that focuses on the Black experience, history, culture and traditions
Ageism:
Negative attitudes and behaviors toward the process of aging or toward older
individuals
Alzheimer's disease:
A form of dementia that generally strikes older adults and is currently incurable
Americans with Disabilities Act:
The Americans with Disabilities Act (ADA) was signed into law in 1990, extending
the federal mandate of nondiscrimination to individuals with disabilities and to state
and local governments and the private sector
Antiracism:
When people, organizations, or social movements work toward the eradication of
racism
Antiracist:
A person with a nonracist identity who advocates and actively intervenes when
injustice makes its presence felt at the individual, institutional, and societal levels
Antiracist white identity:
The complementary identity to a nonracist one in that the person is likely to take
direct action to eradicate its manifestation in individuals, institutions and society
Anti‐Semitism:
Anti‐Semitism is prejudice, discrimination, and hatred of people of Jewish
descent
Arab:
Individuals who originate from countries located in the Middle East and North
Africa and whose primary language is Arabic
Asylum:
Asylum can be granted to certain classes of refugees due to political persecution
Attractiveness:
Attractiveness based upon how similar the client is to the counselor
Attribution error:
Attribution errors occur when the therapist holds a different perspective of the
problem than that of the client and uses it to define problems and to propose
solutions
Aversive racism:
A form of subtle and unintentional racism
Awareness:
Being conscious and mindful of one's own worldview, and the possible differences
between culturally diverse clients, and other group identities
Băt Gió:
Southeast Asian massage treatment called Băt Gió means “catching the wind” and
involves using both thumbs to rub the temples and massaging toward the bridge of
the nose at least 20 times
Behavioral resistance (to multicultural training):
Resistance that entails paralysis or inaction in the presence of discrimination from
majority group individuals
Bicultural orientation:
When an individual ascribes to and values two different cultures
Biculturalism:
When an individual ascribes to and values two different cultures
Bilingualism:
This term describes individuals who speak two languages
Biracial:
Individuals who are come from two racial heritages
Biracial/multiracial identity development:
A model of identity development used to describe the stages of biracial identity
development in contrast to the monoracial development models
Bisexual:
This is a term that describes individuals who have an affectional and/or sexual
attraction to members of both sexes
Brain fag:
This culture‐bound disorder is usually manifested by students in West Africa in
response to academic stress
Broaching:
The skill to address sociocultural issues such as race, gender, class, and sexual
orientation within a therapy context
Cao Gió:
Southeast Asian massage treatment, Cao Gió means “scratching the wind,” or “coin
treatment” and involves rubbing the patient with a mentholated ointment and then
using coins or spoons to strike or scrape lightly along the ribs and both sides of the
neck and shoulders
Cisgender:
One’s gender identity and expression matches the sex they were assigned to at birth
Class‐bound values:
Socioeconomic values that permeate counseling and psychotherapy (middle and
upper class) and may prove disadvantageous to clients from poverty or less affluent
situations
Classism:
Social class oppression is called classism and it operates to limit access to many
kinds of socially‐valued assets
Co‐construction:
Co‐construction involves the client and the counselor working together to identify
problems and solutions
Cognitive and behavioral distancing:
The social exclusion of the poor is captured by society's cognitive and behavioral
distancing from them
Cognitive empathy:
Cognitively understanding the client's predicament associated with others or his or
her life circumstance
Cognitive resistance (to multicultural training):
A form of intellectual denial in which individuals from the majority group provide
alternative reasons or excuses to explain incidences of racism, oppression, or
discrimination
Collaborative approach:
When the therapist and client work together to construct an accurate definition of
the problem and the contextual background
Collaborative assessment:
The clinical approach that values and obtains clients' input regarding social and
cultural elements that may be associated with presenting problems
Collaborative conceptualization:
Developing a joint definition of the problem and treatment through formulating and
testing hypotheses from both the clinician's clinical experiences and perspectives of
the client
Collectivism:
The psychosocial unit of operation resides in the family, group, or collective society
rather than the individual
Collectivistic orientation:
A philosophy that the psychosocial unit of identity resides in the family, group, or
collective society
Coming out:
The process of when a gay, lesbian, bisexual, or transgender person reveals his or
her gender or sexual orientation to others
Commitment to antiracist action phase:
In the Sue and Sue White identity development model, this phase is most
characterized by social action and increased commitment toward eradicating
oppression
Communication styles:
Characteristics of communication associated with race, gender and other group
identities often manifested in verbal and nonverbal communication language
Confirmatory strategy:
Confirmatory strategy involves the search for evidence or information supporting
one's hypothesis and ignoring data that is inconsistent with this perspective
Conformity:
A characteristic of the Racial/Cultural Identity Development model (RCID),
distinguished by an unequivocal preference for dominant cultural values over their
own
Conformity phase:
In the Sue and Sue White racial identity development model, it refers to beliefs that
White culture is the most highly developed and that all others are primitive or
inferior
Conservative Judaism:
Politically conservative Jews who generally support the Republican party
Contextual viewpoint:
An approach or viewpoint that acknowledges the client and therapist are both
embedded in systems such as family, work, and culture
Cooperation:
A cultural value of Native Americans where harmony and betterment of the tribe
holds precedence over individual needs
Countertransference:
Involves the therapist's emotional reaction to the client based on the therapist's own
attitudes, beliefs, values, or life experiences
Covert sexism:
Unequal and harmful treatment of women that is conducted in a hidden manner
Credibility:
People who perceived as possessing expertness and trustworthiness
Cultural adaptations:
The counseling process of attempting to incorporate culture specific variables and
factors into specific treatment strategies, thereby making them more culturally
relevant
Cultural competence:
Cultural competence is the awareness, knowledge and skills needed to function
effectively with culturally diverse populations
Cultural deprivation:
The belief that groups of color are “culturally deprived” because they lack White
middleclass values
Cultural encapsulation:
Counselors who are culturally unaware and who operate in isolation from a broader
cultural context
Cultural Humility:
A complementary component to cultural competence associated with an open
attitudinal stance or a multiculturally open orientation to work with diverse clients
Cultural mistrust:
When a person of one culture develops a mistrust of someone from another culture
due to personal or historical experiences between the two groups
Cultural oppression:
When members of the dominant culture impose their standards upon culturally
diverse populations without regard for differences
Cultural paranoia:
A term used to describe the guardedness, suspiciousness and mistrust of
marginalized group members toward majority group members
Cultural relativism:
The belief that the manifestation and treatment of mental disorders must take into
consideration cultural differences
Cultural values:
Values held in common by a cultural group which often help shape worldview and
the perceptions of individuals of that culture
Culturally deficient model:
Belief that people of color are inferior because they were culturally disadvantaged,
deficient, or deprived of a White middle‐class upbringing
Culturally diverse model:
Belief that all cultures are valued and that diversity should not indicate whether one
group's cultural heritage is better than another's
Culturally responsive:
An approach that takes into consideration and responds to the cultural values, life
styles, strengths and assets of the client as they interact with the wider society
Culturally responsive assessment:
The process of understanding and evaluating clients through a collaborative
framework that takes into account cultural and sociopolitical factors
Culturally sensitive intake interviews:
Intake interviews that take into consideration situational, family, sociocultural, or
environmental issues that impact the client and includes other areas of diversity and
identity
Culture bound syndromes:
Mental disorders unique to various cultures
Culture‐bound training:
Multicultural training that reflects only one cultural perspective, usually the White,
EuroAmerican, middle‐class perspective
Culture‐bound values:
Traditional western counseling and therapy are seen to possess the values of the
dominant culture
Dementia:
Memory impairment and declining cognitive functioning as a result of brain disease
Diagnostic overshadowing:
Misdiagnosing a problem by focusing on a salient characteristic that has nothing to
do with the problematic issue
Disability:
The ADA defines disability as “a physical or mental impairment that substantially
limits one or more of the major life activities of such individual
Discrimination:
Negative or prejudicial treatment toward a person or group of people usually based
on biased beliefs and stereotypes
Dissonance:
Under the Racial/Cultural Identity Development model (R/CID), people of color
become more aware of inconsistencies between dominant‐held views and those of
their own group resulting in a sense of dissonance
Dissonance phase:
In the Sue and Sue White identity development model, it refers to how Whites are
forced to deal with inconsistencies in their racial attitudes and behaviors as they
encounter information/experiences at odds with their racial denial and naiveté
Dreamers:
Individuals brought to the U.S. at an early age without documentation
Egalitarian roles:
When roles are based on equality between genders
Ego statuses:
Reference to the different levels of ethnic identity development and the traits and
defenses associated with them
Elder abuse and neglect:
The abuse and/or neglect of an elderly person
Elderspeak:
A derogatory way of speaking to someone of the geriatric generation
Emic (culturally specific):
The belief that cultural differences must be considered in the diagnosis and
treatment of culturally diverse groups
Emotional affirmation:
Occurs when individuals from marginalized groups feel their lived experiences of
oppression and discrimination has been heard, acknowledged, understood, and
validated
Emotional bond:
The strength of the therapeutic relationship is often due to the emotional
understanding or emotional connection with the client
Emotional empathy:
An emotional understanding or emotional connection with the client
Emotional expressiveness:
The value placed upon clients who are encouraged to express their feelings and to
verbalize their emotional reactions
Emotional invalidation:
When individuals negate or dismiss the lived experiences of oppression and
discrimination of marginalized groups
Emotional resistance (to multicultural education):
A defensive maneuver that entails emotions such as guilt, anger, defensiveness, or
helplessness that block self‐exploration
Emotional self‐revelation:
An uncovering of strong personal feelings in response to race‐ and diversity‐
related stimuli
Emotionality:
A term used to describe the degree to which an individual or group is taught to
express or restrain emotional displays
Empathy:
The ability to place oneself in the client's world, to feel or think from the client's
perspective, or to be attuned to the client
Empirically supported relationships:
Therapeutic interventions that possess empirical support for the efficacy of the
therapeutic relationship, client values and beliefs, and the working alliance between
client and therapist
Empirically supported treatments:
Treatments that have empirical evidence regarding their effectiveness
Encounter:
The second stage of the Cross black identity development model where African
Americans encounter situations which challenge their previous acceptance of White
ways
Enculturation:
The process of learning and internalizing the values, beliefs and traditions of one’s
home culture
Enlightenment:
Asian psychologies states of consciousness in which attaining the highest level
enhances perceptual sensitivity and clarity, concentration, and sense of identity, as
well as emotional, cognitive, and perceptual processes
Espiritismo:
The belief that good and evil spirits affect mental health
Ethnocentric monoculturalism:
Refers to a belief in the superiority of one's group's cultural heritage over another,
and the imposition of those standards upon the less powerful group
Ethnocentricity:
The belief that one's culture is superior to other cultures
Etic (culturally universal):
The belief that human beings share overwhelming commonalities and that the
manifestation and treatment of disorders are similar across all cultures and societies
Evidence‐based practices:
Counseling interventions based on research evidence from qualitative studies,
clinical observations, systematic case studies, and interventions delivered in
naturalistic settings
Expertness:
Typically a function of reputation, evidence of specialized training, and behavioral
evidence of proficiency/competency
Extended family:
Families that include others outside of the nuclear unit such as godparents, aunts,
uncles, cousins, or fictive kin
Familismo:
Reference to the importance of the extended family kinship system and its
importance to a sense of connectedness, support, and identity of members
Family systems:
This comprises the system that makes up the family and includes structural
alliances and communication patterns
Fatalism:
Latinos often believe that life's misfortunes are inevitable and feel resigned to their
fate (fatalismo)
Feminism:
A philosophical stance that refers to beliefs and practices directed toward gender
equality—equal economic, social, and political rights and opportunities for women
Gay:
This is a term that describes a man who has an affectional and/or sexual attraction
to another man
Gender Dysphoria:
A mental health condition defined in DSM‐5 as significant distress and
impairment resulting from an incongruence between a person's gender identity and
assigned gender
Gender microaggressions:
The everyday slights, put‐downs, invalidations, and insults directed toward a
specific gender, typically women
Gender roles:
Societal and cultural expectations and rules governing gender role definitions of
acceptable behaviors, values and beliefs for males and females
Genetically deficient model:
Belief that people of color are inferior by virtue of their biological makeup
Ghost sickness:
A culture‐bound syndrome in which victims become preoccupied with the
deceased and suffer from nightmares, terror, and loss of appetite
Giác Hoi:
Southeast Asian massage treatment, Giác Hoi means “pressure massage,” or “dry
cup massage” and involves steaming bamboo tubes so that the insides are low in
pressure, applying them to a portion of the skin that has been cut, and sucking out
“bad air” or “hot wind”
Group level of identity:
Identity associated with group membership such as race, gender, sexual orientation,
religious affiliation and so on
Hardiman White racial identity development:
The White racial identity development model formulated by Rita Hardiman
Helms White racial identity development:
The White racial identity development model formulated by Janet Helms
Heterosexism:
Cultural ideology that assumes heterosexuality to be the societal norm and
distinctively superior to homosexuality
Heterosexist bias:
The assumption that everyone is a heterosexual and its manifestation in societal
practices
Heterosexual:
This is a term that describes a person who has an affectional and/or sexual
attraction to a person of the opposite sex
Hierarchical relationships:
A family structure whereby males and older individuals are given higher status in
decision making and females and children are expected to defer to the authority of
males and their elders
High context cultures (HC):
Communications that rely more on the context to interpret the meaning of messages
High‐/low‐context communication:
Reference to whether a person relies more on the context to interpret the meaning
or the content of the message
Historical loss:
Cross‐generational losses of land, language, and cultural practices
Historical stereotypes:
Stereotypes which are fueled by the historical relationship between cultural groups
Hmong Sudden Death Syndrome:
A culture‐bound mental disorder or phenomenon observed among the Hmong of
Southeast Asian whereby individuals die suddenly in their sleep from unknown
causes
Holistic outlook:
Most non‐Western indigenous forms of healing make minimal distinctions
between physical and mental functioning and believe strongly in the unity of spirit,
mind, and matter
Holocaust:
An incredibly traumatic period in Jewish history in which Nazi Germans murdered
approximately 6 million Jewish men, women, and children
Holocaust denier:
Individuals who do not acknowledge or who question the genocide that occurred
during the Holocaust
Homonegativity:
Includes homophobia, or phobia of homosexual individuals, and cultural attitudes
that devalue sexual minorities
Ho'oponopono:
A healing ritual of Native Hawaiians that attempts to restore and maintain good
relations among family members and between the family and the supernatural
powers
Hypodescent:
Also known as the “one drop rule,” which is a class‐based social system that
maintains the myth of monoracialism by assigning the person of mixed racial
heritage to the least desirable racial status
Identity synthesis:
The process of successfully integrating multiple identities such as ethnicity, sexual
orientation, gender and so forth
Immersion‐emersion:
The third stage of the Cross black identity development model is characterized by a
withdrawal from the dominant culture and immersion in African American culture
Immigrants:
People who have moved from their country of origin to the United States in which
they now reside
Indigenous healing:
Helping beliefs and practices that originate within the culture or society
Individual level of identity:
Identity which acknowledges that no two individuals are alike, because people are
unique and do not share the same experiences in life, not even identical twins
Individual‐centered:
A culture‐bound value in mental health practice in which the individual is the
psychosocial unit of operation and independence and autonomy are the primary
goals to treatment
Individualism:
One of the primary values of U.S. culture and society and refers to valuing
individualism
Information‐processing strategies:
These are strategies that White people use to avoid or assuage anxiety and
discomfort around the issue of race
Insight:
A generic characteristic of counseling that values the attainment of insight in
mental health and treatment
Institutional racism:
A set of institutional policies, practices, and priorities, designed to subjugate,
oppress, and force dependence of individuals and groups on the larger society
Integration/biculturalism:
Entails an individual retaining many Asian values while simultaneously learning
the necessary skills and values for adaptation to the dominant culture
Integrative awareness:
Under the Racial/Cultural Identity Development model (R/CID), people of color
develop an inner sense of racial security and can own and appreciate unique aspects
of their culture as well as those in US culture
Integrative awareness phase:
In the Sue and Sue White identity development model, this phase is marked by an
understanding of self as a racial/cultural being, being aware of sociopolitical
influences regarding racism, appreciating racial/cultural diversity, and becoming
more committed toward eradicating oppression
Internalization:
The fourth stage of the Cross black identity development model characterized by
resolution of conflicts between the old and new identities and a movement toward
becoming more bicultural/multicultural
Internalization‐commitment:
The last stage of the Cross black identity development model characterized by
commitment to social change, social justice, and civil rights
Internalized racism:
The term used to describe the process by which persons of color absorb and
internalize the society's racist messages about their own group, and other groups of
color
Interpreters:
Bilingual individual who acts as a language translator between two individuals who
do not speak each other's language
Interracial/interethnic bias:
This is the bias that a person of one racial/ethnic group harbors for members of
another racial/ethnic group which can be fueled by erroneous stereotypes or
negative experiences with a member of the other racial/ethnic group and can cause
cognitive dissonance or denial by the holder of the bias
Interracial/interethnic conflict:
These are differences and conflicts between interracial/interethnic groups that are
infrequently publicly aired because of possible political ramifications for group
unity
Interracial/interethnic discrimination:
This is discrimination that is extended to a racial/ethnic group or member by
another racial/ethnic group or member
Interracial/interethnic group relations:
This pertains to the historical and current relationships between racial/ethnic groups
Introspection:
Under the Racial/Cultural Identity Development model (R/CID), the introspection
stage includes self‐reflection and rethinking of rigidly held racial beliefs and its
relationship to whiteness
Introspective phase:
In the Sue and Sue White identity development model, the introspective phase is
characterized by a state of relative quiescence, self‐reflection, introspection, and
reformulation of what it means to be White
Invisible veil:
The invisibility of people's values and beliefs (worldviews) which are outside the
level of conscious awareness
Islam:
Islam is the religion of Muslims and it means “submission to God”
Islamaphobia:
Prejudice directed toward Muslim individuals or followers of Islam
Jewish identity:
Refers to a highly complex and personal sense of shared cultural and historical
experiences among Jews
Judaism:
Judaism is a religion with a belief in an omnipotent God who created humankind; it
is one of the earliest monotheistic religions
Judgmental heuristics:
Judgmental processes commonly used to make quick‐decisions by short‐
circuiting the ability to engage in self‐correction
Kinesics:
The study of how bodily movements that include facial expression, posture,
characteristics of movement, gestures, and eye contact orientation affect
interpersonal transactions
Kinship bonds:
Bonds between relatives
Knowledge:
The presence of accurate information about diverse groups
Latinx Americans:
Describes individuals of Mexican or Latin descent
Lesbian:
This is a term that describes a woman who has an affectional and/or sexual
attraction to another woman
Levels of intervention:
The intended target(s) toward which mental health professionals aim the intended
beneficial impact of their work; may range from a single individual to an entire
organization to a society‐wide institution or policy
LGBT Q:
This is an acronym that stands for Lesbian, Gay, Bisexual, Transgender, and Queer
(or Questioning)
Linguistic barriers:
Language barriers often place culturally diverse clients at a disadvantage because
counseling is usually provided in standard English
Locus of control:
Locus of control refers to people's beliefs about the degree of control they have
over their life circumstance
Locus of responsibility:
Locus of responsibility refers to the degree of responsibility or blame placed on the
individual or system
Low‐context cultures (LC):
Communications that rely more on the content of what is said to interpret the
meaning of the message
Machismo:
In traditional Latino/a culture, men are expected to be strong, dominant, and the
provider for the family (machismo)
Mahiki:
The actual work that occurs during the Native Hawaiian healing ritual of
Ho'oponopono begins through mahiki, a process of getting to the problems
Marianismo:
In traditional Latino/a culture, women are expected to be nurturing, modest,
virtuous, submissive to the male, and self‐sacrificing (marianismo)
Medical model:
Regards disability as a defect or loss of function that resides in the individual
Microaggression:
Brief, everyday exchanges that send denigrating messages to a target group
Microaggressions:
Microaggressions are the everyday slights, put‐downs, invalidations, and insults
directed to socially devalued group members by well‐intentioned people who may
be unaware that they have engaged in such biased and harmful behaviors
Microassault:
Blatant verbal, nonverbal, or environmental attacks intended to convey
discriminatory and biased sentiments
Microinsult:
Behaviors or verbal comments that convey rudeness or insensitivity or demean a
person's group identity heritage
Microinvalidation:
Verbal comments or behaviors that exclude, negate, or dismiss the psychological
thoughts, feelings, or experiential reality of the target group
Migration:
The movement of groups of people from one geopolitical area to another
Minority model:
Views disabilities as an external problem involving an environment that is filled
with negative societal attitudes and that fails to accommodate the needs of
individuals with special needs
Minority standard time:
A reference to how people from situations of poverty often perceive time, and the
resultant effects it has on behavior
Miscegenation:
This term describes the “mixing” of two or more different races
Model minority:
A term used to describe the myth of Asian American success in U.S. society
Model minority myth:
The “model minority” myth is the overgeneralization of the Asian American
success story in the United States and depicting the group as the ideal racial/ethnic
minority group
Monoracial:
Individuals who are, or who are perceived to be, of just one racial heritage
Moral model:
Regards the “defect” as representing some form of sin or moral lapse
Mosque:
A mosque is a place of worship for followers of Islam
Muhammad:
Muhammad is the messenger of God according to the Muslim religion and its holy
book the Quran
Multicultural counseling/therapy:
A helping role and a process that uses modalities and defines goals consistent with
the life experiences and cultural values of diverse clients
Multiculturalism:
Multiculturalism is the integration, acceptance, and embracing of cultural
differences that include race, gender, sexual orientation, and other
sociodemographic identities
Multiple discrimination:
Discrimination based on more than one aspect of diversity
Multiracial:
Individuals who are of mixed racial heritage
Muslim:
Muslims are followers of Islam or the Quran, the Islamic holy book
Naiveté phase:
The Naiveté phase of the Sue and Sue White racial identity development is
characterized by racial naiveté, and innocence
Naturalized citizens:
Naturalization is the process by which an immigrant can obtain citizenship in the
United States after he or she meets the criteria set by the U.S. Congress
Nature of people dimension:
A reference to how different culture groups view human nature (“good, neutral, or
bad”)
Nested/Embedded emotions:
Unacknowledged emotions such as anger, anxiety, defensiveness, or guilt regarding
one's thoughts about race, culture, gender, and other variables of culture
Nigrescense:
Nigrescense is the process of becoming “Black” and formulating a Black identity
Noninterference:
A Native American value and outlook in life associated with living with nature and
people rather than attempts to change it or others
Nonracist:
Individuals who own up to their biases, and acknowledge their past oppressive
attitudes and actions
Nonracist white identity:
An identity associated with the Whites recognizing their own racial biases, and an
internal commitment to eradicating prejudice and commitment
Nonverbal communication:
Nonverbal communication includes such things as body language, vocal tone, or
vocal inflection
Nonverbals as triggers to bias:
Nonverbal behaviors that may trigger racist stereotypes and fears in the individual
Nuclear families:
A reference to the family unit composed of only the husband, wife, and biological
children
Oia'i'o:
The Native Hawaiian healing ritual of Ho'oponopono elicits ‘oia'i'o or (truth
telling), sanctioned by the gods, and makes compliance among participants a
serious matter
One Drop rule:
Describes the racist practice of classifying individuals as African American even if
they possess minimal African American blood in their heritage
Orthodox Judaism:
Jews who follow strictly all Jewish rules and traditions of Judaism
Overt sexism:
Blatant unequal and unfair treatment of women
Pani:
Following the closing prayer of the Native Hawaiian healing ritual of
Ho'oponopono, the family participates in pani, the termination ritual in which food
is offered to the gods and to the participants
Paralanguage:
The study of how vocal cues such as loudness of voice, pauses, silences,
hesitations, rate of speech, and inflection affect communication
Patriarchal roles:
A division of roles where males are given greater status, prestige and influence in
the family and society
Personalismo:
A Latino/a cultural orientation whereby people relationships are more valued over
institutional obligations and responsibilities
Playing it cool:
A survival mechanism to appear serene while concealing one's true feelings of
anger and frustration toward oppressors
Playing the dozens:
A form of verbal provocation and impromptu speaking
Post‐traumatic stress disorder (PTSD):
A mental health condition that often accompanies someone who has been subjected
to trauma or terror in which the individual thought he or she would die or that
another individual would or did die
Poverty:
A condition in which individuals possess chronic inadequate financial resources
and occupy the bottom‐most rungs of society
Preencounter:
The first stage of the Cross black identity development model characterized by
anti‐Black attitudes and a positive White orientation
Prejudice:
An erroneous preconceived judgment about another person based on one's group
membership
Progressive Judaism:
These are individuals of Reform Judaism, which advocates the freedom of
individuals to make choices about which traditions to follow
Proxemics:
The study of how sociodemographic identities affect the use of conversing
distances and their meanings
Pule ho’opau:
The closing prayer of the Native Hawaiian ho'oponopono healing ritual
Pule weke:
The opening prayer of the Native Hawaiian healing ritual of Ho'oponopono
Queer:
An umbrella term that encompasses many categories of sexual minorities and
reclaimed by activists to remove its' stigma
Qur'an:
The Quran is the Islamic holy book and it is considered to be the literal word of
God
R/CID model:
A racial/cultural development model that attempts to integrate the racial/cultural
development of groups of color
Rabbi:
A religious leader of the Jewish faith
Race salience:
The degree to which race is an important and integral part of a person's approach to
life
Racial awakening:
An individual's understanding of themselves as racial/cultural beings and how it
impacts their perception of the world and relationships with others
Racial identity:
The identity one forms as a member of a racial or ethnic group
Racial identity invalidation:
Others denial of a person's racial identity that creates a significant racial stressor,
especially for people of multiracial descent
Racial/ethnic ambiguity:
Racial/ethnic ambiguity occurs when people are not easily able to distinguish the
monoracial category of the multiracial individual from phenotypic characteristics
Racial/Ethnic identity:
The identity one forms as a member of a racial or ethnic group
Racial socialization:
The process by which parents of color inform and educate their children about the
realities of racism in society
Racism:
Blatant and overt acts of discrimination that are epitomized by White supremacy,
that denies people of color their equal rights and opportunities, and can include
having hate crimes perpetuated against
Ramadan:
An annual event of Muslims that involve fasting during daylight hours throughout
the holy month of Ramadan—a time for inner reflection, devotion to God, and
spiritual renewal
Reform Judaism:
Reform Judaism advocates the freedom of individuals to make choices about which
traditions to follow
Refugees:
In contrast to other immigrants who voluntary left their country of origin, refugees
are individuals who flee their country of origin in order to escape persecution or
oppression
Rehabilitation approach:
The rehabilitation approach has historically been a drive to remediate the
individuals with disabilities and “make them as normal as possible”
Relational dimension:
A reference to cultural group relations and whether they are more collateral or
individualistic in orientation
Religious discrimination:
Discrimination against individuals of certain religious affiliations, usually non‐
Christians
Reservation:
A legally designated place under the U.S. Bureau of Indian Affairs, upon which a
Native American people reside
Resistance and immersion:
Under the Racial/Cultural Identity Development model (R/CID), the primary
orientation of these individuals is they tend to endorse minority‐held views
completely and to reject the dominant values of society and culture
Resistance and immersion phase:
In the Sue and Sue White identity development model, the White person begins to
question and challenge his or her own racism and begins to become aware of the
existence or racism in society
Respecto:
Respecto is the act of showing respect
Scientific empiricism:
Western value placed on empiricism which involves objective, rational, linear
thinking as the means to define and solve problems
Scientific racism:
Racist attitudes and beliefs expressed under the guise of science and scientific
findings
Self‐disclosure:
In counseling, the value and desire for clients to talk about the most intimate
aspects of their life and to share it with the counselor
Self‐reflection:
Self‐reflection entails truthfully taking stock of one's emotions, beliefs, values,
thoughts, and actions and how those impact the self and others
Sexism:
Unequal and unfair treatment of women that is embedded in our culture and often
perceived as normal appropriate behaviors
Sexual harassment:
Verbal or physical conduct of a sexual nature, sometimes with explicit or implicit
expectations that a woman or a man submit to sexual requests
Sexual orientation:
The term that describes how one identifies in terms of which gender he or she has
an affectional and/or sexual attraction
Shaman:
The name given to many healers in different cultures who are believed to possess
special powers to cure troubled individuals through their ability to communicate
with the spirit world via divination skills
Sharing:
A cultural value of Native Americans in which honor and respect are gained by
sharing and giving, in contrast with the dominant culture where status is gained by
the accumulation of material goods
Shiite:
Shiites compose 10% of the Muslim population worldwide
Simpatico:
The relational style displayed by many Latinos—a style emphasizing social
harmony and a gracious, hospitable, and personable atmosphere
Skills:
Specific expertise and ability to effectively utilize therapies and knowledge to help
clients from cultures different from the therapist
Social class:
Refers to where one falls on the socioeconomic spectrum and are usually classified
as upper, middle, and lower class
Social class privilege:
This describes the social, economic and cultural privileges afforded to the upper
class population that does not apply to those of other classes
Social justice:
Active engagement and action in working toward equal access and opportunity for
all people and in fighting injustice in all its forms
Social justice counseling:
Counseling that operates from an active philosophy and approach to producing
conditions that allow for equal access and opportunity
Social stratification theory:
A description of a hierarchical system that not only positions poverty and economic
characteristics of groups in our society, but involves sociopolitical relationships as
well
Socially marginalized groups:
These are groups that are excluded from the dominant social order and are often
linked to culture and social status
Somatic complaints:
Within the meaning of this term, bodily or physical symptoms are means by which
Asian clients may express their emotional distress
Spirituality:
The life force that resides within individuals which makes them inherently worthy,
and connects them to other living creatures
Stereotype threat:
When an individual of a marginalized group fear inadvertently confirming a
mistaken notion (stereotype) about their group
Stereotypes:
Stereotypes are inflexible generalizations based on limited or inaccurate
information that can create biases and discriminatory treatment towards
marginalized groups in our society
Stereotyping:
A common but inaccurate belief and perception about a cultural group
Strong Black woman:
A term that refers to African American women's pride in racial identity, self
reliance and capability in handling life challenges
Subtle sexism:
Unequal and unfair treatment of women that is embedded in our culture and often
perceived as normal appropriate behaviors
Sunni:
Sunnis are the largest group of Muslims, accounting for about 90% of Muslims
Survivor's guilt:
The guilt associated with surviving atrocities in their country of origin and the
necessity of leaving other family members behind
Sweat lodge:
A form of healing and purification that involves rituals filled with American Indian
cultural and spiritual symbolism and meaning that takes place in a sweat lodge
Sweat lodge ceremony:
A form of healing and purification that involves rituals filled with American Indian
cultural and spiritual symbolism and meaning that takes place in a sweat lodge
Synagogue:
A place of worship for individuals who follow traditional Judaism
Therapeutic alliance:
Refers to the importance of the interpersonal bond such as collaboration, empathy,
warmth, and genuineness which are all factors known to be critical for effective
multicultural counseling
Therapeutic bond:
The strength of the working relationship between client and therapist
Therapeutic style:
The helping style of the therapist as influenced by their theoretical orientation, race,
gender and other variables
Thùôc Nam:
Among the Vietnamese, Thùôc Nam, or traditional medicine, involves using natural
fruits, herbs, plants, animals, and massage to heal the body
Time dimension:
How different societies, cultures, and people view time can be divided into being
past, present or future oriented
Transgender:
The term describes individuals whose gender identification is inconsistent with
their assigned gender
Transphobia:
Prejudice against transgender individuals
Tribe:
An indigenous social grouping and unit connected by heritage, history, and culture
and important for individual and group identity
Trustworthiness:
The degree to which people perceive the communicator as motivated to make valid
or invalid assertions
Uncle Tom Syndrome:
A survival mechanism used by people of color to appear docile, nonassertive, and
happygo‐lucky
Undocumented immigrants:
This is the less stigmatized term for individuals who are foreign born and have
immigrated to a country without following the host country's laws
Unintentional racism:
Racism and unconscious bias that is invisible to those who perpetuate it
Universal level of identity:
Identity that acknowledges people have a universal level of identity, are similar to
one another, originate from the same species, and share qualities that make them
human
Universal–diversity orientation:
The therapist's orientation that balances the universal and diversity perspective
Universal shamanic tradition:
Refers to the centuries‐old recognition of healers (shamans) such as those called
witches, witch doctors, wizards, medicine men or women, sorcerers, and magic
men or women
Verbal communication:
Spoken or written language and communication in which the content of what is said
is important
Victim blaming:
Explanations that attribute blame to marginalized group members for their status in
life when the cause is due to external barriers such as bias and discrimination
Victimization:
The experience of becoming a victim of a negative act such as of crime,
discrimination, or another aversive event
Vision quest:
A rite of passage among many Native American nations and is often used to
reestablish connections between the mind, body, and spirit and to seek spiritual
guidance
Western healing:
Interventions based upon Western European science and empiricism
White fragility:
The inability for many Whites to tolerate racial stress and discomfort when racial
topics, issues or activities are brought to their attention
White privilege:
The unearned advantages and privileges that accrue to people of light‐colored
skin (usually White European descent)
White racial identity development:
The process and accompanying stages or phases by which Whites achieve various
racial identities
White racial identity development descriptive model:
The White Racial Identity Model developed by Sue and Sue
White supremacy:
A belief that individuals of White European descent are superior to people of color
Whiteness:
A reference to the light skin tone of European Americans and the surrounding
assumptions and norms associated with it used to judge all other groups
Who's more oppressed game:
When one uses his or her own group's oppression to negate, diminish, and
invalidate that of another socially devalued group
Worldview:
Worldviews are composed of people's attitudes, values, and beliefs that affect how
people think, define events, make decisions, and behave
YAVIS syndrome:
An acronym meant to indicate counselor preference for clients who are young,
attractive, verbal, intelligent, and successful (YAVIS)
Yom Kippur:
Yom Kippur, the Day of Atonement, is a major holy day of the Jewish religion set
aside to atone for sins during the past year
Index
A
Ability variable, expertness as, 107
Ableism, 122, 124, 125, 432, 438
Abnormality, 77, 78–79
Abu‐Salha, Razan Mohammad, 382
Abuse: child, 217–218; elder, neglect and, 465–466, 470; trauma history and, in
culturally sensitive intake interview, 292–293. See also Alcohol and substance abuse
ACA. See American Counseling Association
Acceptance stage, of Hardiman White Racial Identity Development model, 261
Acculturation, 317, 332, 339, 398
Acculturation conflicts: of AI/AN, 323–324; of Arab Americans and Muslim Americans,
388; of Asian Americans, 340, 345; of Latinx population, 356–359, 360
Acculturation stress, 351, 357
Accuracy, of communication, 170
ACES. See Association for Counselor Education and Supervision
ACLU. See American Civil Liberties Union
Activity dimension, in MCT, 160–161
Activity schedules, 193
Acupuncture, 220
ADA. See Americans with Disabilities Act
Adamson, R., 482
Adelson, S. L., 452
Adoption, by LGBTQ, 446
Advocacy: counseling roles, 92, 484; feminist relational, 495–496; for organizational
change, 90–91
Advocate, 179
Affective/experiential component, in curriculum and training, 80
Affordable Care Act, 480
African Americans, 301; Asian Americans conflicting relationships with, 54;
characteristics and strengths of, 303–309; communication styles of, 173, 179, 181;
counseling of, 311–312; as criminals, media on, 309–310; cultural strengths of, 308–
309; Dee case study and, 306; educational characteristics of, 306–307; extended family
of, 304, 308; family structure of, 304–305; Galton and Rushton on inferiority of, 81;
incarceration of, 303, 310; interaction of four sets of factors in Jones model, 310–311;
Jackie case study and, 306–307; Johnny case study and, 305; kinship bonds of, 160, 304,
308; Latinx Americans conflicting relationships with, 55–56; LGBTQ, 448; medical
experiments on, 75–76; Michael case study and, 307; overview, 302–303; poverty of,
303; present‐time orientation of, 158; racial and ethnic identity of, 303–304; racism
and discrimination of, 303, 305, 306–307, 309–311; spiritual and religious values of,
222–223, 306; stereotypes of, 50; women scientists, 302; worldview of, 37; youth, 307–
308. See also Black Lives Matter movement
Afrocentric attitudes, 304
Ageism, 462, 463, 470; women and, 496–497, 500
AI/AN. See American Indians and Alaska Natives
Alaska Natives. See American Indians and Alaska Natives
Alcohol and substance abuse: of AI/AN, 318, 322, 324–325; history, in culturally
sensitive intake interview, 294; of Latinx population, 356; of LGBTQ individuals, 445,
447, 450, 452; older adults and, 466–467
Alcorn, Leelah, 447
Aldarondo, E., 483
Allison, Dorothy, 478
Allport, Gordon, 270
AlterNative Education Program, 323
Alzheimer's Association, 463
Alzheimer's disease, 463, 464
American Association of People with Disabilities, 427
American Civil Liberties Union (ACLU), 396
American Community Survey, of Census Bureau, 426
American Counseling Association (ACA): on end‐of‐life care provision, 469;
LGBTQ and, 452; MSJCC and, 51, 85
American Indian Life Skills Development Program, 204
American Indians and Alaska Natives (AI/AN), 316, 426; acculturation conflicts of,
323–324; alcohol and substance abuse of, 318, 322, 324–325; characteristics and
strengths of, 318–320; communication styles, 152, 181; counseling of, 327; cultural and
spiritual values of, 319–320, 325, 328; cultural strengths of, 222, 320; domestic violence
of, 325–326; educational concerns of, 322–323; extended family of, 319, 320, 321, 322;
family structure of, 319; HC‐MC ritual of, 205–206; historical and political
relationships between groups of color and, 56; historical and sociopolitical background
of, 321–322; kinship bonds of, 159–160; Mary case study and, 322; overview, 317–318;
patriarchal roles and, 319; present‐time orientation of, 158; self‐disclosure and, 150;
suicide of, 326–327; sweat lodge ceremony, 222–223, 320; tribal social structure of,
318. See also Indigenous healing
American Psychiatric Association, 29, 214, 291
American Psychological Association (APA): on discrimination, 131; Division 29
Psychotherapy Task Force, 195–196; ESRs focus by, 203; ESTs list and ethnic minority
practice guidelines, 192; Multicultural Competency in Geropsychology of, 452;
Multicultural Guidelines of, 76–77; Presidential Task Force on Evidence‐Based
Practice, 80, 191; Presidential Task Force on Immigration, 398, 399; Presidential Task
Force on Preventing Discrimination and Promoting Diversity, 270; Report of the Task
Force on Gender Identity and Gender Variance, 452; Report of the Task Force on
Resources for the Inclusion of Social Class in Psychology Curricula, 482; Task Force on
Socioeconomic Status, 147, 153; Thorndike Prize of, 81; on violence against women,
493
Americans with Disabilities Act (ADA), 427–428
Amok (attacking furiously), 215
Anger, meaning of, 18–19
Animal Farm (Orwell), 74
Anti‐Defamation League, 417
Antigay harassment, 123, 126
Antihomophobia, curriculum on, 79–80
Anti‐Latinx sentiments, 349
Antiracism, 92; curriculum on, 79–80
Antiracist, 20
Antiracist White identity, 267–273
Anti‐Semitism, 125, 411, 414, 416, 417, 418–419, 420
Antisexism, curriculum on, 79–80
Anxiety, meaning of, 17–18
APA. See American Psychological Association
Aponte, H. J., 482
Appropriate Therapeutic Responses to Sexual Orientation, in APA Multicultural
Competency in Geropsychology, 452
Appropriateness, of communication, 170
Arab American Community Coalition of Washington State, 385
Arab American Institute, 382, 383
Arab Americans and Muslim Americans, 381; acculturation conflicts in, 388;
characteristics and strengths of, 382–385; collectivistic orientation of, 384, 385;
counseling of, 389; cultural and religious values of, 384; cultural strengths of, 385;
family structure and values of, 384–385; identifying Muslim Americans, 383–384;
patriarchal roles of, 384, 390; stereotypes, racism, and discrimination, 385–388
Arabs, 382
Arthur Ashe Courage Award, 442
Asian American identity development models, 240–242
Asian Americans and Pacific Islanders, 331; academic and occupational goal orientation
of, 338, 345; acculturation conflicts of, 340, 345; African Americans conflicting
relationships with, 54; CBT and, 341–342; characteristics and strengths, 333–339;
collectivistic orientation of, 37, 148, 334–335, 342; communication styles of, 152, 172,
181; counseling of, 343; cultural strengths of, 338–339; depression of, 332, 335–336;
emotionality and, 337, 345; expectations regarding counseling, 341–342; hierarchical
relationships of, 335–336, 345; holistic view on mind and body of, 220, 337–338;
Katherine case study, 334; Latinx Americans conflicting relationships, 55; overview of,
332; parenting styles of, 336, 345; past‐present orientation of, 158; patriarchal roles of,
335, 342, 343; racial identity issues of, 339–340; racism and discrimination of, 333–334,
342; self‐disclosure and, 150; stereotypes of, 50, 80; as success story, 333–334;
worldview of, 37
Assertiveness, 149
Assertiveness training, 193, 498
Assessments: clinical, 291–294; collaborative and culturally responsive, 282, 295;
diversity‐focused, 294. See also Culturally competent assessment
Assimilated cultural orientation, 324
Assimilation, 332, 339
Association for Counselor Education (ACES), 223
Association of Black Psychologists, 79
Asylum, 395, 403
Ataques de nervios (attack of the nerves), 29, 30, 215
Atkinson, D. R., 238
Atman, in India, 147
Attack of the nerves (ataques de nervios), 29, 30, 215
Attacking furiously (Amok), 215
Attorney's Office, U.S., 302
Attractiveness, 117; of counselor, 107–110
Attribution errors, 283–284, 295–296
Authority set, 108
Autobiography of Malcolm X (Haley), 241
Autonomy, 147
Autonomy status, of Helms White Racial Identity Development model, 263
Aversive racism, 123
Awareness, 29, 39–40, 43; integrative awareness phase, 239, 245–246, 249, 251, 267;
sociocultural, of racism, 100. See also Self‐awareness
Azalea, Iggy, 30
B
Baby Boomers, 459, 467
Banyard, V., 477
Barakat, Deah Shaddy, 382
Băt Gió (catching the wind), 218
Behavioral expressiveness, 149
Behavioral resistance, to multicultural training, 20–21
Benedict XVI (pope), 386
Bertrand, M., 309
Betty Ford Center, 366
Bias: class, 154; in culture‐bound training systems, 77; heterosexist, 451, 452, 454;
interracial and interethnic, 49, 52–54; MCT individual and universal, in mental health,
36; nonverbals as reflections of, 177–178, 185; nonverbals as triggers to fear and, 178–
181, 185; therapeutic class, 153–154; therapy gender, 498–499, 500; unintentional
expressions of, 131
Bicultural orientation, 324, 357; of Arab Americans, 388
Bicultural values, 357
Biculturalism, 55, 147, 290, 340, 358
Bieber, Justin, 125
BigFoot, D. S., 191, 205–206
Bilingualism, 55, 103, 156, 163, 323, 359
Bill of Rights, 104; multiracial, 374
Biracial, 365, 366, 368
Bisexual, 442, 444, 449, 454
Black Lives Matter (BLM) movement, 75, 120, 126, 131, 269, 302, 309
Bland, Sandra, 309
BLM. See Black Lives Matter
B'nai Brith, 92
“Booty” pop music video, of Lopez, 30
Boston Marathon bombing, 386
Brain fag, 213
Brewer, R., 482
Brinkley, D., 220
Broaching, 61
Brown, Jerry, 443
Brown, Michael, 237, 242, 262
C
CACREP. See Council for Accreditation of Counseling & Related Educational Programs
California Assembly Bill 775, 155
Candid Camera television show, 177
Cao Gió (scratching the wind), 218
Caregivers, women as, 489, 490–491
CARRP. See Controlled Application Review and Resolution Program
Carson, Andre, 382
Carter, R. T., 293
Castile, Philando, 302
Catching the wind (Băt Gió), 218
CBT. See Cognitive behavioral therapy
CCD. See Counseling the Culturally Diverse
Census Bureau, U.S.: American Community Survey of, 426; on multiracial category,
366; on poverty rate, 476
CFI. See Cultural Formulation Interview
Chakras, 220, 221
Characteristics: counseling and psychotherapy standard, 146–147; of dissonance phase,
241–242; Latinx populations cultural values and, 350–351; White culture normative, 102
Characteristics and strengths: of African Americans, 303–309; of AI/AN, 318–320; of
Arab Americans and Muslim Americans, 382–385; of Asian Americans and Pacific
Islanders, 333–339; of Jewish Americans, 412–415; of Latinx populations, 350–355; of
LGBTQ, 443–447; of multiracial populations, 366–369; of older adults, 459–462; of
PWD, 427–432; of women, 490–491
Charlie Hebdo magazine, 386
Chicago Police (CPD), 302
Chicano‐Filipino United Farm Workers Movement (1930s), 55
Child abuse, 217–218
Chinese Americans. See Asian Americans and Pacific Islanders
Cisgender, 443, 444, 452
Civil rights movement, 54, 396
Clark, Le Ondra, 13–14
Class bias, 154
Class‐bound values: poverty impact and, 152–153, 163; therapeutic class bias and,
153–154
Classism, 152, 477–478, 482; poverty and minimum wage, 480–481
Classist microaggressions, 483
Clients: of color, overidentification with, 62; ethnic group, counselor preferences by,
197; marginalized group counselors working with majority and marginalized group, 51;
stereotyping, 108, 162; systems, 38; therapy resistance, 15; victim blaming of, 30, 78,
100, 122; White, counselors of color challenges with, 58–62, 67; worldview, MSJCC on,
42
Clinical assessments: CFI, 288, 291; culturally sensitive intake interview, 291–294;
diversity‐focused assessment, 294
Clinical clues, attuning to, 30–31
Clinton, William “Bill,” 74, 75, 76
Closing prayer (pule ho’opau), 222
Coates, Ta‐Nehisi, 75, 256
Co‐construction, 341
Cognitive and behavioral distancing, 482
Cognitive behavioral therapy (CBT), 189; Asian Americans and, 341–342; Horrell on,
194; TF‐CBT, 205–206
Cognitive empathy, 198, 199, 200
Cognitive resistance, to multicultural training, 16–17, 80
Cognitive restructuring, 193
Collaboration, 198, 208
Collaborative approach, 287–288, 295
Collaborative assessment, 282, 295
Collaborative conceptualization model, 287, 288; principles of, 289–290
Collectivism, 38, 56, 147–149, 335
Collectivistic cultures, 30, 159
Collectivistic orientation: of Arab Americans, 384, 385; of Asian Americans, 37, 148,
334–335, 342
Colom, Alvaro, 76
Color blindness, 126, 199–200, 259
The Color of Wealth (Lui, Leondar‐Wright, Brewer, and Adamson), 482
Columbia University, 323
Colville, Rupert, 394
Coming out process, of LGBTQ, 443, 447–449, 451–452, 453, 454
Commitment to antiracist action phase, of White racial identity development model, 267
Communication styles, 65, 67; accuracy and appropriateness of, 170; of African
Americans, 173, 179, 181; of AI/AN, 152, 181; of Asian Americans and Pacific
Islanders, 152, 172, 181; counseling and psychotherapy impacted by, 168–185;
counseling and therapy as, 181–184; differences in, 57, 181; differential counseling
skills in, 181–182; immigrants and refugees linguistic, 402; implications of, for MCT,
152, 182–184; of Latinx Americans, 152, 173, 181; therapeutic practice and, 63–64;
verbal, 170; of Whites, 179. See also Nonverbal communication
Competencies, MSCJJ on, 42
Confidentiality, 109, 359; interpreters and, 155–156
Confirmatory strategy, 283, 295
Conformity phase: of R/CID, 239–241, 244, 246, 247, 249, 251; of White racial identity
development, 264–265
Confucian philosophy, 157–158
Connectedness, for therapeutic alliance, 196
Consciousness‐raising component, in curriculum and training, 80
Conservative Judaism, 413
Contact status, in Helms White Racial Identity Development model, 262
Contemporary forms, of oppression, 75–77
Contextual viewpoint, 288
Control. See Locus of Control
Controlled Application Review and Resolution Program (CARRP), 396
Cooperation, of AI/AN, 319, 328
Council for Accreditation of Counseling & Related Educational Programs (CACREP),
51
Counseling and psychotherapy: of African Americans, 311–312; of AI/AN, 327; of Arab
Americans and Muslim Americans, 389; of Asian Americans and Pacific Islanders, 341–
342, 343; client resistance to, 15; communication styles impacted by, 168–185;
credibility and attractiveness in, 59, 107–110, 117; differential skills, for communication
styles, 181–182; EBP and diversity issues in, 203–206; emotional expressiveness and,
149; family, for PWD, 434–435; of immigrants and refugees, 403, 405–406;
individual‐centered, 99, 113, 147, 183; interracial relationships in, 49–50; interventions
in, 85, 86; of Jewish Americans, 418–419; of Latinx populations, 359–360; of LGBTQ,
452–453; of marginalized groups, 66; mental health definitions, 77–80; mental health
impact from sociopolitical oppression, 75–77; mental health literature, 80–83; of
multiracial populations, 374–375; of older adults, 468–469; political and social justice
implications of, 73–94; of poverty individuals, 482–483; of PWD, 435–436, 437; social
justice advocacy and roles of, 91; standard characteristics of, 146–147; of women, 499–
500. See also Multicultural counseling and therapy; Social justice counseling;
Therapeutic alliance
Counseling the Culturally Diverse (CCD) (Sue), reactions to reading, 6–8
Counselor credibility and attractiveness, 59, 117; expertness and, 107–109;
trustworthiness and, 109–110
Counselors of color and dyadic combinations: challenges associated with, 62–65, 67;
challenges associated with counselors of color and White client dyads, 58–62, 67
Countertransference, 62; of counselors of color, 60; management of, 198, 201–202, 208
Covert racism, 11–12
Covert sexism, 123, 492, 499
CPD. See Chicago Police
Credibility, 117; of counselors of color, 59; expertness and, 107–109; trustworthiness,
109–110
Criminalization of poverty, 478
Criminals, media on African Americans as, 309–310
Cross nigrescence model, 303; encounter stage, 237; immersion‐emersion stage, 237;
internalization stage, 237; internalization‐commitment stage, 237; preencounter stage
in, 236, 304
Cullors, Patrisse, 302
Cultural adaptations, 202; to ESTs, 194, 195; of TF‐CBT, 205–206
Cultural and spiritual values, of AI/AN: cooperation, 319, 328; noninterference, 319–
320, 328; nonverbal communication, 320, 328; sharing, 319, 325, 328; spirituality, 320,
328; time orientation, 320, 328
Cultural clues, attuning to, 30–31
Cultural competence: behavioral resistance to, 20–21; cognitive resistance to, 16–17, 80;
cultural humility and, 41; cultural knowledge and, 286; defined, 38–42, 75; emotional
resistance to, 17–20; emotions and, 21–23; multicultural skills and, 287; obstacles to, 5–
24; self‐awareness and, 285–286; social justice and, 41–42; understanding resistance to
multicultural training and, 13–21. See also Multicultural counseling competence
Cultural deficit models, 147
Cultural deprivation, 82–83
Cultural encapsulation, 102
Cultural Formulation Interview (CFI), in DSM‐5, 288, 291
Cultural humility, 38, 43–44; cultural competence and, 41; obstacles to, 5–24; social
justice advocacy and, 91
Cultural incompetence, 32
Cultural insensitivity, 32
Cultural knowledge, 286
Cultural mistrust, 304
Cultural oppression, 113
Cultural orientation: assimilated, 324; bicultural, 324, 357, 388; marginal, 323;
pantraditional, 324; traditional, 323
Cultural paranoia, 78
Cultural racism, 102
Cultural relativism, 31
Cultural strengths: of African Americans, 308–309; of AI/AN, 222, 320; of Arab
Americans and Muslim Americans, 385; of Asian Americans and Pacific Islanders, 338–
339; of immigrants and refugees, 399; of Jewish Americans, 415; of Latinx populations,
355
Cultural syndromes, worldview and, 214–218
Cultural values, 56–57, 63, 65, 67
Culturally competent assessment, 281, 295–296; collaborative conceptualization
principles and, 289–290; contextual and collaborative, 287–290; cultural relevance in,
290–294; diagnostic errors prevention, 284–287; diversity‐focused, 294; Erica case
study and, 289; overview of, 282–283; standard clinical assessments, 290–294; therapist
variables influencing diagnosis, 283–284
Culturally deficient model, 82–83, 93
Culturally Deprived Child (Riessman), 82–83
Culturally diverse model, 83, 93
Culturally responsive, 6, 29, 36, 38
Culturally responsive assessment, 282, 295
Culturally sensitive intake interview, 291; abuse and trauma history in, 292–293; history
of presenting problem in, 292; identifying information in, 292; medical history in, 293;
presenting problem in, 292; psychosocial history in, 292; risk of harm to self or others
in, 294; strengths in, 293; substance abuse history in, 294
Culture: defined, 147; externality and, 111
Culture bound syndromes: Amok (attacking furiously), 215; ataques de nervios (attack of
the nerves), 29, 30, 215; Dhat, Shen‐K'uei, Shenkui, 215; in DSM‐5, 214; ghost
sickness, 213–214, 215; Koro, 215; nervios (nervousness), 215; susto (fright), 215
Culture‐bound training, 77
Culture‐bound values: distinction between mental and physical functioning in, 151–
152; focus on individual and, 147–149, 163; insight use of, 78, 149–150, 154, 163;
patterns of communication in, 152; scientific empiricism and, 151; self‐disclosure
openness and intimacy, 150–151; verbal/emotional/behavioral expressiveness and, 149,
163
Culture‐specific. See Emic formulations
Culture‐universal. See Etic formulations
Curriculum and training deficiencies, in mental health, 79–80
D
DACA. See Deferred Action for Childhood Arrivals
Darwin, Charles, 81
Daryl social justice counseling case study, 84
Davuluri, Nina, 385
DBT. See dialectical behavioral therapy
Deaf community, 426
Declaration of Independence, 105
Dee African American case study, 306
Defensiveness, meaning of, 18–19
Deferred Action for Childhood Arrivals (DACA), 394; Obama authorization of, 397
Dementia, 463, 464–465
Denial, 16–17
Department of Health and Human Services (DHHS), U.S., 467
Department of Homeland Security, 395
Department of Justice, U.S., 302, 321
Depression, 475; of Asian Americans, 332, 335–336; of Latinx population, 193, 355–
356; of LGBTQ, 445; Marshall case study, 120–121; of older adults, 467–468; poverty
and, 478–479; women and, 497–498
Dhat, Shen‐K'uei, Shenkui, 215
DHHS. See Department of Health and Human Services
Diagnostic and Statistical Manual of Mental Disorders‐5 (DSM‐5), of APA, 121;
CFI in, 288, 291; cultural concepts of distress and, 29, 214; culture‐bound syndromes
in, 214; gender dysphoria in, 443–444
Diagnostic errors, in culturally competent assessment: attribution error, 283–284, 295–
296; confirmatory strategy, 283, 295; diagnostic overshadowing, 284, 285, 295;
judgmental heuristics, 284, 295; prevention of, 284–287
Diagnostic overshadowing, 284, 285, 295
Dialectical behavioral therapy (DBT), 189, 190
Dignidad (dignity), 161, 162
Disability: defined, 427; minority and moral models regarding, 429, 437. See also
People with disabilities
Disabled individuals. See People with disabilities
Discrimination: of African Americans, 303, 305, 306–307, 309–311; APA on, 131, 270;
of Arab Americans and Muslim Americans, 385–388; of Asian Americans and Pacific
Islanders, 333–334, 342; of immigrants and refugees, 400–401; interracial and
interethnic, 52–54; of Jewish Americans, 416–417; of Latinx populations, 354; of
LGBTQ, 449–451; of multiracial populations, racism and, 373–374; of older adults,
462–463; politics of interethnic and interracial bias and, 49, 52–54; of PWD, 123, 124,
432–434; racism and, 75; religious, 122, 124, 125; of transgender, 124; of women, 489,
492–493, 497, 500
Disintegration status, of Helms White Racial Identity Development model, 262
Dissonance phase: characteristics of, 241–242; of R/CID, 239, 241–242, 248, 251; of
White racial identity development, 265–266
Distress, cultural concepts of, 29, 214
Diversity, among African Americans, 311
Diversity training, 285
Diversity‐focused assessment, 294
Division 29 Psychotherapy Task Force, of APA, 195–196
Domains, MSJCC on, 42
Domestic violence, 492–493; of AI/AN, 325–326; of immigrants and refugees, 398–399
Dominant group: belief in superiority of, 102; power to impose standards of, 103
Dreamers, 397
Driving while Black, 122
DSM‐5. See Diagnostic and Statistical Manual of Mental Disorders‐5
Duke, David, 415
Dumont, M. P., 483–484
Durbin, Dick, 394
E
Eadie, B. J., 220
EBP. See Evidence‐based practice
EC. See External locus of control
EC‐ER. See External locus of control‐external locus of responsibility
EC‐IR. See External locus of control‐internal locus of responsibility
Economic and employment barriers, of women, 494–496
Education, 223; AI/AN concerns in, 322–323; immigrants levels of, 395; poverty
inequalities of, 478–479; undocumented immigrants and higher, 401; women barriers to,
493–494
Educational characteristics: of African Americans, 306–307; Asian Americans academic
orientation of, 338, 345; of Latinx populations, 354–355
Egalitarian roles, 157, 164, 335
Ego statuses, 262
Ehrenreich, B., 478
Elder abuse and neglect, 465–466, 470
Elderly. See Older adults
Elderspeak, 465, 469
Ellis, Albert, 181
Embraced by the Light (Eadie), 220
Emic (culture‐specific) formulations, 38; etic formulations balancing with, 31; etic
formulations versus, 29–31
Emotional affirmation, emotional invalidation versus, 11–13
Emotional bond, 196, 198–202, 207–208
Emotional empathy, 198–199, 200
Emotional expressiveness, 149
Emotional invalidation, emotional affirmation versus, 11–13
Emotional resistance, to multicultural training: anxiety and fear meaning in, 17–18;
defensiveness and anger meaning in, 18–19; guilt, regret, and remorse meaning in, 19–
20; Winter on, 17
Emotional self‐revelation, fears and, 9–11
Emotionality, 337, 345
Emotions: cultural competence and, 21–23; nested or embedded, 10
Empathy: cognitive, 198, 199, 200; emotional, 198–199, 200; therapeutic alliance and,
196, 208
Empirically supported relationships (ESRs), 195; APA focus of, 203; EBP compared to,
204; variables of, 196
Empirically supported treatment (EST): APA list and ethnic minority practice guidelines
for, 192; cultural adaptations for, 194, 195; EBP compared to, 204; examples of, 192;
implications of, 194; shortcomings of, 193
Encounter stage, in Cross nigrescence model, 237
Enculturation, 340, 343
End‐of‐life provisions, 469
Energy Transfer Partners, 317
Engagement strategies, 193
Enlightenment, 221
Environmental injustice, poverty and, 480
Environmental Protection Agency (EPA), U.S., 479
Erica culturally competent assessment case study, 289
Espiritismo (spiritism), 221
ESRs. See Empirically supported relationships
EST. See Empirically supported treatment
Ethnocentric monoculturalism, 116, 235; historical manifestations of, 104–105;
inferiority of others belief in, 103; invisible veil and, 104, 259; manifestation in
institution, 103; power to impose standards and, 103; superiority of dominant group
belief in, 102
Ethnocentricity, 77
Etic (culture‐universal) formulations, 38; emic formulations balancing with, 31; emic
formulations versus, 29–31
Eureka, California, 317
Evidence‐based practice (EBP): client focus of, 204; diversity issues in counseling and,
203–206; ESRs and, 195–196; EST, ESR compared to, 204; ESTs and, 192–194;
multicultural, 188–208; TF‐CBT as, 205–206; therapeutic alliance and, 196–203, 204;
three pillars of, 203
“Evidence‐Based Practices with Ethnic Minorities: Strange Bedfellows No More”
(Morales and Norcross), 191
Executive Order 13769 (Muslim ban), of Trump, 382, 387
Experiment, 151
Expertness: as ability variable, 107; credibility and, 107–109
Extended family, 159, 160; of African Americans, 304, 308; of AI/AN, 319, 320, 321,
322; of Latinx populations, 350, 355, 358
External locus of control (EC), 111
External locus of control‐external locus of responsibility (EC‐ER), 112, 113, 114–
115
External locus of control‐internal locus of responsibility (EC‐IR), 112, 113–114
Externality: culture and, 111; sociopolitical factors and, 112
Externality, locus of control and, 111, 112
F
Familismo (family), 56–57, 350–351, 352, 357, 358, 360
Family approaches, to individualism, 159–160
Family counseling, for PWD, 436–437
Family structure: of African Americans, 304–305; of AI/AN, 319; of Arab Americans
and Muslim Americans, 384–385; of Latinx populations, 351–352; LGBTQ individuals
and, 446–447. See also Extended family
Family systems, 156, 164; Confucian philosophy and, 157–158
Family Therapy with Ethnic Minorities (Ho), 157
Farley, Melissa, 490
Fatalismo (fatalism), 161, 353
Fears: emotional self‐revelation and, 9–11; meaning of, 17–18; nonverbals as triggers
to biases and, 178–181, 185
Fellowship United Methodist Church, 453
Feminism, 489, 500
Feminist relational advocacy, 495–496
Friedman, M. L., 413
Fright (susto), 215
G
Galton, F., 81
Gambrill, E., 288
Garner, Eric, 237
Garrett, M. T., 323–324
Garza, Alicia, 302
Gay, 442–444, 449, 454
Gay and Lesbian Association of Retiring Persons (GLARP), 452
Gay‐Straight Alliance, 445
Gender: bias, in therapy, 498–499, 500; issues and domestic violence, of immigrants and
refugees, 398–399; ‐related considerations, of Jewish Americans, 414; role
expectations, of Latinx populations, 352–353
Gender dysphoria, 443–444
Gender microaggressions, 498
Gender roles, 352–353, 497
Gender Spectrum, 445
General Electric, 158
Genetically deficient model, 81–82, 93
George III (king), 104
Gerontophobia, 459
Ghost sickness, 213–214, 215
Giác Hoi (pressure massage), 218
Gibson, Mel, 125, 417
Gini coefficient, 476
GLARP. See Gay and Lesbian Association of Retiring Persons
Glum, J., 309
Goal consensus, 196–197, 202–203, 208
de Gobineau, A., 81
Gone, J. P., 195, 286
Goodman, L. A., 483
Group level of identity, 35, 36, 37, 38
Groups: acknowledging differences in, 30; cultural values, of racial and ethnic, 56–57;
dominant, 102, 103; ethnic, therapeutic alliance and, 197; identities, MCT impact on, 37;
interracial and interethnic relations of, 54–56; socially marginalized, 8, 50. See also
Marginalized groups
Guatemalan prisoners experiments, 76
H
Hale, Greta, 459–460
Haley, A., 241
Hall, Edward, 106, 175
Hall, G. Stanley, 81
Hardiman, Rita, 260–261
Hardiman White racial identity development model, 260–261
Harlins, LaTasha, 54
Harmony, 219–220
HC. See High‐context
HC‐MC. See Honoring the Children, Mending the Circle
Health care inequities, poverty and, 481
Helms, Janet, 261–263
Helms White Racial Identity Development model, 261; autonomy status of, 263; contact
status of, 262; disintegration status of, 262; immersion and emersion status of, 262;
pseudo‐independence status of, 262; reintegration status of, 262
Helplessness, 20
Hernandez, Daisy, 349
Heterosexism, 123, 124
Heterosexist bias, 451, 452, 454
Heterosexual, 13, 443, 444, 449, 452
The Hidden Dimension (Hall, E.), 175
Hierarchical relationships, 335–336, 345
High‐context (HC) communication, 175–176, 183, 185
High‐context (HC) cultures, 175–176
Hijab, 385
Hispanics. See Latinx population
Historical loss, for AI/AN, 325, 326
Historical relationships, between people of color, 54–56
Historical stereotypes, 50
History of presenting problem, in culturally sensitive intake interview, 292
Hmong Sudden Death Syndrome, 213–214
Ho, M. K., 157
Holistic outlook: of Asian Americans on mind and body, 220, 337–338; in indigenous
healing, 219–220, 223
Holocaust, 414, 415, 416, 417, 420
Holocaust denier, 415, 416
Homelessness, 477
“Homes Not Handcuffs” report, 478
Homonegativity, 123, 126
Homophobia, 75, 126
Homosexuality, 442
Honoring the Children, Mending the Circle (HC‐MC), American Indian ritual of, 205–
206
hooks, b., 482
Ho'oponopono, 222
Hopelessness, 20–21
Horrell, S. C. V., 194
Howard‐Pitney, B., 326
Huey, S. J., 202
Human Genome Project, 34, 35
Hypodescent, 367, 375
Hypothesis, 289–290
I
IC. See Internal locus of control
ICD‐10. See International Statistical Classification of Diseases and Related Health
Problems
ICE. See Immigration Customs Enforcement
IC‐EC. See Internal locus of control‐external locus of control
IC‐ER. See Internal locus of control‐external locus of responsibility
IC‐IR. See Internal locus of control‐internal locus of responsibility
Identifying information, in culturally sensitive intake interview, 292
Identity: group level of, 35, 36, 37, 38; individual level of, 34, 36, 38; Jewish, 414, 416,
418–419; tripartite framework for understanding dimensions of, 32–35; universal level
of, 35, 36, 38
Immersion and emersion status, of Helms White Racial Identity Development model,
262
Immersion‐emersion stage, of Cross nigrescence model, 237
Immigrants: defined, 407; education levels of, 395; populations of, 394
Immigrants and refugees, 393–407; barriers to seeking treatment among, 401;
counseling of, 403, 405–406; cultural and acculturation issues for, 398; cultural strengths
of, 399; gender issues and domestic violence of, 398–399; historical and sociopolitical
factors for, 396–397; linguistic and communications with, 402; post persecution, torture,
trauma influence on, 403, 404; prejudice and discrimination of, 400–401; safety issues
and coping with loss among, 404–405; Trump on, 394, 396; undocumented, 349, 394–
395, 397, 400, 401, 405–406
Immigration Act, of 1965, 396
Immigration Customs Enforcement (ICE), U.S., 396
Incarceration, of African Americans, 303, 310
Inclan, J., 159
India, atman in, 147
Indian Child Welfare Act, 321, 322
Indian Health Services, 327
Indigenous healing, 212, 226–228; Băt Gió (catching the wind), 218; belief in
metaphysical levels of existence, 220–222; Cao Gió (scratching the wind), 218; cultural
syndromes and, 214–218; espiritismo, 221; examples of, 224–225; ghost sickness, 213–
214, 215; Giác Hoi (pressure massage), 218; HC‐MC, 205–206; holistic outlook,
interconnectedness, and harmony in, 219–220, 223; ho'oponopono, 224; mahiki, 222;
non‐western methods of, 219; ’oia’i’o (truth telling), 222; principles of, 218–223; pule
ho’opau (closing prayer), 222; pule weke (opening prayer), 222; shaman as therapist
commonalities, 215–216; spirituality dangers and benefits in, 226; spirituality in life and
cosmos of, 222–223; sweat lodge ceremony, 222–223, 320; Thùôc Nam, 217, 218
Individual level of identity, 34, 36, 38
Individual‐centered counseling, 99, 113, 147, 183
Individualism, 38, 56; family approaches to, 159–160; U.S. culture and, 147, 159
Individuals: culture‐bound values focus on, 147–149, 163; social justice counseling
focus on, 85; worldview, 110–112
The Inequality of the Human Races (de Gobineau), 81
Inferiority: Galton and Rushton on African American, 81; media on people of color,
240; of others, belief in, 103
“Inside Edition” television program, 442
Insight, 78, 149–150, 154, 163
Institutional racism, 103
Integration/Biculturalism, 340
Integrative awareness phase, of R/CID, 239, 245–246, 249, 251, 267
Interconnectedness, 219–220, 223
Internal locus of control (IC), 111
Internal locus of control‐external locus of control (IC‐EC) dimensions, 111
Internal locus of control‐external locus of responsibility (IC‐ER), 112, 113, 115
Internal locus of control‐internal locus of responsibility (IC‐IR), 112, 113
Internalization stage: of Cross nigrescence model, 237; of Hardiman White Racial
Identity Development model, 261
Internalization‐commitment stage, 237
Internalized racism, 240
International Statistical Classification of Diseases and Related Health Problems (ICD‐
10), 214
Interpersonal distance zones, 171
Interpreters, 336, 359, 400, 402, 406; confidentiality and, 155–156
Interracial and interethnic bias, 49, 52–54
Interracial and interethnic conflicts, 51
Interracial and interethnic discrimination, 52–54
Interracial and interethnic group relations, 54–56
Interracial marriage, 365, 366, 368
Interventions, counseling: foci of, 85; levels of, 86
Intimate interpersonal distance zone, 171
Introspection phase: of R/CID, 239, 244–245, 246, 249, 251; of White racial identity
development, 266–267
Invisible veil, 104, 259
Islam, 383, 384, 390
Islamophobia, 124
Ivey, A. E., 182
J
Jackie African American case study, 306–307
Jackson, Lisa, 479
Jefferson, Thomas, 104
Jenner, Caitlin, 442
Jenny, Sansei (third generation) Japanese American case study, 234–235
Jewish Americans, 410; anti‐Semitism, 125, 411, 414, 416, 417, 418–419, 420;
characteristics and strengths of, 412–415; counseling of, 418–419; cultural strengths of,
415; ethnic identity issues of, 413–414; gender‐related considerations, 414; historical
and sociopolitical background of, 415–416; overview of, 411–412; patriarchal roles and,
414; prejudice and discrimination of, 416–417; spiritual and religious values of, 412–
413
Jewish identity, 414, 416, 418–419
Jewish Issues in Multiculturalism: A Handbook for Educators and Clinicians
(Langman), 418
Johnny African American case study, 305
Jones, A. C., 310–311
Jones, Doug, 302
Jones, J. M., 103
Jones Model, 310–311
Jordan, Vernon E., 75
Journal of Counseling Psychology, 250
Judaism, 411, 414; Conservative, 413; Orthodox, 413, 415, 418, 419; Progressive, 413,
420; Reform, 413
Judgmental heuristics, 284, 295
K
Katherine, Asian American case study, 334
Katz, J., 147, 259
Kemp, N. T., 436
Kinesics, 172–173, 183, 185
King, Rodney, 54
Kinship bonds: of African Americans, 160, 304, 308; of AI/AN, 159–160
Kiselica, Mark, 9–11
Kluckhohn, F. R., 157, 164
Knowledge, 32, 40, 43; component, in curriculum and training, 80
Koro, 215
Kozol, Jonathan, 479
Ku Klux Klan, 415
L
LaFromboise, T., 326
Lakota Sioux, 222
Langman, P. F., 418–419
Language barriers, MCT and, 155–156, 163
Larry P. v. California, 79
Latinx Americans: African Americans conflicting relationships with, 55–56; Asian
Americans conflicting relationships with, 55; communication styles of, 152, 173, 181;
depression of, 193, 335–336; emotional expressiveness of, 149; past‐present
orientation of, 158
Latinx populations, 348, 361; acculturation conflicts of, 356–359, 360; alcohol and
substance abuse of, 356; American identity development models, 241–242;
characteristics and strengths of, 350–355; counseling of, 359–360; cultural strengths of,
355; cultural values and characteristics of, 350–351; educational characteristics of, 354–
355; extended family of, 350, 355, 358; family structure of, 351–352; gender role
expectations of, 352–353; LGBTQ, 448; linguistic issues of, 359; overview of, 349–350;
racism and discrimination of, 354; spiritual and religious values of, 353–354; stigma
associated with mental illness of, 355–356; time orientation of, 159; Trump on, 349
LC. See Low‐context
Learned helplessness, 114
Leondar‐Wright, B., 482
Lesbian, 442–444, 450, 454
Lesbian, gay, bisexual, transgender, queer (LGBTQ) individuals, 12, 441; ACA and,
452; adoption by, 446; African American, 448; aging and, 451–452; characteristics and
strengths of, 443–447; coming out of, 443, 447–449, 451–452, 453, 454; counseling of,
452–453; couples and families, 446–447; microaggressions against, 123, 132–133;
Obama on rights of, 442–443; oppression of, 101; prejudice, discrimination and
misconceptions about, 449–451; sexual and gender identity issues of, 443–444; social
isolation, depression, and suicide of, 445; strengths of, 447; substance abuse of, 445,
447, 450, 452; universal‐diversity orientation and, 200; youth, 444–446
Levels of intervention, 86
LGBTQ. See Lesbian, gay, bisexual, transgender, queer
Lindsey, E. S., 448
Linguistic barriers, for Latinx populations, 359
Locus of control, 113–115, 117; externality and culture factors of, 111; externality and
sociopolitical factors on, 112; powerlessness and, 112; worldview and, 111–112
Locus of responsibility, 112–115, 117–118
Lopez, Jennifer, 30
Los Angeles Police Department, 54
Los Angeles Riots, of 1992, 52, 54
M
Machismo, 356, 357, 360, 448
Mahiki, 222
Mallinckrodt, B., 436
Marcos, L. R., 359
Marginal cultural orientation, 323
Marginalized groups: African American and Asian American relationships, 54;
American Indians and Black, Latinx and Asian Americans, 56; Asian and Latinx
Americans relationships, 55; counseling of, 66; counselors from, working with majority
and other marginalized group clients, 51; counselors of color and dyadic combinations,
58–66; historical and political relationships between groups of color, 54–56; interracial
counseling relationships, 49–50; Latinx Americans and Black Americans relationships,
55–56; mental health underutilization by, 77; politics of interethnic and interracial bias
and discrimination, 49, 52–54; racial/ethnic groups differences, 56–58; stereotypes held
by socially marginalized group members, 50; “who's more oppressed” game of, 50
Marianismo, 352, 360
Marshall depression case study, 120–121
Martin, Trayvon, 75
Mary AI/AN case study, 322
Massacres: Pulse nightclub, 442; Wiyot tribe, 317
May, Genevieve, 466
McCullough, R. J., 41–42
McDonald, Laquan, 302
MCO. See Multicultural orientation
MCT. See Multicultural counseling and therapy
Media: on African Americans as criminals, 309–310; people of color inferiority and,
240; poverty and, 478; women sexualization and marginalization of, 490
Medical experiments, on African Americans, 75–76
Medical history, in culturally sensitive intake interview, 293
Medical model, regarding disability, 429, 437
MENA. See Middle Eastern and North African
Mental disorders: CFI on, 288, 291; cultural expression of, 406; poverty and, 152–153,
479–480; PWD and, 428; science and research on treatment of, 189. See also
Depression; specific disorders
Mental functioning, physical functioning distinction from, 151–152
Mental health: abnormality as presence of certain behaviors, 78–79; curriculum and
training deficiencies, 79–80; definitions of, 77–80; MCT and, 36; normality as ideal, 78;
normality as statistical concept, 77–78; sociopolitical oppression impact on, 75–77
Mental health literature, 80; culturally deficient model and, 82–83, 93; culturally diverse
model and, 83, 93; genetically deficient model and, 81–82, 93; pathology and persons of
color in, 81–83
Mental health services, marginalized groups underutilization of, 77
Merchant of Venice (Shakespeare), 35
Mestizos, 56
Metaphysical levels of existence, 220–222
#MeToo campaign, 49, 489
Mexican Americans. See Latinx Americans
Michael African American case study, 307
Microaggressions, 12, 119–121, 137–138; classist, 483; defined, 122, 124–125;
dynamics and dilemmas of, 129–133; evolution of isms and, 124–126; examples of,
127–129; gender, 498; against LGBTQ, 123, 132–133; microassault and, 125;
microinsult and, 125–126; microinvalidation and, 126; response to, 132–133; therapeutic
implications, 133–136; therapeutic practice examples, 135–136
Microassault, 125
Microinsult, 125–126
Microinterventions, 137
Microinvalidation, 126
MID. See Minority Identity Development
Middle Eastern and North African (MENA) descent, 383
Migration, 394
Milano, Alyssy, 489
Miller, J. B., 483
Mini‐Mental State Examination (MMSE), 464
Minority Identity Development (MID) model, 238
Minority model, regarding disability, 429, 437
Minority standard time, 153–154
Miranda, A. O., 357
Miscegenation, 365
MMSE. See Mini‐Mental State Examination
Model minority myth, 50, 332, 344
Mohammed, Yusor, 382
Monoracial, 367, 371, 374
Montana Indian Reservation, 326
Moore, Roy, 302
Moral model, regarding disability, 429, 437
Morales, E., 191
Morato, Clara, 356
Morita therapy, 220
Mosavi, Abraham, 394
Mosque, 386
The Mother to Son Program, 306
Motivation variable, trustworthiness as, 107
Moua, Ker, 155
Moynihan Report, 83
MSJCC. See Multicultural and Social Justice Counseling Competencies
Muhammad, 384
Mullainathan, S., 309
Multicultural and Social Justice Counseling Competencies (MSJCC) (Ratts, Singh,
Nassar‐McMillan, Butler, and McCullough), 41; ACA and, 51, 85; quadrants,
domains, client worldview, and competencies in, 42
Multicultural Competency in Geropsychology, of APA, 452
Multicultural counseling, 51; APA Multicultural Guidelines on, 76–77
Multicultural counseling and therapy (MCT), 75, 258, 260; activity dimensions of, 160–
161; communication styles implications for, 152, 182–184; defined, 37–38; differential
communication skills in, 181–182; etic versus emic formulations for, 29–31; group
identities impact, 37; individual and universal biases in psychology and mental health,
36; language barriers and, 155–156, 163; nature of people dimension in, 161–162;
overgeneralizing, stereotyping and, 162; patterns of American cultural assumptions,
156–162; people‐nature dimension in, 157–158; relational dimension in, 159–160;
time dimension in, 158–159; tripartite framework on multiple identity dimensions, 32–
35
Multicultural counseling competence: cultural incompetence harm and, 32; culturally
responsive counseling and, 32; nature of, 31–32; superordinate nature of cultural
competence and, 31
Multicultural Guidelines, of APA, 76–77
Multicultural orientation (MCO) framework, 133–134
Multicultural skills, 287
Multicultural training: behavioral resistance to, 20–21; cognitive resistance to, 16–17,
80; emotional resistance to, 17–20; recognizing and understanding resistance to, 13–21
Multiculturalism, 21; evidence‐based practice and, 188–208
Multiracial, 365; Census Bureau on category of, 366
Multiracial populations, 364, 376; characteristics and strengths of, 366–369; counseling
of, 374–375; discrimination and racism of, 373–374; intermarriage, stereotypes and
myths about, 372–373; multiracial bill of rights and, 374; multiracial strengths and, 368–
369; multiracialism in U.S. and, 366–367; one drop of blood rule, 367–368; overview of,
365–366; racial and ethnic ambiguity, 369–370; racial identity invalidation, 370–372
Murdock, Timothy, 256–257
Muslim Americans. See Arab Americans and Muslim Americans
N
NAACP. See National Association for the Advancement of Colored People
Nadella, Satya, 489
Naikan therapy, 220
Naiveté stage: of Hardiman White Racial Identity Development model, 261; of White
racial identity development, 264
Nassar‐McMillan, S., 41–42
National Alliance for Caregiving, 491
National Association for the Advancement of Colored People (NAACP), 92, 366
National Center for Education Statistics, 394
National Center for Public Policy and Higher Education, 479
National Child Traumatic Stress Network, 205
National Coalition for the Homeless, 478, 480
National Coalition for Women and Girls in Education, 493
National Conference of Christians and Jews, 50
National Conference of State Legislatures, 322
National Council on Disability, 427
National Council on Interpreting in Health Care, 155
National Crime Victims Research and Treatment Center (NCVC), 205
National Economic Council, 81
National Immigration Law Center, 400
National Indian Child Welfare Association, 321
National Institute of Alcohol Abuse and Alcoholism, 466
National Law Center on Homelessness and Poverty, 479
National Registry of Evidence‐based Programs and Practices (NREPP), 204
Native Americans. See American Indians
Naturalized citizens, 396, 397
Nature of Prejudice (Allport), 270
NCVC. See National Crime Victims Research and Treatment Center
Nelson, G., 483
Nervios (nervousness), 215
Nested or embedded emotions, 10
Netanyahu, Binyamin, 417
Nguyen family case study, 216–218
Nigrescence, 236, 237, 303, 304
Noninterference, of AI/AN, 319–320, 328
Nonracist, 20
Nonracist White identity, 259, 263, 274; developing, 267–273; principles of prejudice
reduction and, 270–273
Nonverbal communication, 170; of AI/AN, 320, 328; HC and LC communication, 175–
176, 183, 185; kinesics and, 172–173, 183, 185; nonverbals as reflections of bias in,
177–178, 185; nonverbals as triggers to biases and fears, 178–181, 185; paralanguage
and, 174–175, 183, 185; proxemics and, 171–172, 183, 185; sociopolitical facets of,
176–181
Nonverbals as bias reflection, 177–178, 185
Nonverbals as triggers to bias, 178–181, 185
Norcross, J. C., 191
Normality: as ideal mental health, 78; as statistical concept, 77–78
#NotYourAsianSidekick, 342
NREPP. See National Registry of Evidence‐based Programs and Practices
Nuclear families, 157, 159, 160, 164, 305
O
Obama, Barack, 76, 309; DACA authorization by, 397; on LGBTQ rights, 442–443
Office of Minority Health, 317
’Oia’i’o (truth telling), 222
Older adults, 458; characteristics and strengths of, 459–462; counseling of, 468–469;
cultural values and, 57; elder abuse and neglect, 465–466, 470; mental deterioration of,
463–465; overview of, 459–460; physical and economic health of, 459–460; prejudice
and discrimination regarding, 462–463; sexuality and, 460–461; social isolation,
depression, and suicide, 467–468; substance abuse, 466–467
On the Origin of Species by Natural Selection (Darwin), 81
One Drop Rule, 375
Opening prayer (pule weke), 222
Oppression: contemporary forms of, 101–107, 123–124; cultural, 113; ethnocentric
monoculturalism, 102–104; historical manifestations of ethnocentric monoculturalism,
104–105; LGBTQ, 101; sociopolitical, 75–80; systemic, 98–117; “who's more
oppressed” game, 50
Organista, K. C., 193
Organizational focus, of social justice counseling, 85
Orthodox Judaism, 413, 415, 418, 419
Orwell, George, 74
Our Bodies, Ourselves, Lindsey chapter in, 448
Overgeneralizing, stereotyping and, 162
Overt racism, 11–12
Overt sexism, 123, 492, 499
P
Pacific Islanders. See Asian Americans and Pacific Islanders
Pan, D., 202
Pani (termination ritual), 222
Pantraditional cultural orientation, 324
Paralanguage, 174–175, 183, 185
ParentCenterHub.org, 435
Parenting styles, of Asian Americans and Pacific Islanders, 336, 345
Parents, Families, and Friends of Gays and Lesbians (PFLAG), 445
Past‐present orientation, 158
Pathology and persons of color, 81–83
Patriarchal roles: AI/AN and, 319; of Arab Americans, 384, 390; of Asian Americans,
335, 342, 343; Jewish Americans and, 414; in U.S., 489, 500
People of color: historical and political relationships between, 54–56; media on
inferiority of, 240; values and beliefs of, 157. See also Racial, ethnic, cultural identity
People with disabilities (PWD), 425, 438; ADA and, 427–428; characteristics and
strengths, 427–432; counseling of, 435–436, 437; family counseling for, 436–437; life
satisfaction and, 430; mental disorders and, 428; myths about, 428–429; overview of,
426–427; prejudice, discrimination and, 123, 124, 432–434; sexuality, reproduction and,
431; spirituality, religiosity and, 431; suicide and, 430; supports for, 434–435; things to
remember when interacting with, 434
Peoplehood, 62, 160, 223, 306
People‐nature dimension, in MCT, 157–158
Personalismo, 182, 355
Person‐Centered Counseling, of Rogers, 181
Person‐environment interactions, 87, 90
Pew Research Center, on LGBTQ adults, 449
PFLAG. See Parents, Families, and Friends of Gays and Lesbians
Physical functioning, distinction between mental and, 151–152
Pichette, E. F., 323–324
Pierce, Chester, 122
Pinckney, Clementa, 309
Playing it cool, 105, 106
Playing the dozens, 180
Plessy v. Ferguson, 367
Police violence, African Americans and, 302, 309
Political relationships, between people of color, 54–56
Politics, counseling implications and, 73–94
Politics, of interethnic and interracial bias and discrimination, 49; Los Angeles riots, of
1992, 52, 54; Trump and, 52–53
Positive regard, respect, warmth and genuineness, 196, 200–201, 207–208
Post‐traumatic stress disorder (PTSD), 205, 214, 217, 404
Poussaint, Alvin, 367
Poverty, 474–477, 484–485; of African Americans, 303; Census Bureau on rate of, 476;
class‐bound values impact and, 152–153, 163; classism and minimum wage, 480–481;
counseling of, 482–483; criminalization of, 478; cultural invisibility and social exclusion
of, 478; depression and, 478–479; disparities in judicial system and, 480; educational
inequalities, 478–479; environmental injustice and, 480; health care inequities and, 481;
media and, 478; mental disorders and, 152–153, 479–480; negative attitude and beliefs
regarding, 481–482; strengths of, 477–478; women in, 477
Powerlessness, locus of control and, 112
Preencounter stage, in Cross nigrescence model, 236, 304
Prejudice, 304, 308; against immigrants and refugees, 400–401; against Jewish
Americans, 416–417; against LGBTQ, 449–451; against older adults, 462–463;
principles of reduction for, 270–273; against PWD, 123, 124, 432–434
Pre‐migration trauma, of refugees, 403, 404
Presenting problem, in culturally sensitive intake interview, 292
Present‐time orientation, 158
Presidential Task Force on Evidence‐Based Practice, of APA, 80, 191
Presidential Task Force on Immigration, of APA, 398, 399
Presidential Task Force on Preventing Discrimination and Promoting Diversity, of APA,
270
President's Initiative on Race, 1998, 74, 270
President's Initiative on Race, 1999, 270
President's New Freedom Commission on Mental Health, 288
Pressure massage (Giác Hoi), 218
Prilleltensky, I., 483
Problem‐solving set, 107–108
Professional focus, of social justice counseling, 85
Progressive Judaism, 413, 420
Proxemics, 171–172, 183, 185
Pseudo‐independence status, of Helms White Racial Identity Development model, 262
Psychological survival, 178
Psychology and Economic Injustice (Lott and Bullock), 482
Psychosocial history, in culturally sensitive intake interview, 292
Psychotherapy. See Counseling and psychotherapy
R
Rabbi, 418
Race, defining, 82
Race salience, 238
Race‐Based Traumatic Stress Symptom Scale, 293
Racial, ethnic, cultural (REC) identity, in people of color, 233–235, 251–252;
foundational models of, 236–238, 250; R/CID model of, 238–250
Racial and ethnic groups, cultural values of, 56–57
Racial and ethnic identity, 233–252, 312; of African Americans, 303–304; issues
regarding stage of, 58; Jewish Americans issues with, 413–414
Racial animosity, receiving and expressing, 64–65
Racial awakening, 234–235
Racial identity, 303–304, 308–309; Asian Americans issues with, 339–340
Racial identity attitudes, 52
Racial identity invalidation, 370–372
Racial microaggressions. See Microaggressions
Racial profiling, 122
Racial socialization, 310
Racial/Cultural Identity Development model (R/CID): Asian American identity
development models, 240–242; conformity phase of, 239–241, 244, 246, 247, 249, 251;
counseling implications of, 246–249; dissonance phase of, 239, 241–242, 248, 251;
integrative awareness phase of, 239, 245–246, 249, 251, 267; introspection phase of,
239, 244–245, 246, 249, 251; Latinx/Hispanic American identity models, 241–242;
models for, 236–238; racial awakening and, 234–235; resistance and immersion phase
of, 239, 242–244, 248, 251; value of framework in, 249–250
Racial‐cultural microcosm, counseling as, 99–100
Racial/ethnic ambiguity, 369–370
Racism, 263; of African Americans, 303, 305, 306–307, 309–311; of Arab Americans
and Muslim Americans, 385–388; of Asian Americans and Pacific Islanders, 333–334,
342; aversive, 123; covert and overt, 11–12; cultural, 102; discrimination and, 75;
institutional, 103; internalized, 240; of Latinx populations, 354; of multiracial
populations, 373–374; scientific, 80, 81, 82; sociocultural awareness of, 100;
unintentional, 259, 263
Ramadan, 384
Rapport, 101
Rational Emotive Behavior Therapy (REBT), of Ellis, 181
Ratts, M. J., 41–42
R/CID. See Racial/Cultural Identity Development model
Reaching Out About Depression (Road) project, 475
REBT. See Rational Emotive Behavior Therapy
REC. See Racial, ethnic, cultural identity
Redefinition stage, of Hardiman White Racial Identity Development model, 261
Reform Judaism, 413
Refugees: counseling of, 403; defined, 407; pre‐migration trauma of, 403, 404; Trump
cap on settlements of, 397. See also Immigrants and refugees
Regan, Judith, 417
Regret, meaning of, 19–20
Rehabilitation approach, 434–435
Reiman, J., 479
Reintegration status, of Helms White Racial Identity Development model, 262
Relational dimension, in MCT, 159–160
Religion, spirituality versus, 226
Religious discrimination, 122, 124, 125
Remorse, meaning of, 19–20
Report of the APA Task Force on Gender Identity and Gender Variance, of APA, 452
Report of the Task Force on Resources for the Inclusion of Social Class in Psychology
Curricula, of APA, 482
Reservation, 317, 318, 321, 322, 326
Resistance: behavioral, to multicultural training, 20–21; client therapy, 15; cognitive, to
multicultural training, 16–17, 80; emotional, to multicultural training, 17–20;
recognizing and understanding, 13–21
Resistance and immersion phase: of R/CID, 239, 242–244, 248, 251; of White racial
identity development, 266
Resistance stage, of Hardiman White Racial Identity Development model, 261
Respeto (respect), 161, 162
Responsibility, locus of. See Locus of Responsibility
Richards, Michael, 125
Ridley, C. R., 259
Riessman, F., 82–83
Risk of harm to self or others, in culturally sensitive intake interview, 294
Road. See Reaching out about depression
Rogers, Carl, 181
Root, Maria, 374
Rose, T., 483
Rushton, J. P., 81
S
SAGE. See Senior Action in a Gay Environment
Saloy, Mona Lisa, 180
Same‐sex marriage, 442
Sansei (third generation) Japanese American case study, 234–235
Sant‐Barker, S. M., 293
Saved by the Light (Brinkley), 220
Schlosser, L. Z., 414
Schmidt, S. R., 191, 205–206
Schofield, W., 147
Scientific empiricism, 151
Scientific racism, 80, 81, 82
Scratching the wind (Cao Gió), 218
Seinfeld television show, 125
Selective serotonin reuptake inhibition (SSRIs), 468
Self‐awareness, 285–286, 287
Self‐directed, 335
Self‐disclosure, 61–62, 78, 183; of AI/AN, 150; of Asian Americans and Pacific
Islanders, 150; culture‐bound values and, 150–151; therapeutic alliance and, 198, 201
Self‐reflection, 9–10, 80, 99, 153
Self‐silencing, 132
Senior Action in a Gay Environment (SAGE), 452
September 11, 2001 terrorist attacks, 75, 124, 386–387, 390; immigrants and refugees
impacted by, 400
Sexism, 75, 81, 493; covert, 123, 492, 499; curriculum on anti, 79–80; hetero‐, 123,
124; overt, 123, 492, 499; subtle, 123, 492, 498, 499
Sexual harassment, 489, 492–493
Sexual objectification, 490, 492
Sexual orientation, 443; LGBTQ youth and, 445
SFBT. See solution‐focused brief therapy
Shabbat, 414
Shakespeare, William, 35
Shaman, 213, 215–216, 227–228
Shame of the Nation (Kozol), 479
Sharing, of AI/AN, 319, 325, 328
Shenkui, 215
Shiite, 383
Silence, 174
The Silent Language (Hall, E.), 175
Simpatico, 355
Simpson, O. J., 417
Singh, A. A., 41–42
Situation‐centered approach, 111, 112
Skills, 31, 37, 38, 40, 43; component, in curriculum and training, 80; differential, in
communication styles, 181–182
Slavery, 105, 114, 256, 367
Smith, L., 173
Social class, 152, 154, 475
Social class privilege, 475, 479, 483
Social class stratification theory, 475, 483
Social interpersonal distance zone, 171
Social justice, counseling and implications of, 73–94
Social justice advocacy: counseling roles and, 92, 484; cultural humility and, 91
Social justice counseling, 84, 86–89, 93, 483; advocacy and cultural humility, 91;
advocacy counseling roles and, 92, 484; advocacy for organizational change and, 90–91;
goals of, 90; individual focus of, 85; organizational focus of, 85; professional focus of,
85; societal focus of, 85
Social rhythm, 170
Social sciences, Asians study ignored by, 80
Socially marginalized groups, 8, 50
Societal focus, of social justice counseling, 85
Societal roles and expectations, of women, 490–491
Sociocultural awareness, of racism, 100
Sociopolitical factors, externality and, 112
Sociopolitical oppression: mental health impacted by, 75–77; mental health
professionals training and, 77–80
Solution‐focused brief therapy (SFBT), 189–190; Asian Americans and, 341–342
Somatic complaints, 337–338
Soopermexican, 442
Southern Education Foundation, 478
Southern Poverty Law Center, 92, 396
Spiritual and religious values: of African Americans, 222–223, 306; of Jewish
Americans, 412–413; of Latinx populations, 353–354; of PWD, 431
Spirituality: of AI/AN, 320, 328; dangers and benefits of, in indigenous healings, 226;
indigenous healings, in life and cosmos, 222–223; religion versus, 226
Spokesperson, 179
SSRIs. See Selective serotonin reuptake inhibition
Standing Rock Sioux pipeline, 317
Stanford Binet intelligence test, 79
Stereotype threat, 494
Stereotypes, 106, 282–284, 295; of African Americans, 50; of Arab Americans and
Muslim Americans, 385–388; of Asian Americans and Pacific Islanders, 50, 80; cultural
self‐awareness and, 285–286; culturally related responses and, 100, 101; historical, 50;
about multiracial populations, 372–373
Stereotyping, 108; overgeneralizing and, 162
Stiver, I. P., 483
Strengths: in culturally sensitive intake interview, 293; gender, 491; poverty and, 477–
478. See also Characteristics and strengths; Cultural strengths
Strodtbeck, F. L., 157, 164
Strong Black Woman image, 308–309
Substance abuse. See Alcohol and substance abuse
Subtle sexism, 123, 492, 498, 499
Sue, Derald Wing, 74
Suicide: of LGBTQ youth, 445; of older adults, 467–468; PWD and, 430
Summers, Larry, 81
Sunni, 383
Survival, 177–178
Survivor's guilt, 403, 405
Susto (fright), 215
Sweat lodge ceremony, American Indian, 222–223, 320
Swinomish Tribal Mental Health Project, 325
Symbolic logic, 151
Synagogue, 411
Systemic oppression: impact of, 98–117; surviving, 105–107
Systemic worldview, 110–112
T
Talbot, Gary, 430
Tam, Ruth, 342
Task Force on Socioeconomic Status, of APA, 147, 153
Tatum, B. D., 268, 269
Temporary Protected Status (TPS), 397
Termination ritual (Pani), 222
TF‐CBT. See Trauma‐focused cognitive‐behavioral therapy
Therapeutic alliance, 61, 195, 287; communication styles and, 63–64; connectedness,
196; countertransference management and, 198, 201–202, 208; emotional or
interpersonal bond and, 196, 198–202, 207–208; empathy and, 196, 208; ethnic group
clients counselor preferences for, 197; goal consensus and, 196–197, 202–203, 208;
microaggressions and, 133; positive regard, respect, warmth, and genuineness and, 196,
200–201, 207–208; self‐disclosure, 198, 201
Therapeutic bond, 198
Therapeutic class bias, 153–154
Therapeutic style, 183
Thin ideal, for women, 490
Thomas, Charles W., 75
Thomas, Helen, 411
Thorndike Prize, of APA, 81
Thùôc Nam, 217, 218
Time dimension, in MCT, 158–159
Time orientation: of AI/AN, 320, 328; of Latinx populations, 159; minority standard
time, 153–154; in White culture, 158–159
Tometi, Opal, 302
Torah, 412
Toxic rain, 129
TPS. See Temporary Protected Status
Traditional cultural orientation, 323
Transference, 62
Transgender, 442, 443, 444, 452, 453, 454; discrimination of, 124
Transphobia, 124
Trauma, 293; pre‐migration, of refugees, 403, 404; PTSD, 205, 214, 217, 404
Trauma‐focused cognitive‐behavioral therapy (TF‐CBT): cultural adaptations of,
205–206; HC‐MC adaptation to, 205–206
Trevor project, 445
Tribal social structure, of AI/AN, 318
Tribe, 317, 318, 321, 325
Tripartite framework, for understanding identity dimensions, 32–35
Trump, Donald: on immigrants, 394, 396; on Latinx population, 349; on LGBTQ rights,
443; microassault of, 125; Muslim ban of, 382, 387; race relations and, 52–53; refugee
settlements cap by, 397; Standing Rock Sioux pipeline and, 317
Trustworthiness: confidentiality and, 109; credibility and, 109–110; as motivation
variable, 107
Tur, Zoey, 442
Tuskegee experiment, 75–76
U
Umhoefer, D. L., 357
Unbiased person, 20
Uncle Tom Syndrome, 104, 106
Undocumented immigrants, 349, 394–395, 397, 400; counseling of, 405–406; higher
education and, 401
Unintentional expressions, of bias, 131
Unintentional racism, 259, 268
United Cerebral Palsy, 434
United States (U.S.): Attorney's Office, 302; Census Bureau, 366, 426, 476; Department
of Justice, 302, 321; DHHS, 467; EPA, 479; ICE, 396; individualism and, 147, 159;
multiracialism in, 366–367; patriarchal roles in, 489, 500
Universal level of identity, 35, 36, 38
Universal shamanic tradition, 219
Universal‐diversity orientation, 200
University of California, Berkeley, 234
U.S. See United States
V
Values: bicultural, 357; class‐bound, 152–154, 163; cultural, 56–57, 63, 65, 67; of
people of color, 157; of White culture, 104, 147, 148, 157. See also Cultural and
spiritual values, of AI/AN; Culture‐bound values; Spiritual and religious values
Van Dyne, Jason, 302
Verbal communication, 170
Verbal skillfulness, 180
Verbal/emotional/behavioral expressiveness, 149, 163
Victim blaming, 30, 78, 100, 122
Victimization, 492–493, 497, 500
Vision quest, 221–222, 320
W
WAIS intelligence test, 79
Weber, S. N., 180
Weinrach, Stephen, 416
Welfare queen, 477, 483
Western healing, 219, 228
Where We Stand: Class Matters (hooks), 482
White alliance, 269–270
White culture: communication styles, 179; components of, 148; Katz on, 147; normative
characteristics of, 102; time orientation in, 158–159; values and beliefs of, 104, 147,
148, 157; worldview of, 104
White deception, 178
White fragility, 100–101
White Freedom Riders, 412
White genocide, 257
White guilt, 19
White privilege, 257, 258, 267, 339
White racial identity development, 255, 274; conformity phase of, 264–265; developing
nonracist white identity, 267–273; dissonance phase of, 265–266; Hardiman model of,
260–261; Helms model of, 261–263; introspection phase of, 266–267; naiveté stage of,
264; overview, 256–258; prejudice reduction principles, 270–273; process of, 263–267;
resistance and immersion phase of, 266; understanding dynamics of, 258–260; White
antiracist identification, 267–273; White privilege and, 257, 258, 267, 339; White
supremacy and, 258–259, 263, 268, 273
White racial identity development descriptive model, 263; seven‐step process of, 264–
267
White social science, 80
White supremacy, 52, 82, 100, 258–259, 263, 268, 273
Whiteness, 263; understanding dynamics and, 258–260
“Who's more oppressed?” game, 50
Williams, W. R., 478
Winter, Sara, 17
WISC intelligence test, 79
Wiyot tribe, massacre of, 317
Women, 352, 488; African American scientists, 302; ageism and, 496–497, 500; APA
on violence against, 493; as caregivers, 489, 490–491; characteristics and strengths,
490–491; counseling of, 499–500; depression and, 497–498; discrimination, harassment,
and victimization regarding, 489, 492–493, 497, 500; economic and employment
barriers regarding, 494–496; educational barriers and, 493–494; gender bias in therapy,
498–499, 500; in poverty, 477; societal roles and expectations of, 490–491
Worldview, 8, 10, 15, 101; of African Americans, 37; of Asian Americans and Pacific
Islanders, 37; cultural syndromes and, 214–218; differences in, 28–29; EC‐ER and,
112, 113, 114–115; EC‐IR and, 112, 113–114; formation of individual and systemic,
110–112; graphic representation of, 113; IC‐ER and, 112, 113, 115; IC‐IR and, 112,
113; locus of control and, 111–112; locus of responsibility and, 112; MSJCC on client,
42; White culture, 104
Wyche, K. F., 478
Table of Contents
Preface
CHANGES TO CCD
EFFICIENT UP‐TO‐DATE COVERAGE
PEDAGOGICAL STRENGTHS
APPRECIATION
REFERENCE
About the Authors
SECTION ONE: The Multiple Dimensions of Multicultural Counseling and Therapy
PART I: The Affective and Conceptual Dimensions of Multicultural Counseling
and Therapy
1 Obstacles to Developing Cultural Competence and Cultural
Humility
REACTIONS TO READING
COUNSELING THE CULTURALLY
DIVERSE
EMOTIONAL SELF‐REVELATIONS
AND FEARS: MAJORITY GROUP
MEMBERS
EMOTIONAL INVALIDATION VERSUS
AFFIRMATION: MARGINALIZED
GROUP MEMBERS
RECOGNIZING AND
UNDERSTANDING RESISTANCE TO
MULTICULTURAL TRAINING
CULTURAL COMPETENCE AND
EMOTIONS
SUMMARY
GLOSSARY TERMS
REFERENCES
2 Multicultural Counseling and Therapy (MCT)
CULTURE‐UNIVERSAL (ETIC)
VERSUS CULTURE‐SPECIFIC (EMIC)
FORMULATIONS
THE NATURE OF MULTICULTURAL
COUNSELING COMPETENCE
A TRIPARTITE FRAMEWORK FOR
UNDERSTANDING THE MULTIPLE
DIMENSIONS OF IDENTITY
INDIVIDUAL AND UNIVERSAL
BIASES IN PSYCHOLOGY AND
MENTAL HEALTH
THE IMPACT OF GROUP IDENTITIES
ON COUNSELING AND
PSYCHOTHERAPY
WHAT IS MULTICULTURAL
COUNSELING AND THERAPY (MCT)?
WHAT IS CULTURAL COMPETENCE?
SOCIAL JUSTICE AND CULTURAL
COMPETENCE
SUMMARY
GLOSSARY TERMS
REFERENCES
3 Multicultural Counseling Competence for Counselors and
Therapists of Marginalized Groups
INTERRACIAL AND INTERETHNIC
BIASES
IMPACT ON INTERRACIAL
COUNSELING RELATIONSHIPS
STEREOTYPES HELD BY SOCIALLY
MARGINALIZED GROUP MEMBERS
THE WHO‐IS‐MORE‐OPPRESSED
GAME
COUNSELORS FROM MARGINALIZED
GROUPS WORKING WITH MAJORITY
AND OTHER MARGINALIZED GROUP
CLIENTS
THE POLITICS OF INTERETHNIC AND
INTERRACIAL BIAS AND
DISCRIMINATION
THE HISTORICAL AND POLITICAL
RELATIONSHIPS BETWEEN GROUPS
OF COLOR
DIFFERENCES BETWEEN
RACIAL/ETHNIC GROUPS
COUNSELORS OF COLOR AND
DYADIC COMBINATIONS
SUMMARY
GLOSSARY TERMS
REFERENCES
PART II: The Impact and Social Justice Implications of Counseling and
Psychotherapy
4 The Political and Social Justice Implications of Counseling
and Psychotherapy
THE MENTAL HEALTH IMPACT OF
SOCIOPOLITICAL OPPRESSION
SOCIOPOLITICAL OPPRESSION AND
THE TRAINING OF
COUNSELING/MENTAL HEALTH
PROFESSIONALS
DEFINITIONS OF MENTAL HEALTH
COUNSELING AND MENTAL HEALTH
LITERATURE
SOCIAL JUSTICE COUNSELING
SUMMARY
GLOSSARY TERMS
REFERENCES
5 The Impact of Systemic Oppression Within the Counseling
Process
LOCATING CLIENTS' PROBLEMS
ENTIRELY INSIDE THE CLIENTS
CULTURALLY RELATED RESPONSES
THAT REPRODUCE STEREOTYPES
RESPONDING WHEN THE ISSUES ARE
OUR OWN: WHITE FRAGILITY
EFFECTS OF HISTORICAL AND
CURRENT OPPRESSION
COUNSELOR CREDIBILITY AND
ATTRACTIVENESS
FORMATION OF INDIVIDUAL AND
SYSTEMIC WORLDVIEWS
FORMATION OF WORLDVIEWS
SUMMARY
GLOSSARY TERMS
REFERENCES
6 Microaggressions in Counseling and Psychotherapy
CONTEMPORARY FORMS OF
OPPRESSION
THE EVOLUTION OF THE “ISMS”:
MICROAGGRESSIONS
THE DYNAMICS AND DILEMMAS OF
MICROAGGRESSIONS
THERAPEUTIC IMPLICATIONS
MANIFESTATIONS OF
MICROAGGRESSIONS IN
COUNSELING/THERAPY
THE PATH FORWARD
SUMMARY
GLOSSARY TERMS
REFERENCES
PART III: The Practice Dimensions of Multicultural Counseling and Therapy
7 Multicultural Barriers and the Helping Professional
MY THERAPIST DIDN'T
UNDERSTAND
STANDARD CHARACTERISTICS OF
MAINSTREAM COUNSELING
CULTURE‐BOUND VALUES
CLASS‐BOUND VALUES
LANGUAGE BARRIERS
PATTERNS OF “AMERICAN”
CULTURAL ASSUMPTIONS AND
MULTICULTURAL FAMILY
COUNSELING/THERAPY
OVERGENERALIZING AND
STEREOTYPING
SUMMARY
GLOSSARY TERMS
REFERENCES
8 Communication Style and Its Impact on Counseling and
Psychotherapy
COMMUNICATION STYLES
SOCIOPOLITICAL FACETS OF
NONVERBAL COMMUNICATION
COUNSELING AND THERAPY AS
COMMUNICATION STYLE
SUMMARY
GLOSSARY TERMS
REFERENCES
9 Multicultural Evidence‐Based Practice (EBP)
EVIDENCE‐BASED PRACTICE (EBP)
AND MULTICULTURALISM
EVIDENCE‐BASED PRACTICE (EBP)
AND DIVERSITY ISSUES IN
COUNSELING
SUMMARY
GLOSSARY TERMS
REFERENCES
10 Non‐Western Indigenous Methods of Healing
WORLDVIEWS AND CULTURAL
SYNDROMES
THE PRINCIPLES OF INDIGENOUS
HEALING
EXAMPLES OF INDIGENOUS
HEALING APPROACHES
DANGERS AND BENEFITS OF
SPIRITUALITY
SUMMARY
GLOSSARY TERMS
REFERENCES
PART IV: Racial, Ethnic, Cultural (REC) Attitudes in Multicultural Counseling and
Therapy
11 Racial, Ethnic, Cultural (REC) Identity Attitudes in People
of Color
RACIAL AWAKENING
REC IDENTITY ATTITUDE MODELS
A GENERAL MODEL OF REC
IDENTITY
COUNSELING IMPLICATIONS OF THE
R/CID MODEL
VALUE OF A GENERAL REC
IDENTITY FRAMEWORK
SUMMARY
GLOSSARY TERMS
REFERENCES
12 White Racial Identity Development
UNDERSTANDING THE DYNAMICS
OF WHITENESS
MODELS OF WHITE RACIAL
IDENTITY DEVELOPMENT
THE PROCESS OF WHITE RACIAL
IDENTITY DEVELOPMENT: A
DESCRIPTIVE MODEL
DEVELOPING A NONRACIST AND
ANTIRACIST WHITE IDENTITY
SUMMARY
GLOSSARY TERMS
REFERENCES
SECTION TWO: Multicultural Counseling and Specific Populations
PART V: Understanding Specific Populations
13 Culturally Competent Assessment
THERAPIST VARIABLES AFFECTING
DIAGNOSIS
CULTURAL COMPETENCE AND
PREVENTING DIAGNOSTIC ERRORS
CONTEXTUAL AND
COLLABORATIVE ASSESSMENT
INFUSING CULTURAL RELEVANCE
INTO STANDARD CLINICAL
ASSESSMENTS
SUMMARY
GLOSSARY TERMS
REFERENCES
PART VI: Counseling and Therapy with Racial/Ethnic Minority Group Populations
14 Counseling African Americans
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
15 Counseling American Indians/Native Americans and Alaska
Natives
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
16 Counseling Asian Americans and Pacific Islanders
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
17 Counseling Latinx Populations
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
18 Counseling Multiracial Populations
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
PART VII: Counseling and Special Circumstances Involving Racial/Ethnic
Populations
19 Counseling Arab Americans and Muslim Americans
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
20 Counseling Immigrants and Refugees
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
21 Counseling Jewish Americans
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
PART VIII: Counseling and Therapy with Other Multicultural Populations
22 Counseling Individuals with Disabilities
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
23 Counseling LGBTQ Populations
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
REFERENCES
24 Counseling Older Adults
CHARACTERISTICS AND STRENGTHS
SPECIFIC CHALLENGES
SUMMARY
GLOSSARY TERMS
