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OBSTACLES TO CULTURAL COMPETENCE UNDERSTANDING RESISTANCE TO MULTICULTURAL TRAINING

Chapter Objectives

1. Acknowledge and understand personal resistance to multicultural training.

2. Identify how emotional reactions to topics of prejudice, discrimination, and oppression can act as obstacles to cultural competence.

3. Understand worldview differences between majority and socially devalued group members in this society.

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. Be cognizant of how worldviews may influence the ability to understand, empathize, and work effectively with diverse clients.

6. Realize that becoming an effective multicultural counselor is more than an intellectual exercise and 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/therapy 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 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 and discuss their meaning for the students, and the implications for mental health practice.

Reactions to Reading Counseling the Culturally Diverse

Reaction #1

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)

2. 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 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

1. 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)

2. 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

1. 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)

2. 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

1. 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)

2. 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 Counseling the Culturally Diverse: Theory and Practice (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. Over the last 35 years 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 multicultural counseling/therapy 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 two 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 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 (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 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.

Emotional Self-Revelations and Fears: Majority Group Members

It is clear that the two White students are experiencing strong feelings 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 and gender 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 cultural competence, 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.

I was very upset as I read and reread Sue's book. I felt that Sue had an axe to grind with White America and that he was using his book to do so. I believed that his accusations were grossly exaggerated and, at least to some extent, unfair. And I felt defensive because I am White and my ancestors had not perpetrated any of the offenses against ethnic minorities that Sue had charged. I looked forward to the day when I would be relieved of him and his writings.

Becoming culturally competent in counseling/mental health practice demands that nested or embedded emotions associated with race, culture, gender, and other sociodemographic 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/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. Initially, I didn't want to admit this to myself. That is part of the reason I got so angry at Sue for his book. “His accusations don't apply to me!” was the predominant, initial thought that went through my mind. But Sue's words were too powerful to let me escape my denial of my racism. It was as though I was in a deep sleep and someone had dumped a bucket of ice-cold water onto me, shocking me into a state of sudden wakefulness: The sleep was the denial of my racism; the water was Sue's provocative words; and the wakefulness was the painful recognition that I was a racist. (Sue & Sue, 2013, pp. 9–10)

Years later, 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 Kiselica'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/cultural 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. Maintaining one's innocence by 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.

Kiselica's reflection is a powerful statement that addresses a major question: Can anyone born and raised in our society not inherit the racial biases of our ancestors and institutions? When we pose this question to our students, surprisingly an overwhelming number say “no.” In other words, on an intellectual level they admit that people are products of their social conditioning and that escaping internalizing biases and prejudices is impossible. Yet when racial biases are discussed, these same students have great difficulty entertaining the notion that they have personally inherited racial biases and benefited from the oppression of others, because “racism resides in others, not me!”

Mark's honesty in confronting his own racism is refreshing, and his insights are invaluable to those who wish to become culturally competent counselors and allies in the struggle for equal rights (Chao, Wei, Spanierman, Longo, & Northart, 2015). 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 from many readers. Because CCD deals openly, honestly, and passionately with issues of racism, sexism, and homophobia and challenges our belief that we are free of biases, it is likely to evoke defensiveness, resentment, and anger in readers. In Mark's case, he did not allow these reactions to sabotage his own self-exploration and journey to cultural competence. And we hope you will not allow your emotional “hot buttons” to deter you from your journey to cultural competence as well.

Emotional Invalidation versus Affirmation: For 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 were finally validated rather than silenced or ignored. One of the more interesting comments is made by the Latina student that “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, 2002, 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 LGBTQ persons in their day-to-day interactions with well-intentioned members of the dominant society (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 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 narrative provided by an African American man as he describes his day-to-day experiences with microaggressions that label him a dangerous person, a lesser human being, and a potential criminal.

It gets so tiring, you know. It sucks you dry. People don't trust you. From the moment I [African American male] wake up, I know stepping out the door, that it will be the same, day after day. The bus can be packed, but no one will sit next to you. . . I guess it may be a good thing because you always get more room, no one crowds you. You get served last . . . when they serve you, they have this phony smile and just want to get rid of you . . . you have to show more ID to cash a check, you turn on the TV and there you always see someone like you, being handcuffed and jailed. They look like you and sometimes you begin to think it is you! You are a plague! You try to hold it in, but sometimes you lose it. Explaining doesn't help. They don't want to hear. Even when they ask, “Why do you have a chip on your shoulder?” Shit . . . I just walk away now. It doesn't do any good explaining. (Sue, 2010, p. 87)

Here it is important to note the strong and powerful negative emotions and sense of hopelessness that pervades this narrative. The Black man expresses strong anger and resentment toward Whites for how he perceives they are treating him. His daily experiences of racial slights have made him believe that trying to explain to Whites Americans about these indignities would do little good. In fact, he expresses pessimism, rightly or wrongly, that Whites simply do not understand, and worse yet, they do not care to hear his thoughts and feelings about race and racism. He feels hopeless and frustrated about making White Americans understand, and states, “Shit . . . I just walk away now. It doesn't do any good explaining.” Although he does not directly mention it, one can surmise that he is also tired and drained at having to constantly deal with the never-ending onslaught of microaggressions. For some people of color, the sense of hopelessness can lead to simply giving up.

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.

The majority of my cohort was from the Midwest, and their experiences varied greatly from mine. For example, I remember sitting in my Theories of Counseling course during the first week of the semester. The instructor asked each of us to share about our first exposure to individuals who were racially and ethnically different from ourselves. I thought this was a strange question. . . .I was quite surprised as I listened to what my cohort members shared. I listened to several members share that their first exposure to someone different from them had not occurred until high school and, for some, college. When it came time for me to share, I remember stating that, as a racial and ethnic minority, I had never been in a situation where there was not some type of racial and ethnic diversity. Just sharing this made me feel distant from my cohort, as our different cultural experiences were now plainly highlighted. I remember thinking to myself, “Where am I?” For the first time in my life, I felt as if I was a foreigner, and I badly needed something or someone to relate to.

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, for example, we have often encountered students of color who become very contentious and highly outspoken toward White classmates. There are two dangers here that also reveal resistance from students of color to multicultural training. A good example is provided in the reaction of the African American student in the fourth scenario. First, 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 hurting them. 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 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. Although there is some truth to this matter, 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 interethnic/interracial misunderstandings and biases toward one another. Multicultural training is more than White–African American, White–Latino/a American, White–Asian American, White–Native American, and so on. It is also about African American–Asian American, Asian American–Native American, and Latino/a–Native American relationships; and it includes multiple combinations of other sociodemographic 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 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 White counselor working with culturally diverse clients, would you be able to truly relate to the worldview being expressed by people of color?

5. As a counselor of color working with White clients, what challenges do you anticipate in the therapeutic relationship with them?

6. What do you think “understanding yourself as a racial/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). In therapy sessions, clients may change the topic when recalling unpleasant memories, externalize blame for their own failings, not 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 of themselves as racial/cultural beings, and the meaning it 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? Where are these feelings coming from? Why am I feeling this way, and what does it possibly mean?

2. 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.

3. How applicable are the resistances outlined in the following sections to me?

4. 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?

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 (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 (Sue, 2010; Sue, Torino, Capodilupo, Rivera, & Lin, 2010; van Dijk, 1992). 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 (Feagin, 2001; Sue, Rivera, Capodilupo, Lin, & Torino, 2010; van Dijk, 1992). 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 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 of themselves 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 above 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, or physically leaving the situation were notable avoidant ploys used by students. The apprehensions they felt affected them physically as well (Sue 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, a strong sense of confusion as to what was going on, censoring thoughts or statements that could be misunderstood, reluctance in expressing their thoughts, being overwhelmed by the mix of emotions they felt, and the constriction they heard 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.

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 described 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 these 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 egos (“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 becomes the primary goal 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 two sources: (a) feeling unfairly accused (defensiveness) and/or (b) being told the substance or stance they take is wrong. 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?”) or wronged (“I am deeply hurt you see me that way”), or that their good standing is denied (“Don't associate me with racists!”). Unlike defensiveness, which defends one's own stance, anger turns its attention to attacking the threatening behavior of others. Given the choice of the fight-or-flight response, some White students make a choice to take verbal action in stopping the threatening accusations. 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”). In many respects, anger 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 one rightfully residing and 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 neither would they feel guilt nor 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

All the white people I know deplore racism. We feel helpless about racial injustice in society, and we don't know what to do about the racism we sense in our own groups and lives. Persons of other races avoid our groups when they accurately sense the racism we don't see. . . . Few white people socialize or work politically with people of other races, even when our goals are the same. We don't want to be racist—so much of the time we go around trying not to be, by pretending we're not. Yet white supremacy is basic in American social and economic history, and this racist heritage has been internalized by American white people of all classes. We have all absorbed white racism; pretense and mystification only compound the problem. . . .We avoid black people because their presence brings painful questions to mind. Is it OK to talk about watermelon or mention “black coffee?” Should we use black slang and tell racial jokes? How about talking about our experiences in Harlem, or mentioning our black lovers? Should we conceal the fact that our mother still employs a black cleaning lady?. . .We're embarrassedly aware of trying to do our best, but to “act natural” at the same time. No wonder we're more comfortable in all-White situations where these dilemmas don't arise. (Winter, 1977, p. 1)

Although helplessness and hopelessness can rightly be classified as emotions, they also border on providing direct excuses for inaction. Students studying diversity topics often describe two emotions that vary from helplessness (feeling powerless) to hopelessness (despair) when diversity topics are discussed. These feelings are expressed in the quote above by the author when she realizes the vastness and magnitude of individual, institutional and societal racism; how they make themselves felt in all facets of human life; and how deeply racism is ingrained in the individual psyches of people and in the entire nation. Like many students who read CCD and take this course, the author's denial of her own biases has begun to crumble, and her self-awareness places her in a very uncomfortable position. Trainees who have come to recognize and own their biased beliefs and prejudices, their roles in perpetuating racism, the pain their obliviousness has inflicted on people of color, and their privileged and advantaged position in society may feel overwhelmed by the magnitude of the problem. This may cause paralysis or inaction. Taking steps to make the “invisible” visible and to eradicate bias and discrimination requires concrete action. As long as the person feels helpless and hopeless, inaction will result.

Although guilt continues over realizing their potential culpability over past deeds, it is compounded by the knowledge that continued inaction on their part allows for the perpetuation of racism in the self 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 one's racial/cultural identity, for example, White students at this juncture of development may begin to ask two primary questions:

First is the question, “How does one change?” What needs to be changed? How does one become a nonracist or an unbiased person? How do I break the shackles of social conditioning that have taught me 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.”

The second question is “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).

Helplessness that is felt by White students in diversity studies, unless adequately deconstructed as to what it means, 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 are legitimate feelings unless used as an excuse to escape responsibility for taking any form of action. Helplessness is modifiable when these 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, does not necessarily reside simply in not knowing what to do, but in 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. It allows many of us to not change for fear that our actions will result in the negative consequences expressed above. Becoming a multiculturally competent counselor or therapist requires change.

Cultural Competence and Emotions

There are many other powerful emotions often experienced by students during the journey to 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 this passage by Winter (1977, p. 28), who describes her own racial awakening:

Let me explain this healing process in more detail. We must unearth all the words and memories we generally try not to think about, but which are inside us all the time: “nigger,” “Uncle Tom,” “jungle bunny,” “Oreo”; lynching, cattle prods, castrations, rapists, “black pussy,” and black men with their huge penises, and hundreds more. (I shudder as I write.). We need to review three different kinds of material: (1) All our personal memories connected with blackness and black people including everything we can recall hearing or reading; (2) all the racist images and stereotypes we've ever heard, particularly the grossest and most hurtful ones; (3) any race-related things we ourselves said, did or omitted doing which we feel bad about today. . . Most whites begin with a good deal of amnesia. Eventually the memories crowd in, especially when several people pool recollections. Emotional release is a vital part of the process. Experiencing feelings seems to allow further recollections to come. I need persistent encouragement from my companions to continue.

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 cultural competence 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 a necessity 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 (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, Counseling the Culturally Diverse 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 this 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 this 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 cultural competence, it is necessary to supplement your intellectual development with experiential reality.

6. Don't be afraid to explore yourself as a racial/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 helping professional?

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 training)

Cognitive resistance (to multicultural training)

Cultural competence

Emotional affirmation

Emotional invalidation

Emotional resistance (to multicultural training)

Emotional self-revelation

Microaggressions

Multiculturalism

Nested/Embedded emotions

Nonracist

Self-reflection

Worldview

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THE SUPERORDINATE NATURE OF MULTICULTURAL COUNSELING AND THERAPY

Chapter Objectives

1. Compare and contrast similarities and differences between “traditional counseling/clinical practice” and culturally sensitive counseling.

2. Understand the Etic and Emic orientation to multicultural counseling.

3. Become cognizant of differences between counseling/clinical competence and multicultural counseling competence.

4. Identify Eurocentric assumptions inherent in our standards of clinical practice.

5. Discuss and understand the characteristics of the three levels of personal identity.

6. Develop awareness of possible differences in counseling culturally diverse clients who differ in race, gender, sexual orientation, and other group identities.

7. Provide examples of ways that other special populations may constitute a distinct cultural group.

8. Define multicultural counseling and therapy, cultural competence, and cultural humility.

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 6 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 is 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?

Culturally competent care has become a major force in the helping professions (American Psychological Association, 2003; Arredondo, Toporek, Brown, Jones, Locke, Sanchez, & Stadler, 1996; CACREP, 2015; Cornish, Schreier, Nadkarni, Metzger, & Rodolfa, 2010; D. W. 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 that of the White therapist and the Latina client. In many cases, these 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 Latina/o culture, (d) task orientation, (e) failure to pick up clinical clues provided by the client, (f) not being aware 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 previous 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 multicultural 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 six 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 it 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 Latina/o descent), and is distinguishable from panic attacks (American Psychiatric 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 result in inaccurate diagnosis and inappropriate treatment (D. 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 Latina/o culture as a possible barrier to their therapeutic work together. She wonders aloud, for example, whether he can understand her as a Latina (being a racial/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 Latinos, and (d) that everyone is the “same under the skin.” Although there is much truth to these statements, he has unintentionally negated the racialized experiences of Gabriella, 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 the long period of silence by Gabriella, for example, after Dr. D's response. He apparently misinterprets the silence 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 being concerned about her parents' desires. Western European concepts of mental health stress the importance of independence and “being your own person” because it 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 Latino or Asian American, independence may be considered undesirable and interdependence is valued (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 Latina/o 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 4-minute music video Booty shows Jennifer Lopez and Iggy Azalea with many anonymous beauties grinding 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 enjoyment of it? Is there a relationship between the sexiness of big butts to the terms “fetish” and “emotionality” that upset Gabriella? We know, for example, that Latina 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.

Seeing the Forest through the Trees

These important questions are left unanswered because the therapist fails to see the forest through the trees. Dr. D. appears to suffer from “tunnel vision” and seems more task oriented than people oriented. His major goal seems to be “identify the problem (panic attacks) and solve it (relaxation exercises, medication, etc.).” Who Gabriella is as a flesh and blood person seems less important than the problem. In its attempt to mimic the physical sciences, the discipline of mental health practice has often stressed the importance of objectivity, rational thinking, and problem solving—identify the problem and solve it. Although valuable in many respects, this approach may clash with the Latina/o concept of personalismo, in which people relationships are equally if not more important than tasks. Many Latina/o, for example, have described Western-trained counselors or therapists as “remote,” “aloof,” or “cold” (Arredondo et al. 2014; Comas-Diaz, 2010). There are some indications that Gabriella may view Dr. D. in this manner. His task orientation regardless of what she does or says makes her concerns remain invisible; he fails to explore the many clues provided to him by Gabriella. For example, he mistakes her silence for agreement, fails to inquire into the video-song, Booty, dismisses her cultural concerns in favor of finding solutions, and implies that she is responsible for her plight. An interesting observation of how his rigid goal-directness blinds him to what Gabriella says is seen in the description of the aftermath of her attack: “We finally made up and got it on.” The therapist interprets the statement as Gabriella and Russell “smoothing things over,” but is there more to this statement? What does she mean by “got it on”?

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 (Ivey, Ivey, & Zalaquett, 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, although most gravitate toward one or the other.

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 two questions: (a) What is universal in human behavior that is also relevant to counseling and therapy? and (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?

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 Incompetence

Although there are disagreements over the definition of cultural competence, many of us know cultural incompetence 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; Thomas & Sillen, 1972); (b) clients of color, women, and gays and lesbians frequently complain that they feel abused, intimidated, and harassed by nonminority personnel (Atkinson, Morten, & Sue, 1998; President's Commission on Mental Health, 1978); (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 (Parham et al., 2011; Cross, Bazron, Dennis, & Isaacs, 1989); 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).

From our perspective, counseling/mental health professionals have difficulty functioning in a culturally competent manner. Rather, they have functioned in a monoculturally competent manner with only a limited segment of the population (White, male, and straight Euro-Americans), but even that has become a topic of debate (Ridley & Mollen, 2011). We submit that much of the current therapeutic practice taught in graduate programs derives mainly from clinical experience and research with middle- to upper-class Whites (Ridley, 2005). Even though our profession has advocated moving into the realm of evidence-based practice (EBP), little evidence exists that they are applicable to racial/ethnic minorities (Atkinson, Bui, & Mori, 2001; D. W. Sue, 2015). A review of studies on EBP reveals few, if any, on racial minority populations, which renders assumptions of external validity questionable when applied to people of color (Atkinson et al., 1998; Hall, 2001; S. Sue, 1999). If we are honest with ourselves, we can conclude only that many of our standards of professional competence are derived primarily from the values, belief systems, cultural assumptions, and traditions of the larger (Eurocentric) society. We will, however, in Chapter 9 attempt to summarize multicultural evidence-based practices that have recently begun to work their way into the scientific literature.

The Superordinate Nature of Cultural Competence

As we have discussed, values of individualism and psychological mindedness and using 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 percent of the world's population. He concludes that the knowledge of human behavior neglects 95 percent of the world's population and is an inadequate representation of humanity. Thus it is clear to us that the more superordinate and inclusive concept is that of multicultural counseling competence, not merely clinical or counseling competence. Standards of helping derived from such a philosophy and framework are inclusive and offer the broadest and most accurate view of cultural competence.

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 racial or cultural background of the person 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, in press). Dr. D.'s responses toward Gabriella seem to have had this effect. These forms of microinvalidations 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 (D. W. 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; D. W. Sue, 2015). Indeed, in an excellent conceptual/analytical article proposing a new and distinct definition of counseling competence, Ridley, Mollen, and Kelly (2011) conclude that “counseling competence is multicultural counseling competence” and that “competent counselors consistently incorporate cultural data into counseling, and they must be careful never to relegate cultural diversity to the status of a sidebar” (p. 841).

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 rather than with other sociodemographic differences (D. W. 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.

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; D. W. Sue, 2010).

There is an old 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, 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 (D. W. 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

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 answers to 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 percent identical! Although it may be a blow to human dignity, the more 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 less 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 the discussions about whether sexual orientation is determined at birth and whether we should be speaking of sexuality or sexualities (D. 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.

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.

Reflection and Discussion Questions

1. Select three group identities you possess related to race, gender, sexual orientation, disability, religion, socioeconomic status, and so forth. Of the three you have chosen, which one is more salient to you? Why? Does it shift or change? How aware are you of other sociodemographic 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? 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?

Individual and Universal Biases in Psychology and Mental Health

Psychology—and mental health professionals in particular—have 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 and history 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/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, culture, sexual orientation, socioeconomic class, and religious affiliation lead to 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 and beliefs), 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.

Before closing this portion of our discussion, we would like to add a caution. 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, Latino male, for example, represents four potential reference groups operating on the person. The culturally competent helping professional must be willing and able to touch all dimensions of human existence without negating any of the others.

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). Multicultural 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 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 cultural/racial group may have its own distinct interpretation of reality and offer a different 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 quality 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 Asian Americans and African Americans, respectively.

It is therefore highly probable that different racial/ethnic minority groups perceive the competence of the helping professional differently than do mainstream client groups. Further, if race/ethnicity affects 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 Euro-American counterparts?” Anecdotal observations, clinical case studies, conceptual analytical writings, and some empirical studies seem to suggest an affirmative response to the question (Fraga, Atkinson, & Wampold, 2002; Garrett & Portman, 2011; Guzman & Carrasco, 2011; McGoldrick, Giordano, & Garcia-Preto, 2005; Nwachuku & Ivey, 1991).

What Is Multicultural Counseling/Therapy?

In light of the previous analysis, let us define multicultural counseling/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. (D. W. 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/ethnic minority groups might respond best to culture-specific strategies of helping. For example, research seems to support the belief that Asian Americans and Latino/a Americans are more responsive to directive/active approaches (Guzman & Carrasco, 2011; Kim, 2011) and that African Americans appreciate helpers who are authentic in their self-disclosures (Parham et al., 2011). Likewise, it is clear that common features in helping relationships cut across cultures and societies as well.

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, business, and society, the traditional therapeutic role appears ineffective and inappropriate. The focus for change must shift to altering client systems rather than individual clients.

What Is Cultural Competence?

Consistent with the definition of MCT, it becomes clear that culturally competent healers are working toward several primary goals (American Psychological Association, 2003; D. W. Sue et al., 1992; D. W. Sue et al., 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. 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. Let us more carefully explore these attributes of cultural competence.

Competency 1: Therapist Awareness of One's Own Assumptions, Values, and Biases

In almost all human service programs, counselors, therapists, and social workers are familiar with the phrase “Counselor, know thyself.” Programs stress the importance of not allowing our own biases, values, or hang-ups to interfere with our ability to work with clients. In most cases, such a warning stays primarily on an intellectual level, and very little training is directed at having trainees get in touch with their own values and biases about human behavior. In other words, it appears to be easier to deal with trainees' cognitive understanding of their own cultural heritage, the values they hold about human behavior, their standards for judging normality and abnormality, and the culture-bound goals toward which they strive.

As indicated in Chapter 1 , what makes examination of the self difficult is the emotional impact of attitudes, beliefs, and feelings associated with cultural differences, such as racism, sexism, heterosexism, able-body-ism, and ageism. For example, as a member of a White EuroAmerican group, what responsibility do you hold for the racist, oppressive, and discriminating manner by which you personally and professionally deal with persons of color? This is a threatening question for many White people. However, to be effective in MCT means that one has adequately dealt with this question and worked through the biases, feelings, fears, and guilt associated with it. A similar question can be asked of men with respect to women and of straights with respect to gays.

Competency 2: Understanding the Worldviews of Culturally Diverse Clients

It is crucial that counselors and therapists understand and can share the worldviews of their culturally diverse clients. This statement does not mean that providers must hold these worldviews as their own, but rather that they can see and accept other worldviews in a nonjudgmental manner. Some have referred to the process as cultural role taking: Therapists acknowledge that they may not have lived a lifetime as a person of color, as a woman, or as a lesbian, gay, bisexual, or transgendered person (LGBT). With respect to race, for example, it is almost impossible for a White therapist to think, feel, and react as a racial minority individual. Nonetheless, cognitive empathy, as distinct from affective empathy, may be possible. In cultural role taking, the therapist acquires practical knowledge concerning the scope and nature of the client's cultural background, daily living experience, hopes, fears, and aspirations. Inherent in cognitive empathy is the understanding of how therapy relates to the wider sociopolitical system with which minorities contend every day of their lives.

Competency 3: Developing Culturally Appropriate Intervention Strategies and Techniques

Effectiveness is most likely enhanced when the therapist uses therapeutic modalities and defines goals that are consistent with the life experiences and cultural values of the client. This basic premise will be emphasized throughout future chapters. Studies have consistently revealed that (a) economically and educationally marginalized clients may not be oriented toward “talk therapy”; (b) self-disclosure may be incompatible with the cultural values of Asian Americans, Hispanic Americans, and American Indians; (c) the sociopolitical atmosphere may dictate against self-disclosure from racial minorities and gays and lesbians; (d) the ambiguous nature of counseling may be antagonistic to life values of certain diverse groups; and (e) many minority clients prefer an active/directive approach over an inactive/nondirective one in treatment. Therapy has too long assumed that clients share a similar background and cultural heritage and that the same approaches are equally effective with all clients. This erroneous assumption needs to be challenged.

Because groups and individuals differ from one another, the blind application of techniques to all situations and all populations seems ludicrous. The interpersonal transactions between the counselor and the client require different approaches that are consistent with the client's life experiences (Choudhuri, Santiago-Rivera, & Garrett, 2012; Ratts & Pedersen, 2014). It is ironic that equal treatment in therapy may be discriminatory treatment! Therapists need to understand this. As a means to prove discriminatory mental health practices, racial/ethnic minority groups have in the past pointed to studies revealing that minority clients are given less preferential forms of treatment (medication, electroconvulsive therapy, etc.). Somewhere, confusion has occurred, and it was believed that to be treated differently is akin to discrimination. The confusion centered on the distinction between equal access and opportunities versus equal treatment. Racial/ethnic minority groups may not be asking for equal treatment so much as they are asking for equal access and opportunities. This dictates a differential approach that is truly nondiscriminatory. Thus to be an effective multicultural helper requires cultural competence. In light of the previous analysis, we define cultural competence in the following manner:

Cultural competence is the ability to engage in actions or create conditions that maximize the optimal development of client and client systems. Multicultural counseling competence is defined as the counselor's acquisition of 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. (D. W. 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 the 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 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. Box 2.1 provides an outline of cultural competencies related to these three domains.

Box 2.1 Multicultural Counseling Competencies

1. Cultural Competence: Awareness

1. Moved from being culturally unaware to being aware and sensitive to own cultural heritage and to valuing and respecting differences.

2. Aware of 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 sociodemographic 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 sociodemographic group or to different therapists in general.

5. Aware of their own racist, sexist, heterosexist, or other detrimental attitudes, beliefs, and feelings.

2. Cultural Competence: 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. Possess specific knowledge and understanding of the generic characteristics of counseling and therapy.

4. Knowledgeable of institutional barriers that prevent some diverse clients from using mental health services.

3. Cultural Competence: 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 their 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: D. W. Sue et al. (1992), and D. W. Sue et al. (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 acquire 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; D. W. 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 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.

Cultural Humility and Cultural Competence

Can anyone ever be completely culturally competent in working with diverse clients? Are the awareness, knowledge, and skills of cultural competence the only areas sufficient to be an effective multicultural helping professional? The answers to these questions are extremely important not only to the practice of counseling/therapy, but to the education and training of counselors and therapists. The answer to the first question is an obvious “no.” It is impossible for anyone to possess sufficient knowledge, understanding, and experience of the diversity of populations that inhabit this planet. Indeed, those who have developed and advocated multicultural counseling competencies have repeatedly stressed that “cultural competence” is an aspirational goal, that no single individual can become completely competent, and that the journey toward cultural competence is a lifelong process (D. W. Sue et al., 1992; Cornish et al., 2010).

With respect to the second question, it appears that the dimensions of awareness, knowledge, and skills may be necessary, but not sufficient conditions to work effectively with diverse clients. Other attributes, like openness to diversity (Chao, Wei, Spanierman, Longo, & Northart, 2015) and cultural humility seem central to effective multicultural counseling (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, and found to be quite different from cultural competence (Tervalon & Murray-Garcia, 1998). The term has found its way into the field of multicultural counseling, where it also refers to an openness to working with culturally diverse clients (Hook, Davis, Owen, Worthington, & Utsey, 2013; Owen et al., 2014). But exactly how does it differ from cultural competence and what evidence do we have that it is an important component?

Cultural humility appears more like a “way of being” rather than a “way of doing,” which has characterized cultural competence (Owen, Tao, Leach, & Rodolfa, 2011). In the former, we are referring to the virtues and dispositions inherent in the attitudes that counselors hold toward their clients, while the latter refers more to the acquisition of knowledge and skills used in working with clients. The attitudinal components of respect for others, an egalitarian stance, and diminished superiority over clients means an “other-orientation” rather than one that is self-focused (concern with one's expertise, training, credentials, and authority). Recall again the therapeutic encounter between Dr. D. and Gabriella. When asked by Gabriella whether he could understand what it's like to be Latina, and the unique issues she must cope with, his response was “Of course I can” and “I've worked with many Latinos in my practice.” In many respects, the definition of cultural humility is humbleness; thus therapists acknowledging that they may be limited in their knowledge and understanding of clients' cultural concerns may actually strengthen the therapeutic relationship. Dr. D.'s response, however, suggests he is self-oriented (“I am the therapist and I know best”), while cultural humility would entertain the possibility that the therapist may not understand. A therapeutic response that would indicate cultural humility would be: “I hope I can, let's give it a try, okay?” Hook et al. (2013) make the following observations about cultural humility:

Culturally humble therapists rarely assume competence (i.e., letting prior experience and even expertness 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. (p. 354)

Although cultural humility may appear difficult to define and measure, researchers have been able to begin construction of an instrument to quantify it (Hook et al., 2013; Owen et al., 2014). In a therapeutic context, cultural humility of therapists was (a) considered very important to many socially marginalized clients, (b) correlated with a higher likelihood of continuing in treatment, (c) strongly related to the strength of the therapeutic alliance, and (d) related to perceived benefit and improvement in therapy. Thus cultural humility as a dispositional orientation may be equally important as cultural competence (awareness, knowledge, and skills) in multicultural counseling and therapy.

Social Justice and Cultural Competence

Recently, the Multicultural Counseling Competencies Revision Committee of the American Counseling Association (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015) has presented an important draft document, Multicultural and Social Justice Counseling Competencies (MSJCC) that proposes to revise the multicultural counseling competencies devised by D. W. Sue et al. (1992). As indicated in Chapter 4 , at the heart of the revision is integration of social justice competencies with multicultural competencies. Acknowledging that multiculturalism leads to social justice initiatives and actions, they 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 counseling relationships between counselor and client that directly address matters of power and privilege: (1) privileged counselor working with an oppressed client, (2) privileged counselor working with a privileged client, (3) oppressed counselor working with a privileged client, and (4) oppressed counselor working with an oppressed client. In other words, when applied to racial/ethnic counseling/therapy, various combinations can occur: (a) White counselors working with clients of color, (b) counselors of color working with White clients, (c) counselors of color working with clients of color, and (d) White counselors working with White clients. Analysis and research regarding these dyadic combinations have seldom been addressed in the multicultural 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 , 4 , and 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 cultural competence in clinical practice are awareness, knowledge, and skills, how do you hope to fulfill competency one, two, and three? Can you list the various educational and training activities you would need in order to work effectively with a client who differs from you in terms of race, gender, or sexual orientation?

2. What are your thoughts regarding cultural humility? How important is this attitude or stance in your work with culturally diverse clients?

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, gays/lesbians, 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 clients.

9. Understand that one's multicultural orientation, cultural humility, is very important to successful multicultural counseling.

Summary

Traditional definitions of counseling, therapy, and mental health practice arise from monocultural and ethnocentric norms that may be antagonistic to the life styles 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.

Multicultural counseling and therapy 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; 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. Thus cultural competence is the ability to engage in actions or create conditions that maximize the optimal development of client and client systems.

On a personal developmental level, multicultural counseling competence is defined as the counselor's acquisition of 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); 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” rather than a “way of doing.” The attitudinal components of respect for others, an egalitarian stance, and diminished superiority over clients means an “other-orientation” rather than one that is self-focused. Finally, it appears that there is a strong need to integrate social justice competencies with that of 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 incompetence

Cultural relativism

Culture-bound syndromes

Emic (culturally specific)

Etic (culturally universal)

Group level of identity

Individual level of identity

Knowledge

Multicultural counseling/therapy

Multiculturalism

Personalismo

Skills

Social justice

Universal level of identity

Worldview

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THE POLITICAL AND SOCIAL JUSTICE IMPLICATIONS OF COUNSELING AND PSYCHOTHERAPY

Chapter Objectives

1. Understand how the sociopolitical climate affects the manifestation, etiology, diagnosis, and treatment of psychological disturbances in socially devalued groups in our society.

2. Learn why traditional counseling/mental health practice may represent cultural oppression for marginalized groups.

3. Become knowledgeable about how the educational and mental health field has historically portrayed persons of color.

4. Understand the racial realities (worldviews) of people of color and those of White Americans.

5. Know how these differences may pose problems in race relations and multicultural counseling/therapy.

6. Learn how systemic factors (institutional policies, practices, and regulations) affect mental health and counseling practices.

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)

Impact of Political Oppression

Multicultural counseling/therapy means understanding the worldviews and life experience 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. Vernon E. Jordan, Jr., an African American attorney and former confidant of President Bill Clinton, made this point about racism in startling terms. In making an analogy between the terrorist attacks of September 11, 2001, and the racism directed at African Americans, Jordan stated:

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)

Likewise, in speaking about the history of psychological research conducted on ethnic minority communities by White social scientists, the late Charles W. Thomas (1970), a respected African American psychologist, voiced his concerns even more 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. (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. Aren't they simply 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 might be emotional roadblocks you are now 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 (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). Counseling people of color, for example, 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, and transgendered [LGBT] people; women; and the physically challenged). It serves as a microcosm, reflecting Black–White, Asian–White, Hispanic–White, and American Indian–White relations. But as we saw in Chapter 3 , it also mirrors interethnic/interracial relations as well.

We explore the many ways in which counseling and psychotherapy have failed with respect to providing culturally appropriate mental health services to disempowered groups in our society. We do this by using people of color as an example of the damaging oppressor–oppressed relationships that historically characterize many other marginalized groups. Many readers may have a very powerful negative reaction to the following material. However, only by honestly confronting these unpleasant social realities and accepting responsibility for changing them will our profession be able to advance and grow (D. W. Sue, 2010a; D. W. Sue, 2015). Jones (2010) cites an African proverb: “The true tale of the lion hunt will never be told as long as the hunter tells the story.” In other words, the story of racial, ethnic, and cultural groups (people of color) is largely a hunter's story (White Americans). To learn about the hunter (White Americans) and the hunt (balanced history), the story of the lion must be told regardless of how unpleasant.

The Education and 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 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 Latino/Hispanic Americans tend to underutilize traditional mental health services in a variety of contexts (Kearney, Draper, & Baron, 2005; Owen, Imel, Adelson, & Rodolfa, 2012; 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 believed that the presence of ill-prepared mental health professionals was the direct result of a culture-bound and biased training system (Mio, 2005; Utsey, Grange, & Allyne, 2006).

Most graduate programs continue to give inadequate treatment to the mental health issues of persons of color (Ponterotto & Austin, 2005; Utsey et al., 2006). Cultural influences affecting personality formation, career choice, educational development, and the manifestation of behavior disorders are infrequently part of mental health training or are treated in a tangential manner (Parham, Ajamu, & White, 2011; Vazquez & Garcia-Vazquez, 2003). When the experiences of socially devalued groups are discussed, they are generally seen and analyzed from the White, EuroAmerican, middle-class perspective. In programs where these experiences have been discussed, the focus tends to be on pathological lifestyles and/or maintenance of false stereotypes. The result is twofold: (a) professionals who deal with mental health problems of people of color lack understanding and knowledge about ethnic values and their consequent interaction with a racist society, and (b) mental health practitioners are graduated from our programs believing that persons of color are inherently pathological and that therapy involves a simple modification of traditional White models.

This ethnocentric bias has been highly destructive to the natural help-giving networks of ethnic/racial communities (Duran, 2006). Oftentimes mental health professionals operate under the assumption that groups of color never had such a thing as “counseling” and “psychotherapy” until it was “invented” and institutionalized in Western cultures. For the benefit of those people, the mental health movement has delegitimized natural help-giving networks that have operated for thousands of years by labeling them as unscientific, supernatural, mystical, and not consistent with “professional standards of practice.” Mental health professionals are then surprised to find that there is a high incidence of psychological distress in communities of color, that their treatment techniques do not work, and that some culturally diverse groups do not utilize their services.

Contrary to this ethnocentric orientation, we need to expand our perception of what constitutes valid mental health practices. Equally legitimate methods of treatment are nonformal or natural support systems (e.g., family, friends, community self-help programs, and occupational networks), folk-healing methods, and indigenous formal systems of therapy (Gone, 2010; Moodley & West, 2005). Instead of attempting to destroy these practices, we should be actively trying to find out why they may work better than Western forms of counseling and therapy (Trimble, 2010). We cover indigenous healing in Chapter 10 .

Definitions of Mental Health

Counseling and psychotherapy tend to assume universal (etic) applications of their concepts and goals to the exclusion of culture-specific (emic) views (Choudhuri et al., 2012). Likewise, graduate programs have often been accused of fostering cultural encapsulation, a term first coined by Wrenn (1962). The term refers specifically to (a) the substitution of modal stereotypes for the real world, (b) the disregarding of cultural variations in a dogmatic adherence to some universal notion of truth, and (c) the use of a technique-oriented definition of the counseling process. The results are that counselor roles are rigidly defined, implanting an implicit belief in a universal concept of “healthy” and “normal.”

If we look at criteria used by the mental health profession to judge normality and abnormality, this ethnocentricity becomes glaring. Several fundamental approaches that have particular relevance to our discussion have been identified (D. 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 are fraught with hazards and problems. For one thing, they fail to take into account differences in time, community standards, and cultural values. If deviations from the majority are considered abnormal, then many ethnic and racial minorities that exhibit strong cultural differences from the majority have to be so classified. 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. Statements by Blacks that “The Man” is out to get them may be perceived as supporting a paranoid delusion. This interpretation, however, has been challenged by many Black psychologists as being inaccurate (Grier & Cobbs, 1968, 1971; Parham et al., 2011). In response to their heritage of slavery and a history of White discrimination against them, African Americans have adopted various behaviors (in particular, behaviors toward Whites) that have proved important for survival in a racist society. “Playing it cool” has been identified as one means by which Blacks, as well as members of other groups of color, may conceal their true thoughts and feelings. A Black person who is experiencing conflict, anger, or even rage may be skillful at appearing serene and composed. This tactic is a survival mechanism aimed at reducing one's vulnerability to harm and to exploitation in a hostile environment.

Personality tests that reveal Blacks as being suspicious, mistrustful, and paranoid need to be understood from a larger sociopolitical perspective. Marginalized groups who have consistently been victims of discrimination and oppression in a culture that is full of racism have good reason to be suspicious and mistrustful of White society. In their classic book Black Rage, Grier and Cobbs (1968) point out how Blacks, in order to survive in a White racist society, have developed a highly functional survival mechanism to protect them against possible physical and psychological harm. The authors perceive this “cultural paranoia” as adaptive and healthy rather than dysfunctional and pathological. Indeed, some psychologists of color have indicated that the absence of a paranorm (healthy suspiciousness and vigilance of others' motives) among people of color may be more indicative of pathology than its presence. The absence of a paranorm may indicate either poor reality testing (denial of oppression/racism in our society) or naiveté in understanding the operation of racism.

Normality as Ideal Mental Health

Second, humanistic psychologists have proposed the concept of ideal mental health as 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, and 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 socioeconomic groups and people of color may not particularly value insight. Furthermore, the use of self-disclosure as a measure of mental health tends to neglect the earlier discussion presented on the paranorm. One 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).

Definitions of mental health such as competence, autonomy, and resistance to stress are related to White middle-class notions of individual maturity (Ahuvia, 2001; Triandis, 2000). The mental health professions originated from the ideological milieu of individualism (Ivey, D'Andrea, Ivey, & Simek-Morgan, 2007). Individuals make their lot in life. Those who succeed in society do so because of their own efforts and abilities. Successful people are seen as mature, independent, and possessing great ego strength. Apart from the potential bias in defining what constitutes competence, autonomy, and resistance to stress, the use of such a person-focused definition of maturity places the responsibility on the individual. When people fail in life, it is because of their own lack of ability, interest, or maturity, or some inherent weakness of the ego. If, on the other hand, we see minorities as being subjected to higher stress factors in society and placed in a one-down position by virtue of racism, then it becomes quite clear that the definition will tend to portray the lifestyle of minorities as inferior, underdeveloped, and deficient. Ryan (1971) was the first to coin the phrase “blaming the victim” to refer to this process. Hence a broader system analysis would show that the economic, social, and psychological conditions of people of color are related to their oppressed status in America.

Abnormality as the Presence of Certain Behaviors

Third, an alternative to the previous two definitions of abnormality is a research one. For example, in determining rates of mental illness in different ethnic groups, “psychiatric diagnosis,” “presence in mental hospitals,” and scores on “objective psychological inventories” are frequently used (D. Sue et al., 2016). Diagnosis and hospitalization present a circular problem. The definition of normality/abnormality depends on what mental health practitioners say it is! In this case, the race or ethnicity of mental health professionals is likely to be different from that of clients of color. Bias on the part of the practitioner with respect to diagnosis and treatment is likely to occur (Constantine, Myers, Kindaichi, & Moore, 2004). The inescapable conclusion is that clients of color tend to be diagnosed differently and to receive less preferred modes of treatment (Paniagua, 2005).

Furthermore, the political and societal implications of psychiatric diagnosis and hospitalization were forcefully pointed out nearly 40 years ago by Laing (1967, 1969) and Szasz (1970, 1971). Although it appears that minorities underutilize outpatient services, they also appear to face greater levels of involuntary hospital commitments (Snowden & Cheung, 1990). Laing believes that individual madness is but a reflection of the madness of society. He describes schizophrenic breakdowns as desperate strategies by people to liberate themselves from a “false self” used to maintain behavioral normality in our society. Attempts to adjust the person back to the original normality (sick society) are unethical. Szasz states this opinion even more strongly:

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. (1970, pp. 167–168)

Szasz (1987, 1999) views the mental health professional as an inquisitor, an agent of society exerting social control over those individuals who deviate in thought and behavior from the accepted norms of society. Psychiatric hospitalization is believed to be a form of social control for persons who annoy or disturb us. The label mental illness may be seen as a political ploy used to control those who are different, and therapy is used to control, brainwash, or reorient the identified victims to fit into society. It is exactly this concept that many people of color find frightening. For example, many Asian Americans, American Indians, African Americans, and Hispanic/Latino Americans are increasingly challenging the concepts of normality and abnormality. They believe that their values and lifestyles are often seen by society as pathological and thus are unfairly discriminated against by the mental health professions (Constantine, 2006).

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 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; D. W. Sue, 2010b) 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 at the cognitive and objective domain, preventing self-exploration (D. W. Sue, 2015). This allows students to study the material from their positions 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 (2006) recommended that psychology training programs at all levels provide information on the political nature of the practice of psychology and that professionals need to “own” their value positions.

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 America (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, Utsey, & Pedersen, 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 America (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 Latinos that 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 (D. W. Sue, 2003). Although there are many aspects of how persons of color are portrayed in social science literature, two seem crucial for us to explore: (a) people of color and pathology and (b) the role of scientific racism in research.

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 is a common theme. 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 their contention:

· Census figures (fabricated) from 1840 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 was contentment with subservience.

· Psychologically normal Blacks were faithful and happy-go-lucky.

· Black persons' brains were smaller and less developed.

· Blacks were less prone to mental illness because their minds were so simple.

· The dreams of Blacks were juvenile in character and not as complex as those of Whites.

More frightening, perhaps, is a survey that found that many of these stereotypes continue to be accepted by White Americans: 20% publicly expressed a belief that African Americans are innately inferior in thinking ability, 19% believe that Blacks have thicker craniums, 23.5% believe they have longer arms than Whites, 50% believe Blacks have achieved equality, and 30% believe problems of Blacks reside in their own group (Astor, 1997; 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.

Furthermore, the belief that various human groups exist at different stages of biological evolution was accepted by G. Stanley Hall. He stated explicitly in 1904 that Africans, Indians, and Chinese were members of adolescent races and in a stage of incomplete development. In most cases, the evidence used to support these conclusions was fabricated, extremely flimsy, or distorted to fit the belief in non-White inferiority (A. Thomas & Sillen, 1972). For example, Gossett (1963) reports that when one particular study in 1895 revealed that the sensory perception of Native Americans was superior to that of Blacks and that of Blacks was superior to that of Whites, the results were used to support a belief in the mental superiority of Whites: “Their reactions were slower because they belonged to a more deliberate and reflective race than did the members of the other two groups” (p. 364). The belief that Blacks are “born athletes,” as opposed to scientists or statesmen, derives from this tradition. The fact that Hall was a well-respected psychologist, often referred to as “the father of child psychology,” and first president of the American Psychological Association did not prevent him from inheriting the racial biases of the times.

The Genetically Deficient Model

The portrayal of people of color in 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. Terman (1916), using the Binet scales in testing Black, Mexican American, and Spanish Indian families, concluded that they were uneducable.

The genetically deficient model is present in the writings of educational psychologists and academicians. In 1989, Professor Rushton of the University of Western Ontario claimed that human intelligence and behavior were largely determined by race, that Whites have bigger brains than Blacks, and that Blacks are more aggressive (Samuda, 1998). Shockley (1972) has expressed fears that the accumulation of weak or low intelligence genes in the Black population will seriously affect overall intelligence. Thus he advocates that people with low IQs should not be allowed to bear children—they should be sterilized. Allegations of scientific racism can also be seen in the work of Cyril Burt, 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, and 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 of the conference 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, questionable assumptions exist regarding whether research on the intelligence of Whites can be generalized to other groups, whether middle-class 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. More important, we should recognize that the average values of different populations tell us nothing about any one individual. Heritability is a function of the population, not a trait. Ethnic groups all have individuals in the full range of intelligence, and to think of any racial group in terms of a single stereotype goes against all we know about the mechanics of heredity. Yet much of social science literature continues to portray people of color as being genetically deficient in one sense or another.

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 were 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 America, some educators strenuously objected to the term. First, the term culturally deprived means to lack a cultural background (e.g., 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 (Moynihan, 1965) 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” (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 superiority of 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 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 really measure how Anglicized a 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?

The Need to Treat Social Problems—Social Justice Counseling

Case Study

Daryl

Daryl Cokely (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 exhibiting “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 Daryl 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 3 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” when at home and not a behavior problem before moving from Los Angeles to Santa Barbara. They described him as feeling isolated, 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 very 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 enlisted the aid of the only Black counselor in the school, Ms. Jones. Although Ms. Jones seemed 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 feared 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 quite incensed by these “accusatory statements of possible racism.” He indicated to the parents that “your people” do 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 it was not the school climate that was hostile, but 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, “Perhaps it was a mistake to move to Santa Barbara. For the sake of your son, 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.

If you were a counselor, how would you address this case? Where would you focus your energies? Traditional clinical approaches would direct their 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.”

But 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 new proposed ACA Multicultural and Social Justice Counseling Competencies (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015), a strong case is made that multiculturalism is intimately related to social justice and 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 recognition that interventions can occur at four different foci, as illustrated in Figure 4.1 on page 129. 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.

The Foci of Counseling Interventions: Individual, Professional, Organizational, and Societal

Focus 1: Individual

To provide culturally effective and sensitive counseling/mental health services, helping clients acquire changes in personal beliefs, attitudes, emotions, and behaviors has always been a major goal in counseling and therapy. This is especially true when attempting to help clients achieve new insights and to have them acquire new and adaptive behaviors. Most traditional forms of counseling and psychotherapy fall within this category.

Focus 2: Professional

It is clear that our profession has developed from a Western European perspective. As a result, how we define psychology (the study of mind and behavior) may be biased and at odds with different cultural groups. Further, if the professional standards and codes of ethics in mental health practice are culture bound, then they must be changed to reflect a multicultural worldview. As we will see in future chapters, oftentimes it is these professional codes of conduct that require change in order to help a diverse population.

Focus 3: Organizational

Since clients often work for and are influenced by organizations, it is important to realize that institutional practices, policies, programs, and structures may, especially if they are monocultural, be oppressive to certain groups. If organizational policies and practices deny equal access and opportunity for different groups or oppress them (redlining in home mortgages, laws against domestic partners, inequitable mental health care, etc.), then those policies and practices should become the targets for change. In other words, the causes of disorders may not reside in the individual, but in systems of organizational oppression.

Focus 4: Societal

If social policies (racial profiling, misinformation in educational materials, inequities in health care, etc.) are detrimental to the mental and physical health of minority groups, for example, does not the mental health professional have a responsibility to advocate for change? Our answer, of course, is affirmative.

* * *

Often, psychologists treat individuals who are the victims of failed systemic processes. Intervention at the individual level is primarily remedial when a strong need exists for preventive measures. Because psychology concentrates primarily on the individual, it 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).

Figure 4.1 Levels of Counseling Interventions

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) (D. W. Sue et al., 2011); (e) support services (counseling, study skills, etc.) that fail to understand the minority student experience; and (f) the lack of role models (presence of only one Black teacher in the school) (Alexander & Moore, 2008). For example, would it change your analysis and focus of intervention if Daryl gets into fights because he is teased mercilessly by fellow students who use racial slurs (nigger, jungle bunny, burr head, etc.)? 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 (J. Goodman, 2009; L. A. 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). Behavior is always a function of the interactions or transactions that occur between and among the many systems that comprise the life of the person. For example, a micro level of analysis (the individual) may lead to one treatment plan, whereas a macro analysis (the social system) would lead to another (Toporek & Worthington, 2014). In other words, how a helping professional defines the problem affects the treatment focus and plan. If Daryl's problems are due to internal and intrapsychic dynamics, then it makes sense that therapy be directed toward changing the individual. The fighting behavior is perceived as dysfunctional and should be eliminated through Daryl's learning to control his anger or through 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? Will he relate more to the content of courses that denigrate the contributions of African Americans? Treating the symptoms or eliminating fighting 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 that person to a sick situation? In this case, do we focus on stopping the fighting behavior? Or 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 (D. W. 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 to 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, which 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 (D. W. 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.

Alternative helping roles that emphasize systems intervention 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, more 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 would be an endless and losing venture unless the true sources of the problem (stereotypes, prejudice, discrimination, and oppression) are 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 would you need to play?

Social Justice Counseling

The case of Daryl demonstrates strongly the need for a social justice orientation to counseling and therapy (Neville, 2015). Indeed, multicultural counseling/therapy competence is intimately linked to the values of social justice (Koch & Juntunen, 2014; Ratts et al., 2015). 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 a 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 client and client systems; and broadening the role of the helping professional to include not only counselor/therapist but advocate, consultant, psychoeducator, change agent, community worker, and so on.

Thus social justice counseling/therapy has the following goals:

1. Aims to produce conditions that allow for equal access and opportunity;

2. Reduces or eliminates disparities in education, health care, employment, and other areas, that lower the quality of life for affected populations;

3. Encourages mental health professionals to consider micro, meso, and macro levels in the assessment, diagnosis, and treatment of clients and client systems;

4. Broadens the role of the helping professional to include not only counselor/therapist but 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). 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 (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).

Advocacy Counseling Roles

To achieve these conditions is truly an uphill battle. But, just as the history of the United States is the history of racism, 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 (Southern Poverty Law Center, NAACP, and B'nai Brith), political leaders, and especially people of color. Racism, like sexism, homophobia, and all forms of oppression, must be on the forefront of social justice work. Efforts must be directed at social change in order to eradicate bigotry and prejudice. In this respect, psychologists 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 need to openly 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. In closing, we include the words of Toporek (2006, p. 496) about the social justice agenda and its implications for psychologists:

The vastness of social challenges facing humanity requires large-scale intervention. Although the expertise of counseling psychologists is well suited to individual empowerment and local community involvement, likewise, much of this expertise can, and should, be applied on a broad scale. Public policy decisions such as welfare reform, gender equity, same-sex marriage and adoption, and homelessness must be informed by knowledge that comes from the communities most affected. Counseling psychologists, with expertise in consulting, communicating, researching, and direct service, are in a unique position to serve as that bridge.

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 its theories and practices are apolitical and value free.

5. Psychological problems of marginalized group members may reside not within but outside of our clients.

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.

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 believing that people of color are lacking the right genes or the right White middle class values to succeed in this 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 are necessary for accurate assessment, diagnosis, and treatment. Clients are not viewed as isolated units but as embedded in their families, social groups, communities, institutions, cultures, and in major systems of our society.

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. 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

Culture-bound training

Cultural paranoia

Cultural deprivation

Culturally deficient model

Culturally diverse model

Etic

Emic

Ethnocentricity

Genetically deficient model

Levels of intervention

Paranorm

Scientific racism

Social justice counseling

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THE IMPACT OF SYSTEMIC OPPRESSION COUNSELOR CREDIBILITY AND CLIENT WORLDVIEWS

Chapter Objectives

1. Understand how historical oppression in the lives of people of color influences reactions to counselors and the counseling process.

2. Describe how traditional counseling and therapy may be antagonistic to the lifestyles, cultural values, and sociopolitical experiences of marginalized clients.

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. Describe the manifestation, dynamics, and impact of ethnocentric monoculturalism in theories of counseling and psychotherapy and in therapeutic practice.

5. Identify the special challenges that White helping professionals may encounter regarding their credibility (expertness and trustworthiness) when working with clients of color.

6. Understand the concepts of locus of control and locus of responsibility and apply them to multicultural counseling.

7. Define and describe how racial worldviews are formed.

8. Discuss how culturally diverse clients with particular worldviews may respond in the therapy process.

The true tale of the lion hunt will never be told as long as the hunter tells the story.

—African proverb as cited in J. M. Jones (2010)

Case Study

Malachi

I [White male] have worked with very few African American clients during my internship at the clinic, but one particular incident left me with very negative feelings. A Black client named Malachi was given an appointment with me. Even though I'm White, I tried not to let his being Black get in the way of our sessions. I treated him like everyone else, a human being who needed help.

At the onset, Malachi was obviously guarded, mistrustful, and frustrated when talking about his reasons for coming. While his intake form listed depression as the problem, he seemed more concerned about nonclinical matters. He spoke about his inability to find a job, about the need to obtain help with job-hunting skills, and about advice in how best to write his résumé. He was quite demanding in asking for advice and information. It was almost as if Malachi wanted everything handed to him on a silver platter without putting any work into our sessions. Not only did he appear reluctant to take responsibility to change his own life, but I felt he needed to go elsewhere for help. After all, this was a mental health clinic, not an employment agency.

Confronting him about his avoidance of responsibility would probably prove counterproductive, so I chose to focus on his feelings. Using a humanistic-existential approach, I reflected his feelings, paraphrased his thoughts, and summarized his dilemmas. This did not seem to help immediately, as I sensed an increase in the tension level, and he seemed antagonistic toward me.

After several attempts by Malachi to obtain direct advice from me, I stated, “You're getting frustrated at me because I'm not giving you the answers you want.” It was clear that this angered Malachi. Getting up in a very menacing manner, he stood over me and angrily shouted, “Forget it, man! I don't have time to play your silly games.” For one brief moment, I felt in danger of being physically assaulted before he stormed out of the office. This incident occurred several years ago, and I must admit that I was left with a very unfavorable impression of Blacks. I see myself as basically a good person who truly wants to help others less fortunate than myself. I know it sounds racist, but Malachi's behavior only reinforces my belief that Blacks have trouble controlling their anger, like to take the easy way out, and find it difficult to be open and trusting of others. If I am wrong in this belief, I hope this workshop [multicultural counseling/therapy] will help me better understand the Black personality.

Reflection and Discussion Questions

1. What do you think is the source of Malachi's anger?

2. How may the therapist and the therapeutic process be contributing to Malachi's frustration and anger?

3. Was the therapist in physical danger or was his fear based on stereotypes?

4. Might not this potential misinterpretation be due to differences in communication styles?

5. Is giving advice and suggestions, helping clients prepare a résumé, or helping them find a job part of therapy?

The clinical tale being told here was supplied at an in-service training workshop by a White male therapist, and is used here to illustrate the meaning of the lion hunt proverb. In this case, we question neither the sincerity of the White therapist nor his desire to help the African American client. We do, however, wish to tell “the rest of the story.”

The Rest of the Story

It is obvious to us that the therapist is part of the problem and not the solution. The male therapist's preconceived notions and stereotypes about African Americans appear to have affected his definition of the problem, assessment of the situation, and therapeutic intervention. Let us analyze this case in greater detail from the perspective of “the lion.”

Stereotyping the Client

Statements about Malachi's wanting things handed to him on a “silver platter,” his “avoidance of responsibility,” and his “wanting to take the easy way out” are characteristic of social stereotypes that Blacks are lazy and unmotivated. The therapist's statements that African Americans have difficulty “controlling their anger,” that Malachi was “menacing,” and that the therapist was in fear of being assaulted seem to paint the picture of the hostile, angry, and violent Black male—again an image of African Americans to which many in this society consciously and unconsciously subscribe. Although it is always possible that the client was unmotivated and prone to violence, studies suggest that White Americans continue to cling to the image of the dangerous, violence-prone, and antisocial Black man (Babbington, 2008; J. M. Jones, 2010).

Blaming the Client

Mental health practice has been characterized as primarily a White middle-class activity that values rugged individualism, individual responsibility, and autonomy (Ivey, Ivey, & Zalaquett, 2014). Because people are seen as being responsible for their own actions and predicaments, clients are expected to make decisions on their own and to be primarily responsible for their fate in life. The traditional therapist's role should be to encourage self-exploration so that the client can act on his or her own behalf (Lum, 2011). The individual-centered approach tends to view the problem as residing within the person. If something goes wrong, it is the client's fault. Many problems encountered by clients of color reside external to them (bias, discrimination, prejudice, etc.) and they should not be faulted for the obstacles they encounter. To do so is to engage in victim blaming (Ratts & Pedersen, 2014; Ryan, 1971).

Objectifying the Client

Therapists are expected to avoid giving advice or suggestions and disclosing their thoughts and feelings not only because they may unduly influence their clients and block individual development, but also because they may become emotionally involved, lose their objectivity, and blur the boundaries of the helping relationship (Parham & Caldwell, 2015). Parham (1997) states, however, that a fundamental African principle is that human beings realize themselves only in moral relations to others (collectivity, not individuality): “Consequently, application of an African-centered worldview will cause one to question the need for objectivity absent emotions, the need for distance rather than connectedness, and the need for dichotomous relationships rather than multiple roles” (p. 110). In other words, from an African American perspective, the helper and the helpee are not separated from one another but are bound together both emotionally and spiritually. The EuroAmerican style of objectivity encourages distancing and separation that may be interpreted by Malachi as uninvolved, uncaring, insincere, and dishonest—that is, “playing silly games.”

Being Nondirective with the Client

The more active and involved role demanded by Malachi goes against what the helping profession considers therapy. Studies indicate that clients of color prefer a therapeutic relationship in which the helper is more active, self-disclosing, and not adverse to giving advice and suggestions when appropriate (Bemak & Chung, 2015; Choudhuri, Santiago-Rivera, & Garrett, 2012). The therapist in this scenario fails to entertain the possibility that requests for advice, information, and suggestions may be legitimate and not indicative of pathological responding. The therapist has been trained to believe that his role as a therapist is to be primarily nondirective; therapists do therapy, not provide job-hunting information. This has always been the conventional counseling and psychotherapy role, one whose emphasis is a one-to-one, in-the-office, remedial relationship aimed at self-exploration and the achievement of insight (Atkinson, Thompson, & Grant, 1993).

Pathologizing the Client

In almost every introductory text on counseling and psychotherapy, lip service is paid to the axiom, “Counselor, know thyself.” In other words, therapeutic wisdom endorses the notion that we become better therapists the more we understand our own motives, biases, values, and assumptions about human behavior. We are taught to look at our clients, to analyze them, and to note their weaknesses, limitations, and pathological trends; less often do we either look for positive healthy characteristics in our clients or question our conclusions (Choudhuri et al., 2012). When the therapist ends his story by stating that he hopes the workshop will “help me better understand the Black personality,” his worldview is clearly evident. The assumption is that multicultural counseling/therapy simply requires the acquisition of knowledge, and good intentions are all that is needed. This statement represents one of the major obstacles to self-awareness and dealing with one's own biases and prejudices. Without awareness, differences are equated with deviancy and the client is pathologized.

Seeing Race as the Problem

The therapist states that he tried not to let Malachi's “being Black get in the way” of the session and that he treated him like any other “human being.” This is a very typical statement made by Whites who unconsciously subscribe to the belief that people of color are problem people. In reality, color is not the problem, but society's perception of color is! In other words, the locus of the problem (racism, sexism, and homophobia) resides not in marginalized groups but in the society at large. Often this view of race is manifested in the myth of color blindness: If color is the problem, let's pretend not to see it (Neville, Gallardo, & Sue, in press). Our contention, however, is that it is nearly impossible to overlook the fact that a client is Black, Asian American, Hispanic, and so forth. When operating in this manner, color-blind therapists may actually be obscuring their understandings of who their clients really are. To overlook one's racial group membership is to deny an intimate and important aspect of one's identity.

Perceiving the Client as “Paranoid”

Central to the thesis of this chapter is the statement made by the counselor that Malachi appears guarded and mistrustful and has difficulty being open (self-disclosing). In essence, he is paranoid. 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. When the emotional climate is negative, and when little trust or understanding exists between the therapist and the client, therapy can be both ineffective and destructive. Yet 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. One of these, self-disclosure, is particularly crucial to the process and goals of counseling because it is the most direct means by which individuals make themselves known to others. This chapter discusses trust–mistrust and worldviews as they relate to marginalized groups.

Effects of Historical and Current Oppression

Persons of color and other marginalized groups (women, gays/lesbians, and 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 clinical case presented earlier, 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 the therapist 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 encounter with a stranger (i.e., therapy), each party will attempt to discern gross or subtle racial attitudes of the other while minimizing vulnerability. Ethnocentric monoculturalism lies at the heart of oppressor–oppressed relationships that affect 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, American (U.S.) psychology has been severely criticized as being ethnocentric, monocultural, and inherently biased against racial/ethnic minorities, women, gays/lesbians, 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, however, 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; J. M. 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; Thomas & Sillen, 1972).

We believe that ethnocentric monoculturalism is dysfunctional in a pluralistic society such as 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 Superiority of 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 cultures are seen as not only desirable but normative as well. Physical characteristics such as light complexion, blond hair, and blue eyes; cultural characteristics such as a belief in Christianity (or monotheism), individualism, 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 its customs, values, traditions, and language (J. M. Jones, 1997). Other societies or groups may be perceived as less developed, uncivilized, primitive, or even pathological. The groups' lifestyles or ways of doing things are considered inferior. 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 their standards and beliefs on the less powerful group (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. Persons of color can be biased, can hold stereotypes, and can strongly believe that their way is the best way. Yet if they do not possess the power to impose their values on others, then hypothetically they cannot oppress. It is power or the unequal status relationship between groups 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 another, combined with the possession of power to impose those 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). The damage and harm of oppression is likely to be one-sided, from dominant to marginalized group.

Manifestation in Institutions

Fourth, the ethnocentric values and beliefs 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 often dictate and control our lives. Ethnocentric values attain untouchable and godfather-like status in an organization. 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 all products of cultural conditioning, their values and beliefs (worldviews) represent an invisible veil that operates outside the level of conscious awareness (Neville, Gallardo, & Sue, in press). 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 painful 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 European American 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 or wrong, nor good or bad. They become problematic, however, when they are expressed 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 the colonized to adopt European beliefs and customs was seen as civilizing them. In the United States, this practice was clearly evident in the treatment of Native Americans, whose lifestyles, customs, and practices were seen as backward and uncivilized, and attempts were made to make over the “heathens” (Duran, 2006; Gone, 2010).

Monocultural ethnocentric bias has a long history in the United States and is even reflected as early as the uneven application of the Bill of Rights, which favored White immigrants/descendants over minority populations (Barongan et al., 1997). More than 200 years ago, Britain's King George III accepted a Declaration of Independence from former subjects who moved to this 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 those events. 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 were created equal; what about women? Third, many of the founding fathers were slave owners who seemed not to recognize 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), who in the process did not recognize their own role in the oppression of indigenous peoples (American Indians) who had already resided in this country for centuries.

While ethnocentric monoculturalism is much broader than the concept of racial oppression, it is race and color that have been primarily used to determine 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. The oppression of the indigenous people of this country (Native Americans), enslavement of African Americans, widespread segregation of Hispanic Americans, 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 among therapist and client, an interracial encounter may be fraught with historical and current psychological baggage related to issues of discrimination, prejudice, and oppression.

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, our history of discrimination, and America's reaction 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 rear children who would fit into a segregated system and who could physically survive, 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 involves a “mild dissociation” whereby African Americans may separate their true selves from their roles as “Negroes” (Boyd-Franklin, 2010; J. M. 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. From the analysis of African American history, the dissociative process may be manifested in two major ways.

First, “playing it cool” has been identified as one means by which African Americans or other minorities may conceal their true feelings (Boyd-Franklin, 2010; Cross, Smith, & Payne, 2002; Grier & Cobbs, 1971; A. C. Jones, 1985). This behavior is intended to prevent Whites from knowing what the minority person is thinking or feeling and to express feelings and behaviors in such a way as to prevent offending or threatening Whites (C. Jones & Shorter-Gooden, 2003; Ridley, 2005). Thus a person of color who is experiencing conflict, explosive anger, and suppressed feelings may appear serene and composed on the surface. This is a defense mechanism aimed at protecting people of color from harm and exploitation. Second, the Uncle Tom syndrome may be used by Blacks to appear docile, nonassertive, and happy-go-lucky. Especially during slavery, Blacks learned that passivity was a necessary survival technique. To retain the most menial jobs, to minimize retaliation, and to maximize survival of the self and loved ones, many minorities have learned to deny their aggressive feelings toward their oppressors. The overall result of the experiences of minorities in the United States has been to increase their vigilance and sensitivity to the thoughts and behaviors of Whites in society.

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 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 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. Despite their conscious desires to help, White therapists are not immune from inheriting racist attitudes, beliefs, myths, and stereotypes about Asian American, African American, Latino/Hispanic American, and American Indian clients (Sue, 2004). For example, White counselors often believe that Blacks are nonverbal, paranoid, and angry and that they are most likely to have character disorders (Carter, 1995; A. C. Jones, 1985) or to be schizophrenic (Pavkov, Lewis, & Lyons, 1989). As a result, they view African Americans as unsuitable for counseling and psychotherapy. Mental health practitioners and social scientists who hold to this belief fail to understand the following facts:

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 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 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 Americans 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 the Establishment, who have inherited the racial biases of their forebears. Thus socially marginalized clients are likely to 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 an alien 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 present also in the therapy sessions. As pointed out earlier, these mechanisms are attempts to conceal true feelings, to hinder self-disclosure, and to prevent the therapist from getting to know the client. These 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 and break through this maze. 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 tests. 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 therapists lacking such attributes (Heesacker & Carroll, 1997). Regardless of the counseling orientation (psychodynamic, humanistic, behavioral, etc.), therapists' 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 Latino/a client that the White therapist has no knowledge or expertise in working with Latinos. 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.

Understanding Client Mind-Sets

The therapist's credibility and attractiveness depend very much on the mind-set or frame of reference of culturally diverse clients. Understanding a client's psychological mind-set may facilitate the therapist's ability to exert social influence in counseling. The conceptual categories that can be used to understand people's perception of communicator (counselor) credibility and attractiveness are drawn from social psychology (Collins, 1970). We apply those categories with respect to the therapy situation. Note that race, ethnicity, and the experience of discrimination often affect the type of mind-set operative in the clinical encounter.

1. The problem-solving set. In the problem-solving set, the client is concerned about obtaining correct information (solutions and skills) that has adaptive value in the real world. The client accepts or rejects information from the therapist on the basis of its perceived truth or falsity: Is it an accurate representation of reality? The processes that are used tend to be rational and logical in analyzing and attacking the problem. First, the client may apply a consistency test and compare the new facts with earlier information. For example, a White male therapist might try to reassure an Asian American client that he is not against interracial marriage but might hesitate in speech and tense up whenever the topic is broached (Utsey, Gernat, & Hammar, 2005). In this case, the verbal or content message is inconsistent with nonverbal cues, and the credibility and social influence of the therapist are likely to decline.

Second, the Asian client may apply a corroboration test by actively seeking information from others for comparison purposes. If he or she hears from a friend that the therapist has racial hang-ups, then the therapist's effectiveness is again likely to be severely diminished. The former test makes use of information that the individual already has (understanding of nonverbal meanings), while the latter requires him or her to seek out new information (asking a trusted Asian American friend). Through their experiences, clients of color may have learned that many Whites have little expertise when it comes to their lifestyles and that the information or suggestions that they give are White solutions.

2. The consistency set. People are operating under the consistency set whenever they change an opinion, belief, or behavior to make it consistent with other opinions, beliefs, or behaviors. For example, since therapists are supposed to help, we naturally believe that they would do nothing to harm us. A therapist who is not in touch with personal prejudices or biases may send out conflicting messages to a minority client. The counselor may verbally state, “I am here to help you,” but at the same time indicate racist attitudes and feelings nonverbally. This can destroy the counselor's credibility very quickly, for example, in the case of a Latino client who accurately applies a consistency set such as, “White people say one thing, but do another. You can't believe what they tell you.” Culturally diverse clients will actively seek out disclosures on the part of the therapist to compare them with the information they have about the world. If the therapist passes the test, new information may be more readily accepted.

3. The identity set. An individual who strongly identifies with a particular group is likely to accept the group's beliefs and to conform to behaviors dictated by the group. If race or ethnicity constitute a strong reference group for a client, then a counselor of the same race/ethnicity is likely to be more influential than one who is not. It is believed that racial/ethnic similarity may actually increase willingness to return for therapy and facilitate effectiveness. The findings on this matter are quite mixed, as there is considerable evidence that membership group similarity may not be as effective as belief or attitude similarity. It has also been found that the stage of cultural or racial identity affects which dimensions of similarities will be preferred by the racial/ethnic minority client (Cross, Smith, & Payne, 2002). We have much more to say about cultural identity development later in Chapter 11. It is obvious, however, that racial differences between counselor and client make bridging this gap a major challenge.

4. The economic set. In the economic set, the person is influenced because of the perceived rewards and punishments that the source is able to deliver. In this set, a person performs a behavior or states a belief in order to gain rewards and avoid punishments. In the counseling setting, this means that the therapist controls important resources that may affect the client. For example, a therapist may decide to recommend expulsion of a student from school or deny a positive parole recommendation to a client who is in prison. In less subtle ways, the therapist may ridicule or praise a client during a group counseling session. In these cases, the client may decide to alter his or her behavior because the therapist holds greater power. The major problem with the use of rewards and punishments to induce change is that although it may assure behavioral compliance, it does not guarantee private acceptance. For culturally diverse clients, therapy that operates primarily on the economic set is more likely to prevent the development of trust, rapport, and self-disclosure.

5. The authority set. Under this set, some individuals are thought to have a particular position that gives them a legitimate right to prescribe attitudes or behaviors. In our society, we have been conditioned to believe that certain authorities (police officers, chairpersons, designated leaders, etc.) have the right to demand compliance. This occurs via training in role behavior and group norms. Mental health professionals, such as counselors, are thought to have a legitimate right to recommend and provide psychological treatment to disturbed or troubled clients. This psychological set legitimizes the counselor's role as a helping professional. Yet for many minorities, these roles in society are exactly the ones that are perceived as instruments of institutional oppression and racism.

It should be clear at this point that characteristics of the influencing source (therapist) are of the utmost importance in eliciting types of changes. In addition, the type of mental or psychological set placed in operation often dictates the permanency and degree of attitude/belief change. While these sets operate similarly for majority and marginalized clients, their manifestations may be quite different. Obviously, a client may have great difficulty identifying with a counselor from another race or culture (identity set). Also, what constitutes credibility to minority clients may be far different from what constitutes credibility to a majority client.

Counselor Credibility

Credibility (which elicits the problem-solving, consistency, and identity sets) 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 beliefs that the helping professional who is perceived as expert and trustworthy can influence clients more than can one who is perceived to be lower on these traits.

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 to help (problem-solving set). Perceived expertness is typically a function of (a) reputation, (b) evidence of specialized training, and (c) behavioral evidence of proficiency/competency. For clients seeing a therapist of a different race/culture, the issue of therapist expertness seems to be raised more often than when clients go to a therapist of their own culture and race. 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 demonstrating the ability to help a 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 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 lowers 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 and 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 might have the best of intentions, it is possible that his or her intentions 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 is very much dependent on 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 (authority set). 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 it is 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 on the part of the helping professional, something that graduate training programs have taught us to avoid. It places the focus on the therapist rather than on the client and makes many uncomfortable. 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 Male 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 actually 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?

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 America, 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 control (IC) refers to the belief that reinforcements are contingent on our own actions and that we can shape our own fate. External 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 the core features of Western mental health.

On the other hand, it has been found that people of color, women, and people from low socioeconomic status score significantly higher on the external end of the locus-of-control continuum (Sue, 1978; Koltko-Rivera, 2004). Using the I-E 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 (“It's no use trying,” “There's nothing I can do about it,” and “You shouldn't rock the boat”) may interpret the client as being inherently apathetic, procrastinating, lazy, depressed, or anxious about trying. The problem with an unqualified application of the I-E 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 from a lower SES 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 the particular ethnic group as acceptable and benevolent. In this case, externality is viewed positively. American culture, for example, values the uniqueness, independence, and self-reliance of each individual. 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, social roles expectations, and 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 highly values externality.

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 SES 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 attainment. In this case, externality may be seen as a malevolent force to be distinguished from the benevolent cultural ones just discussed. 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 I-E continuum is useful for therapists only if they make clear distinctions about the meaning of the external control 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 (J. M. Jones, 1997). In essence, this dimension measures the degree of responsibility or blame placed on the individual or system. In the case of Latino Americans, their lower standard of living may be attributed to either their personal shortcomings or to racial discrimination and lack of opportunities. The former orientation blames the individual, while the latter explanation 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 or system-blame people view the sociocultural and sociopolitical environment as more potent than the individual. Social, economic, and political forces are powerful; success or failure is generally dependent on the social forces and not necessarily on personal attributes. Defining the problem as residing in the person enables society to ignore the influence of external factors, and to protect and preserve social institutions and belief systems. Thus the individual/system blame continuum may need to be viewed differentially for socially devalued groups. An internal response (acceptance of blame for one's failure) might be considered normal for the White middle class, but for minorities it may be extreme and intropunitive.

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, p. 422. Copyright © 1978 by the Journal of Counseling Psychology. Reprinted by permission.

Internal Locus of Control (IC)–Internal Locus of Responsibility (IR)

As mentioned earlier, individuals high in internal personal control (IC) believe that they are masters of their fate and that their actions do affect the outcomes. Likewise, people high in internal locus of responsibility (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 is attributed 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; self-reliance; pragmatism; individualism; status achievement through one's own effort; and 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 class 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 that they can 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 for 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 due to 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 external control.

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. 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 may 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 external control feels that there is very little one can do in the face of oppression. In essence, the EC response might be a manifestation of (a) having given up or (b) attempting to placate those in power. In the former, individuals internalize their impotence 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 simply give up in their attempts to achieve personal goals.

The dynamics of the placater, however, are not related 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 is little that the individual can do. Passivity in the face of oppression is the primary reaction of the placater. Slavery was one of the most important factors shaping the sociopsychological functioning of African Americans. 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. Conformance 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 African Americans are very likely to see the White therapist as symbolic of any other Black–White 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 approach on the part of the therapist would be (a) to teach the clients new coping strategies, (b) to have them experience successes, and (c) to validate who and what they represent.

Internal Locus of Control (IC)–External Locus of Responsibility (ER)

Individuals who score high in internal control 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 block their paths to the successful attainment of goals. There is a considerable body of evidence to support this contention. 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 stress racial identity and militancy. Pride in one's racial and cultural identity is most likely to be accepted by an IC-ER person. The low self-esteem engendered by widespread prejudice and racism is actively challenged. There is an attempt to redefine a group's existence by stressing consciousness and pride in their own racial and cultural heritage. Such phrases as “Black is beautiful” represent a symbolic relabeling of identity from “Negro” and “colored” to Black or African American. To many African Americans, Negro and colored are White labels symbolic of a warped and degrading identity given them by a racist society. As a means of throwing off these burdensome shackles, the Black individual and African Americans as a group are redefined in a positive light.

Counseling Implications

Much evidence indicates that people of color are becoming increasingly conscious of their own racial and cultural identities as they relate to oppression in U.S. society. If the evidence is correct, it is also probable that more and more persons of color are likely to hold an IC-ER worldview. Thus therapists who work with the culturally different will increasingly be exposed to clients with an IC-ER worldview. In many respects, these clients pose the most difficult problems for the White IC-IR therapist. These clients are likely to raise challenges to the therapist's credibility and trustworthiness. 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 any other worldview, an IC-ER orientation means that clients are likely to play a much more active part in the therapy process and to demand action from the 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 it 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 operates from the assumption of high internal locus of control and responsibility. Be able to apply and understand how Western therapeutic characteristics may detrimentally interact with other worldviews.

Summary

It is important 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 encounter with a stranger (i.e., therapy), each party will attempt to discern gross or subtle racial attitudes of the other while minimizing vulnerability. Ethnocentric monoculturalism lies at the heart of oppressor–oppressed relationships that affect 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 inferiority of all other groups, the power to impose standards on socially devalued groups, manifestation and support of institutions, and the invisibility of the imposition process.

It is clear that past and present discrimination against certain culturally diverse groups is a tangible basis for minority distrust of the majority society. Majority group members are perceived as potential oppressors unless proved otherwise. Under such a sociopolitical atmosphere, marginalized groups 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 therapists lacking such attributes. Social psychologists have identified the “psychological mind-sets” of people that work toward establishing communicator and therapist credibility. In multicultural counseling, client tests of trustworthiness and expertness are likely to enhance or negate the counselor's credibility. Many of these tests are likely to prove challenging to well-intentioned therapists. Cultural competence means understanding the worldviews of diverse clients. Locus of control (people's beliefs that they can shape their own fate—IC, or that chance or luck determines outcomes—EC) and locus of responsibility (causation resides in the person—IR, or 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. We summarize therapeutic implications for each of these dimensions of worldviews.

Glossary Terms

Attractiveness

Color blindness

Credibility

Cultural oppression

Ethnocentric monoculturalism

Expertness

Institutional racism

Invisible veil

Locus of control

Locus of responsibility

Playing it cool

Stereotyping

The authority set

The consistency set

The economic set

The identity set

The problem-solving set

Trustworthiness

Uncle Tom Syndrome

Unintentional racism

Victim blaming

White privilege

Worldview

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MICROAGGRESSIONS IN COUNSELING AND PSYCHOTHERAPY

Christina M. Capodilupo Ph. D.

Teachers College, Columbia University

Chapter Objectives

1. Define and describe microaggressions.

2. Differentiate between the intentions (by the aggressor) and the impact (on the victim) of microaggressions.

3. Understand the psychological impact of microaggressions on marginalized groups.

4. Describe the various psychological dynamics involved in microaggressions.

5. Apply knowledge of microaggressions to understanding therapeutic process and client/counselor dynamics.

Case Study

Can Anybody See Me? The Case of Kiana

Kiana is a 34-year old multiracial bisexual woman living in a large metropolitan city. Her father is African American and her mother is biracial: Korean and Italian American. Kiana has medium skin tone and wears her hair very short and natural. She is currently an administrative assistant at a large university where she has worked for three years. Kiana works in this position while pursuing her Master's degree in Fine Arts. She performs and choreographs modern dance. Kiana has felt marginalized in her place of work and also recently ended a long-term romantic relationship. She struggles with managing her work environment and with re-entering the dating scene. She has also had some trouble getting out of bed in the morning and generally feels melancholy. She asked a friend to recommend a therapist, hoping it might help her feel more energetic and motivated to meet a new partner.

Kiana's friend referred her to a psychoanalyst she had been seeing for years: Alan, a White male in his late 50s. Kiana had some reservations about therapy; her mother felt it was disgraceful and inappropriate to tell a stranger about personal problems and her father felt it was for “crazy” people. In the first therapy session, Kiana described the difficulties she was having meeting other single people in the city. Alan asked Kiana if she might be contributing to her inability to meet men by having an “unapproachable air.” Kiana was surprised by his question and asked him what he meant by “unapproachable”? He shared his first impression of her, which was that her body language seemed closed and she appeared angry. Kiana paused, as this was not the first time someone had perceived her as an “angry Black woman.” She did not have the energy to explore this with him, and so accepted his observation and tried to change the subject by pointing out that she is attracted to both men and women.

Alan was curious about Kiana's bisexuality and how she understands it. He offered an interpretation of bisexuality as being a phase during which a person is trying to find their sexual identity. He asked her if identity issues had been an ongoing theme in her life and wondered aloud about her ethnicity. Once again, the kind of curiosity Alan was expressing was a familiar experience to Kiana, but she did not want to waste her time in therapy educating Alan about her sexuality or her ethnicity. She agreed with him that identity issues were an ongoing theme in her life and moved the discussion to her workplace.

Kiana shared with Alan that in her current role as administrative assistant, she experiences persistent feelings of invisibility. She relayed multiple incidents in which she would be sitting at her desk and people would look right past her, act as if she was not there, and generally treat her as unimportant. Further, though she was in this job to support her Master's degree studies, she felt she was often treated by professors and students as a “second class citizen”: there to serve them. She frequently noted looks of surprise and shock when she revealed that she was a Master's candidate. For example, a professor from a different department had recently come in to inquire about prerequisites for a particular course. Though the professor hadn't directed her question to her, Kiana spoke up, saying that she had taken the course and the student should be fine even with a limited background in the subject matter. The professor looked somewhat stunned and thanked Kiana tentatively before asking, “Why did you take the course? Is it free for staff?”

Kiana shared an office space with another administrative assistant named Michelle, who was a younger White female and newer to the job. When a colleague would come into their office with a policy or inventory question, they always directed it to Michelle. When a delivery person or tech would come in, they would address Michelle, and if Michelle was not at her desk (but Kiana was), they would simply walk out, as if no one were in the office. She shared with Alan that she sometimes wonders: can anybody see me? While exploring this, Alan wondered if Kiana was “making a mountain out of a mole hill.” For example, he asked if Michelle's desk was positioned closer to the door in the office, implying that she is the “first line” for inquiries. He also asked how Michelle greets people: was she smiling and cheerful? Pleasant and warm? Alan felt it was important for Kiana to consider where these feelings of invisibility may be coming from, and invited her to consider if she felt that she was not worthy of others' attention and admiration. He then began to ask her how her relationship was with her parents as a child, with particular interest in how she felt about her father.

These questions frustrated Kiana, but she was aware that Alan was already experiencing her as closed and angry. Actually, she was feeling angry, and it felt very similar to the anger she experienced in her workplace. She felt caught in that moment between sharing her authentic reaction and being type cast as an angry Black woman and holding in her true feelings to avoid the stereotype. It was a familiar scenario. Alan interpreted Kiana's silence as resistance to the therapeutic process. Kiana responded that she had come to therapy to deepen her self-awareness; however, she could see that there were going to be too many barriers between herself and Alan for her to be able to authentically share herself. Alan expressed regret about this and asked if Kiana would consider coming to another session the next day. He felt that Kiana's desire to terminate their work prematurely was a defense mechanism; a common reaction for those who are new to therapy. Somehow, this did not resonate for Kiana and she did not return for a second session.

Reflection and Discussion Questions

1. What are some of the assumptions that Alan makes about Kiana? Why might he be making these?

2. Can you describe the psychological impact these assumptions may be having on Kiana?

3. How may race, gender, age, and sexuality be affecting the therapeutic relationship between Kiana and Alan?

4. If you were Kiana's therapist, how would you approach your work with her? What sociocultural dynamics would exist between you, and how might they influence the therapeutic process?

5. What could Alan do to repair this therapeutic rupture with Kiana? What role might cultural mistrust play in this process?

There is clearly misunderstanding and miscommunication between Kiana and Alan. Kiana was attending therapy in hopes of deepening her self-understanding; however, her initial session has served as a microcosm for her experiences in society at large where she feels invisible. Alan seems to relate to Kiana as a stereotype (“angry Black woman”) and explains her feelings of invisibility as being self-imposed (rather than being caused by the environment and larger climate of racism and sexism). Kiana's feelings and experience are unknowingly invalidated, negated, and dismissed by the therapist. This anecdote illustrates how racial, gender, and sexual orientation microaggressions can have a detrimental impact upon marginalized groups and also undermine the therapeutic process. Let us briefly review Kiana's interactions with others from her perspective.

In her workplace, Kiana experiences persistent feelings of invisibility. She feels she is often overlooked by others and is generally taken to be less important and qualified than her younger and less experienced White officemate. Yet she is placed in an unenviable position of not being absolutely certain that colleagues are reacting to her race. Further, she is keenly aware of the stereotype of the “angry Black woman” and does not want to be typecast should she express her frustrations. She is aware that if she is experienced as hostile and angry, then people may avoid her in the future, only compounding her feelings of invisibility. Therefore, Kiana feels a persistent need to monitor her authentic reactions and her tone of voice, impeding her ability to be her true self (and using a lot of psychic energy!) while at work.

Although the therapist may be attempting to help Kiana by asking her to look inside herself for the cause of these feelings of invisibility (a common psychodynamic intervention is to explore intrapsychic dynamics) he actually undermines and invalidates Kiana's experiential reality. Instead of exploring the workplace environment and considering that racism and sexism cause people to see a Black woman such as Kiana as less capable, intelligent, and important, Alan immediately locates the problem within Kiana (“blaming the victim”). He does the same thing when asking her about dating. He uses his own experience of her in therapy (closed body language, angry expression) and asks her about an “unapproachable air”; again locating the problem within Kiana. Alan also makes a heteronormative assumption about Kiana's sexuality when he asks her why she is having difficulty meeting men. Then, when Kiana responds that she is interested in men and women, he has difficulty owning up to his lack of awareness and instead interprets bisexuality as a phase, thereby invalidating Kiana's sexual identity. He goes on to further alienate his client by suggesting that Kiana struggles with identity issues, given her multiple ethnic identities. Being multiethnic, Kiana has faced questions her entire life about “what she is” and even though she has a strong understanding of herself as a racial being, Alan has enacted the idea that she must be confused and unsure of her identity.

The incidents experienced by Kiana are examples of microaggressions. The term racial microaggressions 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; Pierce, 1995). 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; and gay, lesbian, bisexual, and transgendered individuals (Sue, 2010; Sue, Capodilupo, et al., 2007). These microaggressions are often subtle in nature and can be manifested in the verbal, nonverbal, visual, or behavioral realm. They are often enacted automatically and unconsciously (Pierce et al., 1978; Solórzano, Ceja, & Yosso, 2000), although the person who delivers the microaggression can do so intentionally or unintentionally (Sue, Capodilupo, et al., 2007). Investigators have recently introduced the term hierarchical microaggressions, defined as “everyday slights found in higher education that communicate systemic valuing (or devaluing) of a person because of the institutional role held by that person” (Young, Anderson & Stewart, 2015, p. 66). Consistent with Kiana's experiences, participants in that study felt that staff were devalued and made to feel unimportant.

When colleagues and service workers seek answers only from Kiana's coworker and ignore Kiana, they are sending a nonverbal message (walking out of the office) that they do not believe Kiana is competent to handle the task at hand. When the professor is surprised to learn that Kiana has taken a graduate course and assumes it is free for staff, she is sending a nonverbal (look of surprise) and verbal message that Kiana does not belong in the advanced academic environment. The underlying thought process seems to be that Black people are less qualified, less competent, and less educated. As we shall see, microaggressions may seem innocent and innocuous, but their cumulative nature can be extremely harmful to the victim's physical and mental health. In addition, they create hostile work environments such as Kiana's where she may be denied opportunities and have difficulties advancing because of unconscious biases and beliefs held by the colleagues.

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.

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 what has been called “old-fashioned” racism has seemingly declined (Dovidio & Gaertner, 2000). However, the nature and expression of racism (see Chapter 4) has evolved into a more subtle and ambiguous form, perhaps reflecting people's belief that overt and blatant acts of racism are unjust and politically incorrect (Dovidio, Gaertner, Kawakami, & Hodson, 2002). In a sense, racism has gone underground, has become more disguised, and is more likely to be covert. A similar process seems to have occurred with sexism as well. Three types of sexism have been identified: overt, covert, and subtle (Swim & Cohen, 1997). Overt sexism is blatant unequal and unfair treatment of women. Covert sexism refers to unequal and harmful treatment of women that is conducted in a hidden manner (Swim & Cohen, 1997); for example, a person may endorse a belief in gender equality but engage in hiring practices that are gender biased. The third type, 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). Aversive racism is manifested in individuals who consciously assert egalitarian values but unconsciously hold anti-minority 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, and lesbian, gay, bisexual, or transgendered person [LGBT] populations) is unavoidable and inevitable due to the socialization process in the United States (Sue, 2004), where biased attitudes and stereotypes reinforce group hierarchy (Gaertner & Dovidio, 2006).

Subtle sexism is very similar to aversive racism in that individuals support and actively condone gender equality, yet unknowingly engage in behaviors that contribute to the unequal treatment of women (Cundiff, Zawadzki, Danube, & Shields, 2014). 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 et al., 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 (M. A. Morrison & T. G. Morrison, 2002). Heterosexism and anti-gay harassment has a long history and is currently prevalent in the United States. Recent studies find the following for LGBT persons in the workplace: (a) 15–43 percent experience discrimination or harassment; (b) 7–41 percent report verbal or physical abuse or had their workplace vandalized; and (c) 10–28 percent were not promoted because they were gay or transgender (Burns & Krehely, 2011). Anti-gay 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).

Although anti-gay harassment includes comments and jokes that convey that LGB individuals are pathological, abnormal, or unwelcome, authors identify subtle heterosexism by the indirect nature of such remarks (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).

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, Issa, Griffin, Hamit, & Lyons, 2010; Nadal et al., 2012). 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 et al., 2010). The largest percentage of religious harassment and civil rights violations in the United States are committed against Jewish and Muslim individuals (Nadal et al., 2010). Some commonly held anti-Semitic beliefs are that Jews (a) are more loyal to Israel than to the United States, (b) hold too much power in the United States, and (c) are responsible for the death of Jesus Christ (Nadal et al., 2010).

The prejudice experienced by Muslim individuals is often referred to as Islamaphobia and has been well documented in Western European countries both before and after the September 11, 2001, terrorist attacks (Nadal et al., 2010). The media tends 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, though discriminatory practices toward people with disabilities (PWD) is long-standing 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, p. 242).

What makes this phenomenon of subtle discrimination particularly complex is that ambiguity and alternative explanations obscure the true meaning of the event not only for the person who engages in this behavior, but also for the person on the receiving end of the action. This is the central dilemma created by microaggressions, which are manifestations of these subtle forms of oppression.

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). Microaggressions can also be delivered environmentally through the physical surroundings of target groups, where they are made to feel unwelcome, isolated, unsafe, and alienated. For example, a prestigious Eastern university conducts new faculty orientations in their main conference room, which displays portraits of all past presidents of the university. One new female faculty of color mentioned that during the orientation she noticed that every single portrait was that of a White male. She described feelings of unease and alienation. To her, the all-White-male portraits sent powerful messages: “Your kind does not belong here,” “You will not be comfortable here,” and “If you stay, there is only so far you can rise at this university!” Environmental microaggressions can occur when there is an absence of students or faculty of color on college campuses, few women in the upper echelons of the workplace, and limited or no access for disabled persons in buildings (e.g., only stairs and no ramp; no Braille in elevators).

Research suggests that the socialization process culturally conditions racist, sexist, and heterosexist attitudes and behaviors in well-intentioned individuals and that these biases are often automatically enacted without conscious awareness, particularly for those who endorse egalitarian values (Dovidio & Gaertner, 2000). 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, Capodilupi, et al., 2007). Three types of microaggressions 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; hiring only men for managerial positions; 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 past high-profile examples exemplify the first condition: (a) Paula Deen's use of the N-word and racial harassment to employees of color (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 condition: (a) actor Mel Gibson made highly inflammatory anti-Semitic public statements to police officers when he was arrested for driving while intoxicated, and (b) comedian Michael Richards, who played Kramer on Seinfeld, went on an out-of-control rant at a comedy club and publicly insulted African Americans by hurling racial epithets at them and by demeaning their race. 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. We submit that microassaults are in many respects easier to deal with than those that are unintentional and outside the perpetrator's level of awareness (microinsults and microinvalidations).

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 onto public transportation, the underlying message is that disabled people are in constant need of help and dependent on others. When the coworkers in the case study at the beginning of this chapter look past Kiana to answer workplace-related questions, they were conveying a hidden message: Black females are less competent and capable.

African Americans consistently report that intellectual inferiority is a common communication they receive from Whites in their everyday experiences (Sue, Capodilupo, & Holder, 2008). Latinos also report a variety of incidences in which their academic success is questioned or they are assumed to be less qualified (Ramirez, 2014; Rivera, Forquer, & Rangel, 2010). Native Americans also report constant, continual, and cumulative experiences of microinsults (Jones & Galliher, 2015). A recent investigation of microaggression experiences on college campuses indicates that Black and Latina/o students experience significantly more microaggressions where they are treated as inferiors than their White and Asian counterparts. Further, Black participants reported more experiences of being treated as second-class citizens than all other groups (Nadal, Wong, Griffin, Davidoff, & Sriken, 2014). Similarly, when teachers in a classroom consistently call on male students rather than females to answer questions, the hidden message is that men are brighter and more capable than women.

Microinvalidation

Microinvalidations are verbal comments or behaviors that exclude, negate, or dismiss the psychological thoughts, feelings, or experiential reality of the target group. Like microinsults, they are unintentional and usually outside the perpetrator's awareness. When Alan dismissed Kiana's bisexuality as a “phase,” he negated the client's sexual identity. The hidden message delivered to Kiana is that she is confused and working through her sexual preference, thereby denying that she can be attracted to both sexes. Because Alan is in a position of power as a White therapist, he is able to not only define Kiana's experiential reality but also direct the course of therapy. While Kiana entered therapy to deepen her self-understanding, the therapy has quickly become about Alan's understanding of Kiana—through his racialized, gendered, and sexual assumptions about her. Thus, the entire experience of therapy is microinvalidation for Kiana.

Another common microinvalidation is when individuals claim that they do not see religion or color but instead see only the human being. Common statements such as “there is only one race: the human race” negate the lived experiences of religious and ethnic minorities in the United States. Such statements have been coined by researchers as “color-blind” attitudes and new 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; Sue, 2010). To further illustrate the concepts of microinsults and microinvalidations, Table 6.1 provides examples of comments, actions, and situations, as well as accompanying hidden messages and assumptions. There are 16 distinct categories represented in this table: alien in one's own land; ascription of intelligence; assumption of abnormality; color blindness; criminality/assumption of criminal status; denial of individual racism/sexism/heterosexism/religious prejudice; myth of meritocracy; pathologizing cultural values/communication styles; second-class status; sexual objectification; use of sexist/heterosexist language; traditional gender role prejudice and stereotyping; helplessness; denial of personal identity; exoticization; and assumption of one's own religion as normal. Some of these categories are more applicable to certain forms of microaggressions (racial, gender, religion, ability, or sexual orientation), but they all seem to share commonalities.

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. Can you explore the potential hidden messages they communicate to the 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?

TABLE 6.1 Examples of Microaggressions

Themes	Microaggression	Message
Alien in Own Land When Asian Americans and Latino Americans are assumed to be foreign-born A person asking an Asian American to teach them words in their native language	“Where are you from?” “Where were you born?” “You speak good English”	You are not American.
	You are a foreigner.
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 A person of color is presumed 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 Latino approaches or passes.	You are a criminal/You are dangerous.
	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 LGB persons	Use of the pronoun “he” to refer to all people.	Male experience is universal. Female experience is meaningless.
	Though a male-to-female transgendered employee has consistently referred to herself as “she,” coworkers continue to refer to “he.”	Our language does not need to change to reflect your identity; your identity is meaningless.
	Two options for Relationship Status: Married or Single.	LGB 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 Islamaphobic 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 dominant culture.
	Dismissing an individual who brings up race/culture in work/school setting	Leave your cultural baggage outside.
Second-Class Citizen Occurs when a target group member receives differential treatment from the power group	Person of color mistaken for a service worker	People of color are servants to Whites. They couldn't possibly occupy high-status positions.
	Female doctor mistaken 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.
	Being ignored at a store counter as attention is given to the White customer behind you	Whites are more valued customers than people of color.
	A lesbian woman is not invited out with a group of girlfriends because they thought she would be bored if they were talking to men.	You don't belong.
Traditional Gender Role Prejudicing and Stereotyping Occurs when expectations of traditional roles or stereotypes are conveyed	When a female student asked a male professor for extra help on a chemistry assignment, he asks, “What do you need to work on this for anyway?”	Women are less capable in math and science.
	A person asks a woman her age and, upon hearing she is 31, looks quickly at her ring finger.	Women should be married during child-bearing ages because that is their primary purpose.
	A woman is assumed to be 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 Occurs when women are treated like objects at men's disposal	A male stranger puts his hands on a woman's hips or on the swell of her back to pass by her.	Your body is not yours.
	Whistles and catcalls as a woman walks down the street.	Your body/appearance is for men's enjoyment and pleasure.
	Students use the term gay to describe a fellow student who is socially ostracized at school.	People who are weird and different are “gay.”
Assumption of Abnormality Occurs when it is implied that there is something wrong with being LGBT	Two men holding hands in public receiving stares from strangers.	You should keep your 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 1 Occurs when people frantically try to help people with disabilities (PWDs)	Someone helps you onto a bus or train, even when you need no help.	You can't do anything by yourself because you have a disability.
	People feel they need to rescue you from your disability.	Having a disability is a catastrophe.
Denial of Personal Identity 2 Occurs 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 Occurs when an LGBT, women of color, or 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 LGBT person.	Your privacy is not valued; you should entertain with stories.
	Asking a Muslim person incessant questions about his/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 3	Saying “Merry Christmas” as a universal greeting.	Your religious beliefs are not important; everyone should celebrate Christmas.
	The sole acknowledgment of Christian holidays in work and school.	Your religious holidays need to be celebrated on your time; they are unimportant.
1 Adapted from Sue et al., 2007. 2 Themes and examples are taken from Keller & Galgay, 2010. 3 Themes and examples are taken from Nadal et al., 2010.

The Dynamics and Dilemmas of Microaggressions

Let us use the case of Kiana to illustrate some of the dynamics and dilemmas presented by microaggressions. Research on subtle forms of racism (Dovidio et al., 2002; Ridley, 2005), sexism (Swim et al., 2004), and heterosexism (Morrison & Morrison, 2002) provide evidence that they operate in individuals who endorse egalitarian beliefs, adamantly deny that they are biased, and consider themselves to be moral, just, and fair. What people consciously believe or say (e.g., “I have no gay bias”), however, is oftentimes at odds with what they actually do (e.g., avoiding sitting next to an ostensibly gay man). Further, those who purport to not see race but rather see all people as equal (i.e., color-blind attitude) are significantly less likely to recognize and perceive racial microaggressions (Offermann et al., 2014).

Proving that one's actions or comments stem from an unconsciously held set of negative beliefs toward the target group is virtually impossible when alternative explanations exist. Because Whites who engage in microaggressions truly believe they acted without racial bias toward persons of color, for example, they will disclaim any racist meaning. Not only is the subtle and insidious nature of racial microaggressions outside the level of awareness of perpetrators but also recipients find their ambiguity difficult to handle. Victims are placed in an unenviable position of questioning not only perpetrators, but themselves as well (e.g., “Did I misread what happened?”). Victims often replay the incident over and over again to try to understand its meaning.

A study of Black undergraduates summarizes the energy that can go into the interpretation of microaggressions: “Participants also typically reported trying to balance responding to or educating others about racism, while not ‘overthinking' these incidents or placing too much energy on [these] encounters” (Watkins, Labarrie, & Appio, 2010, p. 35). We see this very dynamic when Kiana chooses not to respond to Alan's questions about her sexual and ethnic identity. Though she feels marginalized by him as she has in her daily experiences in society, she chooses not to educate Alan in that moment, since her experience in therapy is meant to be about and for her. Qualitative narratives speak to the idea that bisexual women have to work to “make their identity understood, seen and accepted, not only by strangers—but by their loved ones” (Bostwick & Hequembourg, 2014, p. 499); consistently having to “prove” one's identity certainly represents an emotional burden.

In the face of microaggressions, many members of historically marginalized groups describe feeling a vague unease that something is not right and that they were insulted or disrespected. In this respect, overt acts of racism, sexism, or heterosexism may be easier to handle than microaggressions because the intent and meaning of the event are clear and indisputable (Solórzano et al., 2000; Sue, 2004). In support of this, recent studies found that racial microaggressions were more impactful, harmful, and distressing to African Americans and Asian Americans than everyday hassles (Utsey, Giesbrecht, Hook, & Stanard, 2008; Wang, Leu, & Shoda, 2011). Microaggressions toward marginalized groups, however, pose special problems. Four psychological dilemmas have been identified when microaggressions occur (Sue et al., 2007).

Dilemma 1: Clash of Sociodemographic Realities

For Kiana, one major question was, “Were people looking past her and ignoring her because of her race?” Although lived experience tells her that many Whites devalue Black women, chances are that her workplace colleagues would be offended at such a suggestion. They would likely deny they possessed any stereotypes and might point to Kiana's own demeanor (not “friendly enough”) as being responsible for her being overlooked (as Alan did). 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 anti-gay 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 important, individuals in power positions do not consider themselves capable of discrimination based on race, gender, or sexual orientation because, they believe, they are free of bias.

On the other hand, people of color perceive Whites to be racially insensitive, enjoy holding power over others, and think they are superior (Sue et al., 2007). LGB individuals consider homonegativity and anti-gay harassment to be a crucial aspect of their everyday existence (Burn et al., 2005; Nadal, 2013), and women contend that sexism is alive and well in social and professional settings. Although research supports the fact that those most disempowered are more likely to have a more accurate perception of reality, it is groups in power that have the ability to define reality. Thus, people of color, women, and LGB 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 Kiana, who has had countless experiences of being taken as an “angry Black woman” when she expresses a strong opinion, she is clear that she needs to monitor and edit her point of view at work. Alan, however, has not experienced this racial reality and tries to “objectively” reason that Kiana may be reading too much into or misinterpreting the situation, or even contributing to others' perceptions of her as angry by not smiling or being “friendly.” Further, Alan invalidates Kiana's sexual identity by referring to bisexuality as a “phase” and he eliminates a healthy space for her to explore her feelings about trying to find a partner.

Microaggressions that dismiss a bisexual identity “reinforce the myth of monosexuality, wherein persons can only be understood to occupy one of two mutually exclusive categories (heterosexual versus homosexual)” (Bostwick & Hequembourg, 2014, p. 494). A recent study of lesbian, gay, bisexual, and transgendered 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).

Dilemma 2: The Invisibility of Unintentional Expressions of Bias

Although Kiana did not ask colleagues about their persistent behavior of ignoring her, nor their treating of her as a second-class citizen (as opposed to an equal), one can imagine that they might feel stunned and surprised to learn how Kiana feels. Especially in a place of higher education where many consider themselves to be liberal and egalitarian, they would likely dismiss Kiana's interpretations and deny their behavior. To Kiana, being ignored and undervalued in the academic community reflected a common experience for her of people seeming surprised that she is articulate, well educated, and intellectually competent.

How could Kiana “prove” that colleagues doubted her intelligence or worth? Her only evidence is her felt experience and interpretation, which are easily explained away and disregarded by coworkers, students, and professors with alternative explanations. For example, Alan wonders if colleagues simply approach Kiana's White officemate first because her desk is closer to the door.

Further compounding the situation is the idea that Kiana is experiencing these microaggressions in her place of work and school: an environment that should be fostering and supporting her intellectual growth. Kiana's academic achievements may be hampered by the stress she is experiencing on campus or she may perceive further education (i.e., pursuit of a doctorate) to be an impossibility for her. Research on microaggressions in higher education showed participants “to take on an identity associated with their status at the university” (Young et al., 2015, p. 69). That the microaggression is essentially invisible to the perpetrator creates a psychological dilemma for victims that can leave them frustrated, feeling powerless, and even questioning their own sanity (Bostwick & Hequembourg, 2014; Sue, Capodilupo, et al., 2007; Watkins et al., 2010).

Dilemma 3: 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. They see the events as innocent and innocuous and often feel that victims are “making a mountain out of a mole hill” (à la Alan). Trivializing the impact of racial microaggressions by some White people can be an automatic, defensive reaction to avoid feeling blamed and guilty (Sue, Capodilupo, Nadal, & Torino, 2008). Despite a lack of acknowledgment 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).

Racism and racial/ethnic discrimination cause significant psychological distress (Fang & Meyers, 2001; Krieger & Sidney, 1996; Sue, Capodilupo, et al. 2008; Sue, Capodilupo, & Holder, 2008; Watkins et al., 2010), depression (Comas-Diaz & Greene, 1994; Kim, 2002), and negative health outcomes (Harrell, Hall, & Taliaferro, 2003). Researchers have even coined the terms racism-related stress (Harrell, 2000) and minority stress framework (for sexual minorities) (Meyer, 2003). Recent qualitative work with bisexual women revealed that “microaggressions that render bisexual women's identity claims faulty or, worse, false and inauthentic, burden bisexual women with additional identity work, which is both cognitively and emotionally taxing” (Bostwick & Hequembourg, 2014, p. 499). One study that looked at racial microaggressions in the lived experience of African Americans found that the cumulative effect of these events was feelings of self-doubt, frustration, and isolation (Solórzano et al., 2000). Another study found that consequences of microaggressions for African Americans included feelings of powerlessness, invisibility, and loss of integrity (Sue, Capodilupo, et al., 2008; Sue, Capodilupo, & Holder, 2008).

In a 2-week daily diary study of Asian American college students' experiences of microaggressions, it was found that 78 percent 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 feel belittled, angry, invalidated, invisible, and trapped by their experiences of racial microaggressions (Sue, Capodilupo, Nadal, & Torino, 2007). Multiple studies suggest that Latino/a 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) and 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). In another study, the experience of microaggressions was significantly associated with low self-esteem (Nadal, Wong, et al., 2014b). 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 are associated with lower self-esteem, negative feelings about one's sexual orientation identity, and obstacles to developing one's sexual identity (Wright & Wegner, 2012). In fact, anti-gay slurs and related hostilities on campus are significantly related to psychological distress, anxiety, and post-traumatic stress disorder symptoms not only for the target of said incidents but also for those who indirectly experience these incidents (e.g., third-party observation) (Nadal, Issa, et al., 2011; Woodford, Han, Craig, Lim, & Matney, 2013).

Dilemma 4: The Catch-22 of Responding to Microaggressions

When a microaggression occurs, the recipient is often placed in an unenviable position of deciding what to do. This is compounded with numerous questions likely to go through the mind of the recipient: 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 coworkers, friends, or acquaintances? Many well-intentioned perpetrators are unaware of the exhausting nature of these internal questions as they sap the spiritual and psychic energy of victims. Kiana was obviously caught in a conflict, asking herself: Should I voice my concerns of being unimportant and overlooked, or should I bother to respond at all?

As a multiracial bisexual female, Kiana has probably experienced many microaggressions throughout her lifetime, and so microaggressive comments from coworkers do not feel random (Ridley, 2005). On the other hand, White colleagues who have not faced similar experiences are unable to see a pattern running throughout incidents encountered by people of color—hidden bias associated with race. People of color, for example, use context and experiential reality to interpret the meaning of microaggressions. The common thread operating in multiple situations is that of “race.” Whites, however, see such situations as “isolated incidents,” so the pattern of racism experienced by persons of color is invisible to them.

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 consequences of responding to microaggressions are relational. Consider when Alan assumed Kiana was heterosexual and asked why she is having difficulty meeting men. Kiana explained her attraction to both sexes only to then have Alan suggest that her sexual identity is a “phase.” In an effort to avoid an uncomfortable exchange with Alan, or to waste her own therapy time explaining her identity, Kiana moves the conversation elsewhere.

If Kiana responds to Alan with frustration or anger over his assumption, she risks being perceived as the “angry Black woman” and potentially jeopardizing their therapeutic relationship. Kiana might feel compelled to avoid this label and to simply forgo the hassles. Unfortunately, it has been found that such a reaction takes a psychological toll on the recipient because it requires her to suppress and obscure her authentic thoughts and feelings in order to avoid further discrimination (Franklin, 2004). Authors have referred to this process as self-silencing and have linked it to “compromising women's success by heightening feelings of alienation and reducing motivation” (London, Downey, Romero-Canyas, Rattan, & Tyson, 2012, p. 219).

Confronting sexual orientation microaggressions is further complicated for LGB individuals who may not necessarily be out of the closet. The reality of looming anti-gay harassment and differential (unequal) treatment may prevent LGB persons from coming out in a variety of settings, especially when there is evidence to suggest that the environment is heterosexist. Anti-gay slurs and pervasive use of the word “gay” to communicate that someone or something is inferior, stupid, or abnormal (Nadal, 2013) all contribute to hostile educational and workplace environments. The therapeutic room can be equally 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).

By not confronting or processing these experiences, marginalized groups are forced to shoulder the burden themselves with detrimental mental health consequences. In one study, African American participants revealed some strategies for dealing with this catch-22: (a) empowering and validating the self and (b) sanity check. Empowering and validating the self refers to a process of interrupting the racism by “calling it what it is” and staying true to one's thoughts and feelings that the incident is related to one's race. Sanity check refers to a process of checking in with like-minded and same-race people about microaggressive incidents. Talking about the incident with someone who has faced similar discrimination helps participants to feel validated in their experience that the incident is racially motivated (Sue, Capodilupo, et al., 2008; Sue, Capodilupo, & Holder, 2008). In another study, Black undergraduates identified support systems, such as family, friends, religious faith, club involvement, journal writing, and academic leadership positions, as being factors that promote resilience in the face of racial microaggressions (Watkins et al., 2010).

Counseling Implications

We have repeatedly emphasized that 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 Kiana). We submit that racial microaggressions may lie at the core of the problem. Take, for example, a recent study which 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). 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 LGBT individuals (Shelton & Delgado-Romero, 2011, 2013). In counseling and psychotherapy, the credibility of the therapist is paramount in determining whether clients stay or leave sessions (Strong, 1969). As we have seen in Chapter 5, credibility is composed of two dimensions: expertness and trustworthiness. Expertness is a function of how much knowledge, training, experience, and skills clinicians possess with respect to the population being treated; it is an ability component. Trustworthiness, however, is a motivational component that encompasses trust, honesty, and genuineness. Although expertness is always important, trustworthiness becomes central in multicultural counseling and therapy.

Effective counseling is likely to occur when both therapist and client are able to form a working relationship, therapeutic alliance, or some form of positive coalition. In mental health practice there is a near universal belief that effective and beneficial counseling requires that clients trust their counselors (Corey, 2012; Day, 2004). Research supports the idea that the therapeutic alliance is a key component in therapy work and is correlated with successful outcomes (Lui & Pope-Davis, 2005). Recent work supports the idea that clients' perceptions of racial microaggressions are negatively associated with therapeutic alliance (Owen et al., 2014).

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 supports a similar finding for work with LGBT clients, where the therapeutic alliance and process has been shown to be diminished and negatively impacted 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).

Because all people inherit bias about various identity groups through cultural conditioning in the United States, no one, including helping professionals, is free from these biases (Ridley, 2005). This fact poses a unique dilemma in therapy for several reasons: Helping professionals are supposed to work for the welfare of all groups, be trained to be “objective,” and be inclined to see problems as internally situated, and are usually in positions of power over the client. The fact that therapists possess unconscious biases and prejudices is problematic, especially when they sincerely believe they are capable of preventing them from entering sessions. Counselors often find themselves in positions of power in their ability to define their client's experiential reality (i.e., interpretation), which may prove harmful, especially if counselors adamantly deny the presence of microaggressions both inside and outside of the therapy situation. Recent research suggests that prejudice and bias continue to be manifested in the therapeutic process, despite the good intentions of mental health professionals (Owen et al., 2010, 2014; Shelton & Delgado-Romero, 2011, 2013; Utsey, Gernat, & Hammar, 2005).

Manifestations of Microaggressions in Counseling/Therapy

The importance of understanding how microaggressions manifest in the therapeutic relationship cannot be understated, 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 Kiana to illustrate how microaggressions may operate in the counseling process.

1. Kiana revealed to Alan her experiences of racial, gender, and sexual orientation microaggressions, using therapy as a space for deeper exploration of a meaningful issue. Because Kiana and Alan are not the same race, gender, or sexuality, 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 sexual orientation microaggressions, how they make their appearance in everyday interactions, how he himself may be guilty of microaggressive behaviors, the psychological toll they take on minorities, and the negative effects they have on the therapeutic relationship. We have emphasized earlier that cultural competence requires helping professionals to understand the worldviews of their culturally diverse clients.

2. The therapist tends to minimize the importance of Kiana's feelings of invisibility and being overlooked, believes these feelings are trivial, and cannot relate to the negative impact these microaggressions have on his client. Even though the workplace feels hostile to Kiana, the therapist concludes that Kiana needs to explore intrapsychic dynamics to better understand her feelings of alienation; the emotional and psychological impact of these experiences on Kiana is thereby minimized (Dilemma 3: minimal harm). For Kiana, on the other hand, the experience of being ignored and the subsequent looks of surprise when she does speak up represent one of many cumulative messages of intellectual inferiority about her race. She is placed in an ongoing state of vigilance in maintaining her sense of integrity in the face of constant invalidations and insults. Racial, gender, and sexual microaggressions are a constant reality for people of color, assailing 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.

3. Another major detrimental event in the first session is that the therapist locates the source of problems within Kiana by insinuating that she is unapproachable. While there may be some legitimacy to this interpretation, Alan is unaware that he has engaged in person-blame and that he has invalidated Kiana's experiential reality by dismissing race and sexuality as important factors. As a mental health professional, Alan probably considers himself unbiased and objective. However, he has cut off meaningful exploration for Kiana by removing the salience of race and sexuality from the conversation (Dilemma 2: invisibility). For example, had he asked Kiana more questions about the dating scene for bisexuals in her city, he might have learned that bisexuals often have to navigate the LGBT community differently from other sexual minorities, frequently experiencing rejection not only from mainstream society but also from those who identify as gay and lesbian (Bostwick & Hequembourg, 2014).

4. As a client, Kiana is caught in a catch-22—a “damned if you do and damned if you don't” conflict (Dilemma 4: catch-22). Both inside and outside of therapy, Kiana 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? If I bring up the topic, how do I prove it? These questions take a tremendous psychological toll on many marginalized groups. If Kiana chooses to do nothing, she may suffer emotionally by having to deny her own experiential reality or allow her sense of integrity to be assailed. Feelings of powerlessness, alienation, and frustration may take not only a psychological toll but also a physical toll on her. If she chooses to raise issues with the coworkers, students, or professors, she risks being isolated by others, seen as oversensitive or angry.

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

Themes	Microaggression	Message
Alien in Own Land When Asian Americans and Latino 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 Latino client that he/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 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 Latino student, “Do you think you're ready for college?”	It is unusual for people of color to succeed.
	A school counselor reacts with surprise that a female student scored high on a math portion of a standardized test.	It is unusual for women to be smart and good in 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 of color 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, the therapist encourages the client 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 women and LGB groups	During the intake session, a female client discloses that she has been in her current relationship for one year. The therapist asks how long the client has known her boyfriend.	Heterosexuality is 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 females or to 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	A client of color asks his/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.
	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 from 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/women are lazy and/or incompetent and need to work harder. If you don't succeed, you have only yourself to blame (blaming the victim).
	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 in the job longer. The counselor responds that “he must have been better suited for some of the job requirements.”
Pathologizing Cultural Values/Communication Styles The notion that the values and communication styles of the dominant/White culture are ideal	A Black client is loud, emotional, and confrontational in a counseling session. The therapist diagnoses her with borderline personality disorder.	Assimilate to dominant culture.
	A client of Asian or Native American descent has trouble maintaining eye contact with his therapist. The therapist diagnoses him with a social anxiety disorder.
	Advising a client, “Do you really think your problem stems from racism?”	Leave your cultural baggage outside.
Second-Class Citizen Occurs when a member of the power group is given preferential treatment over a target group member	A male client calls and requests a session time that is currently taken by a female client. The therapist grants the male client the appointment without calling the female client to see if she can change times.	Males are more valued than women.
	Clients of color are not welcomed or acknowledged by receptionists.	White clients are more valued than clients of color.
Traditional Gender Role Prejudicing and Stereotyping Occurs when expectations of traditional roles or stereotypes are conveyed	A therapist continually asks the middle-aged female client about dating and “putting herself out there” despite the fact that the client has not 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. Gay men 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 Occurs 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 is looking 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 LGBT	When discussing the client's bisexuality, the therapist continues to imply that there is a “crisis of identity.”	Bisexuality represents a confusion about sexual orientation.
	A lesbian comes in for career counseling, but 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.
Adapted from Sue, Capodilupo, et al., 2007.

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. They take a major psychological toll on members of marginalized groups.

2. Be aware that everyone has engaged and continues to engage in unintentional microaggressions. For helping professionals, these microaggressions may serve as impediments to effective multicultural counseling and therapy.

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, or 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, or sexual orientation. Remember, it's how the therapist recovers, not how he or she “covers up,” that makes for successful multicultural counseling.

Summary

Microaggressions represent daily stressors in the lives of marginalized groups in the United States. The literal explosion of research on microaggressions in the last five years has grown to include cultural identities beyond race, gender, and sexual orientation, such as transgender, bisexual, biracial, gender nonconforming, ability, and religion. In addition, researchers have begun to explore the impact of microaggressions on mental health outcomes, behaviors, and functioning. These studies lend support to the previous generation of qualitative investigations, which suggested 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 also invite them to walk where they live 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, and/or sexual orientation, to work to understand their experiential reality. There is evidence to suggest that microaggressions are everyday experiences too innumerable to count. The therapeutic relationship is not immune from these experiences; however, research suggests that when therapist and client are able to successfully discuss the microaggression, 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.

There is much work to be done to better understand the nuances and processes involved in this very complex phenomenon. Therapists and counselors are in a position to learn from their clients about microaggressions and their relationship to the clients' 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

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BARRIERS TO MULTICULTURAL COUNSELING AND THERAPY INDIVIDUAL AND FAMILY PERSPECTIVES

Chapter Objectives

1. Identify the basic values, beliefs, and assumptions that characterize U.S. society, and how these are manifested in counseling practice.

2. Determine how the generic characteristics of counseling and psychotherapy may be barriers to culturally diverse clients.

3. Describe how cultural values of diverse populations may affect the counseling process.

4. Describe how socioeconomic class issues may impact mental health services.

5. Understand linguistic barriers likely to arise in working with clients whose first language is not English.

6. Learn how Western definitions of the family may detrimentally impact counseling and therapy with diverse families.

Whereas the previous three chapters dealt with the sociopolitical dynamics affecting multicultural counseling/therapy, this chapter discusses the cultural barriers that may render the helping professional ineffective, thereby denying help to culturally diverse clients. The following case study illustrates important multicultural issues that are related to both individual and family counseling approaches.

Case Study

The Martinez Family

Elena Martinez is the second oldest of four siblings, ages 15, 12, 10, and 7. The father is an undocumented immigrant from Mexico, and the mother a naturalized citizen. The family resides in a blue-collar Mexican American neighborhood in San Jose, California. Elena, the identified client, has been reported as having minor problems in school even prior to the “drug-selling incident” that resulted in her referral to the counselor's office. For example, she has “talked back to teachers,” refused to do homework assignments, and had “fought” with other students. Because of the seriousness of the drug allegations, the school contacted the parents immediately.

Mrs. B., the counselor, called the parents to set up a day and time to meet at the school. In her conversation with Mrs. Martinez, the mother, Mrs. B. indicated that Elena had been caught by a police officer selling drugs on the school premises, and taken to the vice-principal's office rather than into police custody. After the explanation, Mrs. B. indicated that they should make immediate arrangements for a meeting to have a parent-teacher conference, and determine an appropriate course of action.

According to the counselor, however, Elena's mother seemed hesitant about choosing a time to come and, when pressed by Mrs. B., excused herself from the phone. The counselor reported hearing some whispering on the other end, and then the voice of Mr. Martinez came on the line. She found it difficult to understand Mr. Martinez because he spoke with such a heavy accent and had poor command of English. He immediately asked how his daughter was, and expressed his consternation over the entire incident. The counselor stated she understood his feelings, but it would be best to set up an appointment for tomorrow to discuss the matter.

The counselor asked repeatedly about a convenient time, but Mr. Martinez seemed to avoid the answer and to give excuses. He had to work tomorrow, and could not make the appointment. The counselor stressed strongly how important the meeting was for the daughter's welfare and that several missed hours of work were unimportant in light of the seriousness of the situation. Mr. Martinez suggested the possibility of a home visit, but Mrs. B. said it was impractical. The father then indicated he could make an evening or even a weekend appointment, but the counselor informed him that school policy prohibited evening meetings and she did not work over the weekend. Finally, the counselor suggested that the wife could initially come alone, but Mr. Martinez remained silent. With great reluctance, however, the father agreed to attend with his wife.

The very next day, Mr. and Mrs. Martinez showed up with a brother-in-law (Elena's godfather) at the office. The counselor was clearly upset by the presence of a third party and told the Martinezes that she wished to only speak with the immediate family, and that having another person present would complicate the matter. Whatever they discussed was confidential. Because both parents appeared anxious, the counselor tried to make the situation more personal and casual by addressing both by their first names: Miguel and Esmeralda.

The following day Mrs. B. reported to the school principal the session went poorly with minimal cooperation from the parents. She reported “It was like pulling teeth, trying to get the Martinezes to say anything at all. They were quite guarded and did not seem to understand the seriousness of Elena's behavior.”

Reflection and Discussion Questions

1. What are some possible cultural factors that might be influencing the reactions of the Martinezes?

2. How might socioeconomic factors be affecting the father's response to a request for a meeting?

3. Why do you think the Martinezes had the godfather attend?

4. What role might being an undocumented immigrant play in Mr. Martinez's reluctance to use school or public services?

5. Do you believe that the Martinezes were uninvolved and uncaring parents?

6. If you were a helping professional, when would you consider making home visits? Under what conditions?

Identifying Multicultural Counseling Issues

The interplay of cultural differences and counseling approaches in the case of Elena is both complex and difficult to resolve. They challenge counseling/mental health professionals to (a) understand the worldviews, cultural values, and life circumstances of their culturally diverse clients; (b) free themselves from the cultural conditioning of what they believe is correct therapeutic practice; (c) develop new but culturally sensitive methods of working with clients; and (d) play new roles in the helping process outside of conventional psychotherapy. Let us briefly outline some cultural, class, linguistic, and political issues raised in this case.

Egalitarian versus Patriarchal Roles

It is entirely possible that the incidents reported by the counselor, Mrs. B., meant something quite different in traditional Mexican American culture. In this case, Mrs. B. seems unaware of her value system of egalitarianism in the husband–wife relationship. The Martinezes' division of roles (husband is protector/provider while wife cares for the home/family) may be patriarchal and allows both to exercise influence and to make decisions. Breaking the role divisions (especially by the woman) is done only out of necessity. A wife would be remiss in publicly making a family decision (setting up an appointment time) without consulting or obtaining agreement from the husband. Mrs. Martinez's hesitation on the phone may be a reflection of the husband–wife role relationship rather than a lack of concern for the daughter.

The counselor's insistence in having Mrs. Martinez decide may actually be forcing her to violate appropriate role behaviors. Further, the therapist's attempt to be informal and to put the Martinezes at ease by greeting them by first names (Miguel and Esmeralda) as opposed to a more formal title (Mr. and Mrs. Martinez), may have been a therapeutic mistake. In traditional Latino and Asian families, such initial informality and familiarity may be considered a lack of respect for the man's role as head of the household.

Nuclear versus Extended Families

Mrs. B. may also have seriously undermined the Latino/a concept of the extended family by expressing negativism toward the godfather's attendance at the counseling session. Middle-class White Americans consider the family to be the nuclear unit (husband, wife, and biological children), while most people of color define the family unit as an extended one. A Mexican American child can acquire a godmother (madrina) and a godfather (padrino) through a baptismal ceremony. Unlike in most White American families, the role of godparents in Mexican culture is more than symbolic, as they can become coparents (compadre) and take an active part in raising the child. Indeed, the role of the godparents is usually linked to the moral, religious, and spiritual upbringing of the child. Who else would be more appropriate to attend the counseling session than the godfather? Not only is he a member of the family, but the charges against Elena deal with legal and moral/ethical issues. It is obvious that Mrs. B. did not view the godfather as part of the family or understand his role in Elena's moral/ethical upbringing.

Socioeconomic Class Issues

Mrs. B. seems oblivious to the economic impact that missing a couple of hours' work might have on the family. Again, she tended to equate Mr. Martinez's reluctance to take off work for the “welfare of her daughter” as evidence of the parents' disinterest in their child. Trivializing the missing of work reveals major social class/ work differences that often exist between mental health professionals and those from situations of less affluence. Most professionals are able to take time off for dental appointments, teacher conferences, or other personal needs without loss of income. This indeed is a middle- or upper-class luxury generally unavailable to those who face economic hardships or cannot access a flexible work schedule. For the Martinez family, loss of even a few hours' wages has serious financial repercussions. Most blue-collar workers may not have the luxury or options of making up their work. How, for example, would an assembly-line worker make up lost time when the plant closes at the end of the day? In addition, the worker often does not miss just a few hours, but must take a half or full day off. In many work situations, getting a substitute worker for just a few hours is not practical. To entice replacement workers, the company must offer more than a few hours (full day). Thus Mr. Martinez may actually be losing an entire day's wages! His reluctance to miss work may actually represent high concern for the family rather than lack of concern.

Flexible Alternative Services

The case of Elena raises another important question: What obligation do educational and mental health services have toward offering flexible and culturally appropriate services to their communities? Mr. Martinez's desire for a “home visit” or evening/weekend meetings brings this question into perspective. Must communities of color always conform to system rules and regulations in order to obtain services? We are not arguing with the school policy itself—in some schools there are very legitimate reasons for not staying after school hours. What we are arguing for is the need to provide alternative services to communities that fit their lifestyles and unique situations. It seems that meeting the needs of the M. family might have entailed home visits or some other arrangement, or flexible scheduling. If the M. family was unable to travel to the therapist's office for a conference, what blocked Mrs. B. from considering a home visit? Many therapists feel disinclined, fearful, or uncomfortable with such an arrangement. Their training dictates that they should practice in their offices and clients should come to them.

Linguistic Bias

Mrs. B. seems unaware that linguistic factors may be influencing the verbal participation of the parents. The counselor has already noted the “heavy accent” and limited English proficiency of Mr. Martinez. Their lack of verbal participation in the session may be due to this factor. Language barriers often place culturally diverse clients at a disadvantage. The primary medium by which mental health professionals do their work is through verbalization (talk therapies) via Standard English. Clients who do not speak Standard English, possess a pronounced accent, or have limited command of English (such as the M. family) may be victimized. The need to understand the meaning of linguistic differences and language barriers in counseling and psychotherapy has never been greater. The changing demographics may mean that many of our clients are born outside of the United States and speak English as their second language. In many cultures, mental health concepts are not equivalent to those in the United States. For example, mental health concepts in English often do not translate into equivalent language in Spanish.

Immigration Status

Mr. Martinez is an undocumented immigrant. What does that mean? It means he lives in the shadows of society, in constant fear of deportation, creditors, and especially the police. It means he faces abuses, resentments, and discrimination that create continual stress in his life and those of the family. It means he hides from public view, distrusts official contact with public services, and fears the loss of social services to his family. Studies reveal that undocumented immigrants like Mr. Martinez are more likely to suffer from depression, anxiety and medical problems, but are less likely to seek help for fear of being “outed.” Thus another factor contributing to his reluctance to attend a school parent-teacher conference may be related to his legal status as an undocumented immigrant, and not lack of caring and concern for his daughter.

Generic Characteristics of Counseling/Therapy

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 traditionally been conceptualized in Western individualistic terms (Ivey, Ivey, Myers, & Sweeney, 2005). Whether the particular theory is psychodynamic, existential-humanistic, or cognitive behavioral in orientation, a number of multicultural specialists (Ponterotto, Utsey, & Pedersen, 2006; Ivey, Ivey, & Zalaquett, 2014) indicate that they share certain common components of White culture in their values and beliefs. Katz (1985) has described the components of White culture (see Table 7.1 ) that are reflected in the goals and processes of clinical work.

TABLE 7.1 Components of White Culture: Values and Beliefs

Rugged Individualism Individual is primary unit Individual has primary responsibility Independence and autonomy highly valued and rewarded Individual can control environment Competition Winning is everything Win/lose dichotomy Action Orientation Must master and control nature Must always do something about a situation Pragmatic/utilitarian view of life Communication Standard English Written tradition Direct eye contact Limited physical contact Control of emotions Time Adherence to rigid time Time is viewed as a commodity Holidays Based on Christian religion Based on White history and male leaders History Based on European immigrants' experience in the United States Romanticize war

Protestant Work Ethic Working hard brings success Progress and Future Orientation Plan for future Delay gratification Value continual improvement and progress Emphasis on Scientific Method Objective, rational, linear thinking Cause-and-effect relationships Quantitative emphasis Status and Power Measured by economic possessions Credentials, titles, and positions Believe “own” system Believe better than other systems Owning goods, space, property 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 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 Religion Belief in Christianity No tolerance for deviation from single god concept

In the United States and in many other countries as well, psychotherapy and counseling are used mainly with middle- and upper-class segments of the population (Smith, 2010). These have often been referred to as the “generic characteristics” of counseling (see Table 7.2 ). As a result, culturally diverse clients do not share many of the values and characteristics seen in both the goals and the processes of therapy (American Psychological Association, Task Force on Socioeconomic Status, 2007; Reed & Smith, 2014). Schofield (1964) has noted that therapists tend to prefer clients who exhibit the YAVIS syndrome: young, attractive, verbal, intelligent, and successful. This preference tends to discriminate against people from different minority groups or those from lower socioeconomic classes. This situation led Sundberg (1981) to sarcastically point out that therapy is not for QUOID people (quiet, ugly, old, indigent, and dissimilar culturally). Table 7.3 summarizes these generic characteristics of counseling (culture, class, and linguistic), and compares them to four groups of color. As mentioned earlier, such a comparison can also be done for other groups that vary in gender, age, sexual orientation, ability/disability, and so on.

TABLE 7.2 Generic Characteristics of Counseling

Culture	Middle Class	Language
Standard English Verbal communication Individual centered Verbal/emotional/behavioral expressiveness Client-counselor communication Openness and intimacy Cause-effect orientation Clear distinction between physical and mental well-being Nuclear family	Standard English Verbal communication Adherence to time schedules (50-minute sessions) Long-range goals	Standard English Verbal communication

TABLE 7.3 People of Color Group Variables

Culture	Lower Class	Language
	Asian Americans
Asian language Family centered Restraint of feelings Silence is respect	Nonstandard English Action oriented Different time perspective Immediate, short-range goals	Bilingual background
Advice seeking Well-defined patterns of interaction (concrete structured) Private versus public display (shame/disgrace/pride) Physical and mental well-being defined differently Extended family
	African Americans
Black language Sense of “people-hood” Action oriented Paranorm due to oppression Importance placed on nonverbal behavior Extended family	Nonstandard English Action oriented Different time perspective Immediate, short-range goals Concrete, tangible, structured approach	Black language
	Latino/Hispanic Americans
Spanish-speaking Group centered Temporal difference Family orientation Different pattern of communication Religious distinction between mind/body	Nonstandard English Action oriented Different time perspective Extended family Immediate short-range goals Concrete, tangible, structured approach	Bilingual background
	American Indians
Tribal dialects Cooperative, not competitive individualism Present-time orientation Creative/experimental/intuitive/nonverbal Satisfy present needs Use of folk or supernatural explanations Extended family	Nonstandard English Action oriented Different time perspective Immediate, short-range goals Concrete, tangible, structured approach	Bilingual background

Although an attempt has been made to clearly delineate three major variables that influence effective therapy, these are often inseparable from one another. For example, use of Standard English in counseling and therapy definitely places those individuals who do not speak English fluently at a disadvantage (Ngo-Metzger et al., 2003). However, cultural and class values that govern conversation conventions can also operate via language to cause serious misunderstandings. Furthermore, the fact that many African Americans, Latina/o Americans, and American Indians come from less affluent backgrounds often compounds class and culture variables. Thus it is often difficult to tell which variables are the most important impediments in therapy. Nevertheless, this distinction is valuable in conceptualizing barriers to effective multicultural counseling/therapy.

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. The term marginal person was first coined by Stonequist (1937) and refers to a person's inability to form dual ethnic identification because of bicultural membership. Persons of color are placed under strong pressures to adopt the ways of the dominant culture. The cultural-deficit models tend to view culturally diverse groups as possessing dysfunctional values and belief systems that are often considered handicaps to be overcome and a source 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 negative beliefs.

Focus on the Individual

Most forms of counseling and psychotherapy tend to be individual-centered (i.e., they emphasize the “I-thou” relationship). 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 for Western tradition. Individualism, autonomy, and the ability to become your own person are perceived as healthy and desirable goals. Pedersen and Pope (2010) note that not all cultures view individualism as a positive orientation; rather, it may be perceived in some cultures 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). 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 out on 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. 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 also value behavioral expressiveness and believe that it is important 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 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 this client 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 Latino/a 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. For example, one need only note the proliferation of cognitive-behavioral assertiveness training programs throughout the United States (Craske, 2010) and the number of self-help books that are 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. Yet doing things indirectly can be perceived by the mental health professional as evidence of passivity and a need for an individual 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 imposed by therapists.

Insight

Another generic characteristic of counseling 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. There are major class differences as well (APA Task Force on Socioeconomic Status, 2007). People from lower socioeconomic classes frequently do not perceive insight as appropriate to their life situations and circumstances. Their concern may 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?” When survival on a day-to-day basis is important, it seems inappropriate for the therapist to use insightful processes. After all, insight assumes that one has time to sit back, reflect, and contemplate motivations and behavior. For the individual who is concerned about making it through each day, this orientation proves counterproductive (Reed & Smith, 2014).

Likewise, many cultural groups do not value insight. In traditional Chinese society, psychology has little relevance. It must be noted, however, 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 road 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 don't think about it.”

Self-Disclosure (Openness and Intimacy)

Most forms of counseling and psychotherapy tend to value 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 to possess 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 the 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 Hispanics (Torres-Rivera & Ratts, 2014) and American Indian clients (Thomason, 2014). A therapist who works with a client from a different cultural background may erroneously conclude that the person is 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 are especially reluctant to disclose to White counselors because of hardships that they have experienced via racism (Ratts & Pedersen, 2014). African Americans initially perceive a White therapist more often as an agent of society who may use information 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 Hispanics, 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 quickly, but the relationships do 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 who 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 to the world (Sue, 2015). For example, American Indian worldviews emphasize the 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 be the scientific method. The epitome of this approach is the experiment. In graduate schools we are often told that only through the experiment can we impute a cause–effect relationship. By identifying the independent and dependent variables and controlling for extraneous variables, 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 worldview in Chapter 10 .

Distinctions between Mental and Physical Functioning

Many American Indians, Asian Americans, African Americans, and Latinos 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. Latino/a 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 therapists to treat them in the same manner that doctors or priests do. Immediate solutions and concrete tangible forms of treatment (advice, confession, consolation, and medication) are expected.

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 Latinos 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. Therapy is seen as an authoritative process in which a good therapist is more direct and active and portrays 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 the 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.

Class-Bound Values

Social class and classism have been identified as two of the most overlooked topics in psychology and mental health practice (American Psychological Association, Task Force on Socioeconomic Status, 2007). Although many believe that the gap in income is closing, statistics suggest the opposite—income inequality is increasing. Those in the top 5% of income have enjoyed huge increases, whereas those in the bottom 40% are stagnant (American Psychological Association, Task Force on Socioeconomic Status, 2007). In the United States, 46 million Americans live in poverty; Blacks are three times more likely to live in poverty than Whites; the rate of poverty for Latinos is nearly 27%; for Asian/Pacific Islanders it is 11%; and for Whites it is 8% (Fouad & Chavez-Korell, 2014; Liu et al., 2004). These statistics clearly suggest that social class may be intimately linked to race because many racial/ethnic minority groups are disproportionately represented in the lower socioeconomic classes (Smith, 2010).

Impact of Poverty

Research indicates that lower socioeconomic class 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 not often aware of 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 (cf. the case of Elena Martinez).

The phenomenon of poverty and its effects on individuals and institutions can be devastating (Liu, Hernandez, Mahmood, & Stinson, 2006). The individual's life is characterized by low wages, unemployment, underemployment, little property ownership, no savings, and lack of food reserves. Meeting even the most basic needs of food and shelter is in constant jeopardy. Pawning personal possessions and borrowing money at exorbitant interest rates leads only to greater debt. 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 person. Likewise, poverty may cause many parents to encourage children to seek employment at an early age. Delivering groceries, shining shoes, and hustling other sources of income may sap the energy of the schoolchild, leading to truancy and poor performance. Teachers and counselors may view such students as unmotivated and potential juvenile delinquents.

Therapeutic Class Bias

Considerable bias against people who are poor has been well documented (American Psychological Association, Task Force on Socioeconomic Status, 2007; Smith, 2013). It is clear to us that those who occupy the lower rungs of our society are the most likely to be oppressed and harmed. For example, clinicians perceive lower-social-class clients more unfavorably than upper-social-class clients (as having less education, being dysfunctional, and making poor progress in therapy). Research concerning the inferior and biased quality of treatment of lower-class clients is historically legend (American Psychological Association, Task Force on Socioeconomic Status, 2007). In the area of diagnosis, it has been found that an attribution of mental illness was more likely when the person's history suggested a lower rather than higher socioeconomic class origin (Liu et al., 2006). Many studies seem to demonstrate that clinicians given identical test protocols tend to make more negative prognostic statements and judgments of greater maladjustment when the individual was said to come from a lower- rather than a middle-class background.

In addition, the class-bound nature of mental health practice emphasizes the importance of assisting the client in self-direction through presenting 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 suffice for those living in poverty. As early as the 1960s, Bernstein (1964) investigated the suitability of Standard English for the lower class in psychotherapy and concluded that it works to the detriment of those individuals. In an extensive historic research of services delivered to minorities and low socioeconomic clients, Lorion (1973) found that psychiatrists refer to therapy those persons who are most like themselves—White rather than non-White and from upper socioeconomic status. Lorion (1974) pointed out that the expectations of lower-class clients are often different from those of psychotherapists. For example, lower-class clients who are concerned with survival or making it through on a day-to-day basis 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 seek immediate solutions. Additionally, many lower-class people, through multiple experiences with public agencies, operate under what is called minority standard time (Schindler-Rainman, 1967). This is the tendency of poor people to have a low regard for punctuality. 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 indifference or hostility.

People from a lower socioeconomic status may also view insight and attempts to discover underlying intrapsychic problems as inappropriate. Many lower-class clients expect to receive advice or some form of concrete tangible treatment. When the therapist attempts to explore personality dynamics or to take a historical approach to the problem, the client often becomes confused, alienated, and frustrated. A harsh environment, where the future is uncertain and immediate needs must be met, makes long-range planning of little value. Many clients of lower socioeconomic status are 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.

Because of the lower-class client's environment and past inexperience with therapy, the expectations of the individual may be quite different from those of the therapist, or even negative. The 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 upper 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). Furthermore, the now-classic study of Hollingshead and Redlich (1968) found that lower-class patients tend to have fewer ego-involving relationships and less intensive therapeutic relationships than do members of higher socioeconomic classes.

Poverty undoubtedly contributes to the mental health problems among racial/ethnic minority groups, and social class determines the type of treatment 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. Not confronting one's own classist attitudes can lead to a phenomenon called “White trashism.” Manifestation of prejudicial or negative attitudes can be found in such descriptors as “trailer parkism,” “hillbillyism,” “uppity,” “red-neck,” and so on (Smith, 2013). 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, along with a taboo against information-giving activities, might be more appropriate than the passive, insight-oriented, and long-term models of therapy. Last, poverty and the economic disparities that are root causes affecting the mental health and quality of life of people in our society demand a social justice approach.

Several conclusions can be drawn from these findings: (a) low socioeconomic class presents stressors to people, especially those in poverty, 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 an unintentional class bias, may affect the ability of helping professionals to deliver appropriate mental health services; and (c) classism and its discriminating nature can make its appearance in the assessment, diagnosis, and treatment of lower socioeconomic 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) they 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) published national standards for interpreters of health care that address issues of cultural awareness and confidentiality.

These standards were 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 interpreters are the following:

· Make sure that professional interpreters speak the same dialect. Monitor carefully whether the interpreter and client appear to have significant cultural or social differences.

· Establish a degree of familiarity with the interpreters; 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 in counseling, it 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 interpreters are not fully translating and/or are 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. The therapist may need to work closely with the interpreter, allowing interpreters periodic debriefing sessions.

Clearly, use of Standard English in health care delivery may unfairly discriminate against those from a bilingual or lower socioeconomic background and result in 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 finding that they must interact with clients who may have English as a second language or who may not speak English at all. The lack of bilingual therapists and the requirement that the client communicate in English may limit the person's 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 without the huge loss of emotional complexity and experience (Arredondo, Gallardo-Cooper, et al., 2014).

Patterns of “American” Cultural Assumptions and Multicultural Family Counseling/Therapy

Family systems theory may be equally culture bound, and this limitation may be manifested in marital or couple counseling, parent–child counseling, or work with more than one member of the family. Family systems therapy possesses several important characteristics (Corey, 2013; McGoldrick, Giordano, & Garcia-Preto, 2005):

· Highlights the importance of the family (versus the individual) as the unit of identity.

· Focuses on resolving concrete issues.

· Is concerned with family structure and dynamics.

· Assumes that these family structures and dynamics are historically passed on from one generation to another.

· Attempts to understand the communication and alliances via reframing.

· Places the therapist in an expert position.

Many of these qualities would be consistent with the worldviews of persons of color. The problem arises, however, in how these goals and strategies are translated into concepts of “the family” or what constitutes the “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):

· Allows and encourages expressing emotions freely and openly.

· Views each member as having a right to be his or her own unique self (individuate from the emotional field of the family).

· Strives for an equal division of labor among members of the family.

· Considers egalitarian role relationships between spouses desirable.

· Holds the nuclear family as the standard.

These orientations were first described by Kluckhohn and Strodtbeck (1961) as patterns of “American” values. Table 7.4 outlines the five major dimensions of White culture, and contrasts them with four major groups of color.

People–Nature Relationship

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. As seen in Table 7.4 , the four other ethnic groups view people as harmonious with nature.

TABLE 7.4 Cultural Value Preferences of Middle-Class White EuroAmericans and People of Color: A Comparative Summary

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 & bad	Good	Good	Good & bad	Good
Source: From Family Therapy with Ethnic Minorities (p. 232) by M. K. Ho, 1987, Newbury Park, CA: Sage. Copyright 1987 by Sage Publications. Reprinted by permission.

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 the problem 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 may 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.

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 changing family patterns and relationships may be perceived as the problem because they may potentially unbalance the harmony that existed.

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 the 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 7.4 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 the elderly and one's usefulness in life is believed to be over once one hits the retirement years. As compared to EuroAmerican middle-class norms, Latinos 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 who 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, no establishment of rapport, misinterpretation of behaviors or situations, and probably 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 between the therapist and Mrs. Rivera 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, while resistant, passive-aggressive, or irresponsible in the latter one). 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: (1) The individual is the psychosocial unit of operation; (2) the individual has primary responsibility for his or her own actions; (3) independence and autonomy are highly valued and rewarded; and (4) 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 your 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 the relatives over objective criteria. Businesses that are heavily weighted by family members, and appointments of family members in 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. 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 Latinos/Hispanics 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 Indian values perceive the person as stoic, aloof, passive, noncompetitive, or inactive. In working with families, the counselor role of active manipulator may clash with American Indian concepts of being-in-becoming (noninterference).

Likewise, Latino/Hispanic 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 family 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 the person is 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 (endure the pain and suffering of racism) in the face of adversity 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 the 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.

Latinos 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 for such problems. The preferred mode of help may be religious consultations and ventilation to neighbors and friends who sympathize and understand the dilemmas (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 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.

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 the chapter tables 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.

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.

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 those 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 and result in devastating consequences. The lack of bilingual therapists and the requirement that the client communicate in English may limit the person's 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.

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 the family. For example, the following Western beliefs and assumptions about healthy families may be incongruent with diverse groups: (a) allow and encourage expressing emotions freely and openly, (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, (d) stress egalitarian role relationships, and (e) the nuclear family is the desirable 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

QUOID

Relational dimension

Scientific empiricism

Self-disclosure

Social class

Time dimension

YAVIS syndrome

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NON-WESTERN INDIGENOUS METHODS OF HEALING IMPLICATIONS FOR MULTICULTURAL COUNSELING AND THERAPY

Chapter Objectives

1. Outline basic assumptions of indigenous healing and shamanism.

2. Explain shamanic explanations of illness.

3. Identify commonalities between what therapists and shamans do.

4. Describe how shamanism makes different assumptions from Western scientific approaches in mental health treatment.

5. Discuss the belief in altered states of consciousness or different planes of existence.

6. Explain how religion and spirituality affect the belief systems of indigenous groups.

7. Articulate your beliefs about the discomfort or comfort you would have in talking to clients about religion and spirituality.

8. Outline the argument for the role religion and spirituality play in counseling and therapy.

9. Discuss implications of non-Western indigenous beliefs and practices for work with diverse populations.

Case Study

Vang Xiong

Vang Xiong is a former Hmong (Laotian) soldier who, with his wife and child, resettled in Chicago in 1980. The change from his familiar rural surroundings and farm life to an unfamiliar urban area must have produced a severe culture shock. In addition, Vang vividly remembers seeing people killed during his escape from Laos, and he expressed feelings of guilt about having to leave his brothers and sisters behind in that country. Five months after his arrival, the Xiong family moved into a conveniently located apartment, and that is when Vang's problems began.

Vang could not sleep the first night in the apartment, nor the second, nor the third. After three nights of very little sleep, Vang came to see his resettlement worker, a young bilingual Hmong man named Moua Lee. Vang told Moua that the first night he woke suddenly, short of breath, from a dream in which a cat was sitting on his chest. The second night, the room suddenly grew darker, and a figure like a large black dog came to his bed and sat on his chest. He could not push the dog off, and he grew quickly and dangerously short of breath. The third night, a tall, white-skinned female spirit came into his bedroom from the kitchen and lay on top of him. Her weight made it increasingly difficult for him to breathe; as he grew frantic and tried to call out, he could manage nothing but a whisper. He attempted to turn onto his side but found he was pinned down. After 15 minutes, the spirit left him, and he awoke, screaming. He was afraid to return to the apartment at night, afraid to fall asleep, and afraid he would die during the night, or that the spirit would make it so that he and his wife could never have another child. He told Moua that once, when he was 15, he had a similar attack; that several times, back in Laos, his elder brother had been visited by a similar spirit; and that his brother was subsequently unable to father children due to his wife's miscarriages and infertility. (Tobin & Friedman, 1983, p. 440)

Moua Lee and mental health workers became very concerned in light of the high incidence of sudden death syndrome among Southeast Asian refugees. For some reason, the incidents of unexplained death, primarily among Hmong men, would occur within the first 2 years of residence in the United States. Autopsies produced no identifiable cause for the deaths. All the reports were the same: A person in apparently good health went to sleep and died without waking. Often the victim displayed labored breathing, screams, and frantic movements just before death. With this dire possibility evident for Vang, the mental health staff felt that they lacked the expertise for so complex and potentially dangerous a case. Conventional Western means of treatment for other Hmong clients had proved minimally effective. As a result, they decided to seek the services of Mrs. Thor, a 50-year-old Hmong woman who was widely respected in Chicago's Hmong community as a shaman. The description of the treatment follows.

That evening, Vang Xiong was visited in his apartment by Mrs. Thor, who began by asking Vang to tell her what was wrong. She listened to his story, asked a few questions, and then told him she thought she could help. She gathered the Xiong family around the dining room table, upon which she placed some candles alongside many plates of food that Vang's wife had prepared. Mrs. Thor lit the candles and then began a chant that Vang and his wife knew was an attempt to communicate with spirits. Ten minutes or so after Mrs. Thor had begun chanting, she was so intensely involved in her work that Vang and his family felt free to talk to each other and to walk about the room without fear of distracting her. Approximately 1 hour after she had begun, Mrs. Thor completed her chanting, announcing that she knew what was wrong. . . .she had learned from her spirit that the figures in Vang's dreams who lay on his chest and made it so difficult for him to breathe were the souls of the apartment's previous tenants, who had apparently moved out so abruptly they had left their souls behind. Mrs. Thor constructed a cloak out of newspaper for Vang to wear. She then cut the cloak in two and burned the pieces, sending the spirits on their way with the smoke. She also had Vang crawl through a hoop, and then between two knives, telling him that these maneuvers would make it very hard for spirits to follow. Following these brief ceremonies, the food prepared by Vang's wife was enjoyed by all. The leftover meats were given in payment to Mrs. Thor, and she left, assuring Vang Xiong that his troubles with spirits were over. (Tobin & Friedman, 1983, p. 441)

The most recent attack in Chicago was not the first encounter my family and I have had with this type of spirit, a spirit we call Chia. My brother and I endured similar attacks about six years ago back in Laos. We are susceptible to such attacks because we didn't follow all of the mourning rituals we should have when our parents died. Because we didn't properly honor their memories, we have lost contact with their spirits, and thus we are left with no one to protect us from evil spirits. Without our parents' spirits to aid us, we will always be susceptible to spirit attacks. I had hoped flying so far in a plane to come to America would protect me, but it turns out spirits can follow even this far. (Tobin & Friedman, 1983, p. 444)

Clinical knowledge regarding what is called the Hmong sudden death syndrome indicates that Vang was one of the lucky victims of the syndrome, in that he survived it. Indeed, since undergoing the healing ceremony that “released the unhappy spirits,” Vang has reported no more problems with nightmares or with his breathing during sleep. Such a story may appear unbelievable and akin to mysticism to many people, especially after reading the last chapter on 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. Let us briefly analyze the case of Vang Xiong to illustrate what these valuable lessons might be and to draw parallels between non-Western and Western healing practices.

Legitimacy of Cultural Syndromes: Nightmare Deaths and the Hmong Sudden Death Phenomenon

The symptoms experienced by Vang and the frighteningly high number of early Hmong refugees who have died these so-called “nightmare deaths” have baffled mental health workers for years. Indeed, researchers at the Federal Center for Disease Control and epidemiologists have studied it but remain mystified (D. Sue, D. W. Sue, D. M. Sue, & S. Sue, 2013; Tobin & Friedman, 1983). Such tales bring to mind anthropological literature describing voodoo deaths and bangungut, or Oriental nightmare death. What is clear, however, is that these deaths do not appear to have a primary biological basis and that psychological factors (primarily belief in the imminence of death, either by a curse, as in voodoo suggestion, or by some form of punishment and excessive stress) appear to be causative (Moodley, 2005).

Beliefs in spirits and spirit possession are not uncommon among many cultures, especially in Southeast Asia (American Psychiatric Association, 2013; Faiver, Ingersoll, O'Brien, & McNally, 2001). 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 phenomenon is a cultural form 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. Death from bradycardia (slowing of the heartbeat) seems correlated with feelings of helplessness, as in the case of Vang (when he couldn't get the cat, dog, or white-skinned spirit off his chest).

Beginning with the 4th and continuing into the 5th 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 initial 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. Cultural syndromes and cultural idioms of distress are now recognized in the DSM and some are listed in Table 10.1 .

TABLE 10.1 Cultural Syndromes

Cultural syndromes are disorders specific to a cultural group or society but not easily given a DSM diagnosis. These illnesses or afflictions have local names, with distinct culturally sanctioned beliefs surrounding causation and treatment. Some of these are briefly described. Some taken from DSM-IV-TR are listed below.
Amok	This disorder was first reported in Malaysia but is found also in Laos, the Philippines, Polynesia, Papua New Guinea, and Puerto Rico, as well as among the Navajo. It is a dissociative episode preceded by introspective brooding and then 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	This disorder is most clearly reported among Latinos from the Caribbean but is recognized in Latin American and Latin Mediterranean groups as well. It involves uncontrollable shouting, attacks of crying, trembling, verbal or physical aggression, and dissociative or seizure-like fainting episodes. The onset is associated with a stressful life event relating to family (e.g., death of a loved one, divorce, conflicts with children).
Brain fag	This disorder is usually experienced by high-school or university students in West Africa in response to academic stress. Students state that their brains are fatigued and that they have difficulties in concentrating, remembering, and thinking.
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 describes an episode of sudden and intense anxiety that the penis of the male or the vulva and nipples of the female will recede into the body and cause death. It can occur in epidemic proportions in local areas and has been reported in China, Thailand, and other South and East Asian countries.
Mal de ojo	Found primarily in Mediterranean cultures, this term refers to a Spanish phrase that means “evil eye.” Children are especially at risk, and symptoms include fitful sleep, crying without apparent cause, diarrhea, vomiting, and fever.
Nervios	This disorder includes a range of symptoms associated with distress, somatic disturbance, and inability to function. Common symptoms include headaches, brain aches, sleep difficulties, nervousness, easy tearfulness, dizziness, and tingling sensations. It is a common idiom of distress among Latinos in the United States and Latin America.
Rootwork	This refers to cultural interpretations of illness ascribed to hexing, witchcraft, sorcery, or the evil influence of another person. Symptoms include generalized anxiety, gastrointestinal complaints, and fear of being poisoned or killed (voodoo death). Roots, spells, or hexes can be placed on people. It is believed that a cure can be manifested via a root doctor who removes the root. Such a belief can be found in the southern United States among both African American and European American populations and in Caribbean societies.
Shen-k'uei (Taiwan); Shenkui (China)	This is a Chinese-described disorder that involves anxiety and panic symptoms with somatic complaints. There is no identifiable physical cause. Sexual dysfunctions are common (premature ejaculation and impotence). The physical symptoms are attributed to excessive semen loss from frequent intercourse, masturbation, nocturnal emission, or passing of “white turbid urine” believed to contain semen. Excessive semen loss is feared and can be life threatening because it represents one's vital essence.
Susto	This disorder is associated with fright or soul loss and is a prevalent folk illness among some Latinos in the United States as well as inhabitants of Mexico, Central America, and South America. Susto is attributed to a frightening event that causes the soul to leave the body. Sickness and death may result. Healing is associated with rituals that call the soul back to the body and restore spiritual balance.
Zar	This term is used to describe spirits possessing an individual. Dissociative episodes, shouting, laughing, hitting the head against a wall, weeping, and other demonstrative symptoms are associated with it. It is found in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies. People may develop a long-term relationship with the spirit, and their behavior is not considered pathological.
DSM-IV-TR (American Psychiatric Association, 2000).

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. Most might have prescribed powerful antipsychotic medication or even institutionalization. The fact that he was 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 refugee's emotional condition.

Causation and Spirit Possession

Vang believed that his problems were related to an attack by undesirable spirits. His story in the following passage gives us some idea about beliefs associated with the fears.

Western science remains skeptical of using supernatural explanations 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 have existed in every known culture, including the United States (e.g., the witch hunts of Salem, Massachusetts). Among many Southeast Asian 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). Vang, for example, believed strongly that his problems were due to spirits who were unhappy with him and were punishing him. Interestingly, among the Hmong, good spirits often serve a protective function against evil spirits. Because Vang's parental spirits had deserted him, he believed he was more susceptible to the workings of evil forces. Many cultures believe that a cure can come about only through the aid of a shaman or a healer who can reach and communicate with the spirit world via divination skills.

Although mental health professionals may not believe in spirits, therapists are similar to the Hmong in their need to explain the troubling phenomena experienced by Vang and to construe meaning from them. Vang's sleep disturbances, nightmares, and fears can be seen as the result of emotional distress. From a Western perspective, his war experiences, flight, relocation, and survivor stress (not to mention the adjustment to a new country) have all contributed to combat fatigue (posttraumatic stress disorder, or PTSD) and survivor guilt (APA, 2013). Studies on hundreds of thousands of refugees from Southeast Asia suggest that they were severely traumatized during their flight for freedom (Mollica, Wyshak, & Lavelle, 1987). The most frequent diagnoses for this group were generally major affective disorder and PTSD. In addition to being a combat veteran, Vang is a disaster victim, a survivor of a holocaust that has seen perhaps 200,000 of the approximately 500,000 Hmong die. Vang's sleeplessness, breathing difficulties, paranoid belief that something attacked him in bed, and symptoms of anxiety and depression are the result of extreme trauma and stress. Tobin and Friedman (1983) believed that Vang also suffered from survivor's guilt and concluded:

Applying some of the insights of the Holocaust literature to the plight of the Southeast Asian refugees, we can view Vang Xiong's emotional crisis (his breathing and sleeping disorder) as the result not so much of what he suffered as what he did not suffer, of what he was spared. . . .“Why should I live while others died?” So Vang Xiong, through his symptoms, seemed to be saying, “Why should I sleep comfortably here in America while the people I left behind suffer? How can I claim the right to breathe when so many of my relatives and countrymen breathe no more back in Laos?” (p. 443)

Even though we might be able to recast Vang's problems in more acceptable psychological terminology, the effective multicultural helping professional requires knowledge of cultural relativism and respect for the belief system of culturally different clients (Eriksen, Jackson, Weld, & Lester, 2013). Respecting another's worldview does not mean that the helping professional needs to subscribe to it. Yet the counselor or therapist must be willing and ready to learn from indigenous models of healing and to function as a facilitator of indigenous support systems or indigenous healing systems.

The Shaman 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, the shaman in non-Western cultures 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). Mrs. Thor was a well-known and respected shaman in the Hmong community of the Chicago area. Although her approach to treating Vang (incense, candle burning, newspaper, trance-like chanting, spirit diagnosis, and even her home visit) on the surface might resemble mysticism, 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 this case, Mrs. Thor had all 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. Second, she showed compassion while maintaining a professional detachment, did not pity or make fun of Vang, avoided premature diagnosis or judgment, and listened to his story carefully. Third, like the Western therapist, she offered herself as the chief instrument of cure. She used her expertise and ability 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.

Because Vang believed in spirits, Mrs. Thor's interpretation that the nightmares and breathing difficulties were spiritual problems was intelligible, desired, and ultimately curative. It is important to note, however, that Vang also continued to receive treatment from the local mental health clinic in coming to grips with the deaths of others (his parents, fellow soldiers, and other family members).

In the case of Vang Xiong, non-Western and Western forms of healing were combined with one another for maximum effect. The presence of a mental health treatment facility that employed bilingual/bicultural practitioners, its vast experience with Southeast Asian immigrants, and its willingness to use indigenous healers provided Vang with a culturally appropriate form of treatment that probably saved his life. Not all immigrants, however, are so fortunate. Witness the following 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 had seen 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 Phuoc's 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 the heavy caseload experienced by Child Protective Services, 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 they 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 to beat her son.

A Case of Child Abuse?

There are many similarities between the case of the Nguyen family and that of Vang Xiong. 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 was, 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; and encountering a strange and alien culture 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 disorders. 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 their 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 the social worker, should be placed in the context of the stressors that they 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.

Second, mental health professionals must consider potential linguistic and cultural barriers when working with refugees, especially when one lacks both experience and expertise. In this case, 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 the 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. Yet such knowledge is required by educators and social service agencies in order to make enlightened decisions.

Third, both school and social service personnel are obviously unenlightened about indigenous healing beliefs and practices. In the case of Vang Xiong, 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 and are even more prevalent among the Vietnamese refugees who brought the treatments to the United States (Hong & Domokos-Cheng Ham, 2001). Thùôc Nam, or traditional medicine, 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”). The latter 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.” 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. 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. All three treatments leave bruises on the parts of the body treated.

If the social worker could have understood 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 considered 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 unable to answer this second question directly (we encourage you to engage in dialogue about it), we point out that many medical practitioners in California do not consider it child abuse because (a) medical literature reveals no physical complications as a result of Thùôc Nam; (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.

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 their 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 the culture or society (Edwards, 2011). It is not transported from other regions, and it is designed for treating 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 (M.T. Garrett et al., 2011; Moodley, 2005). Such was the case of Mrs. Thor, a shaman who journeyed to the spirit world in order to find a cure for Vang.

Indigenous healing in non-Western countries found three approaches often used (C. C. 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 them with family or significant others (Korea). Second, spiritual and religious beliefs and traditions of the community are used in the healing process. Examples include reading verses from the Qur'an and using religious houses or churches. Third, use of shamans (called piris and fakirs in Pakistan and Sudan), who are perceived to be the keepers of timeless wisdom, constitutes the norm. In many cases, the person conducting a healing ceremony may be a respected elder of the community or a family member. Two representative indigenous healing approaches are exemplified in the Hawaiian ho'oponopono and the Native American sweat lodge ceremony.

Ho'oponopono

An excellent example that incorporates these approaches is the Native Hawaiian ho'oponopono healing ritual (Nishihara, 1978; Rezentes, 2006). Translated literally, the word 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 in the family. 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 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) (M. T. Garrett & Portman, 2011; M. T. 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 from 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 then poured on the heated rocks, producing a purifying steam.

6. 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.

7. 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.

Those who study indigenous psychologies do not make an a priori assumption that one particular perspective is superior to another (Mikulas, 2006). The Western ontology of healing (counseling/therapy), however, does consider its methods to be more advanced and scientifically grounded than those found in many cultures. Western healing has traditionally operated from several assumptions: (a) reality consists of distinct and separate units or objects (therapist and client, observer and observed); (b) reality consists of what can be observed and measured via the five senses; (c) space and time are fixed and absolute constructs of reality; and (d) science operates from universal principles and is culture free (Highlen, 1996).

Although these guiding assumptions of Western science have contributed much to human knowledge and to the improvement of the human condition, most non-Western indigenous psychologies appear to operate from a different perspective. For example, many non-Western cultures do not separate the observer from the observed and believe that all life forms are interrelated with one another, including mother nature and the cosmos; that the nature of reality transcends the senses; that space and time are not fixed; and that much of reality is culture bound (Walsh & Shapiro, 2006). Let us briefly explore several of these parallel assumptions and see how they are manifested in indigenous healing practices.

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 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, or 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 (M.T. 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 it is believed that strong emotional states, as well as an imbalance in the type of foods eaten, may create illness (Pedersen & Pope, 2010; So, 2005). As we saw in the case of Phuoc Nguyen, treatment might involve eating specific types or combinations of foods or using massage treatment to suck out “bad” or “hot” air. 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).

The Afrocentric perspective also teaches 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 toward being more in tune with others and society, to move away from individualism, and to move 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 them, and how little we demonstrate such gratitude. This ultimately 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 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 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 yoga and meditation are the most widely used of all therapies (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 in the United States have become accepted practices among millions, especially for relaxation and stress management. For practitioners of meditation and yoga, 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), a world where 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). As in the case of Mrs. Thor, shamans, mediums, or indigenous healers often enter these realities on behalf of their clients in order to seek answers, to enlist the help of the spirit world, or to 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 that plane of reality so that he or she may find the solutions. The vision quest, in conjunction with the sweat lodge experience, is used by some American Indians as religious renewal or as a rite of passage (M.T. Garrett et al., 2011; Heinrich, Corbin, & Thomas, 1990; Smith, 2005). Underlying these uses is the human journey to another world of reality. The ceremony of the vision quest is intended to prepare the 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).

Spirituality in Life and the Cosmos

Native 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. Native 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,” “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 (J. T. Garrett & Garrett, 1994, p. 187).

The sacred Native American beliefs concerning spirituality are a truly alien concept to modern EuroAmerican thinking. The United States has had a long tradition in believing that one's religious beliefs should not enter into scientific or rational decisions (Duran, 2006). Incorporating religion in the rational decision-making process or in the conduct of therapy has generally been seen as unscientific and unprofessional. The schism between religion and science occurred centuries ago and has resulted in a split between science/psychology and religion (Fukuyama & Sevig, 1999). This is reflected in the oft-quoted phrase, “separation of Church and State.” The separation has become a serious barrier to mainstream psychology's incorporation of indigenous forms of healing into mental health practice, especially when religion is confused with spirituality. 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 realm of existence. Yet indigenous helpers believe that spirituality transcends time and space, mind and body, and our behaviors, thoughts, and feelings (C. C. Lee & Armstrong, 1995; Smith, 2005).

These contrasting worldviews are perhaps most clearly seen in definitions of “the good life” and in how our values are manifested in evaluating the worth of others. In the United States, for example, the pursuit of happiness is most often conceived to be manifested in material wealth and physical well-being, whereas other cultures value spiritual or intellectual goals. The worth of a person is anchored in the number of separate properties he or she owns and in his or her net worth and ability to acquire increasing wealth. Indeed, it is often assumed that such an accumulation of wealth is a sign of divine approval (Condon & Yousef, 1975). In cultures where spiritual goals are strong, people's worth is unrelated to material possessions but rather resides within individuals, emanates from their spirituality, and is a function of whether they live the “right life.” People from capitalistic cultures often do not understand self-immolations and other acts of suicide in countries such as India. They are likely to make statements such as, “Life is not valued there” or, better yet, “Life is cheap.” These statements indicate a lack of understanding about actions that arise from cultural forces rather than personal frustrations; they may be symbolic of a spiritual-valuing rather than a material-valuing orientation.

One does not have to look beyond the United States, however, to see such spiritual orientations; many racial/ethnic minority groups in this country are strongly spiritual. African Americans, Asian Americans, Latino/Hispanic Americans, and Native Americans all place strong emphasis on the interplay and interdependence of spiritual life and healthy functioning (Boyd-Franklin, 2010; M.T. Garrett & Portman, 2011). Puerto Ricans, for example, may sacrifice material satisfaction in favor of values pertaining to the spirit and the soul. 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 man, 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.

Likewise, a strong spiritual orientation has always been a major aspect of life in Africa, and this was also true during 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 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 family, 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, day care centers, tutoring programs, and counseling. To many African Americans the road to mental health and the prevention of mental illness lie in the health potentialities of their spiritual life.

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. They define 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 (Gallup, 1995; 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 equally uncomfortable, disinclined, or unprepared to speak with their clients about religious or spiritual matters.

The relationship between spirituality and health is highly positive (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 the 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 on 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.

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 the clergy?

3. What are the possible positive and negative outcomes of doing so?

4. Would you feel comfortable talking about religion with your clients?

5. If you were in therapy, how important would it be to discuss your religious or spiritual beliefs?

6. Are you a religious person?

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 belief systems may actually harm rather than heal or enlighten. Such was the case during a period known as 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, especially during the Middle Ages, 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 also been largely silent about the influence or importance of spirituality and religion in mental health. Thus, 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, 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 greater than 80 percent 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, 2009, 2012). 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 found that higher levels of spirituality were 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 culturally diverse client. Entertaining alternative realities does not mean that the counselor must subscribe to that belief system. It does mean, however, that the helping professional 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 are 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

Afrocentric perspective

Băt Gió

Brain fag

Cao Gió

Enlightenment

Espiritismo

Giác hoi

Hmong Sudden Death Syndrome

Ho'oponopono

Holistic outlook

Indigenous healing

Mahiki

'Oia'i'o or 'Oia'i'o

Pani

Pule weke

Shaman

Spirituality

Sweat lodge ceremony

Thùôc nam

Universal shamanic tradition

Western healing

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RACIAL/CULTURAL IDENTITY DEVELOPMENT IN PEOPLE OF COLOR COUNSELING IMPLICATIONS

Chapter Objectives

1. Learn the important factors that are influential in the development of racial/cultural identity in people of color.

2. Become familiar with racial identity development in various groups of color.

3. Describe how sociopolitical forces influence the identity development of people of color.

4. Define the developmental levels of racial consciousness and describe how they affect the attitudes, beliefs, and behaviors toward oneself, toward members of one's own group, and toward majority group members.

5. Become knowledgeable about how the racial consciousness of people of color impacts the counseling/therapy situation.

6. 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.

7. 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

Sansei (Third-Generation) Japanese American Female

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 was 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 a Sansei student class journal)

Racial Awakening

Oriental, Asian, or White?

This Sansei (third-generation) Japanese American female is experiencing a racial awakening that has strong implications for her racial/cultural identity development. 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 the student's beliefs about racial/cultural characteristics: She describes the Asian American male and female 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 behavioral consequences as well. In Arizona, she would not have considered making Asian American friends even if the opportunity presented itself. In her mind, she was not a “typical Oriental”; she disowned or felt ashamed of her ethnic heritage, and she even concludes that she would not consider marrying anyone but a White male.

Denial Breakdown

Second, her 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 ethnic identity issues—a process she has been able to avoid while living in a predominantly White area. In the past, when she encountered prejudice or discrimination, she had been able to deny it or to rationalize it away. The differential treatment she received at a restaurant and her male friend's labeling 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 racial/cultural heritage; and (c) she has been brainwashed into believing that one group is superior over another.

The Internal Struggle for Identity

Third, the student's internal struggle to cast off the cultural conditioning of her past and the attempts to define her ethnic 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 the negative images of Asian American males 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 Asian male friend for doing so; and (f) states that she finds him attractive but could never consider marrying anyone but a White man. Understanding the process by which racial/cultural identity develops in persons of color is crucial for effective multicultural counseling/therapy.

Locus of the Problem

Fourth, it is clear that the Japanese American female is a victim of ethnocentric monoculturalism. As we mentioned previously, the problem being experienced by the student does not reside in her but in our society. It resides in a society that portrays racial/ethnic characteristics as inferior, primitive, deviant, pathological, or undesirable. The resulting damage strikes at the self-esteem and self/group identity of many culturally different individuals in our society; many, like this student, may come to believe that their racial/cultural heritage or characteristics are burdens to be changed or overcome. Understanding racial/cultural identity development and its relationship to therapeutic practice are the goals of this chapter.

Racial/Cultural Identity Development Models

The historic work on racial/cultural identity development among minority groups has led to major breakthroughs in the field of multicultural counseling/therapy (Atkinson, Morten, & Sue, 1998; Cross, 1971, 1995; Cross, Smith, & Payne, 2002; Helms, 1984, 1995; Horse, 2001; J. Kim, 1981; Ruiz, 1990). Most would agree that Asian Americans, African Americans, Latino/Hispanic Americans, and American Indians have distinct cultural heritages that make each different from the other. Yet such cultural distinctions can lead to a monolithic view of minority group attitudes and behaviors. The erroneous belief that all Asians are the same, all Blacks are the same, all Latinas/os are the same, or all American Indians are the same has led to numerous therapeutic problems.

First, therapists may often respond to culturally diverse clients in a very stereotypic manner and fail to recognize within-group or individual differences. For example, research indicates that Asian American clients seem to prefer and benefit most from a highly structured and directive approach, rather than an insight/feeling-oriented one (Hong & Domokos-Cheng Ham, 2001; B.S.K. Kim, 2011; Sandhu, Leung, & Tang, 2003). Although such approaches may generally be effective, they are often blindly applied without regard for possible differences in client attitudes, beliefs, and behaviors. Likewise, conflicting findings in the literature regarding whether people of color prefer therapists of their own race seem to be a function of our failure to make such distinctions. Preference for a racially or ethnically similar therapist may really be a function of the cultural/racial identity of the individual (within-group differences) rather than of race or ethnicity per se.

Second, the strength of racial/cultural identity models lies in their potential diagnostic value. Premature termination rates among clients of color may be attributed to the inappropriateness of transactions that occur between the helping professionals and culturally diverse clients. Research suggests that reactions to counseling, the counseling process, and counselors are influenced by cultural/racial identity and are not simply linked to minority group membership. The high failure-to-return rate of many clients seems to be intimately connected to the mental health professional's inability to assess the cultural identity of clients accurately (Ivey, D'Andrea, & Ivey, 2011).

A third important contribution derived from racial identity models is their acknowledgment of sociopolitical influences in shaping identity (à la the Sansei student). Early models of racial identity development 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 (J. Kim, 2012; S. Sue & Sue, 1971), Latinas/os (Ferdman & Gallegos, 2012), Native Americans (Horse, 2012), women (Downing & Roush, 1985; McNamara & Rickard, 1989), lesbians/gays (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.

Black Identity Development 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 individual encounters a profound crisis or event that challenges his or her previous mode of thinking and behaving; second, the Black person 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 Gardner in New York in 2014 are examples of such events. 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 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 role in his or her identity or a minimal one. 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 two identities: (a) preencounter assimilation and (b) preencounter anti-Black. The former has low salience for race and a neutral valence toward Blackness, whereas the latter describes individuals who hate Blacks and hate being Black (high negative salience). In other words, it is possible for a Black person at the preencounter stage who experiences the salience of race as very minor and whose identity is oriented toward an “American” perspective not to be filled with 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 is the result of the negative images of Blacks portrayed in the mass media; among neighbors, friends, and relatives; and in the 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 female Sansei student described earlier in this chapter, though 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 additional ones: 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 has 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.).

Although Cross's model has been revised significantly and the newer version is more sophisticated, his original 1971 nigrescence theory continues to dominate the racial identity landscape. Unfortunately, this has created much confusion among researchers and practitioners. We encourage readers to familiarize themselves with his most recent formulation (Cross, 1991, 1995).

Asian American Identity Development Models

Asian American identity development models have not advanced as far as those relating to Black identity. One of the earliest heuristic “type” models was developed by S. Sue and Sue (1971) to explain what they saw as clinical differences among Chinese American students treated at the University of California, Berkeley, Counseling Center: (a) traditionalist—a person who internalizes conventional Chinese customs and values, resists acculturation forces, and believes in the “old ways”; (b) marginal person—a person who attempts to assimilate and acculturate into White society, rejects traditional Chinese ways, internalizes society's negativism toward minority groups, and may develop racial self-hatred (à la the Sansei student); and (c) Asian American—a person who is in the process of forming a positive identity, who is ethnically and politically aware, and who becomes increasingly bicultural. Other similar models have been proposed for other groups such as Japanese Americans (Kitano, 1982).

These early type models suffered from several shortcomings (Lee, 1991). First, they failed to provide a clear rationale for why an individual develops one ethnic identity type over another. Although they were useful in describing characteristics of the type, they represented static entities rather than a dynamic process of identity development. Second, the early proposals seem too simplistic to account for the complexity of racial identity development. Third, these models were too population specific, in that they described only one Asian American ethnic group (Chinese American or Japanese American), and one wonders whether they are equally applicable to Korean Americans, Filipino Americans, Vietnamese Americans, and so on. Last, with the exception of a few empirical studies (Lee, 1991; D. W. Sue & Frank, 1973), testing of these typologies is seriously lacking.

In response to these criticisms, theorists have begun to move toward the development of stage/process models of Asian American identity development (J. Kim, 1981; Lee, 1991; Sodowsky, Kwan, & Pannu, 1995). Such models view identity formation as occurring in stages, evolving from less healthy to more healthy identities. With each stage there exists a constellation of traits and characteristics associated with racial/ethnic identity. These models also attempt to explain the conditions or situations that might retard, enhance, or impel the individual forward.

After a thorough review of the literature, J. Kim (1981) used a qualitative narrative approach with third-generation Japanese American women to posit a progressive and sequential stage model of Asian American identity development: (a) ethnic awareness, (b) White identification, (c) awakening to social political consciousness, (d) redirection to Asian American consciousness, and (e) incorporation. Her model integrates the influence of acculturation, exposure to cultural differences, environmental negativism to racial differences, personal methods of handling race-related conflicts, and the effects of group or social movements on the Asian American individual.

1. The ethnic awareness stage begins around the age of three to four, when the child's family members serve as the significant ethnic group model. Positive or neutral attitudes toward one's own ethnic origin are formed, depending on the amount of ethnic exposure conveyed by the caretakers.

2. The White identification stage begins when children enter school, where peers and the surroundings become powerful forces in conveying racial prejudice that negatively impacts their self-esteem and identity. The realization of “differentness” from such interactions leads to self-blame and a desire to escape racial heritage by identifying with White society.

3. The awakening to social political consciousness stage means the adoption of a new perspective, often correlated with increased political awareness. J. Kim (1981) believed that significant political events such as the civil rights and women's movements often precipitate this new awakening. The primary result is an abandoning of identification with White society and a consequent understanding of oppression and oppressed groups.

4. The redirection stage means a reconnection or renewed connection with one's Asian American heritage and culture. This is often followed by the realization that White oppression is the culprit for the negative experiences of youth. Anger against White racism may become a defining theme, with concomitant increases of Asian American self-pride and group pride.

5. The incorporation stage represents the highest form of identity evolution. It encompasses the development of a positive and comfortable identity as Asian American and consequent respect for other cultural/racial heritages. Identification with a stance for or against White culture is no longer an important issue.

Latino/ Hispanic American Identity Development Models

Although a number of ethnic identity development models have been formulated to account for Latino/a identity (Bernal & Knight, 1993; Casas & Pytluk, 1995; Szapocznik, Santisteban, Kurtines, Hervis, & Spencer, 1982), the one most similar to those of African Americans and Asian Americans was proposed by Ruiz (1990). His model was formulated from a clinical perspective via case studies of Chicano/Latino subjects. Ruiz made several underlying assumptions. First, he believed in a culture-specific explanation of identity for Chicano, Mexican American, and Latina/o clients. Although models of the development of other ethnic groups or the more general models were helpful, they lacked the specificity of referring to Latina/o cultures. Second, the marginal status of Latinos is highly correlated with maladjustment. Third, negative experiences of forced assimilation are considered destructive to an individual. Fourth, having pride in one's cultural heritage and ethnic identity is positively correlated with mental health. Last, pride in one's ethnicity affords the Hispanic greater freedom to choose freely. These beliefs underlie Ruiz's five-stage model.

1. Causal stage: During this period messages or injunctions from the environment or significant others ignore, negate, or denigrate the ethnic heritage of the person. Affirmation about one's ethnic identity is lacking, and the person may experience traumatic or humiliating experiences related to ethnicity. There is a failure to identify with Latina/o culture.

2. Cognitive stage: As a result of negative/distorted messages, three erroneous belief systems about Chicano/Latina/o heritage become incorporated into mental sets: (a) Ethnic group membership is associated with poverty and prejudice; (b) assimilation to White society is the only means of escape; and (c) assimilation is the only possible road to success.

3. Consequence stage: Fragmentation of ethnic identity becomes very noticeable and evident. The person feels ashamed and is embarrassed by ethnic markers, such as name, accent, skin color, cultural customs, and so on. The unwanted self-image leads to estrangement and rejection of one's Chicano/Latina/o heritage.

4. Working-through stage: Two major dynamics distinguish this stage. First, the person becomes increasingly unable to cope with the psychological distress of ethnic identity conflict. Second, the person can no longer be a “pretender” by identifying with an alien ethnic identity. The person is propelled to reclaim and reintegrate disowned ethnic identity fragments. Ethnic consciousness increases.

5. Successful resolution stage: This last stage is exemplified by greater acceptance of one's culture and ethnicity. There is an improvement in self-esteem and a sense that ethnic identity represents a positive and success-promoting resource.

The Ruiz model has a subjective reality that is missing in many of the empirically based models. This is expected, since it was formulated based on the study of a clinical population. It has the added advantage of suggesting intervention focus and direction for each of the stages. For example, the focus of counseling in the causal stage is disaffirming and restructuring of the injunctions; for the cognitive stage, it is the use of cognitive strategies attacking faulty beliefs; for the consequence stage, it is reintegration of ethnic identity fragments in a positive manner; for the working-through stage, ethnocultural identification issues are important; and for the successful resolution stage, the promotion of a positive identity becomes important.

A Racial/Cultural Identity Development Model

In the past several decades, Asian Americans, Latinas/os, 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 model (MID) in an attempt to pull out common features that cut across the population-specific proposals. D. W. Sue and Sue (1990, 1999) later elaborated on the MID, renaming it the Racial/Cultural Identity Development model (R/CID), 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 to aid therapists in understanding their culturally 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 cultures are described: conformity, dissonance, resistance and immersion, introspection, and integrative awareness. At each level of identity 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 phases with the attitudes and beliefs.

Conformity Phase

Similar to individuals in the preencounter stage (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 for the person. 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 oneself (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.

TABLE 11.1 The Racial/Cultural Identity Development Model

Source: From D. R. Atkinson, G. Morten, and D. W. Sue, Counseling American minorities: A cross cultural perspective, 5th ed. Copyright © 1998 McGraw-Hill, Boston, MA. 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
Stage 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
Stage 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
Stage 3—Resistance and immersion	Self-appreciating	Group-appreciating experiences and feelings of culturocentrism	Conflict between feelings of empathy for other minority	Group-depreciating
Stage 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
Stage 5—Integrative awareness	Self-appreciating	Group-appreciating	Group-appreciating	Selective appreciation

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 onto 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 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; Hispanics are dirty, sneaky, and criminal; Asian Americans are sneaky, sly, cunning, and passive; Indians are primitive savages. Such portrayals cause widespread harm to the self-esteem of minorities who may incorporate them. 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. In the Autobiography of Malcolm X (Haley, 1966), Malcolm X 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. It is evident that many marginalized group members do come to accept White standards as a means of measuring physical attractiveness, attractiveness of personality, and social relationships. Such an orientation may lead to the phenomenon of internalized racism or racial self-hatred, in which people dislike themselves for being Asian, Black, Hispanic, or Native American. People at the conformity stage 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 racial/cultural 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 the person.

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, the individual 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 Latino/Hispanic Americans in some situations. Although stratification probably exists, we caution readers that such a ranking is fraught with hazards and potential political consequences. Such distinctions often manifest themselves in debates over which group is more oppressed and which group has done better than the others. Such debates are counterproductive when used to (a) negate another group's 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 up one group as an example to others.

4. Attitudes and beliefs toward members of the dominant group (group-appreciating attitude and beliefs): This stage 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. Consider again the example from the Autobiography of Malcolm X, in which the main character would straighten his hair and primarily date White women. Reports that Asian women have undergone surgery to reshape their eyes to conform to White female standards of beauty may typify this dynamic.

Dissonance Phase

No matter how much one attempts to deny his or her own racial/cultural heritage, an individual 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., the Sansei student). A Latina/o who feels ashamed of his or her cultural upbringing may encounter another Latina/o who seems proud of his or her cultural heritage. 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 the Sansei student encountered discrimination at the restaurant.

In all probability, movement into the dissonance stage 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 move into this stage 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 ensuing stage.

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 their own culture or 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 their own group's culture and, with it, 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 may express positive feelings toward the person: “We like you because you are Asian [or Black, American Indian, or Latino].” 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 their own group's strengths and weaknesses begin to be questioned as new, contradictory information is received. Certain aspects of their culture begin to have appeal. For example, a Latino who values individualism may marry, have children, and then suddenly realize how Latina/o 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): Stereotypes associated with other marginalized groups are questioned, and a growing sense of comradeship with other oppressed groups is felt. 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 Phase

The primary orientation of individuals in this phase 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. During the resistance and immersion stage, the three most active types of affective feelings 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. The feelings of guilt and shame extend to the perception that during this past “sellout,” one has been a contributor to and participant in the oppression of one's 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 at this stage is oriented toward self-discovery of one's own history and culture. There is an active seeking out of information and artifacts that enhance that 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 stage 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 stage is now actively challenged in order to raise self-esteem. Phrases such as “Black is beautiful” represent a symbolic relabeling of identity for many Blacks. Racial self-hatred begins to be actively rejected in favor of the other extreme: unbridled racial pride.

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 now 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 identification in an unquestioning manner 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 stage 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 stage 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 Phase

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 more 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 stage 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 individual 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 Latina/o individual who may form 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, in fact, not support this group view.

It is important to note that some clinicians often confuse certain characteristics of the introspective stage with parts of the conformity stage. A person in the introspective stage who speaks against the decisions of his or her group may often appear similar to the conformity-stage person. The dynamics are quite different, however. While the conformity-stage 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 onto the group views and notions in order to submerge personal autonomy. The conflict now 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 stage, 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 one's group may attempt to pressure or influence the individual into making decisions that may be inconsistent with the person's 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 now 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 the 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. American culture that are highly functional and desirable, yet feels confusion about how to incorporate these elements into one's 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 Phase

Persons in this stage have developed an inner sense of security and now can own and appreciate unique aspects of their culture as well as those of U.S. culture. One's own culture is not necessarily in conflict with White dominant cultural ways. Conflicts and discomforts experienced in the previous stage 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 to accept or reject those aspects of a culture that are not seen as desirable. At the integrative awareness stage, 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, the client becomes bicultural or multicultural without a sense of having “sold out one's 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 one's 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 the 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 one'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 one understands other cultural values and beliefs, the greater is the likelihood of understanding among the various ethnic groups. 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.

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 cultural identity development should sensitize therapists and counselors to the role that oppression plays in an individual's development. In many respects, it should make us aware that our role as helping professionals should extend beyond the office and should 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 culturally 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 minority group with respect to their cultural identity. It serves as a useful assessment and diagnostic tool for therapists to gain a greater understanding of their culturally diverse clients. In many cases, an accurate delineation of the dynamics and characteristics of the phases may result in better prescriptive treatment. Counselors who are familiar with the sequence of identity development are better able to plan intervention strategies that are most effective for culturally diverse clients. For example, a client experiencing feelings of isolation and alienation in the conformity phase may require an approach different from the one he or she would require in the introspection phase.

Third, the model allows helping professionals to realize the potentially changing and developmental nature of cultural identity among clients. If the goal of multicultural counseling/therapy is to move a client toward the integrative awareness stage, then the therapist is able to anticipate the sequence of feelings, beliefs, attitudes, and behaviors likely to arise. Acting as a guide and providing an understandable 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 Phase: Counseling Implications

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 in this stage 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 own 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 racial/cultural 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 at this stage 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 one's own cultural value (an ability characteristic of the integrative awareness stage).

Although the goals for the White and 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 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 multicultural counseling/therapy, 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 Phase: Counseling Implications

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 brought in for therapy. More culturally aware than their conformity counterparts, dissonance clients may prefer a counselor or therapist who possesses good knowledge of the client's 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 of this stage. Since the client is so receptive toward self-exploration, the therapist can capitalize on this orientation in helping the client come to grips with his or her identity conflicts.

Resistance and Immersion Phase: Counseling Implications

Clients at this stage 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, openness or self-disclosure to therapists not of one's own group is dangerous because White counselors or therapists are “enemies” and members of the oppressing group.

Clients in the resistance and immersion stage 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 its identification with the status quo. When they do, they are usually suspicious and hostile toward the helping professional. A therapist working with a client at this stage of development needs to realize several important things.

First, he or she will be viewed by the client as a symbol of the oppressive society. If you become defensive and personalize the attacks, you 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 multicultural counseling/therapy. It is not unusual for clients at this stage 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 at this stage prefer a therapist of their own race. However, the fact that you share the same race or culture as your client will not insulate you from the attacks. Again, as outlined in Chapter 3 , therapists of color working with a same-race client at the stage of resistance can encounter unique challenges. For example, an African American client may perceive the Black counselor as a sellout of his or her own race, or as an Uncle Tom. Indeed, the anger and hostility directed at the therapist may be even more intense than that directed at a White one.

Second, realize that clients in this stage will constantly test you. 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 this stage is frequently the most difficult to deal with because counselor self-disclosure is often necessary for establishing 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 racial/cultural issues are well received. It is important that the therapist be willing to help the culturally different client explore new ways of relating to both minority and White persons.

Introspection Phase: Counseling Implications

Clients at 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 therapists understand their clients' worldview. Ironically, clients at this stage 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 marginalized members and their group as a rejection of their own cultural heritage. This is not unlike conformity persons, who also reject their racial/cultural 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 Phase: Counseling Implications

Clients at this stage have acquired an inner sense of security around their self-identity. They have pride in their racial/cultural 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 at the integrative awareness phase 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 their worldviews. In other words, attitudinal similarity between therapist and client is a more important dimension than membership-group similarity.

Value of R/CID 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 racial/cultural group are the same. Depending on their levels of racial consciousness, the attitudes, beliefs, and orientations of clients of color may be quite different from one another. (b) 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 to 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 stage or level of racial/cultural 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, LGBT 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. We have, however, in Chapter 3 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. But 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. We present several questions for you to consider in the following reflection and discussion questions.

Reflection and Discussion Questions

1. What types of conflict and/or challenge confront a therapist of color at the conformity stage when working with a client of color at the resistance and immersion stage? How would they perceive one another? How may 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. Can you discuss other stage combinations and their implications for therapists and clients of color working with one another?

3. Does a counselor of color have to be at the integrative awareness stage to be helpful to clients of color?

Research on racial/cultural identity development has slowed considerably since the 1990s (Ponterotto & Mallinckrodt, 2007; Yoon, 2011), and little change in the models presented in this chapter has occurred. In some respects, this reflects 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). On the other hand, this slowing of research also reflects the considerable confusion about the theory and measurement of racial/cultural identity. 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. Although many measures have been developed in an attempt to assess and/or test the conceptual models, most have proven limited because of the sometimes nuanced aspects of measurement. 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.

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 stages 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 stages? 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 does hold the integrative awareness stage as a higher form of healthy functioning.

6. Be aware that racial/cultural identity development models seriously lack an adequate integration of gender, class, sexual orientation, and other sociodemographic group identities.

7. Know that a great deal of evidence is mounting that suggests that although identity may sequentially move through identifiable stages, affective, attitudinal, cognitive, and behavioral components of identity may not move in a uniform manner. It is entirely possible that the emotions and affective elements associated with certain stages do not have a corresponding one-to-one behavioral impact.

8. 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.

Summary

In the past several decades, work on racial/cultural identity development among marginalized groups has led to major breakthroughs in the field of multicultural counseling/therapy. Racial identity development 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, the counseling process, and counselors are influenced by cultural/racial identity and are not simply linked to minority group membership. Third, they clarify the impact of sociopolitical forces in shaping racial identity. And fourth, identity development models that discuss the oppressor–oppressed relationship seem equally applicable to other marginalized groups, such as women, lesbians/gays, 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 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 cultures 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 phase 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 to how the differences are perceived in our society.

Glossary Terms

Active commitment

Asian American identity development models

Black identity development models

Conformity

Dissonance

Encounter

Identity synthesis

Immersion-emersion

Integrative awareness

Internalization

Internalization-commitment

Internalized racism

Introspection

Latino/Hispanic American identity development models

Marginal person

Nigrescence

Preencounter

R/CID model

Race salience

Racial awakening

Redirection

Resistance and immersion

Traditionalist

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WHITE RACIAL IDENTITY DEVELOPMENT COUNSELING IMPLICATIONS

Chapter Objectives

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. Analyze resistance by White Americans to identifying themselves as “White.”

3. Learn the meaning of nested or embedded emotions experienced by Whites as they come to accept their Whiteness.

4. Define White privilege.

5. Understand how Whiteness advantages Whites and disadvantages people of color.

6. Describe and discuss the various developmental levels of White racial identity development.

7. Learn how the level of White racial consciousness may affect the counseling process.

8. Understand how White racial identity development may influence the definition of normality-abnormality, assessment, diagnosis, and treatment of culturally diverse clients.

9. Learn what a White person needs to do in order to develop a nonracist and antiracist White identity.

10. Learn what White helping professionals need to do in order to prevent their Whiteness from negatively impacting clients of color.

As a person of color, I have often wondered how White people identify themselves as racial/cultural beings. At times, I 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?” These were some of the responses I received (Sue, 2003, pp. 115–117).

42-Year-Old White Male Businessperson

1. Q: What does it mean to be White?

2. A: Frankly, I don't know what you're talking about!

3. Q: Aren't you White?

4. A: Yes, but I come from Italian heritage. I'm Italian, not White.

5. Q: Well then, what does it mean to be Italian?

6. A: Pasta, good food, love of wine (obviously agitated). This is getting ridiculous!

26-Year-Old White Female College Student

1. Q: What does it mean to be White?

2. A: Is this a trick question? . . . I've never thought about it. . . Well, I know that lots of Black people see us as being prejudiced and all that stuff. I wish people would just forget about race differences and see one another as human beings. People are people and we should all be proud to be Americans.

34-Year-Old White Female Stockbroker

1. Q: What does it mean to be White?

2. A: I don't know (laughing), I've never thought about it.

3. Q: Are you White?

4. A: Yes, I suppose so (seems very amused).

5. Q: Why haven't you thought about it?

6. A: Because it's not important to me.

7. Q: Why not?

8. A: It doesn't enter into my mind because it doesn't affect my life. Besides, we are all individuals. Color isn't important.

39-Year-Old Black Male Salesperson

1. Q: What does it mean to be White?

2. A: Is this a school exercise or something? Never expected someone to ask me that question in the middle of the city. Do you want the politically correct answer or what I really think?

3. Q: Can you tell me what you really think?

4. A: You won't quit, will you (laughing)? If you're White, you're right. If you're Black, step back.

5. Q: What does that mean?

6. A: White folks are always thinking they know all the answers. A Black man's word is worth less than a White man's. When White customers come into our dealership and see me standing next to the cars, I become invisible to them. Actually, they may see me as a well-dressed janitor (laughs), or actively avoid me. They will search out a White salesman. Or, when I explain something to a customer, they always check out the information with my White colleagues. They don't trust me. When I mention this to our manager, who is White, he tells me I'm oversensitive and being paranoid. That's what being White means. It means having the authority or power to tell me what's really happening even though I know it's not. Being White means you can fool yourself into thinking that you're not prejudiced, when you are. That's what it means to be White. (Sue, 2003, pp. 118–119).

Reflection and Discussion Questions

1. Is this a fair or unfair question?

2. Can you discern any common responses among the three given by White pedestrians? In what ways do they differ?

3. How do Whites view themselves as racial/cultural beings?

4. What seems to prevent these three individuals from viewing themselves as White?

5. If asked what it means to be White, would people of color also find difficulty answering the question? Why or why not?

6. How does the Black salesman's response differ from his White counterparts?

7. Which perception is the most accurate? Why?

Research on Whiteness, White privilege, and White racial identity development point to one of the greatest barriers to racial understanding for White Americans: the invisibility of their Whiteness (Bell, 2003; 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 often become very defensive (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. 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 accuracy of whether Whiteness defines a race is largely irrelevant. What is more relevant is that Whiteness is associated with unearned privilege—advantages 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, which is unmasked by this Black salesman when asked “What does it mean to be White?”

The response given by the Black salesman is markedly different from those of the other three responders by its specificity, clarity, and perspective. In essence, he believes being White means (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. This worldview is in marked contrast to the White respondents who would rather not think about their Whiteness, are uncomfortable or react negatively to being labeled “White,” deny its importance in affecting their lives, and seem to believe that they are unjustifiably accused of being bigoted by virtue of being White. Strangely enough, “whiteness” is most visible when it is denied, evokes puzzlement or negative reactions, and equated with normalcy. Few people of color react negatively when asked what it means to be Black, Asian American, Latino or a member of their 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 the person of color leads us to the inevitable conclusion that part of the problem of race relations (and by inference multicultural counseling and therapy) 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 straights or gays? 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 they. 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 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 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 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. 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?”

Models of White Racial Identity Development

A number of multicultural experts in the field have begun to emphasize 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 development 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 multicultural counseling/therapy would be 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, more positive opinions toward minority groups, and better 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 multicultural counseling/therapy 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 is 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 this 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. In general, awareness and the meaning of race, racial differences, bias, and prejudice are either absent or minimal. The negative reactions of parents, relatives, friends, and peers toward issues of race, however, begin to convey mixed signals to the child. This is reinforced by the educational system and mass media, which instill racial biases in the child and propel him or her into the acceptance stage.

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 must bear the responsibility for their failure. White EuroAmericans become the social reference group, and the socialization process consistently instills messages of White superiority and minority inferiority into the child. The underemployment, unemployment, and undereducation of marginalized groups in our society are seen as support for the belief that non-White groups are lesser than Whites. Because everyone has an equal opportunity to succeed, the lack of success of minority groups is seen as evidence of some negative personal or group characteristic. 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 because of a monumental event or a series of events that not only challenge but also shatter the individual's denial system. A White person may, for example, make friends with a coworker of color and discover that the images he or she has of “these people” are untrue. The person may have witnessed clear incidents of unfair discrimination toward persons of color and may now begin to question assumptions regarding racial inferiority. In any case, 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. In many cases, the White person may develop a negative reaction toward his or her own group or culture. Although those at this stage may romanticize people of color, they cannot interact confidently with them because they fear that they will make racist mistakes. This discomfort is best exemplified in a passage by Sara Winter (1977, p. 1):

We avoid Black people because their presence brings painful questions to mind. Is it OK to talk about watermelons or mention “black coffee”? Should we use Black slang and tell racial jokes? How about talking about our experiences in Harlem, or mentioning our Black lovers? Should we conceal the fact that our mother still employs a Black cleaning lady?. . .We're embarrassedly aware of trying to do our best but to “act natural” at the same time. No wonder we're more comfortable in all-White situations where these dilemmas don't arise.

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. The intense soul-searching is most evident in Winter's 1977 personal journey as she writes,

In this sense we Whites are the victims of racism. Our victimization is different from that of Blacks, but it is real. We have been programmed into the oppressor roles we play, without our informed consent in the process. Our unawareness is part of the programming: None of us could tolerate the oppressor position, if we lived with a day-to-day emotional awareness of the pain inflicted on other humans through the instrument of our behavior. . . .We Whites benefit in concrete ways, year in and year out, from the present racial arrangements. All my life in White neighborhoods, White schools, White jobs, and dealing with White police (to name only a few), I have experienced advantages that are systematically not available to Black people. It does not make sense for me to blame myself for the advantages that have come my way by virtue of my Whiteness. But absolving myself from guilt does not imply forgetting about racial injustice or taking it lightly (as my guilt pushes me to do). (p. 2)

There is realization that Whiteness has been defined in opposition to people of color—namely, by standards of White supremacy. By being able to step out of this racist paradigm and redefine what her Whiteness meant to her, Winter is able to add meaning to developing a nonracist identity. She no longer denies being White, honestly confronts her racism, and understands the concept of White privilege.

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 come a commitment to social action as well. The individual accepts responsibility for effecting personal and social change without always relying on persons of color to lead the way. As Winter 1977 explains,

To end racism, Whites have to pay attention to it and continue to pay attention. Since avoidance is such a basic dynamic of racism, paying attention will not happen naturally. We Whites must learn how to hold racism realities in our attention. We must learn to take responsibility for this process ourselves, without waiting for Blacks' actions to remind us that the problem exists, and without depending on Black people to reassure us and forgive us for our racist sins. In my experience, the process is painful but it is a relief to shed the fears, stereotypes, immobilizing guilt we didn't want in the first place. (p. 2)

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 also 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 are distributed equally in the two phases: contact, disintegration, reintegration, pseudo-independence, immersion/emersion, and autonomy. Originally, Helms used the term stages to refer to the six; but because of certain conceptual ambiguities and the controversy that ensued, she has abandoned its usage.

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. Such statements as “People are people,” “I don't notice a person's race at all,” and “You don't act Black” are examples. Although there is an attempt to minimize the importance or influence of race, there is on both a conscious and an unconscious level a definite dichotomy between persons of color and Whites regarding stereotypes and the superior/inferior dimensions of the races. Because of obliviousness and compartmentalization, it is possible for two diametrically opposed belief systems to coexist: (a) Uncritical acceptance of White supremacist notions relegates minorities into the inferior category with all the racial stereotypes, and (b) there is a belief that racial and cultural differences are unimportant. This allows Whites to avoid perceiving themselves as dominant group members or as having biases and prejudices. Such an orientation is aptly stated by Peggy McIntosh (1989) in her own White racial awakening:

My schooling gave me no training in seeing myself as an oppressor, as an unfairly advantaged person, or as a participant in a damaged culture. I was taught to see myself as an individual whose moral state depended on her individual moral will. . . .Whites are taught to think of their lives as morally neutral, normative, and average, and also ideal, so that when we work to benefit others, this is seen as work which will allow “them” to be more like “us.” (p. 8)

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 killing of Michael Brown and Eric Garner in 2014). Conflicts between loyalty to one's group and humanistic ideals may manifest themselves in various ways. The person becomes increasingly conscious of his or her Whiteness and may experience dissonance and conflict, resulting in feelings of guilt, depression, helplessness, or anxiety. Statements such as “My grandfather is really prejudiced, but I try not to be” and “I'm personally not against interracial marriages, but I worry about the children” are representative of personal struggles occurring in the White person.

Although a healthy resolution might be to confront the myth of meritocracy realistically, the breakdown of the denial system is painful and anxiety provoking. Attempts at resolution, according to Helms, may involve (a) avoiding contact with persons of color, (b) not thinking about race, and (c) seeking reassurance from others that racism is not the fault of Whites.

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 their attempts to resolve the dissonance created from the previous process, there is a retreat to the dominant ideology associated with race and one's 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.

I'm an Italian grandmother. No one gave us welfare or a helping hand when we came over [immigrated]. My father worked day and night to provide us with a decent living and to put all of us through school. These Negroes are always complaining about prejudice and hardships. Big deal! Why don't they stop whining and find a job? They're not the only ones who were discriminated against, you know. You don't think our family wasn't? We never let that stop us. In America everyone can make it if they are willing to work hard. I see these Black welfare mothers waiting in line for food stamps and free handouts. You can't convince me they're starving. Look at how overweight most of them are. . . . Laziness—that's what I see. (Quoted from a workshop participant)

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 the person 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 individuals to identify with the plight of persons of color. However, the well-intentioned White person at this status may suffer from several problematic dynamics: (a) Although intending to be socially conscious and helpful to minority groups, the White individual may unknowingly perpetuate racism by helping minorities adjust to the prevailing White standards; and (b) identifying with minority individuals is based on how similar they are to him or her, and the primary mechanism used 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. Helms states that the person searches for an understanding of the personal meaning of racism and the ways in which one benefits from White privilege. 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. Winter (1977) states,

Let me explain this healing process in more detail. We must unearth all the words and memories we generally try not to think about, but which are inside us all the time: “nigger,” “Uncle Tom,” “jungle bunny,” “Oreo,” lynching, cattle prods, castrations, rapists, “black pussy,” and black men with their huge penises, and hundreds more. (I shudder as I write.) We need to review three different kinds of material: (1) All our personal memories connected with blackness and black people, including everything we can recall hearing or reading; (2) all the racist images and stereotypes we've ever heard, particularly the grossest and most hurtful ones; (3) any race-related things we ourselves said, did, or omitted doing which we feel bad about today.

. . . Most whites begin with a good deal of amnesia. Eventually the memories crowd in, especially when several people pool recollections. Emotional release is a vital part of the process. Experiencing feelings seems to allow further recollections to come. I need persistent encouragement from my companions to continue. (p. 3)

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 the 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 in 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. Part of its attractiveness and value is the derivation of “defenses,” “protective strategies,” or what Helms (1995) formally labels information-processing strategies (IPSs), which White people use to avoid or assuage anxiety and discomfort around the issue of race. Table 12.1 lists examples of IPS statements likely to be made by White people in each of the six ego statuses. Understanding these strategic reactions is important for White American identity development, for understanding the barriers that must be overcome in order to move to another status, and for potentially developing effective training or clinical strategies.

TABLE 12.1 White Racial Identity Ego Statuses and Information-Processing Strategies

Source: Helms, 1995, p. 185.

1. Contact status: Satisfaction with racial status quo, obliviousness to racism and one's participation in it. If racial factors influence life decisions, they do so in a simplistic fashion. Information-processing strategy. IPS: Obliviousness.

Example: “I'm a White woman. When my grandfather came to this country, he was discriminated against, too. But he didn't blame Black people for his misfortunes. He educated himself and got a job. That's what Blacks ought to do. If White callers [to a radio station] spent as much time complaining about racial discrimination as your Black callers do, we'd never have accomplished what we have. You all should just ignore it” (quoted from a workshop participant).

2. Disintegration status: Disorientation and anxiety provoked by irresolvable racial moral dilemmas that force one to choose between own-group loyalty and humanism. May be stymied by life situations that arouse racial dilemmas. IPS: Suppression and ambivalence.

Example: “I myself tried to set a nonracist example [for other Whites] by speaking up when someone said something blatantly prejudiced—how to do this without alienating people so that they would no longer take me seriously was always tricky—and by my friendships with Mexicans and Blacks who were actually the people with whom I felt most comfortable” (Blauner, 1993, p. 8).

3. Reintegration status: Idealization of one's socioracial group, denigration and intolerance of other groups. Racial factors may strongly influence life decisions. IPS: Selective perception and negative out-group distortion.

Example: “So what if my great-grandfather owned slaves. He didn't mistreat them; and besides, I wasn't even here then. I never owned slaves. So I don't know why Blacks expect me to feel guilty for something that happened before I was born. Nowadays, reverse racism hurts Whites more than slavery hurts Blacks. At least they got three square [meals] a day. But my brother can't even get a job with the police department because they have to hire less-qualified Blacks. That [expletive] happens to Whites all the time” (quoted from a workshop participant).

4. Pseudo-independence status: Intellectualized commitment to one's own socioracial group and deceptive tolerance of other groups. May make life decisions to “help other racial groups.” IPS: Reshaping reality and selective perception.

Example: “Was I the only person left in America who believed that the sexual mingling of the races was a good thing, that it would erase cultural barriers and leave us all a lovely shade of tan?. . .Racial blending is inevitable. At the very least, it may be the only solution to our dilemmas of race” (Allen, 1994, p. C4).

5. Immersion/emersion status: Search for an understanding of the personal meaning of racism and the ways by which one benefits and a redefinition of Whiteness. Life choices may incorporate racial activism. IPS: Hypervigilance and reshaping.

Example: “It's true that I personally did not participate in the horror of slavery, and I don't even know whether my ancestors owned slaves. But I know that because I am White, I continue to benefit from a racist system that stems from the slavery era. I believe that if White people are ever going to understand our role in perpetuating racism, then we must begin to ask ourselves some hard questions and be willing to consider our role in maintaining a hurtful system. Then we must try to do something to change it” (quoted from a workshop participant).

6. Autonomy status: Informed positive socioracial group commitment, use of internal standards for self-definition, capacity to relinquish the privileges of racism. May avoid life options that require participation in racial oppression. IPS: Flexibility and complexity.

Example: “I live in an integrated [Black-White] neighborhood, and I read Black literature and popular magazines. So I understand that the media presents a very stereotypic view of Black culture. I believe that if more of us White people made more than a superficial effort to obtain accurate information about racial groups other than our own, then we could help make this country a better place for all peoples” (quoted from a workshop participant).

The Helms model, however, is not 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 some serious objections.

First, they claim that Helms's model is erroneously based on racial/ethnic minority identity development models (discussed in the previous chapter). Because minority identity development occurs in the face of stereotyping and oppression, it may not apply to White identity, which does not occur under the same conditions.

Second, they believe that too much emphasis is placed on the development of White attitudes toward minorities and that not enough is placed on the development of White attitudes toward themselves and their own identity.

Third, they claim that there is a conceptual inaccuracy in putting forth the model as developmental via stages (linear) and that the progression from less to more healthy seems to be based on the author's ethics.

Last, Rowe (2006) attacks the Helms model of White racial identity development 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. It is important to note that the critique of the Helms (1984) model has not been left unanswered. In subsequent writings, Helms (1994) has disclaimed the Rowe et al. (1994, 1995) characterization of her model and has attempted to clarify her position. The continuing debate has proven beneficial in adding greater clarity to the issues of White racial identity development and has resulted in increased research.

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 the society and therefore inherit all the biases; stereotypes; and racist attitudes, beliefs, and behaviors of the larger society.

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 the following. 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 their relevance to other 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 may consciously believe that all people are created equal and that he or she treats everyone the same suddenly experiences reservations about having African Americans move next door or having one's son or daughter 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 strength of positive forces pushing the individual forward (support for challenging racism) and negative forces pushing the person 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 the issues or to take responsibility for his or her part in a current situation. For example, the person may 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, however, 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 him or her 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 oneself 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, the person 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, the person may resolve this dilemma by moving back into the protective confines of White culture (conformity phase), again 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 or 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, however, 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 feelings or 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 as well.

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 and that is needed 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 it 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 the schools and 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 be disowned, avoidance by colleagues, threats of being labeled a troublemaker or not being promoted at work are all possible pressures for the White person to move 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.

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 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. Let us briefly return to the “walkway” metaphor provided by Tatum (1997) in her classic book, Why Are All the Black Kids Sitting Together in the Cafeteria?

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 naïve and innocent about the harm their inaction imparts on people of color.

Second, as indicated by Tatum (1997), one need not be actively racist in order to be racist. The pace by which one walks with the flow of 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) those slowly strolling may be unintentional racists, unaware of their biases and the direction they are taking, and (c) “passive racists” may choose not to walk at all. Despite choosing not to walk in the direction of the walkway, 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 aware of the harm they are inflicting on people of color. 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 are never-ending activities that are exhausting and energy depleting for people of color. 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) take action by moving in the opposite direction (antiracism), and (d) stop the conveyor belt and/or reverse its direction (institutional and societal change)?

As indicated in the White racial identity development sections, becoming nonracist means 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 action of others. The invisibility of White privilege and Whiteness allow for denying the pain and suffering experienced by people of color, but more importantly, it absolves White Americans of personal responsibility for perpetuating injustice, and allows them to remain passive and inactive.

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 through these phases, 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: (1) having intimate and close contact with others, (2) cooperation rather than competition on common tasks, (3) sharing mutual goals, (4) exchanging accurate information rather than stereotypes, (5) sharing an equal status relationship, (6) support for prejudice reduction by authorities and leaders, and (7) 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 that participants in research projects were of their White racial identity, the more likely they exhibited increased levels of racism.

The seven basic principles outlined above 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 come from recommendations put forth by the American Psychological Association, Presidential Task Force on Preventing Discrimination and Promoting Diversity (2012), from the President's Initiative on Race (1998, 1999), from educators and trainers (Ponterotto et al., 2006; Young & Davis-Russell, 2002), and from 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 from the perspective of people of color. 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 racial/ethnic groups 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.

· Since 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 to increase understanding, you must supplement your factual understanding with the experiential reality of the groups you hope to understand. These experiences, however, must be something carefully planned to be successful.

· 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. 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 Latino/a 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.

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 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 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: (1) naiveté, (2) conformity, (3) dissonance, (4) resistance and immersion, (5) introspective, (6) integrative awareness, and (7) commitment to antiracist action. Becoming nonracist means 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 (1) from the groups you hope to understand, (2) from healthy and strong people of the culture, (3) from experiential reality, (4) from constant vigilance of fears and biases, and (5) 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

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COUNSELING AFRICAN AMERICANS

Chapter Objectives

1. Learn the demographics and characteristics of African Americans.

2. Identify counseling implications of the information provided for African Americans.

3. Provide examples of strengths that are associated with African Americans.

4. Know the special challenges faced by African Americans.

5. Understand how the implications for clinical practice can guide assessment and therapy with African Americans.

Eric Garner was approached by police officers for selling “loosies” or unpackaged cigarettes, a minor offence in Staten Island. When he argued with the officers, one deputy used a headlock to subdue him and other police officers kneeled on this back as he lay face down handcuffed. He complained about not being able to breathe at least 11 times. The coroner ruled his death a “homicide” due to compression of the neck and chest. (Allen, 2015)

A Justice Department civil rights investigation of the Ferguson Police Department and the city's municipal court after the shooting death of Michael Brown concluded that both agencies had engaged in discriminatory practices against African Americans as evidenced by “targeting them disproportionately for traffic stops, use of force, and jail sentences.” (Perez, 2015)

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)

The confederate flag has been removed from the state capitol ground after the killing of nine congregants of the Emanuel African Methodist Episcopal Church. As Governor Haley stated, “While the flag for many South Carolinians stands for noble traditions of history, heritage and ancestry, for many others it's a deeply offensive symbol of a brutally oppressive past.” (Associated Press, 2015) [Confederate symbols are also being removed in other states.]

The African American population was 41.7 million in 2013, representing 13% of the total population. The poverty rate for African Americans remains nearly twice as high as that of all households (25.8% versus 14.3%) (U.S. Census Bureau, 2013, 2014), and the unemployment rate is over twice that of White Americans (9.5% versus 4.6%) (U.S. Department of Labor, 2015). Approximately 23% of African American adults do not have a high school diploma (Fry, 2010). Of African American males, 38% are experiencing greater downward mobility out of the middle class compared with the 21% of White males (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 to 6 years shorter than that of White Americans. Although African Americans are 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. The African American population is 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.

Ethnic and Racial Identity

Many scholars believe that minorities go through a sequential process of racial identity development. For many African Americans, the process involves a transformation from a non-Afrocentric identity to one that is Afrocentric (although some African Americans consistently embrace a Black identity through early socialization). The Cross (1991, 1995) model, as described in Chapter 11 , identifies the stages of preencounter, encounter, immersion-emersion, and internalization. These stages are associated with differences in perspective regarding the self and relationships with others, beginning with the acceptance of White standards and deprecation of Black culture and culminating in an appreciation of both Black culture and aspects of the White culture. The current stage of an individual's racial identity affects awareness of and willingness to discuss racial issues or racism (Forsyth, Hall & Carter, 2015).

Implications

African Americans who are at 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 racial identity report the highest self-esteem (Pierre & Mahalik, 2005). African American preferences for counselor ethnicity are often related to their current stage of racial identity. Parham and Helms (1981) found that African Americans at the preencounter stage preferred a White counselor, whereas those in later stages preferred an African American counselor. In a study involving 128 Black college students, over 75 percent 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 percent 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-blind counselors (those who do not assess for environmental issues such as prejudice) (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 stage of racial identity 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

Although about 44% of African American households are headed by married couples, many African American families are headed by single parents (Vespa, Lewis, & Kreider, 2013). Black children are significantly less likely than other children to be living with two married parents (44% versus 84% for Asian children, 64% for Hispanic children, and 75% for White children) (Child Trends, 2010). In 2008, 72% of all births to Black women were outside of marriage, compared with 29% for non-Hispanic White women (Black Demographics.com , 2011). The African American family is often described as matriarchal; among lower-class African American families, 63% are headed by women versus 33% of all U.S. households (Taylor, Larsen-Rife, Conger, Widaman, & Cutrona, 2010). 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 school disappeared.

Implications

Because of the possibility of extended or nontraditional 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 EuroAmerican 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 economically disadvantaged African American families, 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

D. 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)

Spirituality and religion play an important role in many African American families; 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).

Implications

Spiritual beliefs are important to many African Americans and serve as a protective factor in response to stressors. If a client is heavily involved in church activities or has strong religious beliefs, the counselor might consider enlisting church leaders to help the client (or 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 female, 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)

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). The gap in educational attainment between African American and White children is gradually narrowing. In 2013, over 90% of African Americans vs 94% of White Americans had completed high school, although only 20% had a bachelor's degree or higher compared to 40% of Whites (Child Trends, 2014).

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 et al., 2005, p. 105); but when these researchers visited the homes of parents who were criticized, they often observed parental love, effective parenting skills, and family support for education.

Implications

Factors associated with school failure, especially in African American males, must be identified and system-level intervention strategies applied. Traditional educational practices often do not meet the needs of diverse populations. For example, many African American youths display an animated, persuasive, and confrontational communication style, while schools often have norms of quiet conformity; teacher-focused instruction; and individualized, competitive activities. White teachers may perceive the typical communication patterns, physical movement, and walking style of African American youth as aggressive or noncompliant (Monroe, 2005). It is important for educators to recognize culturally based behaviors that are not intended to be disruptive. If teachers are not sensitive to these cultural differences, they may respond inappropriately to minority group members. Students often learn best when curricula and classroom styles are modified taking cultural factors into consideration.

African American Youth

Case Study

LeaJay Harper

LeaJay Harper says she was a typically rebellious teenager raised by a single mother. She left home at 17 and lived on the streets, surviving on stale donated bread and sleeping on church porches. When she was 18, she was arrested for stealing a $10 bag of McDonald's food. “I was hungry,” she said. She went to jail. (Mulady, 2011, p. 1)

For many urban African American adolescents, life is complicated by problems of poverty, illiteracy, and racism. African American youth are more likely to be victims of violence, such as stabbings or shootings, but are reluctant to report these incidents because of fear of the police or of being accused of “snitching” (Schwartz et al., 2010). Most African American youth feel strongly that race is still a factor in how people are judged (Pew Research Center, 2010). In fact, White undergraduate females are more likely to overestimate the age of African American youth offenders and believe them to have greater culpability for crimes than White or Latina/o juvenile offenders (Goff et al., 2014). Even young African American children are well aware of stereotypes regarding the occupational status of African Americans. In one study, they identified service jobs as those performed by “only Black people” and high-status jobs as those performed by White Americans (Bigler & Averhart, 2003).

Issues presented in counseling may differ to some extent between boys and girls. Although African American adolescent girls display higher self-confidence, lower levels of substance use, and more positive body images than other groups of adolescent girls (Belgrave, Chase-Vaughn, Gray, Addison, & Cherry, 2000), they often encounter sexism as well as racism. While striving to succeed in relationships and careers, African American adolescent girls not only are burdened by living in a male-dominated society but also undergo the stressors associated with being African American or living in poverty (Talleyrand, 2010). Acute awareness of issues of racism and sexism is reflected in the following comment:

Well, in this time I think it's really hard to be an African American woman. . .we are what you call a double negative; we are Black and we are a woman and it's really hard. . .society sees African American females as always getting pregnant and all that kind of thing and being on welfare. (Shorter-Gooden & Washington, 1996, p. 469)

In interviews with African American adolescent girls, Shorter-Gooden and Washington (1996) found that the struggle over racial identity was a more salient factor than gender identity in establishing self-definition. These adolescents believed that they had to be strong and were determined to overcome obstacles resulting from societal misperceptions involving Blackness. About half were raised by single mothers, and most indicated the importance of the mother–daughter relationship. Careers were important to two thirds of the group, and most reported that their parents had instilled strong motivation to succeed academically.

Unfortunately, there is a growing trend toward incarceration of African American girls and young women. They are the fastest-growing incarcerated group of young people in the United States. In California, the arrest rate is 49 per 1,000 for Black girls, compared with 9 per 1,000 for White girls and 15 per 1,000 for Latinas (Pfeffer, 2011). In general, the crimes committed are not violent and are frequently associated with poverty, homelessness, and maltreatment within the home. Further, zero tolerance policies in schools disproportionately affect African American girls, who may be disciplined for talking back, interpersonal conflict, or truancy. LeaJay Harper, quoted at the beginning of this section, was arrested a second time for stealing pajamas and underwear for her young daughter. Instead of jail time, she was sent to a six-month treatment program and now runs the Young Mothers United Program at the Center for Young Women's Development in San Francisco, helping other African American girls and young women who are at risk of losing their children because of arrests for similar nonviolent offenses (Mulady, 2011).

Implications

African American youth often do not come to counseling willingly. They may be referred by social agencies or brought in by family members. Because of this, lack of interest in counseling may be an issue, as seen in the following case.

Case Study

Michael

Michael is a 19-year-old African American male 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 identity and conflict should be explored. Counselors can help African American girls and women counteract negative images associated with being Black and being female. Enhancing internal strength by developing pride and dignity in Black womanhood can serve as a buffer to racism and sexism and can prevent the incorporation of negative images into their own belief systems (Owens, Stewart & Bryant, 2011).

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 et al., 2010). Among low-income single mothers, many displayed substantial parenting involvement with their children and emphasized 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; within a family, males are more accepting of women's work roles and are more willing to share in the 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 difficulty expressing vulnerability or distress (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 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) did find 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 about half of Whites believe Blacks have equal societal opportunities, 81% of Blacks believe more change is necessary (Pew Research Center, 2010). Due to the deaths of unarmed Black men at the hands of the police, 57% of Americans believe that racial relationships are a cause for concern (Dann, 2014a). A Black Lives Matter movement arose 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 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 challenges instances of racism against African Americans.

However, there is a large racial gap between Blacks and Whites in their views about the police and their actions. While 70% of Whites believe that the police treat both races equally, only 28% of Blacks have the same belief (Dann, 2014b). Many African Americans believe that racial profiling occurs frequently. In situations involving suspected racial profiling, Black men often report thinking, “Maybe I am being treated this way because I am Black,” and needing to decide, “Do I protest it or just take it?” (Fausset & Huffstutter, 2009, p. 1).

Consciously or unconsciously, many people associate African Americans with crime and favor harsher punishments for African Americans. 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, harsher sentences were supported when he was described as Black (Weir, 2014). In a study involving African American defendants who were convicted of killing White victims, Eberhardt and colleagues (2006) found that defendants with darker skin and broader noses were twice as likely to receive the death penalty compared to African Americans who looked less stereotypically black. Similarly, Viglione, Hannon, and DeFina (2011) found that African American women with lighter skin received shorter sentences than women 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 brought up by their children. Racial socialization can help buffer the negative effects of racism and discrimination (Lee & Ahn, 2013). Neal-Barnett (1997) found that ignoring racial issues in socialization leaves children vulnerable to anxiety when African American peers accused them of “acting White.” 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 parental focus on increasing positive feelings about self and enhancing a sense of pride in one's culture (Belgrave et al., 2000). Messages of cultural pride from parents is 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.

Figure 14.1 The Interaction of Four Sets of Factors in the Jones Model

Source: From “Psychological Functioning in Black Presenting Americans: A Conceptual Guide for Use in Psychotherapy,” by A. C. Jones, 1985, Psychotherapy, 22, p. 367. Copyright 1985 by Psychotherapy. Reprinted by permission of the Editor, Psychotherapy.

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.

Jones (1985) described four interactive factors that should be considered in working with African American clients (see Figure 14.1 ). The first factor 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 personal experiences of the individual. 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 the 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. African American clients tend to prefer an egalitarian relationship, so it is critically important to answer questions, explain the counseling and assessment process, and enlist the client's assistance in determining goals and treatment strategies. 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 working with a counselor of a different ethnic background. (Although African Americans show a same-race preference, being culturally competent is an even more important factor.) A statement such as, “Sometimes clients feel uncomfortable working with a counselor of a different race. Would this be a problem for you?” Be open if the client discusses any experiences with racism or discrimination.

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), community resources, and 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. Establish an egalitarian relationship. Many African Americans are comfortable establishing a close personal connection with the counselor. This may be accomplished by self-disclosure. If the client appears hostile or aloof, discussing some noncounseling topics may be useful.

7. 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 structure can be helpful in deciding if alternative treatment modes and approaches might be beneficial.

8. Determine any external factors that might be related to the presenting problem. Determine whether and how the client has responded to discrimination and racism, both in 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.

9. 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 an important factor 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.

Summary

African Americans represent approximately 13 percent 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 account 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. Nine clinical implications for counselor practice are identified.

Glossary Terms

Afrocentric

Cultural mistrust

Extended family

Healthy cultural paranoia

Kinship bonds

Prejudice

Racial identity

Racial socialization

Racism

Spirituality

References

1. Acs, G. (2011). Waking up from the American dream. Retrieved from http://www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/Economic_Mobility/Pew_PollProject_Final_SP.pdf

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COUNSELING ASIAN AMERICANS AND PACIFIC ISLANDERS

Chapter Objectives

1. Learn the demographics and characteristics of Asian Americans and Pacific Islanders.

2. Identify counseling implications of the information provided for Asian Americans and Pacific Islanders.

3. Provide examples of strengths associated with Asian Americans and Pacific Islanders.

4. Know the special challenges faced by Asian Americans and Pacific Islanders.

5. Understand how the implications for clinical practice can guide assessment and therapy with Asian Americans and Pacific Islanders.

Among traditionally oriented Chinese Americans, depression is described with terms such as discomfort, pain, dizziness, or other physical symptoms, rather than as feelings of sadness. Many feel that a diagnosis of depression is “morally unacceptable.” (Kleinman, 2004)

Asian parents hold dearly to the centuries-old culture of shame and honor so that when they arrive to the United States, it often gets passed down to the next generation. So much so that if their children need help for issues related to low self-esteem, depression, anxiety, or any personal struggles, they can be seen as tarnishing the family's prestige. (Louie, 2014a)

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)

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 comprise 0.4% of the total population (U.S. Census Bureau, 2015). The largest Asian groups in the United States include

(Pew Research Center, 2013)

· over 4 million Chinese,

· 3.4 million Filipinos,

· 3.2 million Asian Indians,

· 1.7 million Vietnamese,

· 1.6 million Koreans, and

· 1.3 million Japanese.

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 is composed of 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 et al., 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, 2011a) seems to support this contention. Of those over the age of 25, over half of Asian/Pacific Islanders have a bachelor's degree, versus 30% of their White counterparts; 20% have an advanced degree, compared with 10% of Whites (U.S. Census Bureau, 2011b). Words such as intelligent, hardworking, enterprising, and disciplined are frequently applied to this population (Lim, 2014). The median income of Asian American families was $66,000 as compared with $49,800 for the U.S. population as a whole (Pew Research Center, 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 (12.5% for Asian Americans and 15.1% for Pacific Islanders, versus 9.4% for non-Hispanic Whites) (U.S. Census Bureau, 2010). 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 the Hmong, only 40% have completed high school. Fewer than 14% of Tongan, Cambodian, Laotian, and Hmong adults and only 18% of Pacific Islanders have a bachelor's degree (Aronowitz, 2014). 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 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 survey of Chinese Americans, 58% reported being subjected to verbal harassment such as being made fun of, called names, or threatened; disrespectful or unfair treatment; unfairness in career advancement; stereotyping; and physical harassment (Larson, 2009). Perceived racial discrimination is associated with higher psychological distress, anxiety, depression, and suicidal ideation (Hwang & Goto, 2009).

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.

Collectivistic Orientation

I was born and raised in Korea and came to the United States in 1968. . .I must move back to Seoul to take care of my aging mother. I am a man of Asian values (filial piety), and my children are young college graduates of American values (career advancement and development). (Choi, 1999, p. 7)

Instead of promoting individual needs and personal identity, Asian families tend to have a family and group orientation. Children are expected to strive for family goals and not engage in behaviors that might bring dishonor to the family. Parents believe they should have influence on their children's career choices (Pew Research Center, 2013). Asian American parents tend to show little interest in children's viewpoints regarding family matters. Instead, the emphasis is on adherence to “correct” values, family harmony, and adapting to the needs of family members, especially elders (P. H. Chen, 2009). 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 place individual needs over family needs. For example, in the case just given, the client accepted the fact that his adult children would not return home to stay with his wife (their mother) while he was in Korea taking care of his mother. Although he decries American society, in which individualism prevails over collectivism, he acknowledges that his children have honored the family by being successful and that they define family obligations in a different manner.

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 to 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 (e.g., “How important is it for you to consult your family before deciding how to deal with the problem?” and “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.

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 (A. 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 (E. W.-C. Chen, 2009).

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

Amy Chua, author of the book Battle Hymn of the Tiger Mom, raised a storm of criticism when she described her child-rearing strategies, including banning sleepovers, play dates, watching TV, or playing computer games and considering any grade less than an “A” as unacceptable. Her children are required to complete all of their school work and must practice their musical instruments three hours each day. (One daughter, Sophia, played at Carnegie Hall at age 14 and the other daughter, Lulu, is a gifted violinist.) (Corrigan, 2011)

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 the age of 6 or 7 (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 the children (J. S. Lau, Fung, Wang, & Kang, 2009). Problem behavior in children 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?” (A. S. Lau et al., 2010, p. 887). Criticism rather than praise is believed to be effective in changing behaviors. 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. The therapist can help refocus on the more positive aspects of Asian child-rearing strategies, framing the change as helping the children with problems rather than 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 (A. S. Lau, 2012).

Emotionality

Patients may not be willing to discuss their moods or psychological states because of fears of social stigma and shame. In many Asian cultures, mental illness is stigmatizing; it reflects poorly on family lineage and can influence others' beliefs about the suitability of an individual for marriage. (Louie, 2014b)

Strong emotional displays, especially in public, are considered signs of immaturity or lack of self-control; control of emotions is considered a sign of strength (Kim, 2011). Thus, in many Asian families, there is generally less open display of 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 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 the father and the children. When the children are exposed to more open displays of emotions 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 families.

Holistic View on Mind and Body

A female Asian American client described her symptoms, including dizziness, loss of appetite, an inability to complete household chores, and insomnia. She asked the therapist if her problem could be due to “nerves.” The therapist suspected depression, since her symptoms included many of the physical manifestations of the disorder. She asked the client if she felt depressed and sad. At this point, the client paused and looked confused. She finally stated that she feels very ill and that these physical problems are making her sad. Her perspective was that it is natural to feel sad when sick. When the therapist followed up by asking if there was a family history of depression, the client displayed even more discomfort and defensiveness. Although the client never directly contradicted the therapist, she never returned. (Tsui & Schultz, 1985)

Because the mind and body are considered inseparable, Asian Americans may express emotional difficulties through somatic complaints (Grover & Ghosh, 2014). 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 often 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, counselors can 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 way to assess 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

I want to write. I have to write. . . This is not the choice my parents would make, and surely not the choice they would wish me to make. . .I must not let it deter my progress or shut down my dreams, my purpose. (Ying, Coombs, & Lee, 1999, p. 357)

There is great pressure for children to succeed academically and to have a successful career, since both are indicative of a successful upbringing. 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. 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 the 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, 2009).

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) described 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 case above, Lo talks about the struggles encountered during his racial identity development. Individuals undergoing acculturation conflicts may respond in one of the following ways (Huang, 1994):

1. Assimilation. Seeking to become part of the dominant society to the exclusion of one's own cultural group

2. Separation or enculturation. Identifying exclusively with the Asian culture

3. Integration/biculturalism. Retaining many Asian values while simultaneously learning the necessary skills and values for adaptation to the dominant culture

4. Marginalization. Perceiving one's own culture as negative but feeling inept at adapting to the majority culture

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). Assimilated Asian clients 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 resilience in facing stressful situations (Sirikantraporn, 2013). 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 in its participants (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 (R. M. Lee, Su, & Yoshida, 2005) and are often related to dating and marriage issues (Ahn, Kim, & Park, 2009). 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 (R. M. 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 their 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 their perception of healthy family functioning? How are decisions made in the family? How are family members showing respect for each other and contributing 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 this 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 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 (S.W.-H. Chen & Davenport, 2005).

Implications

Carefully describe the client's role in the therapy process, indicating that problems can be individual, relational, environmental, or a combination of these 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 (S.W.-H. 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 actually 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). Then the therapist and client can identify situations where assertiveness might be functional, such as in class or when seeking employment, while recognizing other situations 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 clients to establish self-efficacy.

Racism and Discrimination

Katie also said she had not been “exposed to racism, personally,” defining racism as making fun of or discriminating against others because one feels superior . . . “except for those annoying little people that walk around the street and walk by me and go, ‘ching, chong, ching' or whatever.” (Suyemoto, Day, & Schwartz, 2015, p. 130)

Asian Americans continue to face issues of racism and discrimination (Hwang & Goto, 2009). However, some Asian American youth, such as Katie in the previous example, lack awareness of or minimize discriminatory behavior toward them, describing racial jokes and teasing as unintentional or “just for fun.” Exposure to racism or discrimination does affect mental health. In a sample of 444 Chinese American adolescents, it was found that discrimination in early adolescence was related to depression, alienation, and lower academic performance in middle adolescence (Brenner & Kim, 2009). Experience with discrimination in foreign-born and Asian American–born college students was not only related to depression but also to intergenerational conflicts, especially with the mother, probably because she is the one whom family members interact primarily with to navigate 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 clients 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 the 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 Asian American 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 the cultural beliefs of clients 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 therapies, can be effective, especially if modifications are made for less acculturated clients (W.-Y. 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 include family, community, and societal influences on the problem. Obtain the worldview, degree of acculturation, and ethnic identity of the Asian American client.

5. Conduct a positive assets search. What strengths, skills, problem-solving abilities, and social supports are available to the individual or 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 Asian Americans to choose and evaluate suggested interventions. Asian Americans may prefer an immediate resolution to a problem rather than in-depth exploration.

9. Use problem-focused, time-limited approaches that have been modified to incorporate possible cultural factors.

10. Self-disclosure regarding strategies the counselor has used in the past to solve problems similar to those faced by the client can be helpful.

11. With family therapy, the therapist should be aware that Western-based theories and techniques may not be appropriate for Asian families. Determine the structure and communication patterns among the 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, or affection is shown, including 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.

Summary

Asian Americans/Pacific Islanders are nearly 6% of the population, but are composed of 40 distinct subgroups, each with its own language, religion, and customs. The counselor should not assume that they are all the same. Asian Americans are often seen as a “model minority”; the myth has masked the historical and continuing prejudice and discrimination directed toward them. Counselors working with Asian American/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 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.

Glossary Terms

Acculturation

Assimilation

Co-construction

Collectivistic orientation

Emotionality

Hierarchical relationships

Integration/biculturalism

Model minority

Saving face

Somatic complaints

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COUNSELING LATINAS/OS

Diane M. Sue and David Sue

Chapter Objectives

1. Learn the demographics and characteristics of Latinas/os.

2. Identify counseling implications of the information provided for Latinas/os.

3. Provide examples of strengths that are associated with Latinas/os.

4. Know the special challenges faced by Latinas/os.

5. Understand how the implications for clinical practice can guide assessment and therapy with Latinas/os.

Nearly a quarter of Americans say Hispanics face a lot of discrimination in society today, making them the racial/ethnic group the public sees as most often subjected to discrimination. (Pew Research Center, 2010a)

It was sometimes hard to adjust. When I went outside, I was in America but inside my house, it was Mexico. My father was the leader of the house. It wasn't that way for some of my American friends. (Middleton, Arrendondo, & D'Andrea, 2000, p. 24)

Even the most patriotic of us Mexican-Americans has a couple of members in our family who are here illegally. We also think there is nothing wrong with them being here illegally because we know they're just trying to build a better life for themselves. . . illegal immigrant isn't some random statistic that conservative pundits always seem to bitch about stealing lucrative ‘merican' jobs like picking strawberries and working as dishwasher at Denny's (Felix, 2014).

In this chapter, we use the term Latinas/os in reference to individuals living in the United States with ancestry from Mexico, Puerto Rico, Cuba, the Dominican Republic, and Central or South American Spanish-speaking countries. However, people vary in preference for the terms used for self-identification. For example, more than half of the Latina/o youth (ages 16 to 25) in one sample self-identified first by their family's country of origin (i.e., Mexican, Cuban), while approximately 20% self-identified as “Hispanic” or “Latina/o,” and 24% self-identified as “American.” Among youth who are third-generation or higher, about half chose “American” as their first term of self-description (Pew Research Center, 2009). The U.S. Census uses the term Hispanic as an ethnic descriptor rather than the term Latina/o.

Throughout Latin America, the immigration of European, African, and Asian populations and subsequent mixture with indigenous groups has resulted in a wide range of phenotypes. Thus the physical traits of Latinas/os vary greatly and include characteristics of indigenous groups, Africans, Asians, and fair-skinned Europeans. Latinas/os are currently the largest minority group in the United States, comprising 17.1% of the total U.S. population (U.S. Census Bureau, 2015). Because of immigration patterns and high birthrates (one in four infants born in the United States is Latina/o), more than half of the growth in the total U.S. population between 2000 and 2010 resulted from increases in this population.

According to the U.S. Census Bureau (2014), there are 54.6 million Latina/o Americans, of whom 64% are of Mexican origin, 9.4% are from Puerto Rico or of Puerto Rican descent, 3.7% have Cuban ancestry, and 16% originate from Central and South America.

Approximately 37% of Latinas/os are immigrants, including the 11% of foreign-born individuals who have become U.S. citizens. However, approximately one-fourth of the Latina/o adults are undocumented immigrants; about two-thirds of all undocumented immigrants are from Mexico (Marrero, 2011). It is not surprising that nearly half of all Latina/o American 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 Latina/o 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 Latinas/os 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 Latina/o group in metropolitan areas throughout the United States. Most Puerto Ricans reside in the Northeast, and most Cubans live in Florida (Lopez & Dockterman, 2011). Median wealth of White households is more than 10 times that of Latina/o households (Pew Research Center, 2014b). Members of this group have high unemployment, are overrepresented among the poor, and often live in substandard housing. Many hold semiskilled or unskilled occupations (U.S. Census Bureau, 2010b).

Characteristics and Strengths

In the following sections we describe the characteristics, values, and strengths of Latina/o 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 to the Latina/o culture (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. Each member of the family has a role: mother (self-denial), father (responsibility), children (obedience), grandparents (wisdom), and godparents (resourcefulness) (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, Latinas/os 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 there are many positive features of the extended family, 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

Latinas/os often live in households having five or more members (U.S. Census Bureau, 2010a). Traditional oriented families are hierarchical in form, with special authority given to parents, older family members, and males. Within the family, sex roles are clearly delineated. The father is typically the primary authority figure (Lopez-Baez, 2006). Children are expected to be obedient and are typically not involved in family decisions; parents may expect adolescents to work to help meet family financial obligations (Lefkowitz, Romo, Corona, Au, & Sigman, 2000).

Parents reciprocate by providing for children through young adulthood and even after marriage. This type of reciprocal relationship is a lifelong expectation. Older children are expected to care for and protect their younger siblings; older sisters often function as surrogate mothers. Also, in traditionally oriented marriages, emphasis is placed on social activities involving extended family and friends rather than on activities as a couple (Negy & Woods, 1992).

Implications

Assessment of family structure should consider the family hierarchy and 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 (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

Latinas/os 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 be nurturing, modest, virtuous, submissive to the male, and self-sacrificing (marianismo) (Deardorff et al., 2013). As head of the family, the father expects family members to be obedient. Individuals with greater ethnic identity are more likely to subscribe to traditional male and female roles. Areas of possible gender role conflict for males (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 his 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) inability to express feelings of anger (Lopez-Baez, 2006). Latina immigrants are often socialized to feel inferior and to expect suffering or martyrdom. With greater exposure to the dominant culture, such views may be questioned. Certain roles may change more than others. 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 toward this 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 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 Latinas/os, although less so among younger individuals (Pew Research Center, 2014a). Prayers requesting guidance from patron saints can be a source of comfort in times of stress. Latinas/os often believe that life's misfortunes are inevitable and feel resigned to their fate (fatalismo). Consequently, they may take a seemingly passive approach to problems and lack experience assertively addressing challenges. Also, some Latina/o groups believe that evil spirits cause mental health problems and rely on indigenous healing practices.

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 in fatalism, instead of attempting to change this view, the therapist can acknowledge this attitude and help the individual or family determine the most adaptive response to the situation. A 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. The 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 “Ayudate, 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.

Educational Characteristics

Peer pressure to drop out can be nearly overwhelming in the Latina/o community, as DeAnza Montoya, a pretty Santa Fe teen, can attest. In her neighborhood, it was considered “Anglo” and “nerdy” to do well in school. . . “In school they make you feel like a dumb Mexican,” she says, adding that such slights only bring Latinas/os closer together. (Headden, 1997, p. 64)

Many Latina/o students do not fare well in the public school system and have a high likelihood of dropping out of school; this is particularly true among first-generation (immigrant) youth and those who are third-generation or higher (Pew Research Center, 2009). Approximately 41% of adults do not have a regular high school diploma, including 52% of those who are foreign-born. Additionally, the vast majority (90%) of youth who drop out of high school never attain a General Educational Development (GED) credential and thus are not eligible to attend college or vocational programs or to enter the military (Fry, 2010).

A number of problems contribute to the high dropout rate of Latina/o students. Educational difficulties may be related to limited English proficiency. Spanish is the primary language spoken in over half of the households; others speak Spanish on a more limited basis. Although most second-generation Latinas/os are bilingual (exposed to Spanish in the home and to English in school), their command of both English and Spanish may be marginal. The high pregnancy rate for Latina girls also contributes to school dropout rates. Although teen pregnancy among 15- to 19-year-old Latinas is decreasing, the birth rate (70 live births per 1,000 women in this age group) is significantly higher than for other groups (Hamilton, Martin, & Ventura, 2009). In some schools there is peer pressure against “acting White” or doing well academically. Higher grades in Latina/o youth are associated with a decrease in peer popularity and could explain underperformance in schools (Fryer, 2006).

However, there are some grounds for optimism about education. Many Latina/o youth value education and are optimistic about the future and performing better in school (Pew Research Center, 2009). In 2013, 79% completed high school which is an all-time high and the dropout rate has gone down to 14% in 2013 as compared to 32% in 2000. College attendance is also increasing among Latina/o young people: 18% were in college in 2013 versus 12% in 2009. Although there is improvement, Latina/o young adults continue to lag substantially behind White youth in obtaining a bachelor's degree (9% versus 69%) (Fry, 2014).

Implications

Although teachers often attempt to accommodate Latina/o cultural learning styles and adapt lessons for students with limited English skills, the move against bilingual education and the rapid immersion of Spanish-speaking students in English can exacerbate academic difficulties. Many immigrant parents do not realize they have the right to question school decisions. Difficulty communicating with Spanish-speaking parents compounds the problem. Some parents are unable to attend conferences because of work requirements, and this may be interpreted as a lack of caring about the child's education. To engage parents, conferences can be scheduled at flexible hours and interpreters be made available. Face-to-face communication or other personal contact is more successful than written material (even if written in Spanish) since many parents have limited literacy skills. Trust develops slowly, and it is important to identify and support the family's strengths rather than focusing on its shortcomings (Espinosa, 1997). Altering instructional strategies to fit cultural values (i.e., cooperation) is also important. Latina/o students often have high educational expectations but don't know how to apply for financial assistance and are unaware of university application procedures. Providing information regarding resources and help through this process can increase the chances for a college education (Gonzalez, Stein, Shannonhouse, & Prinstein, 2012).

Cultural Strengths

Cinthya grew up in poverty. She is now attending Columbia University working on her public health degree. Asked how she persevered against the odds, Cinthya speaks with emotion and credits her success to her family. “It's my parents,” she said. “They have sacrificed so much to give us the opportunity to go to school, to grow.” (New Journalism on Latina/o Children, 2010, p. 1)

Most Latina/o 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 Latina/o 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 Latinas/os—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 Latina/o 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. Latina/o 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 Latino 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, Latinas/os 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). Many Latinas/os are afraid to sign up for programs such as the Affordable Care Act 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 (2010), 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, Latinas/os 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 et al., 2008)

Juan's therapist recognized that traditional cognitive behavior therapy (an evidence-based treatment for depression) might not adequately address the environmental stressors, acculturation conflicts, and feeling of isolation and powerlessness Juan was experiencing. Instead, the therapist modified another evidence-based treatment (behavioral activation therapy). He encouraged Juan to participate in free or low-cost activities (e.g., socializing with and 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 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 either 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 score 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, Latina/o children begin to have questions about their identity and question whether they should adhere to mainstream or traditional values. The representation of Latinas/os on English-language channels often involves characters who behave criminally or are violent. The mixed heritage of many Latina/o 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 Latina/o 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, 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 majority culture. Second-generation Latina/o Americans are often marginal in both native and majority cultures. They are often bilingual (exposed to Spanish at home and English at school) but frequently have less-than-optimal use of either language. The therapeutic alliance can be enhanced by beginning the counseling relationship in a more formal manner and working to build trust before beginning comprehensive exploration of the presenting problem or extensive interviewing regarding sensitive topics.

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 resultant 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.

Females may feel overprotected by parents and question their rules or expectations, such as staying at home to care for others and being 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 Latina/o 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).

Racism and Discrimination

Arizona state law allows the state superintendent of Public Education to disallow any ethnic studies class that “promotes resentment towards a race or class of people. . .(or) advocates ethnic solidarity instead of treatment of pupils as individuals.” (Martinez & Gutierrez, 2010, p. 1)

Because of anti-immigration rhetoric, Latinas/os are now seen as the ethnic group suffering from the most discrimination. Almost 80 percent of Latinas/os believe that there is “a lot” or “some” discrimination against their group. (Pew Research Center, 2010b)

Stressors such as racism and discrimination can lead to emotional difficulties, particularly when combined with acculturation conflicts. Legislators in Arizona and Alabama recently enacted some of the broadest measures against undocumented immigrants in U.S. history. Such recent legislation includes making it a crime for noncitizens to be without documents (i.e., a visa or immigration forms) authorizing their presence in the United States and requiring law enforcement officers and other officials (including school personnel) to verify immigration status. These laws (supported by the majority of U.S. citizens) have been heavily criticized for promoting racial profiling.

Additionally, Arizona has implemented a state law banning any ethnic studies classes that “advocate ethnic solidarity instead of treatment of pupils as individuals” and not allowing instructors with “heavy accents” to teach English classes (Martinez & Gutierrez, 2010; Navarrette, 2011). Latina/o adolescents are particularly vulnerable to the effects of acculturation conflict and societal racism. Perceived discrimination among Mexican American adolescents increased psychological distress and such behaviors as drug use, fights, and sexual promiscuity (Flores, Tschann, Dimas, Pasch, & deGroat, 2010). Many youth attempt to deal with family distress, discrimination, and feelings of hopelessness by involvement in gang activities (Baca & Koss-Chioino, 1997).

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 Latinas/os 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). Additionally, many clients may be dealing with issues related to unemployment and poverty, including stressful interactions with bureaucracies (Vasquez, 1997).

Careful assessment of the source of emotional distress is necessary before appropriate action can be taken. This should be done early in the treatment process, as illustrated by the case of a migrant worker in his mid-50s who was fearful of leaving his home because he heard threatening voices. In working with him, Ruiz (1981) initiated an analysis of possible external causes, suggesting that the client undergo a complete physical examination, with special attention to exposure to pesticides and other agricultural chemicals that might result in mental symptoms. Additionally, interviews revealed that the client was quite anxious owing to fears of deportation, suspiciousness of outside authorities, and recent encounters with creditors.

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 Latina/o 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. However, interpreters themselves may present 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 Latina/o 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. Be careful not to interpret slow speech or long silences as indicators of depression or cognitive dysfunction. The client may be struggling with English communication skills.

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 would “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 or problems as they see them. 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 on the problem?

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 individual 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. 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 you have 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 Latinas/os. Although initial meetings may be quite formal, once trust has developed, clients often develop a close personal bond with the counselor, may treat the counselor as a close friend or family member, and may 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 focusing on intrapsychic or relational issues.

Summary

The term “Latina/o” refers to a diverse group of people whose country of origin includes Mexico, Puerto Rico, Cuba, and other Spanish-speaking 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 major differences in family structure (familismo), gender role expectations (machismo and marianismo), spiritual and religious values, educational characteristics, and cultural strengths of this group is important for culturally competent practice. Counselors must anticipate specific challenges they face such as mental illness stigma, acculturation conflicts, linguistic issues, and racism/discrimination. Sixteen clinical implications for counselor practice are identified.

Glossary Terms

Acculturation

Bicultural orientation

Extended family

Familismo

Fatalismo

Latina/o Americans

Machismo

Marianismo

Personalismo

Respecto

Simpatico

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COUNSELING INDIVIDUALS LIVING IN POVERTY

Laura Smith

Chapter Objectives

1. Learn the demographics associated with poverty.

2. Identify counseling implications of the information provided regarding impoverished clients.

3. Recognize strengths associated with experiences involving poverty.

4. Know the special challenges faced by impoverished clients.

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 ROAD [Reaching Out About Depression] 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. Part of this consideration requires that counselors who come from middle-class (and more affluent) backgrounds learn about the realities experienced by those living in poverty. Equally important, 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 (SES), 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 in a subsequent section, 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 American poverty rate was 14.5% in 2013, down from 15.0% in 2012 (DeNavas-Walt & Proctor, 2014). This was the first decrease in the poverty rate since 2006. The trends and data summarized below illustrate further a demographic snapshot of U.S. poverty today:

· The poverty rate for Whites was 9.6% in 2013. For African Americans, the 2013 poverty rate was 27.2%, while the rate for Latinas/os was 23.5%. For Asians, the 2013 poverty rate was 10.5% (DeNavas-Walt & Proctor, 2014). Because Whites are a larger population in the United States, they comprise 42% of those living in poverty. Further, 29% of those living in poverty are Latinas/o and 25% are African American.

· Children (at a poverty rate of 19.9%) continue to be the age group most likely to live in poverty, and the U.S. child poverty rate is one of the highest in the developed world (UNICEF, 2012). Unlike the overall poverty rate, the poverty rate for children did not decline from its 2012 levels (DeNavas-Walt & Proctor, 2014).

· Women are more likely to live in poverty than men. In 2013, 13.1% of males and 15.8% of females were impoverished, differences that are most pronounced among those aged 65 and older. For women aged 65 and older, the poverty rate was 11.6%, while it was 6.8% for men in this age group (DeNavas-Walt & Proctor, 2014).

· Among women, poverty rates are especially high among Black women (25.3%), Latinas (23.1%), and Native American women (26.8%); rates for Asian American women are closer (11.0%) to the poverty rates for White women (10.7%). Poverty rates for all racial groups of adult women are higher than for their male counterparts (Entmacher, Robbins, Vogtman, & Morrison, 2014).

· 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 is second in global inequality (after Chile) (DeSilver, 2013). This inequality has grown steadily in recent decades: in the 1970s, the share of total income earned by the top 1% of families was less than 10%; however, their share exceeded 20% by the end of 2012 (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 comprised of 160,000 families—by itself owned 22% of all U.S. wealth in 2012, up from 7% in the late 1970s (Saez & Zucman, 2014).

The statements above 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 (hence, figures like the ones above) always underestimate the number of families who are struggling economically. For example, the Department of Health and Human Services guidelines (HHS, 2015) specify that a family of four must earn less than $24,250 per year to fall beneath the poverty line; therefore, a family of four attempting to live on $24,251 per year would not be counted among the poor. These data effectively illustrate a significant characteristic of 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 peculiarities (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 was 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 prioritized 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. Understanding classism, therefore, is an essential component of multiculturally competent practice. The sections below 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 people's 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 has chronicled the interface of class, race, and schooling in America in books like The Shame of the Nation (2006), 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 than those attended by 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 from family members or friends, these students are unfamiliar with the process of completing paperwork for admission, financial assistance, choosing housing, or registering for classes. 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. Programs that have been effective in reducing summer melt attritions are bridge programs that facilitate the move from high school to college (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, informing her that she needed to immediately send in $1,700 to cover her deposit and rent. The mother then 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 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 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 where the American public ends up bearing the consequences of the risk.

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 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 has dropped to 41 million from 50 million in 2009 (Kaiser Foundation, 2010; Tavernise, 2014). This decrease is primarily because of enrollment via provisions of the Affordable Care Act. Although this is an improvement, a substantial number of Americans remain uninsured. 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 to restrict the “misuse” of government assistance to low-income individuals are based on the 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 money withdrawn from ATMs by welfare recipients would cause them to spend more money on fees and to travel more frequently to withdraw funds. The drug testing by states for welfare applicants has incurred a cost of nearly one million dollars. Very few drug users are found. Although the national drug use rate is 9.4%, the rate of positive drug tests for welfare applicants ranged from 0.002% to 8.3%. In fact, the positive drug rate for applicants for all states was under 1% except for one (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, or 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 are 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 above 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 (M. 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 [APA], 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. These statements included “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 present 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) discussed the meanings inherent in the name-calling directed toward poor White Americans such as White trash, trailer trash, rednecks, or hillbillies, whereas Rose (2008) analyzed 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 clients' 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, or 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 would raise the minimum wage to a level that allows 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 of the poor and their strengths are 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 the poor. Eight clinical implications for counselor practice are identified.

Glossary Terms

Classism

Cognitive and behavioral distancing

Poverty

Social class

Social class privilege

Social stratification theory

The criminalization of poverty

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