Cultural Competence Forum

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CHAPTER 6

WORKING WITH DIVERSITY

One of the great opportunities and challenges of internships is encountering people who are different from you. Learning to understand and respond to those differences will be a central key to your internship success and to your development as a person and a professional. This task will not be easy because the issues can strike at the core of who we are as individuals and as a society, and they will sometimes touch sensitivities or biases that we did not know existed in us and that may be uncomfortable. Challenging though this may be, it can also be one of the most illuminating and rewarding aspects of your training and future work.

The goal of this chapter is to introduce some of the key ideas about working with diversity and encourage you to explore and understand your own background, knowledge, attitudes, and other factors that affect you personally and will impact your profes- sional development and work. Understand, however, that as with other elements of this text, entire courses and countless books and articles are dedicated to these topics. Thus, whereas you are strongly encouraged to read this chapter carefully and com- plete the exercises for reflection, it is also advisable to engage in more extended and detailed study of these topics through dedi- cated courses and extended reading. Such focused coursework and training are required for graduation and certification in many professions.

BACKGROUND

Until relatively recently, helping professions and techniques devel- oped from, and were largely directed by, a predominantly white Western European/American, male, college-educated, financially well-to-do perspective (Gelso, 2010). With a few exceptions, this perspective was taken for granted and was applied in research, training, diagnosis, and treatment (Constantine, Hage, Kindaichi, & Bryant, 2007; Kress, Eriksen, Rayle, & Ford, 2005; Smedley & Smedley, 2005; Sue, Arredondo, & McDavis, 1992). For example, research by Bernal and Castro (1994) revealed that 46% of the training programs surveyed had no minority faculty, and 39% of accredited clinical psychology programs had no minority-related classes. As a result, great numbers of people were left unserved or in many cases were disserved (Hall, 1997).

Lack of multicultural faculty and training may help account for results from studies described by Sue and Sue (1990), which showed that more than 50% of minority clients terminated ther- apy after just one contact with the therapist. In the case of clients

who terminated early, lack of cultural competence on the part of counselors was shown by Constantine (2002) to be related to cli- ent dissatisfaction with counseling.

Fortunately, things have changed and now all of the major helping professions explicitly address issues of cultural awareness and sensitivity in their ethical codes. What is more, professional associations have published specific guidelines for multicul- tural competencies and practice. Examples include the American Psychological Asociation (APA) Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003), the National Association of Social Workers (NASW) Standards for Cultural Competencies in Social Work Practice (NASW, 2001), and the Multicultural Counseling Competencies and Standards (Sue et al., 1992).

In addition to professional guidelines, a host of books, specialty journals, and training programs have developed to promote research and training in cultural issues and practices. Arredondo, Tovar-Blank, and Parham (2008) and Arredondo and Perez (2006) offer informative and insightful reviews of the history of this movement, whereas Smith, Constantine, Dunn, Dinehart, and Montoya (2006) reported on a meta-analysis of studies on multicultural education, reporting that, overall, the results of such efforts have been positive. Looking at this trend from the perspective of treatment effectiveness, D’Andrea and Heckman (2008) reviewed 40 years of multicultural outcome research. An additional, and often overlooked, perspective is offered by Tseng and Strelzer (2004), who considered medical issues in mental health through a cultural lens, including differences in physiologic reactions to medications, cultural atti- tudes toward psychotropic medicines, traditional healing, and herbal remedies. Also along these lines, Gielen, Draguns, and Fish (2008) gathered fascinating and useful information about cultural approaches to therapy and healing from a variety of peoples, religions, and regions.

REASONS FOR DIVERSITY TRAINING

Proctor and Davis (1994) cited three critical reasons for addressing issues of diversity in clinical practice: (1) traditional segregation that limits the knowledge of different ethnic groups by persons outside that group, (2) the growing percentages of nonwhite per- sons in the population, and (3) the historical as well as present negative tensions that exist between groups. Other authors

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WORKING WITH DIVERSITY 87

Despite the evidence and arguments that have been offered for studying multicultural differences, resistance to such training is quite common. Deal and Hyde (2004) offered an especially thoughtful discussion of this topic and viewed both anxiety and resistance to multicultural training in the context of broader developmental challenges facing trainees. These authors iden- tified three worries that emerge when students are faced with multicultural learning. The first worry pertains to the content of what students are learning, particularly as they are required to study the history and ongoing dynamics of oppression. A sec- ond fear is of self-revelation making the students feel “stupid” or “racist” or possibly forcing them to discover aspects of them- selves that they had been unaware of and would not be comfort- able realizing. The third concern centers on how other students may react. In this context, Deal and Hyde recognized that many students, particularly those who are new to these topics, are afraid they will “make a mistake” in what they say or that they will be subject to criticism or censorship by peers or faculty.

Recognizing the anxiety and resistance that can be evoked by multicultural issues and training, Deal and Hyde (2004) empha- sized the fundamental importance of creating a supporting and safe environment in which these issues can be discussed. Deal and Hyde suggested that instructors need to assess the developmental level of students (e.g., Stoltenberg, 2005) and then help students understand that discomfort and risk taking are inherent elements of clinical education. Whatever the source of discomfort, one must learn to deal with the topic and the discomfort effectively rather than through avoidance. Building on a developmental for- mulation, Deal and Hyde offered a matrix that lists developmen- tal stages across affective, behavioral, and cognitive components, identifying how multicultural issues and training experiences relate to each level and component. If you find yourself encoun- tering some unexpected difficulties or reactions to multicultural issues, it may be helpful to step back for a second and consider your own developmental level in general and as it pertains to mul- ticultural issues specifically.

STEPS TOWARD WORKING WITH DIFFERENCESAWARENESS, KNOWLEDGE, AND UNDERSTANDING OF SELF AND OTHERS

Guidelines to help trainees learn to deal with people who are different from themselves have been offered by a number of authors. Among the most influential of these guidelines were provided some years ago by Sue et al. (1992). These authors began their analysis of multicultural competency in counseling with a three-characteristic by three-dimension matrix. The three characteristics they identified are (1) counselors’ awareness of their own assumptions and biases, (2) understanding the world- view of the client, and (3) developing culturally appropriate techniques and intervention strategies. For each of these char- acteristics, the three dimensions identified are (1) beliefs and attitudes, (2) knowledge, and (3) skills (p. 481). Each of the nine competency areas is then elaborated upon, yielding a final total of 31 specific competencies.

(e.g., Hage & Kenny, 2009) focused on social justice issues and the importance of social service professionals becoming informed about, and active in addressing, mental health issues beyond their clinical settings.

Although the literature just described has focused primarily on ethnic differences, similar principles apply to working with persons of differing genders, economic means, religious beliefs, sexual orientations, physical abilities, and geographic regions of the country (Cohen, 2009; La Roche & Maxie, 2003; Moodley, 2005). To the extent that our personal experience has not afforded contact with people who differ in significant ways from one’s self, and in the context of past and ongoing social tensions and prejudices, we may have difficulty understanding the experiences, strengths, needs, and perspectives of others. Such difficulties not- withstanding, understanding diversity is essential to your devel- opment and work as a professional. As Speight, Myers, Cox, and Highlen (1991) posed the rhetorical question:

If a counselor is unable to work with those she or he is different from, with whom will that counselor be able to work? (p. 30)

RESISTANCE TO DIVERSITY TRAINING

The importance and difficulty of coming to terms with diver- sity issues was illustrated well by the journal entries of a student whose initial response to a discussion of diversity was as follows:

I think too much is made about race and all the other differences. We are all just people, and if we all just treat everyone alike, there wouldn’t be all these problems. I’m not prejudiced myself, and I try to treat everyone the same.

This student’s comments were made in all sincerity; from her per- spective, she believed she had achieved an understanding of how best to deal with differences. Several weeks into her internship, a later journal entry revealed that she was beginning to gain deeper awareness of herself and others:

I always thought that everyone was just the same and that I was not prejudiced at all. Working here I’ve started to understand that just because I think everyone is the same doesn’t mean everyone else thinks that or everyone has had the same chances I have. I wonder what my life would be like if my family was as poor as the people I am working with. I always thought that people who were poor just didn’t want to work hard. I think I was prejudiced and just didn’t know it. Now I see this family working so hard and still not being able to afford the things I just take for granted. They can’t even take the kids to the doctor. I’m beginning to understand why they seem angry. I’m getting angry myself. It isn’t fair, but these people have to live with that every day and I get to go home to my comfortable dormitory. I’m starting to realize how sheltered I’ve been. This is opening my eyes, and it isn’t easy.

This student was coming to understand that one cannot simply dismiss diversity issues by saying they are unimportant or by “treating everyone alike.” A much deeper awareness of ourselves and others is required, and the internship is a good place to start developing that awareness.

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88 CHAPTER 6

also includes counseling that crosses groupings based on economic factors, geography, religion, sexual orientation, and the like.

More obvious, but too often neglected, are differences in the experiences of men and women. In many ways, in fact, gender differences may be the most overlooked of all because men and women, at least in Western cultures, are around each other much of the time and may therefore fail to appreciate the many ways in which their worlds are different. Failure to appreciate and adapt one’s approach in response to such differences can substantially decrease the chances of successful interactions and may increase the potential for iatrogenic effects.

Coleman (1997) took this issue a step further and pointed out that one must not only appreciate and understand ethnic and cultural differences per se, one must also appreciate differences in the ways individuals cope with those differences. Coleman hypothesized that conflicts in multicultural counseling relation- ships may develop either out of cultural differences or out of differences in how the therapist and the client approach their differences. Thus, a counselor who believes it is important to deal directly and explicitly with cultural differences may unwittingly clash with a client who deals with differences by choosing to overlook them and believes that all people are alike.

EXERCISE: KNOWING YOURSELF IN RELATION TO DIVERSITY

This exercise is designed to help you become more aware of your own cultural and personal backgrounds and characteristics. Because this understanding is a first step toward understanding how you will interact with others, it is perhaps more important than anything else in this chapter. I encourage you to spend sub- stantial time on the exercise and, if you feel comfortable and safe doing so, to discuss it with your peers and instructor.

The list that follows identifies certain personal and cultural characteristics that have a profound influence on how people understand the world and interact with others. For each characteristic, begin by describing yourself, then take some time to seriously consider how each aspect of yourself taken separately, and how all the aspects taken together, affect your under standing of yourself and others. Also, give some thought to how these char- acteristics shape the assumptions you bring to your training as an intern. One way to enhance this understanding is to imagine how things you may have taken for granted about yourself are due, at least in part, to your ethnic or cultural background. For example, you might ask yourself, “Because I have [pink/brown/black/red/ yellow] skin, I have experienced . . . ” Or, “Because my family’s economic status was . . . , I have experienced . . . ” Another approach to enhance your understanding is to imagine how your life might be different if you had characteristics other than those you have. For example, you might consider, “If I were of (another) culture, I might . . . ” “If my parents were very (poor/rich), I might . . . ” “If I were a new immigrant, I might experience . . . ” As a final response to this exercise, you may want to discuss your own responses with a peer or some other person. You may also find it helpful to dis- cuss them with people who are much different from you in certain of the key areas identified. One other note, for convenience, items in this exercise ask about characteristics of father and mother in the singular sense. People from blended families may well wish

The core principles elucidated by Sue et al. are reflected in the previously mentioned counseling guidelines of the key associations. Although the specifics of the guidelines vary some- what, they all have several elements in common. These common elements include self-awareness on the part of the therapist; knowledge and appreciation of the cultures of clients, including within-cultural as across-cultural variations; an appreciation of historical issues and power dynamics that have accompanied issues of race and culture; development of specific culturally sensitive and relevant assessment and intervention skills; and finally, a commitment to organizational and social change. Let us consider each of these elements in more detail.

SELF-AWARENESS: KNOWING THE DIVERSITY WITHIN US Guideline #1 of the APA Multicultural Guidelines (APA, 2003) states:

Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves.

That this principle is the first of the guidelines highlights the impor- tance of self-awareness in dealing with differences. Similarly, a number of authors (e.g., Toporek & Reza, 2001; Vasquez, 2007) have recognized that awareness of self is a vital first element for therapists learning to work with clients whose backgrounds dif- fer from their own. Consistent with these ideas, as a step toward developing your ability to work with differences, it can be extremely beneficial to think at length about your personal experiences and perspectives. Unless you have given careful thought to who you are, it is difficult to be sensitive to differences or similarities in your clients.

In this context, it should also be kept in mind that as Atkinson, Morten, and Sue (1993) pointed out, most discussions about counseling “minority” clients assume that the counselor is from the majority group whereas the client is from a minority group. This assumption overlooks the reality that it may well be the counselor who is from a minority group and the client from the majority group. An extensive discussion of issues related to the diversity status of the psychotherapist can be found in the special issue of Psycho- therapy: Theory, Research, Practice, Training (2010, 47[2]), which addresses this issue of therapist diversity from a host of perspectives including ethnicity, gender, sexual orientation, and disability.

An African American intern in a rural community mental health center encountered this dynamic and wrote the following in his journal:

It almost never fails. When people come in to the clinic the first time and see me, their first reaction is something like, “You’re the counselor???” They may not always say that, but you can tell they’re thinking it. Some even seem look around the room as if they’re asking, “Isn’t there someone else here I can work with?”

As an alternative to majority–minority distinctions, Atkinson et al. (1993) preferred the phrase “cross-cultural counseling,” which, they suggested, “refers to any relationship in which two or more of the participants are culturally different” (p. 9). Cross-cultural counseling

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WORKING WITH DIVERSITY 89

CONFRONTING OUR BIASES AND ACKNOWLEDGING OUR IGNORANCE Some interns come to training believing they have everything it takes to treat almost any client who comes to them. Others are not so confident, but very few are really aware of just how limited their own experiences or theories are.

In recognition of the importance of cultural awareness, a number of instruments have been developed to assess the beliefs, knowledge, and skills of therapists and counselors in relation to working with persons of different ethnicities and cultures. Reviews of such instruments have been offered by Hays (2008), Krentzman and Townsend (2008), and Green et al. (2005).

Based on the principles incorporated in these instruments, the exercise that follows is designed to encourage self-exploration of your preparedness to work with others from different back- grounds. In this exercise, you are invited to consider carefully and honestly the kinds of clients with whom you feel you have suf- ficient experience, knowledge, or understanding to interact in a way that will be genuinely helpful.

If you are like many of our interns, you may find that after completing the exercise, you are unsure whether you should try to interact with anyone other than yourself. If that feeling emerges, do not despair. The first step toward learning is acknowledging ignorance. Following the exercise, concepts and suggestions are presented to help build your awareness and abilities to work with differences.

EXERCISE: KNOWING WHAT YOU KNOW AND DO NOT KNOW ABOUT OTHERS

The following list includes some of the many characteristics that distinguish individuals and groups from one another. Consider these and try to identify where your knowledge, understanding, or experience would enable you to understand accurately and relate to their experiences, concerns, thoughts, emotions, or needs in a helpful way. For each group you think you know well enough to work with, give the reasons why. For example, what experi- ences, training, or personal knowledge do you have relating to this group?

Age groups:

Genders:

Appearance (e.g., skin color, facial features):

Ethnic or cultural background:

Generations lived in this country:

Economic status:

Education level:

Religion:

Sexual orientation:

Physical abilities or disabilities:

Geographical locations and related cultural issues:

to add people to this list, for example, stepmother or stepfather, as fits their circumstances.

1. My gender is _____, and this is how it influences my experi- ences and how I understand and relate to others:

2. My age is _____, and this is how it influences my experi- ences and how I understand and relate to others:

3. My physical appearance includes the following qualities (describe these as accurately as you can, and try to avoid oversimplifying or using racial terms):

Skin: Hair: Facial features: Build: Other features:

This is how those features influence my experiences and how I understand and relate to others:

4. The nationality and cultural background of my parents and grandparents are:

My father’s mother: My father’s father: My mother’s mother: My mother’s father: My father: My mother:

This is how the culture of my family influences my experi- ences and how I understand and relate to others:

5. With regard to economic resources, the family I was raised in was _____. This is how that background influences my experiences and how I understand and relate to others:

6. The religious orientation of my mother is _____. The religious orientation of my father is _____. This is how that background influences my experiences and how I understand and relate to others:

7. The political orientation of my mother is _____. The political orientation of my father is ______. This is how that background influences my experiences and how I understand and relate to others:

8. My mother’s educational background is _____. My father’s educational background is _____.

This is how that background influences my experiences and how I understand and relate to others:

9. My own educational background is _____. This is how that background influences my experiences and how I understand and relate to others:

10. My physical health and abilities are _____. This is how that background influences my experiences and how I understand and relate to others:

11. My sexual orientation is _____. This is how that background influences my experiences and how I understand and relate to others:

12. Other characteristics that have influenced my experiences and understanding of others are _____.

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for equality and respect. In addition to nonfiction works, I also strongly recommend studying poetry and fiction as well as other cultural works, including art, film, music, dance, and religion. Garcia and Bregoli (2000) give particularly useful suggestions for incorporating literary sources to help prepare counselors for mul- ticultural practice.

TERMINOLOGY MATTERS As you seek to better understand people from diverse back- grounds, be especially mindful of terminology and the implicit meanings that certain words can carry. For better or worse, the words we use shape how we view and understand people and the world, and this shaping often occurs without our conscious awareness.

You may not have noticed it, but up to now in our discussion of diversity, I have not referred to “race,” whether of clients or of therapists, except in direct quotations or in the context of discus- sion of racism as a social phenomenon. There is a good reason for this. In a special edition of the American Psychologist, Smedley and Smedley (2005), along with Helms, Jernigan, and Mascher (2005), reviewed the use of the term race as it evolved in general usage and in psychological treatment and research specifically. They emphasized that the terms race, culture, and ethnicity are often used interchangeably and without appreciation of their dif- ferent meanings.

Culture refers to the externally acquired set of beliefs, laws, customs, art, and other aspects of a society. Ethnicity is closely related to culture in that it describes external factors, including geographic location, language, and other characteristics that may distinguish one group from another, sometimes within a com- mon overall culture or nationality. For example, within the same nation, there may be clusters of people of markedly different reli- gious beliefs, countries of origin, linguistic patterns, food, dress, and so on (Cohen, 2009).

In comparison to these concepts, race has commonly been used to imply innate biologically based factors that distinguish people from others on such variables as body type and skin, hair, or eye color. These observed characteristics are then assumed to be associated with underlying abilities, tendencies, and person- ality traits. See, for example, Sternberg, Grigorenko, and Kidd (2005) for a discussion of the long-standing debate about race and intelligence.

Although the word race has been used widely in society and in research, it simply does not have scientific validity. As Smedley and Smedly (2005) explained the matter, racial distinctions fail on three counts: “They are not genetically discrete, are not reli- ably measured, and are not scientifically meaningful” (p. 16). Similarly, Helms et al. (2005) asserted, “Race has no consensual theoretical or scientific meaning in psychology, although it is fre- quently used in psychological theory, research, and practice as if it has obvious meaning” (p. 27).

Why is this important? It is important because, as Smedley and Smedley stated in the title of their article, “Race as biology is fiction, racism as a social problem is real.” Attention to termino- logy is not a matter of being “politically correct.” Rather, it is a matter of precision and accuracy in our thinking and our approach to research and treatment.

THE HISTORICAL CONTEXT MUST BE ACKNOWLEDGED A good starting point for beginning to understand groups or individuals who are different from you is assessing both your intellectual and emotional knowledge and ignorance of their history. However tolerant, open, understanding, or empathic ther- apists or interns might believe themselves to be toward others, those qualities cannot erase long histories and continued realities of racial, class, gender, and other discrimination or oppression. If a client, therapist, or both are from a group that has experienced historical or ongoing discrimination or oppression, that fact will unavoidably influence the clinical interaction. So, too, being from a dominant or privileged group or class will influence the interac- tion, albeit in different ways.

Another way to think of this issue is to consider that it would be irresponsible to treat a client without some knowl- edge of his or her individual history. That is why one of the first tasks on intake of a new client is to take comprehensive medi- cal, psychological, and social histories. Taking this concept one step higher helps us understand that the individual’s personal history takes place within a larger context that itself has a his- tory. Although each individual’s experience will be unique, that uniqueness nevertheless stands as part of the overall context of society, and having a sense of the overall context can help one interpret how the individual’s experiences developed and what they may mean.

During discussions of this subject, one often hears such statements as “What happened to those people in the past is not my fault, and I can’t change it. We need to get on with what is happening today.” The problem with such statements is their suggestion that it is possible to somehow erase all that has gone before and all that is, in fact, still going on, without dealing with the cognitive, emotional, economic, social, and other effects that the past and present realities have created.

A colleague who teaches multicultural education sug- gests in regard to history that “we do not have to feel guilty for the past, but we must accept responsibility for the present” (R. Hardiman, personal communication, 1994). Her point is that those who feel overwhelmed with sorrow and guilt for what their ancestors did to others, as well as those who would prefer to ignore the past completely, need to find a realistic, construc- tive, and importantly a personal way to deal with the reality of the past within the context of the present. Others (Comas-Diaz, 2000) argue that it is incumbent on helping professionals to take an active role in the political process to help overcome existing racism and to correct the lingering effects of historical racism and prejudice.

Having advised that one must be aware of historical contexts while working with differences, it is unfortunate but true that very few interns or professionals are well informed about the historical treatment of persons from other groups. Most students know little about the histories of struggles for civil rights, women’s rights, gay and lesbian rights, economic justice, or other long-fought battles to achieve fairness and respect for all peoples. If you are interested in learning more about these topics (and I believe that as part of your training you should be interested), I encourage you to immerse yourself in works describing the histories of the vari- ous groups with whom you work and the histories of the struggles

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UNDERSTANDING GENDER Karen Horney, in her profoundly insightful work “The Flight from Womanhood” (originally published in 1927), wrote:

Women have adapted themselves to the wishes of men as if their adaptation were their true nature. That is, they see or saw themselves in the way that their men’s wishes demanded of them . . . If we are clear about the extent to which all our being, thinking, and doing conform to these masculine standards, we can see how difficult it is for the individual man and also for the individual woman really to shake off this mode of thought. (Horney, 1967, p. 57)

Horney’s observations ring true in many ways today, in spite of several decades of feminist thought and activism and in spite of our society’s belief that it has become somehow more liberated than in the past. Indeed, as Luepnitz (2002) argued with compel- ling evidence, many of our current therapy models are themselves based on and perpetuate gender-biased and sexist assumptions.

Just as it is important for clinicians to be aware of and purposeful in dealing with other areas of difference, so it is with gender differences. In countless ways that most of us take for granted, the existential worlds of men and women in our soci- ety are markedly different, and these differences have significant implications for all aspects of clinical training and work.

A male student described how he suddenly gained new insights into some of these issues as a result of a difficult interac- tion with his girlfriend:

We were having a discussion about a sexual assault on campus, and I made some offhand comment that I thought was funny. All of a sud- den my girlfriend started yelling at me with an anger I had never seen before. I had no idea at all what was going on or what I had done. Eventually after a few hours of talking, and me actually listening for a change, I realized how little I really knew about things. It had never really dawned on me that I take for granted things that women just can’t do safely in our world. Something as simple as walking home from class is nothing to me but it can be a terror for a woman. I’d never even thought of that before. Really, never thought of it. Then I realized how much else I hadn’t thought about before either, and I realized I’ve got some work, no, a lot of work to do.

Much of the emphasis on awareness of gender issues has grown out of feminist psychology and the psychology of women. For a comprehensive review of the history, recent thought and research, and multicultural aspects of this field, see Denmark and Paludi (2008). For a discussion of gender issues in supervision, see Heru, Strong, Price, and Recupero (2006) and Walker, Ladany, and Pate-Carolan (2007).

Although the example of the male student learning difficult lessons revealed how little he knew of the experiences of women, it is important to recognize that, as Horney observed, women may not have considered these issues either. Thus, it is not just men who need to study the literature on the psychology of women; women need to as well. The same holds true of the need for men and women to study the psychology of men. Useful resources for gaining insights into male gender issues as they relate to clinical work include the journal Psychology of Men and Masculinity and Englar-Carlson and Stevens (2006).

As a professional, one learns to understand the world differ- ently and more precisely than one may have before. In the case of discussions about race, it is important for you to understand the imprecision of the term race, and to appreciate how its social applications in the past influenced people’s lives and, for that matter, professional practice. To avoid repeating the conceptual and practical mistakes and the social consequences that have accompanied the uncritical use of the term race, let me encourage you to avoid racial distinctions and refer instead to differences in ethnicity, culture, or background. This does not mean that you do not talk about physical features such as skin color and the impact they have on individuals within our society. It does mean that those features are not used as if they describe a “racial” difference that has some specific innate significance or scientific meaning.

EXERCISE: OBSERVING YOURSELF DEALING WITH DIVERSITY AT YOUR INTERNSHIP

This is a challenging exercise because it asks you to go beyond the theoretical, intellectual understanding of diversity issues and look for subtle ways you might be adjusting or failing to adjust your behavior on a daily basis at your internship. During the next few days at your placement site, take a mental inventory of the people who are there, including not only clients but also staff at all levels. Then ask yourself honestly how your approach, behavior, impressions, cognitions, and emotional reactions to some of these people may be impacted by differences between yourself and them in terms of the issues we have been discussing. For example, are you more frightened, friendly, open, or intimidated with some clients or staff than with others? Do you have certain cognitions or formulate attributions about some people’s behavior because of their skin color, language, or education? Now ask yourself the reverse questions. Do you think clients, other interns, or staff may be reacting to you differently because of diversity issues? Finally, and perhaps most difficult of all, take time to speak with some of the aforementioned people (e.g., selected clients, staff, or peers) and ask them the same questions, requesting that they be as open and honest as possible.

STRENGTHS MUST BE RECOGNIZED ALONG WITH PROBLEMS Much of the literature on multicultural counseling has focused largely on issues of injustice and inequality among groups. As has been emphasized, it is essential for interns to understand these issues, consider them in their clinical work, and work to influence them in society. At the same time, however, it is just as important to recognize that stereotypical images may prevent us from seeing beyond repression to understand and appreciate the cultural rich- ness and heritage of different groups.

It is not uncommon for interns to have at least some sense of the disadvantages faced by other groups but little or no aware- ness of the personal and cultural strengths of others. The roles of family, religion, school, art, and music may be very different for members of different groups and may be great sources of strength and pride that an intern may be unaware of. Understanding these and other institutions and traditions can help us appreciate our clients’ experiences and can provide invaluable resources to help clients deal with their presenting difficulties.

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EXERCISE

In light of the four possible conditions identified by Sue and Sue and some of the cultural differences that have been described, select one or two of your preferred therapy models or tech- niques and consider how these might conflict with the values or traditional practices of people from other cultures. How might the goals you take for granted in therapy conflict with the cultural values of someone from a different background? If possible, after thinking about this for yourself, discuss the matter with some- one from a different culture to learn about his or her impressions and ideas.

Two of the difficult questions raised by an awareness of diversity issues are these: “How can one possibly know every- thing there is to know to work with people from different cultural backgrounds?” “What is more, how can helping professionals make therapeutic use of the self as a tool in therapy when the self of the client has been influenced by so many cultural factors the therapist has not experienced?”

These questions take on added significance when one approaches them from the perspective of evidence-based practice or empirically supported treatments. D’Andrea and Heckman (2008) conducted a comprehensive review of multicultural coun- seling outcome research in the past 40 years. Their review identi- fied some 211 studies that involved culture and outcome studies, but only 53 of these met more strict criteria for relevance. As the authors pointed out, the positive news is that the numbers of such studies have been increasing in recent years, but when one con- siders the multitude of multicultural groups and issues, plus the diversity of presenting clinical problems and possible intervention approaches, it is clear that relatively minimal empirical evidence is available to guide specific interventions with specific client groups.

How does one proceed while recognizing both the complex- ity of the issues and the limitations to the research data from which to guide interventions? There is no easy answer to this question, but several suggestions can provide useful guidance. Hansen et al. (2006) studied the degree to which the actual activities of practitioners corresponded to the values they reported regarding multicultural psychotherapy. Their results showed that almost all therapists reported that they often or very often engaged in efforts to respect the client’s worldview, tried to be aware of their own personal and social biases, sought to establish rapport in “racially/ ethnically sensitive ways,” and considered the impact of race/ ethnicity in diagnoses. On the other hand, 42% of the sample of psychotherapists had not implemented a professional develop- ment plan to enhance their competence in multicultural issues, 39% rarely or never sought culture-based case consultations, and 27% said they rarely or never referred clients to providers who were more qualified. More broadly, Hansen et al. reported that for 86% of the items that they identified as being recommended multicultural competencies, their respondents “did not always practice what they believed to be important” (p. 69).

Responding to these findings, Hansen et al. emphasized that it is not enough to simply study issues in the abstract; one must have a concrete plan for applying what one has studied and be diligent in that application. Hansen et al. suggested the use of

EXERCISE: DISCUSSING GENDER DIFFERENCES WITH PEERS

Take some time to have a discussion with your peers, and ask them to tell you how they think their world experience, from childhood up to the present day, has been influenced by and is different because of gender. Then, reverse roles and think about the same question from your own perspective. Next, build on this discussion to explore how the experience of men and women may differ in the role of therapist or client Finally, ask yourself how much study and reading you have done on this subject, particularly in areas that are beyond your traditional comfort zone.

DEVELOPING CULTURALLY SENSITIVE AND RELEVANT SKILLS

As if it were not enough to challenge students to better understand their own backgrounds and those of others, we must now confront another difficult reality: Many fundamental principles that under- lie the leading techniques of treatment and assessment are anti- thetic to the values and practices of people from different cultures (Gielen et al., 2008).

The structure of the typical therapy interaction is, if one thinks about it, a rather strange arrangement. Two or more indi- viduals who have not formerly known one another get together and talk about the most intimate details of the life of one of them. The strangeness is compounded by the assumption that part of the purpose of the interaction is to help one of the people become aware of, understand, and modify things that are not even acces- sible to that person’s own consciousness. Strangeness can be transformed into harmfulness when the assumptions of a therapy model imply that an oppressed person’s problems are the sole result of intrapsychic processes, with no attention to the social pressures and challenges the person faces (Priest, 1991).

Pedersen (1987) listed 10 common assumptions reflecting cultural bias in counseling, including assumptions about what constitutes normal behavior, the emphasis on individualism and independence, neglect of support systems, linear thinking, neglect of history, and a focus on changing individuals rather than systems.

Sue and Sue (1990) identified comparable issues, noting that even fundamental assumptions about counseling, such as verbal and emotional expressiveness, the value of insight, cause-and- effect orientations, and the process of communication itself, may differ across cultures. Sue and Sue also addressed the possibility that not only the techniques of counseling but also the goals may not be compatible across cultures. They delineated four condi- tions that may apply to culturally different clients.

The ideal situation, according to Sue and Sue, is one in which the therapist uses culturally appropriate treatment processes to help the client achieve culturally appropriate treatment goals. In contrast to this condition are situations in which processes are culturally appropriate but the therapy goals are not; situations in which the goals are culturally appropriate but the processes are not; and finally, but all too commonly, situations in which neither the goals nor the therapy processes are culturally appropriate.

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statement of purpose, actively recruiting and retraining students and faculty from diverse populations, reviewing course content for multicultural infusion, and annual evaluations of student cul- tural competence. Other authors, such as Resnick (2006), have described efforts to infuse multicultural awareness and skills in counseling centers and other applied settings. Ponterotto, Mendelowitz, and Collabolletta (2008) promoted the concept of a “multicultural personality” and offered recommendations on how this can be incorporated as an integral part of counselor education.

Beyond academic and clinical settings, I believe that mem- bers of the helping professions also have a unique role to play in contributing to broader social awareness and change. The issue of community and political involvement is addressed in more detail in Chapter 11, but for the present let me emphasize that multicul- tural awareness does not simply involve studying historical issues of discrimination or injustices. Those issues continue to be real and present today, and they continue to impact the lives of our clients as well as our own. Contributing your professional skills and insights along with your time and effort can help bring about these changes today and for the future.

REFERENCES

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Arredondo, P., Tovar-Blank, Z. G., & Parham, T. A. (2008). Challenges and promises of becoming a culturally competent counselor in a sociopolitical era of change and empowerment (Expanding cul- tural considerations). Journal of Counseling and Development, 86, 261–268.

Arredondo, P., & Perez, P. (2006). Historical perspectives on the mul- ticultural guidelines and contemporary applications. Professional Psychology: Research and Practice, 37, 1–5.

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their research checklist as a means of self-assessment for prac- titioners to evaluate the degree to which their personal practices correspond to recommended competencies. Roysircar (2004) also offered a self-appraisal checklist combined with group and individual activities to enhance awareness of and competence in dealing with cultural issues. Other considerations have been recommended by La Roche and Maxie (2003), who identified 10 suggestions for addressing cultural differences in psychotherapy.

The take-away messages from all these sources are that dealing with cultural diversity is best approached as an aware- ness and a process of problem solving rather than a formula to be memorized and applied automatically. Central to this process are many of the factors that have been discussed in this chapter. These include awareness of one’s own background and biases, awareness and understanding of the backgrounds of other indi- viduals and cultures, appreciation of the current context in which different people and peoples live, sensitivity to traditional healing models within other cultures and how those models may conflict with or complement more Western-based interventions, and a preparedness to address cultural and other differences as part of the treatment process itself.

Like all areas of professional development and practice, mul- ticultural competence is not something one simply acquires and then maintains for life. Rather, it is an ongoing process requiring continued study, training, assessment, and supervision. In recent years, numerous books, special issues of journals, and individual articles have been written about working with clients from dif- ferent populations. In addition, a number of journals focus spe- cifically on diverse populations. Examples include the Journal of Multicultural Counseling and Development, Journal of Black Psychology, International Journal of Intercultural Relations, Journal of Gay and Lesbian Social Services, and Journal of Multicultural Social Work. I strongly encourage you to consult these resources as a regular part of your professional study and to seek out specific opportunities for training workshops and for supervision as part of your internship and your future professional practice.

CULTURAL AND ORGANIZATIONAL CHANGE

The final element of multicultural competence involves work- ing within one’s organizational setting and beyond to bring about greater sensitivity to diversity issues. This task is not always easy, and it requires sustained effort.

Tori and Ducker (2004) described a multiyear initiative to enhance inclusion of multicultural issues and training in a gradu- ate training program. Elements of this effort included outreach to increase minority representation among all campus groups, specific training for faculty in faculty meetings and through con- tinuing education, and requiring students to take courses and participate in experiential activities to increase their intercultural awareness.

Comparable initiatives were undertaken by Fouad (2006), who identified seven critical elements for a “multiculturally infused curriculum.” These elements include making an explicit

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