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Multicultural Clinical Skills


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Title: Multicultural Clinical Skills

Multicultural Clinical Skills
  • Putting Awareness and Knowledge into Practice

Getting to know each other
  • Introductions
  • Syllabi
  • Grades
  • Pams current updating project for this book and
    how you can help.
  • What have you already learned?
  • What do you want to learn?

My goals for the course
  • In this course you will learn to
  • Understand clients complex identities
  • Establish a respectful relationship rapport
  • Conduct culturally responsive assessment
  • Make a culturally responsive diagnosis
  • Develop and implement culturally responsive
    treatment plans and therapies at both the
    individual and systemic levels

Format of the class
  • Lectures and practice of skills
  • While this is not a personal awareness class,
    awareness often accompanies skill building.
    Please feel free to share new awareness of self
    with the class.
  • I am notoriously less structured than what some
    students need (thus the power points). I work
    hard to maintain a level of structure, while
    allowing for flexibility in learning. Thus at
    times we will move off topic or may extend a
    lecture into the next class. If you find
    yourself having difficulty with this during the
    class, come and speak with me as soon as it is a
    problem so we can work on a plan to ensure your
    learning success.

Todays class Setting the foundation
  • PART 1 Why is there a need for Multicultural
    Competence in the Provision of Mental Health
  • PART 2 Conversations about race and other
    diversity issues and choices you make in these
  • PART 3 Practicing diversity discussions
    (Difficult Dialogues)

PART 1Why is there a need for Multicultural
Competence in the Provision of Mental Health
To respond to current and projected demographic
changes in the U.S.
  • 110 Persons in U.S. is foreign born (U.S.
    Census, 1997)
  • Between 2000-2010 expect 5.5 million more
    Latina/o children, 2.6 million more African
    American children, 1.5 million more children of
    other race/ethnicities and 6.2 million fewer
    white children (Childrens Defense Fund).

To remedy racial/ethnic disparities reported by
the Surgeon General (1999), compared to whites
people of color have
  • Less access to and availability of mental health
  • Are less likely to receive mental health services
  • Often receive poorer quality of care
  • Are underrepresented in mental health research

To reduce disparities in utilization and attrition
  • 50 of racial/ethnic minorities terminate therapy
    after one session compared to a 30 rate for
    white clients (SS, 1990).

To increase relevance of empirically based
treatment guidelines for diverse populations
APA (1994) Practice Guidelines for Treatment of
Bipolar Disorder
  • Randomized trials conducted from 1983-1994
  • 17 studies, 16 patient populations
  • 825 participants
  • 29 non-white
  • 32 black
  • No comparative analyses conducted

APA (1997) Practice Guidelines for Treatment of
  • 25 randomized clinical trials, 1986-1997
  • 2,865 participants
  • 316 non-white
  • 376 African American
  • 40 Hispanic
  • 3 Asian American
  • No comparative analyses

APA (2000) Guidelines for Treatment of Depression
  • 27 randomized clinical trials, 1986-1997
  • 3,980 patients
  • 241 nonwhite
  • 150 African American
  • 2 Asian American
  • One study examined outcomes for African-Americans
  • similar clinical but different functional outcomes

Agency for Healthcare Research Quality (1999)
Evidence-Based Report on Treatment for AD/HD
  • 32 studies, 1988-1999
  • 1,657 children with AD/HD
  • 126 African American
  • 55 Hispanic
  • 2 nonwhite
  • 1 ea. Asian-Am, P.I., East Indian, As.Ind.

NIMH Study Only Study to Include More Than 5
Ethnic/Minority Children
  • 115 African Americans
  • 48 Latinos
  • No conclusions regarding comparative treatment

EVTs (Chambless, et al., 1996)
  • Examining the citations for empirically validated
    therapies identified in the 1995 task force
    report, we find not a single study which included
    tests of the efficacy of the treatment for ethnic
    minority populations. Most investigators did not
    specify ethnicity of subjects or used only white
    subjects. Out of about 41 studies cited, only
    6-7 made any reference to race or ethnicity of
    subjects. No one used ethnicity as a variable of

Barriers to ServiceWhich Impact All Clients
  • Cost
  • Fragmentation of Services
  • Lack of availability
  • Societal stigma

Additional Barriers to Treatment for
Racial/Ethnic Minorities
  • Mistrust and fear of treatment
  • Racism discrimination
  • Contributes to lower economic, social, and
    political status, which affects mental health
  • Differences in language and communication
  • Poor communication between consumers and providers

Disparities Impose a Greater Disability Burden on
  • Less likely to receive services
  • More likely to receive poorer quality care
  • Greater lost work days
  • Over-represented in homeless, incarcerated, and
    institutionalized populations

Heterosexism, Homonegativity, Binegativity in
Psychotherapy (Morrow, 2000, p. 139)
  • Homonegativity may be defined as negative
    cognitions and affect about LG people and
  • Binegativity may be defined as negative
    cognitions and affect about bisexual people and

Harmful/Null Treatment
  • Persistence of sexual re-orientationor
    reparative therapy
  • APA Taskforce on Heterosexual Bias in
    Psychotherapy (1991) identified biased,
    inappropriate, or inadequate practice in
    understanding, assessing, and intervening in a
    wide range of topics identity development,
    lesbian/gay relationships, parenting.

  • DSM II (1968) described homosexuality as mental
    illness in the section on sociopathy crimes
    against society (like substance abuse sexual
  • Dec. 15, 1973 APA removed homosexuality from list
    of mental illnesses
  • Retained ego-dystonic homosexuality
  • DSM III R (1987) eliminated it altogether
  • DSM IV (1999) DSMIV-TR (2000) Gender Identity

  • The silent and passive gay or lesbian who still
    lives in fear, ignorance, and self-hate is not
    only the more common outcome of many
    psychotherapy processes, but is a blatant and
    disturbing results of mistreatment by the
    therapist. If psychotherapy with gays and
    lesbians is truly successful, the outcome will be
    numerous individuals who no longer attempt to
    conform to a heterosexual world, but who will
    instead creatively seek the enhancement of their
    own identities (McHenry Johnson, 1993, p. 150).

Are You Able to Provide LGB-Affirmative Therapy?
Review of Key Concepts
Multiculturalism is about social justice,
cultural democracy, and equity.
Multiculturalism is about helping all of us to
acquire the attitudes, knowledge, and skills
needed to function effectively in a pluralistic
democratic society.
It is about celebrating realistic achievements of
other cultures and involves a willingness to
explore the positive and negative aspects of our
groups and other groups behaviors.
Is a central component of analytical thinking
challenges us to develop multiple perspectives.
Respects and values other perspectives, but it is
not value neutral. It involves an activist
orientation and commitment to social change.
It means change at the individual,
organizational, and societal level.
Multiculturalism is about achieving valuable
individual, community, and societal outcomes
because it values inclusion, cooperation, and
movement towards mutually shared goals. (Sue,
et al., 1998, pp. 5-6)
Eurocentric Monoculturalism
  • Belief in Superiority
  • Belief in Inferiority of Others
  • Power to Impose Standards
  • Manifestation in Institutions

A biological classification system determined
by physical characteristics. It is also a social
construction. Within-group differences are
greater then between-group differences.
Has no biological foundation. Refers to a
groups of people who share a unique social and
cultural heritage. Multiple racial groups can be
found within one ethnicity or different
ethnicities can be found in one racial group.
Includes cultural norms and values, can vary in
strength, salience, and meaning for individuals,
and may be associated with minority status.
Set of learned behaviors and attitudes (e.g.,
customs and beliefs) that are shared and
transmitted by group members.
A preconceived judgment or opinion without
sufficient justification or sufficient knowledge
(Axelson, 1985).
  • Simplified generalized labeling of certain people
    or social groups. Stereotypes are resistant to
    change and bias perceptions. Prejudiced people
    commonly stereotype, but you can stereotype
    without prejudice (Ridley, 1989, p. 59).

Unearned assets (McIntosh, July/August, 1989,

The imposition of constraints
one group actively subordinating another to
forward its own interests (Jaggar, 1983, p. 6).

Any behavior or pattern that systematically tends
to deny access to opportunity or privilege to one
social group while perpetuating privilege to
members of another group (Ridley, 1989, p, 60).
System of advantage based on race (Welman, 1977,
ch 1).
White Privilege
(McIntosh, July/August, 1988, 1-13)
I have come to see white privilege as an
invisible package on unearned assets, which I can
count on cashing in each day, but about which I
was intended to remain oblivious. The pressure
to avoid it is great, for in facing it I must
give up the myth of meritocracy. Some privileges
make me feel at home in the world. I can
measure up to the cultural standards and take
advantage of the many options I see around me
to make what the culture would call a success of
my life. 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 Moreover, though
privilege may confer power, it does not confer
moral strength.
White Privilege(Neville, Worthington,
Spanierman, 2001)
  • Differentially benefits Whites.
  • Systemic and individual benefits
  • Consists of unearned advantages
  • Offers immunity to selected social ills
  • Embodies an expression of power
  • Is largely invisible unacknowledged
  • Contains costs to Whites

Other Types of Privilege
  • Heterosexual
  • Class
  • (Temporarily) Able-Bodied
  • Gender
  • Age
  • Another?

Multicultural Clinical Counseling Competencies
Multicultural Counseling Psychotherapy
  • Both a helping role and 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, in press, as cited by Sue
    Sue, 2003, p. 16).

  • Metatheoretical Approach

Recognizes that therapies arise from a
particular cultural context.
Applies to multicultural interactions.
Recognizes the use of western and non-western
approaches to helping.
Characterized by a therapists culturally
appropriate awareness, knowledge, skills.
Multicultural Awareness
  • Awareness of ones own
  • Culture
  • Worldview
  • Values
  • Prejudice
  • Privilege
  • Oppression

Multicultural Knowledge
  • Mental Health in Communities of Color
  • Group Characteristics
  • Psychological Assessment Research Standards
  • Within-Group Differences
  • Racial Identity
  • Class
  • Acculturation

Multicultural Skills
  • Assessment
  • Diagnosis
  • Case Conceptualization
  • Treatment Planning
  • Goal Setting
  • Interventions Techniques
  • Case Management
  • Supervision

Context for Adaptive Learning
  • Fear
  • Hope
  • Values
  • Professional Ethics
  • Commitment

Key is Openness to Experience
Proactive seeking and appreciation of experience
for its own sake as well as toleration for and
exploration of the unfamiliar (Leong Bhagwat,
2001, p. 256).
Openness to experience is a critical dimension
for a counselors ability to deal with the
complexity of race, gender, and class as salient
variables in the counseling relationship (p.
  • Conversations about race and other diversity

What have you already learned.
  • About conversations concerning race when a person
    from majority culture and person from minority
    culture are involved?
  • Does context change this?
  • What changes when you enter into a group setting?
  • What might be the minority culture persons
  • What might be the majority culture persons

Three important conversations
  • As a therapist you will often enter into three
    different roles
  • As a student or client
  • As a therapist or supervisor
  • As a peer
  • What is the difference in power in these three
  • What effects your power in these three roles?
  • Can you judge a persons behavior as a therapist
    by their interactions as a student in a

How do you imagine the experience of
  • A minority student in a class will differ from
  • A majority student in a class
  • A minority person as a therapist
  • A majority person as a therapist
  • Both as peers.
  • Why are these different?

Lets Discuss Cultural Communication Differences
  • 1) Emotional expression
  • Anger
  • Crying
  • Vulnerability
  • 2) Definitions
  • Integrity
  • Maturity
  • 3) Dominant rules
  • Making space

Integrated Identities and Power
  • We all have several identities, which you began
    to look at last quarter. Some of these
    identities carry majority power and others
    receive oppression. For example here are my
  • Who has more power? An African-American,
    middle-class, woman in a wheelchair who is a
    psychologist or a Euro-American, poor,
    unemployed, able-bodied man? Why?

  • Practicing Difficult Discussions

How does choice play into this?
  • Do you want to be able to choose your actions or
    react to others automatically?
  • If you want to choose your actions, then
    depending on the power dynamics, you have
    choices. In order to choose, you have to know
    your choices.

If you choose not to be reactive
  • What are some of the choices?
  • How you will handle your feelings
  • If you will open or close the dialogue
  • What cultural norms will you use to interpret the
    others behavior?
  • What cultural norms you will engage in?
  • For Minorities
  • Communicating in the dominant cultures ways.
  • Do not have to, but may choose to in order to
    meet goals, gain more power for future activism,
    or other reasons. I personally prefer to do this
    with awareness and choice instead of an
    internalized racism. One take the risk of
    feeling like they are selling out, being accused
    of this, and feeling like their soul has to die a
  • Acting from ones own cultures norms. You take
    a risk that you will be misunderstood,
    punished, labeled or lose something.

Lets see if we can come up with other skills.
  • When was the last time you had trouble
    understanding someone that was different from you
    in a conversation?
  • What was the context of the conversation?
  • What emotions or feelings came up for you
    personally? Not thoughts, feelings
  • How did you resolve the conflict?
  • Lets identify some skills and barriers to
    constructive dialogues from your experiences.

Psychology Taught Skills
  • We are all at different places in our growth
    processes and often those of us who believe we
    are furthest along, are often the furthest behind
    (Stage 1 vs. Stage 5 in identity development
    models). So please let go of judgment of
    yourself and others (since there is no way to
    know if your judgments are right) during this
    class and allow each person to simply be where
    they are at in their process. I believe this
    allows people the air to grow (there is always
    room to grow). Letting go of judging the person
    does not mean agreeing with the person. It is ok
    to have a differing perspective and express it in
    a respectful manner. This often works best when
    we first show we have heard and understood the
    other person and find something we can agree with
    that the other person said. After this, people
    tend to be more open to hearing our opinions
    (communication skills).
  • It is also ok to laugh, become upset, be
    confused, or even cry.we all know that no
    experience lasts forever and that we have the ego
    strength to simply experience what ever is in the
    moment without having to act to change that
    feeling (emotional regulation, emotional
    tolerance, being vs doing).

  • Sharing your experience can help promote growth
    in all, as long as it is shared as yours, not as
    caused by anyone else (avoid projection of
    emotional reasoning). When I become emotionally
    triggered, sometimes this can be very hard to do
    (stress leads to regression in the developmental
    level of functioning). What helps in these times
    for me is to fall back on short basic sentences
  • I feel ___________,
  • when _________,
  • because ___________,
  • I need____________.
  • No cheating and saying I feel angry when YOU.

  • Remember basic communication/relational skills
  • No blaming,
  • No labeling,
  • No name calling,
  • No Always or Never,
  • No one is ever all good or all bad,
  • Separate a behavior from a label of the person,
  • No analyzing the other and
  • Remember that communication in the classroom is
    to build relationships and learn/grow together
    not an exercise to prove you are right and the
    other is wrong.

  • Sometimes I will be too triggered (usually my
    defenses come up due to some fear) and forget to
    see the other in front of me, lost in my own
    emotions, ideas, thoughts or attempts to
    protect my sense of self or avoid tough
    emotions (Primary/Mature Defenses). This happens
    to all of us. I recognize this is even more true
    for you in the class since you have less power
    than me and are being evaluated.
  • Thus, have compassion for yourselves and each
    other, and lets all be open to gentle reminders
    when we get defensive.

Practical Skills for shifting your attitude in a
difficult dialogues
  • Ouch!
  • R E S P E C T tell you what it means to me
  • Tell me more
  • Who is the client
  • Listen to the record

Next Class
  • We will review the ADDRESSING Assessment and
    conduct clinical interviews.
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