Multicultural%20Theories%20of%20Psychotherapies

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Multicultural Theories of Psychotherapies

• Slides created by
• Barbara A. Cubic, Ph.D.Professor
• Eastern Virginia Medical School
• To accompany
• Current Psychotherapies 10

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Learning Objectives

• This presentation will focus on
• Overview of multicultural issues related to
  psychotherapies
• History of multicultural approaches
• Ways to integrate multicultural issues into
  therapies
• Research on multiculturalism

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Are Prevailing Therapies Relevant to the
Culturally Diverse?

• Most therapeutic orientations recognize
  individual differences must be respected.
• However, dominant models of psychotherapy tend to
  be grounded in a monocultural perspective.
• As such, they support mainstream cultural values
  that neglect multicultural worldviews.

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Dominant Models of Psychotherapy

• May unintentionally promote ethnocentrism.
• The belief that ones worldview is inherently
  superior and desirable to others.

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Terminology

• Culture is defined as an individuals total
  environment.
• Worldview refers to peoples systemized ideas and
  beliefs about the universe.
• Multicultural refers to the interaction between
  people across a culture.

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Multicultural Psychotherapies

• Promote cultural sensitivity.
• Awareness, respect, and appreciation for cultural
  diversity.
• Believe definitions of health, illness, healing,
  normality, and abnormality are culturally
  embedded.
• Promote empowerment and social justice and affirm
  strengths.

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Multicultural Psychotherapies
Consider power differentials based on

• Race
• Gender
• Social class
• Sexual orientation
• Age
• Religion

• National origin
• Ability/disability
• Language
• Place of residence
• Ideology
• Membership in other marginalized groups

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Unity through diversity is a multicultural maxim.
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Basic Concepts
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Multiculturalism

• Acknowledges the presence of diverse worldviews.
• Views each culture as unique and dynamic, to be
  understood within its own context.
• Embodies cultural constructionism.
• A process whereby individuals construct their
  world through social processes that contain
  cultural symbols and metaphors.

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Worldviews

• Harry Triandis (1995)
• Classified worldviews according to how
  individuals define themselves and relate to
  others across an individualist-collective
  spectrum.
• Collectivistic Identity is associated with
  relationships to others.
• Denominated View themselves independently from
  others.

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Multicultural Psychotherapists

• Work towards cultural competence, an individual.
• Becomes aware of their worldview.
• Examines their attitude towards cultural
  differences.
• Learns about different worldviews.
• Develops multicultural skills.
• Learns about ones position in relation to
  societal power and privilege.

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Multicultural Guidelines

• Guidelines for Providers of Psychological
  Services to Ethnic, Linguistic, and Culturally
  Diverse Clients
• Exhorted practitioners to
• Recognize cultural diversity.
• Understand central role culture, ethnicity, and
  race play in culturally diverse individuals.
• Appreciate the significant impact of
  socioeconomic and political factors on mental
  health.
• Help clients understand their cultural
  identification.

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Multicultural Guidelines

• Guidelines on Multicultural Education, Training,
  Research, Practice, and Organizational Change
• We are cultural beings.
• Value cultural sensitivity and awareness.
• Use multicultural constructs in education.
• Conduct culture-centered and ethical
  psychological research with culturally diverse
  individuals.
• Use culturally appropriate skills.
• Implement organizational change process.

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Cultural Competence is a Lifelong Process

• Cross and colleagues (1989) identified a cultural
  spectrum from
• Destructiveness
• Incapability
• Blindness
• Pre-competence
• Competence

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Cultural Competence is a Lifelong Process
Destructiveness Incapability Blindness Pr
e-competence Competence  
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Destructiveness

• Attitudes, policies, and practices are
  destructive to cultures and individuals.

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Incapacity

• Racial superiority of the dominant group.
• Cultural blindness Belief that culture makes no
  difference.

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Blindness

• Individuals believe that culture makes no
  difference.
• The values of the dominant culture are
  universally applicable and beneficial.

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Cultural Pre-Competence

• Do not know exactly how to proceed.

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Cultural Competence

• Possessing a set of knowledge, behaviors,
  attitudes, skills, and policies needed to work
  effectively in multicultural situations.

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Cultural Competence Guidelines for Organizations

• Therapists should
• Evaluate institutions mission statement to
  include diversity.
• Assess diversity policies.
• Evaluate how people of color perceive specific
  policies.
• Acknowledge within group diversity.
• Be aware that diversity requires examination.
• Recognize that multicultural sensitivity may mean
  advocating.

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Multicultural Practitioners Can Help
Organizations Achieve Cultural Competence

1. Include community representation and input at all
   stages of implementation.
2. Integrate all organizational systems.
3. Ensure changes made are manageable, measurable,
   and sustainable.
4. Make the business case for cultural competency
   polices.
5. Require commitment from leadership.
6. Help establish staff training on an ongoing basis.

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Empowerment

• Racial micro-aggressions refer to assaults
  individuals experience because of race, color,
  and ethnicity.
• Cultural trauma refers to a legacy of adversity,
  pain, and suffering among many minority group
  members.
• Research has identified a human tendency to
  categorize individuals into in- and out-group
  members leading to unconscious biases.

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Empowerment Multicultural Psychotherapists
Subscribe To

1. Reality is constructed into a context.
2. Experience is valuable knowledge.
3. Learning/healing results from sharing multiple
   perspectives.
4. Learning/healing is anchored in meaningful and
   relevant contexts.

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Empowerment

• Emphasis on empowerment frequently leads
  psychotherapists to commit to social justice.
• Psychotherapy will be unsuccessful if clients
  feel that their therapist is unconsciously
  racist, ethnocentric, sexist, elitist,
  xenophobic, homophobic, etc.

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Multicultural Psychotherapies Underlying
Assumptions

• Culture is complex and dynamic.
• Every encounter is multicultural.
• Reality is constructed and embedded in context.

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Western Worldviews Dominanceof Mainstream
Psychotherapy

• Multicultural psychotherapies are relevant to all
  individuals.
• Cultural competence is crucial for effective
  psychotherapy.
• Multicultural psychotherapists engage in
  self-awareness.
• Healing
• Empowers individuals and groups.
• Involves multiple perspectives.
• Holistic and liberatory.

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Comparing Multicultural Approaches to Other
Therapy Systems
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Impact of Culture on Treatment Outcomes

• In contrast to European-Americans, African
  Americans
• Tend to drop out of CBT at a higher rate.
• Found treatment less positive after receiving
  services even when they expressed positive
  expectations initially.

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Culture Affects Psychotherapeutic Process

• Cultures impact is greater on therapy process
  than outcome.
• Personal/collective history is important in
  people of colors lives.
• Transcultural psychiatry and psychology advocate
  for the use of community/indigenous resources.
• Minority empowerment movements further the
  development of multicultural psychotherapies.

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History of Multicultural Psychotherapies
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Multicultural Psychotherapies Interdisciplinary
Origins

• Early theoretical influences include
• Psychological anthropology
• Ethnopsychology
• Cultural anthropology
• Psychoanalytic anthropology
• Folk healing

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Evidenced Based Practices (EBP)

• EBP appear effective for a number of culturally
  diverse populations.

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Paulo Freire (1973)

• Identified dominant models of education as
  instruments of oppression.
• Conscientization Critical consciousness as a
  process of person and social liberation.
• Involves questions of What? Why? How? For whom?
  Against whom? By whom? In favor of whom? In favor
  of what? To what end?
• Helps oppressed individuals to author their own
  reality.

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 Types of Therapy/Counseling Re-evaluation
Counseling (RC)

• An empowering co-counseling approach where two or
  more individuals take turns listening to each
  other without interruption.
• Counselor encourages the client to discharge
  emotions (catharsis).
• Next, client becomes the counselor and
  listens.

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Types of Therapy/CounselingFeminist Therapy

• Attempts to empower all people and promote
  equality at individual, interpersonal,
  institutional, national, and international
  levels.
• Women of Color feminist therapists address the
  interactions between racism, sexism, classism,
  heterosexism, ethnocentrism, ableism, and other
  forms of oppression.

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Types of Therapy/CounselingEthnic Family Therapy

• Know their own culture.
• Avoid ethnocentric attitudes and behaviors.
• Achieve an insider status.
• Use intermediaries.
• Have selective disclosure.
• Often use cultural genograms.

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Current Status of Multicultural Psychotherapies
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Current Status Three Models

• Multicultural psychotherapists practice following
  three models (or a combination thereof).
• Cultural adaptation of dominant psychotherapy

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Current Status Three Models

• Ethnic psychotherapies
• Integrates cultural variables in treatment
  through the examination of worldviews, cultural
  transitions, relationships and context.
• Based on a philosophical spiritual foundation
  that promotes connective, ancestral and sacred
  affiliations in healing.

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Current Status Three Models

• Ethnic psychotherapies (continued)
• Include approaches based on Eastern philosophical
  traditions and narratives as a collectivistic way
  of relating.
• Testimonio Chronicles traumatic experiences in
  Latin America.
• Cuento therapy Empirically proven to be an
  effective treatment for Puerto Rican children.
• Dichos (sayings) Form of flash psychotherapy
  that consists of Spanish proverbs or idiomatic
  expressions capturing folk wisdom.

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Current Status Three Models

• Holistic approaches
• Folk healing is form of indigenous psychotherapy.
• Fosters empowerment, encourages liberation, and
  promotes spiritual development.

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Current Status

• Several professional and academic organizations
  have supported the development of multicultural
  psychotherapies.
• Publications on the topic include
• Cultural Diversity and Ethnic Minority Psychology
• Journal of Multicultural Counseling and
  Development
• Psychology of Women Quarterly
• Women and Therapy

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8 Cultural Dimensions
Bernal, Bonilla and Bellido Eight Cultural Dimensions
Language Fits clients worldview. Persons Therapeutic relationship. Metaphors Shared concepts of a cultural group. Content Therapists cultural knowledge. Concepts Treatment concepts culturally consonant with clients context. Goals Objectives congruent with clients adaptive cultural values. Method Cultural adaptation and validation of methods and instruments. Context Clients environment, including history and sociopolitical circumstances. Language Fits clients worldview. Persons Therapeutic relationship. Metaphors Shared concepts of a cultural group. Content Therapists cultural knowledge. Concepts Treatment concepts culturally consonant with clients context. Goals Objectives congruent with clients adaptive cultural values. Method Cultural adaptation and validation of methods and instruments. Context Clients environment, including history and sociopolitical circumstances.
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Ricardo Munozs Suggestions for Culturally
Adapting CBT

• Involvement of culturally diverse people in the
  development of interventions.
• Inclusion of collectivisitic values.
• Attention to religion/spirituality.
• Relevance of acculturation.
• Acknowledgement of the effects of oppression.

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Pamela Hays (2001) Framework
A Age
D Developmental
D Disabilities (acquired)
R Religion
E Ethnicity
S Socioeconomic status
S Sexual orientation
I Indigenous heritage
N National origin
G Gender
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Culturally Sensitive Psychotherapy (CSP)

• Targets specific ethnocultural groups.
• A group may benefit from a specific intervention
  more than from interventions designed for others.

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APA Multicultural Guidelines No. 5

• Encourages psychologists to strive to learn about
  non-Western healing traditions and to acknowledge
  and enlist the assistance of recognized helpers
  and traditional healers in treatment.

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Other Approaches

• Carolyn Attneaves Network Therapy
• Community-based approach.
• Recreates the social context clans network to
  mobilize a persons family and social support.
• Ignacio Martin-Baros Psychology of Liberation
• Collaborative approach focused on assisting
  oppressed clients in developing critical analysis
  and engaging in transformative actions.
• Resonates with African-American psychology as it
  is based on Black liberation theology and
  Africanist traditions.

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Theory of Personality
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Multicultural Clinicians Adhere to Diverse
Theories of Personality

• A unique contribution of multicultural
  psychotherapy is the formulation of cultural
  identity development theories.
• View the self as an internal representation of
  culture.
• Ethnic and racial identity stage affects beliefs,
  emotions, behaviors, attitudes, expectations, and
  interpersonal style.

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Diverse Models of Identity Development Propose
Members of Groups Move Through Stages
Value Dominant Group/De-Value Own Group Value
Own Group/De-Value Dominant Group Integrate
Appreciation for Multiple Groups
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Ethnic Minority Groups (Atkinson, Morten Sue,
1998)

• Conformity
• Internalize racism.
• Choose dominant groups values, lifestyles, role
  models.
• Dissonance
• Question and suspect dominant groups values.
• Resistance-immersion
• Endorse minority-held values, reject dominant
  cultures values.

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Ethnic Minority Groups (Atkinson, Morten Sue,
1998)

• Introspection
• Establish their own racial ethnic identity.
• Synergistic
• Experience self-fulfillment without categorically
  accepting minority values.

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White American Groups (Helms, 1990)

• Contact
• Individuals are aware of minorities, but do not
  perceive themselves as racial beings.
• Disintegration
• Acknowledge prejudice and discrimination.
• Reintegration
• Engage in blaming the victim and in reverse
  discrimination.

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White American Groups (Helms, 1990)

• Pseudoindependence
• Become interested in understanding cultural
  differences.
• Autonomy
• Accept, respect, and appreciate both minority and
  majority group members.

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Model of Bi-Racial Identity Formation (Poston,
1990)

• Personal identity
• Choice of group categorization
• Enmeshment or denial
• Appreciation
• Integration

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Gay and Lesbian Groups (Cass, 2002)

• Confusion
• Questions their sexual orientation.
• Comparison
• Accepts possibility that they may be a sexual
  minority.
• Tolerance
• Recognition that one is gay or lesbian.

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Gay and Lesbian Groups (Cass, 2002)

• Acceptance
• Increases contact with other gays and lesbians.
• Pride
• Prefer to be gay or lesbian.
• Synthesis
• People find peace with their own sexual
  orientation.

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Feministic Identity (Downing Rush, 1985)

• Passive/acceptance
• Revelations
• Embeddedness/emanation
• Synthesis
• Active commitment

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The Psychotherapy Process
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No Unifying Theory of Psychotherapy

• Focus is on how the therapist can understand the
  life of a culturally different client.
• Therapeutic alliance requires cultural congruence
  between clients and therapists worldviews.
• To begin moving towards cultural self-awareness,
  the therapist identifies the dominant cultures
  values in which they communicate and practice.

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Bennets (2004) Multicultural Sensitivity
Development Model

• The ethnocentric stages
• Denial Deny existence of cultural differences,
  avoid culturally diverse people.
• Defense Recognize other cultures but denigrate
  them.
• Minimization View own culture as universal.

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Bennets (2004) Multicultural Sensitivity
Development Model

• The ethnorelative stages
• Acceptance Recognize and value cultural
  differences.
• Adaptation Develop multicultural skills.
• Integration Sense of self expands to include
  diverse worldviews.

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Multiculturalism and Therapy

• Atkinson, Thompson and Grant (1993) asserted
  that
• Low acculturated clients expect therapists to
  behave as advisor, advocate, and or facilitator
  of indigenous support systems.
• More acculturated clients may expect their
  clinician to act as a consultant, change agent,
  counselor and or psychotherapist.

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Multiculturalism and Therapy

• Besides acculturation, clients expectations are
  shaped by interpersonal needs, developmental
  stages, ethnic identity, spirituality, and other
  factors.
• Most dominant psychotherapists ignore
  transferential cultural issues.
• Multicultural psychotherapists examine it through
  a dialogue on cultural differences and
  similarities.

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Cultural Empathy

• Empathy is an interpersonal concept referring to
  a clinicians capacity to attend to the emotional
  experience of clients.
• Somatic aspect of empathy refers to non-verbal
  communication and body language.
• Cognitive aspect of empathy occurs by becoming an
  empathic witness.

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Cultural Empathy

• Affective component involves emotional
  connectedness.
• Development of affective empathy is critical in
  multicultural psychotherapy.
• Learned ability to obtain understanding of the
  experience of culturally diverse individuals
  informed by cultural knowledge and interpretation.

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Cultural Empathy

• Cultural empathy is the ability to place self in
  the others culture and is developed through
  self-reflection.
• Therapy promulgates the projection of conscious
  and/or unconscious messages about the client and
  therapists cultures.
• Clients of color expect psychotherapists to
  demonstrate cultural credibility.

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Comas-Diaz Jacobsen (1991)

• Intra-ethnic transference may transform the
  therapist into one of several roles
• Omniscient/omnipotent therapist
• Traitor
• Auto-racist
• Ambivalent

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Comas-Diaz Jacobsen (1991)

• Inter-ethnic transferential reactions may lead
  the patient to
• Overcompliance and friendliness.
• Denial.
• Mistrust, suspiciousness and hostility.
• Ambivalence.

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Interethnic Dyads Countertransferential Reactions

• Denial of cultural differences
• Clinical anthropologists syndrome
• Excessive curiosity about clients ethnocultural
  backgrounds at the expense of their psychological
  needs.
• Guilt (re societal and political realities)
• Pity
• Aggression
• Ambivalence

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Intraethnic Dyads Countertransferential Reactions

• Us and them mentality
• Shared victimization.
• Cultural myopia
• Inability to see clearly due to ethnocultural
  factors that obscure therapy.
• Distancing
• Survivors guilt
• Overidentification
• Ambivalence
• Anger

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Mechanisms of Psychotherapy
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Mechanisms of Psychotherapy

• Multicultural psychotherapists may
• Use contemplative practices.
• Promote spiritual development
• Foster creativity through use of art, folklore,
  ethnic practices, and other creative cultural
  forms.
• Lead the patient to cultural consciousness.
• Example The affirmation, redemption, and
  celebration of ones ethnicity and culture.

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Ethnopsychopharmacology

• Field that specializes in the relationship
  between ethnicity and responses to medications.
• Ethnocentrism has resulted in culturally diverse
  clients mistrust of psychopharmacology.
• Racial and ethnic groups may respond or use
  medications differently.

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Ethnopsychopharmacology

• African Americans with affective disorders are
  often misdiagnosed and thus mistreated with
  antipsychotic medications.
• Common for Latinos to share medications with
  family members and significant others (due to
  familism), self-medicate and combine medications
  with herbal remedies.
• Diets of some people of color contain foods that
  are incompatible with certain kinds of
  psychotropic medications.

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Applications of Multicultural ism
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Multiculturalism

• Multicultural psychotherapies apply to everyone
  and are particularly helpful when individuals
  present to treatment with identity issues,
  relationship problems, cultural adaptation,
  ethnic and racial stressors, and conflicts of
  diverse nature.

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Multicultural Assessment Explanatory Model

• Explanatory model of distress
• A culture-centered assessment based on an
  anthropological method that elicits a clients
  perspectives of their illness, experience and
  healing.

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Multicultural Assessment Cultural Formulation

• Cultural formulation and analysis
• Process oriented approach that places diagnosis
  in cultural context examining
• Individuals cultural identity.
• Cultural explanations for individual illnesses.
• Cultural factors related to the psychosocial
  environment and levels of functioning.
• Cultural elements of the therapist-client
  relationship.
• Overall cultural assessment of diagnosis and
  treatment.

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Multicultural Assessment Genograms

• Cultural genogram
• Diagram of a genealogical tree highlighting
  dynamics from a nuclear to an extended family
  perspective.
• www.genopro.com/genogram_rules/default.htm

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Multicultural AssessmentGenograms

• Cultural genogram places individuals within their
  communal contexts.
• Uses three or more generations of ancestors.
• Clients invited to use imagination to summon up
  family information (e.g. photos).
• Share the symbols used in family genograms.

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Multicultural AssessmentGenograms

• Important factors might include

• Individual and family culture(s)
• Meaning of race and ethnicity
• Sexual orientation
• Family
• Social class
• Marriage
• Gender roles
• Relations

• Migration
• Refugee experience
• Acculturation
• Stress
• Spirituality and faith
• History and politics
• Trauma (i.e., sexual and gender trauma)
• Meaning of differences

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Ethnocultural Assessment
Explores diverse stages in cultural identity development Explores diverse stages in cultural identity development
Heritage Explores ethnocultural ancestry, history, genetics, and sociopolitical contexts and cultural trauma.
Family saga Entails examining the family, clan and group story.
Niche Attends to the post-transition analysis with special emphasis on clients intellectual and emotional interpretation of family saga.
Self adjustment Cultural resilience assessed during this stage.
Relationships Explores clients significant affiliations, including exploration of the therapist-client relationship.
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Multicultural Assessment

• Multicultural assessments can be complemented
  with a power differential analysis.
• An analysis of the clients cultural groups
  social status compared to the therapist.

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Evidence for Integrating Multicultural Issues
into Therapy

• Karlsson (2005)
• Inconclusive results and low validity for ethnic
  matching.
• Evidence suggests clients working with
  psychotherapists of similar ethnic backgrounds
  and languages tend to remain in treatment longer.
• Ethnic and linguistic match does not necessarily
  translate into mutual cultural identification
  nor is it necessarily desirable for some clients.

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Evidence for Integrating Multicultural Issues
into Therapy

• More research is needed on multicultural
  psychotherapies.
• Multicultural therapists advocate for research
  funding that is applicable to the lives of
  culturally diverse individuals and communities.