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Multicultural Theories of Psychotherapies

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Title: Multicultural Theories of Psychotherapies


1
Multicultural Theories of Psychotherapies
  • Slides created by
  • Barbara A. Cubic, Ph.D.Professor
  • Eastern Virginia Medical School
  • To accompany
  • Current Psychotherapies 10

2
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

3
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.

4
Dominant Models of Psychotherapy
  • May unintentionally promote ethnocentrism.
  • The belief that ones worldview is inherently
    superior and desirable to others.

5
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.

6
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.

7
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

8
Unity through diversity is a multicultural maxim.
9
Basic Concepts
10
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.

11
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.

12
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.

13
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.

14
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.

15
Cultural Competence is a Lifelong Process
  • Cross and colleagues (1989) identified a cultural
    spectrum from
  • Destructiveness
  • Incapability
  • Blindness
  • Pre-competence
  • Competence

16
Cultural Competence is a Lifelong Process
Destructiveness Incapability Blindness Pr
e-competence Competence  
17
Destructiveness
  • Attitudes, policies, and practices are
    destructive to cultures and individuals.

18
Incapacity
  • Racial superiority of the dominant group.
  • Cultural blindness Belief that culture makes no
    difference.

19
Blindness
  • Individuals believe that culture makes no
    difference.
  • The values of the dominant culture are
    universally applicable and beneficial.

20
Cultural Pre-Competence
  • Do not know exactly how to proceed.

21
Cultural Competence
  • Possessing a set of knowledge, behaviors,
    attitudes, skills, and policies needed to work
    effectively in multicultural situations.

22
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.

23
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.

24
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.

25
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.

26
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.

27
Multicultural Psychotherapies Underlying
Assumptions
  • Culture is complex and dynamic.
  • Every encounter is multicultural.
  • Reality is constructed and embedded in context.

28
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.

29
Comparing Multicultural Approaches to Other
Therapy Systems
30
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.

31
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.

32
History of Multicultural Psychotherapies
33
Multicultural Psychotherapies Interdisciplinary
Origins
  • Early theoretical influences include
  • Psychological anthropology
  • Ethnopsychology
  • Cultural anthropology
  • Psychoanalytic anthropology
  • Folk healing

34
Evidenced Based Practices (EBP)
  • EBP appear effective for a number of culturally
    diverse populations.

35
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.

36
 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.

37
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.

38
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.

39
Current Status of Multicultural Psychotherapies
40
Current Status Three Models
  • Multicultural psychotherapists practice following
    three models (or a combination thereof).
  • Cultural adaptation of dominant psychotherapy

41
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.

42
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.

43
Current Status Three Models
  • Holistic approaches
  • Folk healing is form of indigenous psychotherapy.
  • Fosters empowerment, encourages liberation, and
    promotes spiritual development.

44
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

45
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.
46
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.

47
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
48
Culturally Sensitive Psychotherapy (CSP)
  • Targets specific ethnocultural groups.
  • A group may benefit from a specific intervention
    more than from interventions designed for others.

49
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.

50
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.

51
Theory of Personality
52
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.

53
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
54
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.

55
Ethnic Minority Groups (Atkinson, Morten Sue,
1998)
  • Introspection
  • Establish their own racial ethnic identity.
  • Synergistic
  • Experience self-fulfillment without categorically
    accepting minority values.

56
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.

57
White American Groups (Helms, 1990)
  • Pseudoindependence
  • Become interested in understanding cultural
    differences.
  • Autonomy
  • Accept, respect, and appreciate both minority and
    majority group members.

58
Model of Bi-Racial Identity Formation (Poston,
1990)
  • Personal identity
  • Choice of group categorization
  • Enmeshment or denial
  • Appreciation
  • Integration

59
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.

60
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.

61
Feministic Identity (Downing Rush, 1985)
  • Passive/acceptance
  • Revelations
  • Embeddedness/emanation
  • Synthesis
  • Active commitment

62
The Psychotherapy Process
63
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.

64
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.

65
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.

66
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.

67
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.

68
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.

69
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.

70
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.

71
Comas-Diaz Jacobsen (1991)
  • Intra-ethnic transference may transform the
    therapist into one of several roles
  • Omniscient/omnipotent therapist
  • Traitor
  • Auto-racist
  • Ambivalent

72
Comas-Diaz Jacobsen (1991)
  • Inter-ethnic transferential reactions may lead
    the patient to
  • Overcompliance and friendliness.
  • Denial.
  • Mistrust, suspiciousness and hostility.
  • Ambivalence.

73
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

74
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

75
Mechanisms of Psychotherapy
76
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.

77
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.

78
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.

79
Applications of Multicultural ism
80
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.

81
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.

82
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.

83
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

84
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.

85
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

86
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.
87
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.

88
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.

89
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.
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