Multiculturalism and the Delivery of Counseling Services

Transcription

1 Multiculturalism and the Delivery of Counseling Services Multiculturalism and the Delivery of Counseling Services Yi-Jung Lee Lunghwa University of Science and Technology Abstract Multiculturalism, in the sense of diversity, factors into the therapist-client relationship as more ethnic minorities are now utilizing the American healthcare system than ever before. The issue of the diverse base of clients and therapists is especially relevant in the delivery of counseling services, as the foundation of psychological treatment rests in the ability of therapists and clients to form open, understanding avenues of communication. This paper analyzes difficulties created by multicultural counseling in the United States. Keywords: delivery of counseling services; ethnic minorities; multicultural counseling; multiculturalism

2 1. Introduction Increasingly, counselors throughout the United States provide treatment for clients whose cultural backgrounds differ from their own. Although counselors are encouraged to be more sensitive to cultural factors in the diagnosis and treatment of mental disorders, little information is provided to help them determine which aspects of culture are important to the mental health of racial-ethnic minorities. Bias is apparent in the attitudes and behaviors of service providers, the service delivery process, psychiatric diagnoses, tests, and interventions (Dana, 2000). Some research suggests that prejudice and racism are currently factors that create a disparity in the effectiveness of treatment for clients from ethnic minorities. For example, psychiatrists and residents who used identical patient data, except for race, found that African American patients were less able to benefit from psychotherapy because they were evaluated as less articulate and less competent, as well as being less introspective, self-critical, and psychologically minded (Geller, 1988). 2. Diagnosis Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) classification to evaluate a client from a different ethnic or cultural group. A therapist unfamiliar with the nuances of a client s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the client s culture (Whaley, 2001). Ideas that may appear to be delusional in one culture may be commonly held in another. In some cultures, visual or auditory hallucinations with a religious content may be a normal part of religious experience - for example, hearing God s voice. In addition, the assessment of disorganized speech may be made difficult by linguistic variation in narrative styles across cultures that affect the logical form of verbal presentation. As a result, treatment requires sensitivity to differences in styles of emotional expression, eye contact, and body language,

3 Multiculturalism and the Delivery of Counseling Services which vary across cultures (Sue & Sue, 1999). Data collected by the National Institute of Mental Health (NIMH, 1980) suggests startling disparities in the types of diagnosis attributed to racial-ethnic minorities. Studies indicate that the diagnosis of schizophrenia is the most frequent diagnosis given to African Americans (Pavkov, Lewis, & Lyons, 1989). This finding has been explained by some in terms of clinicians insensitivity to a potential cultural norm of paranoia in the black population (Whaley, 2001). The cultural norms of black clients and white clinicians relevant to paranoid behaviors are markedly different. Paranoia may serve a self-protective function against racially-based threats to self-esteem for African Americans, but it may be misinterpreted as pathology by clinicians, leading to the misdiagnosis of schizophrenia (Whaley, 2001). This over-diagnosis of schizophrenia in African Americans by white clinicians reflects, in part, a lack of awareness on the part of clinicians of the heightened public self-consciousness associated with a mistrust that is culturally based. 3. Counseling Service Utilization Minorities demonstrate a marked underuse of services and high dropout rates in the U.S. (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). To examine this idea, an important aspect to consider when establishing a treatment s effectiveness is the extent to which it is deemed credible. Treatment credibility refers to whether a client believes that the therapy will be effective in solving his or her problems (Kazdin & Wilcoxon, 1976). Standard mental health interventions, including both psychotherapies and medications, were developed by mainstream Anglo-Americans and were provided essentially without alterations or modifications to clients with culturally and racially diverse origins. Therefore, it can be difficult for racial-ethnic minorities to perceive interventions as credible. Failure to establish credibility at the onset of therapy may result in premature termination, noncompliance with treatment procedures, and poor outcomes.

4 Racism could also account for a lack of perceived credibility in mental health services by minorities. To assess this potential, racism must be more specifically defined. There are three types of racism: individual, cultural, and institutional (Bowser & Hunt, 1996). The individual racist is one who believes that people of another group are inferior to his own due to a difference in ethnic background. The racist individual believes that this difference is indicative of inferior social behavior and moral or intellectual qualities, and ultimately presumes that this inferiority is a legitimate basis for the substandard social treatment of others. Cultural racism is the belief in the inferiority of the implements, handicrafts, economics, religious beliefs, traditions, or language of another culture. Institutional racism consists of those established laws, customs, and practices that systematically reflect and produce racial inequalities in society whether or not the individuals maintaining those practices have racist intentions (Bowser & Hunt, 1996). Minorities may be less likely to take advantage of psychological services due to a perceived notion that therapists may be insensitive to their needs in a culturally specific way. This perception could come from actual interaction between minority clients and their therapists or simply from the historical trend of cultural insensitivity in the United States. Thus, a question regarding the role of culture in psychotherapy and in the field of mental health arises around the practical problem of providing effective mental health services to racial-ethnic minority populations. Research also shows that intelligent, verbal, attractive, and successful individuals tend to benefit the most from psychotherapy (Sue et al., 1991). As a result, ethnic minorities, who often have less access to education and financial resources, could be at a disadvantage in receiving treatment. From racism to socio-economic disadvantages, these explanations can be grouped into two categories based on examples from the relevant literature (Dana, 1998). The first category, cultural factors, consists of training deficiencies among counselors or therapists who do not share a similar cultural background with the client, negative stigmas frequently associated

5 Multiculturalism and the Delivery of Counseling Services with going outside of the community for assistance with personal problems, different or unrealistic treatment expectations, and clinically inappropriate or culturally inconsistent services. The second category, service access barriers, includes those economic, job, and resource factors that preclude racial-ethnic minorities from gaining access to services as often as they may need of desire. 4. Problems in Effective Multicultural Counseling Although within-group differences may sometimes be greater than between-group differences, most of the applicable literature seems to endorse the notion that various racial groups may require approaches or techniques that differ from those used to treat white, middle-class clients. Many cross-cultural scholars believe that racial-ethnic minority clients tend to prefer and respond better to directive rather than nondirective approaches; that active rather than passive counseling approaches are more effective; that a structured, explicit approach may be more effective than an unstructured, ambiguous one; and that minority clients may desire a counselor who discloses his or her thoughts and feelings (Ivey, 1986; Sue, 1978). Multicultural theorists explain that, to be effective in working with culturally different clients, mental health professionals need to be aware of and challenge the stereotyped images they have of clients, be able to interpret clients behavior within appropriate cultural contexts, and use culturally appropriate interventions (Arredondo, 1999). According to Sue and Sue (1999), there are three major potential barriers to effective multicultural therapy: class-bound values, language bias/misunderstanding, and culture-bound values: 4.1 Class-bound Factors Counseling and psychotherapy often focus on the internal dynamics of clients, but when treatment is not effective, there is often a failure to consider external sources as causes. As mentioned earlier in this paper, mental health practice has been described as a white,

6 middle-class activity that often fails to recognize the economic implications in the delivery of mental health services. Class-bound factors related to socioeconomic status may place those suffering from poverty at a disadvantage and obstruct their efforts to obtain help. Furthermore, clients of lower socioeconomic status may perceive sitting to talk about things as a luxury of the middle and upper classes. For the counselors who generally come from middle to upper class backgrounds, it can be difficult to relate to the circumstances and hardships affecting the client who lives in poverty. It has been found that the attribution of mental illness was more likely to occur when the client s history suggested a lower class rather than higher socioeconomic class origin (Sue & Sue, 1999). Clients from lower classes also form less intensive therapeutic relationships than members of higher socioeconomic classes (Sue & Sue, 1999). 4.2 Language Barriers Linguistic or language barriers often operate to place culturally different clients at a disadvantage as well. The primary medium by which mental health professionals do their work is through verbalizations. The assumption is that the clients must be able to verbalize their thoughts and feelings to a practitioner in order to receive the help acquired. As a result, in the United States, clients who do not speak standard English, possess a pronounced accent, or have limited command of English may experience less effective care (Sue et al, 1991). 4.3 Culture-bound Values The theories of counseling and psychotherapy, the standards used to judge normality and abnormality, and the actual process of mental health practice are culture-bound, and reflect the historically monocultural perspective of the helping professionals (Highlen, 1994). As such, they are often culturally inappropriate in understanding the lifestyles and values of minority groups in the society. For example, most forms of counseling and psychotherapy tend to be individual-centered. In the U.S. culture, individualism, autonomy, and the ability to become your own person are

7 Multiculturalism and the Delivery of Counseling Services perceived as healthy and desirable goals. In contrast, many cultures tend to focus more on family and group. Racial-ethnic minorities often value collectivism over individualism. Many counselors also tend to believe that clients who obtain insight into themselves will be better adjusted (Moncayo, 1998). Many cultures do not value this kind of introspection as highly as traditional white American culture does. Most forms of counseling and psychotherapy tend to value one s ability to self-disclose and to talk about the most intimate aspects of one s life. However, intimate revelations of personal or social problems may not be acceptable for some cultures (Sue & Sue, 1999). According to Pearson (1985), communication styles are correlated with race, culture, ethnicity, and gender. Since counseling is a process of interpersonal interaction and communication, it is important to address the differences in communication styles among racial-ethnic minorities. Different cultures, for instance, value different distances in personal space. For Latin Americans, Africans Americans, Indonesians, Arabs, South Americans, and French populations, conversing with a person dictates a much closer stance than normally comfortable for Northwest Europeans (Stewart & Bennett, 1991). A Latin American client may cause the counselor to back away because of the closeness taken. The client may therefore interpret the counselor s behavior as indicative of coldness or a desire not to communicate. On the other hand, the counselor may misinterpret the client s behavior as an attempt to become inappropriately intimate, or as a sign of aggressiveness. Another cultural variation is that different cultures have different meanings for the directness of a gaze (Stewart & Bennett, 1991). For Asians, the avoidance of eye contact may be a sign of respect. African Americans communication styles are often high-keyed, animated, heated, interpersonal, and confrontational (Sue & Sue, 1999). However, White middle-class styles are characterized as detached, objective, impersonal, and nonchallenging. Because a significant part of counseling assessments are based on people s facial expressions

8 (Pearson, 1985), this is potentially problematic in treatment. Facial cues are assumed to express emotions and demonstrate the degree of responsiveness and involvement of the individual. However, for Japanese and Chinese, restraint of strong feelings is considered a sign of maturity and wisdom. People are taught that outward emotional expressions including facial expressions, body movements, and verbal content are inappropriate (Sue & Sue, 1999). Culture in the United States is low-context, which means a greater reliance is placed on the verbal part of communication, while many minority groups have high-context culture (Hall, 1976). A high-context culture places less reliance on the explicit code or content (Hall, 1976). A high-context communication relies heavily on nonverbal gestures and group identification and understanding shared by those communicating. Racial-ethnic minority clients use fewer words to communicate the same content as do their white counterparts, and their high-context cues may lead their white counselors to characterize them as nonverbal, inarticulate, or even unintelligent. 5. Multicultural Counseling Competence Multicultural counseling competence refers to the awareness, knowledge, and skills that mental health professionals display in the context of working with culturally diverse clients (Sue et al., 1991). Being multiculturally competent means the ability to free one s personal and professional development from the unquestioned socialization of our society and profession. According to Sue et al. (1998), there are three dimensions counselors need to actively address. The first dimension deals with counselors attitudes and beliefs about race, : work on culture, ethnicity, gender, and sexual orientation; the need to check biases and stereotypes; development of a positive orientation toward multiculturalism; and the way counselors values and biases may hinder effective counseling and therapy. The second dimension recognizes that the culturally skilled professional is knowledgeable and understanding of his or her own worldview, has specific knowledge of the cultural groups he or she works with, and understands sociopolitical influences. The third dimension deals with specific skills needed in

9 Multiculturalism and the Delivery of Counseling Services working with culturally different groups; it includes both individual and institutional competencies. Sue (1998) proposed three cultural competency ingredients in his article, and the three characteristics are scientifically mindedness, dynamic sizing, and culture-specific expertise. By scientific mindedness, he means counselors should form hypotheses about the status of culturally different clients. They should then develop creative ways to test their hypotheses and, finally, act on the basis of acquired data. By forming hypotheses rather than assuming the clients processes are the same across different cultures, therapists can then test their clinical inferences. A clinician that is uncertain of the cultural meaning of certain symptom should engage in hypothesis testing. If a counselor is not sure if his or her minority client exhibits psychotic symptoms, the therapist should form hypotheses. For example, if a client reports seeing spirits, the counselor may not be sure if it is a culturally grounded hallucination or a psychotic episode. The counselor should check if the client manifests other psychotic symptoms, if other individuals in the culture are unfamiliar with the symptom, and if experts in the culture indicate that the symptom is unusual in that culture. This scientific mindedness can help therapists free themselves from potentially harmful ethnocentric biases. Dynamic sizing means the counselors can flexibly generalize in a valid manner (Sue, 1998). Appropriate dynamic sizing is a critical part of cultural competency according to Sue (1998). It allows counselors to avoid stereotypes of members of a group while still appreciating the importance of culture. In dynamic sizing, the counselor is able to place the client in a proper context and to evaluate whether the client has characteristics typical of, or idiosyncratic, to the client s cultural group. Counselors should be able to use culturally based interventions and have the ability to translate interventions into culturally consistent strategies (Sue, 1998). Culturally skilled counselors have an understanding of their own worldviews, have specific knowledge of the cultural groups with which they work, understand sociopolitical influences, and possess

10 specific skills needed in working with culturally different groups. 6. Conclusions In attempting to address cultural differences while maintaining the competency of treatment, one possible idea is to match therapists with their clients in terms of ethnicity. Some research indicates that Asian Americans, especially those who were unacculturated, generally fared better - attending more sessions, dropping out less, and experiencing better treatment outcomes - when they saw a therapist who was matched ethnically, linguistically, or both. Similar effects were found for Latin Americans. Ethnic matches were significantly related to increased session attendance for African Americans and whites (Sue, 1998). The importance of ethnic matches, however, may heavily depend on the acculturation level, racial and cultural identity of the clients (Carter, 1995). Ethnic-specific services mean that therapeutic practices are modified or developed so that the cultural customs, values, and beliefs of clients are considered (Sue, 1998). Studies indicate that ethnic clients who attended ethnic-specific programs had lower dropout rates and stayed in the programs longer than did those using mainstream services (Takeuchi, Sue, & Yeh, 1995). Still, some cautions should be taken when counselors implement ethnic-specific services. Would having ethnic-specific services encourage segregation? Various ethnic groups would have services catering to their own group needs, so would this prevent a broader practice of encouraged multicultural understanding? One point to take into consideration is that ethnic or language matches do not ensure cultural matches, which may be of major importance. Ethnicity is more of a demographic variable than a psychological variable. The psychological aspects, such as identity, attitudes, beliefs, and personality may be of greater importance. As mentioned before, the importance of ethnic match may heavily depend on the acculturation level, racial and cultural identity of the clients. Therefore, maybe instead of matching ethnicity of the counselor and the client, it is better to match their status of racial identity.

11 Multiculturalism and the Delivery of Counseling Services I think this idea also points to the notion of the effectiveness of treatment as evaluated on basis of ethnicity. Personality types differ drastically regardless of origin. Ensuring culturally empathetic treatment should therefore not take precedence over making a connection with the client; it should instead be used as a means of forming a trusting relationship with the client. To this end, efforts in cultural sensitivity should be provided in the form of educational materials to therapists, but the therapists should be encouraged to use this information not as a means of evaluation, but instead as a potentially useful way to find common ground with a client. This could, in turn, increase treatment effectiveness and bridge the cultural gaps that prevent minorities from receiving adequate treatment within the current structure of the American healthcare system. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4 th ed.). Washington DC: Author. Arredondo, P. A. (1999). Multicultural counseling competencies as tools to address oppression and racism. Journal of Counseling and Development, 77, Bowser, B. P., & Hunt, R. G. (1996). Impacts of racism of White Americans. Thousand Oaks, CA: Sage Publication. Carter, R. T. (1995). The influence of race and racial identity in psychology. New York: John Wiley & Sons, Inc. Dana, R. H. (1998). Understanding cultural identity in intervention and assessment. Thousand Oaks, CA: Sage Publication. Dana, R. H. (2000). Multicultural assessment of adolescent and child personality and psychopathology. Langerich, Germany: Pabst Science.

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