Multicultural Perspectives on Psychotherapy

Where did we leave off? Clinical Implications Should we focus on race, class, and culture in therapy? The two “good” arguments NOT to: 1. We are all fundamentally the same. 2. Each of us is a unique person with unique life experiences.

Researchers and practitioners who advocate for the opposite stance – that focusing on class, race, and culture is necessary – cite a broad range of reasons to support their claims. So… let’s consider some of them…

What do we mean by “culture”? Culture is the traditions, beliefs, and values which are present in and passed down among members of a certain group. Sources of culture can include: - race - ethnicity - sexual orientation - gender

Issue #1: Accurate Assessment & Diagnosis The DSM – IV - Uses discrete categories to classify disorders according to the presence of certain symptoms.  Does our classification system work across cultural groups? - Research/clinical observation used to produce the categories come from populations that were predominantly White. - Some critics will argue that the categories of the DSM are not directly useful for diagnosing individuals of different cultural backgrounds.

Issue #1: Accurate Assessment & Diagnosis The DSM acknowledges the existence of “culture- bound” syndromes… - The “culture-bound” disorders mentioned by the DSM are relegated to an appendix, and relatively little consideration is given to cultural differences throughout the rest of the book. - This implies that the disorders in the regular sections of the DSM are universal (i.e. not culture-bound).

Issue #1: Accurate Assessment & Diagnosis The same disorder, different presenting problems - What if the disorder really is the same, but it doesn’t look the same because of culture?  Culture may influence manifestations of disorders. - Depression  Dhat  Hwa-byung - PTSD in Southeast Asians

Issue #1: Accurate Assessment & Diagnosis Completely different disorders - It is possible that the disorders we see in the U.S. are only found in the U.S. because of our social norms and experiences, which are specific to the “American culture.” - Major Depressive Disorder prevalence rates. - Culture may influence what disorders we have altogether. - The disorders mentioned previously may really be different. - On the other hand, how can we know? We might be misdiagnosing or failing to recognize the disorders.

Issue #2: Appropriate Training APA accreditation: - APA requires its graduate programs to recognize the importance of diversity in the training and education they provide to their students.  UIUC, for example… Coursework and Practica: - As students, we want to receive training and education in the most effective therapeutic techniques and approaches.

Issue #3: Treatment Research & Applicability RCTs and ESTs: - RCTs tend to be performed on homogeneous populations – mostly White, middle class populations. - Yet, the population of ethnic minorities (for example) in the U.S. is approximately 30%, and it is expected to increase over the next few decades. - We have no evidence that our current treatments work specifically with these populations.

Issue #3: Treatment Research & Applicability -It is important to note that this is not necessarily because researchers are purposefully excluding members of other races or ethnicities. But, for some reason, these populations are underrepresented in these studies.  What does this mean for the generalizability of the findings of RCTs? How does that limit the treatments we consider to be ESTs? - We do know that these individuals underutilize services and drop out of therapy earlier in the process.

Issue #4: Therapist Characteristics The majority of clinicians are White. They grew up in the U.S. And they are obviously well-educated and likely to be middle-class. - Many proponents of multiculturalism in psychotherapy will advocate for “ethnic matching.”  Does ethnic matching improve psychotherapy outcomes?  What if ethnic matching is not possible?

Alright, so I just gave you a bunch of problems… Now, what do we do to fix them?

Cultural Competency What is Cultural Competency? It’s not easily defined, but what might it entail? What might it NOT entail?

Considerations about the Therapist Be aware of your attitudes regarding culture. - S/he needs to consider the role that culture plays in his/her own life. - Consider how s/he perceives culture as an influence on individuals and society. - Be aware of a tendency to advocate for assimilation into American culture or maintenance of traditional cultural beliefs and practices. Never make assumptions. - Don’t assume that a person’s cultural background tells you anything important.

Considerations about the Therapist Be cognizant of cultural explanations of phenomena. - The behaviors displayed may not be considered maladaptive or abnormal in the other culture. - there may be a cultural explanation for the client’s experiences. Beware of oversimplified cultural explanations. - For example, the idea of collectivism vs. individualism is a broad dichotomy. In reality, these differences probably lie on a continuum…with not only variation between cultural groups but also within cultural groups.

Considerations about the Therapist Issues of Cultural Relativism - There may be times when the client’s culture seriously clashes with the values/beliefs of the therapist. - It is difficult to know what to do in these situations.  Fowers & Richardson (1996) assert that the therapist can choose to reject the questionable behaviors of the other culture. However, this is contingent upon the therapist first having an accurate and complete perspective on the client’s culture. How might we accomplish this?

Considerations about the Client Traditional culture may only be a part of the client’s identity - A person’s identity is complex, and cannot be summed up simply by considering their culture of origin. - The individual may or may not be very connected with the traditions, beliefs, and values of the other culture. Acculturation: “the process of psychosocial change generated when a group or an individual comes into [continuous first- hand] contact w/ another culture and is, thus, affected by both adherence to traditional culture and exposure to a [new] culture” (Karlsson, 2005).

Considerations about the Client Each client is an individual, not a stereotype - Be careful about what you think you know about a person given their cultural background. Be aware of the social experiences the client may have due to his/her cultural background - Society often places certain stigmas on people of differing cultures. It is important to recognize the impact that experiences of prejudice/discrimination may have on the client.

Considerations about the Relationship Recognize that culture is there - Cultural differences between the therapist and the client can and do influence the relationship; however, these influences do not have to be negative. - Differences can be used as a catalyst for important and beneficial discussions regarding the client’s cultural experiences. They can educate both members of the relationship and breakdown stereotypes.

Considerations about the Relationship Address necessary cultural content - If the client’s cultural background is salient, then it should not be ignored. Use culture in developing treatment - There may be strengths in the client’s cultural orientation that the client and therapist can use. - Alternatively, engaging others who are relevant to the person’s culture can enhance treatment (e.g. indigenous healers, church leaders, etc.).

Ok, can we consider an example? Earlier in the course we saw Gina – an African American woman – interact with two White male therapists. - Would the therapists have been more effective in this particular case if they had paid more attention to Gina’s cultural identity and background? - If so, what might they do to display appropriate cultural competence?