Why Do We Need a Strengths-Based Approach to Suicide Assessment and Treatment?
Imagine this: You’re living in a world that seems like it would just as soon forget you exist. Maybe your skin color is different than the dominant people who hold power. Maybe you have a disability. Whatever the case, the message you hear from the culture is that you’re not important and not worthy. You feel oppressed, marginalized, unsupported, and as if much of society would just as soon have you become invisible or go away.
In response, you intermittently feel depressed and suicidal. Then, when you enter the office of a health or mental health professional, the professional asks you about depression and suicide. Even if the professional is well-intended, judgment leaks through. If you admit to feeling depressed and having suicidal thoughts, you’ll get a diagnosis that implies you’re to blame for having depressing and suicidal thoughts.
The medical model overfocuses on trying to determine: “Are you suicidal?” The medical model is also based on the assumption that the presence of suicidality indicates there’s something seriously wrong with you. But if we’re working with someone who has been or is currently being marginalized, a rational response from the patient might be:
“As it turns out, I’ve internalized systemic and intergenerational racism, sexism, ableism, and other dehumanizing messages from society. I’ve been devalued for so long and so often that now, I’ve internalized societal messages: I devalue myself and wonder if life is worth living. And now, you’re blaming me with a label that implies I’m the problem!”
No wonder most people who are feeling suicidal don’t bother telling their health professionals.
When I think of this preceding scenario, I want to add profanity into my response, so I can adequately convey that it’s completely unjust to BLAME patients for absorbing repeated negative messages about people who look like or sound like or act like them. WTH else do you think should happen?
This is why we need to integrate strengths-based principles into traditional suicide assessment and prevention models. Of course, we shouldn’t use strengths-based ideas in ways that are toxically positive. We ALWAYS need to start by coming alongside and feeling with our patients and clients. As it turns out, if we do a good job of coming alongside patients/clients who are in emotional pain, natural opportunities for focus on strengths and resources, including cultural, racial, sexual, and other identities that give the person meaning.
I’m reminded of an interview I did with an Alaskan Native person from the Yupik tribe. She talked at length about her depression, about feeling like a zombie, and past and current suicidal thoughts. Eventually, I inquired: “What’s happening when you’re not having thoughts about suicide?” She seemed surprised. Then she said, “I’d be singing or writing poetry.” I instantly had a sense that expressing herself held meaning for her. In particular, her singing Native songs and contemporary pop songs became important in our collaborative efforts to build her a safety plan.
This coming Wednesday morning I have the honor of presenting as the keynote speaker for the Maryland Department of Health 36th Annual Suicide Prevention Conference. During this keynote, I’ll share more ideas about why a strengths-based model is a good fit when working with diverse clients who are experiencing suicidal thoughts and impulses.
With all that said, here’s the title and abstract of my upcoming presentation.
Strengths-Based Assessment, Treatment, and Prevention with Diverse Populations
Traditional suicide assessment tends to be a top-down information-gathering process wherein healthcare or prevention professionals use questionnaires and clinical interviews to determine patient or client suicide risk. This approach may not be the best fit for people from populations with historical trauma, or for people who continue to experience oppression or marginalization. In this presentation, John Sommers-Flanagan will review principles of a strengths-based approach to suicide prevention, assessment, and treatment. He will also discuss how to be more sensitive, empowering, collaborative, and how to leverage cultural strengths when working with people who are potentially suicidal. You will learn at least three practical strengths-based strategies for initiating conversations about suicide, conducting culturally-sensitive assessments, and implementing suicide interventions—that you can immediately use in your prevention work.
In the lasting glow of Saturday’s Mental Health Academy’s annual Suicide Prevention Summit, I discovered 33 new blog followers. We had right around 3,000 for the session, and the chat-based posts were overwhelmingly positive and affirming. One person wrote, “You can use these comments to think about 1,000 good things from today.” The comments were THAT GOOD. I am deeply grateful for the positive feedback and amazing support of my work. Thank-you!
This year I’m embarking, along with Dylan Wright of Families First (thanks Dylan!), on something new, and possibly ill-advised. We’re hosting three Montana Happiness Project interns! My thinking was that because I’m growing long of tooth (haha), I need to begin formally passing on my knowledge and skills to the next generation. Of course, as most of you know, I’ve been passing on information and doing supervision for decades, but in this case, the process is somewhat outside of the University of Montana, and will involve a bit more mentoring. You’ll be hearing about this new wave of Montana Happiness stuff off and on in the coming months.
Here’s the first volley.
To get our interns ready, Dylan and I are creating content. I guess that makes us content creators. Cool. One of our first creations is a Step-by-Step Suicide Assessment Guide. I like to give stuff away, and so I’ve included a pdf of the guide here.
This guide is designed to be used flexibly. Mostly, it’s a knowledge-base (complete with some interesting links) that you can use to frame how you do suicide assessment and safety planning. I hope it’s useful to you in your work.
Good Morning or Good Afternoon (wherever you may be),
In 28 minutes I’ll be online presenting for the Mental Health Academy Suicide Prevention Summit. A big thanks to Pedro and Greg for their organizing and broadcasting of this worldwide event. I’m honored to be a part of it.
It’s still not too late to register. The link is here: https://www.mentalhealthacademy.net/suicideprevention. It’s all free . . . or you can pay a whopping $10 and have access to all the recordings. TBH, I’m not sure if I’d pay $10 to hear me (jokes), but tomorrow morning features Craig Bryan, and I’ll be an early-riser to catch him live (and free). There are also some other FABULOUS presenters.
Today, I’m online doing the final webinar in a three-part series for PacificSource. The PacificSource organizers and participants have been fabulous. Everything has worked smoothly and the participants have engaged with many excellent thoughts and questions. We’ve got 503 registered for today.
Here’s the title and description of today’s webinar.
Strengths-Based Approaches to Management of Patient Suicidality
John Sommers-Flanagan, Ph.D.
Healthcare providers need to do more than conduct suicide assessments; they also need to flow from assessment into providing interventions to help patients move out of crisis and toward greater emotional regulation, hope, and health. In this webinar, using video clips and vignettes, you will learn at least five specific assessment and management interventions designed to help facilitate patient transitions from crisis to constructive problem-solving. These interventions are based on robust suicide theory, clinical wisdom, and empirical evidence on strategies for working effectively with patients who are suicidal.
For anyone interested, here are the ppts for today:
Tomorrow, I’ll be online again with PacificSource, doing Part 2 of a three-part webinar series titled, “Caring for People Who are Suicidal.” Last week we focused on how to talk with people in general about this challenging topic. This week, the focus is on: “Blending Traditional and Strengths-Based Approaches to Suicide Assessment“
I’ll be talking for about an hour, which means we’ll really only quickly graze the topic. Below, for webinar viewers and other interested readers, I’ve posted the ppts, and excerpted the section in our Clinical Interviewing text that focuses on assessing suicide plans, patient impulsivity, suicidal intent, and a bit of information on talking with patients about previous attempts.
Once rapport is established and the client has talked about suicidal ideation, it’s appropriate to explore suicide plans. You can begin with a paraphrase and a question:
You said sometimes you think it would be better for everyone if you were dead. Some people who have similar thoughts also have a suicide plan. Do you have a plan for how you would kill yourself if you decided to follow through on your thoughts?”
Many clients respond to questions about suicide plans with reassurance that they’re not really thinking about acting on their suicidal thoughts; they may cite religion, fear, children, or other reasons for staying alive. Typically, clients say something like “Oh, yeah, I think about suicide sometimes, but I’d never do it. I don’t have a plan.” Of course, sometimes clients will deny having a plan even when they do. However, if clients admit to a plan, further exploration is crucial.
When exploring and evaluating a client’s suicide plan, assess four areas (M. Miller, 1985): (a) specificity of the plan; (b) lethality of the method; (c) availability of the proposed method; and (d) proximity of social or helping resources. These four areas of inquiry are easily recalled with the acronym SLAP.
Specificity
Specificity refers to the details. Has the person thought through details necessary to die by suicide? Some clients describe a clear suicide method, others avoid the question, and still others say something like “Oh, I think it would be easier if I were dead, but I don’t have a plan.”
If your client denies a suicide plan, you have two choices. First, if you believe your client is being honest, you can drop the topic. Alternatively, if you suspect your client has a plan but is reluctant to speak about it, you can use the normalizing frame discussed previously.
You know, most people who have thought about suicide have at least had passing thoughts about how they might do it. What kinds of thoughts have you had about how you would [die by suicide] if you decided to do so? (Wollersheim, 1974, p. 223)
Lethality
Lethality refers to how quickly a suicide plan could result in death. Greater lethality confers greater risk. If you believe your client is a very high suicide risk, you might inquire not simply about your client’s general method (e.g., firearms, toxic overdose, or razor blade), but also about the way the method will be employed. Does your client plan to use aspirin or cyanide? Is the plan to slash their wrists or throat with a razor blade? In both of these examples, the latter alternative is more lethal.
Availability
Availability refers to availability of the means. If clients plan to overdose with a particular medication, check on whether that medication is available. (Keep in mind this sobering thought: Most people keep enough substances in their home medicine cabinets to die by suicide.) To overstate the obvious, if the client is considering suicide by driving a car off a cliff and has neither car nor cliff available, the immediate risk is lower than if the person plans to use a firearm and keeps a loaded gun in an unlocked location.
Proximity
Proximity refers to proximity of social support. How nearby are helping resources? Are other individuals available to intervene and provide rescue if an attempt is made? Does the client live with family or roommates? Is the client’s day spent alone or around people? The further a client is from helping resources, the greater the suicide risk.
If you have an ongoing therapy relationship with clients, you should check in periodically regarding plans. One recommendation is for collaborative reassessment at every session until suicide thoughts, plans, and behaviors are absent in three consecutive sessions (Jobes, 2016).
Assessing Client Self-Control
Asking directly about self-control and observing for agitation, arousal, and impulsivity are the main methods for evaluating client self-control.
Asking Directly
If you want to focus on the positive while asking directly about self-control, you can ask something like this:
What helps you stay in control? Or, What stops you from killing yourself?
If you want to explore the less positive side, you could ask:
Do you ever feel worried that you might lose control and make a suicide attempt?
Exploring both sides of self-control (what helps maintaining self-control and what triggers a loss of self-control) can be therapeutic. This is done together with clients to understand their perception of self-control. Rudd (2014) recommended having clients rate their subjective sense of self control using a 1-10 scale (although we prefer 0-10). When clients are feeling or acting “out of control” hospitalization should be considered. Hospitalization can provide external controls and safety until clients feel more internal control.
Here’s an example of a discussion that shows (a) an interviewer focusing on the client’s fear of losing control and (b) an indirect question leading the client to talk about suicide prevention.
Client: I’m afraid of losing control late at night.
Therapist: Sounds like night is the roughest time.
Client: I hate when I’m awake and alone into the night.
Therapist: So, late at night, you’re sometimes afraid you’ll lose control and kill yourself. What has helped keep you from doing it.
Client: I think of how my kids would feel when they couldn’t get me to wake up. I can’t even think of that.
A brief verbal exchange, such as this, isn’t a final determination of safety or risk. However, this client’s children are a mitigating factor that may help with self-control.
Observing for Arousal/Agitation
Arousal and agitation are contemporary terms used to describe what Shneidman originally referred to as perturbation. Perturbation is the inner push that drives individuals toward suicidal acts. Arousal and agitation are underlying components of several other risk factors, such as akathisia associated with SSRI medications, psychomotor agitation in bipolar disorder, and command hallucinations in schizophrenia.
Arousal or agitation adversely affect self-control. Unfortunately, systematic methods for evaluating arousal are lacking. This leaves clinicians to rely on five approaches to assessing arousal, agitation, and impulsivity:
Subjective observation of client increased psychomotor activity (as in an MSE)
Client self-disclosure of feeling unsettled, unusually overactive, or impulse ridden (often accompanied by statements like, “I need to do something”)
Questionnaire responses or scale scores indicating agitation
A history of agitation-related suicide gestures or attempts
Clients report impulsivity around aggression and/or substance use
Assessing Suicide Intent
Suicide intent is defined as how much an individual wants to die by suicide. Suicide intent can be evaluated via clinical interview (Lindh et al., 2020), standardized questionnaire (e.g., the Beck Suicide Intent Scale, Beck et al., 1974), or after completed suicides. When evaluated after suicide deaths, higher suicide intent is linked to lethality of means, more extensive planning, and a negative reaction to surviving the act.
Assessing suicide intent prior to potential attempts is challenging. In an interview, the question can be placed on a scale and asked directly:
On a scale from 0 to 10, with 0 being you’re absolutely certain you want to die and 10 that you’re absolutely certain you want to live, how would you rate yourself right now?
Suicide intent is also related to suicide planning; that means when you’re evaluating suicide plans, you’re also evaluating suicide intent. More specificity and lethality in planning is linked to intent. Overall, standardized questionnaires and clinical interviews are equivalent in their predictive accuracy (Lindh et al., 2020).
Obtaining detailed information about previous attempts is important from a medical-diagnostic-predictive perspective, but less important from a constructive perspective, where the focus is on the present and future. Whether to explore past attempts or to stay focused on the positive is a dialectical problem in suicide assessment protocols. On the one hand, suicide scheduling, rehearsal, experimental action, and preoccupation indicate greater risk and, therefore, are valuable information (Rudd, 2014). On the other hand, to some extent, detailed questioning about intent, plans, and past attempts reinforces client preoccupation with suicide and suicide planning.
Balance and collaboration are recommended. As you inquire about intent, continue to integrate positively oriented questions into your protocol:
How do you distract yourself from your thoughts about suicide?
As you think about suicide, what other thoughts spontaneously come into your mind that make you want to live?
Now that we’ve talked about your plan for suicide, can we talk about a plan for life?
What strengths or inner resources do you tap into to fight back those suicidal thoughts?
Eventually you may reach the point where directly asking about and exploring previous attempts is needed.
Exploring Previous Attempts
Previous attempts are considered the strongest of all suicide predictors (Franklin et al., , 2017). Information about previous attempts is usually obtained through the client’s medical-psychological records or an intake form, or while discussing depressive symptoms during a clinical interview (see Case Example 10.2). It’s also possible that you won’t have information about previous attempts, but you decide to ask directly:
Have there been any times when you were so down and hopeless that you tried to kill yourself?
Once you have or obtain information about a previous attempt or attempts, you have a responsibility to acknowledge and explore it, even if only via a solution-focused question.
You’ve tried suicide before, but you’re here with me now . . . What has helped?
If you’re working with a client who’s severely depressed, it’s not unusual for your solution-focused question to elicit a response like this:
Nothing helped. Nothing ever helps.
One error clinicians often make at this point is to venture into a yes-no questioning process about what might help or what might have helped in the past. If you’re working with someone who is extremely depressed and experiencing the problem-solving deficit of mental constriction, your client will respond in the negative and insist that nothing ever has helped and that nothing ever will help. Encountering a negative response set requires a different assessment approach. Even severely depressed clients can, if given the opportunity, acknowledge that every attempt to address depression and suicidality isn’t equally bad. Using a continuum where severely depressed and mentally constricted clients can rank intervention strategies (instead of a series of yes-no questions) is a better approach:
Therapist: It sounds like you’ve tried many different things to help you through your depressed feelings and suicidal thoughts. Of all the things you’ve tried and all the ideas that professionals like me have recommended, which one has been the worst?
Client: The meds were the worst. They made me feel like I was already dead inside.
Therapist: Okay. Let’s put meds down as the worst option you’ve experienced so far. So, which one was a little less bad than the meds?
Instead of asking the client “What worked best?” and getting a bleak depressive response, the therapist asked which therapeutic recommendation had been “the worst?” Focusing on what’s worst resonates with the negative emotional state of depressed clients. Identifying the most worthless of all therapeutic strategies is more likely to produce a response and you can build from there to strategies that are “a little less bad.” Later in the interview process, you can add new ideas that you suggest or that the client suggests and put them in their appropriate place on the continuum. When this strategy works, it produces a list of ideas (some new and some old) for potential homework and experimentation (see also Sommers-Flanagan & Sommers-Flanagan, 2021).
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As I read through the preceding excerpt, I realize there’s so much more that could be covered. For more info, we also have our strengths-based suicide assessment book, which you can find online through different booksellers. Just search for our name and strengths-based suicide assessment to find a plethora of resources, many of which are free.
When I wrote this, I was listening to Dr. Jennifer Crumlish, a consultant for the CAMS-Care program. Dr. Crumlish provided a fantastic overview of the challenges associated with suicide prevention and interventions, along with introductory information pertaining to implementing the CAMS model. For more on CAMS-Care, see this link: https://cams-care.com/
Earlier in the day, Leah Finch—one of our excellent doc students in counseling—and I, did our presentation. Our participants were awesome. A bit later, I got to be on an “expert panel” along with several very cool people, facilitated by Dr. Jen Preble. We fielded an array of interesting questions from the audience. Very fun.
For those of you interested, here are the ppts Leah and I developed, here they are:
Yesterday I was at Camp Mak-A-Dream talking with young people about happiness. Today, I’ll be online with 400+ professionals doing a presentation titled: Strategies for Listening and Responding to People Who are Suicidal. Today’s presentation is offered through PacificSource, a health insurance provider in the NW United States.
I’m continuing with the theme of featuring diverse identities from the Clinical Interviewing (7th edition) textbook with a case example written by Dr. Umit Arslan. Dr. Arslan is writing about his experience as an international graduate student in counseling, when he was at the University of Montana. Currently, he’s a faculty member at the University of Nebraska-Kearney.
The photo is from when I visited him in Istanbul in January, 2023.
Enjoy!
As you’ll see below, Umit’s experience was unique. Given his Turkish heritage and cultural background, he needed to reflect and engage in a self-awareness process to experiment with finding a better way to introduce himself to clients. What I love most about this essay is Umit’s authentic description of his own experience. His answer to a better way to introduce himself won’t be the right answer for everyone. But his process is open and admirable.
CASE EXAMPLE 2.2: BEING A COUNSELOR FIRST . . . AND TURKISH SECOND, WORKED BETTER THAN BEING TURKISH FIRST . . . AND A COUNSELOR SECOND
Finding the right words and ways to introduce yourself is important. In this essay, Ümüt Arslan, Ph.D., an associate professor of counseling at İzmir Democracy University (Turkey), writes about challenges he faced as an international doctoral student in counseling at the University of Montana. Put yourself in Dr. Arslan’s shoes as he discovers (for him) a better way of introducing himself.
While pursuing my doctoral degree in the U.S., my supervisor and I discussed how to share my cultural identity and accent to clients. When I shared, my clients were not only interested in my appearance and accent, but also about my diet, coffee preferences, job, and of course, about my native country, Turkey. But they were reluctant to talk about themselves.
Clients assumed I was Muslim and against alcohol. Their assumptions were especially challenging because they were inaccurate. I was not religious, and like many Americans, I enjoyed having a beer after work. I wanted to challenge clients’ assumptions about my identity, but worried about countertransference and focusing too much on myself.
One cisgender female client came for an intake interview. She saw me, grabbed her bag (almost the size of a camping tent), and put it on her knees. I couldn’t see her face. I told her she could put the bag down if she wanted to. She declined.
When I re-watched this and other sessions, the striking thing was that my clients (mostly White) appeared stressed at the sight of me, a bearded Turkish man with dark skin. They didn’t even talk about the problems they had written on their intake form. My identity as a Turkish man overshadowed everything else. I needed a path forward.
In class, my supervisor discussed alternative ways to open sessions. I tried asking clients: “If you were the counselor today, what question would you ask yourself?” Clients suddenly engaged with me, giving deep and enthusiastic answers to their own questions. I stopped opening sessions by emphasizing cultural differences. Instead, I focused on my counselor identity, saying: “I completed my master’s degree and am currently a doctoral student. What do you think is the best question for me to ask you for us to have a good start here today?”The message, “I am here with my counselor identity” instead of “I’m a Turkish man in the U.S., and desperate to explain my culture to you,” had an amazing effect. Using a less cultural opening was more culturally sensitive. Clients could naturally introduce their own cultural identities, with fewer assumptions about me. Although I could still talk about culture, emphasizing my counselor identity enabled me to focus on counseling goals, the therapeutic relationship, and evidence-based counseling interventions.
To continue with my plan to feature culturally diverse case examples from the latest edition of Clinical Interviewing, the following excerpt is from Chapter One and focuses on cultural self-awareness. In particular, I LOVE the quotation on intersectionality from Kimberlé Crenshaw.
Cultural Self-Awareness
Those who have power appear to have no culture, whereas those without power are seen as cultural beings, or “ethnic.” (Fontes, 2008, p. 25)
Culture and self-awareness interface in many ways. As Fontes (2008) implied, individuals from dominant cultures tend to be unaware of and often resistant to becoming aware of their invisible and unearned culturally-based advantages (Sue et al., 2020). In the U.S., these “unearned assets” are often referred to as privilege in general, and White privilege in particular (McIntosh, 1998).
Privilege and oppression are best understood in the context of intersectionality. Intersectionality is the idea that overlapping or intersecting social identities within individuals create whole persons that are different from the sum of their parts (Crenshaw, 1989). Social identities that intersect include, but are not limited to: Gender, sexual orientation, sexual identity, race, ethnicity, religion, nationality, mental disorder, physical disability/illness, citizenship, and social class (Hays, 2022). Understanding multiple social identities helps clinicians understand how feelings of oppression can multiply, be activated under distinct circumstances, and be moderated under other circumstances.
Kimberlé Crenshaw (1989, 1991) introduced intersectionality as a lens to facilitate cultural awareness and understanding, but ideas about intersectionality date back at least to Black female abolitionists. In the 1860s, Sojourner Truth articulated Black women’s simultaneous oppression through classism, racism, and sexism (aka “Triple oppression”; Boyce Davies, 2008). Thirty years after she defined intersectionality, Time Magazine asked Crenshaw, “You introduced intersectionality more than 30 years ago. How do you explain what it means today?” (Steinmetz, 2020). She said,
These days, I start with what it’s not, because there has been distortion. It’s not identity politics on steroids. It is not a mechanism to turn white men into the new pariahs. It’s basically a lens, a prism, for seeing the way in which various forms of inequality often operate together and exacerbate each other. We tend to talk about race inequality as separate from inequality based on gender, class, sexuality or immigrant status. What’s often missing is how some people are subject to all of these, and the experience is not just the sum of its parts.
Through the lens of intersectionality, we can develop nuanced ways to have empathy for clients. For example, sometimes clients simultaneously feel privilege and oppression. Thinking and feeling from an intersectional frame can help clinicians be more prepared to view the world from clients’ perspectives (see Case Example 1.2).
CASE EXAMPLE 1.2: EMPATHY FIRST
Maya, an international student of color was in her first practicum. As was her routine, when introducing herself, she acknowledged her accent, her country of origin, along with her eagerness to be of assistance. Her client, a cisgender male university student, was initially polite, but quickly shifted the conversation to his feelings about White privilege, becoming somewhat agitated in the process. He said, “One thing I think you should know that I don’t believe in that White privilege thing. I just came from a class where that’s all everyone was talking about. I know I’m white, but I didn’t get any privilege. I grew up in a trailer park in West Texas. We were what they call ‘White trash.’ Nobody I grew up with had any privilege. We had poverty, abuse, alcoholism, meth, and government bullshit.”
Maya stayed calm. Even though she was activated by her client’s disclosure and was taking some of what he said personally, she focused on empathy first. She also remembered intersectionality and how common it could be for people to have multiple social identities. She said, “I hear you saying that the White privilege concept really doesn’t fit for you. Being in your very last class before coming here made you realize even more that it doesn’t fit. The idea of trying to make it fit feels annoying.”
Maya’s client simply said, “Damn right,” and continued ranting about White privilege, White fragility, and what he viewed as the politically correct environment at the university. As she continued listening and tried feeling along with him, she was able to see glimpses of his personal perspective. Not surprisingly, Maya’s client had social problems related to his tendency to be angry and abrasive. Eventually, after several sessions, they were able to begin talking about what was underneath his agitated emotional response to multicultural ideas and how his tendency to lead with his anger when in conversations with others might be contributing to him feeling even more isolated and different than everyone else. In the end, the client thanked Maya for “being patient with this dumb ass White boy” and helping him learn to be more aware, softer, and less reactive to triggering cultural conversations.
This case illustrates the importance of intersectionality as a concept that can facilitate counselor and client awareness, while also enhancing empathy. Although Maya’s client may have had even worse oppressive experiences had he been a person of color, he was neither interested nor ready to hear that message (Quarles & Bozarth, 2022). Instead, Maya used her knowledge of intersectionality to have empathy with the part of her client’s social identity that had experienced oppression.
Developing cultural self-awareness is difficult. One way of expressing this is to note, “We don’t know what we don’t know.” When someone tries to help us see and understand something about ourselves that’s outside our awareness, it’s easy to feel defensive. Despite the challenges, we encourage you to be as eager for change and growth as possible, and offer three recommendations:
Be open to exploring your own cultural identity. Gaining greater awareness of your ethnicity is useful.
If you’re from the dominant culture, be open to exploring your privilege (e.g., White privilege, wealth privilege, health privilege) as well as hidden ways that you might judge or have bias toward diverse groups and individuals (e.g., transgender, disabled).
If you’re outside the dominant culture, be open to discovering ways to have empathy not only for members within your group, but also for other diversities and for the struggles that dominant cultural group members might have as they navigate challenges of increasing cultural awareness. Engaging in mutual empathy is a cornerstone of relational cultural psychotherapy (Gómez, 2020).
For the next several weeks I’ll be sharing from our almost new 7th edition of Clinical Interviewing.
One of our goals for the 7th edition of Clinical Interviewing is to move toward greater representation of different ethnic/cultural/sexual identities. We want all potential counseling, psychology, and social work students to be able to identify with counseling, psychology, and social work professionals. To accomplish this goal, we added greater representation by broadening our usual chapter content, as well as including case examples contributed by professionals with diverse identities.
Here’s an excerpt from Chapter 1 on culture-specific expertise
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Culture-Specific Expertise
Culture-specific expertise speaks to the need for clinicians to learn skills for working effectively with diverse populations. For example, learning the attitudes and skills associated with affirmative therapy is important for clinicians working with diverse sexualities, including lesbian, gay, bisexual, transgender, queer/questioning (sexual or gender identity), intersex, and asexual/aromantic/agender (LGBTQIA+) clients (Heck et al., 2013). Similarly, integrating skills for talking about spiritual constructs into your work with African American, Latinx, Indigenous, and traditionally religious clients is often essential (Mandelkow et al., 2021; Sandage & Strawn, 2022).
Stanley Sue (1998, 2006) described two general skills for working with diverse cultures: (a) scientific mindedness and (b) dynamic sizing.
Scientific mindedness involves forming and testing hypotheses about client culture, rather than coming to premature conclusions. Although many human experiences are universal, it’s risky to assume you know the underlying meaning of your clients’ behavior, especially minoritized clients. As Case Example 1.3 illustrates, culturally sensitive clinicians avoid stereotypic generalizations.
Dynamic sizing is a complex multicultural concept that guides clinicians on when they should and should not generalize based on an individual client’s belonging to a specific cultural group. For example, filial piety is a value associated with certain Asian families and cultures (Ge, 2021). Filial piety involves the honoring and caring for one’s parents and ancestors. However, it would be naïve to assume that all Asian people believe in or have their lives affected by this particular value; making such an assumption can inaccurately influence your expectations of client behavior. At the same time, you would be remiss if you were uninformed about the power of filial piety in some families and the possibility that it might play a large role in relationship and career decisions in many Asians’ lives. When clinicians use dynamic sizing appropriately, they remain open to significant cultural influences, but they minimize the pitfalls of stereotyping clients.
Another facet of dynamic sizing involves therapists’ knowing when to generalize their own experiences to their clients. S. Sue (2006) explained that it’s possible for clinicians who have experienced discrimination and prejudice to use their experiences to more fully understand the discrimination-related struggles of clients. However, having had experiences similar to a client may cause you to project your own thoughts and feelings onto that client—instead of drawing out the client’s emotions and showing empathy. Dynamic sizing requires that you know and understand and not know and not understand at the same time. Not knowing—or at least not presuming you know—is essential to interviewer-client collaboration.
CASE EXAMPLE 1.3: NOT AT HOME ANYWHERE
In this case, Devika Dibya Choudhuri, Ph.D., LPC (CT/MI), a self-described Buddhist, South Asian, cisfemale, middle-aged, middle-class, Queer, disabled counselor and professor at Eastern Michigan University, illustrates sophisticated cultural-specific expertise in cross-cultural work with a bi-cultural college student. Dr. Choudhuri uses self-disclosure, researches her client’s culture, and integrates culturally meaningful symbols into her sessions. Imagine how you can aspire to be like Dr. Choudhuri.
Darla, a 19-year-old Ghanian-American cisfemale college student, felt something was wrong with her. Her mother was from Ghana, while her father, with whom she had little contact, was generationally African American. She was halting in the first session, trying to decide whether she could trust me, and talking about her recent visit to Accra where her mother’s family lived. I said, “I know when I go to India, I’m American, and when I’m here, I’m Indian. Is it a bit like that for you?” She emphatically replied, “Yes! I’m not at home anywhere!” “Or,” I returned, “almost at home everywhere, like the rest of us global nomads.” She laughed, then spoke far more comfortably about her friends and boyfriend. I had, in that brief exchange, told Darla very important things about me. I self-disclosed casually about my ethnicity and international navigation, normalized her sense of homelessness, while reframing it to join a new group identity.
After having done some research, I asked Darla if her Ghanian kin were the majority Akan or a minority group. She said they were minority. I reflected on whether she might have picked up a sense of marginalization, not just from being Black in America, but also from being minority in Ghana. This became a deep and intense conversation. She reflected on how her American status in Ghana protected her from discrimination, but also alienated her from her cousins.
Another use of culture as intervention came when I brought in Adinkra (visual pictograph meaning saturated symbols originating in Ghana) for her use. Darla chose four to represent her aspirations, and then designed ways to use them in her daily life, incorporating her cultural roots into her present. One of them, Sankofa, is a symbol of the wisdom of learning from the past to build for the future; expressed in the proverb, “it is not taboo to go back for what you left behind.” Feeling grounded in multiple cultures, and being able to navigate from one context to another with her whole and complex self, rather than fragmenting, led her to see she wasn’t “wrong.” Sometimes the spaces were too limited; it was ok to fit and not fit, just as leftover food on a Ghanian table represented abundance.
[End of Case Example 1.3]
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