Category Archives: Multicultural

Integrating Multicultural Sensitivity into CBT

Woman Statue

A question and brief discussion on Twitter about integrating multicultural competence into CBT inspired me to look back and see what the heck we wrote for that section in our theories text. In the Twitter discussion, we agreed that Pam Hays’s work on CBT and multicultural content is good.

Here’s what I found in our theories text. Obviously it’s a short section and limited, but there are a few interesting points and a citation or two.

Cultural and Diversity Considerations in CBT

CBT focuses on symptoms as manifest within individuals. This position can be (and is) sometimes viewed as disregarding important culture, gender, and sexual diversity issues. For most cognitive-behavioral therapists, culture, gender, and sexuality aren’t primary factors that drive successful outcomes.

This position is a two-edged sword. In the featured case (in Chapter 8), Richard is a white male living a life squarely in the middle of the dominant culture. The therapist was committed to Richard’s well-being. If the client had been an Asian Indian or a bisexual or a woman experiencing domestic abuse the cognitive-behavioral therapist would have been equally committed to the client’s well-being. This is the positive side of CBT being less diversity-oriented.

The negative side is that CBT can be viewed and experienced as blaming clients for their symptoms, when the symptoms may be a function of diversity bias. D. Dobson and K. S. Dobson (2009) articulated the potential for clients to experience blame,

By virtue of looking for distorted thoughts, cognitive-behavioral therapists are more likely than other therapists to find them. Furthermore, some clients do react to the terms distorted, irrational, or dysfunctional thinking. We have heard clients say something to the effect—” Not only do I feel bad, but now I’ve learned that my thoughts are all wrong.” (p. 252)

Awareness of the possibility of client blaming is crucial. For example, what if Richard were a Black American male? And what if his therapist noticed that Richard’s thought record included numerous personalization examples? If so, instead of concluding that Richard is displaying oversensitivity and paranoid cognitions, his therapist should explore the possibility of microaggressions in Richard’s daily life.

The term microaggression was coined by Chester Pierce (1978). Microaggressions were originally defined as “the everyday subtle and often automatic ‘put-downs’ and insults directed toward Black Americans” but now this is expanded so they “can be expressed toward any marginalized group in our society” (Sue, 2010, p. 5).

Microaggressions are typically unconscious. For example, we had a female client come to us in great distress because her vocational instructor had told her “You’re pretty strong for a girl.” Although the vocational instructor defended his “compliment,” the young woman clearly didn’t experience the statement as a compliment. In this circumstance if a therapist is insensitive to culture and gender issues, the young woman might feel blamed for having irrational thoughts and overreactive behaviors. Sue (2010) recommends that mental health professionals exercise vigilance to address microaggression issues inside and outside of counseling. One way in which cognitive behavioral practitioners have addressed the potential for committing microaggressions against sexually diverse clients is by using LGBTQ affirmative CBT (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015).

Returning to racial/cultural microaggressions, let’s briefly pretend that Richard is a 6′7′′ Black American male. In his thought record he notes:

Situation: Walking into the local grocery store. Young female makes eye contact with me and then quickly turns around and goes back and locks her car.

Thoughts: She thinks I’m going to steal her car.

Emotions: Anger.

Behavior: I act rude toward her and toward other white people I see in the store.

If the Black American version of Richard has a therapist who looks at this thought record and then talks with Richard about the distorted thinking style of mind-reading (“Richard, you didn’t really know what she was thinking, did you?”) this therapist is showing cultural insensitivity and will likely be fired by Richard. This is an example of one of the many growing edges CBT should address with respect to women and minority clients.

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As always, your reactions to this content are welcome.

 

It’s Not Unusual: John’s Weekend Reflections

john-rapA stranger posted a comment on my blog today. As Tom Jones might say, “It’s not unusual” for my blog to stimulate reader commentary. After all, I’m expressing my opinion, distributing professional information, and often I specifically ask for reader feedback.

Mostly I get positive feedback. Occasionally, I touch a nerve with someone and get pushback or criticism. What’s most interesting to me is that the nerves I touch are nearly always nerves related to White privilege or feminism. I suppose that’s not unusual either.

Today’s comment started with, “Wow. All u do is wafle here. . .” and went on to provide a rambling critique of White privilege (I think). Three thoughts on this: First, to find my several year-old White privilege blog post requires significant effort and searching. Second, with the advent of spellcheck, typically it’s very hard for your computer to let you misspell “waffle” as “wafle.” Third, the critique, as is not unusual, didn’t seem to have much to do with the content of my blog post. Instead, the commenter was clearly focusing in on his own personal issues and history and not so much on what I had written.

The next part of all is also not unusual. In response, I felt disappointment, hurt, and defensiveness. To be perfectly honest, I wanted to counterpoint or counterpunch my commenter. I managed to stop myself. Instead, I labeled his comment as spam and moved on.

Upon reflection, my “spamming” his comment was probably passive-aggressive. And, it was (and is) clear that I haven’t moved on. Funny how criticism has a way of hanging on long after the party has ended and everyone should go home.

In conclusion, here’s the sort of thing I wish I’d written . . .

“Hello beloved fellow human. I’m grateful that you took the time to read my blog and make a comment. Thank you for that. Based on your comment, I think you and I probably disagree on this topic. Rather than arguing and trying to convince you that I’m right and you’re wrong (which likely wouldn’t work anyway), I want to say that I respect your right to a perspective and opinion that’s different from mine. I’m sure we’ve lived very different lives and so it’s not unusual that we would disagree on White privilege. Although I feel defensive about what I wrote, I can also feel a part of myself that’s way down deep and not defensive. That part of me wants to reach out and say ‘Hey. No big deal that we disagree. It wasn’t my intent to write something that offended you. I wish you health and happiness. I wish us a better and deeper mutual understanding. Wherever you feel hurt or pain, I wish you healing. I hear your disagreement with me and, in the future, although I know I won’t be perfect, I will try to be more sensitive and compassionate in what I write.’

If you like, you can read the offending blog post here: https://johnsommersflanagan.com/2012/09/14/a-white-male-psychologist-reflects-on-white-privilege/

Have a fantastic Saturday night.

John SF

Working with Parents Across Cultures

This morning I have the honor and privilege to present an ACA Education session on working with culturally diverse parents. Part of the presentation is business as usual. Sara Polanchek and I will take turns talking about some of the ways in which we work with parents. This content is mostly linked to the “How to Listen so Parents will Talk and Talk so Parents will Listen” book.

But what’s exciting this morning is that two of our U of Montana doc students will intermittently offer cultural commentary on how to work with parents who are culturally diverse. Maegan Rides At The Door and Salena Beaumont Hill are the doc student co-presenters. I have already learned much from them . . . and will be learning more this morning. To share the learning, the powerpoints are here: ACA Parenting 2018 REV #274

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

This is a rough preview of a section from the 6th edition Clinical Interviewing. As always, your thoughts and feedback are welcome.

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

Research on how to practice with culturally diverse youth is especially sparse. To make matters more complex, youth culture is already substantially different from adult culture. This means that if you’re different from young clients on traditional minority variables, you’ll be experiencing a double dose of the cultural divide. These complications led one writer to title an article “A knot in the gut” to describe the palpable transference and countertransference that can arise when working with race, ethnicity, and social class in adolescents (Levy-Warren, 2014).

To help reduce the size of the knot in your gut, we’ve developed a simple research- and common-sense list to guide your work with culturally diverse youth (Bhola & Kapur, 2013; Norton, 2011; Shirk, Karver, & Brown, 2011; Villalba, 2007):

1. Use the interpersonal skills (e.g., empathy, genuineness, respect) that are known to work well with adult minority group members. Keep in mind that interpersonal respect is an especially salient driver in smoothing out intercultural relationships.

2. Find ways to show genuine interest in your young clients, while also focusing on their assets or strengths.

3. Treat the meeting, greeting, and first session with freshness and eagerness. There’s evidence that young clients find less experienced therapists easier to form an alliance with.

4. Use a genuine and clear purpose statement. It should capture your “raison d’etre” (your reason for being in the room). We like a purpose statement that’s direct and has intrinsic limits built in. For example: “My goal is to help you achieve your goals . . . just as long as your goals are legal and healthy.” One nice thing about this purpose statement is that sometimes young clients think the “legal and healthy” limitations are funny.

5. Don’t use a standardized approach to always talking with youth about your cultural differences. Instead, wait for an opening that naturally springs up from your interactions. For example, when a teen says something like, “I don’t think you get what I’m saying” it’s a natural opening to talk about how you probably don’t get what the youth is saying. Then you can discuss some of your differences as well as you’re desire to understand as much as you can. For example: “You’re right. I probably don’t get you very well. It’s obvious that I’m way older than you and I’m not a Native American. But I’d like to understand you better and I hope you’ll be willing to help me understand you better. Then, in the end, you can tell me how much I get you and how much I don’t get you.”

6. Provide clear explanations of your procedure and rationale and then linger on those explanations as needed. If young clients don’t understand the point of what you’re doing, they’re less likely to engage.

7. Be patient with your clients; research with young clients and diverse clients indicate that alliance-building (and trust) takes extra time and won’t necessarily happen during an initial session

8. Be patient with yourself; it may take time for you to feel empathy for young clients who engage in behaviors outside your comfort zone (e.g., cutting)

I hope these ideas can help you make connections with youth from other cultures. The BIG summary is to BE GENUINE and BE RESPECTFUL. Nearly everything else flows from there.

A Guest Essay on the Girl Code and Feminism

The past several years I’ve offered a few extra credit points for students in my theories class who write me a short essay on the Girl Code. The Girl Code is defined–using William Pollack’s Boy Code as a guide–as the unhealthy societal and media-based rules by which girls and women are supposed to live. These rules are typically limiting (e.g., women who get angry are considered bitches) and are often damaging to girls and women.

This year students had to watch three feminist-related video clips as a part of this extra credit assignments and then write a short essay. The clips are listed below so you can click on the links and watch them if you like:

Eve Ensler doing a TED talk: Embrace Your Inner Girl — https://www.youtube.com/watch?v=YhG1Bgbsj2w

Emma Watson speaking to the U.N.: https://www.youtube.com/watch?v=c9SUAcNlVQ4

Cameron Russell’s TED talk: http://www.ted.com/talks/cameron_russell_looks_aren_t_everything_believe_me_i_m_a_model?language=en

The following essay was written by Tristen Valentino. He gave me permission to post it here.

I’m featuring Tristen’s essay not only because I found it to be well-written and insightful, but also because his ideas stretch my thinking. Frequently I find myself puzzled as to why so many people in our society have such negative reactions to the word “feminist.” Why would anyone be against equal rights and opportunities for males and females? What’s the problem with that? In fact, this past year Time Magazine went so far as to suggest it be eliminated from the dictionary (inserted stunned silence here). For me, Tristen’s essay is important because, although he strongly criticizes what he sees as the overly generalized messages within the assigned video clips (which I happen to like), he also explicitly condemns the mistreatment of women based on gender.

Here’s Tristen’s essay. I hope you enjoy it . . . or at least find it thought-provoking.

Extra Credit Commentary on Feminism Clips
Tristen Valentino
COUN 485
November 24, 2014

Advocating equal rights is a noble and admirable pursuit. The video clips featuring Eve Ensler, Emma Watson, and Cameron Russell each speak about sexual discrimination, and their own personal roles in feminism. While I fully support equality in opportunity, and applaud their intention, I believe their execution was flawed. The three of them generalized men across the globe, lumping all men from all cultures and nations together in the oppression of women. The three of them claimed that male chauvinism is not only prevalent but pervasive in all societies.

Eve Ensler speaks briefly of her violent and abusive father and alludes that her experiences at the hands of her father set her in motion to help end the victimization of women. In this case I feel that Eve Ensler is looking at everything through the same tinted lens. In her world, the lens with which she views the world is completely blue (victimization of women), so when she looks upon the world she sees everything as blue. While not incorrect, since there are many things blue in the world, this view is incomplete as there are many things not blue. So too with her view on victimization and the causes of it.

Emma Watson’s speech appealed to emotion, but wilted under even slight pressure from a factual basis. She claimed that in her country (United Kingdom) women were oppressed and drew comparisons between the UK and African nations. She failed to mention that in her country the longest serving Prime Minister was a female (Margaret Thatcher) and that the longest living monarch, and second longest reigning monarch, is a female (Queen Elizabeth II).

Cameron Russell speaks about how damaging the media can be to female self-esteem and the female identity. She attributes insecurity, eating disorders, and other self-image issues with fantastical, and often fictional, portrayals of the female form. I find this to be incredibly hypocritical and disingenuous coming from someone who is an active participant in the very mechanism that she claims is doing harm to the female psyche.

However, those issues aside, the issue of gender equality is a serious one, and one that deserves our attention. There is little doubt that acts of female oppression and victimization are completely evil. There is no arguing that in some areas, horrible atrocities happen to women simply because they are women. This culture of male predatory behavior resulting in the victimization of women needs to be addressed and halted immediately. The damage that is caused is not always as easily seen and overt as physical injury. The mental and psychological injuries inflicted by the gender expectations of such things as the “Girl Code” apply pressure to already stressed women to perform up to a standard, and in such a way, as to be unrealistic. Expectations—such as women must always look pretty, must always be as thin as they can be, or must be sexy, but not too sexy—place the value of women on their physical appearance. It prevents their self-expression and their validation of life by stripping away the value of all their other qualities. Women are not objects to be used or abused at the whims of men. Women are not toys to be played with and then discarded. They are equal partners in the venture of life. They are doctors, lawyers, teachers, police officers, and politicians. They are mothers, daughters, sisters, friends, confidants, and mentors. They are strong, intelligent, indomitable, competent, and capable. They are all that and more. They are women. They are human.

Cultural Adaptations in the DSM-5: Insert Foot in Mouth Here

Sometimes it just seems easier to be snarky than balanced. This basic truth comes to mind because of a recent analysis I did of the Cultural Formulation Interview (CFI) from the DSM-5. As I read about the CFI and looked through its Introduction and 16 questions for “patients,” I kept thinking to myself things like,

“Seriously . . . could this really be the best cultural sensitivity that the American Psychiatric Association can manage when it comes to guidelines for interviewing minority cultures?”

And,

“Who wrote this and why didn’t they ask me for some help?” (insert smiley face here; please note that some of my colleagues at the University of Montana have noticed—and commented—on the fact that I tend to insert a smiley face icon right after texting or emailing my personal version of punchy, snarky, sarcasm).

Ha! is all I have to say to them (FYI: Ha! is my programmed default back up to my default smiley face snark signal).

Anyway . . . the point! It’s way easier for me to be critical of the American Psychiatric Association than balanced. In truth, the CFI is a reasonable effort. And, if you think about where the APA is coming from (and likely going to) then the CFI is a massive effort. I should be saying, “Cool! I’m so excited to see the CFI as part of the DSM-5.

All this is prologue for the excerpt I include below. This is an excerpt from a draft chapter I’m writing for the Handbook of Clinical Psychology . . . to be published at some point in the not too distant future. Here’s the excerpt; it focuses on cultural adaptations we can make when conducting initial clinical interviews with minority clients; forgive the roughness of the draft.

Cultural Adaptations

A clinical interview is a first impression, and first impressions are powerful influences on later relational interactions, which is why we need to make cultural adaptations when conducting clinical interviews. One of the best sources for cultural adaptations is the already-existing guidance from psychotherapy research on working multiculturally. These guidelines include: (a) using small talk and self-disclosure with some cultural groups, (b) when feasible, conducting initial interviews in the patient’s native language, (c) seeking professional consultations with professionals familiar with the patient’s culture; (d) avoiding the use of interpreters except in emergency situations; (e) providing services (e.g., childcare) that help increase patient retention, (f) oral administration of written materials to patients with limited literacy, (g) having awareness and sensitivity to client age and acculturation, (h) aligning assessment and treatment goals with client culturally-informed expectations and values, (i) regularly soliciting feedback regarding progress and client expectations and responding immediately to client feedback, and (j) explicitly incorporating cultural content and cultural values into the interview, especially with patients not acculturated to the dominant culture (see Griner & Smith, 2006; Hays, 2008; Smith, Rodriguez, & Bernal, 2011).

Cultural awareness, cross cultural sensitivity, and making cultural adaptations are especially important to assessment and diagnosis. This is partly because mental health professionals have a long history of inappropriately or inaccurately assigning psychiatric diagnoses to cultural minority groups (Paniagua, 2014). To address this challenge, in the latest edition of the Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association, 2014), a Cultural Formulation Interview (CFI) protocol is included to aid the diagnostic interview process.

The CFI is a highly structured brief interview. It is not a method for assigning clinical diagnoses; instead, its purpose is to function as a supplementary interview that enhances the clinician’s understanding of potential cultural factors. It also may aid in the diagnostic decision-making process. The CFI includes an introduction and four sections (composed of 16 specific questions). The four sections include:

1. Cultural definition of the problem
2. Cultural perceptions of cause, context, and support
3. Cultural factors affecting self-coping and past help seeking
4. Cultural factors affecting current help seeking

Questions from each section are worded in ways to help clinicians gently explore cultural dimensions of their clients’ problems. Question 2 is a good representation: “Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?” (American Psychiatric Association, 2014).

Clinicians are encouraged to use the CFI in research and clinical settings. There is also a mechanism for users to provide the American Psychiatric Association with feedback on the CFI’s utility. It may be reproduced for research and clinical work without permission, which is a cool thing.

If you Google: “Cultural Formulation Interview” the first non-advertised hit should be a .pdf of the CFI.

If you Google: “Clinical Interviewing” the first several hits will take you to some form or another of our text on the topic.

Here’s a photo of me “working” inter-culturally with my brother-in-law (insert smiley face here):

Rebekah.Johnson.photo_0451

 

 

Talking About White Privilege with Tommy Flanagan

Tonight I’m in Absarokee, MT and had a chance to talk awhile with my very cool nephew, Tommy Flanagan. Tommy attends Pacific Lutheran University in Tacoma, WA. He shared with me this evening that he’s currently enrolled in several courses focusing on gender, feminist, and cultural issues. We talked about our respective invisible knapsacks and he even asked me how a White guy like me would approach counseling with a Black Lesbian woman. In response, I said, “Well, I just wrote something about that in the Clinical Interviewing text and I had a Black Lesbian woman review it so I would be sure to get some feedback.”

And so here’s the piece:

Working with Gay and Lesbian couples or couples and families from different cultural backgrounds can present clinicians with unique challenges (Bigner & Wetchler, 2004). As discussed in Chapter 11, when a clinician and client have clear and unmistakable differences, the client may initially scrutinize the clinician more closely than if the client and clinician are culturally similar or of the same sexual orientation. These circumstances call for sensitivity, tact, and a discussion of the obvious. Imagine the following scenario:

You’re a white, heterosexual, Christian male. You have a new appointment at 3pm with Sandy Davis and Latisha Johnson for couple counseling. When you get to the waiting room, you see two African American females sitting side by side. You introduce yourself and on the short walk back to your office you mentally process the situation and come to several conclusions: (a) You’re about to meet with an African American Lesbian couple; (b) you’ve never done therapy with this particular cultural minority group; (c) you’re aware of your uncertainty and your concerns about your lack of knowledge makes you feel uncomfortable . . . but also recognize that you want the couple to be comfortable with you . . . and realize they may be feeling similar discomfort about your cultural differences; (d) you are clear that it’s your ethical mandate to provide services to the best of your ability; and (d) although you don’t feel competent to work with this couple, this is a low-income clinic and so the couple may not have many alternatives. How do you proceed?

Below is a brief list of how a clinician might specifically handle this situation. After this list, we provide a description of the underlying principles:

  1. Welcome the couple to your office with the warmth and engagement you offer to all clients (e.g., “I’m glad you could come to the clinic today for your appointment and am happy to meet you. . .”).
  2. Explain confidentiality and the limits of confidentiality. Also, review relevant agency policies that you routinely review with new clients.
  3. If you know the purpose of their visit (e.g., couple counseling) because of the registration form, explain how you usually work with couples.
  4. Let the couple know you’d like them to ask any questions of you they may have . . . but before they ask the questions, explain: “My usual approach with couples is primarily based on work with heterosexual couples. I don’t have experience working with African American Lesbian couples. I’d like to work with you as long as you’re comfortable working with me and it seems like the work is helpful. I know there aren’t lots of couple’s counseling options available. What I propose—if it’s okay with the two of you—is that we start working together today. Today I’ll be asking you directly about your goals for counseling, but also about your interests, values, spirituality and other things that will help me know you better as individuals and as a couple. And toward the end of our session I’ll ask you for feedback about how you think our work together is going and I’ll try to honor that feedback and make adjustments so we can work well together. If, for whatever reason, it looks like we can’t work together effectively, I’ll offer you a good referral to another therapist. What do you think of that plan?”

As described in Chapter 11, the general multicultural competencies include: (a) Awareness (e.g., knowing your biases and limitations); (b) knowledge (e.g., gathering information pertaining to specific cultural groups); and (c) skills (e.g., applying culturally-specific interventions in a culturally sensitive manner). In addition to these competencies, the preceding case illustrates the need for clinicians to explicitly address cultural differences using the following strategies:

  • Cultural universality (treating culturally different clients with same respect you offer to culturally similar clients)
  • Collaboration (working with the clients to understand the particulars of their culture and situation)
  • Feedback (soliciting ongoing feedback regarding client perceptions of how the interview is proceeding and make adjustments based on that feedback).

No clinician can be expected to have awareness, knowledge, and skills for working with every possible diverse client. That being the case, if you also rely on cultural universality, collaboration, and feedback to help strengthen the therapeutic alliance, you’ll have a better chance for therapy to proceed in an ethically and professionally acceptable manner.