Tag Archives: multicultural

Counseling and Psychotherapy Theory and Practice

Breathing New Life into Your Dead, White Counseling and Psychotherapy Theories Course

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Artwork by Rita Sommers-Flanagan**

On April 18 at 1:00p.m. EST, I’ll be doing a Wiley Webinar. This webinar is free, and especially geared toward academics who want to expand their repertoire for teaching counseling and psychotherapy theories. Because this webinar is sponsored by my publisher, John Wiley & Sons, there will be some minor marketing of my textbook, Counseling and Psychotherapy Theories in Context and Practice (3rd ed.). However, you can attend this webinar regardless of the textbook you use. My goal is to help open all of us up to how we can integrate new ideas into existing “older” theoretical perspectives.

Here’s the link to register: https://www.wileyplus.com/wiley-webinar-series/#john-sommers-flanagan

And here’s the official blurb for the webinar:

Teaching traditional counseling and psychotherapy theories courses can feel dull and boring. In this webinar session, John Sommers-Flanagan will share pedagogical strategies for integrating culture into theory, and engaging students with here-now activities that bring the dusty old theories to life. This webinar will include specific recommendations for how to integrate culture and feminist ideas into traditional theories. Learning activities will be demonstrated, including: (a) early intercultural memories; (b) sex, feminism, and psychoanalytic defense mechanisms; (c) empowered narrative storytelling; and (d) spiritual and behavioral forms of relaxation. Handouts for each activity will be available later on this blogsite.

Beyond this short description, I also want to acknowledge the obvious. As a living White person who writes about, teaches, and practices theory-based counseling and psychotherapy, I know that my ability to claim expertise in making cultural adaptations is limited. I don’t want to be the expert on this (or most things). The purpose of this webinar is NOT to “tell” anyone exactly what diversity modifications “should” be made when teaching counseling and psychotherapy theories. Instead, my purpose is to talk about and illustrate ways in which new diversity-sensitive ideas might be creatively integrated into old theoretical perspectives. From there . . . the application of these and your own ideas about how to breathe new life into old theories is up to you and your unique personal and professional worldview.

Given this big preceding caveat, the webinar’s learner objectives are to help participants:

  • Identify compatibilities of culture, spirituality, and feminist thought with traditional counseling and psychotherapy theories
  • Implement an intercultural memory activity with large or small groups
  • Implement and discuss diverse sexualities along with psychoanalytic defense mechanisms
  • Implement a multicultural empowered storytelling strategy
  • Implement and debrief spiritual and behavioral integrations to achieve relaxation

Soon (right around 4/18/19) I’ll be posting more information related to this webinar. In the meantime, let me know your thoughts on this topic. As always, I value alternative perspectives and enjoy hearing your reactions to the posts on this blog.

Suicide Assessment and Intervention

An Early Peek at the Suicide Assessment and Intervention Video Project

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Helicopter CroppedBack in March, 2012, I settled into a Starbucks in Vancouver, Washington to reflect on my experiences at the annual American Counseling Association conference in San Francisco. Memories of Dr. Irvin Yalom’s keynote bubbled up in my mind, so that’s what ended up in my fingers, on my screen, and in my blog.

Several days later, I got an email from a “Dr. Yalom.” Seeing the name, I immediately felt anxiety and anticipation. First thoughts, “I meant to be positive. I hope I didn’t write anything offensive?”

The email was from Dr. Victor Yalom. It was nice . . . and supportive . . . and positive . . . and a big relief.

Victor is the owner/publisher/president or grand sultan of psychotherapy.net. Psychotherapy.net is a publisher of psychotherapy training and continuing education materials, mostly videos. Over the past 6 years Victor and I have struck up a collegial friendship. He is the biggest fan and proponent of our Clinical Interviewing video series (which he sells through psychotherapy.net). After viewing the Clinical Interviewing video, he has repeatedly asked Rita and I about doing a video for psychotherapy.net. Unfortunately, the timing never worked out, until this past fall, when we agreed to collaborate on a six-hour suicide assessment and intervention training video.

As they say in the film industry, everything is in the can. We’re down to final editing and other details. We filmed in Missoula and Mill Valley. Rather than working directly with imminently suicidal clients, we got volunteers to channel previous or potential suicide-related experiences. All this is just my way of introducing this sneak peek into this upcoming video.

Of course, reading isn’t the same as watching, but the next 2,000 words can give you a glimpse of one of the cases featured on the video. The client is a young Native American man and veteran. Many cultural issues emerge during the session, along with suicide ideation. Here’s the clip, along with my side “commentary” in bold:

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John:            Cory, I know a little bit about you, but not very much. And so maybe the best place to start is for you to tell me some things about yourself, some things about how you’ve been feeling in your life, some things about the situations that you’ve been in, and maybe help me get a sense of how I might be of help.

Cory:            Yeah, I come from a small reservation in Eastern Montana, and I was kind of – it was a comfortable life growing up. I didn’t know anything different. And I remember sitting there with my family watching the war and kind of spurred us to want to help bring honor to our tribe. So, I signed up at 17.

John:            Yeah, what tribe?

Cory:            I’m from the Lakota Sioux tribe from the Fort Peck Indian Reservation.

John:            Okay. Great, thank you. Sorry.

Cory:            So, I left at 17, and it was kind of a big deal. We had a big honor, big gathering for me, big sendoff, and it was pretty great and feeling pretty good. Deployed when I was 18 years old over to Iraq. It was going great. I felt like I was doing something. I didn’t get to talk to my family much, maybe every three months. And I didn’t know what was going on at home. Had a fiancée when I left. Life was great. Eventually time to come home and came home. And my family’s kind of in disarray. My grandma died. I didn’t get to go to her funeral. They didn’t tell me.

John:            Yeah.

Cory:            So, kind of tore me up. My fiancée left me for one of my best friends, so that was the shock of my life.

John:            Yeah. So, at least at this point I’m hearing that you were on kind of a high and feeling good at 17, get a big sendoff from your tribe, from your family, and you go, and you go to Iraq. And you get back, and things are a mess.

Cory:            Yeah. Meth kind of hit our reservation pretty hard. And family members on meth and prison and kind of whole world changed, I guess. Eventually, I didn’t – just came back and started drinking. Not sure who I was anymore. So, that was difficult, didn’t have very many people to turn to anymore. Never had a father growing up. My mom was always raising us with a couple jobs. And eventually her and her boyfriend got into drugs, so that’s kind of pretty difficult. And I didn’t know what to do anymore. And I was kind of feeling down and just kept drinking, and I kind of don’t know what to do anymore. For us it’s a honor to serve and kind of makes us who we are.

John:            Yeah.

Cory:            We view it as becoming a warrior man.

John:            Yeah.

Cory:            And I felt like I did that, and I’d bring honor back to my culture, my tribe. Yeah, just I came home. Everything’s in disarray, and I thought I was pretty stable. Eventually – and one thing, on the reservation we don’t – or culturally we don’t talk about our feelings or emotions. So, every time we do, feel pretty shame. A lot of shame comes from it. So, it’s kind of you just deal with it.

John:            Yeah, yeah. Yeah, so a couple of cultural pieces. One is that sense of honor of serving, and you hooked onto that and were living that. And then another cultural thing is, it’s a little shameful to express emotions, sadness, that kind of emotion or others.

Cory:            Yeah, I mean, I guess I could just describe it as shame. Like I feel guilty talking about it because we’re supposed to be men.

John:            You’re warriors. You’re strong.

Cory:            Yeah.

John:            And so you keep it all –

Cory:            Yeah, it’s part of who we are, death, fighting, honor, celebrating together, just part of who we are.

John:            Yeah, yeah. And then as you get back, and you’re in this disarray, and the meth on your reservation is prevalent, and you start drinking, and it sounds like that could be connected with the emotional warrior. Is that one of the ways that you might cope?

Cory:            I guess I just – kind of just helped me feel nothing.

COMMENTARY: Cory has covered lots of ground quickly. He has articulated his collectivist identity. Knowing about his collectivist identity early in the session is a very good thing. He has also mentioned multiple stressors and losses; these stressors and losses are traditional risk factors and load onto the various risk dimensions. These include: coming back from war, being a veteran, loss and betrayal by his girlfriend, his grandmother’s death, the disarray of his tribal community from meth, and other issues. In addition, one immediate challenge that’s coming into my mind is how to address alcohol, because it’s a suicide desensitizer, but it’s also helping him “feel nothing” which is consistent with his cultural value of not expressing his feelings. At this point I’m choosing to build a relationship with Cory before jumping in and discussing alcohol directly.

John:            Okay.

Cory:            Just kind of, I guess, how I dealt with it because I couldn’t talk about stuff that happened over there, and I didn’t have no male role models in my life to kind of talk about culturally with or anything.

John:            Yeah. So, I’m aware of the fact that you’ve told me, and I really appreciate it, some cultural things about you, about being a Lakota Sioux, about the reservation that you grew up on and some of the things you experienced, about the honor, about the shame, about the warrior mentality. And I’m going to do my best to track all those things. Occasionally if you think I’m just not getting it from your cultural perspective, I would love it if you would tell me, but I don’t want to put all that responsibility on you. So, I will probably every once in a while just check in to see, am I getting this right? Is that okay with you if we –

Cory:            Yeah, that’s fine.

John:            Yeah, because I just don’t want to misunderstand things because of my lack of the same cultural experience as yours. And so as I’m imagining it, you’re back. You’re drinking. It’s part of being numb.

Cory:            Uh-huh.

John:            And getting rid of those emotions. And as you talk, one question that comes to mind to me, and my guess is that this would be a dishonorable thought to have, although not an abnormal thought because it’s not unusual when people come back and life is disappointing and hard, and you’re drinking, and you’re managing those emotions, it’s just not unusual to have a thought about suicide or about killing yourself. And my guess is that would be in opposition to your culture, too, but I don’t know.

Cory:            Yes and no. One way we look at is from we’ve had everything taken from us. That’s one thing you can’t take from us. Our life is ours to give to the Creator, to Wakan Tanka which is our God. So, when it’s our time, it’s kind of our choice.

John:            Okay.

Cory:            The sad thing about it is, I’m feeling down, and a lot of times like as I grew up I had – I was probably nine years old. My first friend committed suicide. And it brings the community together. We have big honoring, big feast for his family, for him, and just days of celebrating. It’s kind of like bring the family back together. I had another friend do it after that because he was – couldn’t graduate high school and didn’t have nobody there, and he wanted his family to come back together, so he committed suicide, just felt like it’s going to bring his family back together. And it did for a bit, but meth came in again, so it kind of tore it apart.

John:            Uh-huh.

John:            So, I’m hearing two suicides of people that you knew well around the time that you graduated high school?

Cory:            Oh, one was when I was 9, and a good friend was 16. And by the time I was 18, I probably lost maybe 7 friends from drinking and driving, drugs, stabbings. So, I guess to us, I mean, death is death, so it wasn’t really a big deal, kind of a celebration and we’ll see them again.

John:            Yeah. So, for each one the family celebrates, the community celebrates –

Cory:            Uh-huh.

John:            – the life. And sometimes it almost sounds like somebody might choose suicide as an effort, it sounds like, to pull the family together to get everybody closer.

Cory:            Yeah, I guess, too, they know people will care. Pretty big sense of hopelessness there. Not many people know where to turn.

John:            Yeah. Yeah, so that’s a lot of death that you saw even by the time you graduated high school. Have you had some thoughts of suicide yourself?

Cory:            Originally when I first came back, I did. I just didn’t know what to do anymore. Then I came to college, thought I was going to – wanted to do something honorable again. Again, big celebration and sent us off to college. And I get here, and things are going well at first. Then just the culture differences, like nobody understood me, didn’t know what to do. I was doing all right in classes, but I just kind of couldn’t fit in, didn’t feel like anybody understood me. I mean, they’re all pretty nice guys and gals. I could tell they were trying to, but just something I knew they didn’t.

And then now things are getting bad again. I’m trying to sleep at night. Yeah, just every time I go to sleep, I remember one time in Iraq we were sitting there, and they decided – well, I guess Al-Qaeda, they blew a whole street, whole city block, and it just – I mean, every building came down. And we were there trying to help, and you had kids with missing arms and missing eyes and moms with no legs and crying, screaming. We were trying help as best we can, and same time people shooting at us and just didn’t know what to do.

My friend’s crying. Like why the fuck are we here? Like what are we doing here? Like this isn’t what we – not what we’re here for. Yeah, I just remember a mom with no leg carrying her helpless child just in her arms, and the child was dead. I mean, just every time I go to sleep, I just remember that kid helpless laying there. And so I’m not sleeping much, a lot of drinking still. I guess I don’t know what to do anymore.

COMMENTARY: It’s not unusual for suicidal clients to present with a vast array of psychological pain. That can be overwhelming to the client and to the therapist. Cory has shared several layers of unresolved grief, traumatic war memories. The number of people whom he has known who have died by suicide is immense. Additionally, because of his cultural norms of stoicism, I’m wanting to address these parts of his experience, while not activating intense emotions. my strategy has been and will be to use reflection of content, to avoid reflecting back strong emotions like sadness or anger, to keep his collectivist perspective in mind, and to take notes in a way so that he and I can take a more intellectual and problem-solving approach to working with him on his experiences.

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If you made it this far, a big congratulations. Acquiring skills to work effectively with clients who are suicidal is challenging, but dealing with the emotions that come up is probably even more difficult. The purpose of this training video (when it becomes available) is to help practitioners obtain knowledge, learn skills, and refine their awareness of the inner and interpersonal dynamics associated with suicide assessment and intervention. When I have more information on the video’s availability, I’ll let you know.

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Multicultural, Therapy with Adolescents

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

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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.

Counseling and Psychotherapy Theory and Practice

A Short Existential Case Example from Counseling and Psychotherapy Theories . . .

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Each chapter in Counseling and Psychotherapy Theories in Context and Practice includes at least two case vignettes. These vignettes are brief, but designed to articulate how clinicians can use specific theories to formulate cases and engage in therapeutic interactions. The following case is excerpted from the Existential Theory and Therapy chapter.

This post is part of a series of free posts available to professors and students in counseling and psychology who are teaching and learning about theories of counseling and psychotherapy. It, as well as the recommended video clip at the end, can be used for discussion purposes and/or to supplement course content.

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Vignette II: Using Confrontation and Visualization to Increase Personal Responsibility and Explore Deeper Feelings

In this case, a Native American counselor-in-training is working with an 18-year-old Latina female. The client has agreed to attend counseling to work on her anger and disruptive behaviors within a residential vocational training setting. Her behaviors are progressively costing her freedom at the residential setting and contributing to the possibility of her being sent home. The client says she would like to stay in the program and complete her training, but her behaviors seem to say otherwise.

Client: Yeah, I got in trouble again yesterday. I was just walking on the grass and some “ho” told me to get on the sidewalk so I flipped her off and staff saw. So I got a ticket. That’s so bogus.

Counselor: You sound like you’re not happy about getting in trouble, but you also think the ticket was stupid.

Client: It was stupid. I was just being who I am. All the women in my family are like this. We just don’t take shit.

Counselor: We’ve talked about this before. You just don’t take shit.

Client: Right.

Counselor: Can I be straight with you right now? Can I give you a little shit?

Client: Yeah, I guess. In here it’s different.

Counselor: On the one hand you tell me and everybody that you want to stay here and graduate. On the other hand, you’re not even willing to follow the rules and walk on the sidewalk instead of the grass. What do you make of that?

Client: Like I’ve been saying, I do my own thing and don’t follow anyone’s orders.

Counselor: But you want to finish your vocational training. What is it for you to walk on the sidewalk? That’s not taking any shit. All you’re doing is giving yourself trouble.

Client: I know I get myself trouble. That’s why I need help. I do want to stay here.

Counselor: What would it be like for you then . . . to just walk on the sidewalk and follow the rules?

Client: That’s weak brown-nosing bullshit.

Counselor: Then will you explore that with me? Are you strong enough to look very hard right now with me at what this being weak shit is all about?

Client: Yeah. I’m strong enough. What do you want me to do?

Counselor: Okay then. Let’s really get serious about this. Relax in your chair and imagine yourself walking on the grass and someone asks you to get on the sidewalk and then you just see yourself smiling and saying, “Oh yeah, sure.” And then you see yourself apologize. You say, “Sorry about that. My bad. You’re right. Thanks.” What does that bring up for you.

Client: Goddamn it! It just makes me feel like shit. Like I’m f-ing weak. I hate that.

In this counseling scenario the client is conceptualized as using expansive and angry behaviors to compensate for inner feelings of weakness and vulnerability. The counselor uses the client’s language to gently confront the discrepancy between what the client wants and her behaviors. As you can see from the preceding dialogue, this confrontation (and the counselor’s use of an interpersonal challenge) gets the client to look seriously at what her discrepant behavior is all about. This cooperation wouldn’t be possible without the earlier development of a therapy alliance . . . an alliance that seemed deepened by the fact that the client saw the counselor as another Brown Woman. After the confrontation and cooperation, the counselor shifts into a visualization activity designed to focus and vivify the client’s feelings. This process enabled the young Latina woman to begin understanding in greater depth why cooperating with rules triggered intense feelings of weakness. In addition, the client was able to begin articulating the meaning of feeling “weak” and how that meaning permeated and impacted her life.

To check out a 4+ minute existential counseling video clip go to: https://www.youtube.com/watch?v=jiirtIKcIeM

This clip is taken from our Counseling and Psychotherapy Theories 2 DVD set. The 2 DVD set is available through Psychotherapy.net: http://www.psychotherapy.net/video/counseling-psychotherapy-theories and Amazon: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1118402537/ref=asap_bc?ie=UTF8

Clinical Interviewing, Multicultural, Personal Reflections

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

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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

 

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

DSM-5 and the Universal Diagnostic Exclusion Criteria

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Sometimes, even when someone appears to meet all the diagnostic criteria for a mental disorder, assigning a psychiatric diagnosis is still not the right thing to do.

In the following excerpt from the forthcoming 5th edition of Clinical Interviewing, we offer an example of when and why psychiatric diagnosis is inappropriate (see: http://lp.wileypub.com/SommersFlanagan/). We refer to this as the “Three-Dimensional Universal Exclusion Criterion” which is our highly esoteric way of saying, “Whoa on psychiatric diagnosis until you’ve checked to see if there’s an alternative explanation for the observed behaviors!”

Multicultural Highlight 6.2

The Three-Dimensional Universal Exclusion Criterion: Is the Behavior Rationally or Culturally Justifiable or Caused by a Medical Condition?

Let’s say you meet with a client for an initial interview. During the interview the client describes an unusual belief (e.g., she believes she is possessed because someone has given her the “evil eye”). This belief is clearly dysfunctional or maladaptive because it has caused her to stop going out of her house due to fears that an evil spirit will overtake her and she will lose control in public. She also acknowledges substantial distress and her staying-at-home-and-being-anxious behavior is disturbing her family. In this case it appears you’ve got a solid diagnostic trifecta—her belief-behavior is (a) maladaptive, (b) distressing, and (c) disturbing to others. How could you conclude anything other than that she’s suffering from a psychiatric disorder?

This situation illustrates why diagnosis (see Chapter 10) is a fascinating part of mental health work. In fact, if the client has a rational justification for her belief-behavior . . . or if there’s a reasonable cultural explanation . . . or if the belief-behavior is caused by a medical condition—then it would be inappropriate to conclude that she has a mental disorder. One source of support for a universal exclusion criterion is the DSM-5. It includes the statement: “The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individual’s cultural reference groups” (American Psychiatric Association, 2013, p. 750).

To explore our three-dimensional “universal” exclusion principle in greater depth, partner up with one or more classmates and discuss the following questions:

Can you think of any rational explanations for the client’s belief-behavior?

Can you think of any reasonable cultural explanations for the client’s belief-behavior?

Can you think of any underlying medical conditions that might explain her belief-behavior?

After you’ve finished discussing the preceding questions, see how many new examples you can think of where a client presents with symptoms that are (a) dysfunctional/maladaptive, (b) distressing, and (c) disturbing to others. Then discuss potential rational explanations, cultural explanations, and medical conditions that could produce the symptoms (e.g., you could even use something as simple as major depressive symptoms and explore how rational, cultural, or medical explanations might account for the symptoms, thereby causing you to defer the diagnosis.

 

Counseling and Psychotherapy Theory and Practice, Parenting

Practicing Cultural Humility with Parents

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Alfred Adler (1958) claimed that every child is born into a new and different family. He believed that with every additional member, family dynamics automatically shift and therefore a new family is born (J. Sommers-Flanagan & Sommers-Flanagan, 2004a). If we extend Adler’s thinking into the cultural domain, it might be appropriate to conclude: “Every family is born into a new and different culture.”

[This is an excerpt from “How to Listen so Parents will Talk and Talk so Parents will Listen.” It’s at: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1369460232&sr=1-5%5D

To be sure, culture is not a static condition; it’s a malleable and powerfully influential force in the lives of parents and children. Vargas (2004) stated,

“Culture is not about outcome. Culture is an ever-changing process.  One cannot get a firm grip of it just as one cannot get a good grasp of water.  As an educator, what I try to do is to teach about the process of culture—how we will never obtain enough cultural content, how important it is to understand the cultural context in which we are working, and how crucial it is to understand our role in the interactions with the people with whom we want to work or the communities in which we seek to intervene. . . .  I do not want to enter the intervention arena (whether in family therapy or in implementing a community-based intervention) as an “expert” who has the answers and knows what needs to be done.  I am not a conquistador, intent on supplanting my culture on others.  I have a certain expertise that, when connected with the knowledge and experience of my clients, can be helpful and meaningful to my clients.” (p. 429)

In part, Vargas was making the point that it’s more important for professionals to practice cultural humility than it is to view ourselves as culturally competent.

A Cultural Dialectic

All professionals should strive to be culturally sensitive and humble, seeking to respect and prize human diversity for the richness, variety, and surprises it brings to life.  But while embracing culture, it’s important to acknowledge that there’s no perfect culture, and sometimes cultural practices need to change or evolve for the sake of a given child, parent, or family.  Therefore, although we value divergent cultural perspectives, it’s also reasonable  to question whether specific cultural beliefs and rituals are useful or healthy to individuals, families, and communities. This is a cultural dialectic—similar to the radical acceptance dialectic discussed in Chapter 1.

When working with parents, it’s the professional’s job to do the cultural accepting and the parents’ job to do the cultural questioning. You should accept the parents’ cultural background, heritage, and parenting practices. However, if in the process of examining cultural influences on parenting, parents take the lead in questioning their culturally influenced parenting practices, you can and should remain open to helping parents push against cultural forces to make positive changes. For example, parents may want to discuss any of the following topics with you:

  • Whether or not to have their infant son circumcised
  • Their daughter’s body-image issues as they relate to American cultural values toward thinness
  • Whether it’s acceptable for their Muslim daughter to attend school or pursue higher education
  • Traditional Native American values and their children’s potential tobacco use

Helping parents determine whether their own cultural values clash with individual and/or family well-being is a delicate and potentially explosive process.  The challenge is to remain relatively neutral while helping parents evaluate cultural practices using their own parent-child-family health and well-being standards.

Case: Tobacco, Culture, and Addiction

Parent: I’m worried about my son and whether he’s started smoking. I use tobacco, in traditional Indian ceremonies, but I usually end up smoking more than I want to, and I see it as a bad habit, too. I’m not sure how to approach this with him because I don’t want to be a hypocrite.

Consultant: Tell me some ideas you’ve had, from your cultural perspective, about how to get the message you want to get to your son.

Parent: I want him to know that tobacco use should beceremonial or sacred, even though I use it more often than that. I know regular smoking is very unhealthy and so I don’t want him to have it as a habit, but I don’t know how to tell him that.

Consultant: If you think about someone from your tribe whom you really respect, how do you think that person would handle it?

Parent: In my tribe it’s really important to respect your elders. I’m my son’s mother and he should respect me, but you know how that goes. Maybe if I asked someone else, someone older and with even more respect than me, maybe that would help.

Consultant: Whom would you pick to help you talk with your son about this?

Parent: My older brother, his uncle, is pretty high up in the Tribal Government and maybe I could ask him to tell my son it would be better not to smoke, even though lots of Indian people smoke.

Consultant: Do you think your brother would be willing to give your son that message?

Parent: Yes. He’s traditional in some ways, but he’s very much against all smoking and drinking.

Consultant: You and your brother are both right about the dangers of regular tobacco use. As I imagine this discussion, I can see the two of you having a big impact on your son. But I guess there’s also the issue of your smoking and your son’s knowledge of that. Can you have your brother talk about that with your son, too? Or maybe both of you should do this together. How do you think this might work best?

In this case example, for the most part, the consultant is remaining neutral and respectful of the parent’s cultural traditions and yet, at the same time, helping her explore how to get her son a strong and clear message about not smoking tobacco.

Following the Parents’ Lead in Cultural Identity and Cultural Understanding

For most of us, culture is so deeply woven into our lives that it travels below awareness. From time to time we may glimpse it and wonder how it came to be that we choose to engage in specific cultural behaviors, such as:

  • Sitting on the couch with our children watching The Simpsons
  • Getting eggs from the store rather than directly from backyard chickens
  • Going to church on Palm Sunday where a processional, complete with a donkey, waits quietly in the sanctuary
  • Deferring to one’s husband
  • Expecting our oldest son to take care of us
  • Gathering with friends to overeat and watch the Super Bowl
  • Wearing a yarmulke, burkha, or other garments or pieces of cloth to cover our bodies or heads

Culture carries with it many questions, answers, and mysteries. As you can see from the preceding list, culture is ubiquitous; it’s impossible to escape its influence. It’s also impossible to accurately judge someone else’s cultural identity on the basis of physical appearance or initial impressions (Hays, 2008).

When working with parents, you shouldn’t assume parents’ cultural attitudes and experiences in advance. This is true no matter how similar or dissimilar to you the parents appear.  It’s best to begin with a clearly stated attitude of openness and then follow the parents’ lead.

Consultant: So, you grew up in Malawi?

Parent: Yes. I came to the United States when I was twenty-four.

Consultant: I don’t know how much of your Malawi tradition influences your parenting and so I hope it will be okay with you if, on occasion, I ask you about that.

Parent:  That’s no problem at all.

Consultant: And, as we talk, I hope you’ll feel free to tell me about anything that comes up or seems important about your particular cultural approach to parenting.

Parent: Yes. I’m comfortable with that.

Whether the parent is Laotian, Belizean, Argentine, French Canadian, or from any other cultural tradition, you should remain open to his or her particular and potentially diverse parenting approaches. However, you should also be open to helping parents question whether their own approaches to parenting are bringing them the results they desire. This is your professional duty. Again, the basic principle is to follow the parents’ lead in questioning cultural parenting practices and not become a cultural conquistador who tells all parents the one right way to be a parent.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Multicultural

Talking About White Privilege with Tommy Flanagan

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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.

 

Clinical Interviewing

Psychic Communications . . . and Cultural Differences in Mental Status

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You may or may not have noticed that I haven’t posted anything on this blog in the past 10 days or so. This is because I’ve been experimenting with my telepathic (psychic) communication abilities. As it turns out, my telepathy skills aren’t as refined as I wish they were and so instead of any specific communications from me, receivers have only experienced warm and fuzzy positive sensations. And so if you experienced anything positive like that over the past ten days, it probably means I was thinking of you and trying to psychically send you some pleasant holiday wishes.

Below please find another installment in my intermittent Mental Status Examination series. This posting includes an activity you can use yourself or with a class to facilitate a discussion (with yourself or among class members) about cultural differences in mental status.

Happy New Year! and Happy Mental Statusing!!

Cultural Differences in Mental Status

Part One: Cultural norms must be considered when evaluating mental status. In the following Table, read through the MSE category, the MSE observation, and then contemplate the “invalid conclusion” along with the “explanation.” The purpose of this activity is to illustrate how cultural background and context can affect the meaning of specific client symptoms.

Category Observation Invalid Conclusion Explanation
Appearance Numerous tattoos and piercings Antisocial tendencies Comes from region or area or subculture where tattoos and piercings are the norm
Behavior/psychomotor activity Eyes downcast Depressive symptom Culturally appropriate eye-contact
Attitude toward examiner Uncooperative and hostile Oppositional-defiant or personality disorder Has had abusive experiences from dominant culture
Affect and mood No affect linked to son’s death Inappropriately constricted affect Expression of emotion about death is unaccepted in client’s culture
Speech and thought Fragmented and nearly incoherent speech Possible psychosis Speaks English as third language and is under extreme stress
Perceptual disturbances Reports visions Psychotic symptom Visions are consistent with Native culture
Orientation and consciousness Inability to recall three objects or do serial sevens Attention deficit or intoxication Misunderstands questions due to language problem
Memory and intelligence Cannot recall past presidents Memory impairment Immigrant status
Reliability, judgment, and insight Lies about personal history Poor reliability Does not trust White interviewer from dominant culture

Part Two: For each category addressed in a traditional MSE, try to think of cultures that would behave very differently but still be within “normal” parameters for their cultural or racial group. Examples include differences in cultural manifestations of grief, stress, humiliation, or trauma. In addition, persons from minority cultures who have recently been displaced may display confusion, fear, distrust, or resistance that is entirely appropriate to their situation.

Work with a partner to generate possible MSE observations, in addition to those listed in Part One of this Multicultural Highlight and using the Table below, that might lead you to an inappropriate and invalid conclusion regarding client mental status.

Category Observation Invalid Conclusion Explanation
       
       
       

This Table is adapted from the text, Clinical Interviewing, by John and Rita Sommers-Flanagan: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=la_B0030LK6NM_1_1?ie=UTF8&qid=1357167677&sr=1-1

 

Counseling and Psychotherapy Theory and Practice, Multicultural, Personal Reflections

A White Male Psychologist Reflects on White Privilege

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I’m a white male writing about white privilege. This irony makes the task all the more challenging.

Gyda Swaney asked if I would write this piece. This brings me mixed feelings. I am honored. I met Gyda in 1981 and I like and respect her as a person and as a Native American leader in Montana. But the fact that she thinks I might have something useful to say to psychologists about white privilege is humbling. Rarely have I been asked to write about something I know so well and understand so little.

On Invisibility

The challenge begins with the definition. White privilege is defined as an “invisible package of unearned assets” (see McIntosh, 1988 or 2001 for more on this).

As a white, male, psychologist, and university professor, I’m pretty much a white privilege poster boy. Consequently, white privilege, by definition, is generally invisible to me . . . although I do occasionally glimpse it from the corner of my eye or notice its shadow if I sneak up on it when it’s not looking. In fact I think I just saw it – as evidenced by my certainty that I can write a sentence as silly as this last one and get it published in the Montana Psych Association Newsletter.

Like most things invisible (think UFOs, Harry Potter with his invisibility cloak on, ghosts) white privilege is problematic and controversial. This is because white privilege is not always invisible; it’s selectively invisible. It’s obvious to many (e.g., oppressed minorities), but beyond the awareness of those who are busily experiencing the luxury of their unearned assets.

Common Responses to White Privilege

This brings up what may be the most fascinating and disturbing component of white privilege: When the idea of white privilege is brought to the attention of those to whom it’s invisible, it typically evokes a response of defensiveness combined with anger, hostility, outrage, and occasionally guilt. And as we know from our work in psychology, dealing with people who are feeling angry, hostile, outraged, and guilty is very difficult.

There’s something about white privilege that has the potential to make everyone angry.

Personal Reflections

Although White privilege precedes me and I hold no responsibility for its origins, I was born into it and have lived with it every day for nearly 55 years. Even my birth, characterized by greater-than-equal access to healthcare, is an example of my white privilege.

Maybe that’s a phrase that captures much of the white privilege experience—greater-than-equal. My whiteness and the whiteness of most Montana psychologists affords us greater-than-equal treatment, greater-than-equal power, greater-than-equal access, and greater-than-equal perceptions of ourselves. But privilege is complicated . . . and so it’s possible that we also have a greater-than-equal means of denying our privilege.

Privilege grows in complexity when we look at all the different factors that contribute to a more privileged status in one person and a less privileged status in others. My wife consistently reminds me of my male privileged status and although I’m inclined to deny this along with my white privilege, I know better. I was born male and being born male is like being dealt an ace as your first card in a round of Texas Hold-Em. In most cultures it’s clear that to be male is to be superior. That’s the case even though, as most males know, being handed an expectation of superiority isn’t always comfortable or easy. Paradoxically or dialectically, being a white male cuts both ways and isn’t only an unearned asset or gift, it’s also an unearned burden. It’s a burden like having to carry too many gold coins and diamonds to the bank. The weight of gold hurts your back and the diamonds cut your hands, but it’s ridiculous to complain about the fact that you have to carry a treasure to the bank.

Solutions

There are no easy ways to make white privilege quickly materialize and become visible. The resistance and pain associated with being told: “You’ve got unearned assets” is natural, partly because most people hold the perception that they’ve worked very hard to get what they deserve. Here’s a short list of ideas:

  • Teaching and learning about Peggy McIntosh’s Invisible Knapsack is a good place to start. One of the items from her knapsack is:

“I can swear, or dress in secondhand clothes, or not answer letters, without having people attribute these choices to the bad morals, poverty, or illiteracy of my race.”

  • Damn. That’s a nice privilege.
  • Teaching and learning about white privilege can be dangerous and so courage is another important factor in dealing with white privilege. Boatright-Horowitz and Soeung (2009) titled their commentary in the American Psychologist, “Teaching White Privilege to White Students Can Mean Saying Good-bye to Positive Student Evaluations.” When I recently posted about white privilege on my blog, I received one response that was so rabidly irrational it was frightening. Speaking out against the status quo always risks blowback.
  • A big part of the solution is to stop clinging to ideas about white superiority and instead, openly embrace and value the lessons we learn from other cultures. We should actively seek out other cultural perspectives. That isn’t about making the other culture better than ours . . . it just places it on the same, equal cultural footing where it belongs.
  • It’s also important to work on calming our anxiety over displacement from the top of the economic and power pyramid. We all get displaced someday; denying reality is dysfunctional. Actively sharing power along with values of egalitarian personal and community relationships is functional. This is part of the very important personal and communal work we need to do.

In closing, I’m painfully aware that I write this short column from a position of unearned privilege in a cabin on former Crow country on the beautiful Stillwater River; thank you Gyda Swaney, for handing me this challenge and opportunity.

This essay was published in the Montana Psychologist Newsletter in September, 2012.