Working with All Families: Developing Cultural Competence

OBJECTIVES:

 Clinicians will understand how implicit bias affects access to, and the effectiveness of, mental
health treatment for some minority communities.
 Clinicians will appreciate the multidimensional aspect of culture and cultural influences on
family life.
 Family workers will appreciate the necessity of lifelong learning and personal growth when it
comes to understanding culture and the implications it has on their treatment with families.

“We live in the most ethnically diverse society that has ever existed on the planet and have struggled
since its beginning over issues of ethnicity.”

 Monica McGoldrick, Joe Giordano and Nydia Garcia-Prieto

To this statement from the third edition (2005) of the tremendously important book, Ethnicity & Family
Therapy, we can add that we are still struggling with these issues. Even as our demographics change to
accommodate and reflect a small and interdependent world (non-Hispanic whites now make up less
than 70 percent of the population), and even as interracial marriages are now 10 percent of all
marriages – and 17 percent (1 in 6) of all new marriages (Bialik) – we are forced to note with concern
such recent phenomena as:

 The nation’s first African-American (or biracial) president was continuously hounded and libeled
as a “Muslim” and an “alien” until he felt compelled to publicly display his birth certificate;
 It seems that hardly a week goes by without police officers being caught on video killing an
unarmed, unoffending or fleeing black suspect. A common defense is that the officers feared for
their safety. The officers are seldom charged, and even less often convicted;
 Our government is unable to come up with a satisfactory immigration policy for people from our
southern neighbor and close trading partner Mexico – a country from which we seized the
territories that are now Texas, California, Nevada, Arizona, New Mexico, Utah, and parts of
Colorado and Wyoming;
 The same is true for immigrants from Central America, who are fleeing lawlessness and violence
perpetrated by the inheritors of arms belonging to militias and death squads that were trained,
armed, and sometimes created by our government in the 1980s and 1990s during unrest and
civil wars in that region.

Furthermore, race and ethnicity are just two of the identities through which our “culture wars” are daily
contested in the news media, on social media, and in the political arena. Some examples: the oft-recited
separation between church and state that was supposedly settled at the nation’s birth is anything but
settled to many Americans who expect their government to public support Christian values; successive

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waves of feminist movement have not brought equality to women in public life, as shocking, long-
running sexual abuse scandals keep surfacing; in fact, we still argue over what equality for women even
means and if it’s even desirable; gay and lesbian people had been steadily, if unevenly, gaining legal
rights and social acceptance when suddenly (it seems) the public was forced to wrestle with a related
controversy: the idea – and the reality – of gender uncertainty, fluidity and even change.

To initiate a conversation on culture in these times is to enter a bewildering maze: it’s easy to get in, but
how does one see their way through? And yet, the conversation must surely be had, over and over. To
insist that “we” (which we?) have nothing to learn about “them” (which them?) is to unwittingly admit
just how much there is to learn.

While much of the “culture war” (and its attendant anxiety) is instigated for political gain, its messages
resonate with very real values and beliefs held by many people. Some values are deep-seated, rooted in
lived experience and family and/or group beliefs and myths; while others are less solidly held, fueled by
uncertainty, fear and ignorance. It is relatively easy to fear (or be manipulated into fearing) the
unknown, and we are people with short memories and little curiosity about history, which renders
confusing that which could be known. But as President Franklin Roosevelt said, “we have nothing to
fear but fear itself.” For history tells us that people have always migrated for a variety of reasons
unrelated to harming their hosts; that people of different races and nationalities have always mixed
whenever they have come into contact with one another; that the definition of family and the
prescribed roles of women, men and children have varied, depending on cultural context; and that some
people have always existed outside the male/female binary.

As therapists, counselors, social workers, case managers and related professionals, we may like to think
that we are more culturally competent and accepting of the differences in people. We may be tempted
to skip the whole uncomfortable conversation on cultural competence. Rather than place people in
categories or boxes and emphasize differences, shouldn’t we accept everyone as a unique individual and
help that individual be the best person that he or she can be? After all, everyone is just a human being.

More than “just human”

Everyone is indeed “just human” and an individual as well, but what went into making and shaping this
individual? Psychologist Derald Wing Sue posits a “tripartite framework for identity” that operates in
everybody: there is the universal identity (Homo sapiens), group identity (race, nationality, gender, age,
etc.) and the individual identity. Mental health professionals have historically concentrated on the
universal and individual identities, while ignoring the group (Sue). But despite our similarities and
universally-shared needs (for food, shelter, nurturance and group cooperation), there is no one
“universal” template for how human societies and families function.

In a similar vein, McGoldrick and colleagues write, “Although human behavior results from intrapsychic,
interpersonal, familial, socio-economic, and cultural forces, the mental health field has paid greatest
attention to the first of these – the personality factors that shape life experiences and behavior”
(McGoldrick, Giordano & Garcia-Preto, 3). They go on to note that a diagnosis can be given and an

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entire course of treatment undertaken “with no thought of the patient’s culture at all” (ibid). That was
2005; how true is that statement today?

Just as we now realize that it is impossible to truly help people who have been traumatized if we are
unaware of the trauma, so too must we be cognizant of the cultural influences in the lives of the people
we serve. Culture orients people to think, feel, believe, and act in somewhat predictable ways in certain
contexts. McGoldrick et al. remind us that besides race and ethnicity, other dimensions of culture
include gender, socio-economic status, religion, and politics. Professional helpers are also the products
of, and therefore influenced by, cultural forces. As discussed in module III (“Joining, Assessment and
Contracting”), “the self” of the helper – our unique personality – is our greatest tool, but only if we are
aware of our personal weaknesses as well as our strengths. Among our biggest weaknesses are our
biases and prejudices about people, including our attitudes and beliefs about “the Other” – people
whose cultural background, beliefs and experiences are different from ours.

Social science uses the term “implicit bias” to describe attitudes we have towards people, or stereotypes
we associate with them, without our conscious knowledge. A common example of this is seen in
numerous studies that show white people frequently associate criminality with African Americans
without realizing they’re doing it (Perception Institute). Everyone holds implicit biases about some
group of people or another; they are inevitable, the result of a kind of unconscious psychological sorting
process that humans use, and the bias can be aversive or preferential. If we are aware of our biases, we
can adjust our actions accordingly. When we fail to do so, these biases can lead to serious negative
consequences in the delivery of services.

We aren’t the world

Mental health clinicians are overwhelmingly white and we do ourselves and our clients an injustice
when we fail to acknowledge this. While about 13 percent of the population is African American, just
two percent of psychiatrists, two percent of psychologists, and four percent of social workers are black
(Turner 2014; Williamson). Numerous studies have found that African-American clients are less likely to
receive accurate diagnoses than their white counterparts (Turner 2014; Williams; Williamson). Severe
depression is underdiagnosed in black patients and schizophrenia is over-diagnosed (Poussaint &
Alexander); African-American children are twice as likely to be misdiagnosed as disruptive before they’re
diagnosed Autistic (Harper’s). Is there any doubt that implicit bias on the part of clinicians accounts for
many of these errors?

Similarly, although Hispanics now account for almost one-fifth of the population and their mental health
needs are no different than the rest of the population in terms of the prevalence of mental health
conditions, they are less likely to seek services and more likely to discharge early when they do enter
treatment (Dingfelder; Fierros & Smith; Kouyoumdjian et al.; Mental Health America; NAMI; Sue; Turner
2016). Could the fact that Hispanic clinicians are as scarce as African-American clinicians contribute to
the problem?1
1
Just how scarce is hard to even say. Mental Health America’s website (accessed in July 2018) states that “in
2005” the APA (psychology) noted that “only one percent of psychologists identified themselves as Hispanic” –
possibly leaning on Dingfelder’s 2005 APA Monitor article. The literature abounds with statements about the

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The benefits of having “a diverse pool of practitioners” are many. First, minority clinicians are more
likely than their white counterparts to treat minority clients. And “ethnic matching (i.e., having Hispanic
patients see Hispanic mental health practitioners) has been shown to be effective in aspects of mental
health treatment and for some Hispanic groups” (Acevedo et al., 14). When there is a “concordance of
race and ethnicity, patients are more likely to be satisfied and to adhere to treatment
recommendations” (ibid). The APA (psychiatry) has noted: “Several studies have found that bilingual
patients are evaluated differently when interviewed in English as opposed to Spanish and that Hispanics
are more frequently undertreated.”

None of the above means that white clinicians are inherently “bad” for clients of color, or that their
implicit bias has to get in the way of constructive treatment. In fact, as long as the overwhelming
majority of mental health professionals are white, white clinicians will have to be “good enough” for
both white clients and minority clients. Perhaps the first step for all clinicians, white or otherwise, in
overcoming implicit bias is to understand that “. [t]o say that White culture is the dominant subculture
in the United States is not an indictment of individual White people. It is to say that White culture
holds greater power to control resources, set rules, and influence events in comparison to other
subcultures”2 (Giordano & McGoldrick, 510).

Our mental health system – our diagnostic methods and categories, our treatment models – is firmly
embedded in Western European-American culture. If we are unable to think and intervene outside of
this “ethnocentric monoculturalism” (as D.W. Sue calls it), then we are in danger of stigmatizing as
“dysfunctional” or misdiagnosing people whose cultural norms we do not understand. Our outcomes
when working with them will be poor, they may leave treatment early, or they may not bother seeking
help at all.

To be culturally competent

Sue gives an example of how Western cultural values could lead to giving poorly-received advice to
Asian-American clients. One of the hallmarks of Western culture, and therefore psychotherapy and
counseling, is a strong belief in individual autonomy. However, in traditional Asian societies, and among
Asian Americans who follow those traditions, a group orientation is highly valued whereas a self-
orientation is seen as, well, selfish. Thus, the Japanese have a saying that translates: “The nail that
stands up should be pounded back down” (Sue, 796). Imagine how a Japanese American family might
respond to professional advice to give a troubling adolescent more autonomy!

Sue champions a “multidimensional cultural competence (MDCC)” model in which the core components
are the clinician’s attitudes and beliefs; knowledge, and skills. Given that our field is immersed in the
Western tradition and therefore disseminates implicit assumptions of Western cultural superiority, he
believes that multicultural competence “must be about social justice—providing equal access and
opportunity, being inclusive, and removing individual and systemic barriers to fair mental health

shortage of Hispanic clinicians but we could find no recurrent figures like the often-cited “2-2-4” number for
African-American clinicians.
2
Our emphasis.

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services” (801). His definition of cultural competence is broad and demands action at all levels, from
that of the individual helper all the way up to the systems and decision-making levels:

Cultural competence is the ability to engage in actions or create conditions that maximize the
optimal development of client and client systems. Multicultural counseling competence is
defined as the counselor’s acquisition of awareness, knowledge, and skills needed to function
effectively in a pluralistic democratic society (ability to communicate, interact, negotiate, and
intervene on behalf of clients from diverse backgrounds), and on an organizational/societal
level, advocating effectively to develop new theories, practices, policies, and organizational
structures that are more responsive to all groups (802).

If the prescriptions embedded in that definition seem daunting, perhaps these words from a young
clinician will make the challenge seem less imposing to the individual helper: “[C]ultural sensitivity is not
knowing everything about a culture but being willing to accept other cultures’ practices as being of
equal value” (Williams, 36). We believe that is the attitude Sue is looking for; it will serve us well in
serving others, regardless of our beliefs about our own culture. When we combine an accepting attitude
with respectful curiosity about the people before us, we are likely to connect with clients in a way that
allows us to enter into their world.

Sue’s commitment to social justice and emphasis on race and ethnicity reminds that there is more to
cultural identity than just race and ethnicity, and that one can be oppressed, misunderstood or
underserved for other cultural characteristics. Celia Falicov seeks to address these other complexities
through a “multidimensional position” that takes into account the positions that she calls “universalist”
(all families are more alike than they are different), the “particularist” (each family is so unique that
generalizations aren’t possible), and the “ethnic-focused,” which, Falicov says, attributes differences in
families primarily to ethnicity (Falicov, 2).

Falicov’s multidimensional stance acknowledges the concept of syncretism, “the blending of cultural
influences,” and states that “in a multicultural society, each person is raised in a number of cultural
subgroups and draws selectively from the groups’ relative influences” (ibid). Simultaneous membership
in multiple groups with sometimes overlapping contexts makes generalization much harder than a
particular focus on ethnicity implies. She recognizes that “key concepts or parameters” are necessary
for “cultural comparison” in learning and training environments but also for doing actual family work.
The four parameters or “large categories” she focuses on “encompass connections and as well as
variations across groups:”

1. Ecological context. Every family occupies an “ecological niche” where overlapping cultural
influences shape views and values, provide belonging or deny access, and afford experiences of
relative power or powerlessness (ibd, 3).
2. Migration/acculturation. We of course are a nation of immigrants; increasing numbers of
immigrants and second-generation Americans are seeking, or in need of, mental health services.
Migration histories are both similar and dissimilar, affecting relative levels of acculturation.
3. Family organization. All families are organized in some fashion.

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 4. Family life cycle. Families everywhere have life cycles that include mating, raising children and
caring for the elderly.

Falicov views her “multidimensional comparative” position as a “both-and” situation, rather than an
“either/or proposition.” It is a “cultural lens” and “mainstream way of thinking that should always be
present when anyone is learning about families and family therapy” (ibid, 9).

Even with the proper attitude, it takes time to develop and hone the skills needed to work with diverse
populations. These words of advice about working with African Americans (Hines & Boyd-Franklin, 98)
can equally serve as a guide for working with any clients at any stage of one’s career:

Key to effective engagement, assessment, and intervention with African Americans is to convey
genuine respect, to move beyond generalizations, to communicate interest in learning about the
clients’ specific realities, and to help them reclaim and retain a sense of hope while moving
toward the changes that will enhance their well-being.

SOME US CULTURAL GROUPS

D.W. Sue’s third core component of cultural competence for the clinician is knowledge (attitudes/beliefs
and skill being the other two). Below are short historical-cultural sketches of just some of the cultural
groups you may encounter in your work, and implications for family work. These profiles are woefully
short and shamefully few. Even a mammoth tome like McGoldrick and colleagues’ Ethnicity & Family
Therapy (some 760 pages) raises almost as many questions for further research as answers. Learning
about the Other is a never-ending – and to us, always fascinating – journey. Remember that
generalizations merely provide a context from which to explore our – and our clients’ – hypotheses
about their particular issues, and nothing more. The key to, and beauty of, family work is the process of
immersing oneself in another family’s unique struggles and experiences in this journey we call life.

American Indians

Also called Native Americans, First Americans, Indigenous Americans and members of the First Nations,
the people who Europeans called Indians didn’t think of themselves as one people; they belonged to a
multiplicity of societies and civilizations with similar and differing practices and worldviews. Despite the
horrific genocide that decimated their populations over three centuries, the last census counted 6.7
million people who identified as either full-blooded “American Indian/Alaska Native” or mixed with one
or more other races – only two percent of the population but a substantial increase since the previous
census.

Most people will not be surprised to learn that “Indian cultures are rooted in family ties, a unique
attachment and respect for their natural surroundings, and a distinct spirituality” (Sutton & Broken
Nose, 47). Readers may be pleased to hear (and not for the last time, in this section) that family therapy
is a good treatment modality because of the “Indian way” of extended family life. For many American
Indians, “the primary relationship is not the parents, but the grandparents” (ibid, 45); great uncles and
aunts are respected like grandparents and cousins are viewed as siblings.

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However, these strong traditions and ties have been strained not only by the physical genocide and
removal to reservations, but also by the boarding school system which began in the late 1800s and
continued in force into the early 1980s. Federal policy required Indian children to be educated
according to strict Anglo-American standards until passage of the Indian Self-Determination and
Education Assistance Act of 1975. A system of boarding schools was created to augment existing
missionary schools on reservations. Children as young as five years of age were taken from their homes
to boarding schools far away.

As most families were poor, visits to pupils were few. Students were forbidden from speaking their
native languages, wearing traditional dress or hairstyles, and performing familiar ceremonies and rituals;
and they were subjected to harsh discipline and forced labor. The children and their family members
often became strangers to one another. Even after a 1928 report noted that students suffered
malnutrition, overcrowding, overwork, poor sanitary conditions and extremely high mortality rates,
enrollment increased, peaking in the early 1970s – when complaints by tribal authorities, Native
American activism, studies, and finally legislation forced the creation of community schools and
deemphasized the boarding schools (Tafoya & Del Vechhio; Wikepedia).

“As a result of the boarding school system,” write Tafoya and Del Vechhio, “several generations of
Native Americans were raised without family ties.” Unsurprisingly, this “historical oppression and
internalized oppression” have resulted in negative coping strategies by the victims (61). High rates of
substance abuse, depression, in-group violence, suicidality and other negative social indicators should
be seen as the predictable responses to unresolved grief and intergenerational trauma and treated
accordingly (Sutton & Broken Nose; Tafoya & Del Vecchio).

European Americans

It has taken some time for all white Americans to become white. White Americans have origins in at
least 53 European nationalities, the largest being British (England, Scotland and Wales), Irish and
German. While the immigration policy from 1790 to 1952 only allowed immigrants from Europe to
become naturalized citizens, immigrants from southern and eastern Europe, as well as Ireland, were
often believed to be inferior and not “real Americans” by nativist Anglo-Saxon Protestants (Giordano &
McGoldrick).

Even though ethnicity continued to be important in the lives of many Americans, as “ethnics” entered
their second and third generations here, the official image was of a “melting pot” nation of whites who
were of one culture. Until the upheavals of the civil rights movement, minorities were largely invisible
or seen as peripheral. It was during this same upheaval, when in the 1960s African Americans and other
minorities began demanding rights and recognition, that many white people began reexamining their
own ethnic roots and identities, ushering in a “pluralistic society” (Girodano & McGoldrick).

The belief in and celebration of universal whiteness had obvious detrimental outcomes for nonwhites:
slavery and Jim Crow segregation for blacks; outright exclusion from immigrating here (the Chinese
Exclusion Act of 1880 and similar laws); no citizenship for first-generation immigrants; the seizure of
property and freedom (e.g., Japanese detention camps during World War Two), and periodic riots and

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other forms of violent repression. But belief in universal whiteness has also had drawbacks on whites
and the nation as a whole. For example, our public discourse on class is far less penetrating than in
many other countries. We believe that “anyone can make it” if they work hard enough, persevere and
sacrifice; after all, didn’t all those previous immigrants from Europe achieve the American Dream in that
way? Those that don’t (mostly those minorities) are undeserving. Even as wealth and income
stratification reach record levels, our society is more preoccupied by differences in race, gender identity
and expression, and opinions on gun ownership. Economic worries center on immigrants “taking
American jobs” or “unfair” international trading partners, but seldom focus on the enormous
concentration of wealth at the top echelons of our society (Eidelson).

Nevertheless, there is reason to believe that white ethnicity is often a “hidden factor” in therapy even
though the “conscious and unconscious aspects of ethnicity” make it “elusive” in research studies
(Giordano & McGoldrick, 503). Even as our fast-moving, mass-communications society rushes on,
people feel the pull of family history and experiences, especially in times of stress. An example can be a
conflict between parents, based on different ways of child-rearing that each learned from their family of
origin. If the families of origin’s ways were based on ethno-cultural values, such an explanation might
lessen the mutual blaming and create an opening for dialogue.

Of course, many European Americans are ambivalent about, and even uninterested in, their ethnic
heritage. But family workers should be alert to the possibilities, just in case.

LGBTQ people (Lesbian, gay, bisexual, transgender or questioning)

About 11 million adults currently identify as LGBT, 4.5 percent of the population. There has been a
steady increase in those who self-identify since Gallup began asking the question in 2012. Millennials
(those born between 1980 and 1999) are much more likely to identify as LGBT than people from any
other generation. Respondents were also more likely to be lower-income (household income of less
than $36,000) and perhaps even more surprising to some, Hispanics (6.1 percent) and African Americans
(5 percent) are more likely to self-identify as LGBT than whites (4 percent). For Asian Americans, the
figure was 4.9 percent (Eidelson).

While a 2015 Supreme Court ruling now forbids states from denying this population the right to marry,
LGBTQ people still have a long way to go to gain equal rights and acceptance (Jones). In many states,
there is still no legal recourse for job or housing discrimination.

It is estimated that about 2 million children have a gay, lesbian or bisexual parent and that at least
130,000 same-sex couples are raising at least one child – biological, step, adopted or foster – under the
age of 18 (AAP; van Eeden-Moorefield & Nacer). As these families come out of the closet and are
studied, we find that demographically they are similar to different-sex blended families but their
relationships are slightly more durable (van Eeden-Moorefield & Nacer). Due to the historical hostility
and discrimination they have faced, same-sex couples have had to create their own models of family
organization and functioning. Considering the circumstances, they’ve done a good job: “research shows
same-sex stepfamilies to be particularly good at rule setting as parents as well as communicating with
one another” (Nacer & van Eeden-Moorefield).

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As the above paragraph suggests, LGBTQ families make excellent family work clients – if clinicians have
no unresolved biases against them. They fall everywhere along the “universalist”/“particularist”
continuum (p. 5 above). As the accepted and preferred terminology around sexual orientation and
gender identity issues is constantly changing – including among LGBTQ people themselves – the
respectfully curious clinician should allow him- or herself to be taught by the clients. Our clinical
experience and the impressive efforts of this population to gain rights and recognition suggest that
LGBTQ clients are willing to accept us and our help if we are willing to accept them.

The situation for the estimated 5 to 10 percent of young people who are gender-questioning or
nonconforming is not rosy:

 In 2013, 23 percent of LGBT youth attempted suicide; the rate was almost twice that among
Hispanic and African-American youth;
 LGBTQ youth are three times more likely to report childhood sexual abuse;
 LGBTQ youth are more likely to report parental physical abuse;
 78 percent of LGBTQ youth in foster care ran way or were removed due to hostility toward their
identity or orientation;
 They are twice as likely to report being threatened or assaulted by heterosexual peers;
 Over 40 percent of homeless youth are LGBTQ.
(Allegheny County Department of Human Services).

The biggest risk factor for these young people is family rejection. Those who report family rejection are
8.4 times more likely to attempt suicide and 3.4 times more likely to use drugs and engage in
unprotected sex; they are 5.9 times more likely to report high levels of depression (Allegheny County).
The job of the family worker is to help parents, caretakers and other family members overcome their
own prejudices, fears or disappointments so that they can support the young person. Some
organizations – such as the Family Acceptance Project (www.familyproject.sfsu.edu) and Gender
Spectrum (www.genderspectrum.org) – work specifically to help educate and mobilize families in
support of LGBTQ youth. Connecting youth to social support outside the family system is also important.

African Americans

As the historian Lerone Bennett, Jr. pointed out, blacks were brought to the English colonies “before the
Mayflower.” However, after nearly 250 years of chattel slavery, another 100 years of legal segregation,
discrimination and terror, and 50 years of civil rights activity and legislation, most African Americans
today feel anything but free and equal. No matter how the individual clinician feels about that
statement, if one partners with African-American clients in a way that builds trust and elicits honesty,
one is likely to discover some mistrust of white people and “the system,” anger, and feelings of
powerlessness, even among the middle class and well-to-do. Fear of stigmatization and lack of
knowledge about mental health and treatment are also common barriers to blacks seeking or sticking
with mental health services (Boyd-Franklin; Poussaint & Alexander; Williams; Williamson).

As Hines and Boyd-Franklin were quoted above, the key to working with black families “is to convey
genuine respect, to move beyond generalizations, to communicate interest in learning about the clients’

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specific realities” (98). Those realities include a so-called “collectivist” orientation that often differs from
our society’s individualist/nuclear family orientation, favoring instead an extended family network that
may include non-blood “kin” (Boyd-Franklin; Hines & Boyd-Franklin; Williams; Williamson). See module
vii of Engaging Families in Service, “The American Family in Transition: Working with Nontraditional
Families,” for a more detailed discussion of black extended family strengths and vulnerabilities.

Nevertheless, African-American families are as diverse in their organization and structure as white
families, and the issues that bring black families and individuals to treatment are many. One finds that
African-American clients only want to be approached and treated like everyone else, rather than a
mysterious or exotic “Other.” After 400 years, that is probably not asking too much.

Hispanics/Latinos

One will also find a strong family orientation among Hispanics, or Latinos. Hispanic refers to anyone
whose roots are from a Spanish-speaking country, whether from Spain or a Latin American country;
Latino refers specifically to people of Latin American descent. U.S. Hispanics are overwhelmingly Latino,
thus the words are generally used interchangeably.

Hispanics now make up 18 percent of the population and accounted for more than half of US population
growth since 2000.3 They are the youngest ethnic group in the country. Hispanics are a heterogeneous
group who would never think of themselves as “Latinos” or “Hispanics” in their countries of origin, but
“[r]egardless of differences, living in a country that is racist and unwelcoming . . . is a common
experience” (Garcia-Preto-a, 162). So is poverty, especially for first- and second-generation Hispanics,
and the darker-complexioned (Kouyoumdjian et al.; Garcia-Preto-a; Smith, Bakir & Ricard).

“It has been well documented,” write Kouyoumdjian and colleagues, “that the number of individuals
experiencing psychological maladjustment and mental health problems is highest among the most
socioeconomically disadvantaged members of society” (396). The stress of poverty, compounded with
the “acculturative stress” of living in a new cultural environment, leave Latinos especially vulnerable to
depression and stress-related symptoms, making their underutilization of the mental health system
troubling (ibid). 4

Despite different points of origin and culture, one can safely make some generalizations about Hispanics
that may be useful to helpers. Many writers and practitioners will agree with this statement by a
clinician: “Throughout therapy, the therapist will likely notice the Latino patient’s tendency to phrase
personal issues in the frame of the family” (Fieros and Smith, 51). Familismo is a value that indicates a
deeper connection and loyalty than any English translation could convey. Unmarried adults will often
live with their parents; if their parents are deceased, they may live with the family of a married sibling
(Falicov, 2006). The importance of godparents – comadres and compadres – should not be

3
This number does not include undocumented immigrants, whose numbers cannot be accurately counted.
4
In 2016 the psychology APA’s Stress in America survey found that “Hispanic and Latino Americans reported the
highest levels of stress.” Major sources of stress were money, employment, family responsibilities and health
(Turner 2016).

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underestimated. It is common for children of family members or close friends – hijos de crianza – to be
informally adopted (Garcia-Preto-b).

Respeto is another term that connotes “more emotional dependence and dutifulness” than its English
translation (Falicov, 2005). Most Latino parents expect or demand respeto from their children into
adulthood.

Machismo, and its counterpart for females, marianismo, is often misunderstood. Rather than inflexible
constructs for male superiority and domination over women, they should be viewed as cultural
guidelines for the proper roles of men and women in society. As Patricia Arredondo has observed,
“Messages for women are similar to those given to women across cultures.” And research has actually
shown a preference for “an egalitarian method of decision making in their relationships” among first-,
second- and third-generation Hispanics. “Therapists should use the multiple positive qualities of
machismo, such as fairness, responsibility, respect for self and others, strength of will, and self
assertiveness, to further therapeutic understanding and alliance with Hispanic males” (Fierros and
Smith, 55).

Hispanics accepting services expect warmth and personable treatment, 5 including some self-disclosure
by the helper. They expect formality at a first meeting, which is associated with respect. “In therapy,
eliciting, listening, and validating stories about how their lives are affected by living in this country will
help families view themselves beyond their problems,” writes Garcia-Preto (a). Of course, clinicians who
can speak Spanish are enormously valued, but Hispanic clients appreciate non-Hispanic helpers who
make the effort to learn even a few words or phrases. It is also helpful to learn the client’s religious and
cultural traditions and incorporate them into treatment. And as suggested above, a multitude of
researchers and clinicians endorse the effectiveness of family therapy and counseling approaches with
Hispanic clients.

With apologies to Asian Americans (who have a long and complex history here; come from countries in
East Asia, South Asia and the Pacific region; and represent about 5.6 percent of the US population), Jews
(40 percent of the world’s Jewish population resides in this country), Arabs and other Middle Eastern
peoples, Muslims of all nationalities, and people with origins from points not mentioned, we would like
to use the last section to highlight a particularly neglected subculture.

Deaf culture

There are perhaps 10 million people in this country who are “hard of hearing,” and perhaps one million
who are functionally deaf (Mitchell). 6 But is the condition a disability? Not to those who self-identify as
Deaf with the capital “D.” To them, they are a legitimate subculture, not a disabled population. Their
main problems stem not from their disability, but from society’s inability or reluctance to learn to

5
Personalismo, another widely-held value, places warmth and a person’s inner qualities above rules and
regulations or material achievements (Garcia-Preto-a; Smith and Montilla, p. 240).
6
However, the National Center for Health Statistics puts the number of “hard of hearing” adults at 37 million, of
which “3.3% were Deaf or had significant difficulty understanding speech,” which is about 1.2 million (Tate).

Engaging Families in Service: Core Philosophy, Principles and Methods, module X.

communicate with them in their language, ASL. These communication barriers may make it easier to
target and victimize Deaf individuals, and harder for the traumatized to receive proper treatment.

The prevalence of serious mental illness in Deaf adults and serious emotional disturbances in children is
related to trauma: half of all Deaf boys and girls have been sexually abused; sexual abuse incidents are
four times as common in institutional settings as in the community (Missouri).

Trauma victimization is related to the problem of language deprivation – when those around Deaf
individuals fail to learn to sign or the Deaf individual him or herself has not learned to communicate
through signing or lip-reading. The term “information deprivation trauma” or IDT has been used to
define an event that is experienced as traumatic (or more traumatic) because knowledge or information
about the event is limited or unavailable (Tate). And perhaps as few as two percent of Deaf people in
need of behavioral health support actually receive appropriate care (Missouri).

These statistics speak – no, cry out – for attention.

* * * *

We would leave the last word to Giordano and McGoldrick (p. 503), with the slight qualification of
replacing the word “ethnic” with “cultural,” and “ethnicity” with “cultural heritage”:

Shared ethnic heritage hardly produces homogeneity of thought, emotions, or group loyalty.
Individuals may embrace, change, or reject aspects of their ethnicity, as well as aspects of their
broader American identity.

REFERENCES

Acevedo, G., Gonzalez, M.J., Santiago, V., Vargas-Ramos, C. (2007) “The State of Latino Health and
Mental Health,” Policy Report, vol. 1, no. 4 Fall 2007. Centro de Estudios Puertorriquenos, Hunter
College CUNY.

Allegheny County PA Department of Human Services (n.d.) “Introduction to Sexual Orientation, Gender
Identity and Expression (SOGIE), training and PowerPoint presentation.

American Academy of Pediatrics (AAP) (2015) “Different Types of Families: A Portrait Gallery”
https://healthychildren.org/English/family-life/family-dynamics/types-of-families/Pages/Different-
Types-of-Familes-A-Portrait-Gallery.aspx.

American Psychiatric Association (2017) “Mental Health Disparities: Hispanics and Latinos,”
psychiatry.org.

Arredondo, P. (2006) “Multicultural Competencies and Family Therapy Strategies With Latino Families,”
in Counseling and Family Therapy with Latino Populations: Strategies that Work, R.L. Smith and R.E.
Montilla, eds., pp. 77-95.

Engaging Families in Service: Core Philosophy, Principles and Methods, module X.

Bialik, K. (2017) “Key facts about race and marriage, 50 years after Loving v. Virginia,” Pew Research
Center http://www.pewresearch.org/fact-tank/2017/06/12/key-facts-about-race-and-marriage-50-
years-after-loving-v-virginia/.

Boyd-Franklin, N. (1989) Black Families in Therapy: A Multisystems Approach, New York: Guilford Press.

Dingfelder, S.FG. (2005) “Closing the gap for Latino patients,” Monitor, January 2005, vol. 36, no. 1;
accessed http://www.apa.org/monitor/jan05/closingthegap.aspx.

Eidelson, J. (2018) “U.S. Income Inequality Hits a Disturbing New Threshold,” Bloomberg.com, posted
March 1, 2018.

Falicov, C.J. (2006) “Family Organization: The Safety Net of Close and Extended Kin,” in Counseling and
Family Therapy with Latino Populations: Strategies that Work, R.L. Smith and R.E. Montilla, eds., pp. 41-
62.

Falicov, C.J. (2005) “Mexican Families,” in Ethnicity & Family Therapy, third edition, McGoldrick,
Giordano and Garcia-Preto, eds., pp. 229-241.

Falicov, C.J. (1999) “Training to Think Culturally: A Multidimensional Comparative Framework,” The
Family Process CD-ROM, 1999 Family Process.

Fierros, M. and C. Smith (2006) “The Relevance of Hispanic Culture to the Treatment of a Patient with
Posttraumatic Stress Disorder (PTSD),” Psychiatry October, 2006, pp. 49-56.

Flores, A. (2017) “How the US Hispanic population is changing,” September 18, 2017, Pew Research
Center, http://www.pewresearch.org/fact-tank/2017/09/18/how-the-u-s-hispanic-population-is-
changing/.

Garcia-Preto, N. (2005-a) “Latino Families: An Overview,” in Ethnicity & Family Therapy, third edition,
McGoldrick, Giordano and Garcia-Preto, eds., pp. 153-165.

Garcia-Preto, N. (2005-b) “Puerto Rican Families,” in Ethnicity & Family Therapy, third edition,
McGoldrick, Giordano and Garcia-Preto, eds., pp. 242-255.

Giordano, J. & M. McGoldrick (2005) “Families of European Origin: An Overview,” in Ethnicity & Family
Therapy, third edition, McGoldrick, Giordano and Garcia-Preto, eds., pp. 501-519.

Harper’s Magazine (2018) “Findings,” March 2018.

Hines, P.M. & N. Boyd-Franklin (2005) “African American Families, in Ethnicity & Family Therapy, third
edition, McGoldrick, Giordano and Garcia-Preto, eds., pp. 87-100.

Jones, J.M. (2017) “In U.S., 10.2% of LGBT Adults Now Married to Same-Sex Spouse,” Gallup.com, June
22, 2017.

Kouyoumdjian, H., Zamboanga, B., Hansen, D. (2003) “Barriers to Community Mental Health Services for
Latinos: Treatment Considerations,” Faculty Publications, Department of Psychology, University of
Nebraska, 128. http://digitalcommons.unl.edu/psychfacpub/128

McGoldrick, M., Giordano J., Garcia-Preto, N., eds. (2005) Ethnicity & Family Therapy, third edition, New
York: Guilford Press.

Engaging Families in Service: Core Philosophy, Principles and Methods, module X.

Mental Health America (n.d.) “Latino/Hispanic Communities and Mental Health,”
http://www.mentalhealthamerica.net/issues/latinohispanic-communities-and-mental-health, accessed
7/11/2018.

Missouri Department of Mental Health (n.d.) “DMH Facts: Trauma and the Deaf Community.” Jefferson
City, MO.

Mitchell, R.E. (2006) “How Many Deaf People Are There in the United States? Estimates From the Survey
of Income and Program Participation,” The Journal of Deaf Studies and Deaf Education, Volume 11, Issue
1, 1 January 2006, Pages 112–119.

Nacer, C. and B. van Eeden-Moorefield “The Experiences of Stepfamilies Headed by Same-Sex Couples,”
National Stepfamily Resource Center, http://www.stepfamilies.info/articles/your-stepladder-to-
success.php.

National Alliance on Mental Illness (NAMI) “Latino Mental Health,” https://www.nami.org/find-

support/diverse-communities/latino-mental-health, accessed 7/11/2018.

Newport, F. (2018) “In U.S., Estimate of LGBT Population Rises to 4.5%,” Gallup.com, May 22, 2018.

Notaras Murphy, S. (2005) “Embracing Latin America’s nuances,” Counseling Today, Dec. 29, 2005,
http://ct.counseling.org/2005/12/ct-online-embracing-latin-americas-nuances/

Perception Institute, “Implicit Bias,”https://perception.org/research/implicit-bias/, accessed 7/11/2018.

Poussaint, A.F. and A. Alexander (2000) Lay My Burden Down: Unraveling Suicide and the Mental Health
Crisis Among African-Americans, Boston: Beacon Press.

Smith, R.L., Bakir, N., and Ricard, R.J. (2006) “Contemporary Issues and Research,” in Counseling and
Family Therapy with Latino Populations: Strategies that Work, R.L. Smith and R.E. Montilla, eds., pp. 199-
220.

Smith, R.L. and Montilla, R.E., eds. (2006) Counseling and Family Therapy with Latino Populations:
Strategies that Work, New York: Routledge Taylor & Francis Group.

Sue, D.W. (2001) “Multidimensional Facets of Cultural Competence,” The Counseling Psychologist, Vol.
29 No. 6, November 2001 pp. 790-821.

Sutton, C.T. and M.A. Broken Nose (2005) “American Indian Families: An Overview,” in Ethnicity &
Family Therapy, third edition, McGoldrick, Giordano and Garcia-Preto, eds., pp. 43-54.

Szapocznik, J., Schwartz, S.J., Muir, J.A., Brown, C.H. (2012) “Brief Strategic Family Therapy: An
Intervention to Reduce Adolescent Risk Behavior,” Couple and Family Psychology: Research and
Practice, June 2012.

Tafoya, N. and A. Del Vecchio (2005) “Back to the Future: An Examination of the Native American
Holocaust Experience,” in Ethnicity & Family Therapy, third edition, McGoldrick, Giordano and Garcia-
Preto, eds., pp. 55-63.”

Tate, C. (2012) Trauma in the Deaf Population: Definition, Experience, and Services. Alexandria, VA:
National Association of State Mental Health Program Directors (NASMHPD) .

Engaging Families in Service: Core Philosophy, Principles and Methods, module X.

Turner, E. (2016) “Stress and Latino Mental Health,” Psychology Today online, posted April 24, 2016.

Turner, E. (2014) “African American Mental Health: What are the Facts” Psychology Today online,
posted June 29, 2014.

United States Census https://www.census.gov/newsroom/facts-for-features/2017/aian-month.html

van Eeden-Moorefield, B. and C. Nacer “Stepfamilies Headed by Same-Sex Couples: Demographics,

Formation, and Legal Considerations,” National Stepfamily Resource Center,
http://www.stepfamilies.info/articles/a-new-journey-to-intimacy.php .

Wikipedia, “American Indian boarding schools,”

https://en.wikipedia.org/wiki/American_Indian_boarding_schools, accessed on 7/20/2018.

Williams, M.T. (2011) “Why African Americans Avoid Psychotherapy,” Psychology Today online, posted
November 2, 2011.

Williamson, M. E. (2014) “The Reluctance of African-Americans to Engage in Therapy,” masters thesis,

University of Nebraska-Lincoln, College of Education and Human Sciences.

Engaging Families in Service: Core Philosophy, Principles and Methods, module X.