Individual and Cultural-Diversity Competency:

Focus on the Therapist

䊲

Jessica Henderson Daniel

Children’s Hospital—Boston
䊲

Gargi Roysircar
Antioch New England Graduate School
䊲

Norman Abeles
Michigan State University
䊲

Cyndy Boyd
University of Illinois—Chicago

The Competencies Conference: Future Directions in Education and Cre-

dentialing in Professional Psychology was held in Arizona in November
2002. One of the workshops, Individual and Cultural Differences (ICD),
focused on racism, homophobia, and ageism. The consensus was that
self-awareness and knowledge about the three “isms” are critical compo-
nents in the education and training of psychologists. This article, authored
by four of the workshop attendees, is a review of the current research and
theoretical literature. Implications that address both content and context in
graduate programs and training sites are presented. This is one of a series
of articles published in this issue of the Journal of Clinical Psychology.
Several other articles that resulted from the Competencies Conference will

The authors wish to thank Robert G. Hall, Ph.D., ABPP, and Karen M. Taylor, Ph.D., for their thoughtful
feedback on an earlier draft of this manuscript.
The members of the Individual and Cultural Diversity Workgroup were Drs. Norman Abeles, Jeff Baker, Cyndy
Boyd, Robin Buhrke, Jessica Henderson Daniel (work-group leader), Kelly Ducheny (recorder), Linda Forrest
(steering-committee member), Robert Hall, Robert Knight, Gargi Roysirkar, Juan Jose Sanchez Sosa, Derald
Wing Sue, and Karen Taylor.
Correspondence concerning this article should be addressed to: Jessica Henderson Daniel, Ph.D., ABPP, Depart-
ment of Psychiatry-Fegan 8, Children’s Hospital—Boston, 300 Longwood Avenue, Boston, MA 02115; e-mail:
Jessica.Daniel@childrens.harvard.edu.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 60(7), 755–770 (2004) © 2004 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20014
756 Journal of Clinical Psychology, July 2004

appear in Professional Psychology: Research and Practice and The Coun-

seling Psychologist. © 2004 Wiley Periodicals, Inc. J Clin Psychol 60:
755–770, 2004.

Keywords: education and training; racism; heterosexism; ageism

Introduction

Clinical literature has focused primarily on the patient’s history, presenting problem, and
diagnosis, with the goal of ascertaining and implementing an appropriate treatment plan/
intervention. Individual and cultural-diversity (ICD) competency broadens this perspec-
tive to include the psychologist’s historical and professional persona. The emphasis is on
learning domains relevant to diversity responsiveness in education and training to increase
therapists’ (a) awareness of their own assumptions, values, and biases and (b) knowledge
of research, assessment, and practice. These two ICD competences are addressed in
this article.
Individual and cultural diversity includes persons who may experience discrimination
based on race and ethnicity, age, sexual orientation, gender identity, disability, religion,
language, and social class. While this article will discuss only the first three sociocultural
categories, many concepts presented here apply to the other categories of ICD.
The rationale for addressing diversity competencies in trainees and psychologists is
derived from present contexts in the United States (US). First, the level of racial/ethnic
diversification in the US, as reflected in the U.S. Census (United States Bureau of the
Census, 2001), continues to change. The current combined populations of persons of
color have increased; the Caucasian population has decreased. Second, clinical-,
counseling-, and school-psychology program training content has been based on Euro-
centric perspectives and European American research subjects (Guthrie, 1976; Ohye &
Daniel, 1999). Given current demographics, such an approach is no longer a valid source
of knowledge and meaning for various groups living in the US. Third, the reality of
discrimination and prejudice in the lives of many marginalized groups impacts their access
to institutions such as health-care resources (Collins et al., 2002; United States Depart-
ment of Health and Human Services, 2001a). Fourth, the conceptualization of individual
and cultural differences as a multidimensional construct has expanded the variables that
need to be included in analyses and assessments, that is, historical, sociopolitical, and
cultural factors, as well as the individual’s views and experiences (Dana, 2000; Kurasaki,
Okazaki, & Sue, 2002). Fifth, the legal and ethical issues raised in the Surgeon General’s
report document the disparities along racial and ethnic lines in both mental-health access
and service delivery (United States Department of Health and Human Services, 2001b).
Individual and cultural diversity matters in psychology. Surveys of licensed psychol-
ogists have shown that most practitioners will work with at least one lesbian, gay, or
bisexual (LGB) client in their careers (Garnets, Hancock, Cochran, Goodchilds, &
Peplau, 1991; Murphy, Rawlings, & Howe, 2002). Psychologists of color (Black African
descent, Asian American, American Indian, and Latina/o) are only 6% of all psycholo-
gists (American Psychological Association, 1997). Consequently, the likelihood of a per-
son of color (POC) receiving services from a non-POC is very high. People are living
longer. In addition, older persons are an integral part of extended families and increas-
ingly provide care for their grandchildren (Jimenez, 2002). Consequently, not just gero-
psychologists, but child, family, and school psychologists, among others, will provide
services to older persons.
 Individual and Cultural-Diversity Competency 757

The lack of ICD competency can result in inappropriate and even harmful case con-
ceptualizations and interventions in therapy. In the 1984 survey of 2,544 American Psy-
chological Association (APA) members by a task force appointed by the APA Committee
on Lesbian and Gay Concerns (Garnets et al., 1991), psychologists reported inappropri-
ately using a heterosexual frame of reference when working with same-sex couples,
encouraging clients to change their sexual orientation, and erroneously focusing on sex-
ual orientation as the cause of the client’s problems.
Over the years, various administrative structures within the discipline of psychology
have addressed ICD issues. Since 1999, four APA Divisions (Division 17—Counseling
Psychology; Division 35—Society for the Psychology of Women; Division 44—Society
for the Psychological Study of Lesbian, Gay and Bisexual Issues; and Division 45—Society
for the Psychological Study of Ethnic Minority Issues) have hosted the biennial Multi-
cultural Summit and Conference. Over the course of the three summit conferences, the
focus has expanded from race/ethnicity, gender, and sexual orientation to include persons
with a disability. The APA Council of Representatives has approved three major docu-
ments: in 2000, The Guidelines for Psychotherapy with Lesbian, Gay and Bisexual Cli-
ents (American Psychological Association, 2000); in 2002, The Guidelines on Multicultural
Education, Training, Research, Practice and Organizational Change for Psychologists
(American Psychological Association, 2003a); and in 2003, The Guidelines for Psycho-
logical Practice with Older Adults (American Psychological Association, 2003b). In addi-
tion to the guidelines, the APA Ethical Principles of Psychologists and Code of Conduct
(American Psychological Association, 2002) specifically address ICD issues in the stan-
dards of Competence (standard 2) and Human Relations (standard 3).
The Council of National Psychological Associations for the Advancement of Ethnic
Minority Issues (CNPAAEMI) has published two relevant documents: Guidelines for
Research in Ethnic Minority Communities (Council of National Psychological Associa-
tions for the Advancement of Ethnic Minority Issues, 2000) and Psychological Treatment
of Ethnic Minority Populations (Council of National Psychological Associations for the
Advancement of Ethnic Minority Interests, 2003).
The above documents are important, as ICD issues become more prominent in edu-
cation and training in psychology. It is reasonable to assume that therapists: (a) more
likely will recognize biases and question assumptions about clients/patients if they have
professional guidelines for self-monitoring, and (b) will acquire knowledge about diver-
sity characteristics of their clients to be in compliance with APA and Association of
Psychology Postdoctoral and Internship Centers (APPIC) accreditation requirements.

Self-Awareness of Attitudes, Biases, and Assumptions

All three APA Guidelines (American Psychological Association, 2000, 2003a, 2003b)
address the importance of self-awareness about the three isms—racism, heterosexism,
and ageism. While each has a unique history in the US in terms of visibility, stigmatiza-
tion, marginalization, and social activism, all have stereotypes that frequently lead to
attitudes and behaviors based on biases and unwarranted assumptions. Therapists who
reside in the US are highly likely to have been exposed to the stereotypes and actually
may subscribe to them, consciously or unconsciously. In this article, the guidelines that
address sexual orientation will be referred to as the LGB guidelines, the guidelines that
deal with issues related to older persons as the geropsychology guidelines, and the guide-
lines that focus on a range of multicultural matters as the multicultural guidelines. It is
noteworthy that all three guidelines refer to attitudes at the beginning of the documents.
The therapist’s persona and self-awareness are critical to the development of the
therapeutic alliance. Self-awareness requires a therapist’s understanding of the interface
758 Journal of Clinical Psychology, July 2004

between therapist and client worldviews; therapist self-examination of reactions to race,

sexual orientation, and ageism along with issues of defensiveness, racial-identity atti-
tudes, White privilege, and differential power status in therapy; and how these impact the
client (Richardson & Molinaro, 1996; Roysircar, 2003). Self-assessment to identify atti-
tudes and behaviors may include the use of self-report standardized measures, journaling,
process notes, self-reflection skills, and critical incidents (Brislin, 1986; Carter, 2003;
Pedersen, 1994; Roysircar et al., 2003). Other sources of feedback are patients, super-
visors, peers, faculty members, and collateral colleagues (Constantine, 2001; Fuertes &
Brobst, 2002; Roysircar, Gard, Hubbell, & Ortega, 2005; Worthington, Mobley, Franks,
& Tan, 2000).

Homophobia

As a heterosexist perspective is pervasive in western culture, Brown (1996) proposed that

all counselors must assume that heterosexist and homophobic biases are part of their
worldview. In order to ensure appropriate treatment of LBG clients and students, it is
essential that psychologists fully explore their own identities and belief systems before
practicing psychotherapy or teaching (Hansen, Pepitone-Arreola-Rockwell, & Greene,
2000; Phillips, 2000).
Sexual orientation is a construct applicable and relevant to all. A well-grounded
heterosexual identity development model can be highly effective in facilitating self-
awareness for therapists of any orientation. Such models (Mohr, 2002; Worthington,
Bielstein Savoy, Dillon, & Vernaglia, 2002) highlight the concept that heterosexual coun-
selors can and should be aware of their own identity formation and how their develop-
mental process may affect their work with LGB clients.
To address the need to train therapists on issues related to sexual-orientation aware-
ness, courses and workshops designed for this purpose are critical. (Stein & Burg, 1996;
Whitman, 1995). Central to these courses must be an affective–attitudinal component
incorporated to facilitate the confrontation of one’s own homophobia, heterosexist bias,
and sexism (Whitman, 1995). Whitman (1995) and Phillips (2000) highlighted the spe-
cific need to help students recognize and address their more subtle and covert heterosex-
ist behaviors, in addition to their more obviously homophobic reactions. Role plays with
direct feedback and the provision of examples of the more institutionalized forms of
heterosexism have been noted as powerful teaching tools.

Ageism

Robert Butler stated that he first used the word ageism in 1968 when he served as chair-
man of the Washington, D.C. committee on aging. He described ageism “as a systematic
stereotyping of and discrimination against people simply because they are old, just as
racism and sexism accomplish this with skin color and gender” (U.S. Congressional
Senate, 2003, p. 15). He cited the underlying basis for ageism as a fear of growing older
and no longer being able to take care of oneself. Negative stereotypes result in discrim-
inatory practices in the workplace and elsewhere, including elder abuse. Some common
myths about older adults include assumptions that older adults generally are isolated,
depressed, and unable to cope, and consequently need to depend on others. Older adults
are seen as forgetful and cognitively impaired (Abeles et al., 1998). Falk and Falk (1997)
cited a Harris poll that found that only 8% of people found the word “old” acceptable.
Gatz and Pearson (1988) suggested that most practitioners do not hold globally neg-
ative biases, but instead may have specific misconceptions, that is, older people do not
 Individual and Cultural-Diversity Competency 759

warrant long-term therapeutic interventions. Specifically, some practitioners may believe

that depression is part of aging and thus does not warrant treatment. Alternatively,
practitioners may believe that complaints about memory imply the presence of early
Alzheimer’s disease. Paradoxically, older adults performing well are seen as the excep-
tion rather than the rule.

Racism
Racism is a complicated phenomenon in that its manifestation may vary for different
groups of racial and ethnic minorities in the US. Heterogeneity within the particular
groups adds to its complexity. Stereotypes abound in the popular culture about ethnic/
racial-minority persons based on phenotype, perceived intellectual functioning, and English-
language usage.
Psychologists who reside in the US are not immune from the prejudice that has been
so inextricably woven into the fabric of the society. Given the segregated housing pat-
terns and consequently segregated elementary and high schools (Massey & Denton, 1993),
it is possible for persons of European-American descent to grow up in the US with little
or no personal contact with persons of color (POC). The media—print, electronic, and
cinematic—are the primary information sources about POC in the US. The images often
fail to portray the heterogeneity of a racial and ethnic minority group, focusing instead on
stereotypes.
Therapists’ self-reports on their racial attitudes and diversity competence, with many
studies controlling for social desirability (Ladany, Inman, Constantine, & Hofheinz, 1997;
Roysircar et al., 2005; Sodowsky, Kuo-Jackson, Richardson, & Corey, 1998), suggest
that diversity training interventions may prove ineffective unless a trainee or supervisee
believes that racial and cultural differences are important to them and to therapy. In
addition, trainees need to consider developing a collectivist orientation, respecting exter-
nal and interpersonal meanings and attributions of people of color (Worthington et al.,
2000).
Predoctoral interns, doctoral practicum students, and psychologists (Sodowsky et al.,
1998) who gave greater endorsement to collective actions taken by African Americans or
to societal changes than to personal efforts of individual African Americans self-reported
more diversity competence, greater degree and types of diversity training, and higher
self-esteem in social and interpersonal contexts (Sodowsky et al., 1998).
Research suggests that Caucasian trainees’ self-reported racial-identity attitudes are
related to their self-reported diversity competence (Helms, 1990; Ladany et al., 1997;
Roysircar et al., 2005; Sodowsky, Taffe, Gutkin, & Wise, 1994). Connections to POC
clients were related to positive Caucasian racial-attitude scores, as were high levels of
positive racial identity to high diversity competence.
Therapists can benefit from regular feedback from their racial and ethnic clients
regarding their effectiveness. The types of cultural knowledge that clients identified as
important included specific knowledge of family relationships and expectations, racism
and discrimination, acculturation, sexism and gender-role issues, communication styles,
cultural beliefs about counseling, cultural issues related to sexual orientation, ethnic and
cultural identity, and norms for behavior.

Knowledge
With respect to “knowledge,” ICD-competent therapists know and appreciate
(a) the growing and multidisciplinary theoretical and empirical literature on the topic
of therapy with culturally diverse individuals;
760 Journal of Clinical Psychology, July 2004

(b) that there is more than one way to conceptualize and deliver diversity-sensitive
services, and that at this point there is no evidence suggesting that one perspec-
tive is more effective than another;
(c) that diversity perspectives do not supplant a theoretical and technical approach
to helping;
(d) that these perspectives all suggest that race, ethnicity, sexual orientation, and
issues of age are dynamic and thus are present and operate within the therapy
session;
(e) that these perspectives address an important common factor in diversity-
competent therapy, namely core conditions of safety, support, rapport, and the
relationship; and
(f ) the intersecting fabric of personality, which includes individual, cultural, GLB,
age-related, and universal components.

Each of the Guidelines (American Psychological Association, 2000, 2003a, 2003b)

cites the need for knowledge and education: LGB guidelines 14–16; the multicultural
guideline 2-3; and the geropsychology guidelines 3– 6 (American Psychological Associ-
ation, 2002, 2003, 2003a).
In psychology graduate education and training programs, students and trainees might
not be taught about invisible systems of dominance in U.S. society. A Caucasian person’s
skin, a heterosexual person’s sexual orientation, and the assets of a person young in age
open doors of privilege, which often are unseen by those who are privileged. While
psychologists may not choose this state of affairs, systems of dominance inherent within
the structure of society are enforced subtly by the notion of equality in a democracy that
allows one to deny power differentials or dismiss evidence of inequality (McIntosh,
2001). Therapy sessions are a subsystem of society and are influenced by societal values,
attitudes, and practices. Some therapists deny the existence of inequality or injustices.
When therapists do that, they enhance the illusion that racism and exclusionary isms do
not exist in the larger system and within therapy itself.
Keeping in mind how stereotypes shape intellectual identity (Steele, 1997), profes-
sional psychology can take it upon itself to communicate to marginalized groups that they
can expect equality, success, and identification both within the academic domain for
trainees and within the therapy domain for clients. Similarly, professional psychology
can provide an environment where all trainees can identify with achievement in cultural-
diversity competence in the sense of its being a part of one’s self-definition—a personal
identity to which one is self-evaluatively accountable. Indeed, trainers must prevent the
risk of overestimating or underestimating the level of ICD competence in trainees that
result from halo effects, negative self-fulfilling prophecy, or stereotype threat (in this
case, Caucasian trainees feeling threatened by being seen as racially insensitive).

Racism

Knowledge of and respect for the worldview of a culturally different client are funda-
mental in creating trust with the therapist and therapist credibility (Sodowsky, 1991; Sue,
Arredondo, & McDavis, 1992). Problems occur when therapists do not know and respect
the client’s worldview and value-based goals. Clinical work in cultural diversity that
endorses interventions in which therapists use manipulation, persuasion, and assimilation
into the Caucasian-dominant society shows a lack of knowledge of the client’s worldview
and is flawed.
 Individual and Cultural-Diversity Competency 761

During the therapy process, issues of discrimination, nature of immigration, cultural

confusion, language barriers, guilt, and grief may emerge as the patient attempts to define
herself/himself in a different culture, redefine her/his ethnic identity, or integrate two
cultures that can clash. The therapist may experience such a process as a complicated
course on cultural knowledge. The therapist may need to add to this knowledge the
complexity of contextual and idiographic data; although knowledge of diversity may be
complicated and entirely new, it is essential that therapists learn about the cultures with
which they work. They cannot expect clients to educate them when in fact clients have
come to them for help.
Findings indicate that therapists (Fuertes, Mueller, Chauhan, Walker, & Ladany, 2002)
with a knowledge of racial-identity theory (Helms, 1990) and awareness of its central
role in their clients’ lives were able to make statements about their clients’ racial identity.
They also were able to describe their clients’ interpersonal concerns as deeply inter-
twined with factors such as racism, homophobia, and poverty. Concerning the therapy
process, therapists reported better rapport, increased intimacy, and disclosure on the part
of their clients, some risk taking with respect to clients’ disclosures in aspects never
before discussed, and overall improved client involvement in therapy. All therapists reported
appreciable gains for their clients.
A one-semester multicultural psychology course taught at three predominantly Cau-
casian state universities in the Midwest and on the East Coast and West Coast (Neville
et al., 1996) was related to Caucasian trainees’ adoption of more positive Caucasian
racial-identity attitudes and with stronger endorsement of diversity competence, whereas
higher levels of negative racial-identity attitudes were related to lower levels of self-
reported diversity competency. Changes in racial-identity attitudes were sustained over a
1-year period. There are other studies that show that multicultural counseling training has
an impact on developing a positive Caucasian racial identity, as well as increasing inter-
racial comfort, (e.g., Parker, Moore, & Neimeyer, 1998; Roysircar et al., 2005; Vinson &
Neimeyer, 2000).

Homophobia
Despite the obvious necessity for training on LGB issues, many students and profession-
als report inadequate preparation for work with LGB clients (Buhrke, 1989; Murphy
et al., 2002; Phillips & Fisher, 1998). Even when training is offered on lesbian and gay
issues, it often omits bisexuality, pathologizes it, or denies its existence (Murphy et al.,
2002; Phillips & Fisher, 1998). As a reflection of past education and training of psychol-
ogists, in a survey of 456 psychologists from the members of APA Division 29 (Psycho-
therapy), respondents were asked about 83 different behaviors with regard to the degree
to which they have engaged in them and the degree to which they consider the behaviors
to be ethical (Tabachnik, Keith-Speigel, & Pope, 1991). Slightly more than one in five of
the respondents reported treating homosexuality as pathological, either rarely (12.7%) or
more often (10.8%). However, over half (55.7%) viewed such a practice as unethical. In
their survey of 125 licensed psychologists, Murphy et al. (2002) found that this lack of
therapist training can have many serious consequences, including unfamiliarity with the
coming-out process, the effects of discrimination, and the process of identity formation.
When supervision on these issues was provided, it was endorsed as a primary source
of training. Half of those supervised reported that their supervisors had limited or inad-
equate knowledge of LGB issues (Murphy et al., 2002). The same study found that the
most popular form of training was reading articles, which is not surprising since students
often report a lack of confidence in the knowledge held by supervisors and faculty (Burhke,
1989; Pilkington & Cantor, 1996).
762 Journal of Clinical Psychology, July 2004

Searching the literature for adequate training can be problematic however, because
reviews of mainstream clinical and counseling journals have revealed that articles with a
significant focus on LGB issues represented from only 0.8% to 2.11% of all articles
during a given period of time (Murphy et al., 2002; Phillips, Ingram, Smith, & Mindes,
2003). Even less perceptible is the amount of literature published specifically on bisexual
issues (Bowman, 2003; Phillips, 2000). Morrow (2003) addsed that scholarship with a
focus on LGB people of color, LGB people with disabilities, and transgendered individ-
uals are underrepresented greatly in the literature, thereby rendering individuals with
multiple oppressions virtually invisible.
The literature emphasizes that a safe learning environment be in place before train-
ing can occur (Buhrke & Douce, 1991; Phillips, 2000). Important components of a safe
environment include open objections to anti-gay jokes and comments; understanding and
minimizing the oppression faced by LGB students and faculty; initiating discussions of
LGB issues; and recruiting LGB faculty (Buhrke & Douce, 1991). In a broader view,
Bieschke, McClanahan, Tozer, Grzegorek, and Park (1998) asserted that LGB affirmative
attitudes are critical at the university, as well as at the departmental level, such that
university policies and practices should be assessed and advocated in order to promote a
facilitative climate. Therefore, it is necessary to address the context in which learning
takes place, as it is to determine the particular content.
As strategies for imparting information about LGB issues, both creating a separate
course on the topic (Phillips, 2000; Stein & Burg, 1996; Whitman, 1995) and infusing the
issues into already existing courses (Burhke, 1989; Burhke & Douce, 1991) are recom-
mended. To structure training, three basic areas of focus have been suggested: (a) infor-
mation about sexual orientation and community resources; (b) the interface between the
LGB client and the effects of living in a heterosexist or homophobic society; and (c) the
interaction between feelings, attitudes, and sexual orientation of the clinician and client
(Murphy, 1992). Other suggested topics to be highlighted in training include the inter-
actions of racism (Greene, 1997; Phillips, 2000) and sexism (Herek, 1993) with homo-
phobia and the effects on LGB individuals, the validity of the construct of bisexuality
(Morrow, 2000), and healthy functioning in same-sex couples and LGB families (Green,
1996).
Trainers may consider using a variety of teaching modalities. For instance, Croteau
and Kusek (1992) and Nelson and Krieger (1997) have found evidence of effectiveness
for the use of panel presentations to reduce homophobia in students. Although not designed
to provide therapy training, the panels so serve to introduce students to LGB people and
the issues associated with these sexual orientations.
As training is prioritized in this area, outcome measures must be administered in
order to ensure effectiveness and to demonstrate the acquisition of basic competencies.
For this purpose, Bidell (2003) has introduced the Sexual Orientation Counselor Scale
(SOCS), which assesses awareness, knowledge, and skills and for which reliability and
validity have been established. Dillon and Worthington (2003) also have introduced recently
the Lesbian, Gay, and Bisexual Affirmative Counseling Self-Efficacy Inventory (LGB-
CSI). It is designed as a self-report measure to assess the following affirmative counsel-
ing behaviors: application of knowledge, advocacy skills, self-awareness, relationship,
and assessment skills.

Ageism

Palmore (1999) has developed a questionnaire, The Facts of Aging, to assess ageism.
This three-part instrument samples knowledge about aging and attitudes toward the aged.
Palmore (2001) also has developed an ageism survey that lists 20 types of ageism. He
 Individual and Cultural-Diversity Competency 763

notes that ageism is common in the US, observing no differences in respondents over 75
years of age and respondents under 75 years of age. No gender differences were found.
However, some 23% of all the respondents stated that they had not experienced ageism.
Ragan and Bowen (2001) studied negative attitudes about older adults associated
with ageism using college students as participants. Three groups were examined: the first
group was provided information only, the second group included information plus innoc-
uous discussion, and the third group involved information plus reinforcement to change.
Results showed that initial changes to ageism were produced in all groups. However, only
those groups who received the reinforcement to change maintained positive attitude changes
at a 1-month follow up.
Gatz and Pearson (1988) suggested that Alzheimer’s disease, with its accompanying
media exposure and the public’s concern, may result in its over diagnosis. They reviewed
a number of surveys conducted with several different populations of younger and older
individuals (including caregivers), all of whom tended to overestimate the prevalence of
Alzheimer’s disease. They concluded that this supports the existence of bias and suggest
that the media may have contributed to the general public’s perception of the prevalence
of Alzheimer’s disease. Even some professionals may contribute to this by estimating
that 20% of those over 80 have Alzheimer’s disease when that figure represents all demen-
tias including those that are reversible. They suggest that Alzheimer’s disease in itself
may be a form of ageism.
Palmore (1999) concluded that health professionals are more familiar with pathology
than with normal processes and have biased experiences with older adults because the
patients they treat are more impaired than other older adults. Additionally, health pro-
fessionals who deal with death and dying are more likely to associate age with death.
Uncapher and Arean (2000) found that primary-care physicians are less willing to treat
suicidal patients if the patient is described as older and retired, believing that suicidal
ideation in older patients was rational and normal.
Edelstein & Semenchuk (1996) suggested that the deleterious effects of ageism can
be prevented by increasing exposure to older adults and knowledge about the impact of
physical and mental changes as aging occurs. Abeles et al. (1998) pointed out that older
adults develop coping mechanisms that assist them despite any age-related physical or
cognitive changes. Making people aware of these coping mechanisms can materially
reduce beliefs and erroneous assumptions that tend to be at the heart of ageism.
Whitbourne and Sneed (2003) emphasized the theoretical construct of identity pro-
cesses that assume most adults attempt to view themselves in a positive, competent, and
ethical fashion. Identity accommodation has the risk of buying into social stereotypes of
aging and may result in an over accommodation to changes associated with aging. Con-
sequently, the individual may internalize negative stereotypes that can make life even
more painful as these attitudes become self-fulfilling prophecies. On the other hand,
many can accommodate by becoming actively engaged in programs that may help them
adjust more adequately and realistically and if needed, seek physical and psychological
interventions.

Gender Across Racism, Heterosexism, and Ageism

Initially, the women’s movement in the United States highlighted the plight of mainly
Caucasian middle-class women in relation to powerful Caucasian males. While issues
related to equal employment, compensation, and representation were dominant, the omis-
sion of a focus on class and color led to the exclusion of both WOC and poor Caucasian
women. The broadening of the women’s movement to include a range of women has been
an on-going process (Worrell & Johnson, 1997).
764 Journal of Clinical Psychology, July 2004

Women of color often experience discrimination based on both gender and race/
ethnicity. Comas-Diaz and Greene (1994) addressed the importance of the integration of
both ethnic and gender identities in the provision of therapeutic services. For some racial/
ethnic groups, the emblematic person is male, resulting in the invisibility of the female.
The particular challenges of this combination need to be both acknowledged and addressed.
The heterogeneity among women of color is substantial. Chin (2000) and Jackson and
Greene (2000) respectively portrayed the lives of a range of Asian-American and African-
American women.
Whitbourne and Sneed (2003) noted that women are frequent targets of ageism based
in part on social definitions of attractiveness. Woolf (1997) noted that while both genders
experience ageism, women also experience sexism. While the differential effect of ageism
on women has not been examined thoroughly, women in general are perceived as being
more hypochondriacal and less healthy even though women have a longer life span than
do men. Woolf characterized this labeling of women as myth. Edelstein and Semenchuk
(1996) suggested that ageism often is compounded in older women because of sexism
and the tendency to view them as stereotypically sick and alone. The geropsychology
guideline 5 addresses issues related to older women, including the reality that women are
more likely to be care providers.
The LGB guidelines (American Psychological Association, 2000) specifically
include women, that is, lesbians and bisexual women. While lesbians, gays, and bisex-
uals are discussed in all the guidelines, number six specifically addresses the topic of
lesbian mothers. It is noted that there has been more research on lesbian mothers than
on gay fathers. Guideline three reports the lack of research on the impact of “social
stigmatization” in the lives of lesbian and bisexual women.
Banks and Kaschak (2003) have expanded the discussion to include women with
both visible and invisible disabilities. The text is about intersections in all their com-
plexities, therefore, gender, disability, ethnicity, and class.
In the provision of psychological services, gender-free discussions about racism,
heterosexism, and ageism effectively limit perceiving women as integrated persons. Women
deserve services that acknowledge that perceptions about gender have and continue to
make differences in the lives of women.

Multiple Identities and ICD

People have multiple identities. All three of the APA Guidelines (American Psycholog-
ical Association 2000, 2003a, 2003b) recognize the interconnections among the isms.
Greene (1994) noted that lesbian women of color are in triple jeopardy due to racism,
homophobia, and sexism. LGB guidelines 9, 12, and 13 (American Psychological Asso-
ciation, 2000) address lesbian, gay, and bisexuals at three identity intersections: (1) race/
ethnicity; (2) age; and (3) physical, sensory, and /or cognitive/emotional disabilities. In
the multicultural guidelines (American Psychological Association, 2003a), the heteroge-
neity within various racial/ethnic groups is highlighted in guidelines 2, 3, and 4 which
encourage psychologists to become familiar with minority, racial, ethnic, and multiracial/
biracial identity models; the effects of acculturation on generational differences in immi-
grants and on the oppressed status of Native Americans; and gender-related concerns
involved with immigration and refugee status. The geropsychology guideline 5 (Ameri-
can Psychological Association, 2003b) encourages psychologists to consider gender, eth-
nicity, socioeconomic status, sexual orientation, disability status, and urban/rural residence
factors when working with older persons. While the current old population is mainly
Caucasian, it is estimated that by the year 2050, POC will be one third of the older adults
in the United States. The discrimination faced by POC in their youth will impact the lives
 Individual and Cultural-Diversity Competency 765

of older POC. It already has been demonstrated that POC older adults have more prob-
lems than Caucasian adults.
Knowledge about individual ICD variables is the beginning of a potentially exten-
sive process. The challenge is to be able to discriminate among the relevant ICD variables
to ascertain their possible connections to the current presenting problem.

Implications
The research literature on self-awareness and knowledge about the three isms—racism,
homophobia, and ageism—supports the use of more self-awareness assessments, as well
as expanded instruction about persons who are marginalized. Faculty members and super-
visors who are both role models and providers of instruction and training may benefit
from raising the level of their own self-awareness and knowledge base about issues of
race, sexual orientation, and age. Stereotypes for all three marginalized groups are long-
standing in the US. Consequently, most people have been exposed to them and even had
them reinforced by their family, friends, and the media.
Therapists who are unaware of their feelings about members of marginalized groups
may burden their patients who consequently take care of their therapists, that is, patients
monitoring their disclosures in order to protect the therapist (Daniel, 2000). Such behav-
iors may compromise the effectiveness of the therapy. The inclusion of ICD-awareness
tasks in the curriculum increase therapists’ receptivity to issues and events related to the
isms.
Graduate programs and training sites that are experienced as safe learning environ-
ments may be more suited to tackle such emotionally laden topics. The reduction and,
ideally, the elimination of racial epithets (i.e., saying the “Black student” but never say-
ing the “White student” or saying the “lesbian student” but never the “heterosexual stu-
dent”), racial slurs (i.e., such as the “n” word for persons of African descent), the assumption
of affirmative-action acceptance for only Blacks as opposed to acceptance based on merit,
and homophobic comments, including jokes, would be a priority. The increased presence
of students and faculty who are members of marginalized groups can facilitate discus-
sions about the isms and provide opportunities for interactions with persons who hereto-
fore may have been met only via literature and media. For both homophobia and ageism,
contact with individuals from those groups has been effective in decreasing negative
feelings.
Various ICD forms of assessment provide a broad picture of this complex construct.
Each may measure a different component; the sum of the assessments may be more
informing than a single global measurement. The information yielded can be a source of
knowledge and reinforcement for providing quality services from any number of
perspectives.
Finally, when the therapist is self-aware and has information about the particular
isms, she/he is more likely to see the patient in context, including information about
development—both racial and sexual orientation, as well as age.
The various guidelines are important steps toward moving the discipline of psychol-
ogy in the direction of education and training with a focus on ICD. Progress can be
facilitated by understanding the process of achieving ICD competency. It begins with
self-awareness and knowledge.

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