CulPsy M4L4
Working with Culturally Diverse Clients
How is Cross-Cultural Helping Different?
- general agreement among practitioners
that cross-cultural helping is more
demanding, challenging, and energy-
draining than work with same-culture
clients.
- tends to be more experiential, malleable,
and collaborative.
- is more likely to affect the provider
directly and emotionally
- akin to culture shock
- more labor-intensive and more likely to
result in fatigue.
Malleable
- refers to the fact the helping process
must be continually adapted to the
specific cultural needs of differing
clients.
Shared Humanity
- the only constant
- and unconscious, that satisfy a
Standard approaches-
- overwhelmingly culture-bound and
northern European in nature
The authors suggest:
1. Be prepared to adapt your
techniques to the cultural
background of the client;
2. communicate acceptance of and
respect for the client in terms that
make sense within his or her cultural
frame of reference
3. Be open to the possibility of more
direct intervention in the life of the
client that the traditional ethos of the
counseling profession would dictate
or permit.
Collaborative
- The very nature of cross-cultural work is
the provider is more dependent on the
client for help in defining the process
itself.
Culturally competence professionals
- adapt and adjust their efforts to the
cultural milieu of the client.
Conceptualizing Cross-Cultural Work
Cross-cultural work
- is challenging in yet another respect,
which has to do with the complexity of
emotional and psychological dynamics
at work in the lives of ethnic individuals.
Ethnic children
- must negotiate not only the same
developmental challenges that all other
children face, but also a series of issues
resulting from race, ethnicity, and
minority status.
4 different systems of psychological
dynamics that influence cross-cultural
work and the relationships between
client and practitioner:
1. difference
2. ethnicity,
3. race,
4. power.
Self-awareness
- is a critical aspect of cultural
competence.
Ethnicity
- is connected to process, both conscious
fundamental need for historical
connection and security.
- Societal definition and assigned value,
among other factors, help determine
whether ethnic meaning for a given
group or individual becomes positive or
negative, which then has great
significance for how they behave
Race
- in turn, refers to an acquired social
meaning in which biological differences
- skin color identity
- These power-assigning social
structures, in the form of institutional
racism, affect the life opportunities,
lifestyles, and quality of life for both
whites and people of color
Table 8.1 The Therapist’s Cultural Self-
Assessment: Example of Olivia
Cultural Olivia’s self-assessment
influences
Age and 52 years old; third-
generational generation U.S. American;
influences member of politically active
generation of Chicanos and
Chicanas in California; first
generation affected by post-
civil rights academic and
employment opportunities in
the 1970s.
1
 Developmental No developmental disability
disability
Disability Chronic knee problems,
acquired later since early adulthood,
in lie including multiple surgeries;
sometimes I use crutches to
walk.
Religion and Mother is practicing Catholic,
spiritual father nonpracticing
orientation Presbyterian; my current
beliefs are a mixture of
Catholic and secular; I do not
attend mass.
Ethnic and Mother and father both of
racial identity mixed Mexican (Spanish and
Indian) heritage, both born in
the United States; my own
identity is Chicana; I can
speak Spanish, but my
primary language is English
Socioeconomic Parents urban, working,
status lower-middle-class-
members of an ethnic
minority culture; however,
my identity is as a university-
educated Chicana; I identify
with working-class people,
although my occupation and
income are middle class.
Sexual Heterosexual; I have one
orientation friend who is lesbian
Indigenous My maternal grandmother
heritage was Indian and immigrated
to the United States from
Mexico with my grandfather
when they were young
adults; what I know about
this part of my heritage came
from her, but she died when
I was 10 years old.
National origin United States, but deep
understanding of the
immigration experience from
my grandparents
Gender Woman, Chicana, divorced,
mother of two children
Understanding Differences
- how the provider responds to being
different and what it means to him or her
are issues that are rarely attended to in
preparing people for culturally diverse
work.
Feelings generated by the experience of
being different tend to be negative and
can include the reactions of
- confusion, hurt, pain, anger, and fear,
as well as envy, guilt, pity, sympathy,
and privilege.
Understanding Power
Power
- is having control and authority or
influence over others; powerlessness, in
turn, is the inability to influence others.
The helping relationship
- is by nature a power imbalance in favor
of the practitioner;
Helpers
- must strive to develop greater
awareness of how power impacts their
clients’ lives and relationships.
Powerlessness
- can be an unpleasant and painful
psychological experience, and people
respond to it by trying to end their pain
and regain a sense of power.
Gain power
- through self-development,
achievement, and personal mastery.
False sense of power
- can be gained by pitting down others,
inspiring fear, and/or manipulating them.
Accommodation and dependency
- can be seen as strategies for
overcoming powerlessness.
Understanding Therapeutic Presence
- service provider’s ability to be
therapeutically present with his or her
clients (Geller, 2017).
- the service provider behaves and
communicates in a way that respects
and enhances the worth of the client.
- empathic attunement allows him or her
to be impacted by the client’s
experience in the world.
- “it is more than communication, it is
communion-full interpersonal contact”
- is a developmental process
- can be defined as a student’s ability to
be aware of him or herself, the client,
and the therapeutic relationship and
using that awareness to act (behave and
communicate) in a way that is
therapeutic
- it influences that polyvagal system,
causing them to feel safer within the
therapeutic relationship.
The polyvagal system
- is a social engagement system that
helps us navigate relationship.
A client’s feelings of safety
- in cross-cultural work is pivotal to
positive treatment outcomes
2
Hays’s Addressing Framework
- Pamela Hays (2208, 2012) has created
what she calls ADDRESSING framework
- a list of cultural influences or identity
dimensions that human services
providers need to address in their work
as therapists. The framework includes
the following:
• Age and generational influence
• Developmental disabilities
• Disabilities acquired later in life
• Religion and spiritual orientation
• Ethnic and racial identity
• Socioeconomic status
• Sexual orientation
• Indigenous heritage
• National origin
• Gender
Assessing Culturally Diverse Clients
Collecting data about the client’s cultural
history and lifestyle
- is an excellent place to start.
The following list of specific items can serve
as a starting point:
• Place of birth
• Number of generations in the United
States
• Family roles and structure
• Language spoken at home
• English fluency
• Economic situation and status
• Amount of acculturation
• Traditions still practiced in the home
• Familiarity and comfort with the
Northern European lifestyle
• Religious affiliation
• Community and friendships patterns
Together these items provide a good initial
basis for understanding the client ethnically
and culturally.
6 additional areas of assessment
• Client’s level of psychological
mindedness
• Family’s level of psychological
mindedness
• Client’s and the family’s attitudes
toward helping
• Client’s level of acculturation
• Family’s level of acculturation
• Family’s attitude toward acculturation
Series of questions that further pinpoint
and define the cultural dimensions
• To what extent is the problem related
to issues of transition, such as
migration and immigration?
• To what extent is the client’s
understanding of the problem based
on cultural explanation, for example,
“evil curse,” “mal ojo,” and so forth?
• Is the behavior that is a problem
considered normal within the culture
or is it considered dysfunctional?
• To what extent is the problem a
manifestation of an environmental
lack of access to resources and
supports?
• To what extent is the problem related
to culture conflict in identity, values,
or relationships?
• To what extent is the behavior a
consequence of psychological
conflict or characterological
problems?
• What are the cultural strengths and
assets available to the client, such as
cultural values and practices, social
networks, and support systems
Making Culturally Sensitive DSM-5
Diagnosis
DSM diagnoses
- are made with consideration of normal
and abnormal behaviors.
- these behaviors originate from an
individual’s culture.
- “have symptoms that are very similar
across cultures… however, there are
cultural differences in the definition,
descriptions, and understanding of
mental illness.”
Cultural backgrounds
- can greatly influence behaviors and
perceptions of mental illness.
The DSM-5
- (American Psychiatric Association,
2013) is the most widely used clinical
diagnostic tool in the Unites States.
- It has, however, been repeatedly
criticized for its ethnocentrism and
insensitivity to issues of culture and
ethnicity.
3
Outline for Cultural Formations
- which can be found in the Appendix of
DSM-5
- the outline was developed to help
clinicians identify cultural factors in
individual cases that may dictate special
attention or alternative approaches or
conceptions to diagnosis and treatment.
5 general components:
1. the cultural identity of the individual
(aspects of self-definition);
2. cultural conceptualizations of
distress (a description of the illness
from within the individual’s culture):
3. psychosocial stressors and cultural
features of vulnerability and
resilience (stresses and supports
related to the psychosocial
environment and levels of
functioning);
4. cultural features of the relationship
between the individual and the
clinician;
5. and the overall assessment (how
cultural considerations specifically
affect diagnosis and treatment
activities and interpretations).
Establishing Rapport and the First
Session
first session
- is especially critical.
When clients of color do seek services,
past research show that up to 50 percent
of these clients do not return for a
second session
Some common barriers
- “poverty, inadequate insurance
coverage, access to transportation,
access to childcare, cultural mistrust of
mental health professionals and medical
establishments, insufficient
understanding of the mental health
profession, institutional racism,
discrimination, and stigma associated
with mental illness”
Goals for the first session should include:
• Establishing good rapport
• Gaining an understanding of the
client’s problem
• Gaining an understanding of what he
or she expects from the helping
relationships
• Communicating clearly what the
provider can reasonable offer
• Providing the client with the
experience of being heard and
understood and (if possible and
appropriate) hope that the process
into which he or she has entered can
offer some immediate help.
General suggestions will contribute to
approaching these goals
• Be warm, sincere, and respectful in
your manner. Introduce yourself by
the tile and name you wish you’re the
client to use. Mutual introductions are
very important. Northern European
American culture is unusual in its desire
to “get down to business.” Other
cultures are more personal in their
approach, preceding business matters
with introduction and inquiries as to
health, family, and the like. Refer to
adult clients as Mr., Miss, or Mrs.
Initially. (It is usually appropriate to
address the oldest family members
present if it is a family session.) Be sure
to inquire as to whether you are
pronouncing their name correctly and
how they wish to be addressed. Also,
ask by what name or names they wish
you to refer to their ethnic group. If you
are comfortable doing so, share with
them some personal information (e.g.,
family data, where you reside) along
with your professional credentials.
Most cultures do not view others in
terms of their social roles to the extent
that European Americans do with
regard to professional behavior.
• If you are anxious about your lack of
knowledge about your client’s
culture, do something about it by
researching it prior to meeting with
him or her. At the same time, it is
unrealistic to expect that you can
become an expert on their culture and
all its diverse aspects; exhibiting such a
position about another person’s culture
is, in fact, likely to be taken very
negatively- as haughty, presumptuous,
or even demeaning. It is fat better to be
open about one’s lack of knowledge
and ask questions. For example: “I
have not worked with many clients from
your community and feel I do not know
as much about your culture as I would
like. I would appreciate your help in
4
 explaining certain things I may not believe can be accomplished in
understand as you refer to them.” Your terms of both more immediate and
sincere openness and desire to learn is long-range needs. It is important to
not a hindrance, but rather a matter of describe possible goals in collaborative
respect for the client and the client’s terms (but at the same time, do so in a
culture. At the same time, it is manner that continues to emphasize
necessary to point out that many your skills and knowledge) and indicate
people of color (e.g., African that if they choose to proceed, the
Americans) may react negatively to specific goal setting will be done jointly.
being expected to educate whites Also, discuss what might be some of
about their culture, which they may the changes associated with achieving
express in statements such as “If you the goals.
want to learn about me, read a book.” • Ask the clients if there are any
Anger at such expectations reflects a aspects of the helping process, as it
historical experience of people of color, has been described and
which involves both an attitude on the experienced so far, that may be
part of whites that is the responsibility difficult for them. Similarly, if you
of people of color to deal with racism notice anything that already seems
and injustice and the feeling that the problematic, it would be good to raise
desire to “learn about us” is not really your concerns at this point.
sincere. I would suggest asking the • The session should end with a
client if he or she is comfortable playing formal goodbye and concrete plans
such role. for what will transpire next: another
• Give a brief and nonethical appointment, a referral, or a call to the
description of the helping process, client with some additional information,
its purposes, and the specifics of at which time you will discuss
how often you would like to meet, for continuing.
how long, when, where, and so forth, as
well as any other relevant information, Remember that these general suggestions
such as where and how to contract you. must be altered and adjusted in relation to
Describe what is expected of him or her the individual circumstances and personal
and what can be expected from you. Be characteristics of each client.
sure to discuss confidentiality and what
happens to the information shared with
you. Remember that this may be the
client’s first experience with a
professional helper, and such roles
may not exist formally in their culture.
• Have clients describe in their own
words the problem(s) for which they
are asking help. Feel free to ask
questions and get as much clarification
as necessary. Then, summarize for
them what you heard and ask if your
summary is accurate. It is critical that
you truly understand what they are
communicating and similarly, that they
are aware you understand. Also, ask
what kind of help they need most
immediately, how other family
members or significant others are
willing to participate in future sessions.
Throughout this phase of the process,
try to determine what the client expect
vis-à-vis gaining help with the problem.
• On the basis of the information you now
have, share with them what you