Multicultural counseling and psychotherapy assumes

THE SUPERORDINATE NATURE OF MULTICULTURAL COUNSELING AND THERAPY

Chapter 2 Objectives

1. Compare and contrast similarities and differences between “traditional counseling/clinical practice” and culturally sensitive counseling.

2. Understand the Etic and Emic orientation to multicultural counseling.

3. Become cognizant of differences between counseling/clinical competence and multicultural counseling competence.

4. Identify Eurocentric assumptions inherent in our standards of clinical practice.

5. Discuss and understand the characteristics of the three levels of personal identity.

6. Develop awareness of possible differences in counseling culturally diverse clients who differ in race, gender, sexual orientation, and other group identities.

7. Provide examples of ways that other special populations may constitute a distinct cultural group.

8. Define multicultural counseling and therapy, cultural competence, and cultural humility.

9. Explain how cultural humility is different from cultural competence.

The following is the third counseling session between Dr. D. (a White counselor) and Gabriella, a 29-year-old single Latina, who was born and raised in Brazil but came to the United States when she was 10 years old.

Dr. D:

So how did it go last week with Russell (White boyfriend of 6 months).

Gabriella:

Okay, I guess (seems withdrawn and distracted).

Dr. D:

You don't sound too sure to me.

Gabriella:

What do you mean?

Dr. D:

Well, from the last session, I understood that you were going to talk to him [Russell] about your decision to live together, but that you wanted to clarify what moving into his apartment meant for him.

Gabriella:

I didn't get a chance to talk about it. I was going to bring it up, but I had another attack, so I didn't get a chance. It was awful (begins to fidget in the chair)! Why does this always happen to me?

Dr. D:

Tell me what happened.

Gabriella:

I don't know. I had a disagreement with him, a big stupid argument over Jennifer Lopez's song “Booty”.

Dr. D:

“Booty”?

Gabriella:

Yeah, he kept watching the video over and over on the computer. He loves the song, but I find it vulgar.

Dr. D:

Lots of songs press the limits of decency nowadays. . . .Tell me about the attack.

Gabriella:

I don't know what happened. I lost control and started screaming at him. I threw dishes at him and started to cry. I couldn't breathe. Then it got really bad, and I could feel the heat rise in my chest. I was scared to death. Everything felt unreal and I felt like fainting. My mother used to suffer from similar episodes of ataques. Have I become like her?. . . .God I hope not!

Dr. D:

Sounds like you had another panic attack. Did you try the relaxation exercises we practiced?

Gabriella:

No, how could I? I couldn't control myself. It was frightening. I started to cry and couldn't stop. Russell kept telling me to calm down. We finally made up and got it on.

Dr. D:

I'm glad things got smoothed over. But you always say that you have no control over your attacks. We've spent lots of time on learning how to manage your panic attacks by nipping them in the bud. . . before they get out of control. Maybe some medication might help.

Gabriella:

Yes, I know, but it doesn't seem to do any good. I just couldn't help it.

Dr. D:

Did you try?

Gabriella:

Do you think I enjoy the attacks (shouts)? How come I always feel worse when I come here? I feel blamed. . .Russell says I'm a typical emotional Latina. What am I to do? I come here to get help, and I just get no understanding (stated with much anger).

Dr. D:

You're angry at me because I don't seem to be supportive of your predicament, and you think I'm blaming you. But I wonder if you have ever asked yourself how you contribute to the situation as well. Do you think that fighting over a song is the real issue here?

Gabriella:

Maybe not, but I just don't feel like you understand.

Dr. D:

Understand what?

Gabriella:

Understand what it is like to be a Latina woman dealing with all those stereotypes. My parents don't want me living with Russell. . .they think he benefits from having sex with no commitment to marriage, and that I'm a fool. They think he is selfish and just wants a Latina. . . .like a fetish. . . .

Dr. D:

I think it's more important what you think and want for yourself, not what your parents would like you to do. Be your own person. And we've talked about cultural differences before, in the first session, remember? Cultural differences are important, but it's more important to recognize that we are all human beings. Granted, you and I are different from one another, but most people share many more similarities than differences.

Gabriella:

Yes, but can you really understand what's it like to be a Latina, the problems I deal with in my life? Aren't they important?

Dr. D:

Of course I can. And of course they [differences] are. . .but let me tell you, I've worked with many Latinos in my practice. When it comes right down to it, we are all the same under the skin.

Gabriella:

(period of silence)

Dr. D:

Now, let's go back and talk about your panic attacks and what you can do to prevent and reduce them.

Reflection and Discussion Questions

1. What are your thoughts and feelings about the counseling encounter between Dr. D. and Gabriella?

2. Do you think that Dr. D. demonstrated cultural awareness? Is this an example of “good counseling”? If not, why not?

3. When Gabriella described her episodes as ataques, do you know what is meant?

4. What are the potential counseling and cultural issues in this case?

5. Is it important for the counselor to know what the song “Booty” is about?

6. When the parents suggest that their daughter might be a “fetish,” what could they possibly mean? Is it important?

7. What images of Latinas exist in our society? How might they affect Gabriella's relationship with Russell?

8. If you were the counselor, how would you have handled the situation?

Culturally competent care has become a major force in the helping professions (American Psychological Association, 2003; Arredondo, Toporek, Brown, Jones, Locke, Sanchez, & Stadler, 1996; CACREP, 2015; Cornish, Schreier, Nadkarni, Metzger, & Rodolfa, 2010; D. W. Sue, Arredondo, & McDavis, 1992). The therapy session between Dr. D. and Gabriella illustrates the importance of cultural awareness and sensitivity in mental health practice. There is a marked worldview difference between that of the White therapist and the Latina client. In many cases, these differences reflect the therapist's (a) belief in the universality of the human condition, (b) belief that disorders are similar and cut across societies, (c) lack of knowledge of Latina/o culture, (d) task orientation, (e) failure to pick up clinical clues provided by the client, (f) not being aware of the influence of sociopolitical forces in the lives of marginalized group members, and (g) lack of openness to professional limitations. Let us briefly explore these factors in analyzing the previous transcript.

Culture-Universal (Etic) versus Culture-Specific (Emic) Formulations

First and foremost, it is important to note that Dr. D. is not a bad counselor per se, but like many helping professionals is culture-bound and adheres to EuroAmerican assumptions and values that encapsulate and prevent him from seeing beyond his Western therapeutic training (Comas-Diaz, 2010). One of the primary issues raised in this case relates to the etic (culturally universal) versus emic(culturally specific) perspectives in psychology and mental health. Dr. D. operates from the former position. His training has taught him that disorders such as panic attacks, depression, schizophrenia, and sociopathic behaviors appear in all cultures and societies; that minimal modification in their diagnosis and treatment is required; and that Western concepts of normality and abnormality can be considered universal and equally applicable across cultures (Arnett, 2009; Howard, 1992; Suzuki, Kugler, & Aguiar, 2005). Many multicultural psychologists, however, operate from an emic position and challenge these assumptions. In Gabriella's case, they argue that lifestyles, cultural values, and worldviews affect the expression and determination of behavior disorders (Ponterotto, Utsey, & Pedersen, 2006). They stress that all theories of human development arise within a cultural context and that using the EuroAmerican values of normality and abnormality may be culture-bound and biased (Locke & Bailey, 2014). From this case, we offer six tentative cultural/clinical observations that may help Dr. D. in his work with Gabriella.

Cultural Concepts of Distress

It is obvious that Dr. D. has concluded that Gabriella suffers from a panic disorder and that her attacks fulfill criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association, 2013). When Gabriella uses the term ataques to describe her emotional outbursts, episodes of crying, feeling faint, somatic symptoms (“heat rising in her chest”), feeling of depersonalization (unreal) and loss of control, a Western-trained counseling/mental health professional may very likely diagnose a panic attack. Is a panic attack diagnosis the same as ataques? Is it simply a Latin American translation of an anxiety disorder? We now recognize that ataque de nervios (“attack of the nerves”) is a cultural syndrome, occurs often in Latin American countries (in individuals of Latina/o descent), and is distinguishable from panic attacks (American Psychiatric Association, 2013). Cultural syndromes that do not share a one-to-one correspondence with psychiatric disorders in DSM-5 have been found in South Asia, Zimbabwe, Haiti, China, Mexico, Japan, and other places. Failure to consider the cultural context and manifestation of disorders often result in inaccurate diagnosis and inappropriate treatment (D. Sue, Sue, Sue, & Sue, 2016). Chapter 10 will discuss these cultural syndromes and treatments in greater detail.

Acknowledging Group Differences

Dr. D. seems to easily dismiss the importance of Gabriella's Latina/o culture as a possible barrier to their therapeutic work together. She wonders aloud, for example, whether he can understand her as a Latina (being a racial/cultural being), and the unique problems she faces as a person of color. Dr. D. attempts to reassure Gabriella that he can in several ways. He stresses (a) that people are more similar than different, (b) that we are all “human beings,” (c) that he has much experience in working with Latinos, and (d) that everyone is the “same under the skin.” Although there is much truth to these statements, he has unintentionally negated the racialized experiences of Gabriella, and the importance that she places on her racial/ethnic identity. In multicultural counseling, this response often creates an impasse to therapeutic relationships (Arredondo, Gallardo-Cooper, Delgado-Romero, & Zapata, 2014). Note the long period of silence by Gabriella, for example, after Dr. D's response. He apparently misinterprets the silence as agreement. We will return to this important point shortly.

Being Aware of Collectivistic Cultures

It is obvious that Dr. D. operates from an individualistic approach and values individualism, autonomy, and independence. He communicates to Gabriella that it is more important for her to decide what she wants for herself than being concerned about her parents' desires. Western European concepts of mental health stress the importance of independence and “being your own person” because it leads to healthy development and maturity, rather than dependency (in Gabriella's case “pathological family enmeshment”). Dr. D. fails to consider that in many collectivistic cultures such as Latino or Asian American, independence may be considered undesirable and interdependence is valued (Ivey, Ivey, & Zalaquett, 2014; Kail & Cavanaugh, 2013). When the norms and values of Western European concepts of mental health are imposed universally upon culturally diverse clients, there is the very real danger of cultural oppression, resulting in “blaming the victim.”

Attuning to Cultural and Clinical Clues

There are many cultural clues in this therapeutic encounter that might have provided Dr. D. with additional insights into Latina/o culture and its meaning for culturally competent assessment, diagnosis, and treatment. We have already pointed out his failure to explore more in depth Gabriella's description of her attacks (ataques de nervios), and her concern about her parents' approval. But many potential sociocultural and sociopolitical clues were present in their dialogue as well. For example, Dr. D. failed to follow up on why the song “Booty” by Jennifer Lopez precipitated an argument, and what the parents' use of the term “fetish” shows us about how Russell may view their daughter.

The 4-minute music video Booty shows Jennifer Lopez and Iggy Azalea with many anonymous beauties grinding their derrieres (booties) in front of the camera while chanting “Big, big booty, big, big booty” continuously. It has been described as provocative, exploitative and “soft porn.” Nevertheless, the video has become a major hit. And while Dr. D. might be correct in saying that the argument couldn't possibly be over a song (implying that there is a more meaningful reason), he doesn't explore the possible cultural or political implications for Gabriella. Is there meaning in her finding the song offensive and Russell's enjoyment of it? Is there a relationship between the sexiness of big butts to the terms “fetish” and “emotionality” that upset Gabriella? We know, for example, that Latina and Asian women are victims of widespread societal stereotyping that objectifies them as sex objects. Could this be something that Gabriella is wrestling with? At some level, does she suspect that Russell is only attracted to her because of these stereotypes, as her parents' use of the word “fetish” implies? In not exploring these issues, or worse yet, not being aware of them, Dr. D. may have lost a valuable opportunity to help Gabriella gain insight into her emotional distress.

Seeing the Forest through the Trees

These important questions are left unanswered because the therapist fails to see the forest through the trees. Dr. D. appears to suffer from “tunnel vision” and seems more task oriented than people oriented. His major goal seems to be “identify the problem (panic attacks) and solve it (relaxation exercises, medication, etc.).” Who Gabriella is as a flesh and blood person seems less important than the problem. In its attempt to mimic the physical sciences, the discipline of mental health practice has often stressed the importance of objectivity, rational thinking, and problem solving—identify the problem and solve it. Although valuable in many respects, this approach may clash with the Latina/o concept of personalismo, in which people relationships are equally if not more important than tasks. Many Latina/o, for example, have described Western-trained counselors or therapists as “remote,” “aloof,” or “cold” (Arredondo et al. 2014; Comas-Diaz, 2010). There are some indications that Gabriella may view Dr. D. in this manner. His task orientation regardless of what she does or says makes her concerns remain invisible; he fails to explore the many clues provided to him by Gabriella. For example, he mistakes her silence for agreement, fails to inquire into the video-song, Booty, dismisses her cultural concerns in favor of finding solutions, and implies that she is responsible for her plight. An interesting observation of how his rigid goal-directness blinds him to what Gabriella says is seen in the description of the aftermath of her attack: “We finally made up and got it on.” The therapist interprets the statement as Gabriella and Russell “smoothing things over,” but is there more to this statement? What does she mean by “got it on”?

Balancing the Culture-Specific and Culture-Universal Orientations

Throughout our analysis of Dr. D., we have made the point that culture and life experiences affect the expression of abnormal behavior and that counselors need to attune to these sociodemographic variables. Some have even proposed the use of culture-specific strategies in counseling and therapy (Ivey, Ivey, & Zalaquett, 2014; Parham, Ajamu, & White, 2011). Such professionals point out that current guidelines and standards of clinical practice are culture bound and often inappropriate for racial/ethnic minority groups. Which view is correct? Should treatment approaches be based on cultural universality or cultural relativism? Few mental health professionals today embrace the extremes of either position, although most gravitate toward one or the other.

Proponents of cultural universality focus on disorders and their consequent treatments and minimize cultural factors, whereas proponents of cultural relativism focus on the culture and on how the disorder is manifested and treated within it. Both views have validity. It would be naive to believe that no disorders cut across different cultures or share universal characteristics. Likewise, it is naive to believe that the relative frequencies and manners of symptom formation for various disorders do not reflect the dominant cultural values and lifestyles of a society. Nor would it be beyond our scope to entertain the notion that various diverse groups may respond better to culture-specific therapeutic strategies. A more fruitful approach to these opposing views might be to address the following two questions: (a) What is universal in human behavior that is also relevant to counseling and therapy? and (b) What is the relationship between cultural norms, values, and attitudes, on the one hand, and the manifestation of behavior disorders and their treatments, on the other?

The Nature of Multicultural Counseling Competence

Clinicians have oftentimes asserted that “good counseling is good counseling” and that good clinical practice subsumes cultural competence, which is simply a subset of good clinical skills. In this view, they would make a strong case that if Dr. D. had simply exercised these therapeutic skills, he would have worked effectively with Gabriella. Our contention, however, is that cultural competence is superordinate to counseling competence. How Dr. D. worked with Gabriella contains the seeds of a therapeutic bias that makes him susceptible to cultural errors in therapy. Traditional definitions of counseling and psychotherapy are culture bound because they are defined from a primarily White Western-European perspective (Gallardo, 2014). Let us briefly explore the rationale for our position.

The Harm of Cultural Incompetence

Although there are disagreements over the definition of cultural competence, many of us know cultural incompetence when we see it; we recognize it by its horrendous outcomes or by the human toll it takes on our marginalized clients. For some time now, multicultural specialists have described Western-trained counseling/mental health professionals in very unflattering terms: (a) They are insensitive to the needs of their culturally diverse clients; do not accept, respect, and understand cultural differences; are arrogant and contemptuous; and have little understanding of their prejudices (Ridley, 2005; Thomas & Sillen, 1972); (b) clients of color, women, and gays and lesbians frequently complain that they feel abused, intimidated, and harassed by nonminority personnel (Atkinson, Morten, & Sue, 1998; President's Commission on Mental Health, 1978); (c) discriminatory practices in mental health delivery systems are deeply embedded in the ways in which the services are organized and in how they are delivered to minority populations and are reflected in biased diagnoses and treatment, in indicators of dangerousness, and in the type of people occupying decision-making roles (Parham et al., 2011; Cross, Bazron, Dennis, & Isaacs, 1989); and (d) mental health professionals continue to be trained in programs in which the issues of ethnicity, gender, and sexual orientation are ignored, regarded as deficiencies, portrayed in stereotypic ways, or included as an afterthought (Ponterotto et al., 2006; Ratts & Pedersen, 2014).

From our perspective, counseling/mental health professionals have difficulty functioning in a culturally competent manner. Rather, they have functioned in a monoculturally competent manner with only a limited segment of the population (White, male, and straight Euro-Americans), but even that has become a topic of debate (Ridley & Mollen, 2011). We submit that much of the current therapeutic practice taught in graduate programs derives mainly from clinical experience and research with middle- to upper-class Whites (Ridley, 2005). Even though our profession has advocated moving into the realm of evidence-based practice (EBP), little evidence exists that they are applicable to racial/ethnic minorities (Atkinson, Bui, & Mori, 2001; D. W. Sue, 2015). A review of studies on EBP reveals few, if any, on racial minority populations, which renders assumptions of external validity questionable when applied to people of color (Atkinson et al., 1998; Hall, 2001; S. Sue, 1999). If we are honest with ourselves, we can conclude only that many of our standards of professional competence are derived primarily from the values, belief systems, cultural assumptions, and traditions of the larger (Eurocentric) society. We will, however, in Chapter 9 attempt to summarize multicultural evidence-based practices that have recently begun to work their way into the scientific literature.

The Superordinate Nature of Cultural Competence

As we have discussed, values of individualism and psychological mindedness and using rational approaches to solve problems have much to do with how competence is defined. Many of our colleagues continue to hold firmly to the belief that “good counseling is good counseling,” dismissing in their definitions the centrality of culture. The problem with traditional definitions of counseling, therapy, and mental health practice is that they arose from monocultural and ethnocentric norms that excluded other cultural groups. Mental health professionals must realize that “good counseling” uses White EuroAmerican norms that exclude most of the world's population. In a hard-hitting article, Arnett (2009) indicates that psychological research, which forms the knowledge base of our profession, focuses on Americans who constitute only 5 percent of the world's population. He concludes that the knowledge of human behavior neglects 95 percent of the world's population and is an inadequate representation of humanity. Thus it is clear to us that the more superordinate and inclusive concept is that of multicultural counseling competence, not merely clinical or counseling competence. Standards of helping derived from such a philosophy and framework are inclusive and offer the broadest and most accurate view of cultural competence.

A Tripartite Framework for Understanding the Multiple Dimensions of Identity

All too often, counseling and psychotherapy seem to ignore the group dimension of human existence. For example, a White counselor who works with an African American client might intentionally or unintentionally avoid acknowledging the racial or cultural background of the person by stating, “We are all the same under the skin” or “Apart from your racial background, we are all unique.” We have already indicated possible reasons why this happens, but such avoidance tends to negate an intimate aspect of the client's group identity (Apfelbaum, Sommers, & Norton, 2008; Neville, Gallardo & Sue, in press). Dr. D.'s responses toward Gabriella seem to have had this effect. These forms of microinvalidations will be discussed more fully in Chapter 6 . As a result of these invalidations, a client of color might feel misunderstood and resentful toward the helping professional, hindering the effectiveness of the counseling. Besides unresolved personal issues arising from counselors, the assumptions embedded in Western forms of therapy exaggerate the chasm between therapists and culturally diverse clients.

First, the concepts of counseling and psychotherapy are uniquely EuroAmerican in origin, as they are based on certain philosophical assumptions and values that are strongly endorsed by Western civilizations. On the one side are beliefs that people are unique and that the psychosocial unit of operation is the individual; on the other side are beliefs that clients are the same and that the goals and techniques of counseling and therapy are equally applicable across all groups. Taken to its extreme, this latter approach nearly assumes that persons of color, for example, are White, and that race and culture are insignificant variables in counseling and psychotherapy (D. W. Sue, 2010). Statements such as “There is only one race, the human race” and “Apart from your racial/cultural background, you are no different from me” are indicative of the tendency to avoid acknowledging how race, culture, and other group dimensions may influence identity, values, beliefs, behaviors, and the perception of reality (Lum, 2011; D. W. Sue, 2015). Indeed, in an excellent conceptual/analytical article proposing a new and distinct definition of counseling competence, Ridley, Mollen, and Kelly (2011) conclude that “counseling competence is multicultural counseling competence” and that “competent counselors consistently incorporate cultural data into counseling, and they must be careful never to relegate cultural diversity to the status of a sidebar” (p. 841).

Second, related to the negation of race, we have indicated that a most problematic issue deals with the inclusive or exclusive nature of multiculturalism. A number of psychologists have indicated that an inclusive definition of multiculturalism (one that includes gender, ability/disability, sexual orientation, and so forth) can obscure the understanding and study of race as a powerful dimension of human existence (Carter, 2005; Helms & Richardson, 1997). This stance is not intended to minimize the importance of the many cultural dimensions of human identity but rather emphasizes the greater discomfort that many psychologists experience in dealing with issues of race rather than with other sociodemographic differences (D. W. Sue, Lin, Torino, Capodilupo, & Rivera, 2009). As a result, race becomes less salient and allows us to avoid addressing problems of racial prejudice, racial discrimination, and systemic racial oppression. This concern appears to have great legitimacy. We have noted, for example, that when issues of race are discussed in the classroom, a mental health agency, or some other public forum, it is not uncommon for participants to refocus the dialogue on differences related to gender, socioeconomic status, or religious orientation.

On the other hand, many groups often rightly feel excluded from the multicultural debate and find themselves in opposition to one another. Thus enhancing multicultural understanding and sensitivity means balancing our understanding of the sociopolitical forces that dilute the importance of race, on the one hand, and our need to acknowledge the existence of other group identities related to social class, gender, ability/disability, age, religious affiliation, and sexual orientation, on the other (Anderson & Middleton, 2011; D. W. Sue, 2010).

There is an old Asian saying that goes something like this: “All individuals, in many respects, are (a) like no other individuals, (b) like some individuals, and (c) like all other individuals.” Although this statement might sound confusing and contradictory, Asians believe these words to have great wisdom and to be entirely true with respect to human development and identity. We have found the tripartite framework shown in Figure 2.1 (D. W. Sue, 2001) to be useful in exploring and understanding the formation of personal identity. The three concentric circles illustrated in Figure 2.1 denote individual, group, and universal levels of personal identity.

Figure 2.1 Tripartite Development of Personal Identity

Individual Level: “All Individuals Are, in Some Respects, Like No Other Individuals”

There is much truth in the saying that no two individuals are identical. We are all unique biologically, and recent breakthroughs in mapping the human genome have provided some startling findings. Biologists, anthropologists, and evolutionary psychologists had looked to the Human Genome Project as potentially providing answers to comparative and evolutionary biology that would allow us to find the secrets to life. Although the project has provided valuable answers to many questions, scientists have discovered even more complex questions. For example, they had expected to find 100,000 genes in the human genome, but only about 20,000 were initially found, with the possible existence of another 5,000—only two or three times more than are found in a fruit fly or a nematode worm. Of those 25,000 genes, only 300 unique genes distinguish us from the mouse. In other words, human and mouse genomes are about 85 percent identical! Although it may be a blow to human dignity, the more important question is how so relatively few genes can account for our humanness.

Likewise, if so few genes can determine such great differences between species, what about within the species? Human inheritance almost guarantees differences because no two individuals ever share the same genetic endowment. Further, no two of us share the exact same experiences in our society. Even identical twins, who theoretically share the same gene pool and are raised in the same family, are exposed to both shared and nonshared experiences. Different experiences in school and with peers, as well as qualitative differences in how parents treat them, will contribute to individual uniqueness. Research indicates that psychological characteristics, behavior, and mental disorders are more affected by experiences specific to a child than are shared experiences (Bale et al., 2010; Foster & MacQueen, 2008).

Group Level: “All Individuals Are, in Some Respects, Like Some Other Individuals”

As mentioned earlier, each of us is born into a cultural matrix of beliefs, values, rules, and social practices. By virtue of social, cultural, and political distinctions made in our society, perceived group membership exerts a powerful influence over how society views sociodemographic groups and over how its members view themselves and others. Group markers such as race and gender are relatively stable and less subject to change. Some markers, such as education, socioeconomic status, marital status, and geographic location, are more fluid and changeable. Although ethnicity is fairly stable, some argue that it can also be fluid. Likewise, debate and controversy surround the discussions about whether sexual orientation is determined at birth and whether we should be speaking of sexuality or sexualities (D. Sue et al., 2016). Nevertheless, membership in these groups may result in shared experiences and characteristics. Group identities may serve as powerful reference groups in the formation of worldviews. On the group level of identity, Figure 2.1 reveals that people may belong to more than one cultural group (e.g., an Asian American female with a disability), that some group identities may be more salient than others (e.g., race over religious orientation), and that the salience of cultural group identity may shift from one to the other depending on the situation. For example, a gay man with a disability may find that his disability identity is more salient among the able-bodied but that his sexual orientation is more salient among those with disabilities.

Universal Level: “All Individuals Are, in Some Respects, Like All Other Individuals”

Because we are members of the human race and belong to the species Homo sapiens, we share many similarities. Universal to our commonalities are (a) biological and physical similarities, (b) common life experiences (birth, death, love, sadness, and so forth), (c) self-awareness, and (d) the ability to use symbols, such as language. In Shakespeare's Merchant of Venice, Shylock attempts to acknowledge the universal nature of the human condition by asking, “When you prick us, do we not bleed?” Again, although the Human Genome Project indicates that a few genes may cause major differences between and within species, it is startling how similar the genetic material within our chromosomes is and how much we share in common.

Reflection and Discussion Questions

1. Select three group identities you possess related to race, gender, sexual orientation, disability, religion, socioeconomic status, and so forth. Of the three you have chosen, which one is more salient to you? Why? Does it shift or change? How aware are you of other sociodemographic identities?

2. Using the tripartite framework just discussed, can you outline ways in which you are unique, share characteristics with only certain groups, and share similarities with everyone?

3. Can someone truly be color-blind? What makes seeing and acknowledging differences so difficult? In what ways does a color-blind approach hinder the counseling relationship when working with diverse clients?

Individual and Universal Biases in Psychology and Mental Health

Psychology—and mental health professionals in particular—have generally focused on either the individual or the universal levels of identity, placing less importance on the group level. There are several reasons for this orientation. First, our society arose from the concept of rugged individualism, and we have traditionally valued autonomy, independence, and uniqueness. Our culture assumes that individuals are the basic building blocks of our society. Sayings such as “Be your own person, (à la Dr. D.),” “Stand on your own two feet,” and “Don't depend on anyone but yourself” reflect this value. Psychology and education represent the carriers of this value, and the study of individual differences is most exemplified in the individual intelligence testing movement that pays homage to individual uniqueness (Suzuki et al., 2005).

Second, the universal level is consistent with the tradition and history of psychology, which has historically sought universal facts, principles, and laws in explaining human behavior. Although this is an important quest, the nature of scientific inquiry has often meant studying phenomena independently of the context in which human behavior originates. Thus therapeutic interventions from which research findings are derived may lack external validity (Chang & Sue, 2005).

Third, we have historically neglected the study of identity at the group level for sociopolitical and normative reasons. As we have seen, issues of race, gender, sexual orientation, and disability seem to touch hot buttons in all of us because they bring to light issues of oppression and the unpleasantness of personal biases (Lo, 2010; Zetzer, 2011). In addition, racial/ethnic differences have frequently been interpreted from a deficit perspective and have been equated with being abnormal or pathological (Guthrie, 1997; Parham et al., 2011). We have more to say about this in Chapter 4 .

Disciplines that hope to understand the human condition cannot neglect any level of our identity. For example, psychological explanations that acknowledge the importance of group influences such as gender, race, culture, sexual orientation, socioeconomic class, and religious affiliation lead to more accurate understanding of human psychology. Failure to acknowledge these influences may skew research findings and lead to biased conclusions about human behavior that are culture bound, class bound, and gender bound.

Thus it is possible to conclude that all people possess individual, group, and universal levels of identity. A holistic approach to understanding personal identity demands that we recognize all three levels: individual (uniqueness), group (shared cultural values and beliefs), and universal (common features of being human). Because of the historical scientific neglect of the group level of identity, this text focuses primarily on this category.

Before closing this portion of our discussion, we would like to add a caution. Although the concentric circles in Figure 2.1 might unintentionally suggest a clear boundary, each level of identity must be viewed as permeable and ever-changing in salience. In counseling and psychotherapy, for example, a client might view his or her uniqueness as important at one point in the session and stress commonalities of the human condition at another. Even within the group level of identity, multiple forces may be operative. As mentioned earlier, the group level of identity reveals many reference groups, both fixed and nonfixed, that might impact our lives. Being an elderly, gay, Latino male, for example, represents four potential reference groups operating on the person. The culturally competent helping professional must be willing and able to touch all dimensions of human existence without negating any of the others.

The Impact of Group Identities on Counseling and Psychotherapy

Accepting the premise that race, ethnicity, and culture are powerful variables in influencing how people think, make decisions, behave, and define events, it is not far-fetched to conclude that such forces may also affect how different groups define a helping relationship (Herlihy & Corey, 2015). Multicultural psychologists have long noted, for example, that different theories of counseling and psychotherapy represent different worldviews, each with its own values, biases, and assumptions about human behavior (Geva & Wiener, 2015). Given that schools of counseling and psychotherapy arise from Western European contexts, the worldview that they espouse as reality may not be shared by racial/ethnic minority groups in the United States, or by those who reside in different countries (Parham et al., 2011). Each cultural/racial group may have its own distinct interpretation of reality and offer a different perspective on the nature of people, the origin of disorders, standards for judging normality and abnormality, and therapeutic approaches.

Among many Asian Americans, for example, a self-orientation is considered undesirable, whereas a group orientation is highly valued (Kim, 2011). The Japanese have a saying that goes like this: “The nail that stands up should be pounded back down.” The meaning seems clear: Healthy development is considering the needs of the entire group, whereas unhealthy development is thinking only of oneself. Likewise, relative to their EuroAmerican counterparts, many African Americans value the emotive and affective quality of interpersonal interactions as qualities of sincerity and authenticity (West-Olatunji & Conwill, 2011). EuroAmericans often view the passionate expression of affect as irrational, impulsive, immature, and lacking objectivity on the part of the communicator. Thus the autonomy-oriented goal of counseling and psychotherapy and the objective focus of the therapeutic process might prove antagonistic to the worldviews of Asian Americans and African Americans, respectively.

It is therefore highly probable that different racial/ethnic minority groups perceive the competence of the helping professional differently than do mainstream client groups. Further, if race/ethnicity affects perception, what about other group differences, such as gender and sexual orientation? Minority clients may see a clinician who exhibits therapeutic skills that are associated primarily with mainstream therapies as having lower credibility. The important question to ask is, “Do such groups as racial/ethnic minorities define cultural competence differently than do their Euro-American counterparts?” Anecdotal observations, clinical case studies, conceptual analytical writings, and some empirical studies seem to suggest an affirmative response to the question (Fraga, Atkinson, & Wampold, 2002; Garrett & Portman, 2011; Guzman & Carrasco, 2011; McGoldrick, Giordano, & Garcia-Preto, 2005; Nwachuku & Ivey, 1991).

What Is Multicultural Counseling/Therapy?

In light of the previous analysis, let us define multicultural counseling/therapy (MCT) as it relates to the therapy process and the roles of the mental health practitioner:

Multicultural counseling and therapy can be defined as both a helping role and a process that uses modalities and defines goals consistent with the life experiences and cultural values of clients; recognizes client identities to include individual, group, and universal dimensions; advocates the use of universal and culture-specific strategies and roles in the healing process; and balances the importance of individualism and collectivism in the assessment, diagnosis, and treatment of client and client systems. (D. W. Sue & Torino, 2005)

This definition often contrasts markedly with traditional views of counseling and psychotherapy. A more thorough analysis of these characteristics is described in Chapter 7 . For now, let us extract the key phrases in our definition and expand their implications for clinical practice.

1. Helping role and process. MCT broadens the roles that counselors play and expands the repertoire of therapy skills considered helpful and appropriate in counseling. The more passive and objective stance taken by therapists in clinical work is seen as only one method of helping. Likewise, teaching, consulting, and advocacy can supplement the conventional counselor or therapist role.

2. Consistent with life experiences and cultural values. Effective MCT means using modalities and defining goals for culturally diverse clients that are consistent with their racial, cultural, ethnic, gender, and sexual orientation backgrounds. Advice and suggestions, for example, may be effectively used for some client populations.

3. Individual, group, and universal dimensions of existence. As we have already seen, MCT acknowledges that our existence and identity are composed of individual (uniqueness), group, and universal dimensions. Any form of helping that fails to recognize the totality of these dimensions negates important aspects of a person's identity.

4. Universal and culture-specific strategies. MCT believes that different racial/ethnic minority groups might respond best to culture-specific strategies of helping. For example, research seems to support the belief that Asian Americans and Latino/a Americans are more responsive to directive/active approaches (Guzman & Carrasco, 2011; Kim, 2011) and that African Americans appreciate helpers who are authentic in their self-disclosures (Parham et al., 2011). Likewise, it is clear that common features in helping relationships cut across cultures and societies as well.

5. Individualism and collectivism. MCT broadens the perspective of the helping relationship by balancing the individualistic approach with a collectivistic reality that acknowledges our embeddedness in families, relationships with significant others, communities, and cultures. A client is perceived not just as an individual, but as an individual who is a product of his or her social and cultural context.

6. Client and client systems. MCT assumes a dual role in helping clients. In many cases, for example, it is important to focus on individual clients and to encourage them to achieve insights and learn new behaviors. However, when problems of clients of color reside in prejudice, discrimination, and racism of employers, educators, and neighbors or in organizational policies or practices in schools, mental health agencies, government, business, and society, the traditional therapeutic role appears ineffective and inappropriate. The focus for change must shift to altering client systems rather than individual clients.

What Is Cultural Competence?

Consistent with the definition of MCT, it becomes clear that culturally competent healers are working toward several primary goals (American Psychological Association, 2003; D. W. Sue et al., 1992; D. W. Sue et al., 1998). First, culturally competent helping professionals are ones who are actively in the process of becoming aware of their own values, biases, assumptions about human behavior, preconceived notions, personal limitations, and so forth. Second, culturally competent helping professionals are ones who actively attempt to understand the worldview of their culturally diverse clients. In other words, what are the client's values and assumptions about human behavior, biases, and so on? Third, culturally competent helping professionals are ones who are in the process of actively developing and practicing appropriate, relevant, and sensitive intervention strategies and skills in working with their culturally diverse clients. These three attributes make it clear that cultural competence is an active, developmental, and ongoing process and that it is aspirational rather than achieved. Let us more carefully explore these attributes of cultural competence.

Competency 1: Therapist Awareness of One's Own Assumptions, Values, and Biases

In almost all human service programs, counselors, therapists, and social workers are familiar with the phrase “Counselor, know thyself.” Programs stress the importance of not allowing our own biases, values, or hang-ups to interfere with our ability to work with clients. In most cases, such a warning stays primarily on an intellectual level, and very little training is directed at having trainees get in touch with their own values and biases about human behavior. In other words, it appears to be easier to deal with trainees' cognitive understanding of their own cultural heritage, the values they hold about human behavior, their standards for judging normality and abnormality, and the culture-bound goals toward which they strive.

As indicated in Chapter 1 , what makes examination of the self difficult is the emotional impact of attitudes, beliefs, and feelings associated with cultural differences, such as racism, sexism, heterosexism, able-body-ism, and ageism. For example, as a member of a White EuroAmerican group, what responsibility do you hold for the racist, oppressive, and discriminating manner by which you personally and professionally deal with persons of color? This is a threatening question for many White people. However, to be effective in MCT means that one has adequately dealt with this question and worked through the biases, feelings, fears, and guilt associated with it. A similar question can be asked of men with respect to women and of straights with respect to gays.

Competency 2: Understanding the Worldviews of Culturally Diverse Clients

It is crucial that counselors and therapists understand and can share the worldviews of their culturally diverse clients. This statement does not mean that providers must hold these worldviews as their own, but rather that they can see and accept other worldviews in a nonjudgmental manner. Some have referred to the process as cultural role taking: Therapists acknowledge that they may not have lived a lifetime as a person of color, as a woman, or as a lesbian, gay, bisexual, or transgendered person (LGBT). With respect to race, for example, it is almost impossible for a White therapist to think, feel, and react as a racial minority individual. Nonetheless, cognitive empathy, as distinct from affective empathy, may be possible. In cultural role taking, the therapist acquires practical knowledge concerning the scope and nature of the client's cultural background, daily living experience, hopes, fears, and aspirations. Inherent in cognitive empathy is the understanding of how therapy relates to the wider sociopolitical system with which minorities contend every day of their lives.

Competency 3: Developing Culturally Appropriate Intervention Strategies and Techniques

Effectiveness is most likely enhanced when the therapist uses therapeutic modalities and defines goals that are consistent with the life experiences and cultural values of the client. This basic premise will be emphasized throughout future chapters. Studies have consistently revealed that (a) economically and educationally marginalized clients may not be oriented toward “talk therapy”; (b) self-disclosure may be incompatible with the cultural values of Asian Americans, Hispanic Americans, and American Indians; (c) the sociopolitical atmosphere may dictate against self-disclosure from racial minorities and gays and lesbians; (d) the ambiguous nature of counseling may be antagonistic to life values of certain diverse groups; and (e) many minority clients prefer an active/directive approach over an inactive/nondirective one in treatment. Therapy has too long assumed that clients share a similar background and cultural heritage and that the same approaches are equally effective with all clients. This erroneous assumption needs to be challenged.

Because groups and individuals differ from one another, the blind application of techniques to all situations and all populations seems ludicrous. The interpersonal transactions between the counselor and the client require different approaches that are consistent with the client's life experiences (Choudhuri, Santiago-Rivera, & Garrett, 2012; Ratts & Pedersen, 2014). It is ironic that equal treatment in therapy may be discriminatory treatment! Therapists need to understand this. As a means to prove discriminatory mental health practices, racial/ethnic minority groups have in the past pointed to studies revealing that minority clients are given less preferential forms of treatment (medication, electroconvulsive therapy, etc.). Somewhere, confusion has occurred, and it was believed that to be treated differently is akin to discrimination. The confusion centered on the distinction between equal access and opportunities versus equal treatment. Racial/ethnic minority groups may not be asking for equal treatment so much as they are asking for equal access and opportunities. This dictates a differential approach that is truly nondiscriminatory. Thus to be an effective multicultural helper requires cultural competence. In light of the previous analysis, we define cultural competence in the following manner:

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. (D. W. Sue & Torino, 2005)

This definition of cultural competence in the helping professions makes it clear that the conventional one-to-one, in-the-office, objective form of treatment aimed at remediation of existing problems may be at odds with the sociopolitical and cultural experiences of the clients. Like the complementary definition of MCT, it addresses not only clients (individuals, families, and groups) but also client systems (institutions, policies, and practices that may be unhealthy or problematic for healthy development). Addressing client systems is especially important if problems reside outside rather than inside the client. For example, prejudice and discrimination such as racism, sexism, and homophobia may impede the healthy functioning of individuals and groups in our society.

Second, cultural competence can be seen as residing in three major domains: (a) attitudes/beliefs component—an understanding of one's own cultural conditioning and how this conditioning affects the personal beliefs, values, and attitudes of a culturally diverse population; (b) knowledge component—understanding and knowledge of the worldviews of culturally diverse individuals and groups; and (c) skillscomponent—an ability to determine and use culturally appropriate intervention strategies when working with different groups in our society. Box 2.1 provides an outline of cultural competencies related to these three domains.

Box 2.1 Multicultural Counseling Competencies

1. Cultural Competence: Awareness

1. Moved from being culturally unaware to being aware and sensitive to own cultural heritage and to valuing and respecting differences.

2. Aware of own values and biases and of how they may affect diverse clients.

3. Comfortable with differences that exist between themselves and their clients in terms of race, gender, sexual orientation, and other sociodemographic variables. Differences are not seen as deviant.

4. Sensitive to circumstances (personal biases; stage of racial, gender, and sexual orientation identity; sociopolitical influences; etc.) that may dictate referral of clients to members of their own sociodemographic group or to different therapists in general.

5. Aware of their own racist, sexist, heterosexist, or other detrimental attitudes, beliefs, and feelings.

2. Cultural Competence: Knowledge

1. Knowledgeable and informed on a number of culturally diverse groups, especially groups with whom therapists work.

2. Knowledgeable about the sociopolitical system's operation in the United States with respect to its treatment of marginalized groups in society.

3. Possess specific knowledge and understanding of the generic characteristics of counseling and therapy.

4. Knowledgeable of institutional barriers that prevent some diverse clients from using mental health services.

3. Cultural Competence: Skills

1. Able to generate a wide variety of verbal and nonverbal helping responses.

2. Able to communicate (send and receive both verbal and nonverbal messages) accurately and appropriately.

3. Able to exercise institutional intervention skills on behalf of clients when appropriate.

4. Able to anticipate the impact of their helping styles and of their limitations on culturally diverse clients.

5. Able to play helping roles characterized by an active systemic focus, which leads to environmental interventions. Not restricted by the conventional counselor/therapist mode of operation.

Sources: D. W. Sue et al. (1992), and D. W. Sue et al. (1998). Readers are encouraged to review the original 34 multicultural competencies, which are fully elaborated in both publications.

Third, in a broad sense, this definition is directed toward two levels of cultural competence: the personal/individual and the organizational/system levels. The work on cultural competence has generally focused on the micro level, the individual. In the education and training of psychologists, for example, the goals have been to increase the level of self-awareness of trainees (potential biases, values, and assumptions about human behavior); to acquire knowledge of the history, culture, and life experiences of various minority groups; and to aid in developing culturally appropriate and adaptive interpersonal skills (clinical work, management, conflict resolution, etc.). Less emphasis is placed on the macro level: the profession of psychology, organizations, and the society in general (Lum, 2011; D. W. Sue, 2001). We suggest that it does little good to train culturally competent helping professionals when the very organizations that employ them are monocultural and discourage or even punish psychologists for using their culturally competent knowledge and skills. If our profession is interested in the development of cultural competence, then it must become involved in impacting systemic and societal levels as well.

Fourth, our definition of cultural competence speaks strongly to the development of alternative helping roles. Much of this comes from recasting healing as involving more than one-to-one therapy. If part of cultural competence involves systemic intervention, then such roles as consultant, change agent, teacher, and advocate supplement the conventional role of therapy. In contrast to this role, alternatives are characterized by the following:

· Having a more active helping style

· Working outside the office (home, institution, or community)

· Being focused on changing environmental conditions, as opposed to changing the client

· Viewing the client as encountering problems rather than having a problem

· Being oriented toward prevention rather than remediation

· Shouldering increased responsibility for determining the course and the outcome of the helping process

It is clear that these alternative roles and their underlying assumptions and practices have not been historically perceived as activities consistent with counseling and psychotherapy.

Cultural Humility and Cultural Competence

Can anyone ever be completely culturally competent in working with diverse clients? Are the awareness, knowledge, and skills of cultural competence the only areas sufficient to be an effective multicultural helping professional? The answers to these questions are extremely important not only to the practice of counseling/therapy, but to the education and training of counselors and therapists. The answer to the first question is an obvious “no.” It is impossible for anyone to possess sufficient knowledge, understanding, and experience of the diversity of populations that inhabit this planet. Indeed, those who have developed and advocated multicultural counseling competencies have repeatedly stressed that “cultural competence” is an aspirational goal, that no single individual can become completely competent, and that the journey toward cultural competence is a lifelong process (D. W. Sue et al., 1992; Cornish et al., 2010).

With respect to the second question, it appears that the dimensions of awareness, knowledge, and skills may be necessary, but not sufficient conditions to work effectively with diverse clients. Other attributes, like openness to diversity (Chao, Wei, Spanierman, Longo, & Northart, 2015) and cultural humility seem central to effective multicultural counseling (Gallardo, 2014). The concept of cultural humilitywas first coined in medical education, where it was associated with an open attitudinal stance or a multicultural open orientation to diverse patients, and found to be quite different from cultural competence(Tervalon & Murray-Garcia, 1998). The term has found its way into the field of multicultural counseling, where it also refers to an openness to working with culturally diverse clients (Hook, Davis, Owen, Worthington, & Utsey, 2013; Owen et al., 2014). But exactly how does it differ from cultural competence and what evidence do we have that it is an important component?

Cultural humility appears more like a “way of being” rather than a “way of doing,” which has characterized cultural competence (Owen, Tao, Leach, & Rodolfa, 2011). In the former, we are referring to the virtues and dispositions inherent in the attitudes that counselors hold toward their clients, while the latter refers more to the acquisition of knowledge and skills used in working with clients. The attitudinal components of respect for others, an egalitarian stance, and diminished superiority over clients means an “other-orientation” rather than one that is self-focused (concern with one's expertise, training, credentials, and authority). Recall again the therapeutic encounter between Dr. D. and Gabriella. When asked by Gabriella whether he could understand what it's like to be Latina, and the unique issues she must cope with, his response was “Of course I can” and “I've worked with many Latinos in my practice.” In many respects, the definition of cultural humility is humbleness; thus therapists acknowledging that they may be limited in their knowledge and understanding of clients' cultural concerns may actually strengthen the therapeutic relationship. Dr. D.'s response, however, suggests he is self-oriented (“I am the therapist and I know best”), while cultural humility would entertain the possibility that the therapist may not understand. A therapeutic response that would indicate cultural humility would be: “I hope I can, let's give it a try, okay?” Hook et al. (2013) make the following observations about cultural humility:

Culturally humble therapists rarely assume competence (i.e., letting prior experience and even expertness lead to overconfidence) for working with clients just based on their prior experience working with a particular group. Rather, therapists who are more culturally humble approach clients with respectful openness and work collaboratively with clients to understand the unique intersection of clients' various aspects of identities and how that affects the developing therapy alliance. (p. 354)

Although cultural humility may appear difficult to define and measure, researchers have been able to begin construction of an instrument to quantify it (Hook et al., 2013; Owen et al., 2014). In a therapeutic context, cultural humility of therapists was (a) considered very important to many socially marginalized clients, (b) correlated with a higher likelihood of continuing in treatment, (c) strongly related to the strength of the therapeutic alliance, and (d) related to perceived benefit and improvement in therapy. Thus cultural humility as a dispositional orientation may be equally important as cultural competence(awareness, knowledge, and skills) in multicultural counseling and therapy.

Social Justice and Cultural Competence

Recently, the Multicultural Counseling Competencies Revision Committee of the American Counseling Association (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015) has presented an important draft document, Multicultural and Social Justice Counseling Competencies (MSJCC) that proposes to revise the multicultural counseling competencies devised by D. W. Sue et al. (1992). As indicated in Chapter 4 , at the heart of the revision is integration of social justice competencies with multicultural competencies. Acknowledging that multiculturalism leads to social justice initiatives and actions, they propose a conceptual framework that includes quadrants (privilege and oppressed statuses), domains (counselor self-awareness, client worldview, counseling relationships, and counseling and advocacy interventions), and competencies (attitudes and beliefs, knowledge, skills, and action).

Perhaps the most important aspect of the proposed MSJCC is seen in the quadrants category, where they identify four major counseling relationships between counselor and client that directly address matters of power and privilege: (1) privileged counselor working with an oppressed client, (2) privileged counselor working with a privileged client, (3) oppressed counselor working with a privileged client, and (4) oppressed counselor working with an oppressed client. In other words, when applied to racial/ethnic counseling/therapy, various combinations can occur: (a) White counselors working with clients of color, (b) counselors of color working with White clients, (c) counselors of color working with clients of color, and (d) White counselors working with White clients. Analysis and research regarding these dyadic combinations have seldom been addressed in the multicultural field. Further, little in the way of addressing counseling work with interracial/interethnic combinations is seen in the literature. We address this topic in the next chapter. We will also cover the issues raised in the MSJCC framework more thoroughly in Chapters 3 , 4 , and 5 . In Chapter 3 we focus on enumerating the quadrants of power and privilege relationships between counselor and client, in Chapter 4 we address the importance of social justice advocacy and action on behalf of the client, and in Chapter 5 we deal with individual and systems level work.

Reflection and Discussion Questions

1. If the basic building blocks of cultural competence in clinical practice are awareness, knowledge, and skills, how do you hope to fulfill competency one, two, and three? Can you list the various educational and training activities you would need in order to work effectively with a client who differs from you in terms of race, gender, or sexual orientation?

2. What are your thoughts regarding cultural humility? How important is this attitude or stance in your work with culturally diverse clients?

3. Look at the six characteristics that define alternative roles for helping culturally diverse clients. Which of these roles are you most comfortable playing? Why? Which of these activities would make you uncomfortable? Why?

Implications for Clinical Practice

1. Know that the definition of multiculturalism is inclusive and encompasses race, culture, gender, religious affiliation, sexual orientation, age, disability, and so on.

2. When working with diverse populations, attempt to identify culture-specific and culture-universal domains of helping.

3. Be aware that persons of color, gays/lesbians, women, and other groups may perceive mental illness/health and the healing process differently than do EuroAmerican men.

4. Do not disregard differences and impose the conventional helping role and process on culturally diverse groups, as such actions may constitute cultural oppression.

5. Be aware that EuroAmerican healing standards originate from a cultural context and may be culture-bound. As long as counselors and therapists continue to view EuroAmerican standards as normative, they may judge others as abnormal.

6. Realize that the concept of cultural competence is more inclusive and superordinate than is the traditional definition of clinical competence. Do not fall into the trap of thinking “good counseling is good counseling.”

7. If you are planning to work with the diversity of clients in our world, you must play roles other than that of the conventional counselor.

8. Use modalities that are consistent with the lifestyles and cultural systems of clients.

9. Understand that one's multicultural orientation, cultural humility, is very important to successful multicultural counseling.

Summary

Traditional definitions of counseling, therapy, and mental health practice arise from monocultural and ethnocentric norms that may be antagonistic to the life styles and cultural values of diverse groups. These Western worldviews reflect a belief in the universality of the human condition, a belief that disorders are similar and cut across societies, and a conviction that mental health concepts are equally applicable across all populations and disorders. These worldviews also often fail to consider the different cultural and sociopolitical experiences of marginalized group members. As a result, counseling and therapy may often be inappropriate to marginalized groups in our society, resulting in cultural oppression. The movement to redefine counseling/therapy, and identify aspects of cultural competence in mental health practice has been advocated by nearly all multicultural counseling specialists.

Multicultural counseling and therapy is defined as both a helping role and a process that uses modalities and defines goals consistent with the life experiences and cultural values of clients; recognizes client identities to include individual, group, and universal dimensions; advocates the use of universal and culture-specific strategies and roles in the healing process; and balances the importance of individualism and collectivism in the assessment, diagnosis, and treatment of client and client systems. Thus cultural competence is the ability to engage in actions or create conditions that maximize the optimal development of client and client systems.

On a personal developmental level, 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); on an organizational/societal level, it is defined as advocating effectively to develop new theories, practices, policies, and organizational structures that are more responsive to all groups. Another attribute, cultural humility seems central to effective multicultural counseling. Cultural humilityappears more like a “way of being” rather than a “way of doing.” The attitudinal components of respect for others, an egalitarian stance, and diminished superiority over clients means an “other-orientation” rather than one that is self-focused. Finally, it appears that there is a strong need to integrate social justice competencies with that of cultural competence. Becoming culturally competent is a lifelong journey but promises much in providing culturally appropriate services to all groups in our society.

Glossary Terms

Awareness

Collectivism

Cultural competence

Cultural humility

Cultural incompetence

Cultural relativism

Culture-bound syndromes

Emic (culturally specific)

Etic (culturally universal)

Group level of identity

Individual level of identity

Knowledge

Multicultural counseling/therapy

Multiculturalism

Personalismo

Skills

Social justice

Universal level of identity

Worldview