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Supervision Regarding Culturally Sensitive Treatment Approaches
Katz (1981) suggests that individual treatment should address the cultural differences between the clinician and the patient as soon as possible and that prejudice and stereotyping can be bidirectional, that is, that stereotyping of both the dominant and the minority culture may occur. Clearly, patients should be evaluated on an individual basis, but therapists may erroneously attribute to their patients cultural traits that may not be present or may fail to recognize traits that are.
Pinderhughes (1989) observes that since the feelings aroused in clinicians who work with patients whose culture differs from their own "are more frequently than not negative and driven by anxiety, they can interfere with successful therapeutic outcome" (p. 21). Bradshaw (1978) calls attention to the fact that the cultural distance between therapist and client serves to trigger an unconscious use of distancing and defense mechanisms. Self-knowledge can control such maneuvers and enable the therapist to be more sensitive toward supervisees of different cultures and races (Pinderhughes, 1989).
Cultural values about personal relationships affect the patient- therapist interaction. In the following excerpt Kunce and Vales (1984) discuss Mexican-American patients:
"When the counselor becomes viewed as a personal friend, that counselor may later be rejected for not living up to the client's expectations for overt assistance and concern. . .
Another prevalent way of relating to persons in authority is to forestall responsibility or action by responding to requests in a genial, polite, and accommodating fashion that belies one's true intention of not conforming. A closely allied strategy is the use of either flattery or saying what the official wants to hear to divert attention away from one's personal problems....
In the Mexican culture being late for appointments and social events is commonplace and under many circumstances expected. These types of behavior can create considerable frustration to the counselor who needs to meet schedules." (pp. 104-105)
Minrath (1985) suggests that white therapists should examine their underlying prejudicial beliefs and attitudes. She delineates several unconscious reasons whites may want to work with minority populations, reasons that, if gone unexamined, could impede therapeutic progress. These include a desire to resolve identity issues, to cure social ills, and to achieve a sense of superiority, as they actually view the minority patient as inferior. She also calls attention to the likelihood that clinicians, overwhelmed with "white guilt," often wonder about their own contribution to oppression and may become anxious and preoccupied when treating the urban poor. Therapists who become distant and detached are unable to listen sensitively to their patients. They become sympathetic instead of empathic and must consult a supervisor to resolve these issues.
A potential for conflict exists with culturally homogeneous patient-therapist dyads. Pinderhughes (1989) notes that clinicians can have a blind spot and may perceive patients from their own culture as being like themselves. This interferes with treatment, as these clinicians fail to explore the meaning of events for their patient and assume the issues are similar to their own.
Many minority patients must be informed about the purpose of questions pertaining to clinical history, previous treatment information, family background, and psychosocial stressors (Tsui & Schultz, 1985). If during the initial assessment the need for a more psychodynamic approach is recommended, educating the patient about the therapeutic process becomes important. Patients, particularly immigrant patients, may have had little exposure to mental health approaches and may view such treatment as irrelevant to their illness and not return. For example, Yamamoto (1982) contends that to overcome the barrier to treatment on the part of Japanese-Americans, a good educational campaign is necessary.
Minority patients may perceive therapists to be knowledgeable experts who will guide the family's behavior in the proper course of action. Viewed as authority figures and respected as such, therapists need to convey an air of confidence and should not hesitate to make reference to their educational background and work experience (Lee, 1982). It may prove helpful for therapists to be well informed about the patient's history and to show the patient that they have considerable knowledge of his or her background. Thus, "How's your headache?" as the first question may be more sensitive than "How can I help you?" or "Can you tell me more about yourself?"
Therapists working with Asian-American patients must be sensitive to issues of shame and guilt when probing for personal information. To avoid leaving patients with the impression that they have "caused" their problems, therapists must help them understand that supervisees often encounter difficult situations as the result of inevitable and unavoidable circumstances. In effect, the clinician uses the cultural belief in "fate to neutralize the client's excessive guilt and responsibility" (Tsui & Schultz, 1985).
Many Asians express love through caring or tending to physical needs; consequently, "just listening" may be interpreted by them as "non-caring" (Hsu, 1983). An active demonstration of care, such as showing concern over a patient's physical condition or sleep pattern or prescribing some common remedies for the usual discomforts, is useful in establishing and maintaining good rapport (Hsu, 1983). Therapists should acknowledge and treat the patient's reported physical symptoms. A didactic component often facilitates the therapist's understanding that the patient's suffering is real. For those Asian-Americans who have not acculturated, comments such as "Your facial color looks better today" or "You ought to eat more vegetables" convey concern and care.
When rating the directive style of counseling, Korean subjects who were born in Korea and presently resided there provided higher ratings of counselor effectiveness, expertness, attractiveness, and trustworthiness than when therapy was nondirective (Foley & Fuqua, 1988). Of course these findings would only be relevant to first-generation Korean-Americans. The instruments used were the Counselor Rating Form and the Counselor Effectiveness Rating Scale.
Franklin (1982), who writes about individual therapy with urban African-American adolescents, identifies some ways traditional techniques can be modified to suit this population. Since many youths are referred by an outside authority figure, he suggests that it is important for the therapist not to be cast in the same role. To counteract this impression, a more active role is indicated in order for the therapist to be seen as empathic and caring. Additionally, therapists need to explain their own role as well as the extent of the adolescent's responsibility in the therapeutic process.
Paster (1985) makes a similar point and advocates the use of therapy contracts with poor, depressed, and acting-out African-American male adolescents. The therapist and youth agree upon a trial period of 6 to 8 weeks of therapy and discuss the adolescent's goals for therapy. At the end of the trial period the therapist and patient decide if a continuation of treatment is warranted or desired. Giving the adolescent an active part in the therapy "defuses dropout as a symbolic gesture of independence" (p. 413).
Franklin (1982) also delineates a series of "roles" that may be adapted by some adolescents to either test the therapist or stalemate the process of therapy:
"There are those who become mummified as a test of strength to endure the stress of silence; you will also encounter the seducer, who seeks validation from you as they do from their peers; the starer, who will rivet you with constant eye contact; and the abuser, who will verbally or physically try to intimidate you. The basic dynamic issue in the first sessions of therapy with the adolescent is one of control. The streetwise kid is very adept at maintaining control over the situation by adopting various roles. (p. 278)"
The literature reports success in the use of psychoanalytically oriented individual psychotherapy of some inner-city African-American children (Meers, 1970; Spurlock & Cohen, 1969). The following vignette illustrates how combining the ego capacity, motivation, and energy levels of the patient with the motivation of the therapist allowed Carol, a 15-year-old African-American, to expand her ego and her life.
Carol, the older of two daughters, was referred because of dizzy spells, mild palpitations, and anxiety attacks in school, where she was entering her junior high school year. She lived with her parents and sister in a housing project in the ghetto area. The family was supported by disability and blind assistance allotments because of the father's failing eyesight. Carol was seen for two periods of treatment by the same social worker: The first period ended when she completed high school, one-and-a-half years after referral. The second period was of two-and-a-half years' duration, from the time she was eighteen-and-a-half until she became twenty-one. Both parents were seen for the diagnostic evaluation. Neither parent was referred for treatment. Early in the treatment experience, a marked change in the family dynamics occurred: With a worsening of his visual problem, the father began to display paranoid and violent behavior. The mother responded by turning to Carol with the expectation that her "emergence into the labor market would provide an exit from life in the housing project ghetto." Carol, always a passive, compliant child with reaction formation defenses against anger, could not manage her rage over the obstruction of her long-standing wish to go to college, nor could she endure the guilt over separation wishes which defended her against sexual interest in boys. This is not to imply that Carol had no regressive wishes for the sadomasochistic and dependent gratification available from the mother. However, she effectively used her therapy to deal with the ambivalence, separation, and budding sexual interests so as to complete high school, to enter the local teacher's college, acquire part-time employment, and leave the therapist.
A bit over a year after termination of the first period of therapy, Carol called her therapist with complaints of panic and trembling on the job and in classroom recitations. She was taken back into treatment immediately, the foci of which were (1) to mitigate the intense rage and tie to the mother; (2) to support her against her regressive wishes; and (3) to help her achieve a sense of self-confidence in her reasonable dating patterns which were opposed by both parents.
The passive-aggressive defense against helplessness in the face of parental demands and social deprivation began to crumble as Carol experienced the therapist's confidence in her, which was supported by the larger culture. Carol's sense of autonomy expanded, and she became cognitively aware of the personal and social opportunity to make choices. Although she made much progress in achieving her goals, she could not move away from home when invited to do so by friends. (Spurlock & Cohen, 1969, pp. 28-29)
In the preceding vignette the therapist suggested that the patient apply for financial assistance as a means of relieving her guilt about choosing school rather than the full-time employment that would have allowed her to make a financial contribution to her family. Work with inner-city children, adolescents, and their families often calls for and involves collaborative efforts with another service agency to assist with handling pragmatic issues.
References have been made to the similarity of goals in individual psychotherapy with African-American children and those of the dominant group. There may be, however, a need to introduce parameters. As indicated previously, attention should be directed to specific culturally related transferences and countertransferences that may develop (Spurlock, 1985).
A segment of a resident's notes (minimally revised) provides a glimpse into psychotherapy with an 8-year-old African-American inner-city boy:
"There was no need to introduce parameters in the individual treatment (which followed a period of work in a group). The child responded to confrontations with apparent interest and eagerness to examine a bit of behavior and readily supplied associations in the effort to "find other pieces to the puzzles of my life" (this was a reflection of his long-standing exposure to the television "soaps"). As in other therapeutic encounters, the therapist was supportive of the child's self-mastery and his movement in the direction of reinforcing those behaviors which decreased the sense of his inability to control his impulses. (Spurlock, 1985, p. 173)"
In work with inner-city African-American children, Spurlock finds it helpful to see the patient and parents together for the initial session for the purpose of providing an explanation about the nature of the therapeutic process. This procedure is followed regardless of any previous contact with other staff. The rationale is twofold: to provide specific information about the process and ample time for questions and clarification and to grant the patient and the parent(s) an opportunity to size up the therapist and ask questions (such as "Have you ever worked with other families like us?"). This kind of orientation is particularly helpful with those families (regardless of race and ethnicity) who have experienced "investigative interviews" and are weary of revealing information that might disqualify them from the assistance they seek.
The telling of African folk tales is sometimes useful in work with African-American youngsters. Often, the content of the tale fosters or reinforces the self-esteem of youngsters who believe primarily negative things about the African-American culture. The playing of certain audiotapes (e.g., African American Folktales aula, 1969, read by Brock Peters and Diana Sands) that incorporate a lesson in the narrative has been particularly useful in work with younger children as well as in training programs for mental health professionals who are unfamiliar with African-American culture.
- Canino, Ian and Jeanne Spurlock, Culturally Diverse Children and Adolescents: Assessment, Diagnosis, and Treatment, The Guilford Press: New York, 1994.
The article above contains foundational information. Articles below contain optional updates.
Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these "Personal Reflection" Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a "work in progress." You will not be required to provide us with these Journaling Activities.
Personal Reflection Exercise #1
The preceding section contained information about culturally sensitive treatment approaches. Write three case study examples regarding how you might use the content of this section in your practice.
Work with inner city clients often requires what practical aspect? To select and enter your answer go to .