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Section 19
Treating the Invisible Barrier
with the 'Subtle Fears' Exercise

Question 19 | Test | Table of Contents

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In the last section, we discussed the culturally different client’s Locus of Control, as well as the Locus of Responsibility, for Native American and Alaska Native clients. Your culturally different client may have either an Internal Locus of Control or an External Locus of Control. In counseling, your culturally different client may adopt either an Internal Locus of Responsibility or an External Locus of Responsibility.

In this section, we will discuss the ethical treatment of fear in culturally different clients who are coping with the five stages of identity development and the loci of control and responsibility discussed in the previous sections.

Sound interesting?

♦ Case Study Analysis: Nina's Anger & Fear
When Nina, age 39 Alaskan Native, came to my office, she said that she was very unhappy. Nina stated, "No one has ever really appreciated me. My father was abrasive, and my mother was just submissive to him. She really didn’t have a personality at all. She was so caught up in what my dad wanted, she didn’t notice me at all."

She explained that this situation growing up had created a lot of anger inside her. Nina stated, "I just can’t get close to anyone. I’ve dated some men, but it just seems like there’s this invisible barrier. I’ve also tried to go out socially with some girlfriends, but we were never really that tight." Sound like a culturally different client of yours? Ethically how would you handle Nina’s problems?

As you can see Nina’s problem is not just her anger. I suspected that Nina’s anger was actually rooted in another emotion. I asked Nina, "When you try to comprehend the reasons for your anger, what do you come up with?" Nina stated, "I know I have a hard time trusting people that aren’t Alaska Natives. It becomes a never-ending cycle. I want to get close to someone, but I’m sure I send signals indicating discomfort. So that person rejects me and I get mad. Then when another potential relationship comes along I’m all the more skeptical, so the cycle repeats itself."

I stated to Nina, "I’m hearing you say that you are guided by your fears." Nina looked surprised. She stated, "Fear? I always knew I was angry, but I didn’t think I was living in fear." It seemed to me that Nina needed guidance in identifying fear. Do you agree?

As you are well aware, fear implies hesitancy, apprehension, and doubt. I have found that fear is an emotional governor that inhibits many culturally different and non-culturally different clients from living with full-throttle confidence.

However, as you are well aware fear is not always expressed in hesitancy, apprehension, and doubt. To help Nina understand her fears, I decided to have her work through a couple of techniques. As I explain them, think of your client of a different culture. Would these techniques be ethically appropriate?

♦ "Describing Fear" Technique
The first technique I asked Nina to do was the "Describing Fear" technique. The "Describing Fear" technique is based on just one question. I handed Nina a notebook and asked her to answer the question, "When you think of a fearful person, what mental image is most typical?"

Nina began writing, "Someone unassertive, cowardly, shy." I stated to Nina, "Most people identify fear in overtly weak characteristics like the ones you wrote. As you know, those qualities have strong elements of fear. However, fear is not one-dimensional. Fear can be expressed in any way that shows the inner insecurity that inhibits us from living in the healthy ways we know we should."

♦ "Subtle Fears" Technique
For the second exercise, which I call the "Subtle Fears" exercise, I asked Nina to flip to a blank sheet in the notebook. I stated, "I’m going to list ten statements. I want you to give yourself a point for each statement that applies to you."

Subtle Fear Statements
I then read the following statements to Nina:
1. I feel antsy or uncomfortable when I am not in control of things.
2. I have been told I don’t receive others’ feedback well.
3. There are parts of my personality no one knows about.
4. Sharing intimate feelings or personal thoughts with others is not natural for me.
5. Sometimes I use humor to avoid delicate subjects or I change topics quickly.
6. The moods of other people can have a strong effect on my moods.
7. I have a habit of letting my frustrations fester inwardly; I don’t let go of them easily.
8. I have been known to tell lies to cover up flaws or to keep from being accountable.
9. When someone is clearly angry, I habitually seek to "cover my flank."
10. I worry more about my public image than most people would suspect.

Nina counted her tally marks and stated, "I have seven points." I explained to Nina that each of the statements represented a subtle form of fear. I stated, "Having more than five points in the ‘Subtle Fears’ exercise usually may mean you struggle often with fear. That fear, in turn, brings frustration and anger into your world."

Do you have a client of a different culture who, like Nina, is expressing his or her fear through anger? Ethically would your Nina benefit from the "Describing Fear" technique? Or would your Nina benefit more from the "Subtle Fears" exercise? From an ethical perspective, how might her cultural background influence the counseling process?

In this section, we have discussed the treatment of fear in culturally different clients.

In the next section, we will discuss discuss relevant processes and goals in counseling culturally different clients. We will also discuss Ivey and Authiur’s four conditions that may arise in counseling a client of a different culture. These four conditions are Appropriate Process and Appropriate Goals, Appropriate Process and Inappropriate Goals, Inappropriate Process and Appropriate Goals, and Inappropriate Process and Inappropriate Goals.
Reviewed 2023

Update
Satisfaction and Cost-Related
Access Barriers Among American Indian
and Alaska Natives Adults by Insurance Type

- Moss-Vazquez, T., Wray, C. M., Lopez, L., Khare, M., & Keyhani, S. (2023). Satisfaction and Cost-Related Access Barriers Among American Indian and Alaska Natives Adults by Insurance Type. Journal of general internal medicine, 38(6), 1576–1578.

Peer-Reviewed Journal Article References:
Desai, M. U., Paranamana, N., Restrepo-Toro, M., O'Connell, M., Davidson, L., & Stanhope, V. (2020). Implicit organizational bias: Mental health treatment culture and norms as barriers to engaging with diversity. American Psychologist. Advance online publication.

Engle, R. L., Tyler, D. A., Gormley, K. E., Afable, M. K., Curyto, K., Adjognon, O. L., Parker, V. A., & Sullivan, J. L. (2017). Identifying barriers to culture change: A qualitative analysis of the obstacles to delivering resident-centered care. Psychological Services, 14(3), 316–326.

Lardon, C., Wolsko, C., Trickett, E., Henry, D., & Hopkins, S. (2016). Assessing health in an Alaska native cultural context: The Yup’ik Wellness Survey. Cultural Diversity and Ethnic Minority Psychology, 22(1), 126–136.

McAdams, D. P. (2019). Young men fight wars, and they do it for the tribe. Peace and Conflict: Journal of Peace Psychology, 25(4), 349–350. 

Mujica, C., Alvarez, K., Tendulkar, S., Cruz-Gonzalez, M., & Alegría, M. (2020). Association between patient-provider racial and ethnic concordance and patient-centered communication in outpatient mental health clinics. Journal of Psychotherapy Integration, 30(3), 423–439.

Pomerville, A., & Gone, J. P. (2018). Behavioral health services in urban American Indian health organizations: A descriptive portrait. Psychological Services, 15(1), 1–10. 

QUESTION 19
How is fear expressed in culturally different clients? To select and enter your answer go to Test.