Culturally Responsive Interventions

Innovative Approaches to Working with Diverse Populations

Julie R. Ancis

• Publisher: Routledge
• Year: 2004
• Topic: Psychology
• eBook ISBN:
  9781135953973
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book fills the widening gap in multicultural literature by providing specific culture-centered interventions. The first section of the text highlights culturally based interventions. The second section focuses on the treatment of Culture-Bound Syndromes (CBS). Culture-Bound Syndromes are defined as recurrent, locality specific behavior patterns that are observed only in certain cultural environments. The third section, clinical and training implications, includes a chapter describing how training will need to be reconceptualized in order to promote counselors who are effective with a wide range of clients.

Part I
Culturally Responsive Interventions

Chapter 1
Culturally Responsive Practice

Julie R.Ancis

This chapter presents a rationale for culturally responsive practice and interventions. Research on clinical approaches with diverse clients is reviewed. The author discusses the clinical significance of social and cultural factors in terms of distress expression, attribution, and treatment approaches. The influence of contextual factors such as acculturation, discrimination, and culture-related stressors on psychosocial functioning and therapy are examined. The author defines culturally responsive approaches and discusses their clinical significance in meeting the needs of an increasingly diverse population.

Demographic Diversity

The demographic composition of the United States has become increasingly racially and ethnically diverse (United States Census Bureau, 2001). This demographic shift has been attributed to both high immigration rates and differential birth rates (Sue & Sue, 1999). Population shifts include new immigrants, yoimger individuals of Latino descent (Judy & D’Amico, 1997), and a greater portion of Americans speaking a language other than English at home (U.S.Census Bureau, 2001). Conservative projections estimate that ethnic minorities will comprise over 50% of U.S. society by the year 2050 (U.S. Census Bureau, 2001). As a result, clinicians will interface regularly with culturally pluralistic populations (D’Andrea & Daniels, 2001; Lewis, Lewis, Daniels, & D’Andrea, 1998).

Relatedly, the mental health profession in the United States has increasingly recognized that psychological practice and interventions must be responsive to the needs of a diverse clientele. This recognition is evident in the development of several key documents. The American Psychological Association (APA) Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations (1990) outlines the importance of psychological services that are sensitive to factors such as gender, age, culture, and ethnicity. More recently, the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists approved by the American Psychological Association (2002) outline a rationale and need for addressing multiculturalism and diversity in each domain. Documents such as the Guidelines for Psychological Practice with Girls and Women (American Psychological Association, 2003) attend to the interactions of such dimensions as gender, race, ethnicity, sexual orientation, socioeco nomic status, and social context in psychological practice.

Attention to the importance of culture in psychological practice within the United States parallels ongoing developments worldwide. There has been a rapid growth of international population migration and relatedly population heterogeneity within nations of the world (Chiu, 1996). Moreover, there has been an increased focus on approaches and interventions designed to meet the needs of individuals and communities globally. The international counseling movement has focused on the training of clinicians and the development of professional counseling associations in locations such as Western Europe, Central and Eastern Europe, New Zealand, Africa, Asia, North America, and South America (Harper & Deen, 2003).

Clinical Practice with Diverse Clientele

Many racial and ethnic minorities, particularly American Indians, Asian Americans, African Americans, and Hispanics tend to underutilize traditional outpatient mental health services (Cheung & Snowden, 1990), despite the fact that prevalence rates for psychiatric disorders are analogous across ethnic groups (Hough et al, 1987; U.S. Department of Health and Human Services, 2000, 2001; Weissman, Livingston, Leaf, Florio, & Holzer, 1991). Among ethnic minorities who do use mental health services (Rogler, Malgady, Costantino, & Blumenthal, 1987; Sue, 1977), there are often high dropout rates after one session (Wierzbicki & Pekarik, 1993), infrequent use of therapy sessions (Krebs, 1971; O’Sullivan & Lasso, 1992; Solomon, 1988), and poor levels of functioning at the end of treatment (Jerrell & Wilson, 1997; Rosenheck, Leda, Frisman, & Gallup, 1997; Zane, Enomoto, & Chun, 1994).

Several hypotheses may explain the preceding findings, including barriers such as societal stigma and the use of alternative helping networks among individuals such as the extended family, clergy, or traditional healers; lack of bilingual or multilingual staff; culturally inconsistent treatment modalities; and prejudicial attitudes among mental health professionals (Ancis & Szymanski, 2001; Rogler et al., 1987; Sue, Fujino, Hu, & Takeuchi, 1991; U.S. Department of Health and Human Services, 2001). Sue, Ivey, and Pedersen (1996) asserted that contemporary counseling approaches do not adequately explain or predict the behavior of many racial and ethnic groups. Similarly, the relevance and effectiveness of contemporary theories of counseling and psychotherapy for cul turally diverse populations has been questioned (e.g., Atkinson, Morten, & Sue, 1998; Ivey, Ivey, & Simek-Morgan, 1993; Katz, 1985; Sue, Ivey, & Pedersen, 1996). Culture-bound values of counseling such as a focus on individualism versus a more collectivistic notion of identity found in many non-Western cultures, are often inconsistent with the world views of many diverse clients (D.W. Sue, 1995). The Surgeon General’s Report on culture and mental health (USDHHS, 2000, 2001) suggests that “cultural misunderstanding or communication problems between clients and therapists may prevent minority group members from using services and receiving appropriate care” (p. 42).

The Clinical Significance of Culture and Context

Culture has been defined in various ways in the behavioral sciences literature. Alarcón, Foulks, and Vakkur (1998) define culture “as a set of meanings, behavioral norms, and values used by members of a particular society, as they construct their unique view of the world” (p. 6). Reference points include habits, customs, political beliefs, social relationships, and language. Culture is both changing and permanent. Individual-culture interactions are viewed as contributors to the molding of styles and strategies. Cultural institutions, ideologies, and practices provide the context for and shape affect, behavior, and personality (Alarcón et al., 1998; Kirmayer, 2001). Because cultural norms prescribe and proscribe certain behaviors and norms for men and women, young and old, “ill” and “healthy,” these dimensions and associated socio-identities may also be considered cultural constructs.

As such, culture has been found to have a significant influence on multiple dimensions of the therapeutic process. Culture influences the source of distress, the form and quality of illness experience, symptomatology, the interpretation of symptoms, modes of coping with distress, help seeking and response to treatment, and social responses to distress (Kirmayer, 2001; Kirmayer & Young, 1999; U.S. Department of Health and Human Services, 2001). The ways in which culture specifically influences illness expression, attribution, and treatment are reviewed in the following.

Expression, Attribution, and Treatment

The phenomenology of disorders and symptomatic expression seems to vary across cultures (Good & Kleinman, 1985; Kirmayer, 1989; Westermeyer, 1987). Culture influences internal ideation and external behavior. Kleinman (1988) describes how the experience of illness (or distress) is always a culturally shaped phenomena. Complaints of distress are often expressed through culture-specific idioms; a situation that often results in diagnostic challenges. For example, several studies have demonstrated that Asians demonstrate a greater number of somatic complaints compared to non-Asians (Kleinman, 1977; S.Sue & Sue, 1974). A number of explanations may account for this finding. Chinese traditional medicine’s emphasis on the correspondence between human emotions and body organs may explain this tendency (Tseng, 1975). Asian patients complaints of suffering due to weakness of the kidney are often associated with psychosexual problems, elevated fire in the body or liver to anger or anxiety, and loss of soul to depression or disassociation (Tseng, 1997). Thus, somatization may be a way of expressing distress. An additional explanation may be that in societies influenced by Confucian notions, such as China, disorders such as depression can be perceived as self-centered and asocial. The expression of physical suffering and bodily pain, which are amenable to treatment and do not threaten social relationships, may be more acceptable (Kirmayer & Groleau, 2001; Yen, Robins, & Lin, 2000).

An association between somatic expression and anxiety and depression also has been recorded in countries such as Saudi Arabia, Iraq, Peru, and India (see Kleinman, 1988). Among South Indians, a significant relationship has been demonstrated among psychiatric stigma, somatization, and depression (Raguram, Weiss, Channabasavanna, & Devins, 1996; Raguram, Weiss, Keval, & Channabasavanna, 2001). Again, somatic complaints may be perceived as more socially acceptable expressions of distress. Interestingly, some research has shown that although depressed Chinese patients express complaints somatically, they admit to affective symptoms when asked about them directly (Cheung, Lau, & Waldmann, 1980–1981), thereby challenging the notion of experience versus expression.

Alarcón and Foulks (1995) describe how culture shapes many personality styles. One’s sociocultural background often influences one’s reactions to stimuli, coping style, problem-solving approaches, and social interactions. Some individuals may experience the formative influence of their culture in ways that emphasize the most salient features of their culture, and consequently develop the maladaptive and rigid traits of a Personality Disorder. Self-concept and selfimage are influenced by cultural factors; such as child-rearing practices, intrafamily roles, and social expectations (Alarcón & Foulks, 1995). In some cases, culture may serve as a pathogenic/pathoplastic factor in the occurrence of clinical situations. For example, the “overcontrolled” problems such as fearfulness and sleep difficulties seen in Jamaican children compared to their U.S. counterparts may be attributed to Jamaican child-rearing practices in which subservience and submissiveness are reinforced. Conversely, the higher rate of “undercontrolled” problems such as fighting and disobedience among U.S. youngsters may be attributed to the expectation of nonconformity and brashness among this population (Lambert, Weisz, & Knight, 1989). Similarly, women’s social roles, status, and life circumstances including limited access to power outside of the home may explain gender differences in rates of depression and symptom expression in Puerto Rican women (Koss-Chioino, 1999).

In addition to variations in symptom expression, individuals in various cultures hold different beliefs about the causes of illness (Torrey, 1972). For example, although primary care patients of diverse cultural backgrounds complain of somatic symptoms, they differ in their preferred attributions for these symptoms (Kirmayer & Groleau, 2001). Some attribute disruptive symptoms to metaphysical causes such as loss of the soul, spirit possession, sorcery, and angering a deity (Koss-Chioino, 1992). In some cultures, mental illness is often attributed to shameful causes, such as being unfair in social dealings, failure to respect nature, misdeeds in past lives, past family transgressions, immoral excesses, or personal weakness (Flaskerud & Soidevilla, 1986; Gong-Guy, Cravens, & Patterson, 1991; Lee, 2001). It is important to consider that some experiences, such as possession, may be considered a sign of “unnatural illness” or an experience against nature as determined by God. As such, the stigma of mental illness is often not associated with it (Koss-Chioino & Canive, 1993).

In addition, varying explanations of distress influence whether treatment is pursued. People in most of the world do not view health care services as an appropriate venue for emotional concerns. Rather, emotional difficulties are viewed as sociomoral problems and it is considered more appropriate to discuss these problems with a family member, elder, or spiritual or community leader (Kirmayer, 2001). Lay, cultural interpretations of distress may relate to interpersonal, intrafamilal struggles over power within a social group, such as the case of embrujado in Hispanic patients, rather than intrapersonal conflicts (Koss-Chioino & Canive, 1993). Moreover, among some clients, such as refugees from South East Asia, all conditions requiring mental health treatment are highly stigmatized, often resulting in the underutilization of such services (Gong-Guy, Cravens, & Patterson, 1991). Rather, mental health services are sought as a last resort, after family resources, traditional healers, and general medical approaches have proven ineffective.

Attributions also influence beliefs about cures for psychological problems and appropriate treatment (Shimoji & Miyakawa, 2000). Many cultural groups seek help from an indigenous leader or shaman (Das, 1987) and value experiences such as trances, dissociative states, communicating with spirits and gods, vision quests, and herbal remedies as therapeutic elements of healing (Koss-Chioino, 1992; Lebra, 1972). For example, Spiritist healers in Puerto Rico seek to eliminate pain and upset by bringing to the session spirits held responsible for the client’s distress (Koss-Chioino, 1992). Remedies such as candle lighting, herbs, and aromatic baths may be prescribed (Koss-Chioino, 1995). Moreover, the medium-healer is not viewed as the agent of intervention in Spritism, but only a vehicle. Some Asian ethnic groups have been reported to believe that mental health can be attained through willpower and focusing on pleasant thoughts (Sue & Morishima, 1982).

Symptom attributional style has been found to affect the recognition rate of certain disorders. For example, patients who attribute their depression-related somatic symptoms to physical illness or environmental causes are less likely to have their depression recognized and treated by clinicians (Kirmayer & Groleau, 2001).

Culturally Based and Contextual Factors Relevant to Counseling

Historically, psychology has focused on biological determinants of behavior at the exclusion of historical and sociopolitical dynamics (Bronstein & Quina, 1988). The influence of individual’s social, political, and economic context on one’s behavior is often not considered or misinterpreted, often resulting in faulty diagnosis and inappropriate interventions. Sue, Ivey, and Pedersen (1996) argue that understanding the client’s cultural and sociopolitical context is essential to accurate assessment, interpretation, and treatment.

Contextually based risk factors often influence an individual’s world view and behavior and may make those with limited resources or protection more susceptible to mental disorders. Moreover, contextual factors linked to race or ethnicity, such as socioeconomic status or country of origin can increase the likelihood of exposure to these types of stressors (U.S. Department of Health and Human Services, 2000, 2001). Racial and ethnic minorities are often overrepresented among the vulnerable, high-need groups, such as homeless and incarcerated persons. The similar prevalence rate of mental disorders, combined with lower utilization and poorer quality of care, means that minority communities have a higher proportion of individuals with unmet mental health needs. Social and contextual factors relevant to individual’s psychosocial functioning and to the therapeutic process are reviewed in the following.

Acculturation

Acculturation refers to the process of adapting to the rules and behavioral characteristics of another group of people (Smart & Smart, 1995). Typically, this refers to the process by which immigrants adapt to the host society. Acculturation is multidimensional as acculturation occurs across emotions, cognitions, and behaviors (Barón & Constantine, 1997). Language difficulties, cultural differences, changing socioeconomic status, underemployment, prolonged phases of social isolation, and disrupted social ties often accompany the process of acculturation (Vargas-Willis & Cervantes, 1987). Many immigrants experience acculturative stress, defined as a set of emotions and behaviors that include depression, anxiety, feelings of marginality and alienation, and identity confusion (Smart & Smart, 1995).

Forced acculturation to urban living and the dominant culture and unsatisfactory adjustment to a discriminatory social environment have been linked to the high rate of unemployment, alcohol and drug abuse, delinquency, and depression and adjustment reactions among American Indians (Choney, Berryhill-Paapke, & Robbins, 1995; LaFromboise, 1988). Similarly, research with Hispanic populations has demonstrated a relationship between acculturation levels, self-esteem, alcohol and drug abuse, delinquency, and depression (Rogler, Cortes, & Malgady, 1991). In addition, parent-child discrepancies in acculturation level combined with normative parent-adolescent intergenerational differences often result in intrafamilial conflicts (Szapocznik, Kurtines, & Fernandez, 1980).

Research has demonstrated a relationship between acculturation and help-seeking attitudes. Studies have demonstrated that more highly acculturated Asian Americans had more positive attitudes toward seeking professional psychological help than those with lower levels of acculturation (Atkinson & Gim, 1989; Tata & Leong, 1994).

It is important to consider that attributes developed during the acculturation process can function as coping skills given the demands of the environment and social context (Choney, Berryhill-Paapke, & Robbins, 1995). Understanding and successfully negotiating customs, institutions, and policies associated with the dominant culture allows for a range of opportunities and flexibility in cognitive, behavioral, affective, and interpersonal domains.

Violence and Trauma

The number of refugees in the world today is estimated to be between 16 and 22 million (Kinzie, 2001). Many refugee and immigrant populations have experienced the trauma of war, indiscriminate killings, starvation, statesponsored torture, rapes, forcible detainment in refugee camps, and witnessed the death of family members and friends (Kinzie, 2001; Vernez, 1991). Repeated exposure to such catastrophic env...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Preface
• Part I Culturally Responsive Interventions
• Part II International Applications
• Part III Diagnosis and Practice
• Part IV Conclusion
• About the Editor and Contributing Authors