Addressing Race-Based Stress in Therapy with Black Clients

Using Multicultural and Dialectical Behavior Therapy Techniques

Monica Johnson, Michelle L. Melton, Monica M. Johnson

• Publisher: Routledge
• Year: 2020
• Print ISBN:
  9781138339521
• eBook ISBN:
  9780429804861
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Despite Black Americans being at high risk for negative mental health symptoms due to racism and other chronic stresses, disparities persist in the provision of mental health services to this population. This book addresses that gap in clinical practice by explicitly calling attention to the experience of race-based stress in the Black community.

Johnson and Melton urge mental health practitioners to action in promoting societal understanding, affirmation, and appreciation of multiculturalism against the damaging effects of individual, institutional, and societal racism, prejudice, and all forms of oppression based on stereotyping and discrimination. Chapters include worksheets, vignettes, and case studies to provide a practical framework for implementing an effective, nonpathological approach to ameliorating the damaging effects of race-based trauma and stress.

This book will give tools and strategies for mental health professionals to responsibly use scientific and professional knowledge to improve the condition of individuals, communities, and, by extension, society.

PART I

Foundational Knowledge

Chapter 1 Components of Cultural Competence

Chapter 2 Re-envisioning Ethics Through a Multicultural-Oriented Framework

Chapter 3 Advocacy and Consultation Regarding Race-Based Stress

CHAPTER 1

Components of Cultural Competence

█ Adopting a Multicultural Orientation

Within psychotherapy communities increased attention has been given to the importance of a multicultural orientation (MCO). Much is owed to Sue et al.’s (1982) tripartite model of multicultural competencies that consists of three components: attitudes/beliefs, knowledge, and skills. The model asserts that therapists’ awareness of their own cultural background, attitudes and beliefs, knowledge of diverse clients’ worldviews, and use of culturally appropriate skills are the foundation of developing competency. Additional research has been conducted since that time that seeks to provide more contextualization to addressing multicultural concerns in the therapy room. Owen et al. (2011) introduced the multicultural orientation framework as a way to better conceptualize and define the variables that arise within therapists’ culturally focused interventions in session. The multicultural orientation framework consists of three components: cultural humility, cultural opportunities, and cultural comfort (Hook, Davis, Owen, Worthington, & Utsey, 2013, Hook et al., 2017; Tervalon & Murray-Garcia, 1998), which will be discussed in more detail later. Research supports that several race-related variables affect the mental and physical health of Black Americans (Harrell, Hall, & Taliaferro, 2003; Pieterse & Carter, 2007). Given this knowledge and the focus of this text to address race-based stress (RBS), we believe that adopting an ethnopolitical approach, as discussed by Comas-Díaz (2000), in combination with MCO is important. An ethnopolitical approach is one that recognizes the impact of oppression, racism, and political repression. Comas-Díaz (2000) argued that therapists must take an anti-racist stance in their work with people of color. An anti-racist stance is one in which the therapist does not minimize, ignore, or intellectualize racism. We utilize this orientation with the purpose of opening a space for Black clients to liberate themselves from the negative effects of racial oppression. Regardless of the terms (e.g. cultural sensitivity, humility, competence, etc.) one uses to convey their approach, to truly work with diverse populations takes continual education and self-assessment. If you share diversity variables with the populations that you are treating it does not remove this requirement.

Assumptions of Multicultural Orientation

1. We assume that therapists and clients co-created cultural expression within therapy (Hook et al., 2017). As such the therapist can influence the cultural safety felt in the environment. They also have an impact on which cultural identities are more or less prominent to the client. Finally, therapists impact how much cultural heritage is integrated in the therapeutic process (Hook et al., 2017). Consequently, we encourage you to be explicit about the need for and safety of cultural expression early in treatment. It is also imperative to remain aware of the intersectional identities. Typically, multiple factors play a role in culture and identity (e.g. gender, sexuality, religion, etc.) outside of race. All of these identities form the client’s unique perspective and experience and should be honored and addressed in treatment. Your cultural identities may influence what you are aware of and have a tendency to highlight. For instance, an Asian, male, secular therapist may underestimate the role of religion for the client. While this text focuses on race-based traumatic stress, the multicultural orientation is the foundation for all that we do and leaves room to address the whole person.
2. We assume that multicultural orientation involves a way of being with clients rather than a way of doing therapy (Owen, 2013; Owen et al., 2011). Owen et al. posit that the multicultural orientation framework is more about the therapist’s values regarding culture and the integration of those values throughout the therapy. The actual interventions that are implemented are secondary. Values consistent with the multicultural orientation framework involve being genuine and authentic in engaging in conversations about culture. We feel that this value system, in combination with adapting therapeutic tools to address the psychological impact of race-based stress, can be beneficial to clients.
3. We assume that cultural processes (e.g. cultural humility) are especially important for connecting with the client’s most salient cultural identities: feeling deeply known and accepted sets the stage for effective therapy (Hook et al., 2017). Talking about the race and the impacts of living in a society that marginalizes those based on race and other variables requires openness, vulnerability, and trust. If the therapist is unable to display humility, the opportunity to effect change may be lost. It is imperative as the therapist that you engage in self-reflection and consult with colleagues that you trust in order to maintain the humility necessary for this work.
4. We assume that having a strong multicultural orientation motivates therapists to learn new things about their own and their clients’ cultural perspectives and worldviews (Hook et al., 2017). This includes understanding your own limits and seeking out experiences that allow you to learn more about diverse cultures. We have a tendency to surround ourselves with people and things that are similar, likeminded, and support our worldview. It is important to engage with stimuli that challenge us and force us to grow. When is the last time you watched a foreign film or documentary that was about a group of people that were dissimilar to you? How diverse is your network of friends and colleagues? How proactive are you in seeking out experiences that expand your perspective?

Critical Concepts of a Multicultural Orientation

Cultural humility is the foundational concept that underlies both cultural opportunities and cultural comfort. It is a lifelong process that involves self-reflection, self-critique, and examination of one’s own assumptions, biases, and beliefs (Tervalon & Murray-Garcia, 1998). At the same time, culturally humble therapists maintain an other-oriented approach that involves respect and lack of superiority toward other’s perspectives and values, etc. There are both intrapersonal and interpersonal aspects of cultural humility. The intrapersonal aspect encompasses how therapists view themselves culturally including their biases, strengths, areas for growth, world view, etc. A key component of the culturally humble therapist is a nondefensive, open stance that allows them to take in feedback and incorporate it to improve their approach and broaden awareness. The interpersonal aspect of cultural humility describes a way of being curious and open toward other’s cultural beliefs, rather than being ethnocentric.

Cultural opportunities are moments in therapy in which a client’s cultural beliefs, values, or other aspects of cultural identity can be explored (Hook et al., 2017). Each session provides numerous occasions in which culture can be explored and integrated into the process. However, they often go unnoticed because the therapist is not attuned or is fearful of approaching these topics. Sometimes these missed opportunities take the form of microaggressions. Thinking about a missed opportunity, or unintentionally engaging in a microaggression can cause anxiety for a therapist. It is important to remember that perfection is neither expected nor required. Cultural humility and cultural opportunities work in concert with each other. For instance, missed cultural opportunities can lead to poorer treatment outcomes, but these negative effects can be mitigated if the therapist is perceived as being high in cultural humility (Owen et al., 2016). Moreover, microaggressions cause harm to therapeutic alliance, but when therapists address them in session, the alliance can recover to pre-existing levels. The goal is to display a willingness to challenge your biases, build awareness of yourself and others, fine tune your skill set to reduce missteps, and repair when mistakes inevitably occur.

Cultural comfort relates to the therapist’s emotional state before, during, and after culturally relevant conversations. We find that many therapists have a tendency to avoid cultural topics due to their discomfort. We want to validate that addressing cultural aspects of others can feel awkward or tense and we encourage you to explore those feelings with the intent of acting opposite. Owen et al. (2017) found that therapists who were less culturally comfortable with racial and ethnic minority (REM) clients had a higher rate of dropout for their REM clients than their White clients. As with any type of exposure, the more you engage with the stimulus that causes fear, the more comfort you gain over time. The goal with cultural comfort is to have feelings of calm, openness, ease, and relaxation. As an example, review the dialog below between Dr. Banach and her client Jennifer, a 32-year-old African American and Mexican female.

Jennifer: I found out a few days ago that I’m pregnant and I’m super anxious and I don’t know what to do about it. I’m not in a relationship with the dad and he doesn’t want anything to do with the situation. I don’t know that I can raise a child by myself. I’ve tried to pray about it, but I’m not getting any answers.

Dr. Banach: This seems to be causing you a lot of stress and confusion.

Jennifer: Yes, it is.

Dr. Banach: You mentioned anxiety, how has it been affecting you?

Jennifer: I can’t sleep because I keep thinking about what I should do? Should I have the baby? Should I have an abortion? Should I give it up for adoption? I know ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Illustrations
• Preface
• Acknowledgments
• Part I. Foundational Knowledge
• Part II. Implementing Culturally Responsive Care
• References
• Index