Assessing and Treating Culturally Diverse Clients

A Practical Guide

Freddy A. Paniagua

• Publisher: SAGE Publications, Inc
• Year: 2013
• Print ISBN: 9781412999779
• eBook ISBN: 9781483320823
• Edition: 4
• Topic: Education
• Subtopic: Education Counseling

Now in its Fourth Edition, the best-selling Assessing and Treating Culturally Diverse Clients offers effective, practical guidelines in working with culturally diverse clients. Author and clinician Freddy A. Paniagua first summarizes general guidelines that clinicians can apply when assessing, diagnosing, or treating culturally diverse clients, but also addresses clinical work with specific culturally diverse groups such as African American, Hispanic, American Indian, and Asian clients. Two new chapters in this edition deal with the assessment, diagnoses, and treatment of emotional problems experienced by LGBT and older adult clientsfrom these culturally diverse groups.

1

Minority, Multicultural, Race, and Ethnicity Concepts

Minority Groups Versus Multicultural Groups

Many Americans use the term “minority” to refer both to certain cultural groups’ numbers in the population and to disadvantages in terms of socioeconomic status (Ho, 1987, 1992; Jun, 2010; Liu, 2011; Sue & Sue, 2003; Wilkinson, 1993). Thus, in the United States, Anglo Americans, or Whites, are not considered a “minority group” because there are too many of them (approximately 223.5 million in 2010), and as a group, their socioeconomic status is higher than that of other racial/ethnic groups (U.S. Bureau of the Census, 2010a). African Americans and Hispanics are often referred to as minority groups because they number approximately 38.9 and 50.4 million, respectively (U.S. Bureau of the Census, 2010a) and their socioeconomic status, at the group level, is lower than that of the “majority” (i.e., Whites). Other examples of “minority groups” in the United States, in terms of their number and socioeconomic status, include American Indians and Alaska Native (2.9 million), Asians (14.6 million), and Native Hawaiian and Other Pacific Islanders (540.013) (U.S. Bureau of the Census, 2010a).

In 1994, I suggested the elimination of the term “minority” from the genetic, social, and psychological literature. In the past 19 years following this suggestion, most major textbooks have avoided the use of that term in their title. Examples of this finding can be found in Constantine (2007), Ponterotto, Casas, Suzuki, and Alexander (2010), and Sue and Sue (2003). In addition, most scholars are now using the label “people of color,” with less emphasis on the “minority” term, to refer to the four groups discussed in this book (e.g., see Comas-Díaz, 2012, p. 94). As noted in prior editions of this volume (Paniagua, 1994, 1998, 2005), the use of the term minority in regard to these groups, however, may not be appropriate for three reasons: discrepancies in income levels across these groups, the impact that these groups can have on other groups, and the connotation of “inferiority” that the term minority has in the minds of some members of these groups.

Discrepancy in Income Levels Across “Minority” Groups

Comparisons of the median income level across “minority” groups (e.g., Asians versus African Americans) reveal discrepancies. For example, in 2010 the median income for the Asian and Pacific Islander population in the United States (persons of Japanese, Chinese, Filipino, Hawaiian, and other Asian/Pacific Island heritage) was $67,022 and $52,776, respectively, whereas the median income for African Americans and Hispanics in the same year was $33,578 and $40,165. At that time, the national U.S. median income was $50,046 (U.S. Bureau of the Census, 2010b). Thus, although African Americans, Asians, Hispanics, and Pacific Islanders are examples of “minority” groups in terms of their numbers (and in comparison with the White/Anglo Americans), Asians and Pacific Islanders have a median income far above the national average.

A similar point can be made through a comparison of income levels across subgroups within the same ethnic group. For example, in 2004 the median household income for the Cubans (a subgroup of Hispanics) residing in the United States was $38,000, whereas the median income for other Hispanics residing in this country was $36,000 (Pew Hispanic Center, 2006). Although both of these groups are part of the Hispanic “minority” group, it is evident that, as a group, Cubans have a better standard of living than do other Hispanics in the United States.

Thus, the term “minority” might be accurate regarding an individual’s being a member of a group with a smaller number of people in it than the “majority” group, but it may not be an appropriate way to describe that person in terms of income level (which can vary between “minority” groups and between subgroups within the same racial or ethnic group.

Impact of “Minority” Groups on Other Groups

Another problem with the use of the term minority is that it does not take into consideration the impact that population size of a minority group upon another “minority” group can have on other groups (Wilkinson, 1986). For example, many African Americans and Hispanics reside in Florida. Currently, a major problem confronting the African Americans is that in several areas of the state (e.g., Miami) they constitute a minority of the population, whereas Hispanics constitute a “majority” group. Both African Americans and Hispanics are example of minority groups in relation to the total number of people in the United States, but in certain parts of Florida, Hispanics take on majority status. A similar situation exists in the Lower Rio Grande Valley of Texas, which is concentrated around the border between the United States and Mexico. In this region, Mexican Americans are the majority; other Hispanics (e.g., Puerto Ricans, Cubans), Asians, African Americans, and American Indians are “minority” groups. In addition, in four of the larger cities in the Lower Rio Grande Valley, namely, Brownsville (population, 175,027), Edinburg (76,960), Harlingen 64,869), and McAllen (129,877), the “minority” populations are Black or African Americans (0.4%), American Indians and Alaska Natives (0.4%), and Asians (0.7%). The Hispanics are the “majority” in that region: Brownsville, 93.2%; Edinburg, 88.2%; Harlingen, 79.5%; and McAllen, 84.6% (see U.S. 2010 Census at http://quickfacts.census.gov/qfd/states/48/48000.html).

In addition, it should be noted that among all “minority groups” in the United States, the Hispanic population is the largest. The 2010 U.S. Census counted more Hispanics (50.4 million) than African Americans (38.9 million) (U.S. Bureau of the Census, 2010a).

The Concept of “Minority” Equals to “Inferiority”

Mental health practitioners should be aware that some people object to being referred to as minority or as a member of minority group because they feel that the terms imply inferiority and a sense of superiority on the part of those in the majority (i.e., Anglo Americans). For example, in a letter sent to the San Antonio Express News, one Hispanic person wrote “when an individual labels me a ‘minority’, I feel small, weak and irrelevant. On the other hand, ‘ethnically diverse American’ is empowering and more accurate” (Martinez, R. E., 1993, p. 5B). McAdoo (1993a) pointed out that a major reason she advises others to avoid the term minority [emphasis added] is that “it has an insidious implication of inferiority. . . . A sense of superiority is assumed by those of the implied superior status” (p. 6).

Thus, the term minority may not be applicable when one considers issues of income level or the size of particular minority groups in relation to other groups, and it may be undesirable given the potential use of the term as synonymous with “inferiority” (Kim, McLeod, & Shantzis, 1992; McAdoo, 1993a; Wilkinson, 1986). Perhaps terms such as multicultural or diverse are more appropriate to describe the many different populations or groups that make up the U.S. population. These terms emphasize the differences in terms of cultural values rather than the relative sizes of the groups. The use of such terms has been increasing gradually in the literature since I initially presented the reason noted above in arguing that mental health practitioners and scholars should eliminate the use of the term minority (Ancis, 2003; Cuéllar & Paniagua, 2000; Gibbs & Huang, 2003; Paniagua, 1994; Pedersen, 2004; Ponterotto, et al., 2010; Sue & Sue, 2003).

In the assessment and treatment of people with mental disorders, a practical guideline for practitioners is that, rather than focusing on the “minority” group per se, they should emphasize the ways in which individuals from diverse groups express their cultural values, their view about the world, and their view of their place in this society. For example, in the multicultural society of the United States, African Americans and Anglo Americans are examples of cultural groups. Other groups whose members mental health practitioners may see with less frequency include subgroups of Anglo Americans, such as Greek, Italian, Irish, and Polish Americans, and the West Indian Islanders (Allen, 1988; Jalali, 1988). As in prior editions, this book updates practical guidelines in the assessment and treatment of four multicultural groups often seen in mental health services: African Americans, American Indians, Asians, and Hispanics.

Race Versus Ethnicity

Many people use the terms race and ethnicity interchangeably, although this practice is somewhat controversial (Lee & Bean, 2004; McAuliffe, Gomez, & Grothaus, 2008; McAuliffe, Kim, & Park, 2008; Phinney, 1996; Richardson, Bethea, Hayling, & Williamson-Taylor, 2010; Yoon, 2011). The two terms may be understood to apply two different processes (Berry, Poortinga, Segall, & Darsen, 1992; Betancourt & Lopez, 1993; Borak, Fiellin, & Chemerynski, 2004; Garza-Trevino, Ruiz, & Venegas-Samuels, 1997; Wilkinson, 1993). An understanding of these processes is important for mental health practitioners who are involved in the assessment and treatment of individuals from multicultural groups. As Wilkinson (1993) defines the terms, race “is a category of persons who are related by a common heredity or ancestry and who are perceived and responded to in terms of external features or traits” (p. 19). In this definition, examples of external features include “hair types, color of eyes and skin, and stature” (McAuliffe, Gomez, & Grothaus, 2008, p. 105; see also Borak, Fiellin, & Chemerynski, 2004, p. 242; Casas & Pytluk, 1995, p. 162; Juby & Conception, 2004, pp. 31–34; Jun, 2010, pp. 101–107).

McAuliffe, Kim, and Park. (2008) defined ethnicity “as the recognition of common social ties among people due to shared geographic origins, memories of historical past, cultural heritage, religious affiliation, language and dialect forms, and/or tribal affiliation” (p. 85). Carter and Pieterse (2004) provided further distinctions between race and ethnicity, including that whereas “one’s ethnic group can change over time; one’s racial group membership does not” (p. 42); traditional customs and laws often “determine who belongs to a particular racial group, while ethnic group membership is usually determined by in-group customs and desires” (p. 42), and that “one’s racial group membership is observable by others, whereas ethnic group membership is seldom recognized or observed by others” (p. 42). As noted by Fontes (2010), clinicians should avoid guessing about race or ethnicity when assessing and treating clients from the culturally diverse communities discussed in this book. Fontes (2010) provided two examples to illustrate this point: “a counselor may be interviewing a child who appears White and whose mother is White, but actually the child is biracial” (p. 59). In this example, the counselor “observed” external features suggesting that the child is White (in addition to observing similar external features in the mother), missing the biracial status of the child. In the second example, “a counselor may see that someone’s name is Roberto Sanchez and therefore assume the person is Latino [or Hispanic], but he might come from the Philippines instead” (Fontes, 2010, p. 59). To avoid guessing about the race or ethnicity of the client, Fontes (2010, p. 59) recommends to directly ask the client the question “How would you like me to identify your race or ethnicity?” Fontes also suggests to review race categories to the client and to ask how he or she wants to be labeled on the section of the intake form collecting demographic and/or personal data. In this context, clinicians are encouraged to be familiar with the summary of race categories in Chapter 2 (Box 2.1).

Thus, an individual may belong to a particular race without sharing ethnic identity with others of that race. For example, the fact that two African American clients (or two American Indian, Asian, or Hispanic clients) share a common heredity or ancestry does not mean that they necessarily also share the same ethnic identity (i.e., their cultures, values, lifestyles, beliefs, and norms may be very different). Differences in ethnic identities across clients of the same race may be explained in terms of the processes of internal and external acculturation processes (described in Chapter 2), which can have important implications for the assessment and treatment of members of many diverse groups. Practitioners should not assume that two clients who share the same racial group will also share the same ethnicity.

2

General Guidelines for the Assessment, Diagnosis, and Treatment of Culturally Diverse Clients

This chapter summarizes general guidelines and recommendations found in the literature concerning mental health practitioners’ assessment, diagnosis, and treatment of clients from all the culturally diverse groups discussed in this book (e.g., Ancis, 2003; Cuéllar & Paniagua, 2000; Dana, 1993a; Gallardo, Yeh, Trimble, & Parham, 2012; Ho, 1987, 1992; Ivey, Ivey, & Simek-Morgan, 1996; Pedersen, 1997; Pedersen, Draguns, Lonner, & Trimble, 2008; Ponterotto, Casas, Suzuki, & Alexander 2010). Clinicians working with clients from the various communities described in this book are also strongly encouraged to review the American Psychological Association (2003) “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists,” particularly Guideline No. 5, which deals with the need for culturally appropriate skills in clinical practices (see pp. 390–391). Although the APA guidelines address the clinical practice of psychologists in a multicultural context, they are also relevant for the practice of mental health professionals and administrators of mental health services from other disciplines (e.g., psychiatrists, social workers, marriage and family therapists, licensed professional counselors). Training programs in clinical, counseling, marriage and family therapy, school psychology, social work, general psychiatry, and child and adolescent psychiatry should also use those guidelines to enhance their curriculum regarding the culturally appropriate skills that students (e.g., doctoral students in clinical psychology) and residents (e.g., residents in general psychiatry) are expected to demonstrate after the completion of training. In its website, the APA inserted the following statement:

The APA Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists, approved by Council in 2002, are currently being reviewed in accordance with the APA Association Rules. The expiration date, originally set for 2009, has been extended until 2012. Therefore, the current Guidelines [American Psychological Association, 2003] remains in effect until December 2012. (http://www.apa.org/pi/about/newsletter/2011/04/multicultural-guidelines.aspx)

Clinicians can inquire about the current status of the guidelines by contacting the APA Public Interest Directorate.

Development of a Therapeutic Relationship

In mental health practice, the therapeutic relationship appears to be of paramount importance to clients from all cultural groups (Comas-Díaz, 2008; Ho, 1992; Sue & Sue, 2003). In general, the development of this relationship involves three levels: conceptual, behavioral, and cultural.

The conceptual level includes such issues as the client’s and therapist’s perception of sincerity, openness, honesty, motivation, empathy, sensitivity, inquiring concerns, and credibility in their relationship. The behavioral level includes the client’s perception of the therapist as competent in his or her profession, which may include issues such as the therapist’s training as well as evidence of the therapist’s specialization in the assessment and treatment of particular mental health problems (e.g., expertise in the assessment and treatment of depression; Fuertes & Brobst, 2002). The behavioral level also reflects the therapist’s perception of the client as competent in terms of the client’s ability to follow direction and to use skills learned in therapy to self-implement the treatment plan as the therapist and the client have discussed.

The cultural level generally includes two hypotheses (Lonner & Ibrahim, 1996; Paniagua, 1996; Paniagua, Wassef, O’Boyle, Linares, & Cuéllar, 1993; Tharp, 1991). The cultural compatibility hypothesis suggests that the assessment and treatment of clients from multicultural groups are enhanced when any racial and ethnic barriers between the client and the therapist are minimized. As racial and ethnic differences between the client and the therapist approach zero, the therapist is more effective in terms of providing culturally sensitive assessment and treatment to the client (Dana, 1993a; Lopez, Lopez, & Fong, 1991; Paniagua, 1996; Sue & Sue, 2003; Sue & Sundberg, 1996) This hypothesis suggests, for example, that the assessment and treatment of an African American client are enhanced if the therapist is also an African American. Racial/ethnic similarity between client and therapist reinforces the therapeutic relationship.

Cultural compatibility between client and therapist may not always improve...

Table of contents

• Cover Page
• Halftitle
• Dedication
• Title
• Copyright
• Contents
• Series Editor’s Foreword
• Preface
• Acknowledgments
• 1 Minority, Multicultural, Race, and Ethnicity Concepts
• 2 General Guidelines for the Assessment, Diagnosis, and Treatment of Culturally Diverse Clients
• 3 Guidelines for the Assessment, Diagnosis, and Treatment of African American Clients
• 4 Guidelines for the Assessment, Diagnosis, and Treatreatment of Hispanic Clients
• 5 Guidelines for the Assessment, Diagnosis, and Treatment of Asian Clients
• 6 Guidelines for the Assessment, Diagnosis, and Treatment of American Indian Clients
• 7 Guidelines for Evaluating and Using the Epidemiological Mental Health Literature With Culturally Diverse Groups
• 8 Using Culturally Biased Instruments
• 9 Using Cultural Variables in the Diagnostic and Statistical Manual of Mental Disorders
• 10 Counseling Guidelines for Culturally Diverse Lesbian, Gay, Bisexual, and Transgender Clients
• 11 Counseling Guidelines for Culturally Diverse Older Adult Clients
• References
• Author Index
• Subject Index
• About the Author
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