Case Studies in Multicultural Counseling and Therapy

Derald Wing Sue, Miguel E. Gallardo, Helen A. Neville

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118715833
• Edition: 1
• Topic: Psychology
• Subtopic: Social Psychology
• Index: Psychology

An indispensable collection of real-life clinical cases from practicing experts in the field of multicultural counseling and psychotherapy

Case Studies in Multicultural Counseling and Therapy is a one-of-a-kind resource presenting actual cases illustrating assessment, diagnostic, and treatment concerns associated with specific populations. The contributors—well-known mental health professionals who specialize in multicultural counseling and psychotherapy—draw on their personal experiences to empower therapists in developing an individually tailored treatment plan that effectively addresses presenting problems in a culturally responsive manner.

Providing readers with the opportunity to think critically about multicultural factors and how they impact assessment, diagnosis, and treatment, this unique book:

• Covers ethical issues and evidence-based practice
• Integrates therapists' reflections on their own social identity and how this may have influenced their work with their clients
• Considers the intersectionality of racial/ethnic, class, religious, gender, and sexual identities
• Contains reflection and discussion questions, an analysis of each case by the author, and recommended resources
• Includes cases on racial/ethnic minority populations, gender, sexuality, poverty, older adults, immigrants, refugees, and white therapists working with people of color
• Aligns with the ACA's CACREP accreditation standards, tha APA guidelines for multicultural competence, and the AMCD Multicultural Counseling Competencies

PART I

Case Studies With U.S. Racial/Ethnic Minority Populations

1

Clinical Applications With African Americans

Shelly P. Harrell and Daryl M. Rowe

AND STILL I RISE: THE STORY OF NIA

Case Description

Nia, a 16-year-old African American girl self-referred for therapy, was accompanied to the first session by her mother, Joyce, a 52-year-old woman who worked as a professor of nursing at the local state university. Nia was nearing the end of her sophomore year at a public high school in a large urban city. Nia described bad grades, outbursts of crying and anger, problems with peers at her school, and conflict with her father, Eric, as her reasons for wanting to come to therapy. Nia had tried speaking with a counselor at her school but told her mother that “the lady talked to me like I was stupid.” Joyce disclosed in the first session that Nia had said in one of her tantrums that she wanted to kill herself but that she did not believe Nia really meant it.

Nia lived alone with her mother. Her parents had never married, and she was 2 years old when they split up. She had a 23-year-old half-brother (father's son) who was married and living in another state. They had begun to form a relationship as she got older, and she spoke with him regularly. Their father was currently married to another woman, and Nia had two younger half-sisters, ages 5 and 8. Nia's relationship with her father was characterized by starts and stops, hopes and disappointments. She described her father as always “depressed and complaining” and that he had lots of health problems. She shared that her father blamed her for the problems in their relationship, telling her that she should call and check on his well-being more often. She was very distraught regarding her father's inability to tolerate hearing about her concerns and his inappropriate disclosure to her that he wanted to kill himself. Joyce was a quiet woman who was very thoughtful in her speech. She took great care in providing a strong extended family kinship network for Nia that included numerous uncles, aunts, and cousins not related by blood. She engaged intentionally in racial socialization by exposing Nia to books and events related to African and African American history as well as cultural organizations. Joyce practiced Buddhism but shared multiple religious traditions with Nia, including African American Christianity and Black Liberation theology, traditional African religious beliefs, and contemporary metaphysical spirituality. Nia liked all of them and felt like she should not have to choose one. Nia's father was very critical of Joyce's spirituality and commitment to African cultural and racial socialization. He stated, “That's why Nia is all messed up . . . all that African crap you constantly shove down her throat.”

Nia reported feeling isolated at school. She was very critical of the Black girls, stating that they were superficial and that she “hates them.” She felt that teachers at school saw her as intimidating and stereotyped her as probably being in a gang based on her large stature, clothing choices, and “dark” complexion. She talked about the “light girls with good hair or weaves” who just wanted to talk about fashion, shoes, sex, and how they were going to get a man with “long bank” and have his baby. She tried befriending the “smart, good girls” but shared that they all seemed to be really religious and told her she was going to hell when she disclosed that she liked to do Buddhist chants with her mother. One day she said, “I'm not anybody's homegirl, I'm not a gold digger, I have no plans to have babies and be on welfare, and I'm not trying to be a holier-than-thou church lady, so where do I fit in?” She perceived that the Black boys were attracted to the “gold diggers.” She had a couple of good friends but felt that “the religious thing” was a barrier. Nia had played competitive soccer where she was top scorer, and although she made the varsity team at school, she reported being marginalized and treated more harshly than her mostly Latina teammates. She loved to read and tried to participate in class discussions but reported that teachers completely ignored her when she raised her hand, responded to her questions as if she were challenging them, or shot down her ideas completely. She described a paper she wrote for a history class and being upset about her “liberal” White male teacher's comment that slavery and racism had destroyed culture for Black people and that there was no such thing as positive African American culture. This teacher also frequently made reference to his African American wife. Nia was focused on attending a historically Black college and university school with her dream college being one of the most highly competitive. She expressed significant fear and worry that her grades were going to ruin her dream and disclosed that she became particularly anxious when preparing for and taking a test. In addition, Nia reported that it was really hard to study, that she would get distracted by thoughts about her father and things that had happened at school during the day, and that she replayed past negative events in her mind repeatedly.

Nia shared that she did not want to burden her mother with her problems because she knew how hard her mother worked and how much she was trying to be a good mom. She experienced significant guilt that she was causing her mother stress. However, Nia also reported that she felt her mother did not really understand how much pain she was in and would just tell her that she was “beautiful.” Nia felt that she should be able to handle her life better like her mother, whom she perceived as “above my petty concerns.” She also felt she would be disappointing her mother if she didn't have high self-esteem and conduct herself with dignity and pride as a woman of African descent.

Reflection and Discussion Questions

1. What internal and external strengths can you identify for Nia?

2. Do you think that therapy with Nia should include attention to racism and social justice themes? Why or why not?

3. What ways do the various stereotypes about African American girls and women potentially play a role in this case (consider Nia, Joyce, teachers and coaches, peers)?

4. What role might Nia's parents' experiences and cultural identity play in their expectations of and responses to Nia's distress?

5. How might the concepts of internalized racism, colorism, racial identity, racial socialization, and stereotype threat be helpful in conceptualizing this case? For understanding Nia? For understanding Nia's peers and family members?

6. How are issues of intersectionality and negotiation of multiple (and sometimes conflicting) dimensions of diversity relevant in this case?

7. In what ways were cultural considerations integrated into treatment strategies used with Nia?

8. What treatment and conceptual ideas may have been dominant if culture were not considered? How might a therapist have conceptualized and worked with Nia if culture were not a central consideration? What would be the risks of a non–culture-centered approach in working with Nia? With Joyce?

Brief Analysis of the Case

• Diagnostically, Nia fit criteria for generalized anxiety disorder accompanied by sadness, loneliness, and difficulty with emotion regulation. Primary themes of treatment included identity, racism, and relationships (family, peers, interracial). Nia requested that she be seen individually, and I honored this despite cultural “cookbook” recommendations that one should always see African Americans as a family. I saw Joyce separately approximately once every three weeks with sessions focused on parenting and how she could support Nia. Toward the end of treatment I saw them together for a few sessions.
• I worked with Nia from an integrated multicultural-humanistic orientation with a postmodern sensibility that values transparency, collaboration, technical flexibility, self-determination, and experiential awareness, and supports therapist self-disclosure where clinically indicated. I am a 50-plus-year-old, married African American woman with two adolescent sons. Over the course of therapy with Nia, I made these disclosures, as well as others related to my religious/spiritual journey and experiences coping with racism. We read Maya Angelou's poetry and autobiographies, sharing a particular love for the poem “Still I Rise.” Nia was already ­familiar with meditation and chanting. We identified the phrase “I rise” as her personal mantra and integrated it into breathing, meditation, visualization, and chanting processes to address her excessive worry and rumination. Her name, which means “purpose” in Swahili, served as an organizing frame for working on issues related to identity and achievement of her goals.
• Nia's case raises many multicultural considerations that are important when working with African American clients:
  • In addition to differential diagnostic procedures, early assessment should be culture and context centered. The genesis and maintenance of symptom expression can be understood, in part, as a function of the cultural and racial dynamics of the contexts of daily life. For example, assessing the racial-ethnic composition of Nia's environments (e.g., neighborhood, school, etc.) and the cultural norms and behaviors of the contexts within which she functioned (e.g., “soccer” culture) were very important to getting a comprehensive understanding of this client.
  • Specific treatment strategies should be a culturally syntonic fit with the client's sociocultural experience, identities, and sensibilities. Treatment should be informed by examining how the intersections of person, culture, and context, and the congruence (or incongruence) between them, contribute to the African American client's internally experienced and externally expressed distress. Central to case conceptualization and treatment planning with Nia was constantly keeping in mind the interrelationships between her multiple cultural identities, her personal and psychological characteristics, and relevant contextual considerations. The use of bibliotherapy focusing on Maya Angelou's work was an example of selecting and implementing an intervention strategy that was a cultural fit for Nia.
  • Conceptually, psychotherapeutic work with African American clients should be understood as treating the whole person-­culture-context transaction, as a person cannot be understood or understand themselves outside of the relationships and contexts that make up their entire field of experiences. In an African-centered context, it is limiting to restrict oneself to a therapy that artificially separates the interconnected person-culture-context experience into segmented “types” of therapy. Even in meeting primarily with Nia in one-on-one sessions I conceptualized my client not as Nia the individual but rather as “Nia in context,” which included Joyce, her father, Eric (whom I never met), her brother in another state, other friends and family members, her school, as well as the African American community as a whole.
  • It is important to identify not only a client's individual strengths but also strengths of African culture and the African American community and how these are manifested in the client's life. Therapeutic practice with African American clients benefits from infusing a strengths-centered perspective into the work. Nurturing confidence, self-efficacy, and empowerment are important treatment goals to consider. Joyce's parenting practices had integrated and capitalized on many cultural strengths, and it was important to highlight and affirm these strengths regularly with both Nia and Joyce.
  • Identifying and challenging internalized racism is critical in work with African American clients. The insidious and pervasive presence of racism and anti-Black sentiments results in inevitable exposure to negative images, dominant narratives, and socialization messages that pathologize and devalue people of African descent. Historical hostility and internalized racism were conceptualized within a larger understanding of Nia's developing identity and relationships with her parents, teachers, coaches, and peers. With Nia, this issue was approached using an acceptance-based orientation. Interventions were designed to help Nia move from “fusing” with her negative thoughts as reflecting a reality about herself or others to experiencing her thoughts and feelings as completely understandable, given her familial and sociopolitical contexts. We worked with self-compassion as a path to freeing herself from the emotional hold of her negative self-judgments that kept her paralyzed with overwhelming emotions and prevented her from making choices and changes.
  • Incorporating attention to a client's multiple and intersecting dimensions of diversity that can contribute to the development of a healthy identity characterized by a sense of wholeness and pride is important. With Nia, it was critical to implement exposure to socialization messages and experiences that took into accou...