Counseling Across Cultures

Counseling Across CulturesSeventh Edition Counseling Across Cultures Seventh Edition Edited by Paul B. Pedersen Syracuse University (Emeritus); University of Hawaii (Visiting); Maastricht School of Management Walter J. Lonner Western Washington University (Emeritus) Juris G. Draguns Pennsylvania State University (Emeritus) Joseph E. Trimble Western Washington University María R. Scharrón-del Río Brooklyn College City University of New York For INFORMATION: SAGE Publications, Inc. 2455 Teller Road Thousand Oaks, California 91320 E-mail: [email protected] SAGE Publications Ltd. 1 Oliver’s Yard 55 City Road London EC1Y 1SP United Kingdom SAGE Publications India Pvt. Ltd. B 1/I 1 Mohan Cooperative Industrial Area Mathura Road, New Delhi 110 044 India SAGE Publications Asia-Pacific Pte. Ltd. 3 Church Street #10-04 Samsung Hub Singapore 049483 Copyright © 2016 by SAGE Publications, Inc. All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Printed in the United States of America A catalog record of this book is available from the Library of Congress. ISBN 9781452217529 This book is printed on acid-free paper. 15 16 17 18 19 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Kassie Graves Associate Editor: Abbie Rickard Editorial Assistant: Carrie Montoya Production Editor: Claudia A. Hoffman Copy Editors: Judy Selhorst, Linda Gray Typesetter: C&M Digitals (P) Ltd. Proofreader: Victoria Reed-Castro Indexer: Karen Wiley Cover Designer: Candice Harman Cover Photograph: Walter J. Lonner Marketing Manager: Shari Countryman Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Acknowledgments Foreword Dedication Introduction: Learning From Our “Culture Teachers” PART I. ESSENTIAL COMPONENTS OF CROSS-CULTURAL COUNSELING 1. 1. Toward Effectiveness Through Empathy 2. 2. Counseling Encounters in Multicultural Contexts: An Introduction 3. 3. Assessment of Persons in Cross-Cultural Counseling 4. 4. Multicultural Counseling Foundations: A Synthesis of Research Findings on Selected Topics PART II. ETHNOCULTURAL CONTEXTS AND CROSS-CULTURAL COUNSELING 1. 5. Counseling North American Indigenous Peoples 2. 6. Counseling Asian Americans: Client and Therapist Variables 3. 7. Counseling Persons of Black African Ancestry 4. 8. Counseling the Latino/a From Guiding Theory to Practice: ¡Adelante! 5. 9. Counseling Arab and Muslim Clients PART III. COUNSELING ISSUES IN BROADLY DEFINED CULTURAL CATEGORIES 1. 10. Gender, Sexism, Heterosexism, and Privilege Across Cultures 2. 11. Counseling the Marginalized 3. 12. Counseling in Schools: Issues and Practice 4. 13. Reflective Clinical Practice With People of Marginalized Sexual Identities PART IV. COUNSELING INDIVIDUALS IN TRANSITIONAL, TRAUMATIC, OR EMERGENT SITUATIONS 1. 14. Counseling International Students in the Context of Cross-Cultural Transitions 2. 15. Counseling Immigrants and Refugees 3. 16. Counseling Survivors of Disaster 4. 17. Counseling in the Context of Poverty 5. 18. The Ecology of Acculturation: Implications for Counseling Across Cultures PART V. PROFESSIONAL COUNSELING IN A SELECTION OF CULTURE-MEDIATED HUMAN CONDITIONS AND CIRCUMSTANCES 1. 19. Health Psychology and Cultural Competence 2. 20. Well-Being and Health 3. 21. Family Counseling and Therapy With Diverse Ethnocultural Groups 4. 22. Religion, Spirituality, and Culture-Oriented Counseling 5. 23. Drug and Alcohol Abuse and Health Promotion in Cross-Cultural Counseling 6. 24. Group Dynamics in a Multicultural World Index About the Editors About the Contributors Elder Wisdom An elder Lakota was teaching his grandchildren about life. He said to them, “A fight is going on inside me... it is a terrible fight and it is between two wolves. One wolf represents fear, anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego. The other stands for joy, peace, love, hope, sharing, serenity, humility, kindness, benevolence, friendship, empathy, generosity, truth, compassion, and faith. This same fight is going on inside you, and inside every other person, too.” The grandchildren thought about it for a minute, and then one child asked her grandfather, “Which wolf will win?” The Elder replied simply, “The one you feed.” The Western conception of the person as a bounded, unique, more or less integrated motivational and cognitive universe, a dynamic center of awareness, emotion, judgment, and action, organized into a distinctive whole and set contrastively—both against other such wholes and against social and natural background—is however incorrigible it may seem to us, a rather peculiar idea within the context of the world’s cultures. (p. 34) Geertz, C. (1973). The interpretation of cultures: Selected essays. New York: Basic Books. The first peace, which is the most important, is that which comes within the souls of men when they realize their relationship, their oneness, with the universe and all its Powers, and when they realize that at the center of the universe dwells Wakan-Tanka, and that this center is everywhere,it is within each of us. This is the real Peace, and the others are but reflections of this. The second peace is that which is made between two individuals, and the third is that which is made between two nations. But above all you should understand that there can never be peace between nations until there is first known that true peace which... is within the souls of men. (p. 198) Black Elk, in Neihardt, J. G. (1961). Black Elk speaks: Being the life story of the holy man of the Oglala Sioux. Lincoln: University of Nebraska Press. Conscientization does not consist, therefore, of a simple change of mind about reality, of a change in individual subjectivity that leaves intact the objective context; conscientization supposes a change in people in the process of changing their relationship with the environment, and above all, with others. True knowledge is essentially bound with transformative social action and involves a change in the relationship between human beings. Martín-Baró, I., & Blanco Abarca, A. (1998). Psicología de la liberación. Madrid: Editorial Trotta. Acknowledgments Nearly every academic book ever published has acknowledged individuals who in some way played important roles in the book’s development. In this book we depart from the usual custom and acknowledge those who, on one hand, were important in organizing, editing, and producing the book, as well as those who, on the other hand, played important roles in the lives of the five coeditors. The former can be considered general acknowledgments that we all share. The latter are necessarily different for each of us. Thus we have agreed to contribute individually. In the general category we want to thank SAGE Publications for the confidence it has shown in us throughout the years. The two key SAGE people with whom we have worked are Kassie Graves, who has been part of this effort for many years, and her assistant, Carrie Baarnes. Although a relative newcomer to SAGE, Carrie was a big help in the latter stages. We were flattered that Claudia Hoffman, SAGE’s director of U.S. book production, pointedly selected Counseling Across Cultures as a book she wanted to usher through its final copyediting and production stages. In characteristic good judgment, Claudia chose Judy Selhorst to be copy editor for the book. It is remarkable how careful and efficient Judy was during the latter part of the process, when it is so important to be complete and precise. Candace Harman and her crew in the graphics department did an excellent job with the cover. Further north, on the campus of Western Washington University, is Genavee Brown. A graduate student in the Department of Psychology and a most promising young scholar, Genavee was “the organizer” in crucial stages. When the book is published, the first copy will go to Paul Pedersen and the second will go to Genavee. On the personal side, we offer the following highly individualized acknowledgments: Paul B. Pedersen. I would like to acknowledge and to dedicate my role in the preparation of this book to Anthony J. “Tony” Marsella, professor emeritus of the University of Hawaii. Tony was my prime teacher at so many different levels. He was as comfortable in the village council of a Borneo community as he was, for example, during a World Health Organization committee meeting many years ago, or as he was in his lectures throughout his illustrious career. The classes he taught would frequently end with standing ovations by his students. He originated the awareness, knowledge, and skill model, which became the basis of the measures for competence within the field of multicultural counseling. Many other examples of his influence come to mind. Most important, he has in recent years become a first-class friend and co-traveler in life’s journey. In the metaphor of family, Tony has fathered many children among his students, his colleagues, and his other brothers and sisters. For all that you have given, Tony, I send you my thanks. Walter J. Lonner. Above all else I want to thank my immediate family, consisting of many people, both living and dead. Among the living are my everything-and-then-some wife, Marilyn, and our three great children (Jay, Alyssa, and Andrea), each of whom has two daughters with terrific spouses. The world had better watch out for those six little dynamos. By name and current age they are Sika (14) and Brenna (11) Lonner, Sophia (11) and Alena (8) Naviaux, and Nina (7) and Sage (4) Howards. I was blessed with great parents and two brothers: Terry, the youngest of us, who is a beacon of honor and dependability and a jack-of-all-trades; and George, the oldest. We grew up in beautiful and generous western Montana. George died October 8, 2012, about midway through the work on this book. George was the family’s Don Quixote, dreaming big things and imagining the impossible. It is he, not I, who should have been a university professor, for he would have dazzled thousands of students with his talent of mixing fact with fantasy. The encouragement and praise that Terry and George and the rest of my family piled upon me, through thick and thin, has always kept me going. I also want to acknowledge the multidimensional influence that an international network of scholars has had on my 50-plus years of trying to understand the nature of culture’s influence on everything we say, think, and do. Part of this network consists of the many talented people, including the current slate of coeditors, who have contributed to one or more of the seven editions of Counseling Across Cultures. Juris G. Draguns. Throughout the seven editions of Counseling Across Cultures, I have enjoyed marvelous support, encouragement, and understanding from my wife, Marie. We have shared 52 wonderful years, and Marie’s love and empathy have helped me overcome whatever obstacles have stood in my way, sometimes tangible, more often subjective. As I thought about, wrote, and edited Counseling Across Cultures, I would temporally disappear into the book, and Marie was always there to welcome me when I reemerged from its pages. My two children, Julie and George, were young when Counseling Across Cultures first appeared. They grew up as the book evolved through its several transformations, and the two processes intertwined. What has remained constant is our mutual love and my vicarious enjoyment of and pride over Julie’s and George’s families, careers, and achievements. Thinking back on my early years, I gratefully remember my parents, especially my mother, who instilled in me a curiosity and love of learning and protected me from the dangerous world outside our home. It is thanks to her that I survived and was able to work toward the realization of my version of the American Dream. And in the course of the ensuing multiple transitions I benefited from a host of culture teachers who helped me become more empathetic and perhaps more helpful across cultural barriers. They are too numerous to mention, but my sincerest thanks go to them all. Joseph E. Trimble. I owe Paul Pedersen a special measure of personal gratitude and appreciation. In August 1972 Paul met with me and my wife, Molly, at a lanai in Honolulu. Over a late-morning breakfast he vividly described his new triad theory of counseling training to underscore his strong growing interest in culture and psychological counseling. It was a memorable occasion for the three of us. A few years later, Paul invited me to give a symposium paper on counseling American Indians and later publish a chapter in the first edition of Counseling Across Cultures. Molly was extremely helpful when I wrote that first chapter and continues to be insightful and helpful in almost all of my writing activities. She has a keen eye for detail and a spirited mind for novel concepts and ideas. Throughout the course of each of the Counseling Across Cultures editions our three lovely and talented daughters, Genevieve, Lee Erin, and Casey Ann, have been with me when each edition arrived home for their review and comment, and it has always been a proud moment for me when they read their names in the acknowledgments and commented on it. Also, I am deeply grateful for all of the people who have provided me with guidance, advice, and collaboration on the contents of the various chapters put together for the seven editions. Thank you especially to Candace Fleming, Fred Beauvais, Pamela Jumper Thurman, and John Gonzales. María R. Scharrón-del Río. I am very grateful for the love, guidance, and support of mi familia. My mother, Rosarito, and my sister Marilia housed and fed me in Puerto Rico as I was finishing the final editing process for this book. My sister Marichi also assisted me with her commentary during this time, and my father, Rafael, accompanied me on a couple of hour-long mental health escapades to the ocean. I am also grateful to my partner, Yvonne, for her love, support, and understanding, and for providing a home for me in Germany during part of my sabbatical. Many thanks also to my chosen family in New York City—Cody, Mara, Barb, Wayne, Paul, and Flo—who helped in too many ways to count. I owe a special thanks to Joseph Trimble and Guillermo Bernal, who have been outstanding mentors and friends since I was an undergraduate student in the Career Opportunities in Research (NIMH-COR) program at the University of Puerto Rico. I also want to thank Eliza Ada Dragowski for her exceptional work and support in the completion of this book. Finally, my thanks to the wonderful group of people who provided additional guidance on the content of various chapters of the book: Priscilla Dass-Brailsford, Stuart Chen-Hayes, Hollyce Giles, Vic Muñoz, Delida Sánchez, and Avi Skolnik. Paul B. Pedersen Walter J. Lonner Juris G. Draguns Joseph E. Trimble María R. Scharrón-del Río Foreword During a lifetime of more than four score and four years, I have seen culture change before my eyes like a fast-moving kaleidoscope. Old ways of being are replaced rapidly by new ones. Each generation upgrades its relationships with the various environments that affect its existence. As I developed and acquired more information about my time-and-space world, I understood the complexity of culture. In high school, I heard it discussed in connection with geography. My teachers talked about how the natural environments in which people live necessarily influence their ways of life. Their environments determine the kinds of homes they build to protect themselves from outside elements. Since climates vary from one time zone to another, it is tenable to conclude that the structures in which people live and work also differ from one part of the world to another. In undergraduate school, I learned other things about culture. People in various groups often dress differently from one another and may speak languages other than English. They often observe religious practices different from the ones I knew. From the social science classes I took, I acquired a general understanding of culture. After graduating from college, I spent two years in Europe. There I saw up close what my professors had meant about people being different from one part of the world to another. I kept journals on places I visited and people I met that confirmed the content of my professors’ lectures. Notable among my experiences was the day I encountered Jean-Paul Sartre and his companion Simone de Beauvoir in a small Parisian café where they were reading some of their works. When I entered graduate school at Indiana University, understanding culture was my passion. I read as much as I could about it; I took as many sociology courses as I could work into my academic program. I learned that there were more than a hundred definitions of culture and that cultural theorists used a variety of concepts to highlight ideas that they deemed uniquely theirs. I learned that culture is not only material but also immaterial. That is, there are objects in our environment that determine the nature of our existence. There are also many things we cannot see. For example, we have values and attitudes about everybody and everything. People interact with their surroundings. The individual’s behavior is influenced by that of others. Culture is learned. It is experienced and internalized. This internalization is often referred to as personality. It is conscious and unconscious, affective and cognitive, perceptible and imperceptible, and much more. When I became a practicing psychologist and counselor educator, I felt the need to understand the cultures of my clients, because I soon became aware that their problems were usually related to the cultural contexts in which they grew up and resided. By the 1960s, the civil rights movement in the United States was going full blast. Integration was becoming a reality for African Americans who had previously lived in an apartheid-like society. They had always lived in segregated communities and attended segregated schools. After the changes of the 1960s, African Americans began showing up in formerly all-White classrooms and in the offices of school counselors. The American Personnel and Guidance Association (now called the American Counseling Association, or ACA), officially organized in 1952, soon found itself in the midst of the turmoil of a dramatically changing society. Throughout the country, White counselors were expected to help Black clients; Black counselors were expected to help White clients. It was out of the new clienteles and the different cultures they represented that a new interest area emerged in the counseling profession. Paul Pedersen was among the first educators to take the lead in helping counselors and psychologists to meet more effectively the needs of clients who came to be referred to as culturally different. As I got to know Paul, I recognized that he was visionary and just the right person to convene a panel of counselors, counselor educators, and psychologists to discuss cross-cultural counseling at the 1973 convention of the American Psychological Association in Montreal. Out of the panel presentations came the first edition of Counseling Across Cultures, published in 1976. Becoming a classic in cross-cultural counseling, it has contributed significantly to what is now the fastest-growing movement in counseling. I am proud to have been one of the participants on the APA Montreal panel and a chapter contributor to the first edition of the book. After the Montreal panel presentation, I conceptualized a model of culture designed to help counselors meet the needs of their culturally challenging clients. I argue that most human beings are molded by five concentric cultures: (1) universal, (2) ecological, (3) national, (4) regional, and (5) racio-ethnic. The human being is at the core of these cultures, which are neither separate nor equal. The first and most external layer is the universal culture, or the way of life that is determined by the physiology of the human species. People are conceived in a given way, they consume nourishment to live, they grow into adulthood, they contribute to the group, and they grow old and die. These and other ways of life are invariable dimensions of human existence. During the course of the social development of the species, people learn to play a variety of roles essential for survival. These are internalized and transmitted from one generation to another. It seems important that counselors recognize themselves and their clients as members of this culture that is common to all humanity. The recognition helps counselors to identify with and assist all clients, regardless of their cultural and socioeconomic heritage. Human existence is also shaped by the ecosystem, which is the lifeline for everybody. Climatic conditions, indigenous vegetation, animal life, seasonal changes, and other factors determine how people interact with nature and themselves. People who use dogsleds to go to the grocery store experience life differently from those who need only to gather foodstuffs from the trees and plants in their backyards. Inhabitants of Arabian deserts wear loose body coverings and headgear to protect themselves from the dangerously hot rays of the sun and from unexpected sandstorms. The way of life that people develop in order to survive in a specific geographical area of the world may be called the ecological culture, the second layer of culture. The third environment that molds human beings is the national culture. It is reasonable to conceptualize a national culture for several reasons. Most people are born into particular nations. In general, each country has a national language, basic institutions, and a form of government, and the residents of the country have a way of seeing the rest of the world and particular values and attitudes about themselves and their fellows. Individuals born within the confines of a country’s borders are usually socialized to adjust to the rules and regulations of that country. They learn to fit into the prevailing way of life. People first start learning to fit into the national social order in the home, and they continue their socialization in school and other settings. Although a country may contain several national subcultural groups, members of all such groups cannot escape the influence of the overarching national culture. A fourth influence on the lives of people is regional culture. In many countries, individuals identify not just with the national culture but also with the cultures of specific parts of their countries. For example, Americans who live along the U.S.–Mexico border may feel as Mexican as they do American. Many such residents speak Spanish and enjoy the food, music, and way of life common to Mexico. Regional cultures are evident in many African countries. In the north of Nigeria, where the country borders Niger, the Housas, one of the country’s largest ethnic groups, straddle the border that separates the two countries, thereby causing the same regional culture to exist in both countries. The final layer is racio-ethnic culture. It is based on the recognition that racially or ethnically different groups often reside in areas separate from those in which a country’s dominant racial or ethnic group live. People inhabiting such racial or ethnic enclaves usually develop and maintain cultures that are unique to the communities in which they live. Although citizens of and participants in the national culture, they may also identify strongly with their racial or ethnic group and its way of life. For example, because of their slave heritage, African Americans have developed and continue to maintain a culture that is in many ways different from the national culture. Many institutions, such as the Black church, which dates back to slavery, contribute to the continuation of a “Black culture” in some communities. The fivefold concentric conception of culture indicates that people are the products of several influences over which they have little or no control. No individual should be considered only a member of a single national, racial, or ethnic culture. People are often simultaneously members of several cultures—they are individually multicultural. Even so, across all cultures, people are more alike than they are different. Counselors who recognize the commonalities that humans share are apt to be more effective in helping all clients than those who focus on perceived cultural differences. Universal and ecological cultures unify the human group more than regional, national, or racio-ethnic differences separate the species. Readers who compare this seventh edition of Counseling Across Cultures with the earlier editions will be able to appreciate how much the study of culture and counseling has evolved over the years. One thing that I notice is how many more clienteles described as needing cross-cultural intervention exist today than in 1973. Culture is no longer just an esoteric concept discussed in sociology classes and texts. It has now become an idea appreciated, espoused, expanded, and exploited by most counselors and counselor educators. In graduate school, I mentioned to my major professor an interest in writing my dissertation on a topic related to the effect of culture on the outcomes of counseling. He discouraged me from pursuing that research topic and added, “Everybody knows that counseling is counseling.” Feeling downhearted, I pursued a dissertation topic more in keeping with his view of what was an appropriate research idea. However, since receiving the PhD in 1965, I have written countless articles, chapters, and books on how culture influences the counseling process. Culture has become the linchpin of counseling throughout the world. Having devoted my career to studying the relationship of culture and counseling, I am understandably pleased to write the foreword to this significant contribution to the increasingly large literature on cross-cultural counseling. The seventh edition of Counseling Across Cultures is a historical landmark. It is noteworthy because it, along with the previous editions, provides a long view of culture and counseling as they have evolved in a rapidly changing profession. It is evident that culture has taken on a more inclusive meaning today than it had more than 50 years ago, when I was in graduate school. Then, some of my sociology professors talked unabashedly about certain segments of our society being culturally “deprived” or “disadvantaged.” Being the only African American in most of my classes, I was shocked and hurt to hear such assertions, because I had learned in undergraduate school that everybody has a culture. I now understand that my professors were talking about the culture of White Americans. It was their way of being, not that of most Americans of Native, Asian, African, or Hispanic descent, or a host of other citizens who were identified with a hyphen in their group designations to set them apart from the dominant cultural group. Counseling has also evolved since the formation of the American Counseling Association in 1952 as the Personnel and Guidance Association. Subsuming the National Vocational Guidance Association, the National Association of Guidance and Counselor Trainers, the Student Personnel Association for Teacher Education, and the American College Personnel Association, the newly formed organization extended the work of social workers, teachers, and vocational counselors. Today, ACA consists of 20 chartered divisions and 56 branches in the United States and abroad. The divisional membership breakdown usually reflects the clienteles in which the various professionals specialize. Moreover, there are wide variations in how counselors identity themselves. Some see themselves as guidance counselors similar to how most school counselors saw themselves in the 1950s. Others consider themselves psychologists. Still others identify with psychiatrists. In spite of the broad definitions of culture and counseling and the wide range of counselor identifications, multiculturalism became what Paul Pedersen calls the “fourth force” in counseling. It continues to be the most important thrust of counseling in the 21st century. This new edition of Counseling Across Cultures is, in effect, a status report on this very important aspect of counseling. The chapters in this book were written by some of the most outstanding counseling authorities in the United States and abroad. The information contained in them is a godsend for graduate students, professors, and therapeutic professionals working in a variety of settings. Clemmont E. Vontress, PhD Professor Emeritus of Counseling George Washington University Our Deepest Thanks to Paul B. Pedersen—Friend, Scholar, and Gentleman Paul Pedersen’s fervent passion about counseling across cultures began at a time when few psychologists and mental health practitioners considered the importance of the cultural dimension in any significant way. The inclusion and subsequently the infusion of the cultural dimension in counseling and clinical psychology became a longtime commitment for Paul when he was a graduate student and quite possibly even before then. In the late 1960s, Paul developed and carefully nurtured what he eventually called the triad training model of counseling, which emphasized the training of counselors in settings where cultural similarities and differences were the centerpiece for counselor education. It was controversial at the time, yet it resonated with many who were the early innovators and leaders in the emerging field of cross-cultural psychology. In essence, Paul describes triad training as a self-supervision model in which the counselor processes both positive and negative messages a client is thinking but not saying in counseling. Articulating these hidden messages and checking out their validity helps the counselor (1) see the problem from the client’s viewpoint, (2) identify specific sources of resistance, (3) diminish the need for defensiveness, and (4) identify culturally resonant recovery skills. If there was a pivotal moment in the history of counseling across cultures, it happened at the 88th annual convention of the American Psychological Association, held in September 1980 in Montreal, Canada. Paul organized what we believe was the first, and certainly the most visible, symposium focusing on counseling across cultures. The hour-long symposium involved several psychologists who were making seminal contributions to the field, including Edward Stewart, Walt Lonner, Julian Wohl, Joseph Trimble, Juris Draguns, and Clemmont Vontress. In 60 short minutes the panel discussed various cross-cultural counseling topics. Eventually all of the panelists wrote chapters for the seminal cross-cultural counseling textbook that we now present in its seventh edition—what we believe to be a record for a book of its kind. Paul’s career-long commitment to promoting the importance of culture in psychology was sparked by his early travels hitchhiking across Europe and his academic appointments beginning in 1962 as a Visiting Lecturer in Ethics and Philosophy and the Chaplain at Nommensen University in Medan, Sumatra, Indonesia. He studied Mandarin Chinese full-time in 1968 in Taiwan. From 1969 to 1971, Paul was a part-time Visiting Lecturer in the Faculty of Education at the University of Malaya; also, he was the Youth Research Director for the Lutheran Church of Malaysia and Singapore. While in Indonesia and Malaysia Paul quickly realized that what he had learned about conventional counseling in graduate school didn’t accommodate the worldviews of Malaysians, Chinese, and Indonesians, among many others. The daily dose of rich and deep cultural experiences combined with the challenges associated with understanding culturally unique lifeways and thoughtways quietly planted the seeds for his plans to develop, advocate, and promote the value and significance of considering cultural differences in the counseling and clinical psychology professions. In 1971, Paul accepted the position of Assistant Professor in the Department of Psycho-educational Studies at the University of Minnesota in Minneapolis; he also held a joint appointment as an adviser in the International Student Office. Drawing mainly on his experiences in Indonesia, Malaysia, and Taiwan and his daily counseling sessions with international students at Minnesota, Paul became increasingly concerned about the relevance of conventional counseling approaches and began to consider more culturally sensitive counseling strategies. As an alternative to the use of conventional counseling education approaches, Paul devised and implemented his aforementioned triad training model. In 1975, Paul became a Senior Fellow at the Culture Learning Institute at the East-West Center in Honolulu, Hawaii. In 1978–1981, he was director of a large predoctoral training grant from the U.S. National Institute of Mental Health titled Developing Interculturally Skilled Counselors. With eight predoctoral trainees, Paul conducted training programs that emphasized cross-cultural counseling approaches through use of the triad training model. Paul closely maintained his Hawaiian appointments and ties for the rest of his illustrious career by serving as a Visiting Professor of Psychology at the University of Hawaii, Manoa, and as a Fellow at the East-West Center. In 1982, Paul accepted an appointment at Syracuse University as Professor and Chair of the Department of Counselor Education. In 1995, he earned the title of Professor Emeritus at Syracuse and subsequently became a Professor in the Department of Human Studies at the University of Alabama, Birmingham. In 2001, after a year as a Senior Fulbright Scholar at Taiwan National University, Paul formally retired from academic life and moved back to his much beloved Hawaii to continue his writing, traveling, and scholarly interests. He retained his appointment as a Visiting Professor in the Department of Psychology at the University of Hawaii, Manoa. Paul’s remarkable career includes the publication of more than 40 books and more than 150 book chapters and journal articles; the concept of culture is the common thread that runs through all of them. In reviewing Paul’s extraordinary accomplishments, one quickly realizes that he is imaginative, farsighted, and truly a pioneer in the field of multicultural counseling. Scholars in the counseling and psychotherapy fields generally consider Paul’s edited book Multiculturalism as a Fourth Force, published in 1999, to be a milestone in the history of psychology. The book surveyed the prospect that we are moving toward a universal theory of multiculturalism that recognizes the psychological consequences of each cultural context. Paul and his colleagues argued that the fourth force supplements the three forces of humanism, behaviorism, and psychodynamism for psychology. Service to the professional community is an important value for Paul, and thus he has found time to serve on numerous boards and committees. His activities have included 3 years as President of the Society for Intercultural Education, Training and Research (SIETAR), Senior Editor for the SAGE Publications book series Multicultural Aspects of Counseling (MAC), and Advising Editor for a Greenwood Press book series in education and psychology. Additionally, Paul is a Board Member of the Micronesian Institute, located in Washington, D.C., and an External Examiner for Universiti Putra Malaysia, University Kebangsaan, and Universiti Malaysia Sabah in psychology. In the American Psychological Association, Paul was a member of the Committee for International Relations in Psychology (CIRP) from 2001 to 2003. In 2010 he was the recipient of CIRP’s Distinguished Contributions to the International Advancement of Psychology Award. In 1994 he was invited to give a master lecture at the American Psychological Association’s annual meeting in Los Angeles. Paul also is a Fellow in Divisions 9, 17, 45, and 52 of the American Psychological Association. About a decade ago Paul was unfortunately stricken with Parkinson’s disease. His mental abilities and all of his fine personal qualities remain intact, but the affliction has affected his vision and ability to type or use computers effectively. With Paul’s permission, we want all who do not yet know about his condition to understand why his work on this edition of Counseling Across Cultures has been somewhat curtailed. In discussing this with Paul we lamented the fact that in this edition there is no chapter that deals directly with what could be called something like the “culture of the afflicted.” Chapters 19 and 20 get into some of these concerns and matters, dealing as they do with health issues. However, Paul reminded us of an intuitively insightful fact: When one is burdened with a physical condition that has no known cure—Parkinson’s is an excellent and tragic example—one enters a new and entirely unexpected culture. Adjustments must be made, old and familiar abilities must be replaced by new ones, and one’s interpersonal network can be radically changed. In a very real sense, then, Paul’s condition has given him, through us, the opportunity to seize another “teaching moment.” Paul, a magnificent teacher and adviser throughout his career and this project, would appreciate that characterization. By all professional and personal standards, Paul is a visionary. He has contributed significantly to the emergence of multiculturalism in psychology and in related disciplines. His commitment to multiculturalism extends well beyond the mental health professions. In thinking about the future of multicultural counseling and social justice, Paul firmly believes that the multicultural perspective will evolve into a perspective that acknowledges how people may share the same common-ground expectations, positive intentions, and constructive values even though they express those expectations and positive intentions through different and seemingly unacceptable behaviors. He also maintains that we must generate a balanced perspective in which both similarities and differences of people are valued and at the same time hope we can avoid partisan quarreling among ourselves and get on with the important task of finding social justice across cultures. We dedicate this seventh edition of Counseling Across Cultures to our dear friend and colleague Paul Bodholdt Pedersen, a true trailblazer, mentor, and leader in making counseling cultural. Walter J. Lonner Juris G. Draguns Joseph E. Trimble María R. Scharrón-del Río Introduction Learning From Our “Culture Teachers” This seventh edition of Counseling Across Cultures is largely guided by the fundamental premise that it shares with most books at the interface of social realities and psychological principles: All behaviors and thoughts are learned in specific cultural contexts. If you can accept that simple premise you are ready to tackle one that is much more complex: While people are much more similar than they are different, the differences are fascinating and sometimes difficult to understand without considerable exposure to and interaction with people from different cultures and ethnic groups. How do these similarities and, especially, differences come about? Paul Pedersen has used a colorful image that is based on the idea that all humans have “culture teachers,” and while some of these teachers have similar characteristics, each is also totally unique. Capture, suggests Pedersen, a panorama of a thousand persons sitting around you. The large gathering consists of some people you have chosen, or who have chosen you, over a lifetime of many interactions. This gathering of people includes parents, siblings, grandparents, close friends, teachers, enemies, heroes, heroines, scientific pioneers, religious figures, political leaders, revolutionaries, poets, entertainers, athletes, individuals with disabilities, and many others who have influenced you in sometimes subtle but often profound ways. Either directly or indirectly, they have all helped to shape who you are. They will likely continue to do so, even those who have been dead for years. Getting to know another person well is a riveting, complex, and exhausting process, but it can also be exhilarating and fulfilling. We believe, therefore, that before we can make accurate assessments, provide meaningful understanding, and offer appropriate interventions, we must learn more about our own cultural contexts and the culture teachers who shaped our lives. Reciprocally, in interactions with others—and especially in counseling and therapeutic relationships—it is imperative that we learn as much as we can about each person with whom we interact. To ignore an individual’s “culture teachers” and the cultural context that shaped his or her life is to invite little or no progress in professional interventions. You are probably reading this book because, either intuitively or from direct experience, you already know this to be true. Moreover, you probably agree with us that it would be impossible for a counselor to know, in depth and in great detail, everything about all clients with whom he or she interacts. However, by using the precepts of inclusive cultural empathy (ICE), which is a theme running through this book and a concept explained in Chapter 1, we can emphatically endorse the idea that we try to understand each and every client. Such understanding does not necessarily have to be in great depth. In many cases it may be close to impossible to understand the worldviews, values, and background of a client in a short period of time. It may be difficult to fathom the plight of a homeless person, or an immigrant from Vietnam, or a transvestite, or a religious zealot. Despite these scenarios and hundreds others like them, it is imperative that we employ ICE and make a sincere attempt to know the other person, even if it is “through a glass, darkly.” Consistent with the demands of what can be a challenging task, it is our job as the editors of this volume, as well as the job of the chapter authors, to help hone your skills and talents in our shared kaleidoscopic multicultural world. All the chapters in this book have been written by dedicated professionals who can inform and advise you. Welcome them all as newcomers to your circle of “culture teachers.” Covet their advice. Since the first edition of Counseling Across Cultures was published in 1976, thousands of publications and research projects have increased our understanding of the roles of culture teachers. Many of these sources are listed in the reference sections of the chapters in this book. We owe a great debt to our culture teachers for the wisdom we have gained from them, and we are pleased to introduce them to you. As recently as 1973, when we presented a seminal symposium at the American Psychological Association titled “Counseling Across Cultures” and subsequently planned the first edition of this book, the terms cross-cultural and multiculturalism were largely neglected or unknown to counseling professionals. The University of Hawaii Press agreed to publish that initial book, provided we waived royalties. The book went through five printings the first year and then through five more editions—in 1981, 1989, 1996, 2002, and 2008. This, the seventh edition, gives testimony to the continued popularity of counseling across cultures, which has evolved into a burgeoning and multifaceted enterprise. The culture-centered or multicultural perspective provides us with at least 12 uniquely valuable goals and outcomes: 1. Accuracy: All behaviors are learned and displayed in specific cultural contexts. 2. Common ground: The basic values in which we believe are expressed through different attitudes, behaviors, and worldviews across cultures and ethnic groups. 3. Identity: We learn who we are from the thousands of culture teachers in our lives as we integrate these multiple threads of experience. 4. Health: Our socio-ecosystems require a diversified gene pool. 5. Protection: Psychology has been culturally encapsulated through much of its history, and we need to identify our own biases to protect ourselves from failure. 6. Survival: Our best preparation for life in the global village is to learn from persons who are culturally different from ourselves. 7. Social justice: History documents that injustices can be expected when a monocultural, dominant group is allowed to define the rules of living for everyone; shifting to a multicultural orientation curbs this tendency. 8. “Out of the box” thinking: Progress in understanding the problems of others is often constrained by traditional linear thinking; we should frequently consider nontraditional, nonlinear alternatives. A multitude of insiders’ and outsiders’ perspectives can help us develop a more differentiated and flexible view of the world. 9. Learning: Effective learning that results in change is also likely to result in our both experiencing and overcoming culture shock and adapting to innovation and transformation. 10. Spirituality: All humans experience the same Ultimate Reality in different ways; there is no single “right” way, and it is ethnocentric folly to assume that there is. 11. Political stability: Some form of cultural pluralism is the only alternative to either anarchy or oppression. 12. Competence: Multiculturalism is generic to a genuine and realistic understanding of human behavior in all counseling and communication. Above and beyond these 12 points, culturally informed counseling can be likened to a bridge that helps transcend the gulf or chasm of differences in practices, expectations, and modes of communication that separate persons whose backgrounds and outlooks have been molded by their respective cultures. That is the reason a photo of a bridge adorns the cover of this book. Effective multicultural counseling will likely not obliterate the need for the bridge, but it may shorten the journey substantially. The present edition includes many new authors and a new coeditor—52 individuals in all—and offers ideas that have emerged since the appearance of the sixth edition, which was published in 2008. Like the sixth, this edition is divided into five parts and a total of 24 chapters. Each part opening features an introduction that briefly surveys the content of the chapters within the part. All chapters begin by identifying primary and secondary objectives, and all (with the exceptions of Chapters 1 and 2) include “critical incident” discussions to illustrate key points at the hypothetical case level. Most of the critical incidents are highlighted at the ends of the chapters, but some are integrated into the text in other ways. Discussion questions are also included. We concede that not all of the incidents presented are critical in the strict sense of the term. All are, however, designed to make abstract concepts concrete and to exemplify, often in a vivid way, the interface between culture and counseling. In addition to this feature, the contributors to the present edition have been liberal in describing instances and offering vignettes of culturally distinctive ways of presenting personal dilemmas, seeking relief from distress, and, in the optimal case, reducing suffering and resolving quandaries and problems of living. On the theoretical plane, the authors of these chapters have contributed several explicit models of culturally sensitive intervention in a variety of contexts. Moreover, the results of several major multinational research projects have been brought to bear on the current multicultural counseling enterprise. In this manner, the contributors to this volume have endeavored to narrow the gap between basic cross-cultural research findings and culturally appropriate intervention at the case level. In what ways is the current edition different from its predecessors? For one, it is more case centered. As already alluded to above, several of the chapter authors have gone well beyond critical or illustrative incidents to build their contributions around a limited number of detailed case studies, an approach that has enabled them to explore cultural issues in counseling in depth. For example, Chapter 20 includes a detailed account of a client overcoming clinical problems by recapturing the themes and values of his original culture. In the process of presenting this account, the authors bridge the gap between culture teaching and therapy. Chapter 23 highlights the traumatic effect of culture loss, or deculturation, and, conversely, demonstrates how the previously suppressed strands of cultural experience may help a counselee achieve more effective functioning and more rewarding experience. Chapter 14 relates the experiences of two international students as they seek and find their way through the maze of the host culture, illustrating the vicissitudes of culture learning and the impact of a multiplicity of culture teachers. The second theme that receives increased emphasis in the current edition is that of promotion of social justice. There was a time when many counseling and mental health professionals considered their interventions to be sharply distinct, or even mutually exclusive, from the work of the advocates for persons in various disadvantaged, oppressed, or poorly understood cultural categories. The recognition that the reformist and the therapeutic thrusts of improving the lives of culturally distinctive counselees are compatible and mutually complementary pervades this edition, and is especially prominent in Chapters 5–9, 10–11, and 14–17. A third theme that is also highlighted in this edition is the importance of considering and examining the intersectionality of identities, privileges, and oppressions. Many of the chapters challenge the reader to critically examine and consider the impacts of intersecting systematic oppressions and privileges in themselves and in their clients as a key step in ICE. Becoming aware of our own privileges and how they affect our lives and our clinical work can be an overwhelming task. Privilege protects those of us who hold it from a lot of psychological struggle (i.e., not having to deal with external and internalized oppression), but it also robs us of gaining knowledge about the world and about ourselves in relation to the world. Privilege is a blind spot in our awareness that slows down the road toward ICE; thus, many of the chapters in this book provide readers with information and questions that can help them to bridge this gap in awareness, knowledge, and empathy. Concurrent with the promotion of ICE, this edition also emphasizes the increasing role of culturally adapted evidence-based procedures, a topic to which Chapter 4 is principally devoted. In several other chapters, the authors describe specific evidence-based procedures that have been successfully applied in various domains of counseling across culture. As these approaches spread and multiply, the challenge is to combine demonstrated effectiveness with empathetic cultural sensitivity, fusing subjectivity with objectivity. Not an easy task, to be sure, but not an unattainable goal either. Although this edition introduces many new topics and approaches, it also reaffirms the relevance of major contributions from earlier editions. In the fourth edition of Counseling Across Cultures, David Sue and Norman Sundberg contributed an important chapter titled “Research and Research Hypotheses About Effectiveness in Intercultural Counseling.” It contained 15 research hypotheses that have held up remarkably well across the intervening decades. For that reason, we reproduce them here: 1. Entry into the counseling system is affected by cultural conceptualization of mental disorders and by the socialization of help-seeking behavior. 2. The more similar the expectations of the intercultural client and counselor in regard to the goals and process of counseling, the more effective the counseling will be. 3. Of special importance in intercultural counseling effectiveness is the degree of congruence between the counselor and client in their orientations in philosophical values and views toward dependency, authority, power, openness of communication, and other special relationships inherent in counseling. 4. The more the aims and desires of the client can be appropriately simplified and formulated as objective behavior or information (such as university course requirements or specific tasks), the more effective the intercultural counseling will be. 5. Culture-sensitive empathy and rapport are important in establishing a working alliance between the counselor and the culturally different client. 6. Effectiveness is enhanced by the counselor’s general sensitivity to communications, both verbal and nonverbal. The more personal and emotionally laden the counseling becomes, the more the client will rely on words and concepts learned early in life, and the more helpful it will be for the counselor to be knowledgeable about socialization and communication styles in the client’s culture. 7. The less familiar the client is with the counseling process, the more the counselor or the counseling program will need to instruct the client in what counseling is and in the role of the 8. 9. 10. 11. 12. 13. 14. 15. client. Culture-specific modes of counseling will be found that work more effectively with certain cultural and ethnic groups than with others. Ethnic similarity between counselor and client increases the probability of a positive outcome. Within-group differences on variables such as acculturation and stage of racial identity may influence receptivity to counseling. Credibility can be enhanced through acknowledgment of cultural factors in cross-cultural encounters. In general, women respond more positively than men to Western-style counseling. Persons who act with intentionality have a sense of capability and can generate alternative behaviors in a given situation to approach a problem from different vantage points. Identity-related characteristics of White counselors can influence their reaction to ethnic minority clients. Despite great differences in cultural contexts in language and the implicit theory of the counseling process, a majority of the important elements of intercultural counseling are common across cultures and clients. The infusion of multiculturalism into the theory and practice of counseling is a long process that requires the understanding of “new rules.” Clients in counseling and psychotherapy come from a multitude of cultures and ethnicities, each with his or her own unique assortment of culture teachers. The imposition of a one-size-fits-all approach to counseling is no longer acceptable for clients who represent a substantial number of diverse cultural contexts. The counselor who thinks there are only two people involved in a transaction—the client and the counselor—is already in great difficulty. In addressing these wide-ranging and key issues, we seek to articulate in this volume the positive contributions that can be realized when multicultural awareness is incorporated into the training of counselors. Properly understood and applied, this awareness of our culture teachers will make our work as counselors easier rather than harder, more satisfying rather than frustrating, and more efficient rather than inefficient and cumbersome. Paul B. Pedersen Walter J. Lonner Juris G. Draguns Joseph A. Trimble María R. Scharrón-del Río Part I Essential Components of Cross-Cultural Counseling A quick look at the table of contents of this text reveals that almost 80% of the chapters—the 20 chapters that make up Parts II through V—focus on specifically targeted perspectives and topics that are systematically spread across important clusters of interrelated chapters. Thus, the operative phrase that they share is specificity of function. All of these 20 chapters feature topics that can, if one desires, be read as unified independent presentations. For instance, if a counselor wishes to review key aspects of counseling Asian clients, or refugees, or issues pertaining to families, specific chapters can serve as informative packages in and of themselves. The operative phrase in Part I, in contrast, is foundational perspectives. The intent of this beginning group of four chapters is to provide a broader view that will help form a coherent basis for the rest of the text. We strongly believe that all approaches used in cross-cultural counseling are best implemented when important generic areas, fundamentally related to all other counseling-oriented topics, are woven into the fabric of counselors’ specific purposes. In that sense, Part I has an integrative function for the text. We recommend reading it first. In this introduction we present only fragmentary comments on the four chapters. Chapter 1 focuses on inclusive cultural empathy, or ICE. Empathy, like related concepts such as sympathy and compassion, is a human universal. It has almost certainly been part of the collective human psyche across countless millennia. A temporary state of emotional symbiosis seems to characterize empathy. One has only to study Rembrandt’s 17th-century masterpiece The Return of the Prodigal Son to see and even feel that acts of empathy, compassion, and sympathy predate the introduction of the root German word Einfühlung, which means “in-feeling” or “feeling in.” It was first used more than a century ago in the psychology of aesthetics. Robert Vischer and then Theodor Lipps introduced it as an interpersonal phenomenon. Freud and others employed the term extensively. Thus it is useless to argue whether or not we have the capacity for empathy. Rather, the question is, To what extent do we have it? That leads to other questions, such as Can it be enhanced by experience and training? and Is too much of this “feeling in” dangerous in counseling relationships? Culture-oriented perspectives in psychology are currently popular and inclusive, and we believe they will remain that way. Whether it is cross-cultural psychology, cultural psychology, indigenous psychology, psychological anthropology, or multiculturalism, psychology has become much more inclusive. Gone are the hegemonic days of Western-based psychology that largely ignored the phenomenon of culture and its multitude of forms. “Leave culture in the hands of anthropologists” was a frequent directive issued by orthodox behaviorists. That narrow vision has almost entirely disappeared. Many of the basic principles of psychology remain, as well they should, because psychology is an important academic and practical discipline with transcendent conceptual and methodological principles. Organized cross-cultural psychology, one of the antidotes to scholarly myopia, is now half a century old, with new developments certain to continue. (For a chronological overview of initiatives that have been heavily influenced by culture-oriented psychologists, see Lonner, 2013.) Inclusive cultural empathy is a concept that stands on the shoulders of these efforts. ICE is such a compelling idea that it serves as the hub for the several spokes that constitute the remaining chapters in this text. In Chapter 1, Paul B. Pedersen and Mark Pope take the experience of empathy, with its roots in Western conceptualizations of self, values, and other popular constructs that make up personhood, to a level made possible by the contributions of thousands of psychologists and counselors throughout the world. Pedersen and Pope note that “inclusion” comes from research in the hard sciences, where something “can be both right and wrong, good and bad, true and false at the same time through ‘both/and’ thinking.” This supplants the rules of “exclusion,” which, as they point out, have depended on “either/or” thinking, wherein one alternative explanation is entirely excluded and its opposite is entirely accepted. Thus, “from this quantum perspective, empathy is both a pattern and a process at the same time.” It is elegantly clear, therefore, that in counseling across cultures, taking both the perspective of the counselor and that of the client, much more can be gained by adopting a two-way attitude than by accepting a traditional “either/or” perspective. Psychotherapy is not a laboratory experiment in which a null hypothesis is either accepted or rejected. This dichotomy would mean that accepting one perspective (usually the counselor’s) over the other would block progress. No doubt thousands of counseling sessions have ended abruptly when one in the dyad (usually the counselor) looked at the problem through culture-colored glasses. It was out of these procedural concerns that Pedersen developed his well-known triad training model. ICE is also central to Pedersen’s idea that multiculturalism is a “fourth force” in psychotherapy and, as such, is as influential as behaviorism, humanism, and psychodynamic approaches. These pioneering viewpoints are briefly discussed in Chapter 1. The intent of Chapter 2 is to examine the basic elements of counseling and to explain how counseling in any cultural setting can be effective. In the chapter, Juris G. Draguns gives examples of classic definitions of counseling, all of which can readily be applied to counseling across cultures. The idea that “counseling is principally concerned with facilitating, rather than more directively bringing about, adaptive coping in order to alleviate distress, eliminate dysfunction, and promote effective problem solving and optimal decision making” is sufficiently transcendent to be used in any relationship that can be described as “counseling.” An additional comment Draguns makes, that “counseling proceeds between two (or sometimes more than two) individuals and is embedded in distinctive sociocultural milieus,” correct as it is, must be considered in connection with ICE, for two, and not just one, cultural milieus will inevitably be involved. This is the sauce that gives meaning to the notion of “cross” in cross-cultural counseling, for these relationships cut both ways. Draguns gives cogent examples of what Pedersen has told us: that a multitude of “culture teachers” have strongly influenced, and continue to influence, all culture-oriented counselors. Like homunculi sitting on a counselor’s shoulder during counseling sessions, these teachers affect what is said and done in each and every encounter. This analogy is in line with the broad sweep of ICE. The more influence these teachers have in a counseling session, the more likely it is they will contribute to a successful outcome. Another consideration of empathy is that it works best if understood as a constantly reciprocating relationship. The counselor will have to be attuned to the many ways that the client has learned his or her own culture, and the client will have to pay attention to what the counselor says and does, for just as the counselor has “culture teachers,” so does the client. This is part of what the therapeutic alliance is all about. Chapter 2 also covers a range of other considerations that to varying degrees cut across all the other chapters in the text. Culturally adapted cognitive-behavioral therapy and its possible convergence with evidence-based treatments have entered culture-oriented counseling. The issues surrounding this convergence are discussed. The latter part of the chapter shifts from the nature of cross-cultural counseling as a process that differs from “routine” counseling to several generalizable characteristics of clients. While it is true that each individual is unique, there are certain domains of personhood that transcend culture and ethnicity. Foremost among these domains is the construct of self. Consistent with aspects of self that are important in assessing persons (see the discussion below regarding Chapter 3), in culture-oriented counseling it is important to keep in mind that the nature of a client’s self is largely shaped by cultural and ethnic factors that leave their indelible imprints on everyone. The most widely researched aspect of the self places all of us on a continuum. On one end we find those who are highly independent and autonomous in thought and action (think of the stereotypic strong male, or of the notion of self-sufficiency). The other end is populated by individuals whose selves are conditioned by a strong sense of belonging to some sort of collectivity, such as a caste, clan, family, or other group (think of the stereotypic female, for whom family, friends, and community come first). The continuum of allocentrism–idiocentrism—or group orientation as opposed to selfreliance—has been used as another way to view opposing configurations of personality traits that help explain how individuals differ. Highly related to this useful concept is the dichotomy of individualism and collectivism. A number of culture-oriented psychological researchers have spent most of their careers studying the roots and dynamics of this hypothetical continuum, which is mostly used at a high level of abstraction, such as a clan or an entire country. It is such a robust construct that one can envision it as being highly related to the bifurcation of extroversion and introversion, an oftused dichotomy that operates at the level of the individual. Draguns also discusses four other dimensions that Hofstede and a large network of fellow researchers have used in hundreds of research projects. He closes the chapter by discussing universal, cultural, and individual threads in counseling. He also includes a helpful list of brief “dos and don’ts” that can help guide counselors in their interactions with clients whose cultural or ethnic backgrounds differ from their own. Chapter 3 gives an overview of issues, problems, and perspectives in the area of psychological assessment. The assessment or appraisal of a person who, for any reason, becomes a counseling client begins the instant that counselor and client meet. The assessment can be quick and impressionistic, involving no formal assessment procedures. On the other hand, it can, and usually does, involve an array of psychological tests and other measurement devices and procedures that help the counselor understand the client’s abilities, personality, values, and virtually any other dimension of personhood that the counselor deems important. Perhaps the key question to be asked and answered is the one that the author of the chapter, Walter J. Lonner, proposes: Is the assessment of this person, in these circumstances, with these methods, and at this time as complete and accurate as possible? The field of psychological measurement and testing has a rich and lengthy history, and it is one of the more ubiquitous areas in the discipline. Lord Kelvin once made a claim that cements the importance of tests and measurements: “If you haven’t measured it you don’t know what you are talking about.” Years later, E. L. Thorndike backed him up with this well-known proclamation: “If a thing exists, it exists in some amount; and if it exists in some amount, it can be measured.” Thus, one dimension in assessment—and arguably the most important in the area of professional counseling—involves carefully planned psychological testing. All counseling clients, regardless of presenting problems and the focus of counseling, are assessed in some fashion, and many of them will be required or asked to take one or more psychological tests. Tests that measure aptitude, abilities, intelligence, personality, interests, values, and other aspects of the person are most common. Most of these psychometric devices originated in the United States, Canada, and their territorial extensions, such as Great Britain, Australia, New Zealand, and Western Europe. Furthermore, most of them were originally conceived by academic psychologists and educational experts who represent a fairly narrow swath of vast populations and normed on “captive audiences” or “samples of convenience.” And therein lies a question that begs an answer in almost any counseling encounter with people for whom the tests may not have been originally normed: What must be done to ensure that the test results are equivalent and unbiased? The ideas of fairness and cultural validity are pervasively on the minds of cross-cultural psychologists, whose careers have been dedicated to the assessment of various dimensions of personhood. As Lonner points out, numerous technical resources are readily available in the literature to help therapists translate and otherwise adapt psychological tests for use in counseling. Counselors can choose between quantitative (nomothetic) and qualitative (idiographic) methods in assessment or use some combination of the two. Because both of these approaches have attractive features, the use of mixed methods is steadily increasing, especially in counseling and clinical work. Neuropsychological testing, briefly surveyed in Chapter 3, is often important in the assessment of acculturating or displaced individuals who have been victims of wars, physical or psychological abuse, malnutrition, or other horrid human conditions. The overriding theme of inclusive cultural empathy that characterizes this book can be extended to inclusivity in empathetic assessment. For this reason, Lonner suggests the use of knowledge-based assessment (KBA). Usually having nothing to do with more traditional and formal assessment devices, KBA includes the knowledge that the counselor has accumulated in all walks of life and especially from reading and becoming familiar with culture-oriented research that, for years, has focused on hypothesized universal personality traits and the ways in which culture helps to shape various dimensions of self as well as values. A client’s personality, conceptions of self, and preferences for certain values over others will always be among the mixture of things that emerge in the process of counseling. The counselor’s ability to use the results of a great deal of culture-driven research in such areas of personhood extends the notion of psychological assessment beyond its more formal and traditional techniques. Counseling across cultures as a recognized professional activity has a lengthy history but a short past. One can imagine thousands of scenarios in the distant past where a person from, for example, Homer, Alaska, was discussing a personal problem presented by an immigrant from rural Norway. The counselor may have little or no psychological background, and both the counselor and the client may have limited fluency in the other’s language. These kinds of conundrums take us back a few pages in this introduction to our brief discussion of assessment across cultures. Thus, in this hypothetical context, one can ask: Is my counseling of this person, in these circumstances, with the methods at my level of competence, and at this time and place as practicable and ethical as possible? The authors of Chapter 4 ask this multifaceted question in the context of a fundamental issue in multicultural counseling—an issue that transcends all 20 chapters in Parts II–V. Timothy B. Smith, Alberto Soto, Derek Griner, and Joseph E. Trimble summarize the current status of research on multicultural counseling. As they note, research in this area has increased exponentially over the past several decades. Clearly, even as recently as 1976, when the first edition of this book appeared, very little research had been conducted bearing on the effectiveness of counseling across cultures. This is especially true with respect to evidence-based psychological treatments, which are currently at a premium. Focusing primarily on the powerful method of meta-analysis, in which the findings of numerous individual studies are integrated prior to analysis in an effort to make sense of the effectiveness (or lack thereof) of counseling across cultures, Smith et al. look into the characteristics of counselors who demonstrate competence in the field. Intercultural competence is clearly the silver chalice for anyone who aspires to reach a recognized level of effectiveness in multicultural competence. An increasing array of research and literature on the topic is coalescing to an extent not heretofore reached. For instance, in 2013 the Journal of Cross-Cultural Psychology published a special issue containing nine articles that are fine examples of current thinking in this area (Chiu, Lonner, Matsumoto, & Ward, 2013). The issue focuses on cross-cultural competence in general, with a decided nod in the direction of cross-cultural competence in the international workplace (among managers, consultants, negotiators, and so on), and not specifically multicultural counseling competence. However, sensitivity, open-mindedness, social initiative, flexibility, cultural empathy (which in this book is essentially equivalent to ICE), critical thinking, emotional stability, emotion regulation, awareness, abilities, knowledge, and skills are descriptors that often surface in attempts to pinpoint the components of cross-cultural competence. It seems to us that if a person is crossculturally competent, that competence should transfer well across all domains of interpersonal interaction. The package of the above descriptors a person possesses would, if realized in sufficient quantities, define ICE. Numerous attempts to measure the concept have been attempted (Deardorff, 2009; Matsumoto & Hwang, 2013). While all chapters in this book can be enhanced and informed by this foundational chapter, perhaps the contribution that is closest to Chapter 4 conceptually and practically is Chapter 18, which focuses exclusively on acculturation, a topic that by definition is saturated with an assortment of counseling needs. This is especially true in North America, which for generations has been the “promised land” for many. Smith et al. mention this as well. A high percentage of the works cited in the abovementioned special issue come from journals such as the International Journal of Intercultural Relations; just a handful are journal articles and books that typically are read by counselors and clinicians. With so much to offer each other, readers of this text are encouraged to do something about this unfortunate territorial bifurcation. The latter pages of Chapter 4 discuss a number of factors that have been researched by culture-oriented practitioners. They include racial and ethnic matching of client and culture and ways in which general theories of counseling have been adapted for multicultural counseling. References Chiu, C. Y., Lonner, W. J., Matsumoto, D., & Ward, C. (Eds.). (2013). Cross-cultural competence [Special issue]. Journal of Cross-Cultural Psychology, 44(6). Deardorff, D. K. (Ed.). (2009). The SAGE handbook of intercultural competence. Thousand Oaks, CA: Sage. Lonner, W. J. (2013). Foreword. In K. D. Keith (Ed.), The encyclopedia of cross-cultural psychology. Hoboken, NJ: Wiley-Blackwell. (Also in Online Readings in Psychology and Culture, http://dx.doi.org/10.9707/2307–0919.1124) Matsumoto, D., & Hwang, H. C. (2013). Assessing cross-cultural competence: A review of available tests. Journal of Cross-Cultural Psychology, 44(6), 849–873. 1 Toward Effectiveness Through Empathy Paul B. Pedersen Mark Pope Primary Objective ■ To provide an overview of the significance and importance of inclusive cultural empathy Secondary Objectives ■ To reframe the counseling concept of “individualistic empathy” into inclusive cultural empathy ■ To develop a more relationship-centered alternative based on Asian ways of knowing and healing Good relationships in counseling psychotherapy emerge as a necessary but not sufficient condition in all research about effective mental health services. Good relationships depend on establishing empathy. Empathy occurs when one person vicariously experiences the feelings, perceptions, and thoughts of another. Most of the research on empathy is predicated on the shared understanding of emotions, thoughts, and actions of one person by another. In Western cultures, psychologists typically focus exclusively on the individual, whereas in traditional non-Western cultures, empathy more typically involves an inclusive perspective focusing on the individual and significant others in the societal context. This chapter explores the reframing of “empathy,” based on an individualistic perspective, into “inclusive cultural empathy,” based on a more relationship-centered perspective, as an alternative interpretation of the empathetic process (Pedersen, Crethar, & Carlson, 2008). The world has changed to make us totally interdependent on a diversified model of society, requiring us to find new ways of adaptation. Globalization, migration, demographic changes, poverty, war, famine, and changes in the environment have led to increased diversity across the globe. Our responses to that diversity, through sociotechnical changes, competition for limited resources, and anger and resentment at the intranational and international levels, all of which depend on conventional Western models, have been inadequate: Powerful global efforts to reduce diversity conflicts by the hegemonic imposition of Western economic, political, and cultural systems is not a solution to the emerging diversity conflict issues. Rather, the “global monoculturalism” being promoted represents an exacerbation of the problem as evidenced by the growing radicalization of individuals, groups, and nations seeking to resist the homogenization pressures. (Marsella, 2009, p. 119) In this context, empathy—reframed as inclusive cultural empathy—provides an alternative perspective to conventional individualism. We believe that psychologists are part of both the problem and the solution to this dilemma, and we call upon the field to take leadership around the world in applying this inclusive cultural empathy model. Cultural Foundations Moodley and West (2005) integrated traditional healing practices into counseling and psychotherapy. They described a rich healing tradition from around the world, going back more than 1,000 years, that is being used today alongside contemporary health care. They explore the complexities of the various approaches and argue for the inclusion and integration of traditional and indigenous healing practices in counseling and psychotherapy. This need to look outside the boundaries of Western psychology is a direct result of the failures of multicultural counseling or the way psychotherapy is practiced in a multicultural context. It seems that multicultural counseling and psychotherapy is in crisis. (Moodley & West, 2005, pp. xv–xvi) Mental health care providers and educators can no longer pretend that counseling and psychotherapy were invented in the last 200 years by European Americans in a Western cultural context. The recognition of indigenous resources for holistic healing and the search for harmony have been recognized in the literature about complementary and alternative medicine. The true history of mental health care includes contributors from around the world during the last several thousand years, although these progenitors are seldom if ever mentioned in the textbooks for training mental health care providers. This omission, however unintentional, is inexcusable and has resulted in violations of intellectual property rights and unnecessary misunderstanding. Although Asia and Africa have been struggling to interface traditional approaches with Western approaches for a long time, this task has only recently emerged as a priority in the United States (Incayawar, Wintrob, & Bouchard, 2009). The practice of psychotherapy is a political action with sociopolitical consequences. Psychologists, counselors, and scholars from Western cultures have presented a history of protecting the status quo against change, as perceived by people in minority cultures (i.e., racial minorities, women, and those who perceive themselves as disempowered by the majority). The lack of trust in people who provide counseling services and the belief that the status quo is being protected are documented in the literature about “scientific racism” and European American ethnocentrism (Pedersen, Draguns, Lonner, & Trimble, 2008; D. W. Sue & Sue, 2003). Cultural differences were explained by some through a genetic deficiency model that promoted the superiority of dominant European American cultures. The genetic deficiency approach was matched to a cultural deficit model that described minorities as deprived or disadvantaged by their culture. Minorities were underrepresented among professional counselors and therapists, the topic of culture was trivialized in professional communications, and minority views were underrepresented in the research literature. Members of the counseling profession were discredited among minority client populations because they viewed counseling as a tool to maintain the boundary differences between those who had power and/or access to resources and those who did not. These cultural differences have resulted in racial microaggressions in the everyday contacts between groups. “Racial microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color” (D. W. Sue et al., 2007, p. 271). Inclusive cultural empathy seeks to minimize or eliminate racial microaggressions from multicultural contacts by emphasizing the importance of context. Alternative Indigenous Psychologies There are already indigenous alternatives to individualistic psychotherapy. China provides examples of indigenous alternatives that de-emphasize individualism. Yang (1995, 1999), Yang, Hwang, Pedersen, and Daibo (2003), and Hwang (2006) conceptualized the Chinese social orientation in two ways—first as a system of social psychological interactions and second as a pattern of inclinations or “natural” tendencies based on past experience. This interaction between the person and the environment is demonstrated in the tension between isolated or independent tendencies and relational or connected tendencies. Although the individuated approach works well in some cultures to facilitate measurement and treatment, for example, it excludes valuable data from other cultures. Santee (2007) described an integrative approach to psychotherapy that bridges Chinese thought, evolutionary theory, and stress management. This approach provides an opportunity to view the culturally diverse perspectives of Buddhism, Daoism, and Confucianism in a context that will allow for the integration of these teachings into Western counseling and psychotherapy. This integration will, it is hoped, contribute to resolving the problems facing contemporary counseling and psychotherapy caused by its own ethnocentric perspective and the need to access cultural diversity. It is a move toward embracing a new paradigm. It is a bamboo bridge. (Santee, 2007, pp. 10–11) The family orientation metaphor constitutes the core “building block” of Chinese society, rather than the isolated individual, as in Western cultures. “The Chinese people tend to generalize or extend their familistic experiences and habits acquired in the family to other groups so that the latter may be regarded as quasi-familial organizations. Chinese familism (or familistic collectivism), as generalized to other social organizations, may be named generalized familism or pan familism” (Yang, 1995, p. 23). This family perspective is significantly different from Western psychology’s focus on the scientific study of individual behavior. Yang had the dream of an alternative to using inappropriate Western psychology to understand balance in Chinese society. He described the consequences of imposing Western psychology on non-Western cultures: What has been created via this highly Westernized research activity is a highly Westernized social science that is incompatible with the native cultures, peoples and phenomena studied in non-Western societies. The detrimental over-dominance of Western social sciences in the development of corresponding sciences in non-Western societies is the outcome of a worldwide academic hegemony of Western learning in at least the last hundred years. (Yang, 1999, p. 182) Liu and Liu (1999) pointed out that interconnectedness is a difficult concept to pin down because it involves synthesizing opposites, contradictions, paradox, and complex patterns that resemble the dynamic, self-regulating process of complexity theory: “In Eastern traditions of scholarship, what is valued most is not truth. In broad outline, the pursuit of objective knowledge is subordinate to the quest for spiritual interconnectedness” (p. 10). Yang (1997) described his thinking as it evolved toward understanding North American psychology as its own kind of indigenous psychology, developing out of European intellectual traditions but much influenced by American society. He developed a list of “seven nos” that a Chinese psychologist should not do so that his or her research can become indigenous: Not to habitually or uncritically adopt Western psychological concepts, theories, and methods; Not to overlook Western psychologists’ important experiences in developing their concepts, theories, and methods; Not to reject useful indigenous concepts, theories, and methods developed by other Chinese psychologists; Not to adopt any cross-cultural research strategy with a Western-dominant imposed etic or pseudo-etic approach . . . ; Not to use concepts, variables, or units of analysis that are too broad or abstract; Not to think out research problems in terms of English or other foreign languages; and Not to conceptualise academic research in political terms, that is, not to politicise research. (pp. 71–72) Along with the “seven nos” Yang (1997) also suggested “10 yes” assertions to guide the psychologist in a more positive direction: To tolerate vague or ambiguous conditions and to suspend one’s decisions as long as possible in dealing with conceptual, theoretical, and methodological problems until something indigenous emerges in his or her phenomenological field; To be a typical Chinese when functioning as a researcher [letting Chinese ideas be reflected in the research]; To take the psychological or behavioural phenomenon to be studied and its concrete, specific setting into careful consideration...; To take its local, social, cultural, and historical contexts into careful consideration whenever conceptualizing a phenomenon and designing a study; To give priority to the study of culturally unique psychological and behavioural phenomena or characteristics of the Chinese people; To make it a rule to begin any research with a thorough immersion into the natural, concrete details of the phenomenon to be studied; To investigate, if possible, both the specific content (or structure) and the involved process (or mechanism) of the phenomenon in any study; To let research be based upon the Chinese intellectual tradition rather than the Western intellectual tradition; To study not only the traditional aspects or elements of Chinese psychological functioning but also the modern ones...; To study not only the psychological functioning of contemporary, living Chinese but also that of the ancient Chinese. (p. 72) The consequences of extreme individualism in psychotherapy are very dangerous to modern societies. Westernized values that became popular in the 19th and 20th centuries have sponsored destructive attitudes and lifestyles; to prevent an ecological disaster, urgent changes are needed in these values. Howard (2000, p. 515) identified nine “killer thoughts” based on Western psychological values and assumptions: (a) Consumption produces happiness; (b) we don’t need to think (or worry) about the future; (c) short-term rewards and punishments are more important than long-term goals; (d) growth is good; (e) we should all get as much of life’s limited resources as we can; (f) keeping the price of energy low is a good thing; (g) if it ain’t broke, don’t fix it; (h) we don’t need to change until scientific proof is found; and (i) we will always find new solutions in time to expand limited resources. The dangers of exclusively imposing dominant-culture values have led psychotherapists to better understand the values of other, contrasting cultures. One example of imposing Westernized, individualistic, dominant-culture values is the primacy of “self-interest.” Miller (1999) examined the “self-interest” motive and the self-confirming role of assuming that “a norm exists in Western cultures that specifies self-interest both is and ought to be a powerful determinant of behavior. This norm influences people’s actions and opinions as well as the accounts they give for their actions and opinions. In particular, it leads people to act and speak as though they care more about their material self-interest than they do” (p. 1053). The more powerful this norm of self-interest is assumed to be, the more self-fulfilling psychological evidence will be found to support that premise. Inclusive Cultural Empathy The importance of “inclusion” comes from research in the hard sciences, where quantum physics demonstrates the importance of opposites, proving that something can be both right and wrong, good and bad, true and false at the same time through “both/and” thinking. The rules of “exclusion” have depended on “either/or” thinking, in which one alternative interpretation is entirely excluded and the opposite is entirely accepted. From this quantum perspective, empathy is both a pattern and a process at the same time. The intellectual construct of empathy developed in a context that favored individualism and described the connection of one individual to another individual. However, globalization is changing that perspective. The individuated self, which is rooted in individualism, is being overtaken by a more familial concept of self, best described by Clifford Geertz (1975): The Western conception of the person as a bounded, unique, more or less integrated motivational and cognitive universe, a dynamic center of awareness, emotion, judgment and action organized into a distinctive whole and set contrastively both against other such wholes and against a social and natural background is, however incorrigible it may seem to us, a rather peculiar idea within the context of the world’s cultures. (p. 48) In the more collectivist non-Western cultures, relationships are defined inclusively to address not only the individual but the many “culture teachers” of that individual in a network of significant others. Being empathetic in that indigenous cultural context requires a more inclusive perspective than that found in the typically more individualistic Western cultures. In identifying the individual, the question should not be “Where” do you come from? but rather “Who” do you come from? Inclusive cultural empathy is an alternative to the conventional empathy concept applied to a culturecentered perspective of counseling (Pedersen, Crethar, & Carlson, 2008). Conventional empathy typically develops out of similarities between two people. Inclusive cultural empathy has two defining features: (1) Culture is defined broadly to include culture teachers from the client’s ethnographic (ethnicity and nationality), demographic (age, gender, lifestyle broadly defined, residence), status (social, educational, economic), and affiliation (formal or informal) backgrounds; and (2) the empathetic counseling relationship values the full range of differences and similarities or positive and negative features as contributing to the quality and meaningfulness of that relationship in a dynamic balance. Inclusive cultural empathy describes a dynamic perspective that balances both similarities and differences at the same time and was developed to nurture a deep comprehensive understanding of the counseling relationship in its cultural context. It goes beyond the exclusive interaction of a counselor with a client to include the comprehensive network of interrelationships with culture teachers in both the client’s and the counselor’s cultural contexts. The inclusive relationship is illustrated by the intrapersonal cultural grid shown in Table 1.1. This visual display shows how a person’s behavior is linked to culturally learned expectations that justify the person’s behavior and the cultural values on which those expectations are based. Table 1.1 shows how each person’s cultural context influences that person’s behavior through the thousands of culture teachers from which each person has learned how to respond appropriately in different situations. To understand the person’s behavior, one must first understand the cultural context. Empathy is constructed over a period of time during counseling as the foundation of a strong and positive working relationship. The conventional description of empathy moves from a broadly defined context to the individual person convergently, like an upside-down pyramid. Inclusive cultural empathy moves from the individual person toward inclusion of the divergent, broadly defined cultural context in which that individual’s many culture teachers live, like a right-side-up pyramid. The conventional definition of empathy has emphasized similarities as the basis of comembership in a one-directional focus on similarities that does not include differences (Ridley & Lingle, 1996; Ridley & Udipi, 2002). “The new construct of cultural empathy presented in much of the literature appears to be indistinguishable from generic empathy except that it is used in multicultural contexts to achieve an understanding of the client’s cultural experience” (Ridley & Lingle, 1996, p. 30). Inclusive cultural empathy goes beyond conventional empathy to understand accurately and respond appropriately to the client’s comprehensive cultural relationships to his or her culture teachers, some of whom are similar to and others of whom are different from the counselor. By reframing the counseling relationship into multicultural categories, it becomes possible for the counselor and the client to accept the counseling relationship as it is—ambiguous and complex— without first having to change it toward the counselor’s own neatly organized self-reference and exclusionary cultural perspective. This complex and somewhat chaotic perspective is what distinguishes inclusive cultural empathy from the more conventional descriptions of empathy. We can best manage the complexity of inclusive cultural empathy in a comprehensive and inclusive framework. This comprehensive and inclusive framework has been referred to as multiculturalism. The ultimate outcome of multicultural awareness, as Segall, Dasen, Berry, and Poortinga (1990) suggested, is a contextual understanding: “There may well come a time when we will no longer speak of cross-cultural psychology as such. The basic premise of this field—that to understand human behavior, we must study it in its sociocultural context—may become so widely accepted that all psychology will be inherently cultural” (p. 352). During the last 20 years, multiculturalism has usually become recognized as a powerful force, not just for understanding “specific” groups but for understanding ourselves and those with whom we work (D. W. Sue, Ivey, & Pedersen, 1996). Increasing Multicultural Awareness Cultural patterns of thinking and acting were being prepared for us even before we were born, to guide our lives, to shape our decisions, and to put our lives in order. We inherited these culturally learned assumptions from our parents and teachers, who taught us the “rules” of life. As we learned more about ourselves and others, we learned that our own way of thinking was one of many different ways. By that time, however, we had come to believe that our way was the best of all possible ways, and even when we found new or better ways it was not always possible to change. We are more likely to see the world through our own eyes and to assume that others see the same world in the same way using a “self-reference” criterion. As the world becomes more obviously multicultural, this “one-size-fits-all” perspective has become a problem. During the last 20 years, multiculturalism has become a powerful force in mental health services, not just for understanding foreign-based nationality groups or ethnic minority groups but for constructing accurate and intentional counseling relationships generally. Multiculturalism has gained the status of a generic component of competence, complementing other competencies to explain human behavior by highlighting the importance of the cultural context. Culture is more complex than these assumptions suggest. Imagine that there are a thousand culture teachers sitting in your chair with you and another thousand in your client’s chair, collected over a lifetime from friends, enemies, relatives, strangers, heroes, and heroines. That is the visual image of culture in the multicultural counseling interview. Psychotherapy in the not-so-far-away future promises to become an inclusive science that routinely takes cultural variables into account. In contrast, much of today’s mainstream psychotherapy routinely neglects and underestimates the power of cultural variables. Soon, there will appear in connection with many psychological theories and methods a series of questions: Under what circumstances and in which culturally circumscribed situations does a given psychological theory or methodology provide valid explanations for the origins and maintenance of behavior? What are the cultural boundary conditions potentially limiting the generalizability of psychological theories and methodologies? Which psychological phenomena are culturally robust in character, and which phenomena appear only under specified cultural conditions? (Gielen, 1994, p. 38) The underlying principle of multicultural awareness is to emphasize at the same time both the culturespecific characteristics that differentiate and the culture-general characteristics that unite. The inclusive accommodation of both within-group differences and between-groups differences is required for a comprehensive understanding of each complicated cultural context. Comprehending Multicultural Knowledge Accurate information, comprehensive documentation, and verifiable evidence are important to the protection of the health sciences as a reliable and valid resource. Knowledge requires an inclusive understanding of all our multiple selves. By defining culture broadly to include ethnographic variables, demographic variables, status, and affiliations, the construct multicultural becomes generic to all counseling relationships. The narrow definition of culture has limited multiculturalism to what might more appropriately be called multiethnic or multinational relationships between groups with a shared sociocultural heritage that includes similarities of religion, history, and common ancestry. Ethnicity and nationality are important to individual and familial identity as aspects of culture, but the construct of culture—broadly defined—goes beyond national and/or ethnic boundaries. Persons from the same ethnic or nationality group may still experience cultural differences that include a variety of within-group differences. This collectivist understanding of culture is more commonly found in non-Western cultures. There are several assumptions that distinguish non-Western therapies (Nakamura, 1964): (a) Self, the substance of individuality, and the reality of belonging to an absolute cosmic self are intimately related. Illness is related to a lack of balance in the cosmos as much as to physical ailments. (b) Asian theories of personality generally de-emphasize individualism and emphasize social relationships. Collectivism more than individualism describes the majority of the world’s cultures. (c) Interdependence or even dependency relationships in Hindu and Chinese cultures are valued as healthy. Independence is much more dysfunctional in a collectivist culture. (d) Experience rather than logic can serve as the basis for interpreting psychological phenomena. Subjectivity as well as objectivity are perceived as psychologically valid approaches to data. In spite of these differences, Western and non-Western approaches are complementary to one another as psychotherapies increasingly include attention to non-Western therapies. Therapies based on non-Western worldviews provide examples of inclusion in understanding the context for any therapeutic intervention: Ayurvedic therapies from India combine the root of the words for life, vitality, health, and longevity (dyus) with the word for science or knowledge (veda) and focus on promoting a comprehensive and spiritual notion of health and life rather than healing or curing any specific illness. Ayurvedic treatments are combined with conventional therapies more frequently in Europe than in the United States. Health is treated as more than the absence of disease and involves a spiritual reciprocity between mind and body. Western-based research has documented the efficacy of Ayurvedic therapies. Yoga has a history of thousands of years as a viable therapy. The word yoga is based on the Sanskrit root yuj, meaning to yoke or bind the body–mind–soul to God. Yoga has its main source in the Bhagavad Gita in understanding the connection of the individual to the cosmos. Research on yoga has demonstrated its benefits in lowering blood pressure and stress levels through meditation, personality change, and therapeutic self-discovery. Chinese therapies include an elegant array of approaches based on the concepts of the Tao, or the way; ch’i, or the energy force; and yin/yang, or the balance of opposites. The various systems of Chinese therapies are grounded in religion and philosophy by the mystical union with God or the cosmos and nature. The Tao describes those patterns that lead toward harmony. Ch’i describes a system of pathways called meridians in the body through which energy flows. Yin/yang describes the balance of paradoxes, each essential to the other. Buddhist therapy is based on the absence of a separate self, the impermanence of all things, and the fact of sorrow. People suffer from desiring and striving to possess things, which are impermanent. The cure is to reach a higher state of being to eliminate delusion, attachment, and desire in the interrelationship of mind and body. Elements of cognitive restructuring, behavioral techniques, and insight-oriented methods are involved in the healing process. Sufism is the mystical aspect of Islam addressing what is inside the person. The outward dimension, or sharia, is like the circumference of a circle, with the inner truth, or haqiqa, being the circle’s center and the path, tariqa, to that center going beyond rituals to ultimate peace and health. The goal in Sufism is to enable people to live simple, harmonious, and happy lives. Jung’s analytical psychology and Freud’s interpretation of the fragmented person are similar but more objective in their emphasis than Sufism, which seeks to go beyond the limited understanding of objective knowledge. Japanese therapies of Zen Buddhism, Naikan, and Morita focus on constructive living, and their aim is for people to become more natural. Morita was a professor of psychiatry at Jikei University School of Medicine in Tokyo who developed principles of Zen Buddhist psychology. Yoshimoto was a successful businessman who became a lay priest at Nara and developed Naikan therapy in the Jodo Shinshu Buddhist psychology. Morita therapy is a way to accept and embrace our feelings rather than ignore them or attempt to escape from them. Naikan therapy emphasizes how many good things we have received from others and the inadequacy of our repayment. Shamanism encompasses a family of therapies involving altered states of consciousness in which people experience their spiritual beings to heal themselves or others. Shamanism is found in cultures from Siberian and Native American cultures to Australian and African cultures, going back perhaps 25,000 years in South Africa. The focus is healing through spirit travel, soul flights, or soul journeys, which distinguish shamans from priests, mediums, or medicine men. These altered states include psychological, social, and physiological approaches that constitute perhaps the world’s earliest technologies for modifying consciousness. Native American healers recognize four main causes of illness: offending the spirits or breaking taboos, intrusion of a spirit into the body, soul loss, and witchcraft. Illness can be a divine retribution for breaking a taboo or offending divine powers, requiring that the patient be purified with song, prayers, and rituals. In the same way, the removal of objects or spirits from the body by a healer restores health. When the soul is separated from the body or possessed by harmful powers it must be brought back to energize the patient, and sometimes the shaman must travel to the land of the dead to bring the soul back. Finally, witchcraft causes illness by projecting toxic substances into the patient. Elements of dissociative reaction, depression, compulsive disorder, and paranoia are present. African healing, as described by Airhihenbuwa (1995), is based on cultural values and is available, acceptable, and affordable; even today African divinities, diviners, and healers continue to be popular in a religious or psychosocial dimension of health care that goes beyond medical care. Beliefs include symbolic representations of tribal realities, illness resulting from hot/cold imbalance, dislocation of internal organs, impure blood, unclean air, moral transgression, interpersonal struggle, and conflict with the spirit world. Health depends on a balance both within the individual and between the individual and the environment or cosmos. Similarities with allopathic medicine are evident. A great variety of other non-Western systems of health care exist, such as Christian mysticism, homeopathy, osteopathy, chiropractic, herbalism, healing touch, naturopathic medicine, qigong, curanderismo, and Tibetan medicine, among many others. Each of these systems is, in turn, divided into a great variety of different traditions. However, many of the same patterns of spiritual reality, mind–body relationships, balance, and subjective reality run through many if not all of these nonWestern therapies. The cultural context provides a force field of contrasting influences, which can be kept in balance through culturally inclusive empathy. There are several implications of considering culturally inclusive empathy to be necessary for competent counseling to occur. Each implication contributes toward a capability for understanding and facilitating a balanced perspective in multicultural counseling. Can a counselor hope to know about all possible cultures to which the client belongs? Probably not, but the counselor can still aspire to know about as many cultural identities as possible, just as in aspirational ethics the counselor tries always to do good but never expects to achieve absolute goodness. Westernized perspectives, which have dominated the field of mental health, must not become the exclusive criteria of modernized psychotherapy. While non-Western cultures have had a profound impact on the West in recent years, many less industrialized non-Western cultures seem more determined than ever to emulate the West as a social model. There is also evidence that the more modernized a society, the more its problems and solutions resemble those of a Westernized society. Although industrialized societies are fearful of technological domination that might contribute to the deterioration of social values and destroy the meaning of traditional culture, less industrialized societies are frequently more concerned that Western technology will not be available to them. The task for psychologists is one of differentiating between modernized alternatives outside the Western model. Otherwise we end up teaching Westernization in the name of modernization. We need indigenous, non-Western models of modernity to escape from our own reductionistic assumptions. Inclusive Cultural Empathy Skills Developing appropriate social action skills depends on accurate assumptions and meaningful knowledge to promote a balanced perspective. Balance involves the identification of different or even conflicting culturally learned perspectives without necessarily resolving that difference or dissonance in favor of either viewpoint. Healthy functioning in a multicultural or pluralistic context may require a person to maintain multiple conflicting and culturally learned roles or viewpoints without the opportunity to resolve the resulting dissonance. Chinese indigenous psychologists have worked to adapt Americanized individualism to make it applicable in both the Western individualistic and the Asian collectivist contexts. David Ho (1999) used the term relational counseling to describe the uniquely Asian indigenous perspective based on a relational self in the Confucian tradition: This relational conception takes full recognition of the individual’s embeddedness in the social network. The social arena is alive with many actors connected directly or indirectly with one another in a multiplicity of relationships. It is a dynamic field of forces and counter-forces in which the stature and significance of the individual actor appears to be diminished. Yet, selfhood is realized through harmonizing one’s relationships with others. (p. 100). Hwang (2000) has also written extensively on relationalism in his “face and favor” model as a manifestation of Confucianism as part of indigenous psychology in China. The process of indigenizing psychology has become a powerful force for psychological change in counseling (Kağitçibaşi, 1996). Western counseling and psychotherapy have promoted the separated self as the healthy prototype across cultures, making counseling and psychology part of the problem, through an emphasis on selfishness and a lack of commitment to the group, rather than part of the solution. Inclusive cultural empathy recognizes that the same behaviors may have different meanings and that different behaviors may have the same meaning. By establishing the shared positive expectations between and among people, the accurate interpretation of behaviors becomes possible. The interpersonal cultural grid shown in Table 1.2 is useful in understanding how cultural differences influence the interaction of two or more individuals (Pedersen, 2000b). It is important to interpret behaviors accurately in terms of the intended expectations and values expressed by those behaviors. If two persons are accurate in their interpretations of one another’s expectations, they do not always need to display the same behavior. The two people may agree to disagree about which behavior is appropriate and may continue to work together in harmony in spite of their different styles of behavior. Table 1.2 provides a visual display of these relationships. In the first quadrant, two individuals have similar behaviors and similar positive expectations. There is a high level of accuracy in both individuals’ interpretations of one another’s behaviors and expectations. This relationship would be congruent and probably harmonious. We are focusing exclusively on positive expectations here. If the two individuals share the same negative expectations (“I hate you”) and behavior (attacking the other person), the relationship may be congruent but certainly not harmonious. In the second quadrant, two individuals have different behaviors (loud/soft, direct/indirect, casual/formal, and so on) but share the same positive expectations. There is a high level of agreement that the two people both expect trust and friendliness, for example, but there is a low level of accuracy because each person perceives and interprets the other individual’s behavior incorrectly. This relationship is characteristic of multicultural conflict, in which each person is applying a selfreference criterion to interpret the other individual’s behavior in terms of his or her own expectations and values. The conditions described in Quadrant II are very unstable, and unless the shared positive expectations are quickly made explicit, the relationship is likely to change toward that in Quadrant III. In the third quadrant, two people have the same behaviors but differ greatly in their expectations. There is actually a low level of agreement in positive expectations between the two people even though similar or congruent behaviors give the appearance of harmony and agreement. For example, one person may continue to expect trust and friendliness while the other person is secretly distrustful and unfriendly. Both persons are, however, presenting the same smiling, glad-handing behaviors. If these two persons discover that the reason for their conflict is their differences in expectations, and if they are then able to return their relationship to an earlier stage in which they did perhaps share the same positive expectations of trust and friendliness, for example, then their interaction may return to the type described by the second quadrant. This would require each person to adjust his or her interpretation of the other’s different behavior to fit their shared positive expectations of friendship and trust. If, however, their expectations remain different, then even though their behaviors are similar and congruent, the conflict is likely to increase until their interaction moves to one described by the fourth quadrant. In the fourth quadrant, the two people have different behaviors and also different or negative expectations. Not only do they disagree in their behaviors toward one another, but now they also disagree on their expectations of friendship and trust. This relationship is likely to result in hostile disengagement. They are at war. If the two persons can be coached to increase their accuracy in identifying one another’s previously positive expectations, however, there may still be a chance for them to return to an earlier stage of their relationship in which their positive expectations were similar even though their behaviors might have been very different, as in the second quadrant. The perspectives of two persons may be and usually are both similar (in expectations) and different (in behaviors). In this way, the interpersonal cultural grid provides a conceptual road map for inclusive cultural empathy to interpret another person’s behavior accurately in the context of that person’s culturally learned expectations. It is not always necessary for the counselor and the client to share the same behaviors as long as they share the same positive expectations. The psychological study of culture has conventionally assumed that there is a fixed state of mind whose observation is obscured by cultural distortions. The underlying assumption is that there is a single universal definition of normal behavior from the psychological perspective. A contrasting anthropological position assumed that cultural differences were clues to divergent attitudes, values, or perspectives that were different across cultures and based on culture-specific perspectives. The anthropological perspective assumed that different groups or individuals had somewhat different definitions of normal behavior resulting from their unique cultural contexts. Anthropologists have tended to take a relativist position when classifying and interpreting behavior across cultures. Psychologists, by contrast, have linked social characteristics and psychological phenomena with minimum attention to the diversity of cultural viewpoints. When counseling psychologists have applied the same interpretation to the same behavior regardless of the cultural context, cultural bias has resulted (Pedersen, 2000a). Try to imagine a dimension with conventional psychology anchoring the extreme end of the scale on one end and conventional anthropology anchoring the extreme other end of the scale. The area between these two extremes is occupied by a variety of theoretical positions that tend to favor one or the other perspective in part but not completely. There is a great deal of controversy about the exact placement of these theoretical positions. Multiculturalism encompasses a collection of different potentially salient perspectives all along the dimension. The Triad Training Model for Interpreting Self-Talk Our internal dialogues are perhaps the most meaningful indicators of our culture, as we listen to our different culture teachers, accepting some of those teachings and challenging others in our internal conversations with them. A measure of empathetic competence is the ability to “hear” what the client is thinking as well as talking about. The more cultural difference there is between the counselor and the client, the more difficult it will be for the counselor to hear what the client is thinking. The triad training model (TTM) helps prepare counselors to be more accurate in their hypotheses about what a culturally different client is thinking but not saying. In the triad training model, a four-person role-played interview is presented to a counselor trainee in which three conversations will be heard. First, the client and counselor will have a verbal conversation that they both hear. Second, the counselor will have her or his own internal dialogue exploring related and/or unrelated factors that the counselor can monitor but the client cannot hear. Third, the client will have her or his own internal dialogue exploring related or unrelated factors that the client can monitor but the counselor cannot hear. The counselor does not know what the client is thinking, but the counselor can assume that some of the client’s internal dialogue will be negative and some will be positive. Internal dialogue is not a new idea. The works of Vygotsky (1962) and Luria (1961) in Russia during the early 1930s on the connection between thought and behavior provided the basis for analyzing “private speech.” The idea of an inner forum (Mead, 1934), self-talk (Ellis, 1962), and internal dialogue (Meichenbaum, 1977) goes back at least as far as Plato, who described thinking as a discourse the mind carries on with itself. As mentioned earlier, each person’s behavior is influenced by as many as a thousand culture teachers in the client’s experiences. The triad training model provides limited access to the influence of these culture teachers by including a procounselor and an anticounselor in the role-played interview. Through immediate and continuous feedback from the anticounselor, the counselor hears the negative messages a client is thinking but not saying. Through continuous and immediate feedback from the procounselor, the counselor hears the positive messages a client is thinking but not saying. In the triad training model, the role of the anticounselor is deliberately subversive; the anticounselor exaggerates mistakes by the counselor during the interview by pointing out differences in behavior that drive the counselor farther apart from the client. The counselor trainee can be expected to gain insight in cultural self-awareness as perceived from the client’s culturally different viewpoint. The procounselor is a deliberately positive force to articulate the client’s positive unspoken messages that emphasize the common ground between the counselor and client. The persons who are role-playing the procounselor and anticounselor are ideally as culturally similar to the client as possible. As a result of participating in a role-played four-person TTM interview, the counselor can be expected to (a) see the problem more accurately from the client’s cultural viewpoint, (b) recognize culture-based resistance in specific rather than vague general terms, (c) reduce his or her need to be defensive when confronted by a culturally different client, and (d) learn recovery skills for what to do after having done the wrong thing with a culturally different client (Pedersen, 2000a, 2000b). Multiculturalism as a Fourth Force There is a great deal of controversy surrounding the term multicultural: “Thus, in the current debate, some advocates in the field strongly support the relevance and necessity of multiculturalism in theory and practice with diverse populations, whereas others have suggested that multiculturalism is of minimal importance and should be treated as a fringe interest so as not to interfere with ‘meaningful’ research and practice” (Reese & Vera, 2007, p. 763). In this chapter we suggest that multiculturalism influences psychotherapy to the same degree that humanism, psychodynamics, and behaviorism influenced psychotherapy in the past and that it therefore presents a “fourth” force or dimension to modern psychotherapy. A culture-centered perspective that applies cultural theories to the counseling process is illustrated in a book on multicultural theory by D. W. Sue et al. (1996). The book’s approach is based on six propositions that demonstrate the fundamental importance of a culture-centered perspective: ■ Each Western or non-Western theory represents a different worldview. ■ The complex totality of interrelationships in the client–counselor experiences and the dynamic changing context must be the focus of counseling, however inconvenient that may become. ■ A counselor or client’s racial/cultural identity will influence how problems are defined and dictate or define appropriate counseling goals or processes. ■ The ultimate goal of a culture-centered approach is to expand the repertoire of helping responses available to counselors. ■ Conventional roles of counseling are only some of the many alternative-helping roles available from a variety of cultural contexts. ■ Multicultural theory emphasizes the importance of expanding personal, family, group, and organizational consciousness in a contextual orientation. As these multicultural theory propositions are tested in practice, they will raise new questions about competencies of multicultural awareness, knowledge, and skill in combining cultural factors with psychological processes. How does one know that a particular psychological test or theory provides valid explanations for behavior in a particular cultural context? What are the cultural boundaries that prevent generalization of psychological theories and methods? Which psychological theories, tests, and methods can best be used across cultures? Which psychological theories, tests, and methods require specific cultural conditions? Culture is emerging as one of the most important and perhaps most misunderstood constructs in the contemporary counseling and psychotherapy literature. Culture may be defined narrowly as limited to ethnicity and nationality or defined broadly to include any and all potentially salient ethnographic, demographic, status, or affiliation variables (Pope, 1995). Given the broader definition of culture, it is possible to identify at least a dozen assets that are available exclusively through the development of a multicultural awareness of culture-centered psychology (Pedersen, 2000b; Pedersen & Ivey, 1993): ■ First, “accuracy,” because all behaviors are learned and displayed in a cultural context. ■ Second, “conflict management,” because the common ground of shared values or expectations will be expressed differently in contrasting culturally learned behaviors across cultures, and reframing conflict in a culture-centered perspective will allow two people or groups to disagree on the appropriate behavior without disagreeing on their underlying shared values. ■ Third, “identity,” as we become aware of the thousands of culture teachers we have accumulated in our own internal dialogues from both friends and enemies. ■ Fourth, “a healthy society,” through cultural diversity, just as, by analogy, a healthy biosystem requires a diverse gene pool. ■ Fifth, “encapsulation protection,” because we will not inappropriately impose our own culturally encapsulated self-reference criteria on others. ■ Sixth, “survival,” with the opportunity to rehearse adaptive functioning across cultures for our own future in the increasingly global village where we will live. ■ Seventh, “social justice,” because applying measures of justice and moral development across cultures helps us differentiate absolute principles from culturally relative strategies. ■ Eighth, “right thinking,” through the application of quantum thinking and complementarity, in which both linear and nonlinear thinking can be applied appropriately. ■ Ninth, “personalized learning,” because all learning and change involves some culture shock when perceived from a multicultural perspective. ■ Tenth, “spirituality,” because the multicultural perspective enhances the completeness of spiritual understanding toward the same shared ultimate reality from different paths. ■ Eleventh, “political stability” in developing pluralism as an alternative to either authoritarian or anarchic political systems. ■ Twelfth, a more “robust psychology,” because psychological theories, tests, and methods are strengthened by accommodating the psychological perspectives of different cultures. The “culture-centered” perspective describes the function of making culture central rather than marginal or trivial to psychological analysis (Pedersen, 2000b; Pedersen & Ivey, 1993). Much of the political controversy surrounding the term multicultural can be avoided by the culture-centered description without diminishing the central importance of culture to psychology. There is considerable resistance to characterizing multiculturalism as a “fourth force.” Tart (1975) claimed that transpersonal psychology was the “fourth force” in psychology, and transpersonal psychologists sometimes resent the movement to describe multiculturalism as a fourth force. Stanley Sue (1998) identified other sources of resistance to the term multiculturalism as a fourth force. He pointed out the tendency to misunderstand or misrepresent the notion of multiculturalism and the dangers of that misunderstanding. Since all behaviors are learned and displayed in a particular cultural context, accurate assessment, meaningful understanding, and appropriate intervention require attention to the client’s cultural or, perhaps better yet, multicultural context. All psychological service providers share the same ultimate goal of accurate assessment, meaningful understanding, and appropriate intervention, regardless of cultural similarities or differences. Conclusion We are at the starting point in developing culture-centered balance as the criterion for inclusive cultural empathy in our comprehension of effective counseling and psychotherapy. Only those who are able to escape being caught up in the self-referential web of their own assumptions and maintain a balanced perspective will be able to communicate effectively with persons from other cultures. The dangers of cultural encapsulation and the dogma of increasingly technique-oriented definitions of social services have been mentioned frequently in the recent rhetoric of professional associations in the social services as criteria for competence (Pedersen, Draguns, et al., 2008). Moodley and West (2005) attributed recent explorations of traditional ways of healing to failures in the ways that we are practicing multicultural counseling and psychotherapy. We think that such explorations are a direct result of the maturing of such practice and, as such, are not an attack on the fundamentals. Even the proponents of multicultural counseling are not immune to criticism for their failures to have a larger, more international worldview that transcends European American theories and techniques. The inclusive cultural empathy skills and approach that we have described here are a way forward. Mental health care providers and educators have pretended for too long that counseling and psychotherapy were invented in the last 200 years by European Americans in a Western cultural context. Successful global leadership by psychologists must come from an understanding of the complexity of our planet, of the limits of our own worldviews, and of the necessity for redefining our historically quite narrow interpretation of empathy. This, however, is only the beginning of cultural sensitivity and knowledge in our field. Arthur and Pedersen (2008) provided examples of 19 case incidents of counseling from different national contexts along with two reactions to each incident articulating positive and/or negative feedback to the counselor for how each case was presented. At least two dozen nontraditional approaches to counseling were included in the case examples incorporating indigenous characteristics of each context. One consistent theme throughout the book was the importance of balance in harmonizing relationships and discovering inclusive cultural empathy. The notion of balance is familiar in Asian cultures—for example, the harmonious tension between yin and yang and the female and male principles of Chinese philosophy. This emphasis on harmonious balance of forces once more underlines the basic theme of this chapter—understanding human behavior in Asian countries requires an understanding of relational units as an alternative to the individualistic assumptions of Western psychological theories (Kim, Yang, & Hwang, 2006). Inclusive cultural empathy as described in this chapter involves increased awareness to prevent false assumptions, increased knowledge to protect against incomplete comprehension, and increased skill to promote right actions. The temptation is to define boundaries in psychology artificially in a homogenization of theories or, worse yet, to impose an Americanization model that presents a partial perspective as the whole field, thereby excluding alternative perspectives. Psychology then becomes only a subset of national/political interests. While we cannot hope to accumulate all relevant knowledge across national/cultural boundaries broadly defined, we can still aspire to take on the complex task as best we can. The task of being inclusive is to acknowledge the validity of a complex and dynamic balance of tendencies that a competent counselor or psychotherapist can manage in order to measure competence. Like the Greek god Janus, who has two faces, one laughing and the other crying, the Janusian skills required for inclusive cultural empathy involve managing a comprehensive balance of essential similarities and differences at the same time. Our task is the saving of psychology from the psychologists! Special interests have come dangerously close to capturing and domesticating the field of psychology by excluding the inconvenient data from a larger international context. Mental health care providers and educators have pretended for too long that counseling and psychotherapy were invented in the last 200 years by European Americans in a Western cultural context. Successful global leadership by psychologists must come from an understanding of the complexity of our planet, of the limits of our own worldviews, and of the necessity for redefining our historically quite narrow interpretation of empathy. This, however, is only the beginning. References Airhihenbuwa, C. O. (1995). Health and culture: Beyond the Western paradigm. Thousand Oaks, CA: Sage. Arthur, N., & Pedersen, P. (Eds.). (2008). Case incidents in counseling for international transitions. Alexandria, VA: American Counseling Association. Ellis, A. (1962). Reason and emotion in psychotherapy. Oxford: Lyle Stuart. Geertz, C. (1975). On the nature of anthropological understanding. American Scientist, 63, 47–53. Gielen, U. P. (1994). American mainstream psychology and its relationship to international and crosscultural psychology. In A. L. Comunian & U. P. Gielen (Eds.), Advancing psychology and its applications: International perspectives (pp. 26–40). Milan: Franco Angeli. Ho, D. Y. F. (1999). Relational counseling: An Asian perspective on therapeutic intervention. Psychologische Beiträge, 41, 99–112. Howard, G. S. (2000). Adapting human lifestyles for the 21st century. American Psychologist, 55, 509–515. doi:10.1037/0003-066X.55.5.509 Hwang, K.-K. (2000). On Chinese relationalism: Theoretical construction and methodological considerations. Journal for the Theory of Social Behavior, 30, 155–178. doi:10.1111/14685914.00124 Hwang, K.-K. (2006). Constructive realism and Confucian relationalism: An epistemological strategy for the development of indigenous psychology. In U. Kim, K. S. Yang, & K. Hwang (Eds.), Indigenous and cultural psychology: Understanding people in context (pp. 73–107). New York: Springer. doi:10.1007/0-387-28662-4_4 Incayawar, M., Wintrob, R., & Bouchard, L. O. (2009). Psychiatrists and traditional healers: Unwitting partners in global mental health. Oxford: Wiley-Blackwell. Kağitçibaşi, Ç. (1996). Family and human development across cultures. Mahwah, NJ: Lawrence Erlbaum. Kim, U., Yang, K.-S., & Hwang, K.-K. (2006). Indigenous and cultural psychology: Understanding people in context. New York: Springer. Liu, J. H., & Liu, S. H. (1999). Interconnectedness and Asian social psychology. In T. Sugiman, M. Karasawa, J. H. Liu, & C. Ward (Eds.), Progress in Asian social psychology (Vol. 2, pp. 9–31). Seoul: Kyoyook-Kwahak-Sa. Luria, A. R. (1961). The role of speech in the regulation of normal and abnormal behavior. Oxford: Liveright. Marsella, A. J. (2009). Diversity in a global era: The context and consequences of differences. Counselling Psychology Quarterly, 22, 119–135. doi:10.1080/09515070902781535 Mead, M. (1934). The use of primitive material in the study of personality. Character & Personality, 3, 1–16. Meichenbaum, D. (1977). Dr. Ellis, please stand up. The Counseling Psychologist, 7, 43–44. Miller, D. T. (1999). The norm of self-interest. American Psychologist, 54, 1053–1060. doi:10.1037/0003-066X.54.12.1053 Moodley, R., & West, W. (2005). Introduction. In R. Moodley & W. West (Eds.), Integrating traditional healing practices into counseling and psychotherapy (pp. xv–xxvii). Thousand Oaks, CA: Sage. Nakamura, H. (1964). Ways of thinking of Eastern peoples: India, China, Tibet, Japan (Philip P. Wiener, Ed.). Honolulu: University of Hawaii Press. Pedersen, P. (2000a). A handbook for developing multicultural awareness (3rd ed.). Alexandria, VA: American Counseling Association. Pedersen, P. (2000b). Hidden messages in culture-centered counseling: A triad training model. Thousand Oaks, CA: Sage. Pedersen, P. B., Crethar, H. C., & Carlson J. (2008). Inclusive cultural empathy: Making relationships central in counseling and psychotherapy. Washington, DC: American Psychological Association. Pedersen, P. B., Draguns, J. G., Lonner, W. J., & Trimble, J. E. (2008). Counseling across cultures (6th ed.). Thousand Oaks, CA: Sage. Pedersen, P. B., & Ivey, A. E. (1993). Culture-centered counseling and interviewing skills: A practical guide. Westport, CT: Praeger. Pope, M. (1995). The “salad bowl” is big enough for us all: An argument for the inclusion of lesbians and gays in any definition of multiculturalism. Journal of Counseling & Development, 73, 301–304. Reese, L. R. E., & Vera, E. M. (2007). Culturally relevant prevention: The scientific and practical considerations of community-based programs. The Counseling Psychologist, 35, 763–778. doi:10.1177/0011000007304588 Ridley, C. R., & Lingle, D. W. (1996). Cultural empathy in multicultural counseling: A multidimensional process model. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (4th ed., pp. 21–46). Thousand Oaks, CA: Sage. Ridley, C. R., & Udipi, S. (2002). Putting cultural empathy into practice. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th ed., pp. 317–333). Thousand Oaks, CA: Sage. Santee, R. G. (2007). An integrative approach to counseling: Bridging Chinese thought, evolutionary theory, and stress management. Thousand Oaks, CA: Sage. Segall, M. H., Dasen, P. R., Berry, J. W., & Poortinga, Y. H. (1990). Human behavior in global perspective: An introduction to cross-cultural psychology. New York: Pergamon. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62, 271–286. doi:10.1037/0003-066X.62.4.271 Sue, D. W., Ivey, A. E., & Pedersen, P. B. (1996). Multicultural counseling theory. Belmont, CA: Brooks/Cole. Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Theory and practice (4th ed.). New York: John Wiley. Sue, S. (1998). In search of cultural competencies in psychology and counseling. American Psychologist, 53, 440–448. doi:10.1037/0003-066X.53.4.440 Tart, C. T. (1975). Some assumptions of orthodox, Western psychology. In C. T. Tart (Ed.), Transpersonal psychologies (pp. 59–112). New York: Harper & Row. Vygotsky, L. S. (1962). Thought and language. Oxford: John Wiley. Yang, K.-S. (1995). Chinese social orientation: An integrative analysis. In W. S. Tseng, T. Y. Lin, & Y. K. Yeh (Eds.), Chinese societies and mental health (pp. 19–39). Hong Kong: Oxford University Press. Yang, K.-S. (1997). Indigenising Westernised Chinese psychology. In M. H. Bond (Ed.), Working at the interface of cultures: Eighteen lives in social science (pp. 62–76). London: Routledge. Yang, K.-S. (1999). Towards an indigenous Chinese psychology: A selective review of methodological, theoretical and empirical accomplishments. Chinese Journal of Psychology, 4, 181–211. Yang, K.-S., Hwang, K.-K., Pedersen, P. B., & Daibo, I. (Eds.). (2003). Progress in Asian social psychology: Conceptual and empirical contributions. Westport, CT: Greenwood. Editors’ Note: Paul B. Pedersen received the Award for Distinguished Contributions to the International Advancement of Psychology. Award winners are invited to deliver an award address at the APA’s annual convention. The original article was prepared for presentation as an award address at the 118th annual meeting, held August 12–15, 2010, in San Diego, California. Articles based on award addresses are reviewed, but they differ from unsolicited articles in that they are expressions of the winners’ reflections on their work and their views of the field. The original reference citation is as follows: Pedersen, P. B., & Pope, M. (2010). Inclusive cultural empathy for successful global leadership. American Psychologist, 65(8), 841–854. Copyright © 2010 by the American Psychological Association. The article is reprinted as a chapter in this edited book with the permission of the American Psychological Association. 2 Counseling Encounters in Multicultural Contexts An Introduction Juris G. Draguns Primary Objective ■ To help make counseling both more effective and more culturally sensitive Secondary Objectives ■ To respond to the challenge of evidence-based treatments in counseling within and across cultures ■ To emphasize the importance of relationship-based aspects of culturally oriented counseling, such as the therapeutic alliance and empathy ■ To highlight the importance of cultural adaptations of counseling in delivering services to culturally diverse populations ■ To narrow the gulf between research and practice by encouraging the further investigation of independent versus interdependent self, individualism–collectivism across and within cultures, and other relevant topics ■ To integrate universal, cultural, and individual strands of counseling into a practically applicable model of delivering human services to a culturally heterogeneous population Preliminary Considerations The Nature of Counseling In Laungani’s (2004) pithy definition, the gist of counseling has been equated with “helping people to help themselves” (p. 97). Although the contemporary repertoire of counseling interventions features a great many specific and directive techniques, its ethos remains unchanged: Counseling is principally concerned with facilitating, rather than more directively bringing about, adaptive coping in order to alleviate distress, eliminate dysfunction, and promote effective problem solving and optimal decision making. The more general and ambitious objectives of counseling are the fulfillment of personal aspirations and the actualization of personal potentials. Counseling achieves all of these goals by marshaling the person’s own resources while scrupulously trying to avoid the imposition of the counselor’s solutions, values, and attitudes on the client. The counselor’s role can then be likened to that of a catalyst; his or her actions are geared to help the counselee seek, find, and apply his or her own most fitting answers to the dilemmas of living. Together with the gamut of overlapping and interrelated human helping services, such as psychotherapy, guidance, and personal coaching, counseling is prototypically an interpersonal experience between a professional counselor and a help-seeking counselee.1 Encounter and dialogue are the two cardinal features of counseling. Counseling proceeds between two (or sometimes more than two) individuals and is embedded in distinctive sociocultural milieus. Each participant in a counseling project brings to it his or her assumptions, expectations, aspirations, and apprehensions, and many of these are widely shared within the participants’ respective cultural settings. The cultural component, then, can be plausibly construed as an interpersonal experience between a counselor and a counselee extended over time, in which culture is the third, implicit and silent, yet essential, participant (Draguns, 1975). Two Canadian psychologists, Arthur and Collins (2010), have introduced the new term cultureinfused counseling, which they describe as “the conscious and purposeful infusion of cultural awareness and sensitivity into all aspects of the counseling process” (p. 18). This definition is especially apposite to the culturally diverse environments in Canada and the United States that are the focus of this book, which is primarily addressed to and designed for the practitioners and students of counseling in these two countries who work with culturally diverse clienteles. Multicultural Diversity: The Populations to Which It Pertains Cultural diversity is prominently manifested in the provision of counseling services to persons in the major ethnoculturally distinctive groupings—Native Americans, Asian Americans, African Americans, Latina/os, and Arabs and other Middle Easterners—to which Chapters 5–9 are devoted. Challenging and stressful cultural transitions across time and space, exemplified by voluntary migrations or forcible displacements, discussed in Chapter 15, and by extended sojourns abroad by international students, discussed in Chapter 14, bring to the fore special problems in counseling and demand innovative solutions. So do the experiences of trauma and disaster, naturally caused or human-made, that are addressed in Chapter 16. Population segments that have been historically excluded from full participation in the American culture, such as lesbians and gays, now seek to assert themselves in dignity and freedom and to benefit from appropriate and sensitive counseling services, as discussed in Chapters 10 and 13. Programs have also been developed and applied to the broader categories of culturally marginalized persons, addressed in Chapter 11, and even though the population of North America and elsewhere is more or less evenly divided between males and females, counseling and other helping services began as a male-dominated endeavor. The current state of the efforts to correct this imbalance is the subject of Chapter 10, while the special problems and challenges in counseling families are presented in Chapter 21, and those encountered in the school setting are the focus of Chapter 12. The process of acculturation, or coming to terms with a new and different culture, is the subject of Chapter 18. Finally, the authors of Chapter 19 remind us that not only psychological but also physical symptoms are the result of the interaction between stressful experiences and ethnocultural factors as they present a rich panorama of research approaches and findings. The Ubiquity of Cultural Concerns Pressing as these various concerns are, they do not exhaust the relevance of culture in the conduct and delivery of counseling services. Especially in countries such as the United States and Canada, composed of both native populations and multiple waves of immigrants over several centuries, several strands of cultural memory and tradition intertwine in complex and unique ways to shape experience, conduct, and adaptation. Oftentimes, these threads find their way into counseling encounters. Paul Pedersen has proposed that culture is transmitted by a multitude of culture teachers. His key statement, from the introduction to the sixth edition of Counseling Across Cultures, is reproduced here: Capture the visual image of a thousand persons sitting around you. People that you have chosen, or have chosen you, over a lifetime from friends, enemies, heroes, heroines, mentors, family members, and fantasy figures that influenced you in sometimes subtle but often profound ways. As these “culture teachers” talk with one another and sometimes include you in their conversations, they provide a vivid and concrete image of “multiculturalism.” Many if not all our decisions are controlled or at least influenced by imagined conversations with our culture teachers. They broadly define the cultural context in which we live through ethnographic, demographic, status-oriented, and personal affiliations. All behaviors are learned and displayed in specific cultural contexts. (Pedersen, Draguns, Lonner, & Trimble, 2008, p. xi)2 In the course of culturally sensitive counseling the lessons of culture teachers are brought to light, disentangled, reassembled, and integrated, presumably in the service of a more fulfilling selfexperience and more effective coping. Thus, all personal counseling stands to benefit from cultural exploration and inquiry, and culturally sensitive services should become the norm in North America and throughout the multicultural societies of the world. Assessment procedures should not only encompass a person’s family background but also attempt to incorporate some of the diverse threads of cultural influence, perhaps by expanding on Kleinman’s (1992) “Eight Questions” and, more generally, on knowledge-based assessment procedures, as discussed in greater detail in Chapter 3. The Scope of This Chapter Beyond the specific concerns related to assessment, this introductory chapter seeks to identify the humanly universal, culturally distinctive, and personally unique aspects of counseling. In pursuit of this goal, I shall attempt to convey information on recent developments in the investigation of counseling and psychotherapy, especially as these pertain to cultural variations. I will introduce and partially explicate the complexities of the concept of culture and then proceed to deal with some of the key features of multicultural counseling, especially as they pertain to the self, individualism, and other cultural dimensions and personality traits. I shall then conclude by attempting to integrate the current state of knowledge on counseling with the culturally diverse North American environment. Cultures: Multiple, Complex, National, and Global Culture is a complex concept with an elusive core and fuzzy boundaries. Most social scientists start with two prototypes: the traditional tribal cultures investigated by the pioneering anthropologists of the 19th and 20th centuries, and the cultures of the current and historic nation-states, from Somalia to Iceland and from Thailand to Portugal. In both cases, culture refers to the distinctive, human-made part of the environment (Herskovits, 1948) that encompasses both the artifacts created by the human species and the mental products that have accrued over many millennia. Marsella (1988) has elaborated on these two aspects as follows: “Shared learned behavior which is transmitted from one generation to another for purposes of individual and societal growth, adjustment, and adaptation, culture is represented externally as artifacts, roles, and institutions, and is represented internally as values, beliefs, attitudes, epistemology, consciousness, and biological functioning” (pp. 8–9). Consonant with the above statement, Hofstede and Hofstede (2005) have equated culture with the “software of the mind,” and Brislin (2000) has construed culture as enabling its members to fill in gaps in their observations and impressions on the basis of shared and accumulated knowledge and experience. As described, the concept of culture is primarily applicable to the geographically removed and linguistically separate national cultures, including that of the United States. The term culture is, however, also frequently extended to the ethnically, linguistically, and/or racially distinctive segments of the American society. Thus, we often refer to Mexican Americans, Lebanese Americans, and other groups, labeled on the basis of their historical and linguistic descent. In dynamic multicultural societies an additional issue must be faced. Individuals in Canada, the United States, and other pluralistic countries have been socialized both within their respective ethnocultural milieus and within the inclusive national culture. Thus, multiculturalism exists not only in interpersonal contacts but in intrapsychic experience as well. In the course of counseling, it is important for the therapist to ascertain the impact on the client of both the generic or dominant American culture and the person’s distinctive cultural heritage. Finally, globalization is a vague, if often invoked, term that refers to a number of trends toward worldwide convergence and homogenization that often engender a sense of insecurity and threat and pose a challenge to traditional modes of adaptation rooted in specific cultures. Globalization may first affect persons whose work and family lives require shuttling between two or more sites in as many countries, with concurrent demands to adapt to several cultures and to balance simultaneously multiple contacts, practices, and relationships. Such situations may tax the resources of even highly adaptable and flexible individuals (Hermans & Kempen, 1998). At the same time, the speed and spread of global communications technology produces virtually instant opportunities for awareness, contact, and communication, generating something like a virtual global village that in the optimal case could provide meaningful sources of needed personal, social, and economic support (Marsella, 1998). Although there has been much speculation on the pathogenic and maladaptive consequences of globalization, I have not yet seen any systematic clinical documentation of such problems. Culturally Oriented Counseling: Its Current State Evidence-Based and/or Culturally Sensitive Services: Isolation, Divergence, or Integration The last decade and a half has been an eventful period in the development, adaptation, and application of culturally sensitive services. At the beginning of the new millennium, Hall (2001) noted a curious disjunction in the field of culturally sensitive mental health services: Empirically supported treatments had only rarely been investigated for their effectiveness in culturally diverse populations, while culturally adapted treatment approaches had been infrequently subjected to examination concerning their efficacy and effectiveness. More than a decade later, this gulf has begun to be bridged. Two developments should be noted: Evidence-based treatments (EBTs) have spread and multiplied, making the uniform application of therapeutic procedures feasible across space and time (APA Presidential Task Force on Evidence-Based Practice in Psychology, 2006; Chambless & Ollendick, 2001; Kazdin, 2008; Norcross, 2011), and meta-analyses of culturally modified psychotherapy programs have demonstrated a moderately strong contribution of culture to the effectiveness of psychotherapy (Griner & Smith, 2006; Huey & Polo, 2008; Smith, Domenech Rodríguez, & Bernal, 2011). The details of these findings are the central topic of Chapter 4, and I will also address their implications later in this chapter. At first glance, culturally oriented counseling appears to be simultaneously pulled in two opposite directions: toward homogeneity and toward cultural variability. To elaborate, in some observers’ minds EBT is prototypically equated with the standardized and manualized application of therapy techniques. At the same time, cultural adaptations of therapy evoke, perhaps in an oversimplified manner, a thoroughgoing transformation of the therapist’s modus operandi in both techniques and conceptions of psychotherapy. In fact, there are a lot of shades of gray between these two extremes and a lot of room for rapprochement and convergence. The official and oft-quoted definition by the APA Presidential Task Force on Evidence-Based Practice in Psychology (2006) describes EBPP as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preference” (p. 273). Culture has been explicitly incorporated into this statement as a contextual variable that must be taken into account in the actual application of EBTs. Norcross and Wampold (2011a) conclude that “evidencebased practice rests on three pillars: best available research, clinical expertise (of the practitioner), and patient characteristics. In fact, evidence-based practice resides at the intersection of overlap of these three evidentiary sources. The patient, the therapist and the research all need to be in an alignment on the same page” (p. 27). It should be added that the patient (or client) characteristics within this triad prominently include those mediated by the individual’s ethnocultural background and experience. Norcross and Wampold (2011b) completed a prodigious number of meta-analyses of psychotherapy in order to identify “relationships that work.” To this end, they ascertained the effect sizes for the numerous likely components of the therapy relationship. The results point to empathy and the therapeutic alliance as the two major contributors to variance, both of them moderate in size. These two variables appear to be linked to culture, a point that remains to be explored further. Relationships That Work: The Therapeutic Alliance The therapeutic alliance is a venerable clinical concept that is traceable to Freud’s pioneering contribution, although it has acquired increasing prominence as a subject of systematic research over the last four decades (Horvath, Del Re, Fluckinger, & Symonds, 2011). According to Horvath et al. (2011), the therapeutic alliance encompasses the constructive, reality-based, aspects of the relationship between the therapist (or counselor) and the client. Bordin (1976) describes its three interconnected foundations: agreement on therapeutic goals, consensus on the tasks that make up therapy, and a bond between the client and the therapist. In counseling relationships that are established across a cultural barrier, a special effort may be required to assure a collaborative stance on these three issues. For example, an anxious, confused, highly traumatized immigrant may be intensely motivated to seek immediate relief and may be baffled and confused by the therapy process, including the quest for biographical and personal information. “What does that have to do with my feeling wretched and miserable, helpless and inadequate?” he or she may well ask. Wolfgang Pfeiffer (1996), a prominent German transcultural psychiatrist, identified several clashes of expectations between Turkish guest workers and German therapists. The clients sought relief from counseling here and now; their therapists insisted on a more extensive exploration. The clients also expected authoritative guidance and directions; their therapists emphasized personal choices. The clients expressed distress in somatic terms (see Chapter 19); their therapists focused on feelings and personal experiences. A therapeutic alliance may be difficult to establish because of lack of trust on the part of ethnocultural and racial minority members, who in many instances may have experienced rejection, insensitivity, and misunderstanding from majority group members, including those in the helping professions (Sue & Sue, 2008). Being interviewed by a member of one’s own cultural group may facilitate the formation of a therapeutic alliance, especially in its early stages. Recent case studies of two women, a severely traumatized American Indian (King, 2012) and an anxious Mexican immigrant (Salgado, 2012), illustrate the confidence-building process during and following intake that helps to solidify the therapeutic alliance. In both cases, therapists expanded their roles to include active advocacy on behalf of their clients; such action is often helpful in demonstrating the genuineness of a therapist’s concern for the client’s well-being. On the therapeutic plane, it is important to separate the therapeutic alliance from the better-known, but less rational and conscious, manifestations of transference and countertransference that may obtrude upon and complicate the therapeutic relationship and may require resolution. The results of metaanalyses, though based on a small number of studies, suggest that ruptures of the therapeutic alliance should be promptly repaired; uncorrected disruptions of the tie between the therapist and client may lead to further, cumulative, complications (Safran, Muran, & Eubanks-Carter, 2011). Empathy: A Pivotal Component of Therapeutic Influence In further meta-analyses, therapist’s empathy with the client, broadly defined as the ability to tune in to and experience and communicate another individual’s emotional and cognitive states, was found to be a moderately strong predictor of therapy outcome (Elliot, Bohart, Watson, & Greenberg, 2011). Rogers (1957) posited the experience and communication of empathy as one of the necessary conditions of therapeutic personality change, and empathy has had a history of investigation extending over several decades (Bachellor & Horvath, 1999; Bohart & Greenberg, 1997; Draguns, 2007; Duan & Hill, 1996). Empathy has transcended the phenomenological framework within which it originated and is now widely recognized as a major active ingredient of psychotherapy and counseling by psychologists of diverse theoretical orientations (Clark, 2007). Several aspects of empathy may differ across cultures. Heinz Kohut (1971), the foremost psychoanalytic conceptualizer of empathy, proposed that empathy declines as the agents and recipients of therapy become less similar, and in my own work I have suggested that empathy may not travel well beyond the empathizer’s accustomed sociocultural milieu (Draguns, 1973). These assertions have not yet been systematically or rigorously tested in cultural counseling or psychotherapy situations. Practitioners should be observant and perceptive of the vicissitudes of communicating and experiencing empathy in culturally relevant helping relationships, yet be cautious and tentative in their case-based conclusions. Researchers have made noteworthy contributions in helping practitioners to employ empathetic sensitivity and responsiveness beneficially across cultural gulfs and barriers. Scott and Borodowsky (1990) developed a training procedure for enhancing culturally sensitive therapy by means of role taking. They also introduced techniques designed to overcome obstacles based on unfamiliar language styles, distinctive ethnic identities, divergent expectations, and discrepant values and worldviews. Ridley and Udipi (2002) have urged counselors to address and work through any prejudices they may harbor against some or all of their culturally diverse clientele, some of which may be hidden but deeply ingrained in cultural environments in which, until recently, discriminatory practices and prejudicial attitudes were the norm (Sue & Sue, 2008). Even though stereotyping should not be equated with prejudice (see Jussim, McCauley, & Lee, 1995), Ridley and Udipi (2002) warn against unchecked stereotyping of social and cultural groups in the course of counseling a culturally diverse clientele. More recently, Ridley, Ethington, and Heppner (2008) broke new ground in helping counselees explore their place in the world in order to confront their cultural values and identify and resolve conflicts within them. These novel and possibly controversial extensions of the concept of empathy go well beyond the classic modes of intuitively experiencing and communicating empathetic understanding. In a sense, the techniques that encourage counselees to work toward the development of coherent cultural value systems within themselves anticipate Pedersen, Crethar, and Carlson’s (2008) development of inclusive cultural empathy (ICE) as a series of systematically trainable counseling skills. The details of this major contribution are presented in Chapter 1. It should be pointed out, however, that ICE constitutes the first set of empirically pretested training procedures that make it possible for counselors to incorporate empathy systematically as a major culturally sensitive component of therapeutic influence. ICE is explicitly designed to scale all cultural barriers: ethnic barriers to be sure, but also those based on race, gender, class, sexual orientation, disability, and stigma. Thus, empathy has been transformed from a somewhat unpredictable, spontaneously occurring, phenomenon into a set of interpersonal competencies that can be systematically applied in counseling and elsewhere without any loss of authenticity in the process. In line with this recognition, Elliott et al. (2011) state: “We encourage psychotherapists to value empathy as both an ‘ingredient’ of a healthy therapeutic relationship as well as a specific response that strengthens the self and deeper exploration” (p. 147). The Impact of Culture on Mental Health Services Cultural accommodation of mental health services is increasingly being implemented in the United States and elsewhere (McCabe & Christian, 2011; Tanaka-Matsumi, 2011). Until recently, however, there was relatively little information on the effectiveness of such procedures. Griner and Smith (2006) completed a landmark meta-analysis of 76 studies of culturally adapted mental health treatment programs with a total of 25,255 participants. Exceeding expectations, they obtained an average random effect size of 0.45, indicative of a moderately strong effect of culturally modifying mental health treatment programs. The implications of these findings are thoroughly discussed in Chapter 4. At this point it is worth noting that the effects on outcomes were more substantial when the adaptations were targeted to ethnoculturally specific groups rather than to a generic composite of various ethnicities. Moreover, interventions offered in the client’s first or preferred language were twice as effective as those that were presented in English. Griner and Smith’s (2006) findings were confirmed and extended in further meta-analyses by Smith et al. (2011), who found that the effectiveness of adapted treatment programs increased with the greater number of cultural adaptations. Smith et al. also reported that older clients and Asian Americans were more responsive to culturally adapted treatments than other segments of the culturally and demographically diverse research population, and they concluded that “culturally adapted mental health services are moderately superior to those that do not explicitly incorporate cultural considerations and should be considered EBPs” (p. 172). McCabe and Christian (2011) distinguish three degrees of such adaptation, from minimal, in which only a few features, such as language and interpersonal style, are adjusted to clients’ needs and expectations, through substantial modifications of a great many therapy techniques, to treatment programs that incorporate culturally meaningful and fitting components that are unique to a circumscribed cultural milieu. As yet there are no systematic data indicating what degree of modification is optimal for what kind of group with what kinds of treatment needs and presenting problems. In the initial interview, these options must be faced, negotiated, and bilaterally resolved on the basis of the client’s needs and expectations and the counselor’s professional expertise and judgment (Tanaka-Matsumi, 2011). Culturally Adapted Cognitive-Behavioral Therapy and EBT: A Case of Convergence A remarkable degree of affinity exists between EBTs and the modi operandi of the investigators and practitioners of cognitive-behavioral therapy (CBT). A high proportion of techniques designated as EBTs for specific categories of mental disorder are CBTs (Roth & Fonagy, 2005; Tanaka-Matsumi, 2011). Both CBTs and EBTs proceed from the same premise: They are based on systematic collection of empirical data, and they eschew speculation. Functional analysis is the privileged procedure in CBT; it involves pinpointing links between a person’s behavior and her or his environment or, more specifically, between a response and its antecedents and consequents. The major tool for investigating EBTs is meta-analysis; its objective is to establish the relationship between the components of psychotherapy and outcome. In preparing for the application of culturally sensitive CBTs, van de Vijver and Tanaka-Matsumi (2008) proposed systematically collecting comprehensive information on such topics as cultural identity and acculturation, conflict over values, modes of expressing distress, explanations of causes of presenting problems, metaphors of health and well-being, motivation for change, and social support networks. This information is elicited by means of the Culturally Informed Functional Assessment (CIFA) structured interview schedule (Tanaka-Matsumi, Seiden, & Lam, 1996). Its originators regard CIFA as a process of negotiating between the therapist and the client that continues throughout CBT. An extensive body of writing has accrued on the adaptation of CBT to the various ethnically distinctive components of the U.S. population (Hays & Iwamasa, 2006; Hinton, 2006; Hwang, Wood, Lin, & Cheung, 2006; Tanaka-Matsumi, 2008, 2011; Tanaka-Matsumi, Higginbotham, & Chang, 2002). Collectively, these studies document the variety of flexible and innovative uses of the cognitive-behavioral framework with culturally diverse help seekers, many of whom have found themselves in new and unfamiliar environments as refugees and immigrants. Thus, traumatized Cambodian and Vietnamese newcomers present a mixture of somatic and mental symptoms with many folk explanations that therapists should take seriously and use as points of departure in initiating CBT and monitoring its effects (Hinton, 2006). Beyond CBT, the notion of assessment as a process that is contiguous with treatment and not just a prelude to it is consistent with the basic tenet, discussed in Chapter 3, of regarding the counselee as an active participant in, rather than an inert object of, preintervention planning. The counselee voluntarily contributes information; he or she does not passively allow the counselor to extract it. Objectives and procedures of counseling are decided jointly through negotiation and explanation rather than imposed on the basis of the counselor’s authority or expertise. EBT and Culturally Sensitive Approaches: Toward Resolving Issues and Arriving at Conclusions Across several theoretical frameworks of service delivery, Gallardo, Parham, Trimble, and Yeh (2012) endorse evidence-based practice in psychology for the culturally diverse portions of the counseling clientele, with the proviso that EBPP be initiated from the bottom up and be developed on the basis of observations and data within the communities in which the clientele resides. Gallardo, Parham, et al. warn against the top-down importation of EBTs developed within the mainstream Caucasian American culture without modification or pretesting at the new site. The skills identification model (SIM) that these authors propose aspires to provide the highest standard of service for counseling and mental health services for the culturally distinctive segments of the U.S. population. In their edited book, Gallardo, Yeh, Trimble, and Parham (2012) include 10 case studies and eight general chapters that illustrate SIM and elaborate on it. It is impossible to do justice to this complex and multifaceted model within the scope of the present chapter. Gallardo, Parham, et al. (2012) emphasize that, within SIM, social issues of justice and power are considered inseparable from personal concerns with competence and well-being. Particularly informative and useful for both majority and minority counselors is Gallardo, Parham, et al.’s Table 1.1, which is designed to represent the five domains of cultural characteristics (pp. 9–11). A major dilemma that confronts counselors and clinicians in applying EBTs has been pointed out by Zeldow (2009). Especially when EBTs involve prescriptive manualized application and when they are used in preference to other, less empirically grounded forms of intervention, reliance on EBTs reduces flexibility, interferes with spontaneity, and impedes reflection, which, according to Zeldow, is the crux of the therapist’s activity. The professional judgment of a seasoned counselor may supersede the research-validated course of action recommended in EBT, especially in the unforeseen and ambiguous situations that are inevitably encountered in therapy. Zeldow’s points are not explicitly advanced in relation to helping services for culturally distinctive clients, but they are relevant to such services. As Petermann (2005), a German psychologist, has stated, EBTs should be an aid, not a shackle. They should enable, and not constrain, professionals working with a multicultural clientele. In fairness, however, it should be added that through their brief history EBTs have grown in flexibility and have in large measure transcended their early limitations. The tension between technique and relationship and between rules and context, articulated as a major theme of psychotherapy conceptualization and research by Wampold (2001), has not been definitively resolved, although the balance has been tipped toward context and flexibility. Yet, as Norcross and Wampold (2011b) remind us, “practitioners can become overly flexible without any research evidence or when adapting a treatment in ways that would markedly deviate from its established effectiveness. While the research supports adaptation in many cases, the research also recommends fidelity to treatments as found effective in controlled research. We need to balance flexibility and fidelity” (pp. 428–429). Specifically, Norcross and Wampold encourage practitioners to adopt a person-centered, open-ended style of inquiry combined with readiness to adapt interventions to clients’ needs. There are also therapy relationships and techniques that demonstrably do not work and should be avoided. These include confrontation as well as expressions of hostility, criticism, rejection, or blame. Moreover, such interventions may have especially negative consequences in multicultural contexts, laden as they are with the potential for misunderstanding and the risk of premature termination. Further, some clients may require more information and guidance about the specifics of the counseling experience, while others may want to cut short such preliminaries. In general, the less familiar the nature of the service and its setting, the greater the need for the initial orientation. In no case should the counselor authoritatively and unilaterally impose the structure on the client. Counseling in Multicultural Contexts: An Overview of General Issues The preceding sections emphasized counseling with the multicultural clientele of the contemporary United States. I now propose to shift the perspective and proceed from counseling to the person. To this end, I introduce below the central concept of the self, followed by individualism and other interfaces between the person and culture. I shall then conclude with the presentation of an integrative model of counseling and psychotherapy within culture. Self in Culture The self is a key concept at the borderline between psychology and philosophy. It is not amenable to observation or measurement and is exceedingly difficult to define. William James’s (1891/1952) classical description of the self as “all that a person can call his” (p. 188) is overinclusive and bears the mark of its place and time. Contemporary psychologists have generally shied away from this task and have less ambitiously limited themselves to defining the self-concept. Miserandino (2012) simply describes the self as “the set of ideas and inferences we hold about ourselves” (p. 405). In cultural psychology what matters is not only the nature or content of the notions of the self but also the mode and manner of how they are held. A multiplicity of proposals, presented in greater detail in Chapter 3, have sought to capture the characteristic features of self-construal and self-experience across cultures. One of the most farreaching and influential such formulations, by Markus and Kitayama (1991, 1998), juxtaposes the independent or autonomous self purportedly prevalent in Euro-American countries with the interdependent or relational self-concept that allegedly holds sway in East Asia and in many other non-Western regions of the world. This contrast should not be regarded as dichotomous or absolute. Rather, these two modes of experiencing oneself are expected to vary in prevalence in their respective regions. Over the past several decades, the contrast between the interdependent self and the independent self has dominated conceptualization and investigation in cross-cultural psychology and has spilled over into applied areas, including counseling and psychotherapy. It is not yet known to what extent this axis of appraisal is pertinent to the ethnocultural macrocosm of North America. In their summary representation of cultural characteristics of the five principal nonmajority groups in North America (African, Latino/a, Asian, American Indian, Middle Eastern), Gallardo, Parham, et al. (2012) assign an interpersonal orientation and imply a relational self to all of these population segments. This characterization should be regarded as plausible but hypothetical. It should be seriously and systematically pursued in both research and practice without any assumptions regarding the universality of interpersonal self experience in all clients of these ethnic backgrounds. In metaphorical terms, the interdependent self can be likened to a bridge, and the independent self, to a wall; the former connects, the latter separates (Chang, 1988). The independent self is crystallized, explicit, differentiated, and slow and difficult to change; the interdependent self is malleable in response to situations and experiences. Interdependent selves are primarily based on bonds, allegiances, and commitments to persons, families, and communities; independent selves shelter the unique attributes of the person. In the multicultural context of the United States conflict may be experienced within the person, pitting the nationally dominant push toward independence against the predilection for interdependence favored within the individual’s ethnocultural group. Alternatively and more benignly, the two strands of self-construal may coexist within the person and may be integrated into his or her personality and identity. Thus, a person may feel “American” in his or her strivings for the realization of professional goals and personal aspirations and may at the same time experience a virtually inextricable sense of belonging to his or her nuclear and extended family and ethnic community. Individualism–Collectivism in Persons and Cultures In one of the largest psychological studies ever conducted, both in numbers of participants and in numbers of countries included, Geert Hofstede (1980), an international industrial organizational psychologist based in the Netherlands, succeeded in identifying four statistically independent factors that accounted for intercountry differences in work-related values. In the ensuing decades, Hofstede’s findings sparked worldwide interdisciplinary research on the correlates of these four dimensions and their implications. More than 20 years after the appearance of his original monograph, Hofstede (2001) reviewed and interpreted the aggregate of these accumulated findings. Of the four factors that Hofstede identified, the bipolar axis of individualism–collectivism has generated the greatest amount of interest among researchers and theoreticians alike. In the words of Hofstede and Hofstede (2005), “Individualism pertains to societies in which the ties between the individuals are loose; everyone is expected to look after himself or herself and his or her immediate family. Collectivism as its opposite pertains to societies in which persons from birth onward are integrated into strong cohesive in-groups which throughout people’s lifetimes continue to protect them in exchange for unquestioning loyalty” (p. 78). Across nations, the United States leads the pack in individualism, followed by Australia, the United Kingdom, Canada, the Netherlands, and New Zealand. East Asian, Middle Eastern, most Latin American, and several Mediterranean cultures cluster toward the collectivistic end of the continuum. In my own work, I further hypothesized that counseling in individualistic cultures would be focused on intrapsychic factors and would aim at increasing self-understanding or insight; counselors in collectivistic settings would place emphasis on social harmony and on enhancing intrafamilial and other close human relationships (Draguns, 2004). Individualists’ counseling experiences would revolve around the uniqueness and primacy of the counselees’ inner lives, while the collectivists’ concerns would center on social acceptance and harmonious human relationships. These predictions, however, have not been systematically or extensively tested. In addition to Hofstede’s research, another major investigator in social psychology, Harry Triandis (1995), has pursued a systematic program of studies on individualism–collectivism for several decades. According to Triandis, collectivism holds a number of advantages in social interaction within small groups, such as teams and families. Individualists, in contrast, tend to function more effectively in impersonal institutions such as corporations and government offices. However, they tend to be susceptible to alienation and loneliness, whereas collectivists may feel thwarted in the realization of their personal aspirations. Triandis (1995) has observed that “we need societies that would do well both in the citizen-authorities and person-to-person fronts, that provide both freedom and security, that have something for their most competent members, but also for the majority of their members” (p. 187). This reasoning also applies to counseling. It may be helpful for counselors to encourage some of their individualistic, but unfulfilled, clients to become more aware of their submerged and overlooked affiliative strivings, while their collectivistic counterparts may derive benefit from working toward the realization of their habitually subordinated individualistic aspirations. Historically, an individualistic ethos has been deeply ingrained in American counseling since its inception (Katz, 1985). Pioneers of American counseling proceeded from the assumption that individuals are the primary recipients of intervention and that they are responsible for their circumstances. In the counseling process, the individual is helped to exercise mastery over the environment. Thus, independence and autonomy are prized; personal problems are construed as intrapsychic and are often traced to the formative socialization experience early in life. Counseling is viewed as work that requires energy, effort, and perseverance. Passivity is decried and interdependence de-emphasized. These values may sometimes be imposed on counselees whose socialization may not be compatible with them. Culturally sensitive counselors urge greater awareness of the assumptions on which mainstream American culture rests. They advocate an open-ended and flexible counseling process in which counselees set their own goals proceeding from their cultural outlooks, sometimes coupled with a recognition of the need to come to terms with the expectations of the mainstream culture. These recommendations are consonant with the suggestions developed earlier in this chapter on the basis of recent research on promoting effective therapy relationships. Hofstede’s Other Dimensions A few words should be added about Hofstede’s other four dimensions. Although the relevance of these four factors for the realm of counseling and psychotherapy has not yet been demonstrated, predictions have been made about the roles they may play in clinical practice (Draguns, 2008). These will be spelled out below. First, however, these dimensions must be defined. To this end, we turn to Keith’s (2011) concise and informative description: PD [power distance] reflects the degree to which the group members accept an unequal distribution of power, or the difference in power between more or less powerful members of the group; UA [uncertainty avoidance] is the degree to which a group develops processes to reduce uncertainty or ambiguity, or to deal with risk and unfamiliarity in everyday life; MA [masculinity] is the extent to which gender roles and distinctions are traditional, and masculine (e.g., aggression) or feminine (e.g., cooperation) traits are viewed favorably; and LTO [longterm orientation] suggests the level of willingness of members of the culture to forego short-term rewards in the interest of long-term goals. (p. 13) I have posited that high PD would be expected to be associated with emphasis on counselors’ officially recognized expertise, authority, and credentials, and low PD with emphasis on such personal qualities as authenticity, egalitarianism, and informality (Draguns, 2008). High PD and social distance would go hand in hand, as would low PD and low social barriers. High UA would bring with it the valuation of scientifically demonstrated effectiveness of treatment, with comprehensive and rigorous legal and administrative control over counseling services. I would venture the prediction that biologically or behaviorally oriented interventions would hold sway over psychodynamic and humanistic ones. At the low end of UA, a multiplicity of orientations would not only be accepted but also celebrated, along with subjective, intuitive, and artistic approaches to human services. High-MA cultures would promote responsibility, conformity, competence, and efficiency; in low-MA or feminine cultures, caring, sensitivity, and compassion would be cultivated. High LTO would concentrate on social harmony and self-subordination; low LTO (or short-term orientation) would accord greater importance to subjective experience, self-assertion, and the pursuit of pleasure. These ideas, however, remain to be subjected to systematic research scrutiny. Toward Integrating Universal, Cultural, and Individual Threads in Counseling Leong (1996) has reminded us of Kluckhohn and Murray’s (1949) dictum that each person is like all other persons, like some other persons, and like no other person. The interplay of the universal, cultural, and individual components poses a special challenge for a counselor dealing with a culturally heterogeneous clientele. In response to this challenge, Leong (1996) has proposed and Leong and Lee (2006) have expanded a comprehensive model of counseling and psychotherapy. In their formulation, culture accommodation is focused on two variables that have also been emphasized in this chapter: self-construal and individualism–collectivism. To these, Leong and Lee have added the person’s current and specific self-defined identity and his or her communication style, high or low in context. High-context communication is characterized by avoidance of confrontation and of verbal assertiveness; low-context communication features a freer, more spontaneous, and less controlled style of expression. Leong (1996) cautions counselors against imputing homogeneity or similarity to their clients from a specific ethnocultural group. At the same time, he emphasizes complementarity, which calls for a differentiated and fitting response to the needs that a counselee brings to the counseling relationship. Culture matters to different degrees and in different ways across individuals, and the counselor should at all times maintain awareness of the unique interaction between a counselee and his or her culturally mediated experience. Leong’s argument is exceedingly subtle and complex, and it defies being adequately recapitulated within the confines of this chapter. With the practical concerns of working counselors in mind, it may be useful to recapitulate the following implications of Leong’s points: 1. Do not assume that the presenting problems of a culturally distinct client are necessarily related to or centered on his or her cultural experience or background. 2. Be prepared to switch levels, from cultural to individual and/or universal, and vice versa, as the client’s needs and situation may require. 3. The extent and nature of a person’s relationship to his or her culture or cultures is likely to be an important area of inquiry in the course of counseling. 4. Complementarity involves empathy, sensitivity, and responsiveness to the client in the context of the counselor’s and counselee’s respective roles within the counseling transaction; complementarity also involves the application of the counselor’s expertise and skill in effectively and fittingly responding to the client’s experience of distress. 5. In the optimal case, counseling may represent human interaction at its most subtle and sensitive, and there is no effective way to simplify it without distorting or reducing its impact. 6. Maximal flexibility, spontaneity, openness to experience, and authenticity are called for during all counseling experience. 7. Do not limit yourself to a single perspective or irrevocably commit yourself to a specific hypothesis or explanation. 8. Remember at all times that each person is unique, yet shaped by his or her culture, and is like all other persons both biologically and existentially. 9. Be aware of the client’s multiple distinctive facets, but do not lose sight of the fact that he or she is a whole and integrated human being. Conclusions Increasingly, counseling across cultures is based on a growing number of thoroughly investigated evidence-based procedures, which, however, are sometimes applied to culturally distinct populations in which they have not been adequately tested. At its source, however, counseling rests on the encounter between two individuals engaged in a subtle and genuine personal contact. The two aspects of counseling, the empirically researched and the subjectively experienced, remain to be fused and integrated. They do not necessarily pull counseling in divergent directions, nor do they invariably operate in tandem. For that to happen, human sensitivity has to fuse with systematically acquired replicable knowledge. In its probably relatively infrequent stellar moments, counseling may represent the actualization of human potential for a genuine encounter: two human beings interacting at their best, and one of them, the counselee, significantly benefiting from the experience. Research evidence has accumulated to demonstrate that empathy and the therapeutic alliance are two of the major active ingredients of therapeutic change. Techniques, interventions, and procedures certainly matter, but they are secondary to the bond between the counselor and the counselee and to the counselee’s experience of being genuinely understood. Researchers and practitioners have proposed and implemented a multitude of approaches aimed at making the benefits of counseling available to all of the culturally diverse segments of the population of the United States, Canada, and, presumably, a host of other multicultural nations around the world. It has been amply demonstrated that cultural adaptations increase the effectiveness of counseling and that counseling programs work best if the community of the potential users participates in planning, designing, and executing these services. On the individual level, negotiation between a potential counselee and his or her counselor is the procedure of choice, much preferred to the unilateral or authoritarian imposition of services on an overtly compliant, yet possibly reluctant and/or bewildered, client. Research-based information has also accrued on what kinds of clients benefit from, and prefer, what services. Researchers and practitioners now know that the person’s self, the aggregate of her or his personal experience, is relevant to the counseling transaction. Is the self construed as a loose network of bonds and links to the significant persons in an individual’s life, as is apparently the case in many Eastern cultures? Or is the self a tightly enclosed nucleus of cherished attributes that contains everything that is deemed to be essential about the person? And, of course, there is plenty of room between these two metaphoric extremes. As yet, little is known about the personality traits of individuals or about the dimensions and attributes of cultures that are associated with preferences for and responsiveness to the various modes and experiences of counseling. This topic and many others remain to be investigated as the enterprise of multicultural counseling continues on its slow progression of disentangling that which is universal, particular, or unique about the human experiences of distress and dysfunction and as the armamentarium of techniques, procedures, and approaches for the relief of human suffering gathers momentum and increases in both sensitivity and effectiveness. Discussion Questions 1. What are “the relationships that work” as demonstrated on the basis of the meta-analyses of psychotherapy research? What is the relevance of these findings for culturally oriented counseling? 2. How can the concept of “culture teachers” be incorporated into all counseling so as to make it 3. 4. 5. 6. 7. more culturally sensitive and personally effective? What is the role of empathy in culturally oriented counseling? What kinds of adaptations and modifications, if any, may the expression and communication of empathy require in the delivery of counseling services across cultures? Are the experiential and evidence-based aspects of culturally oriented counseling necessarily in conflict? If they are not, how can they be reconciled and integrated? Are Hofstede’s five dimensions relevant to multicultural counseling in the United States and Canada? What is their potential and what are their limitations? What are the counseling implications of working with members of a culturally diverse clientele whose selves differ on the independent versus interdependent axis? How can the goal of helping immigrants and sojourners adapt to U.S. culture be combined with the goal of helping them to preserve their cultural distinctiveness and identity? Notes 1. Because of their extensive overlap in meaning and usage, the terms counseling and psychotherapy and their derivatives are used interchangeably throughout this chapter. 2. This quotation is from the introduction to the sixth edition of Counseling Across Cultures by the four editors. The passage quoted, however, was written by Paul B. Pedersen and represents the gist of the concept of culture teachers that he originated. References APA Presidential Task Force on Evidence-Based Practice in Psychology. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285. Arthur, N., & Collins, S. (2010). Culture-infused counseling (2nd ed.). Calgary, AB: Counselling Concepts. Bachellor, A., & Horvath, A. (1999). The therapeutic relationship. In M. A. Hubble, B. J. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association. Bohart, A. C., & Greenberg, L. S. (1997). Empathy and psychotherapy: An introductory review. In A. C. Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 3–32). Washington, DC: American Psychological Association. Bordin, E. S. (1976). The generalizability of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252–260. Brislin, R. (2000). Understanding culture’s influence on behavior (2nd ed.). Fort Worth, TX: Harcourt College. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685–716. Chang, S. C. (1988). The nature of self: A transcultural view. Part I: Theoretical aspects. Transcultural Psychiatric Research Review, 25(3), 169–206. Clark, A. J. (2007). Empathy in counseling and psychotherapy: Perspectives and practices. Mahwah, NJ: Lawrence Erlbaum. Draguns, J. G. (1973). Comparisons of psychopathology across cultures: Issues, findings, directions. Journal of Cross-Cultural Psychology, 4, 9–47. Draguns, J. G. (1975). Resocialization into culture: The complexities of taking a worldwide view of psychotherapy. In R. W. Brislin, S. Bochner, & W. J. Lonner (Eds.), Cross-cultural perspectives on learning (pp. 273–269). Beverly Hills, CA: Sage. Draguns, J. G. (2004). From speculation through description toward investigation: A prospective glimpse of cultural research in psychotherapy. In U. P. Gielen, J. M. Fish, & J. G. Draguns (Eds.), Handbook of culture, therapy, and healing (pp. 369–388). Mahwah, NJ: Lawrence Erlbaum. Draguns, J. G. (2007). Empathy across national, cultural, and social barriers. Baltic Journal of Psychology, 8(1–2), 5–20. Draguns, J. G. (2008). What have we learned about the interplay of culture with counseling and psychotherapy? In U. P. Gielen, J. G. Draguns, & J. M. Fish (Eds.), Principles of multicultural counseling and therapy (pp. 393–418). New York: Routledge. Duan, C., & Hill, C. E. (1996). The current state of psychotherapy research. Journal of Counseling Psychology, 43, 261–274. Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 132–152). New York: Oxford University Press. Gallardo, M. E., Parham, T. A., Trimble, J. E., & Yeh, C. J. (2012). Understanding the skills identification model in context. In M. E. Gallardo, C. J. Yeh, J. E. Trimble, & T. A. Parham (Eds.), Culturally adaptive counseling skills: Demonstrations of evidence-based practices (pp. 1–20). Thousand Oaks, CA: Sage. Gallardo, M. E., Yeh, C. J., Trimble, J. E., & Parham, T. A. (Eds.). (2012). Culturally adaptive counseling skills: Demonstrations of evidence-based practices. Thousand Oaks, CA: Sage. Griner, D., & Smith, T. B. (2006). Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training, 43, 531–548. Hall, G. C. N. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69, 502–510. Hays, P. A., & Iwamasa, G. Y. (Eds.). (2006). Culturally responsive cognitive behavioral therapy: Assessment, practice, and supervision. Washington, DC: American Psychological Association. Hermans, H. J. M., & Kempen, H. J. G. (1998). Moving cultures: The perilous problems of cultural dichotomies in a globalizing society. American Psychologist, 53, 1111–1120. Herskovits, M. J. (1948). Man and his works: The science of cultural anthropology. New York: Alfred A. Knopf. Hinton, D. E. (Ed.). (2006). Culturally sensitive CBT [Special issue]. Cognitive and Behavioral Practice, 13(4). Hofstede, G. (1980). Culture’s consequences: International differences in work-related values. Beverly Hills, CA: Sage. Hofstede, G. (2001). Culture’s consequences: Comparing values, behaviors, institutions, and organizations across nations (2nd ed.). Thousand Oaks, CA: Sage. Hofstede, G., & Hofstede, G. J. (2005). Cultures and organizations: Software of the mind (2nd ed.). New York: McGraw-Hill. Horvath, A. O., Del Re, A. C., Fluckinger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 25–69). New York: Oxford University Press. Huey, S., & Polo, A. (2008). Evidence-based psychosocial treatment for ethnic minority youth. Journal of Child Clinical and Adolescent Psychology, 37, 262–301. Hwang, W.-C., Wood, J. J., Lin, K.-M., & Cheung, F. (2006). Cognitive-behavioral therapy with Chinese Americans: Research, theory, and clinical practice. Cognitive and Behavioral Practice, 13, 293–303. James, W. (1952). The principles of psychology. Chicago: Encyclopedia Britannica. (Original work published 1891) Jussim, L. J., McCauley, C. R., & Lee, Y.-T. (1995). Why study stereotype accuracy and inaccuracy? In Y.-T. Lee, L. J. Jussim, & C. R. McCauley (Eds.), Stereotype accuracy: Toward appreciating group differences (pp. 3–28). Washington, DC: American Psychological Association. Katz, J. H. (1985). The sociopolitical nature of counseling. The Counseling Psychologist, 13, 615–624. Kazdin, A. E. (2008). Evidence-based treatment and practice. American Psychologist, 63, 143–159. Keith, K. D. (2011). Introduction to cross-cultural psychology. In K. D. Keith (Ed.), Cross-cultural psychology: Contemporary themes and perspectives (pp. 3–19). Chichester, England: WileyBlackwell. King, J. (2012). Case illustration: The treatment of PTSD with a Laguna Indian woman: Implementation of the AIAN-SISM. In M. G. Gallardo, C. J. Yeh, J. E. Trimble, & T. A. Parham (Eds.), Culturally adaptive counseling skills: Demonstrations of evidence-based practices (pp. 201–208). Thousand Oaks, CA: Sage. Kleinman, A. (1992). How culture is important for DSM-IV. In J. E. Mezzich, A. Kleinman, H. Fabrega, B. Good, G. Johnson-Powell, K. M. Lin, S. Manson, & D. Parron (Eds.), Cultural proposals for DSM-IV (pp. 7–28). Pittsburgh, PA: University of Pittsburgh Press. Kluckhohn, C., & Murray, H. A. (1949). Personality formation: The determinants. In C. Kluckhohn & H. A. Murray (Eds.), Personality in nature, society, and culture (pp. 35–48). New York: Alfred A. Knopf. Kohut, H. (1971). The analysis of the self. New York: International Universities Press. Laungani, P. (2004). Asian perspectives in counseling and psychotherapy. Hove, England: BrunnerRoutledge. Leong, F. T. L. (1996). Toward an integrative model for cross-cultural counseling and psychotherapy. Applied and Preventive Psychology, 5, 189–209. Leong, F. T. L., & Lee, S.-H. (2006). A cultural accommodation model for cross-cultural psychotherapy: Illustrated with the case of Asian Americans. Psychotherapy: Theory, Research, Practice, Training, 43, 410–423. Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98, 244–253. Markus, H. R., & Kitayama, S. (1998). The cultural psychology of personality. Journal of CrossCultural Psychology, 29, 63–87. Marsella, A. J. (1988). Cross-cultural research on serious mental disorders: Issues and findings. Acta Psychiatrica Scandinavica, 78(Supplement 344), 7–22. Marsella, A. J. (1998). Toward a “global community psychology”: Meeting the needs of a changing world. American Psychologist, 53, 1282–1291. McCabe, K., & Christian, A. (2011). Evidence-based interventions for culturally diverse children and adolescents: The case of Mexican American youth. In K. D. Keith (Ed.), Cross-cultural psychology: Contemporary themes and perspectives (pp. 293–311). Chichester, England: WileyBlackwell. Miserandino, M. (2012). Personality psychology: Foundations and findings. Upper Saddle River, NJ: Pearson Education. Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York: Oxford University Press. Norcross, J. C., & Wampold, B. E. (2011a). Adapting the relationship to the individual patients. Psychotherapy: Theory, Research, Practice, Training, 48, 27–31. Norcross, J. C., & Wampold, B. E. (2011b). Evidence-based therapy relationships: Research conclusions and clinical practices. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 423–430). New York: Oxford University Press. Pedersen, P. B., Crethar, H. C., & Carlson, J. (2008). Inclusive cultural empathy: Making relationships central in counseling and psychotherapy. Washington, DC: American Psychological Association. Pedersen, P. B., Draguns, J. G., Lonner, W. J., & Trimble, J. E. (2008). Introduction to the sixth edition: Learning from our “culture teachers.” In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (6th ed., pp. xi–xv). Thousand Oaks, CA: Sage. Petermann, F. (2005). Evidenzbasierte Psychotherapie und Leitlinien—Hilfe oder Fessel? [Evidencebased psychotherapy: Aid or shackle?] Verhaltenstherapie und Verhaltensmedizin, 26, 452–469. Pfeiffer, W. M. (1996). Kulturspezifische Aspekte der Migration [Culturally specific aspects of migration]. In E. Koch, M. Ozek, & W. M. Pfeiffer (Eds.), Psychologie und Pathologie der Migration (pp. 17–30). Freiburg/Breisgau, Germany: Lambertus. Ridley, C. R., Ethington, L. L., & Heppner, P. P. (2008). Cultural confrontation: A skill of advanced cultural empathy. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (6th ed., pp. 377–394). Thousand Oaks, CA: Sage. Ridley, C. R., & Udipi, S. (2002). Putting cultural empathy into practice. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th ed., pp. 317–333). Thousand Oaks, CA: Sage. Rogers, C. R. (1957). The necessary and sufficient conditions for therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Roth, A., & Fonagy, P. (2005). What works for whom. A critical review of psychotherapy research (2nd ed.). New York: Guilford Press. Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing psychotherapy ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 224–238). New York: Oxford University Press. Salgado, S. O. (2012). Case illustration: Implementation and application of Latina/o cultural values in practice: The case of Julia. In M. E. Gallardo, C. J. Yeh, J. E. Trimble, & T. A. Parham (Eds.), Culturally adaptive counseling skills: Demonstrations of evidence-based practices (pp. 127–136). Thousand Oaks, CA: Sage. Scott, N. E., & Borodowsky, L. (1990). Effective use of cultural role taking. Professional Psychology: Research and Practice, 31, 167–170. Smith, T. B., Domenech Rodríguez, M. M., & Bernal, L. (2011). Culture. Journal of Clinical Psychology: In Session, 67, 166–175. Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5th ed.). Hoboken, NJ: John Wiley. Tanaka-Matsumi, J. (2008). Functional approaches for evidence-based practice in multicultural counseling and therapy. In U. P. Gielen, J. G. Draguns, & J. M. Fish (Eds.), Principles of multicultural counseling and therapy (pp. 169–198). New York: Routledge. Tanaka-Matsumi, J. (2011). Culture and psychotherapy: Searching for an empirically supported relationship. In K. D. Keith (Ed.), Cross-cultural psychology: Contemporary themes and perspectives (pp. 274–292). Chichester, England: Wiley-Blackwell. Tanaka-Matsumi, J., Higginbotham, H. H., & Chang, R. (2002). Cognitive behavioral approaches to counseling across cultures: A functional analytic approach for clinical application. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th ed., pp. 337–354). Thousand Oaks, CA: Sage. Tanaka-Matsumi, J., Seiden, D. Y., & Lam, K. N. (1996). The Culturally Informed Functional Assessment interview (CIFA): A strategy for cross-cultural behavioral practice. Cognitive and Behavioral Practice, 3, 215–233. Triandis, H. C. (1995). Individualism and collectivism. Boulder, CO: Westview Press. van de Vijver, F. J. R., & Tanaka-Matsumi, J. (2008). Multicultural research methods. In D. McKay (Ed.), Handbook of research methods in abnormal and clinical psychology (pp. 463–481). Thousand Oaks, CA: Sage. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum. Zeldow, P. B. (2009). In defense of clinical judgment, credentialed clinicians, and reflective practice. Psychotherapy: Theory, Research, Practice, Training, 46, 1–10. 3 Assessment of Persons in Cross-Cultural Counseling Walter J. Lonner Primary Objective ■ To present a general overview of contemporary issues and perspectives associated with the assessment of individuals whose cultural or ethnic origins differ from those of the professional counselors conducting the assessment Secondary Objective ■ To provide counselors and other professionals with resources designed to increase their competence in a broad spectrum of culture-sensitive assessment Half a century ago there was an unprecedented flurry of activity involving the translation of many popular, and almost entirely American, tests, scales, and inventories for first-time use in other countries and among U.S. ethnic groups (see Lonner, 1976, in the first edition of Counseling Across Cultures, for an earlier description of this activity). Much has been learned since then about how such adaptations should be done correctly and fairly. But, despite its importance, psychological testing is not the only perspective that will be discussed in this chapter. Psychological assessment in various facets of the mental health field should not be limited to Western-based psychometric devices that employ a variety of formats designed to provide information that can be analyzed statistically and, of utmost importance, help counselors understand their clients. As they conduct their multifaceted jobs, mental health professionals are constantly assessing and evaluating clients in numerous ways, many of which have little or nothing to do with measurement of the kind traditionally used by test-oriented psychologists. Additionally, professional counselors should be assessing and monitoring themselves in terms of possible biases or prejudices that may surface in specific cases. Assessment across cultures—“testing”—is still a necessary and vibrant activity in the field of counseling, but assessment in general has become much broader and more informed, thanks to advances made by thousands of culture-oriented psychologists. Chapter Orientation Psychological practitioners use a variety of formats to measure such things as a client’s personality, values, intelligence, and mental health status. To avoid mistakes in adapting any one of thousands of devices chosen to assess persons who belong to myriad cultures and ethnicities, practitioners must recognize the paramount importance of the answer to one crucial question in regard to each unique client: Is the assessment of this person, in these circumstances, with these methods, and at this time as complete and accurate as possible? A wide range of conceptual and methodological hurdles involving the assessment of persons crossculturally has challenged both practitioners and theorists persistently for more than half a century (Brislin, Lonner, & Thorndike, 1973; Dana, 2005; Paniagua, 2010, 2013). Below is a small sample of the questions that counselors who interact with clients from different cultures or ethnic backgrounds will want to consider: ■ To what extent can intelligence tests originally developed by White American psychologists be validly used with individuals who identify with different ethnic groups, or who hail from other cultures? Should such tests be used at all? If not, what, if anything, should replace them? ■ Are components of personality, self, or values so meaningful and tangible across cultures and ethnic groups that they lend themselves to accurate measurement? ■ In educational settings, are tests of achievement and abilities fair to all children and adults who take them, including many whose cultural or ethnic backgrounds may emphasize different learning styles, or who may object to invasive psychometric probing? While the basic issues in traditional cross-cultural assessment remain remarkably stable, the accessibility and sophistication used by researchers and practitioners to explore them have increased dramatically (Byrne et al., 2009). Many texts that have been written to help educate and inform counselors about the range of problems and issues in multicultural counseling have grappled with the question of psychological assessment and where it belongs in the counselor’s toolbox for gathering meaningful information. When culture, ethnicity, religion, sexual orientation, and other ways to differentiate people from each other enter the picture, a variety of quandaries are certain to surface. How practitioners approach and resolve these quandaries will greatly affect culturally appropriate assessment as well as counseling strategies. The goal of assessment is to contribute to the counselor’s professional competence when dealing with diverse clientele (Deardorff, 2009; Lonner & Hayes, 2004; Paniagua, 2010; Sternberg & Grigorenko, 2004; Sue, Arredondo, & McDavis, 1992). This process aims to bring people who are culturally or ethnically diverse (the “clients”) together with psychologists and others in the helping professions (the “experts”) who themselves differ from the clients culturally or ethnically. Counselors and therapists should be acutely aware of the responsibility they have in the assessment of persons as well as in the proper delivery of their professional skills (American Psychiatric Association, 2000, 2013; American Psychological Association, 2003; Draguns, 1998). The Enigmatic Other Human beings are often perplexing, even to insightful scholars. The late esteemed cultural psychologist Ernest Boesch noted that any person—the “enigmatic other,” he called her or him—is forever difficult for even highly trained professionals to understand completely (Lonner & Hayes, 2007). For Boesch, “the other” (a patient, a client, a confused student, an anxious immigrant) is always encapsulated in his or her unique world of thoughts, emotions, reflections, and behaviors, all of which are shaped by the culture(s) or ethnic group(s) in which the individual was nurtured. The enigma can be considerably compounded when “the other” is from a “nonisomorphic” cultural or ethnic group that, as explained below, may be radically different from the culture of another, thereby presenting a second—and quite possibly the most complex—level of difficulty in professional interactions. A common problem faced by professionals who attempt to assess and diagnose other people lies in the imperfections that all humans experience, both as clients and as experts. Human beings tend to be complex and enigmatic, and so are human cultures and the wide assortment of ethnicities that are found in any pluralistic country. Unraveling these complexities and enigmas is a constant challenge. The Cultural Isomorphism of Human Assessment A frequent lamentation of culturally oriented psychologists is that most of the pioneering work in this area involved a rather narrow slice of humanity (Segall, Lonner, & Berry, 1998). Psychologists have dealt primarily with readily available and opportunistic “samples of convenience” from the WEIRD world—that is, from Western, educated, industrialized, rich, and democratic nations (Henrich, Heine, & Norenzayan, 2010). The language and reasoning used by members of the scientific establishment in such efforts are generally mutually understandable, dealing as they do with the lingua franca of the guild and the people in the guild whom they serve. In other words, the great similarity in form and function shared by professionals and their clients—their isomorphism, or the extent of their congruency in thought and action—minimizes some important barriers. Common sense tells us that the most effective counseling takes place in settings that are culturally isomorphic (White clients and White counselors living in rural Kansas, for instance, or Hispanic clients and Hispanic counselors living in New Mexico). This has been called the cultural compatibility hypothesis. High isomorphism (high compatibility) seemingly ensures that individuals, when all barriers are minimized or eliminated in such relationships, will generally be “on the same page.” High compatibility would obviously facilitate (but not guarantee) accurate assessment and communication, even if the presenting problems are complex. At its best, this facilitation would be enhanced because those in the therapeutic relationship would have learned the same language, been socialized in the same country or culture, and shared a “common fate” in a similar social, ecological, economic, familial, and political milieu in which the counseling relationship takes place. But this “clinical matching” hypothesis may not always be the best route. The universalist position argues that assessment, as well as treatment, is independent of any issues involving cultural or ethnic differences. Some researchers have addressed the “compatibility” versus “universalism” issue (see Paniagua, 2013, Chapter 2; Zane, Hall, Sue, Young, & Nunez, 2004). Chapter 2 in this book discusses this topic in more detail. In any case, all professional interactions should involve accurate assessment and sensitive understanding of “the other” in his or her unique and enigmatic form, all of which is shaped by cultural and ethnic forces. An Example of Radical Nonisomorphism/Incongruence A case study wonderfully told by Anne Fadiman in her award-winning book The Spirit Catches You and You Fall Down (1997) provides an excellent example of radical incongruence between patient and doctor. Fadiman’s book is structured around the problems that a Hmong child, Lia Lee, experienced in her adopted United States and the clash of two medical systems—essentially two “worldviews”—in their attempts to explain the child’s behavior. Lia, who died in August 2012, had severe epilepsy (a uniformly accepted condition in the modern world with a number of known symptoms and behaviors). To her refugee parents, however, she suffered from quag dab peg, a culture-bound illness in which “the spirit catches you and you fall down.” Fadiman’s book has become required reading in many medical schools. This fascinating case study challenges the efficacy of two systems of “causality”—the Western paradigm and the Hmong belief system. Getting out of the WEIRD box, which can seriously constrain thinking, is the key to progress. The case study serves as a showcase for what have been called Arthur Kleinman’s (1992) “Eight Questions.” These questions are often used as a tool of preliminary assessment in many intake interviews, where the beliefs held by different cultures and ethnicities may clash with the Western model: 1. 2. 3. 4. 5. 6. What do you call the problem? What do you think has caused the problem? Why do you think it started when it did? What do you think the sickness does? How does it work? How severe is the sickness? Will it have a short or long course? What kind of treatment do you think the patient should receive? What are the most important results you hope the patient will receive from this treatment? 7. What are the chief problems the sickness has caused? 8. What do you fear most about the sickness? These questions emerged in the context of “exotic” ethnopsychiatric conditions and anthropological perspectives. Except for those who work with people who are in various stages of acculturation, not many professional mental health workers in the Western world routinely confront the problems faced by an unacculturated Hmong child. Kleinman (1980), after all, has spent a career in ethnopsychiatry and medical anthropology. His model for cultural assessment was designed to cover all facets of a client’s cultural experience (Kleinman, 1992). Also containing eight points, the model has been useful in professional interactions where cultural differences may be relevant. But the eight questions can be modified slightly for use in various relatively modern and Western counseling settings rather than in specific and exotic ethnopsychiatric circumstances where baffling medical conditions may be involved. Words such as patient and sickness can be replaced by client and psychological condition, thus making the eight questions part of an appropriate and somewhat more isomorphic assessment tool in virtually all multicultural counseling settings. Perhaps accurate answers to these questions could be used as criteria for successful assessment and empathetic understanding in any counseling scenario, regardless of how radically incongruent a given setting may be. Four Approaches to Assessment in Multicultural Counseling There are four different approaches in the assessment toolbox with which all culture-oriented practitioners are involved to varying extents: quantitative, qualitative, mixed-methods, and knowledge-based approaches. Which of these, or combination thereof, a counselor takes will depend on the nature of the individual case as well as on the background and intentions of the counselor. Traditionally, the two main approaches—qualitative (or idiographic) and quantitative (or nomothetic) —have been centerpieces in an ongoing debate about which is “better” (Draguns, 1996; Draguns & Tanaka-Matsumi, 2001; Ponterotto, Gretchen, & Chauhan, 2001). This debate is the entire focus of Meehl’s classic 1954 book Clinical Versus Statistical Prediction, which notes that both approaches have had strong supporters and outspoken opponents. For instance, the clinical (qualitative) method has been described as rich, contextual, sensitive, open-minded, deep, genuine, insightful, flexible, and meaningful. It has also been pejoratively described as mystical, hazy, unverifiable, sloppy, crude, primitive, and intuitive. On the other hand, the statistical (quantitative) approach has been described by its adherents as communicable, testable, reliable, rigorous, precise, and empirical. Its detractors use such adjectives as mechanical, forced, superficial, rigid, pseudoscientific, and blind. Historical and scientific posturing aside, psychology as a field is moving toward a third approach in assessment, which usually is considered to consist of “mixed methods” in research and evaluation. Similarly, assessment usually involves both quantitative and qualitative perspectives. Further, the guidelines for practice endorsed by the American Psychiatric Association (2013), the American Psychological Association (2003), and the American Counseling Association (2005) all emphasize that in working with culturally different clients, it is very important for counselors to use culturally impressionistic approaches to identify the clients’ norm groups, so that quantitative assessments can be conducted ethically. Effective assessment involving individuals from other cultures or ethnic groups can be accomplished only after the persons doing the assessment have accumulated significant knowledge about the histories, customs, and modes of interaction of the groups in question. That kind of assessment, the fourth approach, is here called knowledge-based assessment (KBA) because it relies on the accumulation of increasingly deep understanding of a client’s cultural background. The knowledge-based approach draws heavily from the work of cultural and cross-cultural psychologists who have offered numerous ways to understand entire cultures as well as individuals within them. Much of the remainder of this chapter is built around these four dimensions and the issues that have followed them. The Quantitative Approach Guided by logical positivism, nomothetic (putatively universally “lawful”) approaches tend to be favored by most psychologists, whether or not their focus is on culture or ethnicity. Psychological testing can provide the counselor with the kind of data-oriented information that conforms to the canons of orthodox psychological science. A preference for normative objective data over idiographic clinical interpretation, standardization in both method and scoring, and efficiency of administering and interpreting tests and scales over on-the-spot constructivist approaches tend to be some of the hallmarks of this dimension in the assessment of persons. Some call it the “gold standard” in assessment. Methodological Culture-Centered Concerns in Quantitative Research Numerous problems have been found to be associated with the use of the many data-gathering devices that are designed to assess clients from various cultural and ethnic groups. The measurement of intelligence, for example, continues to be fraught with considerable difficulties when particular tests are applied to individuals from different cultures or ethnic groups (Suzuki, Naqvi, & Hill, 2014). In short, the quest for a truly “culture-fair” intelligence test has been severely damaged on the rocky shoals of rigorous examination. While concepts such as “cultural intelligence” (CQ), “emotional intelligence” (EI), and “street smarts” are currently in vogue, they too demand explication and some kind of measurement. In the domain of personality assessment, psychologists who favor such widely used devices as the NEO Personality Inventory—Revised (NEO-PI-R), the five-factor model (McCrae & Allik, 2002; McCrae & Costa, 1997), the Minnesota Multiphasic Personality Inventory (MMPI; Butcher, 1996), and various values scales (see Dana, 2005) have been especially careful to address the methodological problems of such multi-item scales and inventories when these are extended to other cultures. Methodological concerns tend to center on two major areas: (1) the equivalence (mutual meaningfulness) of assessment devices and (2) the bias that may be inherent in many, if not all, quantitative approaches. Bias and equivalence are highly related because they are mirror concepts, with bias being synonymous with nonequivalence and, conversely, equivalence referring to the absence of bias (van de Vijver, 2001). In their edited volume devoted to cross-cultural counseling, Gerstein, Heppner, Ægisdóttir, Leung, and Norsworthy (2009) correctly assert that many conceptual and methodological issues face counselors across the globe. A chapter in that text by Ægisdóttir, Gerstein, Leung, Kwan, and Lonner (2009) and a popular online readings article by He and van de Vijver (2012) summarize the essence of equivalence and bias in their various forms. Similarly, Kwan, Gong, and Maestas (2010) and van de Vijver and Leung (2011) provide overviews of significant concerns facing scholars and practitioners who wish to adapt psychological tests for use in multicultural counseling. The same concerns must be addressed in research using any kind of psychological measurement involving the admixture of culture/ethnicity and individual differences. The following section summarizes the essence of these issues. Types of Equivalence Conceptual (or Construct) Equivalence Psychological concepts or constructs may never have totally equivalent meanings across different cultures or ethnic groups. Many diagnostic categories, descriptions of syndromes, and adjectives used to describe people do not transfer well across different groups in such a way that their meanings are identical. Even in a homogeneous culture there will be individual differences in understandings of certain words or phrases, or in attaching certain meanings or emotions to them. We should, therefore, expect even more such variation between individuals in different cultural or ethnic groups. In culturally sensitive psychological assessment the goal is to find enough equivalence between disparate cultural or ethnic groups so that the elimination of any bias that favors one group or individual over another is possible. Hofstede (2001) asserts that “culture is the collective programming of the mind that distinguishes the members of one group or category of people from others” (p. 9). In other words, every culture, either explicitly or implicitly, teaches its citizens to process concepts and constructs in ways that may differ substantially from those used by members of other cultures. If differences are present, one of the counselor’s tasks is to try to understand why and how this “cultural programming” occurs and to assess people accordingly. For instance, cultures that are highly individualistic tend to foster autonomy and independence among their citizens. The concept of dependency, therefore, when manifested by a client socialized in the individualistic Western world, could be viewed as “weak” or as indicating an “adjustment problem.” In contrast, in cultures that do not nudge people toward autonomy and independence, dependency and conformity may be the norm. Even specific cultures and ethnic groups within multiethnic societies are usually not homogeneous. There can be, and often are, subtle variations in cultures between regions in specific countries. For instance, Vandello and Cohen (1999) found patterns of individualism and collectivism within the United States, with people in the Deep South being generally more collectivistic than the typically more individualistic residents of the Midwest and Far West. The main theme of a recent best-selling book by the historian and journalist Colin Woodard (2011) is that the United States is not one large and undivided monolithic nation but rather 11 nations, each with its own historical roots that go back centuries. For instance, Woodward names among them the “Left Coast,” “Yankeedom,” “Greater Appalachia,” and the “Deep South,” where some are still fighting the Civil War. He even includes large parts of Canada in his argument (e.g., “First Nation” and “New France”). In multicultural Canada one can find plenty of differences in attitudes and other variables between the Francophones in Quebec and the Anglophones in British Columbia or Saskatchewan. In any pluralistic society one can generally expect to find numerous differences among individuals from different native groups, geographic regions, or generations of immigrants. In fact, one line of contemporary research on values suggests that there may be more differences within than between cultures (see below in the discussion of values). A caution: While these demographic and historical perspectives are generally interesting and broadly historically informative and insightful, it may be a stretch for counselors to rely on them to assess any given individual who resides in one particular culture or identifies with one particular ethnic group. To do so may be to perpetuate stereotypes. Before a counselor uses any data-gathering device to assess or diagnose an individual from another culture or ethnic group, he or she should consider the extent to which his or her own definitions of important concepts, both intrapersonal and interpersonal, match those of the client. In other words, cultural validity and meaningfulness should be established. Unfortunately, there is no objective checklist to guide the counselor in establishing such validity. However, most tests and scales designed or adapted for use in cross-cultural research have a significant body of research to guide the professional counselor. A search of the literature will usually pay off. Dana (2005), for instance, provides an excellent overview of multicultural assessment. Likewise, Gamst, Liang, and DerKarabetian (2011) present an extensive list of multicultural measures. These researchers’ pedagogical goal was “to place as many multicultural instruments summaries as we could create within one text”; at the same time, however, they note that “such ‘one-stop shopping’ can often yield a double-edged sword; convenience must be tempered by the realization that any multicultural measurement compendium is but a beginning of a serious and thorough literature review” (p. xvii). Gamst et al. touch on many of the salient dimensions that will be of some interest in virtually any multicultural counseling encounter. They describe measures of counselor competence, racial and ethnic identity, and acculturation, as well as racism- and prejudice-related, gender-related, sexual orientation– related, and disability attitude measures. Structural (or Functional) Equivalence Structural equivalence is satisfied if an instrument measures the same construct in different cultural or ethnic groups. Somewhat similar to conceptual equivalence is linguistic, or translation, equivalence —this area addresses all aspects of the language(s) used in assessment devices. Psychologists who plan to make comparisons across cultures, and others who simply want to render tests or scales usable in particular cultural or ethnic settings, often spend a great deal of time translating the devices to be used. Back-translation is an almost obligatory procedure to ascertain the linguistic equivalence of scales. Brislin (1986) and Hambleton and Zenisky (2011) provide overviews of the problems associated with translating and adapting tests for use across cultures and ethnic groups. Extensive cross-cultural adaptations of the famous MMPI incorporate lessons learned over many years in this domain of test adaptation (see, for example, Butcher & Williams, 2009). Measurement Unit Equivalence As Marsella (1987) notes in his discussion of depressive experience and disorder across cultures, “virtually everyone in Western society is exposed to Likert-type scales, Thurstone scales, true–false ratings, and other efforts to quantify life experiences, opinions, attitudes, and behavior patterns” (p. 387). Moreover, it is usually assumed that people will readily rate themselves and others, and that they have the ability to be self-reflective, with little or no regard for their right to privacy or concerns about how culture has influenced the individuals’ tendency to disclose themselves to strangers or counselors. Van de Vijver and Leung (1997) give a cogent example of this problem that employs two different scales used to measure temperature—the Kelvin and Celsius scales. If used for two groups, the measurement unit would be identical. However, the origins of the scales are not. As van de Vijver and Leung explain it, “By subtracting 273 from the temperatures in Celsius, these will be converted into degrees Kelvin. Unfortunately, we hardly ever know the offset of scales in cross-cultural research” (p. 8). Suppose, for example, that a scale to measure anxiety is developed in Canada and is subsequently translated and administered to recent immigrants from Vietnam. The original (Canadian) scale may contain a number of implicit and explicit references to the Canadian culture. These references will put Vietnamese respondents at a disadvantage. As a consequence, van de Vijver and Leung note, “the (supposedly) interval-level scores in each group do not constitute comparability at the ratio level” (p. 8). Scalar Equivalence, or Full-Score Comparability Scalar equivalence, the highest level, is the only type of equivalence that permits direct cross-cultural comparisons. It can be achieved only with methods or scales that use the same ratio scale in each cultural group, because this would allow one to conclude that scores obtained in two cultures or ethnic groups are different or equal. Van de Vijver and Leung (1997) use the measurement of body length or weight (using any standard measure in either case) as an example. In a similar context, van de Vijver and Leung (2011) point out that scalar equivalence assumes both an identical interval or ratio scale and an identical scale origin across cultural groups. Psychological constructs are often opaque and slippery. Perhaps scalar equivalence across cultures can be most reliably achieved with biometric scales such as blood pressure readings or eye pressure tests for glaucoma. For reasons already given, it would be much more problematic to develop a totally useful psychological scale to measure, for example, feelings of inferiority across cultural or ethnic lines. Bias in Assessment and Appraisal A large number of unwanted “nuisance” factors can threaten the validity and therefore usefulness of assessment devices when they are used with cultural and ethnic groups other than those for which they were developed. Bias is the general term used to refer to such threats. Van de Vijver and Poortinga (1997; see also van de Vijver & Leung, 1997, 2011) assert that there are three types of bias: construct, method, and item. Construct bias can occur, for example, when ■ definitions of a construct across cultures do not completely overlap; ■ there is poor sampling of all relevant behaviors (such as in short questionnaires or scales); or ■ there is incomplete coverage of the construct. Method bias is a potential problem when, for instance, ■ those who take a test are unequally familiar with the items; ■ the person giving the test has differential effects on the participants, such as in communication problems; ■ the samples are incomparable; or ■ the physical conditions or test administration procedures differ. Item bias occurs when, for instance, ■ one or more items are poorly translated; ■ there is complex wording in items; or ■ there are incidental or inappropriate differences in the content of test items (e.g., the topic of an item in an educational test is absent in the curriculum of one of the cultural groups). Detailed information about the use of tests across cultures, as well as in research designs requiring the use of tests, is readily available. The International Test Commission (ITC) is one highly recommended source of such information. In 1999, the ITC formally adapted guidelines for test usage, and the European Federation of Professional Associations’ Task Force on Tests and Testing endorsed the guidelines that year. Copies of the current guidelines can be obtained from the ITC website (http://www.intestcom.org). A recent book edited by Matsumoto and van de Vijver (2011) contains numerous chapters by specialists in cross-cultural research. Among the topics it covers are the translation and adaptation of tests, sampling, survey research, and multilevel modeling, as well as an assortment of other concerns and problems. Gamst et al. (2011) cover some of this ground as well. The Qualitative Approach Qualitative assessment relies heavily on idiographic, informal, impressionistic, and often unstructured procedures or approaches. In-depth interviews and autobiographies are classic examples. This approach almost completely eschews traditional psychometrics and techniques that tend to objectify and “reduce” people to standard scores, percentiles, personality profiles, or points on Likert-type scales. The qualitative approach includes the assessment of what may well be the most important aspect of a person’s mode of thought and behavior: his or her worldview. Koltko-Rivera (2004) defines worldviews as “sets of beliefs and assumptions that describe reality” (p. 3). (See also the Scale to Assess World View, a social psychological instrument; Ibrahim & Kahn, 1987; Ibrahim, RoysircarSodowsky, & Ohnishi, 2001.) A person’s worldview (Weltanschauung), which is certainly shaped by culture, encompasses a wide range of topics, including morality, appropriate social behavior, political stances, ethical matters, the nature of the universe, ad infinitum. Yet, while a person is the child of one specific culture, he or she of course does not necessarily represent a pristine example of everyone in that particular group. On the other hand, it is highly likely the worldviews of most people from a given culture will be more similar than different. Recent research on “social axioms” supports the view that there is widespread agreement among people in a given culture regarding how the world “works.” Conceptually similar to the measurement of “cultural syndromes” (Triandis, 1996) or the popular mode of “dimensionalizing” cultures via work-related values (Hofstede, 2001, 2011), social axioms represent a way to assess a person’s view of the world (Bond et al., 2004; Leung et al., 2002; Malham & Saucier, 2014). According to Leung et al. (2002), social axioms are “generalized beliefs about oneself, the social and physical environment, or the spiritual world, and are in the form of an assertion about the relationship between two entities or concepts” (p. 289). Detailed, multicultural factor analysis has unearthed a quintet of social axioms: ■ Cynicism: a negative view of human nature, a belief that life produces unhappiness ■ Social complexity: a belief in multiple ways of doing things ■ Reward for application: a belief that hard work and careful planning will lead to positive outcomes ■ Spirituality (or religiousness): a belief in a supreme being and the positive functions of religious practice ■ Fate control: a belief that life events are predetermined and that people have some influence over the outcomes Qualitative approaches include the notion that the person and the culture in which he or she lives are “co-constructed”—they literally define each other. Constructivist assessment emphasizes “local” (emic) as opposed to “universal” (etic) meanings and beliefs shared by individuals in a circumscribed culture (Neimeyer, 1993; Raskin, 2002); it also embraces a fluid and flexible style in constructing meaning. More than a decade ago, Carr, Marsella, and Purcell (2002) noted that interest in the use of qualitative research methods was on the increase. This continues to be true. The key ideas shared by those who tend to favor such methods include a strong desire to preserve and study life in its genuine and earthy form, to examine the essence and nature of things, and to understand the dynamics of phenomena in their natural and nonmanipulated settings. The cultural psychologist Cole (1996) argues that the analysis of everyday life events, the fact that individuals are “active agents in their own development,” and the examination of “mediated action in a context” are, among other factors, quite important. Cultural psychologists and constructivists in general tend to reject, as Cole puts it, “causeeffect, stimulus-response, explanatory science in favor of a science that emphasizes the emergent nature of mind in activity and that acknowledges a central role for interpretation in its explanatory framework.” He also endorses the use of “methodologies from the humanities as well as from the social and biological sciences” (p. 104). Cultural psychologists are far more likely to use qualitative methods than are their cross-cultural colleagues (also see Shweder, 1991). The phenomenological nature of the human being and the belief that there are “multiple realities” rather than a uniform and completely objective and well-ordered world are other themes in qualitative approaches in general (Denzin & Lincoln, 2011) and also in research methodology (J. Smith, 2003). Mixed Methods and Models of Assessment in Multicultural Counseling Many culture-oriented practitioners use both quantitative and qualitative methods. Several models and approaches have recently evolved that are additive. Essentially, this represents the collective thinking of researchers (Dana, 1998; Karasz, 2011). The earliest modular framework took the form of Kleinman’s (1992) “Eight Questions” to guide the assessment process (as listed above). Kleinman developed these questions to understand the client’s explanatory rationale for the “problem” in both physical and mental health. This approach was quite revolutionary at the time because it included the client in the problem-solving process, focusing on understanding what the client believed was the genesis of the problem, what function it was serving in the client’s context, and how it might be treated. This model has provided the framework for ethical cross-cultural diagnosis and assessment such as the cultural formulation of the client’s problem espoused by the American Psychiatric Association (2000, 2013). Castillo (1997) expanded on Kleinman’s questions to include the client and the context as the central components in the assessment and diagnosis process. A closely related approach is the ADDRESSING framework proposed by Hays (2001). The letters of the ADDRESSING acronym serve as prompts for the counselor to address, if desired: age, developmental and acquired disabilities, religion and spirituality, ethnicity, socioeconomic status, sexual orientation, indigenous heritage, national origin, and gender. Mixed methods and models help to clarify what is normal and abnormal in specific cultural contexts, thus reducing fears of misdiagnosis and cultural malpractice. The counselor must make key decisions in planning his or her assessment strategy when using tools of this kind. The decisions pertain to identifying the most salient features for the client that must be assessed before an intervention can be conducted. The determination of key variables depends on several factors, such as deciding if the issues the client is facing are relevant to his or her core values and culture. Dana (2005) has developed an ethnically sensitive model he calls the multicultural assessmentintervention process (MAIP). Using a seven-step procedure, this model incorporates a process whereby the counselor must make frequent and careful selections from among traditional and appropriate psychometric devices (see Figure 3.1). Using MAIP, the therapist 1. identifies the client’s cultural identity; 2. determines the client’s level of acculturation; 3. provides a “culture-specific service delivery style’’ in which he or she phrases questions in accordance with cultural “etiquette”; 4. uses the client’s language (or preferred language), if possible; 5. selects assessment devices or modes that are culturally appropriate to the client or that the client prefers; and 6. uses culture-specific strategies in informing the client about the results of the assessment. The MAIP has been used in conjunction with the California Brief Multicultural Competence Scale (CBMCS). It also includes the possible use of traditional psychological tests, especially in steps 3 and 4. Dana (2005) reports that Ponterotto et al. (2001) have identified the MAIP as his six-step cultural assessment model. He further notes that Morris (2000) has expanded his model to propose a hybrid model for African Americans that combines MAIP with Helms’s (1990) racial identity development process (see also Spengler, Strohmer, Dixon, & Shivy, 1995). Figure 3.1 Schematic Flowchart of MAIP Model Components Source: Gamst, G. C., Liang, C.T.H., & Der-Karabetian, A. (2011). Handbook of multicultural measures. Thousand Oaks, CA: Sage. Ridley, Li, and Hill (1998) have proposed a model they call the multicultural assessment procedure (MAP). It focuses on the incorporation of the client’s culture in the assessment decision-making process. In addition, Ridley et al. emphasize the role of cognitive flexibility in clinical judgment and practice, as well as the role of language in assessments. The main goal of MAP is to enhance the cultural competence of psychologists and other mental health professionals in culture-sensitive assessment. One of the biggest strengths of this model is that it actively engages the client in the assessment process. This can help to avoid misunderstandings and culturally biased judgments by helping therapists engage their clients and get an accurate sense of the clients’ issues and symptoms. Paniagua (2010) notes that the American Psychiatric Association endorses a five-step assessment protocol: (1) Identify the client’s primary racial or ethnic group, (2) record the origin of how the client explains the presenting mental disorder or condition, (3) determine how cultural factors in the psychological environment (e.g., family, church) affect the client, (4) note any potentially significant differences between the counselor and the client that could affect assessment and diagnosis, and (5) summarize major findings in the assessment that appear to be related to culture and ethnicity. Paniagua also discusses how the mental status exam can play a role in assessment and diagnosis. An Interim Perspective: Neuropsychological Assessment and Culture An important approach that merits consideration is neuropsychological assessment. From a medical perspective, assessing patients from diverse cultural and linguistic backgrounds presents unique ethical challenges (Brickman, Cabo, & Manly, 2006) as well as many potentially complex measurement problems (Pedraza & Mungas, 2008). Many neuropsychological measures do not meet acceptable standards when used with most if not all ethnic groups in the United States. Recognized as a specialization within the field of clinical neuropsychology, this type of assessment generally focuses on brain disorders. Many individuals in need of some kind of professional psychological help are foreign-born and not fluent in English (or the dominant language where the professional encounter occurs); they may be victims of human-made or natural disasters or of physical or mental abuse and may be severely malnourished. Several chapters in this book discuss counseling with people—such as immigrants, the impoverished, the marginalized, and substance abusers—who may be in desperate need of neuropsychological evaluation. Unfortunately, most counseling psychologists do not receive detailed training in this highly specialized area. Consequently, they often have to refer clients to medical facilities for proper assessment, diagnosis, and treatment. Counselors are advised to learn as much as possible about such resources in their communities. Assessment in this domain features the use of specialized neuropsychological tests. As such, the same issues—validity, reliability, equivalence, and bias—that are part of routine quantitative procedures must be considered in the assessment of brain disorders, along with unique challenges and how they may interact with culture-mediated factors. Judd and Beggs (2005) note that a number of specific cultural factors are most relevant to neuropsychological evaluation; these include worldview, values, religion and beliefs, family structures, social roles (age, gender, class, and so on), recent history, epidemiology, differential responses to psychotropic medications, attitudes and beliefs about health and illness, communication and interpersonal style, and the nature of any educational system that the client has experienced. Nell (2000) presents an overview of culture-sensitive neuropsychological assessment. Currently more than 500 tests are available to the clinical neuropsychologist. It would be easy to dismiss the “universalist” argument in the use of any of these devices. It is nearly certain that some cultural differences can be found in the employment of all of these tests. However, finding differences is not that important. What is important is whether the differences are based on solid methodology and, if they are, why the differences exist. This inherently challenging domain of clinical assessment and diagnosis is on the radar screen of neuropsychologists, many of whom are aware of the various problems associated with the measurement of cognitive abilities across diverse cultural, racial, and ethnic groups (Pedraza & Mungas, 2008). This includes attention given to the multicultural neuropsychological assessment of children (Byrd, Arentoft, Scheiner, Westerveld, & Baron, 2008). Because culture or ethnicity may mask neuropsychological conditions, professional counselors should enhance their competency by becoming familiar with the current literature in this area, as well as with local medical resources. Important sources of information are the Handbook of Cross-Cultural Neuropsychology (Fletcher-Janzen, Strickland, & Reynolds, 2000) and Assessment and Culture: Psychological Tests With Minority Populations (Gopaul-McNicol & Armour-Thomas, 2002). Neuropsychology and the Hispanic Patient: A Clinical Handbook (Pontón & León-Carrión, 2001) is an excellent methodological and forensic resource for counselors working with Hispanic clients, as is Minority and Cross-Cultural Aspects of Neuropsychological Assessment (Ferraro, 2002). More broadly, the International Handbook of Cross-Cultural Neuropsychology (Uzzell, Pontón, & Ardila, 2007) is a helpful source of information regarding progress in this relatively new field. The website of the National Academy of Neuropsychology (http://www.nanonline.org) is also an excellent resource in this area of individual assessment. The academy’s Culture and Diversity Committee is especially active in such efforts. The American Psychological Association, American Psychological Society, and Canadian Psychological Association are good sources of information, as is the California Association of Psychology’s Cultural Neuropsychology Subcommittee of Culture and Diversity. Brickman et al. (2006) address ethical issues in cross-cultural neuropsychology. Knowledge-Based Assessment A fourth type of culture-centered assessment is offered as a more general path to competent crosscultural assessment. It usually does not rely on traditional modes of psychological testing. Instead, it draws on the rapidly increasing efforts of culture-oriented psychologists over several decades (Berry, Poortinga, Breugelmans, Chasiotis, & Sam, 2011; Keith, 2013; Lonner, 2013; Matsumoto & Juang, 2008; P. B. Smith & Best, 2009; Valsiner, 2012). By becoming familiar with contemporary developments in the psychological study of culture, counselors can greatly enrich their interactions with clients who are culturally different from themselves. KBA is highly related to a number of recent models of and perspectives on cross-cultural competence, several of which focus on motivation, skills, and knowledge (Deardorff, 2009), which are, in turn, related to cultural intelligence, or CQ (Ang & Van Dyne, 2008). A special issue of the Journal of Cross-Cultural Psychology (Chiu, Lonner, Matsumoto, & Ward, 2013) addresses a variety of theoretical and measurement perspectives on cross-cultural competence. This type of assessment also embraces the profound simplicity of what Kahneman (2011) reminds us is part of our biological and cognitive endowment: an ability to evaluate crucial features of present circumstances so that proper action may take place. Knowingly or unknowingly, we always appraise and assess those we meet. Such evaluation, done broadly and deeply and linked to contemporary research, will contribute immensely to empathetic assessment. Predicated on the proposition that counselors’ appraisal of their clients potentially involves all facets of their lives, KBA is informed by the knowledge that counselors have gained over the years in various academic disciplines; in their travels; in the books, poems, movies, and music they have appreciated; in the conferences they have attended, the classes they have taught, and the friendships they have made—in other words, life as it evolves over time and place, life as it is lived in the raw context of everyday discourse, not as it is represented by static and often lifeless psychometric devices. Additionally, interviews, systematic observation in naturalistic settings, personal documents and archives, and unobtrusive measures are aspects of this approach. The assessment of persons— regardless of setting—is a dynamic, automatic, and constantly ubiquitous human process. Abundant knowledge accumulated by the counselor enhances and enriches other forms of assessment. The chapters in this text are excellent examples of the input needed for this type of assessment. Patterns, Categorization, and Dimensionalizing Most culture-oriented psychologists tend to gravitate toward, and create, frameworks or perspectives designed to categorize and dimensionalize culture-related patterns of behavior. While it is often practical to use such frameworks, even if only heuristically, this is a perilous approach in an increasingly complex and globalized world (Hermans & Kempen, 1998; Stewart & Bennett, 1991). When assessing patterns of behavior based on a person’s culture or ethnic group, a counselor must address a problem. This problem includes the unwarranted assumption that the highest level of abstraction (e.g., an entire culture or ethnic group) translates directly to the lowest level of abstraction (the unique individual and his or her specific behaviors). It is tempting, as P. B. Smith (2004) cautions, to “test the plausibility of hypotheses by thinking about how the variables of interest [at the country or ethnic group level] relate at the individual level of analysis” (p. 9). To do so is to commit what Hofstede (2001) calls the “ecological fallacy,” for there is no logical reason why relationships between any two variables at one level of analysis should be exactly the same at another level of analysis (Hofstede, 1980; Leung, 1989). Nor is there any convincing reason to use such descriptions as “national character” or the “typical” Asian or the “modal” Hispanic personality pattern in assessing individuals. There is just too much diversity, too much shifting from region to region, and too much interplay between and among people to be so sweepingly reductionistic. It may be tempting to inch toward unwittingly committing an ecological fallacy. To avoid this, the counselor would be wise to believe that the individual and his or her unique behavioral tendencies trump all higher levels of abstraction. The higher the level of abstraction (e.g., “Asia”), the greater potential for errors at the lowest level (a specific Asian student). The search for patterns of behavior that may be related to culture embraces a research tradition in the social and behavioral sciences that has been central to the understanding of persons for many decades (Lonner, 2009, 2011). One example of this search for regularities is the recent research on “social axioms,” described earlier. Three other examples of this culture-oriented research are summarized below: understanding personality traits, grappling with the nature of “self,” and mapping human values. Understanding Personality Traits The NEO-PI-R purports to measure the everyday “Big Five” dimensions of personality within the general framework of the five-factor model (FFM). The five components of personality emerged from dozens of factor analytical studies showing that consistent regularities, or patterns, were evident in numerous measures of personality. Arguably, the five derived factors are universal and therefore transcend languages, making all items in the 240-item inventory relatively easy to translate. The five factors—Openness, Conscientiousness, Extroversion, Agreeableness, and Neuroticism—are often referred to with the acronym OCEAN (see McCrae & Allik, 2002; McCrae & Costa, 1997, 2008; McCrae, Terracciano, et al., 2005). Proponents of the FFM believe that these components of personality are as universal and “real” as blood type or other biological markers. In assessing personality, perhaps counselors, who also share these traits to varying degrees, quite naturally “cue in” on manifestations of these factors in everyday interactions as well as in counseling sessions. After just one session with a new client the adept counselor could probably construct a convincing profile of the client by using these salient “commondenominator” factors, which may help constitute a lingua franca of interpersonal understanding. But because of the plasticity of personality and the cacophony of cultures and ethnic groups, it is difficult to confirm the universality of these factors and even more difficult to exclude other factors that may prove to be equally robust. Nevertheless, all sentient humans may well be “hardwired” to assess people by using these facets of personality. A counselor will only occasionally have a client’s NEO-PI-R profile in front of him or her before or during a counseling session. So how does this relate to this dimension of KBA? One answer is that by considering patterns of these traits, a counselor can enhance his or her knowledge of a client and the client’s cultural background. For instance, Americans, Canadians, New Zealanders, and Australians tend to be high on Extroversion and at midscale on Neuroticism. Knowing that these patterns exist, at least in the academic world, may provide a counselor with some confirmatory evidence about the general nature of a particular client in a counseling setting. Grappling With the “Self” It is quintessentially human to comprehend, reflect upon, and assess oneself. Theory and research on “self”—self-concept, self-efficacy, self-enhancement, self-disclosure, and self-esteem, among many other aspects of self-ness—has received enormous attention from scholars for centuries. Counseling obviously concerns the client’s “self” and all of its philosophical and psychological underpinnings. “Tell me a little about yourself” is a common opening gambit that professional counselors use. Many attempts to assess aspects of “self” have dotted the literature for decades. One of the most popular devices, and one of the simplest, is the “twenty statements test,” or TST, which simply asks a client or student to complete the phrase “I am ______” 20 times, after which this self-report is analyzed. Since its development (Kuhn & McPartland, 1954), the TST has been used in countless projects, many of which have looked into cultural and ethnic aspects of self-construal (e.g., del Prado et al., 2007). The most prevalent perspective on matters relating to culture and self has involved the highest level of abstraction: culture. The heavily studied concept of individualism versus collectivism is everyone’s favorite example. Within this “great divide,” individualist and collectivist orientations tend to comprehend “self” quite differently. Generally, a person from a highly individualistic culture such as the United States or Australia will likely differ substantially from a person who grew up in a collectivistic culture such as China or Egypt. The heart of the difference is that the individualist will be primarily concerned about his or her self while the collectivist will tend to focus more on the group(s) to which he or she belongs. Within the increasingly complex contemporary American culture, however, care should be used in employing the individualism–collectivism bifurcation (Vargas & Kemmelmeier, 2013). Counseling strategies that aim to promote self-actualization and selfenhancement, as might typically be employed in individualistic settings, may not work so well in settings where the group, and especially the family, is central to the conceptualization of self. Hofstede’s other cultural dimensions, incidentally, include power distance, uncertainty avoidance, and masculinity–femininity. A fifth dimension, long-term versus short-term orientation, was added more recently. The cultural dynamics associated with these dimensions in counseling encounters would be worth studying (see also Chapter 2). Somewhat along the same lines are the polarities of the “independent self” versus the “interdependent self.” Markus and Kitayama (1991) have argued that an individual’s motivation, emotion, and cognition differ depending on the extent to which the person’s culture or ethnic group has fostered a “self-construal” that is independent (self-centered) as opposed to interdependent (group-centered). By contrasting a “rugged individualist” farm boy from rural Iowa with a “group-centered” boy raised in an interdependent and clannish Native American tribe, one can easily see how counseling strategies would have to be altered. Similarly, Nisbett (2003) and Nisbett, Peng, Choi, and Norenzayan (2001) have addressed the matter of differences in thought as a function of geography (which is a reasonable proxy for culture). Thus, we have the polarity of alleged holistic thinking among Asians versus Western analytic thinking. However, caution must again be urged regarding the use of such facile dimensionalizing and pigeonholing. As explained earlier, assessing an individual strictly on the basis of his or her belonging to some demographic group, culture, caste, or clan could be an error with unfortunate consequences. But culture does matter, and how an individual has been socialized certainly affects how that person thinks about him- or herself, especially in interpersonal relationships. Markus and Conner (2013) make everyday use of such dimensionalizing, pointing out that culture “clashes” (as they call them) involving polarizing demographic end points are genuine. But the world is not structured along neat dichotomies such as independent–interdependent, East– West, Black–White, rich–poor, religious–agnostic, male–female, or any other demographic bifurcation. Such dichotomies can, however, be salient “talking points” whenever and wherever interpersonal interactions, such as counseling, take place. Mapping Human Values Either explicitly or implicitly, counseling involves the interplay of human values, the third example of the KBA perspective. Scholars who study human values assert that they are points of view taken by a culture, or members of that culture, that influence action toward both desirable means and ends. A common conception of human values is that they are beliefs and transsituational goals that, while varying in importance and activation, serve as guiding principles throughout the lives of persons (see Schwartz, 2011, 2012; P. B. Smith & Schwartz, 1997). Cross-cultural research on values has shown that values often differ across cultures, but “differences in values held by people within a society are typically larger than differences found between societies” (Berry et al., 2011, p. 92). While there have been hundreds of attempts to define and measure values—the individualism– collectivism paradigm discussed earlier is one of the most influential—currently the most popular approach is that taken by the Israeli psychologist Shalom Schwartz. Using his Value Survey, Schwartz suggests a prototypical structure of 10 universal values: Power, Achievement, Hedonism, Stimulation, Self-Direction, Universalism, Benevolence, Tradition, Conformity, and Security. These values are arranged in “circular” order, whereby juxtaposed values such as Power and Achievement or Benevolence and Universalism are highly correlated, and oppositional juxtaposed values such as Security and Self-Direction or Benevolence and Achievement receive low correlations. Research with the Schwartz model has been robust, especially on an international scale (see P. B. Smith & Best, 2009). In recent refinements of this model, 19 values have been posited (Cieciuch, Schwartz, & Vecchione, 2013; Schwartz et al., 2012; for further details, see Keith, 2013, Vol. 3). The Schwartz paradigm has not yet played a significant role in multicultural counseling research and practice. However, given the importance of values in clinical and counseling practice, there is no reason why it should not. The intent of this brief overview of culture-oriented perspectives and research in three important areas of scholarship—personality, self, and values—is to underscore how important they are in the clinic, in interviews, and in the general assessment of a person’s life and current circumstances. Learning more about them will certainly enhance a counselor’s competence. However, nothing in the broad domain of human assessment can replace the skill with which the empathetic counselor understands the essence of humanness and how it plays out in the frequently tangled and unique circumstances of an individual’s life. Summary and Conclusions The unbiased and accurate assessment of clients who have been socialized in cultures or ethnic groups that differ from that of the counselor presents a number of formidable problems. Regardless of culture of origin, ethnic identity, and other dimensions of human diversity that contribute to a person’s unique identity, the usual psychometric concerns, such as validity, reliability, practicality, and ethical treatment of clients, are involved in all psychological assessment. Added to these concerns are specific, culture-related considerations regarding appropriateness, meaningfulness, and equivalence of numerous constructs, syndromes, and psychological dimensions that counselors and clinicians use in their attempts to understand their clients. Professionals must be constantly aware of these interactions and of all the methodological and conceptual factors that contribute to how clients must be understood and respected, regardless of their cultures of origin or how their ethnic identities were shaped. Critical Incident Suppose that a multicultural counselor wants to assess possible differences in self-concept(s) between two of her female clients, both 19 years old, who recently enrolled in a Wisconsin community college. One client is from a rural Black community in Alabama, the other an immigrant from Sri Lanka who reportedly was the victim of poverty and abuse when she was younger. Neither is doing well in her studies, despite getting reasonably high scores on aptitude and achievement tests routinely taken by incoming students. Also, both clients have taken the same inventory, which purports to measure various facets of self. The young woman from Alabama took the original inventory, which was developed by a counseling psychologist from the University of Kansas and normed on freshmen at that university. A British-trained counseling psychologist who was on sabbatical leave in Sri Lanka had earlier translated the inventory into Tamil, one of Sri Lanka’s major languages, and normed it on a small sample of Tamil-speaking students. The Sri Lankan student, who was not yet fluent in English, took that version. Both clients took the inventory in their senior year in high school. The present counselor notes that the young women’s scores on the inventory strongly suggest that the client from Alabama has a much higher self-concept than does the Sri Lanka student. Discussion Questions This brief, fictional example encompasses some important issues and problems associated with cross-cultural assessment. If you were the counselor in the community college that these two young women are attending, how might you handle the following questions? 1. Considering the problems associated with equivalence and bias in psychological assessment, do you think that the two versions of the same measure are fair? If not, what concerns you the most? 2. Do you think the test has low or high cultural validity? Why? 3. How important is the discrepancy between the scores of the two students? Do you think the difference is significant enough to examine in further detail? 4. If you completely discounted the validity of the two measures but were still interested in looking into how the two students seem to differ substantially in self-concept, what steps might you take to complete more trustworthy pictures of their individual perceptions of self? 5. Do you think that the counselor should learn more about Sri Lankan culture, or perhaps consult with Tamil-speaking adults? 6. Of the four approaches to assessment outlined in this chapter—quantitative, qualitative, mixed methods, and knowledge-based—which would you trust most to help you pinpoint the reasons for the differences in the two students’ scores? What are the strengths and weaknesses of each? References Ægisdóttir, S., Gerstein, L. H., Leung, S.-M. A., Kwan, K.-L. K., & Lonner, W. J. (2009). Theoretical and methodological issues when studying culture. In L. H. Gerstein, P. P. Heppner, S. Ægisdóttir, S.M. A. Leung, & K. L. Norsworthy (Eds.), International handbook of cross-cultural counseling: Cultural assumptions and practices worldwide (pp. 89–110). Thousand Oaks, CA: Sage. American Counseling Association. (2005). Code of ethics. Alexandria, VA: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. Washington, DC: Author. Ang, S., & Van Dyne, L. (Eds.). (2008). Handbook of cultural intelligence: Theory, measurement, and applications. Armonk, NY: M. E. Sharpe. Berry, J. W., Poortinga, Y. H., Breugelmans, S. M., Chasiotis, A., & Sam, D. L. (2011). Cross-cultural psychology: Research and applications (3rd ed.). Cambridge: Cambridge University Press. Bond, M. H., Leung, K., Au, A., Tong, K.-K., Reimel de Carrasquel, S., Murakami, F., et al. (2004). Culture-level dimensions of social axioms and their correlates across 41 cultures. Journal of CrossCultural Psychology, 35, 548–570. Brickman, A. M., Cabo, R., & Manly, J. J. (2006). Ethical issues in cross-cultural neuropsychology. Applied Neuropsychology, 13(2), 91–100. Brislin, R. W. (1986). The wording and translation of research instruments. In W. J. Lonner & J. W. Berry (Eds.), Field methods in cross-cultural research (pp. 1337–1364). Thousand Oaks, CA: Sage. Brislin, R. W., Lonner, W. J., & Thorndike, R. M. (1973). Cross-cultural research methods. New York: Wiley-Interscience. Butcher, J. N. (1996). International adaptations for the MMPI-2. Minneapolis: University of Minnesota Press. Butcher, J. N., & Williams, C. L. (2009). Personality assessment with the MMPI-2: Historical roots, international adaptations, and current challenges. Applied Psychology: Health and Well-Being, 1(1), 105–135. Byrd, D., Arentoft, A., Scheiner, D., Westerveld, M., & Baron, I. S. (2008). State of multicultural neuropsychological assessment in children: Current research issues. Neuropsychology Review, 18, 214–222. Byrne, B. M., Oakland, T., Leong, F. T. L., van de Vijver, F. J. R., Hambleton, R. K., Cheung, F. M., & Bartram, D. (2009). A critical analysis of cross-cultural research and testing practices: Implications for improved education and training. Training and Education in Professional Psychology, 3(2), 94–105. doi:101037/a0014516 Carr, S. C., Marsella, A. J., & Purcell, I. P. (2002). Researching intercultural relations: Toward a middle way? Asian Psychologist, 3(1), 58–64. Castillo, R. J. (1997). Culture and mental illness. Pacific Grove, CA: Brooks/Cole. Chiu, C. Y., Lonner, W. J., Matsumoto, D., & Ward, C. (Eds.). (2013). Cross-cultural competence [Special issue]. Journal of Cross-Cultural Psychology, 44(6). Cieciuch, J., Schwartz, S. H., & Vecchione, M. (2013). Applying the refined values theory to past data: What can researchers gain? Journal of Cross-Cultural Psychology, 44, 1215–1234. Cole, M. (1996). Cultural psychology: A once and future discipline. Cambridge, MA: Harvard- Belknap. Dana, R. H. (1998). Understanding cultural identity intervention assessment. Thousand Oaks, CA: Sage. Dana, R. H. (2005). Multicultural assessment: Principles, applications, and examples. Mahwah, NJ: Lawrence Erlbaum. Deardorff, D. K. (Ed.). (2009). The SAGE handbook of intercultural competence. Thousand Oaks, CA: Sage. del Prado, A. M., Church, A. T., Katigbak, M. S., Miramontes, L. G., Whitty, M. T., Curtis, G. J., et al. (2007). Culture, method, and the content of self-concepts: Testing trait, individual-self-primacy, and cultural psychology perspectives. Journal of Research in Personality, 41, 1119–1160. Denzin, N. K., & Lincoln, Y. S. (Eds.). (2011). The SAGE handbook of qualitative research (4th ed.). Thousand Oaks, CA: Sage. Draguns, J. G. (1996). Multicultural and cross-cultural assessment of psychological disorder: Dilemmas and decisions. In G. R. Sodowsky & J. C. Impara (Eds.), Multicultural assessment in counseling and psychology (pp. 37–84). Lincoln, NE: Buros Institute of Mental Measurement. Draguns, J. G. (1998). Transcultural psychology and the delivery of clinical psychological services. In S. Cullari (Ed.), Foundations of clinical psychology. Boston: Allyn & Bacon. Draguns, J. G., & Tanaka-Matsumi, J. (2001). Assessment of psychopathology across and within cultures: Issues and findings. Behavior Therapy and Research, 41, 755–776. Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus & Giroux. Ferraro, R. (Ed.). (2002). Minority and cross-cultural aspects of neuropsychological assessment. Lisse, Netherlands: Swets & Zeitlinger. Fletcher-Janzen, E., Strickland, T. L., & Reynolds, C. R. (Eds.). (2000). Handbook of cross-cultural neuropsychology. New York: Kluwer Academic/Plenum. Gamst, G. C., Liang, C. T. H., & Der-Karabetian, A. (2011). Handbook of multicultural measures. Thousand Oaks, CA: Sage. Gerstein, L. H., Heppner, P. P., Ægisdóttir, S., Leung, S.-M. A., & Norsworthy, K. L. (Eds.). (2009). International handbook of cross-cultural counseling: Cultural assumptions and practices worldwide. Thousand Oaks, CA: Sage. Gopaul-McNicol, S., & Armour-Thomas, E. (2002). Assessment and culture: Psychological tests with minority populations. San Diego, CA: Academic Press. Hambleton, R. K., & Zenisky, A. L. (2011). Translating and adapting tests for cross-cultural assessments. In D. Matsumoto & F. J. R. van de Vijver (Eds.), Cross-cultural research methods in psychology. Cambridge: Cambridge University Press. Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians and counselors. Washington, DC: American Psychological Association. He, J., & van de Vijver, F. J. R. (2012). Bias and equivalence in cross-cultural research. Online Readings in Psychology and Culture, 2(2). Retrieved from http://dx.doi.org/10.9707/2307-0919.1111 Helms, J. E. (1990). An overview of Black racial identity theory. In J. Helms (Ed.), Black and White racial identify theory: Theory, research, and practice (pp. 9–47). New York: Greenwood. Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world. German Data Forum Working Paper 139. Hermans, H. J. M., & Kempen, H. J. G. (1998). Moving cultures: The perilous problems of cultural dichotomies in a globalizing society. American Psychologist, 53, 1111–1120. Hofstede, G. (1980). Culture’s consequences: International differences in work-related values. Beverly Hills, CA: Sage. Hofstede, G. (2001). Culture’s consequences: Comparing values, behaviors, institutions, and organizations across nations (2nd ed.). Thousand Oaks, CA: Sage. Hofstede, G. (2011). Dimensionalizing cultures: The Hofstede model in context. Online Readings in Psychology and Culture, 2(1). Retrieved from http://dx.doi.org/10.9707/2307-0919.1014 Ibrahim, F. A., & Kahn, H. (1987). Assessment of world views. Psychological Reports, 60,163–176. Ibrahim, F. A., Roysircar-Sodowsky, G., & Ohnishi, H. (2001). Worldview: Recent developments and needed directions. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 425–456). Thousand Oaks, CA: Sage. Judd, T., & Beggs, B. (2005). Cross-cultural forensic neuropsychological assessment. In K. Barrett & W. H. George (Eds.), Race, culture, psychology, and law. Thousand Oaks, CA: Sage. Kahneman, D. (2011). Thinking fast and slow. New York: Farrar, Straus & Giroux. Karasz, A. (2011). Qualitative and mixed methods research in cross-cultural psychology. In F. J. R. van de Vijver, A. Chasiotis, & S. M. Breugelmans (Eds.), Fundamental questions in cross-cultural psychology. Cambridge: Cambridge University Press. Keith, K. D. (Ed.). (2013). Encyclopedia of cross-cultural psychology (Vols. 1–3). New York: WileyBlackwell. Kleinman, A. (1980). Patients and healers in the context of culture. Berkeley: University of California Press. Kleinman, A. (1992). How culture is important for DSM-IV. In J. E. Mezzich, A. Kleinman, H. Fabrega, B. Good, G. Johnson-Powell, K. M. Lin, S. Manson, & D. Parron (Eds.), Cultural proposals for DSM-IV (pp. 7–28). Pittsburgh, PA: University of Pittsburgh Press. Koltko-Rivera, M. E. (2004). The psychology of worldviews. Review of General Psychology, 8, 3–58. Kuhn, M., & McPartland, T. (1954). An empirical investigation of self-attitudes. Sociological Review, 19, 68–76. Kwan, K.-L. K., Gong, Y., & Maestas, M. (2010). Language, translation, and validity in the adaptation of psychological tests for multicultural counseling. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (3rd ed., pp. 397–412). Thousand Oaks, CA: Sage. Leung, K. (1989). Cross-cultural differences: Individual-level vs. culture-level analysis. International Journal of Psychology, 24, 703–719. Leung, K., Bond, M. H., Reimel de Carrasquel, S., Munoz, C., Hernandez, M., Murukami, F., et al. (2002). Social axioms: The search for universal dimensions of general beliefs about how the world functions. Journal of Cross-Cultural Psychology, 33, 286–302. Lonner, W. J. (1976). The use of Western-based tests in intercultural counseling. In P. B. Pedersen, W. J. Lonner, & J. G. Draguns (Eds.), Counseling across cultures. Honolulu: East-West Center. Lonner, W. J. (2009). The continuing quest for psychological universals in categories, dimensions, taxonomies, and patterns of human behavior. In S. Bekman & A. Aksu-Koc̨ (Eds.), Perspectives on human development, family and culture (pp. 17–30). Cambridge: Cambridge University Press. Lonner, W. J. (2011). The continuing challenge of discovering psychological “order” across cultures. In F. J. R. van de Vijver, A. Chasiotis, & S. M. Breugelmans (Eds.), Fundamental questions in crosscultural psychology. Cambridge: Cambridge University Press. Lonner, W. J. (2013). Foreword. In K. Keith (Ed.), Encyclopedia of cross-cultural psychology (Vols. 1–3). New York: Wiley-Blackwell. Lonner, W. J., & Hayes, S. A. (2004). Understanding the cognitive and social aspects of intercultural competence. In R. J. Sternberg & E. L. Grigorenko (Eds.), Culture and competence: Contexts of life success. Washington, DC: American Psychological Association. Lonner, W. J., & Hayes, S. A. (2007). Discovering cultural psychology: A profile and selected readings of Ernest E. Boesch. Charlotte, NC: Information Age. Malham, P. B., & Saucier, G. (2014). Measurement invariance of social axioms in 23 countries. Journal of Cross-Cultural Psychology, 45, 1046–1060. Markus, H. R., & Conner, A. (2013). Clash! 8 cultural conflicts that make us who we are. New York: Hudson Street Press. Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98, 224–253. Marsella, A. J. (1987). The measurement of depressive experience and disorder across cultures. In A. J. Marsella, R. M. A. Hirschfeld, & M. M. Katz (Eds.), The measurement of depression (pp. 376–397). New York: Kluwer Academic/Plenum. Matsumoto, D., & Juang, L. (2008). Culture and psychology (4th ed.). Belmont, CA: Wadsworth. Matsumoto, D., & van de Vijver, F. J. R. (Eds.). (2011). Cross-cultural research methods in psychology. Cambridge: Cambridge University Press. McCrae, R. R., & Allik, J. (Eds.). (2002). The five-factor model of personality across cultures. New York: Kluwer Academic/Plenum. McCrae, R. R., & Costa, P. T., Jr. (1997). Personality trait structure as a human universal. American Psychologist, 52, 509–516. McCrae, R. R., & Costa, P. T., Jr. (2008). The five-factor theory of personality. In O. P. John, R. W. Robins, & L. A. Pervin (Eds.), Handbook of personality: Theory and research (3rd ed., pp. 159–181). New York: Guilford Press. McCrae, R. R., Terracciano, A., & members of the Personality Profiles of Cultures Project. (2005). Universal features of personality traits from the observer’s perspective: Data from 50 cultures. Journal of Personality and Social Psychology, 88, 547–556. Meehl, P. E. (1954). Clinical versus statistical prediction: A theoretical analysis and a review of the evidence. Minneapolis: University of Minnesota Press. Morris, E. F. (2000). Assessment practices with African Americans: Combining standard assessment measures within an Africentric orientation. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 573–603). Mahwah, NJ: Lawrence Erlbaum. Neimeyer, G. J. (Ed.). (1993). Constructivist assessment: A casebook. Newbury Park, CA: Sage. Nell, V. (2000). Cross-cultural neuropsychological assessment: Theory and practice. Mahwah, NJ: Lawrence Erlbaum. Nisbett, R. E. (2003). The geography of thought: How Asians and Westerners think differently... and why. New York: Free Press. Nisbett, R. E., Peng, K., Choi, I., & Norenzayan, A. (2001). Culture and systems of thought. Psychological Review, 108, 291–310. Paniagua, F. A. (2010). Assessment and diagnosis in a cultural context. In M. M. Leach & J. D. Aten (Eds.), Culture and the therapeutic process: A guide for mental health professionals. New York: Routledge. Paniagua, F. (2013). Assessing and treating culturally different clients: A practical guide. Thousand Oaks, CA: Sage. Pedraza, O., & Mungas, D. (2008). Measurement in cross-cultural neuropsychology. Neuropsychology Review, 18, 184–193. Ponterotto, J. G., Gretchen, D., & Chauhan, R. V. (2001). Cultural identity and multicultural assessment: Quantitative and qualitative tools for the clinician. In L. A. Suzuki, J. G. Ponterotto, & A. P. Meller (Eds.), Handbook of multicultural competencies in counseling and psychology (pp. 191–210). Thousand Oaks, CA: Sage. Pontón, M., & León-Carrión, J. (Eds.). (2001). Neuropsychology and the Hispanic patient: A clinical handbook. Mahwah, NJ: Lawrence Erlbaum. Raskin, J. D. (2002). Constructivism in psychology: Personal construct psychology, radical constructivism, and social constructionism. In J. D. Raskin & S. K. Bridges (Eds.), Studies in meaning: Exploring constructivist psychology (pp. 1–25). New York: Pace University Press. Ridley, C. R., Li, L. C., & Hill, C. L. (1998). Multicultural assessment: Reexamination, reconceptualization, and practical applications. The Counseling Psychologist, 26, 827–910. Schwartz, S. H. (2011). Values: Cultural and individual. In F. J. R. van de Vijver, A. Chasiotis, & S. M. Breugelmans (Eds.), Fundamental questions in cross-cultural psychology. Cambridge: Cambridge University Press. Schwartz, S. H. (2012). An overview of the Schwartz theory of basic values. Online Readings in Psychology and Culture, 2(1), 1–20. Retrieved from http://dx.doi.org/10.9707/2307-0919.1116 Schwartz, S. H., Cieciuch, J., Vecchione, M., Davidov, E., Fischer, R., Beierlein, C., & Konty, M. (2012). Refining the theory of basic individual values. Journal of Personality and Social Psychology, 103, 663–688. Segall, M. H., Lonner, W. J., & Berry, J. W. (1998). Cross-cultural psychology as a scholarly discipline: On the flowering of culture in behavioral research. American Psychologist, 53, 1101–1110. Shweder, R. A. (Ed.). (1991). Thinking through cultures: Expeditions in cultural psychology. Cambridge, MA: Harvard University Press. Smith, J. (2003). Qualitative psychology: A practical guide to research methods. Thousand Oaks, CA: Sage. Smith, P. B. (2004). Nations, cultures, and individuals: New perspectives and old dilemmas. Journal of Cross-Cultural Psychology, 35, 6–12. Smith, P. B., & Best, D. L. (Eds.). (2009). Cross-cultural psychology (Vols. 1–4). Thousand Oaks, CA: Sage. Smith, P. B., & Schwartz, S. H. (1997). Values. In J. W. Berry, M. H. Segall, & Ç. Kağitçibaşi (Eds.), Handbook of cross-cultural psychology: Vol. 3. Social behavior and applications. Thousand Oaks, CA: Sage. Spengler, P. M., Strohmer, D. C., Dixon, D. N., & Shivy, V. A. (1995). A scientist-practitioner model of psychological assessment: Implications for training, practice, and research. The Counseling Psychologist, 23, 506–534. Sternberg, R. J., & Grigorenko, E. L. (2004). Culture and competence: Contexts of life success. Washington, DC: American Psychological Association. Stewart, E. C., & Bennett, M. J. (1991). American cultural patterns. Yarmouth, ME: Intercultural Press. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70, 477–486. Suzuki, L. A., Naqvi, S., & Hill, J. S. (2014). Assessing intelligence in a cultural context. In F. T. L. Leong (Ed.), APA handbook of multicultural psychology: Vol. 1. Theory and research. Washington, DC: American Psychological Association. Triandis, H. C. (1996). The psychological measurement of cultural syndromes. American Psychologist, 51, 407–413. Uzzell, B. P., Pontón, M., & Ardila, A. (2007). International handbook of cross-cultural neuropsychology. Mahwah, NJ: Lawrence Erlbaum. Valsiner, J. (Ed.). (2012). The Oxford handbook of culture and psychology. Oxford: Oxford University Press. Vandello, J. A., & Cohen, D. (1999). Patterns of individualism and collectivism across the United States. Journal of Personality and Social Psychology, 77, 279–292. van de Vijver, F. J. R. (2001). The evolution of cross-cultural research methods. In D. Matsumoto (Ed.), The handbook of culture and psychology. New York: Oxford University Press. van de Vijver, F. J. R., & Leung, K. (1997). Methods and data analysis for cross-cultural research. Thousand Oaks, CA: Sage. van de Vijver, F. J. R., & Leung, K. (2011). Equivalence and bias: A review of concepts, models and data analytic procedures. In D. Matsumoto & F. J. R. van de Vijver (Eds.), Cross-cultural research methods in psychology. Cambridge: Cambridge University Press. van de Vijver, F. J. R., & Poortinga, Y. H. (1997). Towards an integrated analysis of bias in crosscultural assessment. European Journal of Psychological Assessment, 13, 29–37. Vargas, J. H., & Kemmelmeier, M. (2013). Ethnicity and contemporary American culture: A metaanalytic investigation of horizontal-vertical individualism–collectivism. Journal of Cross-Cultural Psychology, 44, 195–222. Woodard, C. (2011). American nations: A history of the eleven rival regional cultures of North America. New York: Penguin Books. Zane, N., Hall, G. C. N., Sue, S., Young, K., & Nunez, J. (2004). Research on psychotherapy with culturally diverse populations. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 767–804). New York: John Wiley. 4 Multicultural Counseling Foundations A Synthesis of Research Findings on Selected Topics Timothy B. Smith Alberto Soto Derek Griner Joseph E. Trimble Primary Objective ■ To review and synthesize selected multicultural counseling research regarding counselor attributes, client attributes, and counseling methods to illustrate how research can inform counseling practice Secondary Objectives ■ To provide research evidence regarding the effectiveness of multicultural training for counselors to reduce personal biases and enhance their multicultural competence ■ To identify and describe how clients’ experiences of acculturation, racial and ethnic identity, and perceived racism can affect their well-being and perceptions of counseling ■ To present research evidence regarding clients and counselor match according to race and ethnicity and regarding cultural adaptations to counseling that facilitate positive client outcomes Riza had never attended counseling and was nervous. She had trusted the advice of a coworker and made the appointment, but now that she had entered the counselor’s office, she did not know what to say. Her problems seemed impossible to overcome and were so complex. She loved her husband, but they fought bitterly. Her husband’s family entrusted her with caring for two nephews, who had become like sons to her. She had felt sadness since the boys’ parents died, yet the children provided her with some joy. Most of all, she felt terribly alone since emigrating from her native country. Would the counselor understand anything of her Filipino culture, her religious faith, and her secret yet to be shared? Effective counseling requires trust and mutual understanding between counselor and client. A client cannot be expected to trust the counselor automatically, so the counselor is primarily responsible for facilitating a relationship of trust. Trust is enhanced when the counselor demonstrates understanding of and sensitivity to the multiple cultural contexts influencing the well-being of the client. What would happen if the counselor in the scenario above did not understand Riza’s experiences that intersect cultural and religious values relative to her family dynamics and social introversion? Counseling that is congruent and resonant with Riza’s worldview would be counseling that she could understand and appreciate. If you have engaged in counseling, you can relate to Riza’s initial dilemma: Should I engage or not? The following questions might be others that Riza contemplates: Can a male counselor help me respond to the sexual harassment I experience in public as a woman? Can a White counselor validate my pain from racial prejudice in the workplace without assuming that I’m overly sensitive? If I chose to remain with my verbally abusive partner, how will my counselor respond? Differences between client and counselor are inevitable. Enabling counselors to understand and work across value differences to promote the well-being of their clients is one principal aim of this book. Helping counselors to understand some of the research-based foundations for doing so is the fundamental aim of this chapter. Research on Multicultural Counseling Professional counseling practices are based on psychological theories that have received research support. More than a century of accumulated scientific evidence supports the effectiveness of professional counseling (e.g., Beutler, Forrester, Gallagher-Thompson, Thompson, & Tomlins, 2012), with the profession increasingly emphasizing evidenced-based psychological treatments (McHugh & Barlow, 2010). Which counseling methods work best with different populations? How can counselors best acquire the skills necessary to work effectively across different populations? Answers to questions such as these will help improve client utilization of services, client retention after initiating counseling, and ultimately, client well-being. Thus, research findings can help to improve the practice of multicultural counseling (Trimble, 2009). The amount of research on multicultural issues in counseling and psychology has increased exponentially over the past several decades. For example, the number of citations found in PsycINFO that reference African Americans or Blacks increased from fewer than 2,000 during the years 1960– 1969 to almost 29,000 during 2000–2009 and 4,500 in 2012 alone. Since the year 2000, more than 1,800 articles have referenced acculturation and mental health, more than 4,000 have referenced ethnicity and mental health, and more than 10,000 have referenced culture and mental health. Both scholars and practitioners can benefit from these scholarly findings. However, much of the multicultural counseling literature remains disorganized. There can be so many research findings in a given topic area that trends in the data may be difficult to discern accurately. Students, instructors, and practitioners could all benefit from a concise summary of existing research findings. Given the large volume of research studies on multicultural counseling available in the professional literature, traditional narrative review methods are inadequate to summarize the data accurately. Meta-analytic methods offer clear advantages over qualitative, interpretive summaries of research findings. Meta-analysis... [is] the statistical analysis of a large collection of analysis results from individual studies for the purpose of integrating the findings. It connotes a rigorous alternative to the casual, narrative discussions of research studies which typify our attempts to make sense of the rapidly expanding research literature. (Glass, 1976, p. 3) We rely on the findings of meta-analyses to provide summaries across topics in this chapter. However, the multicultural counseling literature includes many facets of human experience, including macro-level social dynamics (e.g., sexism), environment and circumstances (e.g., access to resources and residential status), and personal attributes (e.g., age), and we cannot even attempt such broad coverage in this chapter. So, after first examining the general concept of multicultural counseling competence, we limit our discussion to race and ethnicity. We have chosen to focus on race and ethnicity because they receive the greatest attention in the multicultural research literature and because they clearly influence many of the other conditions and circumstances that receive specific attention in other chapters of this book. In this chapter we describe selected aspects of multicultural counseling research relevant to counselor attributes, client attributes, and the counseling context itself. Selected Multicultural Counseling Research on Counselor Characteristics In this section we explore how attributes of the counselor may affect the quality of counseling provided for culturally diverse clients. Specifically, we consider the impacts of multicultural competence and multicultural training. Counselor Multicultural Competence Mental health professionals have an ethical responsibility to provide effective interventions to all clients, which necessarily entails adjusting their practices to align with the needs of people who are culturally different from themselves (S. Sue, 2003; Trimble, 2010; Trimble & Fisher, 2006). Although few, if any, counselors would intentionally mistreat clients of different racial and ethnic backgrounds, many counselors are unfamiliar with other groups’ worldviews, lifestyles, and experiences (Gone & Trimble, 2012). Even with substantial professional attention to multicultural issues, contemporary counseling continues to reflect Western cultural values (e.g., Benish, Quintana, & Wampold, 2011). Counselors may give inadequate consideration to contextual factors such as gender, sexual orientation, race and ethnicity, socioeconomic status, religion, and environment (e.g., Chao & Nath, 2011; S. Sue & Zane, 1987). To improve counseling utilization, retention, and outcomes among clients from historically disadvantaged backgrounds, scholars and professional associations have repeatedly emphasized the need for multiculturally competent mental health practices (American Psychological Association, 2003; Arredondo & Toporek, 2004; S. Sue, 2003). Multicultural competencies include awareness, knowledge, and skills (e.g., Constantine, 2002), each of which we describe briefly in the following paragraphs; full descriptions are readily available in the literature (American Psychological Association, 2003; Arredondo et al., 1996). A counselor’s multicultural awareness includes an understanding of his or her own assumptions, biases, values, worldview, theoretical orientation, privileges, and so forth. Without this awareness, counselors may unintentionally project their own values and assumptions onto clients, fail to realize how their own actions are perceived by their clients, misinterpret clients’ actions/intentions, and so on. For instance, a counselor who fails to account for his or her own discomfort about working with a client originally from Ghana who speaks English with an accent could conjecture that the client would prefer counseling in another language and raise that topic in session, insulting the client who has spoken English since early childhood. Examples of counselor multicultural awareness include the following (Arredondo et al., 1996): ■ Understanding how one’s own cultural heritage shapes one’s personal values, assumptions, perceptions, and biases toward clients and their work in therapy ■ Awareness of how one’s theoretical orientation and treatment approach may affect work with people from various multicultural backgrounds ■ Awareness of one’s own discomfort, effectiveness, and defensiveness when working with clients A counselor’s multicultural knowledge involves an understanding of the experiences and worldviews of other people, specifically the differences and similarities across persons of different races/ethnicities, genders, sexual orientations, religions, and so on. Without this knowledge, counselors cannot accurately contextualize or interpret the meanings of others’ actions/perceptions. For instance, a counselor unfamiliar with traditional Diné (Navajo) communication styles may incorrectly conclude that a Diné client lacks social skills because of the client’s infrequent eye contact and brief speech with frequent pauses. Examples of counselor multicultural knowledge include the following (Arredondo et al., 1996): ■ Knowledge of how psychological theory, methods of inquiry, and professional practices are historically and culturally embedded ■ Knowledge of clients’ family structures, roles, values, and worldviews, including the history and manifestation of prejudice that they have encountered ■ Knowledge of the attitudes and perceptions clients have about mental health services A counselor’s multicultural skills involve the ability to work effectively with others while applying multicultural awareness and knowledge (Arredondo et al., 1996). Without these skills, counselors may fail to adapt their work to the needs of culturally diverse clientele. For instance, a counselor who unintentionally offends a client from another race or ethnic group may lack “recovery skills” to repair the therapeutic relationship. When the counselor cannot adapt to the needs/experiences of the client and maintain a strong therapeutic alliance, counseling can be both frustrating and ineffective. The following are some of the multicultural skills recommended by Arredondo and colleagues (1996): ■ Ability to see individuals holistically—accounting for historical, sociopolitical, and economic contexts ■ Ability to show respect for client beliefs and values that differ from one’s own beliefs and values ■ Ability to modify assessment and treatment methods according to the needs of multicultural clientele Research findings on counselor multicultural competence. Abundant research has shown that the therapeutic alliance between client and counselor improves the effectiveness of counseling (e.g., Wampold, 2001). Multicultural competencies are essential for enhancing the quality of the therapeutic alliance and bridging the gap between traditional psychotherapy and the needs of culturally diverse clients (e.g., Arredondo & Arciniega, 2001; Ito & Maramba, 2002; S. Sue, 1998). However, limited research has specifically investigated the association between counselors’ multicultural competence and the counseling outcomes of clients. Across 11 studies with data that we located in the literature, the average correlation coefficient between counselor multicultural competence and client ratings of the counselor was r = 0.30, indicating a moderately strong relationship. When counselor multicultural competence was correlated with client outcomes, the value was r = 0.15, which indicated a very modest association, but it should be kept in mind that only about 8% of variance in client outcomes is attributable to counselors (e.g., Kim, Wampold, & Bolt, 2006). In any case, additional research on counselor multicultural competence is clearly needed to ascertain which specific competencies are most conducive to positive client outcomes in counseling. Implications for counseling practice. Counselors can move toward multicultural competence by reviewing the specific qualities listed in professional guidelines (e.g., Arredondo et al., 1996) and then systematically improving their abilities through ongoing professional development. For instance, counselors can learn about and practice different styles of communication that are effective with clients whose preferred methods of communication differ from the counselors’ own. In acquiring multicultural competence, there is no substitute for experiential learning. Self-reflection is an essential part of that learning, but even self-reflection must be based on concrete experiences to be useful. Purposefully seeking out professional consultation and supervision that attends to multicultural issues can help (Constantine, 2001; Lassiter, Napolitano, Culbreth, & Ng, 2008), as can engaging in cultural immersion experiences (Tomlinson-Clarke, 2010). Reading, engaging in dialogue with culturally different peers, and attending multicultural community events and activities, such as film screenings and public forums, can help raise awareness and knowledge. Counselors unfamiliar with particular cultural groups can identify community leaders or other key stakeholders within those communities and proactively seek consultation. Irrespective of the methods they use to acquire multicultural competencies, counselors should keep in mind that gaining such competencies is an ongoing process involving emotional, cognitive, and experiential components, not simply an academic endeavor. This learning continues across a lifetime. No one is free from bias. Multicultural Training for Counselors Professional associations require graduate training programs to address multicultural issues, and training in multicultural competencies requires specialized instruction (Cates, Schaefle, Smaby, Maddux, & LeBeauf, 2007). Hence, graduate and postgraduate classes and workshops in multicultural counseling constitute one of the primary strategies for improving counselors’ capacity to serve diverse populations effectively (Abreu, Chung, & Atkinson, 2000). Multicultural education for mental health professionals has become commonplace; as Ponterotto and Austin (2005) observe, “The critical importance of training psychologists and mental health professionals for work in an increasingly multicultural society is unquestioned” (p. 19). A key assumption is that that awareness, knowledge, and skills surrounding multicultural issues can be taught and learned (Abreu et al., 2000). To what degree is this specialized instruction in multicultural issues effective? How much do students gain by taking a typical class in multicultural counseling? Research findings on multicultural training for counselors. Just as there is no single form of “counseling,” there is no single type of training to enhance multicultural competence. There are a multiplicity of effective training sequences that vary in their content, format, duration, intensity, and techniques (Ponterotto & Austin, 2005). The majority of the published literature addresses graduate program coursework; however, the research is clear that it is essential for practicing clinicians to engage in ongoing professional development in this domain (Rogers-Sirin, 2008). A meta-analysis of studies of multicultural education for mental health students and professionals yielded a large average effect size of d = 0.92 (Smith, Constantine, Dunn, Dinehart, & Montoya, 2006), meaning that there is a strong correspondence between training and multicultural sensitivity and competence. Mental health professionals clearly benefit from multicultural education. Counselors’ and trainees’ self-reported abilities, self-reported racial attitudes, and clinical performance (as rated by observers or clients) all improve as a result of multicultural education, although there is substantial variability in the quality and effectiveness of the training provided across programs. On average, the effectiveness of multicultural education does not differ depending on whether it is required or voluntary, a finding that provides indirect support for the position taken by professional associations that multicultural education must be required in accredited graduate programs. Similarly, no significant difference was found between participants who were trainees and those who were working professionals. Multicultural education benefits both equally, although training explicitly based on multicultural theories is much more effective than training not grounded in the professional literature. Implications for professional development. Although multicultural education has been shown to be on average at least moderately effective, it is important to reemphasize the finding that the quality of such training varies substantially across settings and programs. Given the variability in training quality, trainees should seek out (or request) training that focuses explicitly on the development of multicultural competence. Obtaining multicultural competence is the objective of participation in multicultural education (e.g., Abreu et al., 2000; Ridley, Mollen, & Kelly, 2011), and aspects of multicultural education that do not directly facilitate multicultural competence should be replaced with more specific learning objectives and activities. The development of multicultural competencies is more than an academic pursuit. Experiential and performance-based evaluations can help ensure that skills are internalized. Case studies, service learning, and training accompanied by supervised practice can be useful to that end. Regardless of the specific methods used, training programs should emphasize general factors conducive to personal and professional development (e.g., high student expectations about their own competence, positive relationships between instructors and trainees, immediate application of material learned). In addition, a common limitation of multicultural education needs to be addressed squarely: Multicultural education should emphasize how counselors can work effectively with ambiguity/complexity; it should not reinforce categorical thinking that perpetuates stereotypes. Often, when trainees acquire general knowledge about a cultural group with which they have had limited prior experience, such as immigrants from Haiti, they tend to believe (falsely) that having learned the material is sufficient for them to work effectively with members of that population, and they may attempt to apply their new knowledge without careful consideration of the individual client. Not all members of a given group hold or even value the attributes common to that group. Not all Haitian immigrants have experienced trauma, for example. Hence, multicultural education must teach not only culturally specific elements but also dynamic sizing and scientific-mindedness so that trainees know how to individualize counseling appropriately (S. Sue, 1998). Too many multicultural training programs focus on awareness and knowledge to the exclusion of incorporating skill development (Pieterse, Evans, Risner-Butner, Collins, & Mason, 2009). Rather than simply talking about historically oppressed groups or promoting trainees’ insight into their personal feelings about those groups, effective training encourages counselors to gain the skills they need to work effectively with clients from diverse groups. An honest self-evaluation of multicultural competence can help students identify areas in which personal skill development is needed (Arredondo et al., 1996; D. W. Sue, Arredondo, & McDavis, 1992). Ultimately, the best multicultural training helps fill gaps in personal skills. Selected Multicultural Research on Client Characteristics Can I let myself enter fully into the world of his feelings and personal meanings and see these as he does?... Can I sense it so accurately that I can catch not only the meanings of his experience which are obvious to him, but those meanings which are only implicit? —Carl R. Rogers, On Becoming a Person, 1961 In this section we direct attention to the subjective world of clients of color, whose daily experiences and cultural worldviews may be misunderstood by counselors from other racial and ethnic backgrounds. We ask three questions related to these clients’ unique racial or ethnic experiences: What effect does received racism have on client well-being? What is the relationship between racial and ethnic identity and well-being? To what degree is the client’s level of acculturation to Western society associated with perceptions about and experiences in counseling? Received Racism and Client Well-Being The landscape of North American society has changed drastically over the past several decades in terms of racial and ethnic relations. Few readers of this book will recall the passage of the Civil Rights Act of 1964, let alone the preceding decades/centuries of overt racial discrimination, such as forced resettlement of Native Americans on federal reservations, and the associated struggle for liberation, such as the civil rights marches held in the South. These events have been relegated to history books. Given that such dramatic improvements in racial relations have taken place over time, why should we consider the psychological effects of racism in our contemporary society? First, we must candidly admit that racial prejudice and stereotypes have not yet been eliminated. Many neighborhoods, schools, and occupations show clear divisions along racial and ethnic lines. It is true that racism is becoming less overt over time, yet it persists in our institutions, our educational system, and our workplaces (Blume, Lovato, Thyken, & Denny, 2012; D. W. Sue et al., 2007; Yosso, Smith, Ceja, & Solórzano, 2009). People of color may be asked, “What are you?” by someone attempting to ascertain race/ethnicity, or they may often hear, “Where are you from?” or “You speak English so well!” These and many other seemingly harmless questions or forms of “praise” produce negative emotional reactions: The subtle messages of differentiation are insulting. Scholars have called these events racial microaggressions, a social maintenance of racial hierarchy (D. W. Sue et al., 2007). Although this kind of treatment may be subtle, how many of these microaggressions does a person of color experience in one week? If counselors are truly to enter the personal worlds of their clients, they must be sensitive to the experiences those clients have with discriminatory acts. Even the most mundane, nuanced hint of racial or ethnic hierarchy can result in psychological distress, selfdeprecation, anger, withdrawal, and so forth. Research findings on the association of perceived racism with well-being. Self-reported perceived racism has been shown to be associated with higher blood pressure, maladaptive coping strategies such as binge drinking, lower self-esteem, and higher levels of psychological distress and anxiety (Blume et al., 2012; Huynh, 2012; Moradi & Risco, 2006; Steffen, McNeilly, Anderson, & Sherwood, 2003). While perceived racism has adverse effects on members of all ethnic and racial groups, experiences with perceived racism differ across groups. Specifically, African Americans tend to report higher levels of exposure to racial discrimination than do members of other racial and ethnic groups (Pieterse, Carter, Evans, & Walter, 2010; Thompson, 2006). Latinas/os tend to have experiences with perceived racism based on assumptions regarding their legal status, language abilities, and level of acculturation (Moradi & Risco, 2006). Other groups, such as Arab Americans, experience racism based on false stereotypes and misinformation specific to their particular groups. Regardless of the uniqueness of the perceived racism, several meta-analytic findings support the connection between perceived racism and psychological distress across various racial and ethnic minority groups. One study found an adverse relationship between perceived discrimination and mental health (r = –0.16) across 105 studies (Pascoe & Smart Richman, 2009). Another found a correlation of r = 0.23 between perceived racism and psychological distress in Asian and Asian American participants in 23 studies (Lee & Ahn, 2011). A third found that perceived racism correlated r = 0.20 with psychological distress across 66 studies with African American participants (Pieterse, Todd, Neville, & Carter, 2012). Although the association between perceived racism and well-being is consistently negative, indicating adverse psychological outcomes, there is great variability in the degree to which individuals and groups cope effectively with such racism, thus counselors should seek to understand the experiences and reaction of their clients. Implications for counseling practice. A professional counselor must first consider how his or her own actions may unwittingly perpetuate perceived racism or microaggressions. Will the client see the counselor as yet one more “professional” to mistrust (Moody-Ayers, Stewart, Covinsky, & Inouye, 2005)? Understanding received racism will help counselors to foster a deeper level of understanding between their clients and themselves; by opening dialogue about received racism, counselors can better understand the experiences of their clients of color and thus be able to help these clients confront and otherwise cope with the negative events. A counselor may also, after establishing sufficient rapport, ask the client about possible microaggressions that have occurred in counseling (Constantine, 2007). Perceived racist events matter to the client, even if they appear to the counselor to be small or taken out of context, so the counselor should avoid perpetuating them, such as by denying their existence. In addition, the counselor can help the client develop a strong sense of community and an affirmative ethnic identity, which can help to buffer some of the adverse effects of received racism (Mossakowski, 2003; Yosso et al., 2009). How a strong ethnic identity may facilitate client wellbeing is the topic we consider next. Racial and Ethnic Identity Development and Well-Being What does it mean to be a Latino/a, an Egyptian American, a White/European American, or an Alaska Native? Is the notion of racial and ethnic identity important in a diverse society? As one example of how race/ethnicity continues to matter in contemporary settings, Peggy McIntosh (2003) has written about how being White in North America confers on her unearned privileges that benefit her daily life and psychological well-being. She acknowledges that it took purposeful examination for her to identify these privileges, but people of other races/ethnicities likely see them more easily. We can see in others what we have difficulty seeing in ourselves, and our own racial or ethnic identity is influenced by our interactions with others (Smith & Draper, 2004). As clients of color negotiate responses to mainstream White culture, they simultaneously negotiate identification with their own racial or ethnic groups. When they act in ways appreciated by Whites, they may sometimes diminish the cultural values of their own groups (e.g., autonomy/assertiveness versus respectful deference to elders), creating problems in their interactions with members of those groups. The balance and trade-offs between relating with Whites and relating to people of their own groups can make identity issues quite prominent for people of color (Murray, Neal-Barnett, Demmings, & Stadulis, 2012). Scholars have differentiated ethnic identity and racial identity as two distinct constructs. Racial identity refers to the development of an identity within a particular racial group (e.g., African Americans); the construct of racial identity takes into account social oppression and an internalization of certain preconceived notions about the racial group (Helms, 1990). Ethnic identity, on the other hand, is not unique to a particular racial group and can be defined as “the subjective sense of belonging to a group or culture”; this sense of belonging tends to center on the sharing of cultural values or beliefs (Phinney, 1990; Phinney, Horenczyk, Liebkind, & Vedder, 2001). Whereas racial identity focuses on the influence of societal oppression on a particular racial group, and how the individual associates him- or herself within that racial group, ethnic identity takes into account a broad range of cultural values that contribute to identity (language, religion, race, and so on). Encounters with racism may trigger explorations of what it means to be a member of a particular racial group (Cross, 1991), but prolonged exposure to perceived racism can contribute to a person’s downplaying his or her racial or ethnic background (Romero & Roberts, 1998). Scholars have suggested that racial/ethnic socialization, learning from family members, peers, and role models, can encourage an individual’s internalization of racial or ethnic heritage, with an accompanying sense of belonging (Bennett, 2006; Seaton, Yip, Morgan-Lopez, & Sellers, 2012). Research findings on the association of racial and ethnic identity with well-being. Researchers have explored the protective nature of racial and ethnic identity and have sought to establish the relationship between a strong racial or ethnic identity and psychological well-being. For instance, African American individuals who report a higher level of racial identity development tend to display less depressive symptoms and report higher levels of well-being; in addition, a strong racial identity has been shown to lessen the effects of race-related stress and to predict mental health (Franklin-Jackson & Carter, 2007; Seaton, Scottham, & Sellers, 2006). Scholars have also suggested that ethnic identity may serve as a predictor of positive self-esteem for Latino adolescents and African American college students, as well as serving as a protective factor against depressive symptoms for Latino adolescents (Phelps, Taylor, & Gerard, 2001; Umaña-Taylor & Updegraff, 2007). A recent meta-analysis found that individuals’ strength of ethnic identity was mildly positively related (r = 0.18) with their psychological well-being (Smith & Silva, 2011). There was substantial variability across studies, such that ethnic identity was more predictive of well-being in some circumstances than in others. Ethnic identity was not strongly related to measures of distress or symptoms of mental illness; thus, it may not provide as strong a buffering effect as had been previously believed. Overall, the research findings about ethnic identity and well-being suggest that the relationship is not as straightforward as had been previously thought; counselors must rely on individual clients’ experiences rather than on clear-cut trends in research findings. Implications for counseling. Clients from all backgrounds vary in terms of their ethnic or racial identity development. How strongly a client associates with her or his racial or ethnic group depends on several factors, including prior socialization, current social networks, and local intergroup dynamics. Taking these factors into account, the counselor can actively consider: How does my client relate to his or her own racial or ethnic background? Additionally, how does my client benefit, or possibly stand to benefit, from a strong(er) racial or ethnic identity? The counselor might facilitate rapport and open exploration about racial and ethnic identity development through self-disclosure (e.g., social reciprocity is normative in Latino cultures) or by exploring with the client potentially valued topics, such as family, friends, and even music and entertainment preferences. Every client has a story to tell, and the counselor’s taking the time to ask the client what it means to be a part of his or her racial or ethnic group can possibly facilitate counseling. Client Acculturation and Counseling Utilization/Outcomes What is life like for a person who is faced with adapting to a radically different culture? Individuals who move to locations with cultural norms different from their own, whether through emigration/immigration or simple relocation from one neighborhood to another, often struggle to adapt to their new cultural surroundings. Imagine individuals who find themselves living in places where the foods, customs, and perhaps even languages are very much different from what they were accustomed to previously. These individuals cannot simply expect for others to understand their customs or values, so often they undergo the difficult process of trying to adjust and fit into their new environments. Acculturation is the process of cultural adaptation that occurs when a person encounters a culture that is different from his or her own and begins to internalize some of the values or customs of the new environment (Berry, 1997). This process can be different across racial, ethnic, and national groups, as some individuals may need to acculturate only toward the values and customs of their host country, while others may have to adopt the language of the majority. The pressure to adapt to the customs of the majority culture may lead some individuals to speak their native language only at home and to abandon some of their prior customs/values. Scholars have termed this pressure acculturative stress (Cervantes, Padilla, & Salgado de Snyder, 1991). This stress is not solely due to social pressure and values conflicts; even small tasks, if unfamiliar, may be stressful to individuals adjusting to a new culture. For instance, when they go to the bank, will the teller be bilingual? The acculturative process pervades daily life. Research findings on the association of client level of acculturation with wellbeing and experiences with mental health services. Abundant research has examined the association of the acculturation process and acculturative stress with a wide range of behaviors/indices of psychological well-being. With regard to acculturative stress, researchers have found a positive relationship between such stress and anxiety, depression, and body image disturbance (Menon & Harter, 2012; Revollo, Qureshi, Collazos, Valero, & Casas, 2011). Additionally, acculturative stress has been shown to be associated with suicidal ideation, suicide attempts, maladaptive stress responses (e.g., binge drinking, eating disorders), and lower reported qualities of life (Belizaire & Fuertes, 2011; Cachelin, Phinney, Schug, & Striegel-Moore, 2006; Gomez, Miranda, & Polanco, 2011). With regard to the acculturation process itself, acculturation to Western society has been shown to affect psychological well-being, increasing the incidence of depression and elevated blood pressure (Steffen, Smith, Larson, & Butler, 2006; Torres & Rollock, 2007). The process of acculturation is stressful, and individuals with low levels of acculturation may feel culturally incompetent because of lack of language mastery, understanding of social systems, and so on. Level of acculturation can influence how individuals perceive professional counseling. Professional counseling is rarely used outside Australia, New Zealand, Europe, and North America. Moreover, cultures have different beliefs about mental health and the disclosure of mental illness to strangers, with great variability in the degree to which someone unfamiliar with Western modes of counseling will actively engage in it. For instance, differences in parent and adolescent acculturation levels (i.e., the adolescent is more acculturated while the parent is less so) are associated with weaker treatment outcomes across depression and delinquency, indicating that a large difference in parent–child acculturation levels can pose a threat to treatment outcomes (Crane, Ngai, Larson, & Hafen, 2005). Treatments for positive behavior changes (i.e., smoking cessation) have been shown to be less effective for less acculturated individuals (Hooper, Baker, de Ybarra, McNutt, & Ahluwalia, 2012). However, among clients who have made the commitment to attend therapy, acculturation levels do not seem to be associated with levels of client attrition or nonattendance of initial intake appointments (Akutsu, Tsuru, & Chu, 2004; McCabe, 2002). Overall, our meta-analytic review of more than 60 studies revealed a high degree of variability in research findings, with the overall association between clients’ levels of acculturation and their experiences in and perceptions of mental health counseling being negligible, except among immigrant populations. Hence, counselors need to attend to individual clients’ perceptions and experiences in counseling rather than make general assumptions about how acculturation may influence those perceptions and experiences. Implications for counseling. By seeking to understand how the acculturation process influences the client’s well-being, the counselor can facilitate a stronger therapeutic alliance and a more holistic conceptualization of the presenting problem(s). How has the client coped with unfamiliar environments and ways of doing things? What supports have been most helpful in the client’s adjustment process? Seeking that kind of information will be more helpful for both counselor and client than counseling that focuses exclusively on the presenting problem and thus ignores critical life circumstances, existing methods of coping, and support systems. Clients with low levels of acculturation may benefit from outside referrals/resources that can assist them with adjustment processes. By providing information that decreases language barriers, facilitates financial management, or supports clients’ religious/spiritual well-being, counselors can help clients access resources that they may not have known existed. Counselors should also address differences in parent–child acculturation levels. For instance, attending a parent–teacher meeting may be a very novel situation for a less acculturated parent and possibly embarrassing for the more acculturated child when the parent’s expectations differ from those of the teacher. Counselors must also keep in mind that they may have to work to overcome a client’s negative preconceived notions about therapy or mental health providers that could affect the therapeutic alliance (Vasquez, 2007). Particularly, counselors may find that clients from diverse racial and ethnic backgrounds may benefit from culturally adapted methods of counseling. Selected Multicultural Research on Counseling Factors The previous sections have described how counselor and client characteristics can influence clients’ experiences in counseling and their psychological well-being. In this section, we consider the interaction between counselor and client. Specifically, we ask two questions about counseling itself: Does it matter whether the client and counselor share the same race/ethnicity? Does it matter whether the counseling content and processes explicitly align with the client’s culture? Racial and Ethnic Matching of Client and Counselor Professionals have consistently emphasized the need for cultural congruence between counselors and clients (Pope-Davis, Coleman, Liu, & Toporek, 2003). So, does this mean that clients have better counseling outcomes when they work with counselors who share their own racial or ethnic backgrounds? Who better than a counselor who has immigrated herself to understand the experiences of a client who recently immigrated? The benefits of racial and ethnic matching of client and counselor seem obvious: The counselor has instant credibility with the client and deep understanding of the nuances of the client’s lived experiences that should enhance the therapeutic alliance and client outcomes. But is it that simple? Interpersonal differences (e.g., socioeconomic status, religion) remain even when counselor and client have identical racial or ethnic backgrounds. Thus, a presumption of client– counselor similarity based on race/ethnicity alone can cause overidentification, countertransference, and so on, which may frustrate or at least disappoint the client, particularly when client and counselor have incongruous values and experiences, as illustrated in the following account from a graduate student counselor: As a Native American woman raised on a reservation but later residing in many regions of the country, I have for many years negotiated the nuances of racial and ethnic diversity. I admit to having felt very confident in working with people across a broad range of differences. My confidence completely failed me when I met with my first Native American client. I thought I could build a strong therapeutic alliance with her because we shared similar experiences, right? When I spoke about the reservation and cultural dances, I learned that she had never participated in cultural dances and had no experience with reservation life at all. All of my assumptions had been wrong. Most of that first session was spent rewinding and starting over again, and again, and again. Individuals make inaccurate assumptions about how similar they are to others (Kenny & West, 2010). People of the same race/ethnicity may not share the same worldview, and people of different races/cultures may have compatible worldviews. There is greater variability within racial and ethnic groups than individuals typically conjecture. Exact similarity of client and counselor is impossible. It is also undesirable. Differences in perspectives promote insight, facilitate reframing, and so on. Effective counseling relationships entail similarities and differences. The issue of racial and ethnic congruence in counseling requires careful consideration, and an accurate understanding relies on an examination of research findings. Research findings on racial and ethnic matching of client and counselor. Evidence cited by reviews and meta-analyses conducted in previous decades generally indicates that even though people prefer counselors of their own race/ethnicity, matching clients and counselors on race/ethnicity does not improve client outcomes (Coleman, Wampold, & Casali, 1995; Karlsson, 2005; Maramba & Hall, 2002). A recent meta-analysis examined the issue in detail using a much broader base of research findings than had been considered previously (Cabral & Smith, 2011). Across 52 studies of individuals’ preferences for counselor race/ethnicity, the average effect size was d = 0.63, indicating a moderately strong preference for a counselor of the same race/ethnicity. Across 81 studies of clients’ perceptions of their counselors as a function of racial and ethnic matching, the average effect size was d = 0.32, indicating a tendency for participants to evaluate matched counselors as somewhat better than unmatched counselors. Across 53 studies of client outcomes in counseling under matched versus unmatched conditions, the average effect size was d = 0.09, indicating minimal improvement in outcome when clients were matched with counselors of their own race/ethnicity. In general, individuals tended to prefer having counselors of their own race/ethnicity (who they likely imagined would share their own worldviews), but once they entered a therapeutic relationship, the counselors’ race/ethnicity made only a little difference in how positively they evaluated the counselors and only a very small difference in how much they benefited from the treatment provided. The notable exception to the overall findings of the meta-analysis just cited concerned African Americans. On average, African Americans not only strongly preferred to be matched with African American counselors and evaluated African American counselors more positively than other counselors but also had mildly improved outcomes in counseling (d = 0.19) when they were matched with African American counselors. This finding may be attributable to strong racial or ethnic identification and concerns about bias in the mental health services provided by White counselors (e.g., Snowden, 1999). Nevertheless, we must keep in mind that the magnitude of the observed difference (d = 0.19) was small, explaining less than 1% of the variance in client outcomes. Implications for counseling practice. Despite evaluating counselors of their own race or ethnicity more positively than those of dissimilar backgrounds, on average clients (and counselors) appear to be able to negotiate differences in race/ethnicity such that the outcomes experienced in counseling are minimally affected. Clients benefit from counseling with counselors whose race/ethnicity differs from their own despite their initial preferences and despite their evaluations of the counselors’ traits and skills being somewhat affected. By implication, the greatest relevance of racial and ethnic matching occurs during the initial sessions of counseling, when the therapeutic alliance is being formed. When client and counselor differ in race or ethnicity, the difference is immediately obvious to both. Yet in that first encounter, the counselor and client remain unaware of the many similarities they already share. When working across race or ethnicity, a counselor should neither become anxious about obvious differences nor ignore them, as in so-called color-blindness (Neville, Spanierman, & Doan, 2006). Neither extreme will engender trust in the client. The key is for the counselor to leverage sufficient interpersonal rapport for the client to engage wholeheartedly in counseling, with the counselor seeking understanding of and bridging differences. Because group biases persist in society and in counseling, some clients may request to see counselors of their own races/ethnicities, and such requests can be appropriately met. Nevertheless, professional agencies should generally avoid policies that automatically match clients with counselors of the same racial or ethnic background (Alladin, 1994). It is more practical to provide in-depth training for all counselors to help them acquire multicultural competencies and thus work more effectively across cultures. The focus of cross-cultural counseling needs to remain on its effectiveness (S. Sue, 1998), with primary emphasis placed on the alignment of the counseling with the client’s worldview. Culturally Adapted Counseling Many counseling strategies and techniques are based on general theories (e.g., behaviorism, psychoanalysis, cognitive therapy), but general theories do not account for individual variation. Clients differ in their attributes and differ in their alignment with the methods used in counseling. No single treatment can meet the needs of every client, so it is no surprise that client factors explain most of the variance in treatment outcome (Bohart & Tallman, 2010), much more than the type of treatment provided (e.g., Asay & Lambert, 1999). Hence, counselors must consider client contexts and provide treatment that is an optimal “fit” for each client (Beutler et al., 2012). Counselors must adapt their own methods to align with the needs, abilities, and worldviews of individual clients. For instance, a counselor would use different methods with a young girl demonstrating externalizing behaviors after experiencing bullying in elementary school than she would with a young woman demonstrating internalizing behaviors after experiencing cyberbullying; differences in developmental status and symptoms/behavior obviously require adaptation, even when some client characteristics remain constant (in this case, gender and encountering inappropriate aggression). The same principle applies to differences across cultures. Counselors should align their work with clients’ cultural worldviews and experiences, such as when depression is conceptualized in terms of somatic symptoms (i.e., lack of energy, headaches, insomnia) among Chinese populations less exposed to Western psychologization (Ryder et al., 2008). Counseling practices must account for culture. How does a counselor adapt counseling based on a client’s culture? First, the counselor must accurately understand the client’s worldview. How does the client conceptualize the problem(s) and previous attempts to address the problem(s)? Often, those conceptualizations will be filtered through the lenses of cultural values. For instance, if a Guatemalan American client continually references interpersonal relationships, that would likely reflect cultural values (familismo, personalismo, respeto, and so on) rather than what might be incorrectly labeled “enmeshment” from a White/European American perspective. Accurate understanding of a client thus requires counselor knowledge of cultural values, but it also requires differentiation skills: What is true in general may not be true for the individual. The Guatemalan American client might be excessively enmeshed in relationships, particularly if the client’s Latino/a peer group is reacting as if the individual is inappropriately dependent. The counselor’s accurate understanding of the client’s worldview and experience necessarily informs treatment decisions. Cultural adaptations of counseling range from superficial to extensive. To avoid superficiality, counselors can follow professional guidelines and models for cultural adaptations of counseling (Barrera & Castro, 2006; Bernal, Bonilla, & Bellido, 1995; Hwang, 2009; Lau, 2006; Leong, 2011; Whitbeck, 2006). These models are multidimensional, inclusive of language (using the client’s preferred language and communication styles), goals (focusing on the client’s preferred outcomes), content (using wording and concepts familiar to the client), and methods (using procedures aligned with the client’s values/experiences). An example of culturally congruent goal setting: If a college student from Pakistan repeatedly worries about his parents’ opinions, the counselor might appropriately explore ways to increase the client’s mutual trust with the parents (and thus decrease anxiety) but should not suggest a counseling goal of assertiveness toward authority figures, because that goal would align with the cultural value of the counselor (individualism) but not necessarily with the values of the client unless explicitly stated. An example of culturally adapted content: Counseling involving bibliotherapy with young Hispanic/Latino(a) Americans could be based on cuentos, folk stories with Hispanic/Latino(a) hero/heroine models (Costantino, Malgady, & Rogler, 1986). Naikan therapy and Morita therapy are examples of culturally adapted treatment methods from Japan that can be modified for Japanese Americans with traditional Japanese worldviews. Naikan therapy emphasizes introspection about relationships, and Morita therapy emphasizes acceptance of emotion and taking constructive action (Hedstrom, 1994). All counseling methods, such as cognitivebehavioral therapy (CBT), can incorporate culturally congruent methods, such as mindfulness and visualization with Vietnamese Americans (Hinton, Safren, Pollack, & Tran, 2006) or faith-based coping and deconstruction of the “Black superwoman” myth among African American women (Kohn, Oden, Muñoz, Robinson, & Leavitt, 2002). The aim of any cultural adaptation, whether it involves language, goals, content, or methods, should be to better align counseling with client experiences/worldviews. Research findings on culturally adapted counseling. A preliminary quantitative review of research indicated that culturally adapted mental health treatments are effective (Griner & Smith, 2006). Two subsequent meta-analyses have confirmed this conclusion. In one of these, culturally adapted treatments compared with any type of control group yielded an effect size of d = 0.46 (Smith, Rodríguez, & Bernal, 2011). In a more rigorous analysis, culturally adapted treatments compared directly with other bona fide treatments (e.g., culturally adapted CBT compared to CBT as usual) yielded an effect size of d = 0.32 (Benish et al., 2011). Counseling is more effective when it is adapted to the cultural background of the client. And the better those adaptations, the better the outcomes (Smith et al., 2011), particularly when they align with the client’s perceptions/explanations about the illness (Benish et al., 2011). Implications for counseling practice. Treatment outcomes are consistently more effective when counselors work to align themselves with the cultural beliefs of their clients. Counselors should specifically work to align themselves with their clients’ beliefs, perceptions, and explanations of their presenting illnesses. At a minimum, this entails asking the clients about their beliefs about the nature and causes of their presenting problems, what they have experienced as a result of their presenting problems, and how these experiences may relate to their environments and to their cultural beliefs. With this information, counselors can identify goals, content, and methods of counseling that are culturally appropriate for individual clients. The key is cultural congruence: Does the client experience the counseling as appropriate, rather than irrelevant to or disrespectful of the client’s heritage and values? Cultural adaptations to counseling should be as specific to the client and the client’s cultural worldview as possible; counselors should avoid implementing a generic approach across various racial and ethnic groups. Counselors should follow professional guidelines for culturally adapting counseling (Barrera & Castro, 2006; Bernal et al., 1995; Hwang, 2009; Lau, 2006; Leong, 2011; Whitbeck, 2006). Examples of adaptations include using cultural metaphors/sayings, sharing culturally relevant literature/quotations/legends, using different mediums of expression such as art, and acknowledging specific cultural values that are either relevant to the presenting problem or conducive to coping (e.g., holistic conceptualizations of experience, denoted by the medicine wheel for many American Indian clients). When a counselor is unfamiliar with culturally appropriate adaptations, he or she should consult with knowledgeable professionals, explore the client’s perceptions about helpful ways of coping with the presenting problem, and closely monitor the client’s experiences in counseling to avoid misalignment. Therapeutic approaches may need to change over the course of the counseling, and the counselor should be prepared to make those changes based on client feedback (Lambert, 2010). Conclusion For several decades scholars and practitioners have affirmed that counselors should focus attention on the cultural values and worldviews of their clients. Research findings provide support for that assertion. Culturally congruent counseling practices are more effective than practices that do not account for clients’ cultural contexts. Counselors who are unfamiliar with their clients’ cultural backgrounds can learn to work with them effectively and demonstrate multicultural counseling competence. Counselors need not necessarily be of the same race/ethnicity as their clients to be effective, but they do need to adapt their own practices to meet the needs and experiences of their clients. Thus, culture should be a primary, not secondary, consideration in counseling, with the information provided across the other chapters in this book building on a solid foundation of accumulated research evidence. Critical Incident Steve is an experienced licensed professional counselor working in a community clinic. He is by nature outgoing, has friends from many walks of life, and feels confident about his many years of practice with diverse clientele. He recently completed a protracted divorce from his wife of seven years and has no children. A fourth-generation Japanese American, Steve was raised in an uppermiddle-class area of the West Coast. When he glanced at the intake form completed by Riza (the female client described at the start of this chapter), Steve immediately felt concerned about how a recent immigrant from the Philippines might react to him, given that the Japanese occupation of the Philippines in the 1940s must have affected the client’s parents and extended family. In session, Riza haltingly described her difficulties in adjusting to life in the United States. Steve observed that Riza had adopted a coping strategy of avoidance of contact with most Americans after several poignantly negative experiences in which she went away feeling incompetent, despite her high level of occupational qualifications. Riza maintained close contact with friends and family members in the Philippines via the Internet, but she did not socialize with anyone outside her immediate family after work hours. Steve observed that Riza’s strongest emotional reactions occurred when she spoke about her husband. She described circumstances that were very similar to those Steve had experienced in his marriage, but when asked whether she had considered divorce, Riza strongly affirmed her commitment to her husband and his family. Steve was at first surprised that many of Riza’s decisions stemmed from her sincere faith in Catholicism. He fought against his initial reaction to judge Riza’s daily devotions and prayers, and he directed conversations back to what he believed were the central issues for Riza: her social isolation, passivity, and excessive guilt, which seemed to be the primary causes of her depressed moods. Even after specific questioning about those issues, Riza seemed to be holding something back. Steve then raised the issue of their different ethnic backgrounds as part of checking Riza’s perceptions about how things had gone during their initial session together. Riza acknowledged that her maternal grandfather had died during the Japanese occupation, but she said that her family seldom recounted the past and she understood that neither Steve nor his family had any connection to her own past. In fact, she believed that her being assigned to work with Steve was a spiritual metaphor: Having a counselor of Japanese ancestry meant that God brought them together to prove that all things can be healed. After the session, Steve recognized that his personal beliefs about taking the initiative in social settings and about family roles and divorce had made it difficult for him to follow up on Riza’s perspectives. After consultation with a Filipino colleague, Steve started to gain appreciation for the cultural contexts influencing Riza’s actions. Discussion Questions 1. How did Steve’s initial assumptions and personal beliefs affect his work with this client? What do you think about his decision to dwell on his own personal experiences and how they may have influenced his relationship with Riza? 2. What specific strategies could Steve use to understand Riza better from her own perspective during subsequent sessions? 3. What might be some effective strategies that Steve could use to address Riza’s social withdrawal, which seems to be associated with judgmental/prejudicial social encounters she has experienced? 4. What specific multicultural counseling competencies will facilitate additional trust between Riza and Steve? 5. Ethnic and racial identity and acculturative status are often noted as major factors in a client’s response to counseling, but research indicates wide variability in how those variables relate with well-being and experiences in counseling. Discuss how those two constructs may affect a counselor’s work with Riza in light of the meta-analytic findings presented in this chapter. 6. After becoming more familiar with Catholicism and Filipino culture, list a series of culturally sensitive adaptations to counseling that might enable Steve to work effectively with Riza. References Abreu, J. M., Chung, R. H. G., & Atkinson, D. R. (2000). Multicultural counseling training: Past, present, and future directions. The Counseling Psychologist, 28, 641–656. Akutsu, P. D., Tsuru, G. K., & Chu, J. P. (2004). Predictors of nonattendance of intake appointments among five Asian American client groups. Journal of Consulting and Clinical Psychology, 72, 891–896. Alladin, W. J. (1994). Ethnic matching in counselling: How important is it to ethnically match clients and counsellors? Counselling Psychology Review, 9(3), 13–17. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. Washington, DC: Author. Arredondo, P., & Arciniega, G. M. (2001). Strategies and techniques for counselor training based on the multicultural counseling competencies. Journal of Multicultural Counseling and Development, 29(4), 263–273. Arredondo, P., & Toporek, R. (2004). Multicultural counseling competencies = ethical practice. Journal of Mental Health Counseling, 26(1), 44–55. Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalization of the multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24(1), 42–78. Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 23–55). Washington, DC: American Psychological Association. Barrera, M. J., & Castro, F. G. (2006). A heuristic framework for the cultural adaptation of interventions. Clinical Psychology: Science and Practice, 13(4), 311–316. Belizaire, L. S., & Fuertes, J. N. (2011). Attachment, coping, acculturative stress, and quality of life among Haitian immigrants. Journal of Counseling & Development, 89(1), 89–97. Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58(3), 279–289. Bennett, M. D. (2006). Culture and context: A study of neighborhood effects on racial socialization and ethnic identity content in a sample of African American adolescents. Journal of Black Psychology, 32(4), 479–500. Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23(1), 67–82. Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology, 46(1), 5–34. Beutler, L. E., Forrester, B., Gallagher-Thompson, D., Thompson, L., & Tomlins, J. B. (2012). Common, specific, and treatment fit variables in psychotherapy outcome. Journal of Psychotherapy Integration, 22, 255–281. Blume, A. W., Lovato, L. V., Thyken, B. N., & Denny, N. (2012). The relationship of microaggressions with alcohol use and anxiety among ethnic minority college students in a historically White institution. Cultural Diversity & Ethnic Minority Psychology, 18(1), 45–54. Bohart, A. C., & Tallman, K. (2010). Clients: The neglected common factor in psychotherapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 83–111). Washington, DC: American Psychological Association. Cabral, R. R., & Smith, T. B. (2011). Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology, 58(4), 537–554. Cachelin, F. M., Phinney, J. S., Schug, R. A., & Striegel-Moore, R. (2006). Acculturation and eating disorders in a Mexican American community sample. Psychology of Women Quarterly, 30(4), 340–347. Cates, J. T., Schaefle, S. E., Smaby, M. H., Maddux, C. D., & LeBeauf, I. (2007). Comparing multicultural with general counseling knowledge and skill competency for students who completed counselor training. Journal of Multicultural Counseling and Development, 35(1), 26–39. Cervantes, R. C., Padilla, A. M., & Salgado de Snyder, N. (1991). The Hispanic Stress Inventory: A culturally relevant approach to psychosocial assessment. Psychological Assessment, 3(3), 438–447. Chao, R. C., & Nath, S. R. (2011). The role of ethnic identity, gender roles, and multicultural training in college counselors’ multicultural counseling competence: A mediation model. Journal of College Counseling, 14(1), 50–64. Coleman, H. L. K., Wampold, B. E., & Casali, S. L. (1995). Ethnic minorities’ ratings of ethnically similar and European American counselors: A meta-analysis. Journal of Counseling Psychology, 42(1), 55–64. Constantine, M. G. (2001). Multiculturally-focused counseling supervision: Its relationship to trainees’ multicultural counseling self-efficacy. Clinical Supervisor, 20(1), 87–98. Constantine, M. G. (2002). Predictors of satisfaction with counseling: Racial and ethnic minority clients’ attitudes toward counseling and ratings of their counselors’ general and multicultural counseling competence. Journal of Counseling Psychology, 49(2), 255–263. Constantine, M. G. (2007). Racial microaggressions against African American clients in cross-racial counseling relationships. Journal of Counseling Psychology, 54(1), 1–16. Costantino, G., Malgady, R. G., & Rogler, L. H. (1986). Cuento therapy: A culturally sensitive modality for Puerto Rican children. Journal of Consulting and Clinical Psychology, 54(5), 639–645. Crane, D. R., Ngai, S. W., Larson, J. H., & Hafen, M. J. (2005). The influence of family functioning and parent–adolescent acculturation on North American Chinese adolescent outcomes. Family Relations, 54(3), 400–410. Cross, W. E. J. (1991). Shades of Black: Diversity in African-American identity. Philadelphia: Temple University Press. Franklin-Jackson, D., & Carter, R. T. (2007). The relationships between race-related stress, racial identity, and mental health for Black Americans. Journal of Black Psychology, 33(1), 5–26. Glass, G. V. (1976). Primary, secondary, and meta-analysis of research. Educational Researcher, 10, 3–8. Gomez, J., Miranda, R., & Polanco, L. (2011). Acculturative stress, perceived discrimination, and vulnerability to suicide attempts among emerging adults. Journal of Youth and Adolescence, 40(11), 1465–1476. Gone, J. P., & Trimble, J. E. (2012). American Indian and Alaska Native mental health: Diverse perspectives on enduring disparities. Annual Review of Clinical Psychology, 8, 131–160. Griner, D., & Smith, T. B. (2006). Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training, 43(4), 531–548. Hedstrom, L. J. (1994). Morita and Naikan therapies: American applications. Psychotherapy: Theory, Research, Practice, Training, 31(1), 154–160. Helms, J. E. (Ed.). (1990). Black and White racial identity: Theory, research, and practice. New York: Greenwood Press. Hinton, D. E., Safren, S. A., Pollack, M. H., & Tran, M. (2006). Cognitive-behavior therapy for Vietnamese refugees with PTSD and comorbid panic attacks. Cognitive and Behavioral Practice, 13(4), 271–281. Hooper, M. W., Baker, E. A., de Ybarra, D. R., McNutt, M., & Ahluwalia, J. S. (2012). Acculturation predicts 7-day smoking cessation among treatment-seeking African-Americans in a group intervention. Annals of Behavioral Medicine, 43(1), 74–83. Huynh, V. W. (2012). Ethnic microaggressions and the depressive and somatic symptoms of Latino and Asian American adolescents. Journal of Youth and Adolescence, 41(7), 831–846. Hwang, W. (2009). The formative method for adapting psychotherapy (FMAP): A community-based developmental approach to culturally adapting therapy. Professional Psychology: Research and Practice, 40(4), 369–377. Ito, K. L., & Maramba, G. G. (2002). Therapeutic beliefs of Asian American therapists: Views from an ethnic-specific clinic. Transcultural Psychiatry, 39(1), 33–73. Karlsson, R. (2005). Ethnic matching between therapist and patient in psychotherapy: An overview of findings, together with methodological and conceptual issues. Cultural Diversity & Ethnic Minority Psychology, 11(2), 113–129. Kenny, D. A., & West, T. V. (2010). Similarity and agreement in self- and other perception: A metaanalysis. Personality and Social Psychology Review, 14(2), 196–213. Kim, D., Wampold, B. E., & Bolt, D. M. (2006). Therapist effects in psychotherapy: A randomeffects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. Psychotherapy Research, 16(2), 161–172. Kohn, L. P., Oden, T., Muñoz, R. F., Robinson, A., & Leavitt, D. (2002). Brief report: Adapted cognitive behavioral group therapy for depressed low-income African American women. Community Mental Health Journal, 38(6), 497–504. Lambert, M. J. (2010). Prevention of treatment failure: The use of measuring, monitoring, and feedback in clinical practice. Washington, DC: American Psychological Association. Lassiter, P. S., Napolitano, L., Culbreth, J. R., & Ng, K. (2008). Developing multicultural competence using the structured peer group supervision model. Counselor Education and Supervision, 47(3), 164–178. Lau, A. S. (2006). Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent training. Clinical Psychology: Science and Practice, 13(4), 295–310. Lee, D. L., & Ahn, S. (2011). Racial discrimination and Asian mental health: A meta-analysis. The Counseling Psychologist, 39(3), 463–489. Leong, F. T. L. (2011). Cultural accommodation model of counseling. Journal of Employment Counseling, 48(4), 150–152. Maramba, G. G., & Hall, G. C. N. (2002). Meta-analyses of ethnic match as a predictor of dropout, utilization, and level of functioning. Cultural Diversity & Ethnic Minority Psychology, 8(3), 290–297. McCabe, K. M. (2002). Factors that predict premature termination among Mexican-American children in outpatient psychotherapy. Journal of Child and Family Studies, 11(3), 347–359. McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments: A review of current efforts. American Psychologist, 65(2), 73–84. McIntosh, P. (2003). White privilege: Unpacking the invisible knapsack. In S. Plous (Ed.), Understanding prejudice and discrimination (pp. 191–196). New York: McGraw-Hill. Menon, C. V., & Harter, S. L. (2012). Examining the impact of acculturative stress on body image disturbance among Hispanic college students. Cultural Diversity & Ethnic Minority Psychology, 18(3), 239–246. Moody-Ayers, S., Stewart, A. L., Covinsky, K. E., & Inouye, S. K. (2005). Prevalence and correlates of perceived societal racism in older African-American adults with type 2 diabetes mellitus. Journal of the American Geriatrics Society, 53(12), 2202–2208. Moradi, B., & Risco, C. (2006). Perceived discrimination experiences and mental health of Latina/o American persons. Journal of Counseling Psychology, 53(4), 411–421. Mossakowski, K. N. (2003). Coping with perceived discrimination: Does ethnic identity protect mental health? Journal of Health and Social Behavior, 44(3), 318–331. Murray, M. S., Neal-Barnett, A., Demmings, J. L., & Stadulis, R. E. (2012). The acting White accusation, racial identity, and anxiety in African American adolescents. Journal of Anxiety Disorders, 26(4), 526–531. Neville, H., Spanierman, L., & Doan, B. (2006). Exploring the association between color-blind racial ideology and multicultural counseling competencies. Cultural Diversity & Ethnic Minority Psychology, 12(2), 275–290. Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135(4), 531–554. Phelps, R. E., Taylor, J. D., & Gerard, P. A. (2001). Cultural mistrust, ethnic identity, racial identity, and self-esteem among ethnically diverse Black students. Journal of Counseling & Development, 79(2), 209–216. Phinney, J. S. (1990). Ethnic identity in adolescents and adults: Review of research. Psychological Bulletin, 108(3), 499–514. Phinney, J. S., Horenczyk, G., Liebkind, K., & Vedder, P. (2001). Ethnic identity, immigration, and well-being: An interactional perspective. Journal of Social Issues, 57(3), 493–510. Pieterse, A. L., Carter, R. T., Evans, S. A., & Walter, R. A. (2010). An exploratory examination of the associations among racial and ethnic discrimination, racial climate, and trauma-related symptoms in a college student population. Journal of Counseling Psychology, 57(3), 255–263. Pieterse, A. L., Evans, S. A., Risner-Butner, A., Collins, N. M., & Mason, L. B. (2009). Multicultural competence and social justice training in counseling psychology and counselor education: A review and analysis of a sample of multicultural course syllabi. The Counseling Psychologist, 37(1), 93–115. Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59(1), 1–9. Ponterotto, J. G., & Austin, R. (2005). Emerging approaches to training psychologists to be culturally competent. In R. T. Carter (Ed.), Handbook of racial-cultural psychology and counseling: Vol. 2. Training and practice (pp. 19–35). Hoboken, NJ: John Wiley. Pope-Davis, D. B., Coleman, H. L. K., Liu, W. M., & Toporek, R. L. (Eds.). (2003). Handbook of multicultural competencies in counseling and psychology. Thousand Oaks, CA: Sage. Revollo, H., Qureshi, A., Collazos, F., Valero, S., & Casas, M. (2011). Acculturative stress as a risk factor of depression and anxiety in the Latin American immigrant population. International Review of Psychiatry, 23(1), 84–92. Ridley, C. R., Mollen, D., & Kelly, S. M. (2011). Counseling competence: Application and implications of a model. The Counseling Psychologist, 39(6), 865–886. Rogers, C. R. (1961). On becoming a person. Oxford: Houghton Mifflin. Rogers-Sirin, L. (2008). Approaches to multicultural training for professionals: A guide for choosing an appropriate program. Professional Psychology: Research and Practice, 39(3), 313–319. Romero, A. J., & Roberts, R. E. (1998). Perception of discrimination and ethnocultural variables in a diverse group of adolescents. Journal of Adolescence, 21(6), 641–656. Ryder, A. G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S. J., & Bagby, R. M. (2008). The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America? Journal of Abnormal Psychology, 117(2), 300–313. Seaton, E. K., Scottham, K. M., & Sellers, R. M. (2006). The status model of racial identity development in African American adolescents: Evidence of structure, trajectories, and well-being. Child Development, 77(5), 1416–1426. Seaton, E. K., Yip, T., Morgan-Lopez, A., & Sellers, R. M. (2012). Racial discrimination and racial socialization as predictors of African American adolescents’ racial identity development using latent transition analysis. Developmental Psychology, 48(2), 448–458. Smith, T. B., Constantine, M. G., Dunn, T. W., Dinehart, J. M., & Montoya, J. A. (2006). Multicultural education in the mental health professions: A meta-analytic review. Journal of Counseling Psychology, 53(1), 132–145. Smith, T. B., & Draper, M. (2004). Understanding individuals in their context: A relational perspective of multicultural counseling and psychotherapy. In T. B. Smith (Ed.), Practicing multiculturalism: Affirming diversity in counseling and psychology (pp. 313–323). Boston: Allyn & Bacon. Smith, T. B., Rodríguez, M. D., & Bernal, G. (2011). Culture. Journal of Clinical Psychology, 67(2), 166–175. Smith, T. B., & Silva, L. (2011). Ethnic identity and personal well-being of people of color: A metaanalysis. Journal of Counseling Psychology, 58(1), 42–60. Snowden, L. R. (1999). African American service use for mental health problems. Journal of Community Psychology, 27(3), 303–313. Steffen, P. R., McNeilly, M., Anderson, N., & Sherwood, A. (2003). Effects of perceived racism and anger inhibition on ambulatory blood pressure in African Americans. Psychosomatic Medicine, 65(5), 746–750. Steffen, P. R., Smith, T. B., Larson, M., & Butler, L. (2006). Acculturation to Western society as a risk factor for high blood pressure: A meta-analytic review. Psychosomatic Medicine, 68(3), 386–397. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(2), 64–89. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286. Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440–448. Sue, S. (2003). In defense of cultural competency in psychotherapy and treatment. American Psychologist, 58(11), 964–970. Sue, S., & Zane, N. (1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. American Psychologist, 42(1), 37–45. Thompson, V. L. S. (2006). Coping responses and the experience of discrimination. Journal of Applied Social Psychology, 36(5), 1198–1214. Tomlinson-Clarke, S. (2010). Culturally focused community-centered service learning: An international cultural immersion experience. Journal of Multicultural Counseling and Development, 38(3), 166–175. Torres, L., & Rollock, D. (2007). Acculturation and depression among Hispanics: The moderating effect of intercultural competence. Cultural Diversity & Ethnic Minority Psychology, 13(1), 10–17. Trimble, J. E. (2009). The principled conduct of counseling research with ethnocultural populations: The influence of moral judgments on scientific reasoning. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (3rd ed., pp. 147–161). Thousand Oaks, CA: Sage. Trimble, J. E. (2010). The virtues of cultural resonance, competence, and relational collaboration with Native American Indian communities: A synthesis of the counseling and psychotherapy literature. The Counseling Psychologist, 38(2), 243–256. Trimble, J. E., & Fisher, C. B. (Eds.). (2006). Handbook of ethical research with ethnocultural populations and communities. Thousand Oaks, CA: Sage. Umaña-Taylor, A. J., & Updegraff, K. A. (2007). Latino adolescents’ mental health: Exploring the interrelations among discrimination, ethnic identity, cultural orientation, self-esteem, and depressive symptoms. Journal of Adolescence, 30(4), 549–567. Vasquez, M. J. T. (2007). Cultural difference and the therapeutic alliance: An evidence-based analysis. American Psychologist, 62(8), 878–885. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum. Whitbeck, L. B. (2006). Some guiding assumptions and a theoretical model for developing culturally specific preventions with Native American people. Journal of Community Psychology, 34(2), 183–192. Yosso, T. J., Smith, W. A., Ceja, M., & Solórzano, D. G. (2009). Critical race theory, racial microaggressions, and campus racial climate for Latina/o undergraduates. Harvard Educational Review, 79(4), 659–690. Part II Ethnocultural Contexts and Cross-Cultural Counseling The focus of the five chapters in Part II is an acknowledgment of the substantial contributions to the multicultural perspective made by Arabs and Muslims, African Americans, Asian Americans, Latinos, and Native Americans, the ethnocultural groups featured in this section. Most of the early and contemporary writings in the field of multiculturalism have approached ethnicity from the perspective that the persons who make up these groups are members of ethnocultural minority groups. The very term minority, however, has become divisive and contentious because of the implicit stigma sometimes associated with it and the fact that these groups are increasing in size; together, their population will soon exceed that of what was once considered the majority group in the United States. The U.S. Census Bureau (2013) predicts that by 2050, the U.S. population will reach more than 600 million, about 47% larger than in the year 2010. The primary ethnic “minority” groups—namely, Latinos, African Americans, Asian Americans, American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders—will constitute more than 50% of the population. About 57% of the population younger than age 18 and 34% older than age 65 will be members of these groups. The demographic profile based on the 2010 census indicates that during the preceding decade, the Latino population grew at a rate eight times faster than that of Whites. Asian Americans and Pacific Islanders also had rapid growth rates, in part due to immigration from Southeast Asia. For Latinos, increased immigration and high birthrates explain the population increase. Projections for the year 2020 suggest that Latinos will be the largest ethnic group, second only to White Americans, and followed by African Americans. Considering the increasing ethnic and cultural diversity occurring in the United States, attention should be given to the growing Muslim population. According to a recent survey, Muslims constitute about 2% of the U.S. population. A 2011 study conducted by the Pew Research Center found that the majority of Muslims in the country are African Americans, Arabs, and Asians, and that overall Muslim Americans come from 77 different countries. The U.S. Census Bureau does not collect information on individuals’ religious affiliations or preferences, hence the census tallies on the Muslim population are estimates. Most Muslims in the United States are members of immigrant populations, and thus their cultural backgrounds contribute to the nation’s growing diversity. On the 2000 and 2010 census forms, individuals had the option of marking more than one “race” category and so were able to declare identification with more than one group. For example, whereas less than 3% of the total U.S. population chose to do so, more than 5,220,579 individuals who chose to mark multiple categories marked “American Indian and Alaska Native” along with one or more others. The “race alone or in combination” count is much higher than the “race alone” count of 2,932,248 (U.S. Census Bureau, 2010). The discrepancy raises the question of which count is more accurate or representative of the “true” Indian population, 2,932,248 or 5,220,579. People with mixed ethnic backgrounds present interesting ethnic identity cases, as they have at least two ethnic groups from which to claim and negotiate an ethnic declaration. Based on extensive interviews with people of mixed ethnic backgrounds, the clinical psychologist Maria P. P. Root (1992) identified four basic reasons why multiethnic persons would choose to identify with particular groups regardless of how others may view them. According to Root: (a) Individuals enhance their sense of security by understanding distinct parts of their ethnic heritage; (b) parental influences, stimulated by the encouragement of grandparents, promote identity, thereby granting permission to the offspring to make their choices; (c) racism and prejudice associated with certain groups lead to sharing experiences with family, which helps multiethnic individuals to develop psychological skills and defenses to protect themselves (the shared experiences help to build self-confidence and create the sense of an ability to cope with the negative elements often associated with particular groups); and (d) “gender alignment between parents and children may exert influence on ethnic and racial socialization particularly when they have good relationships and are mutually held in esteem” (p. 15). The Census Bureau’s introduction of the new multiracial item created contentious debates and problems for all who rely on the use of census outcome data. The addition of the multiracial category presents difficult tabulation and reporting problems for health care professions, economists, demographers, social and behavioral scientists, and others who use “racial” categories for their work. In earlier writings in the field of multicultural psychology, the groups that are the focus of Part II were written about through the use of a broad ethnic gloss, where attention was given to the groups as though they were homogeneous entities. They are not—in fact, there may well be more heterogeneity within these groups than within North America’s majority Euro-American population (Trimble & Bhadra, 2013). Perhaps at one time that approach was necessary to draw general attention to particular groups’ ethnic and cultural differences. However, and fortunately, the entire field of multicultural and cross-cultural counseling has matured to such an extent that scholarly attention must now focus on the between- and within-group variations of ethnocultural populations and the challenges they present for counselors and clinicians. The authors of the five chapters in Part II take that position and more as they lay out the psychological and sociocultural intricacies of their respective populations to illustrate the increasing challenges faced by the groups and how counselors and clinicians can respond to them in an efficacious manner. Moreover, the reader will be challenged to consider conventional self and identity conceptualizations and how they pertain to people from distinctive ethnocultural populations; a deep, thorough exploration of the self-construct has profound implications for the delivery of counseling services to people who straddle multiple ethnic identities. The following five questions serve as a constructive and summative way to introduce the chapters in this section: 1. How adequately do conventional psychodynamic, humanistic, and behavioral approaches relate to cross-cultural considerations in the provision of counseling services for ethnocultural populations? 2. How does the concept of principled cultural sensitivity influence and guide the conduct of research and the delivery of counseling services in traditional ethnocultural communities? 3. What are the influences of historical trauma and delayed grieving and their effects on the provision of counseling services for oppressed and exploited populations? 4. How do degrees of client acculturative status, ethnic identification, and self-esteem or sense of self-worth influence a counselor’s approach to providing counseling services for the groups discussed in this section? 5. What evidence exists for the influence of cultural encapsulation in counselors’ understanding of and ability to work effectively with clients from unique ethnocultural populations? Indeed, some of these questions pertain to other topics and themes covered in this seventh edition of Counseling Across Cultures. Moreover, there is a good chance that many readers have experienced some or all of the circumstances and problems embedded in these questions as well as those posed for the other sections of this book. Perhaps the discussion presented in the forthcoming chapters can help them come to the realization that others acknowledge and avow their experiences and that there are effective and constructive ways of dealing with them. We now turn to a summary of the topics and themes covered in the five chapters in this part of the book. Chapter 5 provides a description of the essential sociocultural factors that lead to effective strategies for counseling with American Indian and Alaska Native clients. Within a specific framework, authors John Gonzalez and Joseph E. Trimble emphasize the counselor characteristics that demonstrate effectiveness in counseling North American indigenous peoples. In Chapter 6, Frederick T. L. Leong, John Lee, and Zornitsa Kalibatseva address the counseling of Asian Americans, carefully describing the cultural factors related to client and therapist variables that may play a significant role in the provision of effective counseling for these clients. Along with this important information, an extensive literature review provides bridges for the existing knowledge base from research to clinical practice. Chapter 7 presents a detailed description of the psychological, cultural, and sociopolitical issues that counselors need to consider in working with clients of Black African ancestry. Ivory Achebe Toldson, Kelechi C. Anyanwu, and Casilda R. Maxwell discuss unique techniques and strategies for providing effective counseling services to African Americans and other clients of African descent. In Chapter 8, J. Manuel Casas, A. Pati Cabrera, and Melba J. T. Vasquez advise counselors and practitioners on how they can become more competent in working with Latino/a clients. They provide guidance for those who work with this rapidly growing population and present an outline of a theoretical approach that unifies theories of person, environment, and the counseling situation. They also offer a culturally sensitive and appropriate framework that practitioners can use to direct and drive their work with Latino/a clients; the framework includes likely sources of both friction and possibility and how counselors can respond to them. Finally, the last chapter in this section focuses on counseling and psychotherapy with Arab and Muslim clients. Marwan Dwairy and Fatimah El-Jamil emphasize that practitioners will note that Arab and Muslim clients are more family or community-oriented and therefore less individually oriented than most Western clients. Terms such as self, self-actualization, ego, opinion, and feeling have collective meanings for them. Arab and Muslim clients may be preoccupied by family issues, duties, expectations, and the approval of others; in conversing with them, counselors may find it difficult to distinguish between their personal needs or opinions and those of their families. Matching the therapist and client on cultural or religious background needs careful attention also. As Dwairy and El-Jamil point out, some Arabs and Muslims prefer therapists of the same ethnic identity in order to ensure a process free of stereotypic judgments, whereas others may fear being judged or blamed by Arab Muslim “authorities” as they may be in their own families. Clients in the latter group may actually prefer therapists who are different in background from themselves. References Pew Research Center. (2011). Muslim Americans: No signs of growth in alienation or support for extremism. Washington, DC: Author. Root, M. P. P. (1992). Back to the drawing board: Methodological issues in research on multiracial people. In M. P. P. Root (Ed.), Racially mixed people in America (pp. 181–189). Newbury Park, CA: Sage. Trimble, J. E., & Bhadra, N. (2013). Ethnic gloss. In K. D. Keith (Ed.), Encyclopedia of crosscultural psychology. New York: Wiley-Blackwell. U.S. Census Bureau. (2010). National population by race, United States: 2010. Retrieved from http://www.census.gov/2010census/data U.S. Census Bureau. (2013). Newsroom: All releases from 2013. Retrieved from http://www.census.gov/newsroom/releases/archives/2013.html 5 Counseling North American Indigenous Peoples John Gonzalez Joseph E. Trimble Primary Objective ■ To describe the essential sociocultural factors that lead to effective strategies for counseling with American Indian clients Secondary Objectives ■ To describe counselor characteristics that demonstrate effectiveness in counseling American Indians ■ To present a framework designed to guide counselors in making culturally resonant choices when counseling American Indians Indian life is tough. It is hard to be Indian. But, I am happy to be born an Indian. As Anishinaabe, we want a good life—mino-bimaadiziwin—but there are always challenges. To have mino-bimaadiziwin you must follow a certain path, like the stem of an eagle feather. As you travel this path, there are many struggles, difficulties, and choices you must make—which are the barbs of the feather. Sometimes we wander off the stem of the feather and find ourselves stuck on those barbs. It is then we must seek help and guidance to find our way back to mino-bimaadiziwin—to live a good life. —Jim “Ironlegs” Weaver This quote is a reflection of a story—many stories, in fact. Stories of hardship and struggle. Stories of genocide and oppression. Stories of loss. But also stories of pride. Stories of resilience. Stories of hope. There are as many stories as there are American Indians, which speaks to the variable lifeways and thoughtways of American Indians in the 21st century. What it means to be American Indian, or what American Indian culture is, is a very difficult question to answer. We do not claim to answer this question, but we can say that American Indian and Alaska Native cultures and the lives of every single American Indian living today are affected by the sociopolitical history of North America. And these things have shaped the stories embedded within the quote above. Learning about this history, learning about those stories, and understanding the diversity in those stories will be the main tasks of the professional counselor looking to work with and provide services to American Indian persons and communities. Each American Indian and Alaska Native (AI/AN) cultural group has developed a sophisticated and elaborate set of beliefs, values, rules, and customs to help guide a person to have minobimaadiziwin. This is part of the definition of culture. In addition, each group has developed healing practices to assist a person when he or she is out of balance, stuck on a feather barb, and needs to find the way back to live a good life. Some of these healing practices are simple and can be done by any tribal member, such as offering tobacco, saying a prayer, singing a song, and the burning of sage, sweet grass, or cedar. But other more complex ceremonies and uses of medicines are to be practiced only by trained healers who have been delegated by the spirits, often as a birthright. These ceremonies and healing rituals vary by tribal nation and sometimes even within tribes by geography— this is a reflection of the importance of time and space for AI/AN (Deloria, 2003). These “ways of living” continue to be endorsed and practiced by most AI/AN tribes today. Mental health and wellness are integral parts of the “good life” for indigenous peoples, and healing ceremonies are also performed to help individuals maintain or achieve wellness. However, not all AI/AN choose or have the opportunity to participate in such ceremonies, owing to a number of factors, including orthodox religious convictions marked by conformity to doctrines or practices held as right or true by some authority, standard, or tradition or distrust of traditional healers and their practices. Other factors might include the geographic distance of traditional healers from their home villages or communities or lack of access to traditional healers, especially in urban settings. Finally, an individual may lack awareness of the availability and effectiveness of traditional practices, or may be confused concerning the choice between traditional healing and use of mental health services. Certainly, the reasons vary from one person to another. For those who choose not to seek the services of traditional healers, the only available alternative is to seek the assistance of professionals in the conventional mental health fields; that choice, too, can be compounded by numerous factors, including distrust, misunderstanding, apprehension, and the real possibility that mental health practitioners may be insensitive to the cultural backgrounds, worldviews, and historical experiences of Native clients. The main issues for these clients are concerns that their “presenting problems” may be distorted by the results of psychological tests that are incongruent with their cultural worldviews and that professionals may arrive at clinical diagnoses grounded in psychological theories that do not value and consider their culture. A variety of intercultural and interpersonal issues can arise when a counselor working with AI/AN clients lacks the necessary cultural awareness, knowledge, and experience—the pillars of multicultural counseling (Sue, Ivey, & Pedersen, 1996). There is ample evidence, however, that by using particular techniques, counselors can promote client trust and improve the counselor–client relationship, both in general and with American Indian and Alaska Native clients specifically. Matters relating to trust and other counseling considerations form the basis of this chapter; in the pages that follow, we provide information aimed at helping to stimulate effective cross-cultural contacts between mental health counselors and American Indians. Overview: Providing Counseling to American Indians and Alaska Natives Contrary to stereotypes, not all “Indians” are alike—a full and wide range of individual differences exist among members of any ethnocultural group. This is very true for both indigenous persons who follow their tribal lifeways and those who only marginally identify with their indigenous cultures (Fryberg, 2003; Fryberg & Markus, 2003; Trimble, 1988). The concept of acculturation provides a useful context for understanding this and suggests different paths that minority individuals and groups may follow when functioning in the mainstream context. In the concept’s simplest form, minority group members have four options: integration, in which they maintain their culture of origin and also adopt the culture of the majority, so that they function biculturally; assimilation, in which they primarily function according the lifeways of the majority culture; separation, in which they maintain their culture of origin with very little adoption of majority culture; and marginalization, in which they may not strongly maintain their culture of origin or adopt the ways of the majority (Berry, 1980, 2002). With all these possible differences in identity, is it possible to provide culturally resonant mental health services to AI/AN populations? Is there a common set of strategies known to be effective? How can a Western-trained counselor prepare for working with members of indigenous communities? We will try to answer these questions, and more, below as we discuss the many factors that facilitate successful counseling services as well as the factors that work as impediments to providing successful mental health services to Native clients. We will present a summary review of the writings in AI/AN mental/behavioral health, along with our own insights organized around the following themes: the nature of AI/AN communities, counselor characteristics, client characteristics, worldviews and values, and counseling styles, which includes the role of traditional healing practices. A critical component of multicultural and cross-cultural counseling is the counselor’s knowledge about the group of people with whom he or she is working. Such knowledge is especially important for counselors working with AI/AN communities, given their unique status in North America (Duran, Firehammer, & Gonzalez, 2008; Herring, 1992; LaFromboise, Berman, & Sohi, 1994). This knowledge cannot just come from a book, movie, or some other type of media; becoming knowledgeable requires experience and time. Newcomers or outsiders will inevitably be met with some suspicion—in any culture. Counselors need to take the considerable time required to learn from the community and to understand their role within it. Along the way, trust, an essential component in all human relations, can develop. The mistrust that members of indigenous communities have for nonNatives is based on the sociopolitical historical and contemporary relations between Natives and Whites, often described as historical or intergenerational trauma and the unresolved and continuing grief associated with such trauma. Historical Loss and Grief It is vital that mental health professionals learn and understand how indigenous people have experienced and continue to experience tremendous trauma and suffering as a consequence of European contact. There is a cumulative sense of trauma as a result of centuries of massacres, disease, forced relocations, forced removal of children, loss of land, broken treaties and other betrayals, unemployment, extreme poverty, and racism. One of the most destructive forms of trauma was perpetrated by the government- and church-run educational systems in Canada and the United States. Thousands upon thousands of indigenous children were taken from their parents, families, and communities and sent to residential boarding schools that were hundreds, sometimes thousands, of miles away from their homes. Children as young as 6 were stripped of their culture and identity, and many experienced unspeakable physical, sexual, and psychological abuse (Gonzalez, Simard, BakerDemaray, & Iron Eyes, 2014; Millar, 1996). Chrisjohn and Young (1997) discuss the long-term effects of the residential school program in Canada and how it continues to contribute to the unresolved grief of former residents and their children. The White Bison organization’s Wellbriety Movement is devoted to addressing the traumatizing impacts of this government policy (Coyhis & Simonelli, 2008). Several scholars have posited that postcolonial historical and intergenerational trauma contributes to the high levels of social and individual problems in Native communities, such as alcoholism and substance abuse, suicide, homicide, domestic violence, and child abuse (Brave Heart & DeBruyn, 1998; Duran, 1999, 2006; Duran & Duran, 1995; Duran et al., 2008; LaDue, 1994). We want to emphasize here the need for counselors to acknowledge and seek to understand this intergenerational trauma from the Native worldview. In addition, counselors should be aware that attempting to “treat” the symptoms or manifestations of the trauma by using only conventional Western psychological and psychiatric approaches often does more harm and perpetuates the trauma. Duran et al. (2008) argue that counselors must work with Native clients to reconstruct their personal and community histories, seeking the course of the trauma. This is important and is related to how conceptualizations of time and history may differ between Native and Western cultures. In many Native cultures, the past, present, and future are viewed as being unified and continuous, whereas in Western culture time and history are not seen as having such continuity. For example, in the Ojibwe language, the word for time, ishise, is a verb, and ishise acts upon us; in the English language time is a noun, and time is seen as something that we possess. Historical trauma and unresolved grief are, in part, reactions to cultural loss and involuntary change. Although culture as a construct has multiple meanings, it represents the essential lifeways and thoughtways of ethnic and national enclaves; culture provides meaning, structure, and direction. In relation to trauma and grief experiences, culture serves a psychological function by providing a buffer against terror (Salzman, 2001). If an indigenous community’s lifeways and thoughtways are under assault, community members will turn to their rituals, ceremonies, and healers to restore balance, fend off destruction, and protect traditions. However, when traditional lifeways and thoughtways are suppressed or stolen, the resulting trauma may be irresolvable and subsequently may be passed along from one generation to the next. In response to the existence of historical trauma and unresolved grief, “cultural recovery movements are occurring among indigenous people throughout the world to reconstruct a world of meaning to act in... and to recover ceremonies and rituals that address life’s problems” (Salzman, 2001, p. 173). For example, to illustrate how tribal rituals promote a sense of community and continuity for troubled individuals, Brave Heart and DeBruyn (1998) and Duran, Duran, Brave Heart, and Yellow HorseDavis (1998) describe the effectiveness of a tradition-based psychoeducational intervention intended to resolve historical trauma and grief. Results from this four-day group experience point to positive and long-term changes that assist individuals in dealing with racism, grief contexts, and the resolution of grief. Similar “cultural recovery” programs are being offered in various parts of North America, as are Native-sponsored conferences devoted to the topic of cultural recovery. The Wellbriety Movement is an example of one of these cultural recovery programs; it uses a “healing forest” metaphor and blended medicine wheel teaching (Coyhis & Simonelli, 2008). Morrissette (1994) has called for more clinical and counseling attention focused on the parenting struggles of those Natives who have experienced “residential-school syndrome.” Gone and colleagues have written extensively on the idea that “culture is treatment” in general, and in particular in relation to addressing historical trauma and its manifestations (Gone, 2008, 2013; Gone & Calf Looking, 2011; Hartmann & Gone, 2012; Wendt & Gone, 2012; Wexler & Gone, 2012). The value of culture and all it represents is being elevated to a higher level of significance as community voices gain influence and power. As Salzman (2001) points out, “Empowering political movements tend to accompany cultural recovery movements and [thus] should be supported by mental health and social workers” (p. 173). Thus, cultural recovery movements are increasingly viewed as effective responses to the existence of historical trauma and unresolved grief among indigenous peoples throughout the world. Recently, we have witnessed the work of the Idle No More movement (http://www.idlenomore.ca) and groups like the Last Real Indians (http://lastrealindians.com), which, although not directly related to mental health services, are framed in a decolonization paradigm and are having a positive impact on historical trauma grief. Idle No More started in Canada in response to the Harper administration’s legislation that would open protected lands and waterways for oil and mineral exploration and essentially eliminate the water rights and protections of the First Nations peoples. It soon spread to the United States and then to indigenous communities around the world. Last Real Indians is a grassroots group of writers and activists from across North America that brings awareness to policies and issues affecting Native communities. This group and one of its cofounders, Chase Iron Eyes, were instrumental in the Lakota/Dakota Nations’ purchase of Pe Sla’, the sacred site at the center of the Black Hills in South Dakota. So You Want to Work With Native People The first pillar of multicultural counseling is awareness. A critical part of this awareness should be self-awareness. Counselors need to examine their motives for wanting to work in mental health settings that serve Native peoples. Related to this, they must become aware of and acknowledge their own biases and assumptions, because everyone has biases. Helms and Cook (1999) put it succinctly: “How can counselors resolve the different manners in which counselors and clients conceptualize mental health problems if the counselors and clients come from different culture-related life experiences?” They add, “To the extent that the therapists’ and clients’ socialization histories in either the racial or cultural domains of life have been incongruent, then one would expect differences in the ways in which therapists and clients conceptualize the problem for which help is sought, as well as what they consider to be appropriate ‘treatment’ for the problem” (p. 7). Counselors cannot ignore or minimize these multicultural factors without jeopardizing counseling relationships and successful outcomes. A counselor working cross-culturally may begin to wonder if conventional methods and styles might be legitimate and/or effective for working with culturally diverse clients. This is a fair question, and one that a counselor should consider when working with any client. The research on therapeutic interventions both in general and cross-culturally does provide some guidance. Effective counselors possess personal characteristics that promote positive relationships with clients, regardless of cultural background—this is the foundation of any healing or helping process. For example, characteristics such as empathy, genuineness, warmth, respect, congruence, and availability are likely to be effective in any setting, including Native communities. In fact, these same characteristics often exemplify the spiritual healers in indigenous communities (Mohatt & Eagle Elk, 2000). Reimer (1999) collected information from Inupiat members of an Alaska Native village concerning the characteristics they found desirable in a healer. Her respondents indicated that a healer is (a) virtuous, kind, respectful, trustworthy, friendly, gentle, loving, clean, giving, helpful, not a gossip, and not one who wallows in self-pity; (b) strong physically, mentally, spiritually, personally, socially, and emotionally; (c) one who works well with others by becoming familiar with people in the community; (d) one who has good communication skills, achieved by taking time to talk, visit, and listen; (e) respected because of his or her knowledge, disciplined in thought and action, wise and understanding, and willing to share knowledge by teaching and serving as an inspiration; (f) substance-free; (g) one who knows and follows the culture; and (h) one who has faith and a strong relationship with the Creator (p. 60). Thus, counselors working with Native clients do not need to abandon their conventional counseling styles, but they must show a willingness to pay attention to what their clients value in respected healers. Moreover, having the ability to suspend disbelief is helpful for counselors working with Native clients—that is, counselors need to be willing to listen to and hear whatever clients may say without judging the credibility of the belief systems associated with healing ceremonies, Indian medicine, and spiritual quests (Duran, 2006; Duran et al., 2008). The critical lesson for counselors is that they should not make assumptions or rush into treatment plans before listening to their clients. This lesson is further highlighted by the results of a qualitative study by Yurkovich, Clairmont, and Grandbois (2002), who found that clinicians’ ability to be culturally responsive varied and was dependent on their awareness of their own personal culture and the diversity within and between American Indian cultures. For example, some of the mental health providers were themselves Native and therefore perceived the client as Native and automatically assumed they were providing culturally responsive care. Another group of providers (Native and non-Native) acknowledged potential differences in cultural background between client and counselor based on their own, but provided culturally relevant care only if the client requested it. Finally, a third group of providers fully acknowledged cultural differences and actively assessed the client’s preferred treatment approach. Although some of the Native mental health providers were not of the same tribal affiliation as the client, they still perceived the client as similar to them and seemed to ignore the diversity that exists within Native cultures. These findings serve as reminders of several issues discussed above. Counselors working with Indian clients need to become aware of the clients’ individual as well as collective cultural backgrounds while examining their own preconceptions, biases, and attitudes about “Indians.” Counselors also need to examine and be aware of their own cultural backgrounds and how these influence the client–therapist relationship. Such self-examination gets at the core of what it takes to become a “cross-cultural” counselor. Working in Native communities requires flexibility and the ability to be comfortable with Native communication styles and patterns. This includes being comfortable with silence, long pauses in responses, and what is sometimes referred to as “reservation” or “village” English. Counselors lacking knowledge about these communication styles of Native clients often misinterpret them as noncompliance or as evidence of cognitive deficits. Counselors must have the flexibility to allow clients to engage in thought processes at their own pace; such flexibility is enhanced by counselors’ awareness of culture-based differences in dyadic relationships (Herring, 1999; Lockhart, 1981). There is a debate in the profession concerning whether Native clients are best served by counselors who are Natives (Darou, 1987; Dauphinais, Dauphinais, & Rowe, 1981; M. Johnson & Lashley, 1989; Lowrey, 1983; Uhlemann, Lee, & France, 1988). Bennett and BigFoot-Sipes (1991) note that Indian clients might actually prefer counselors whom they perceive as having attitudes and values similar to theirs, instead of counselors who are necessarily of the same ethnicity. Indian clients who are involved in their cultural heritage, however, have much stronger preferences for Indian counselors and non-Western methods than do those who are not so involved or who do not identify strongly with their Indian heritage (Gone, 2007, 2008; M. Johnson & Lashley, 1989). As noted above, counselors who plan to work with Native clients need to have some advance knowledge of the clients’ cultures (see Thomason, 1991, 2011). As part of accumulating this knowledge, counselors should learn about what the community or potential clients believe about nonNative counselors and counseling. Native people also have biases, often as a result of actual oppression, thus it is important that counselors inquire about and understand these biases (Peregoy, 1999). A counselor can accomplish such an assessment in many ways, formal and informal. The key is for the counselor to engage community members in genuine conversation and to learn from them; this allows the counselor to gather information while at the same time building trust and rapport. Working in Indian country is more than a 9:00-to-5:00 job, and counselors need to get out of their offices and attend events and functions in the community. As they do so, they are likely to discover some general beliefs that (a) “outsiders” tend to interpret behavior and emotions in terms of norms and expectations not shared by the tribal community, and (b) counselors will attempt to convert Indians to a “better” culture or try to get them to act and think according to the outsiders’ worldview (Anderson & Ellis, 1995). A final consideration we should note before moving on is that counselors must engage in inner self-assessment and evaluation and be prepared to adjust their own values, beliefs, and practices accordingly, to accommodate the bicultural or cultural expectations and perspectives of their Native clients (Matheson, 1986; Thomason, 2011). An Indian in the Room The Native communities of North America are as culturally and psychologically diverse as any group in the United States or around the world, and this diversity presents potential challenges for any counselor (Gone & Trimble, 2012; Lee, 1997; Sage, 1997). Indigenous persons differ from one another in many ways, including in acculturation status, physical appearance, and Indian ancestry. M. T. Garrett and Pichette (2000) and Gone (2006, 2008, 2011) emphasize that counselors must conduct an assessment of each Native client’s degree of acculturation, as physical appearance may be misleading. Degree of acculturation may influence how a particular client responds to a typical counseling session. Some researchers have observed that Native clients who come from traditional backgrounds are not likely to maintain direct eye contact, may avoid personalizing and disclosing troubled thoughts, and may act shy in the presence of non-Indian counselors (Attneave, 1985). Very traditional clients might tell counselors that “Indian doctors” have tended to their problems and that they have no need for any advice or consultation. Clients whose acculturation leans more toward mainstream U.S. culture may have a good idea of counseling goals and procedures and what is expected of them as clients. For any client, Native or non-Native, counseling can evoke strong emotions; in fact, this is often the purpose of counseling. However, for the Native client working with a non-Native counselor an additional layer of emotions may be present, related to both historical events and individual personal experiences. Many indigenous people have had a multitude of personal experiences with White culture that have left them feeling suspicious of outsiders offering help. There is a long, unfortunate history of such experiences negatively affecting Indian people and communities (Deloria, 1969). A counselor must be patient with client concerns and wait for trust to develop. A counselor in this situation may often feel that the client is testing him or her; in fact, this is probably accurate. The client may gradually become more self-disclosing, but only when the client senses that his or her experiences are being heard and respected will full disclosure likely occur. Although such reluctance to disclose has been cast as a cross-cultural issue, it occurs with many non-Indian clients as well; it is best resolved through use of competent counseling skills and approaches (see Marsiglia, Cross, & Mitchell-Enos, 1998). A final note: Counselors should keep in mind that many, but not all, indigenous peoples emphasize the importance of living in harmony and maintaining balance in life and with the environment. This may result in a tendency to wait for the situation or the environment to offer a solution to a problem. This tendency will vary from community to community, and counselors should consult with local community members on what is considered the norm in this area. Worldviews and Values At the core of any culture are the ways the culture’s members see and interpret the world around them and the values they espouse. We all have sets of values and worldviews that guide and affect everything we do, often in very subtle and unconscious ways. As noted above, a Native person’s degree of acculturation, as well as his or her tribal affiliation, will mediate that individual’s value system and worldview. However, there are some values and beliefs that are widely held among Native peoples that are important to note here. Most indigenous persons and tribes are inherently collectivistic, such that they emphasize the group over the individual, placing importance on keeping harmony and maintaining balance in their relationships and the world around them. This value can affect many areas of their lives as well as other values they hold. For example, family and extended family relationships can take precedence over an individual’s own needs and motivations. Many Native people view it as natural and necessary to take time off work to attend family events, such as when a distant relative passes into the spirit world or a cousin gets married, but doing so can create conflicts with the non-Native world they live in. Time orientation is another value and part of worldview that influences behavior in many ways. The Native orientation toward time is sometimes referred to as “Indian time,” which unfortunately has been misconstrued to mean that Indians are always late. The real meaning behind this orientation is that, in the Native worldview, things will happen when they are supposed to happen. This can have profound effects on behavior in many areas of life that conflict with Western or mainstream American values. For example, part of “Indian time” acknowledges that time is really circular rather than linear, as it is viewed in Western thought. Thus, Native people will live for the present moment, with less emphasis on, or indifference toward, planning for the future. This can translate into the idea that if there is a future, it will take care of itself. This concept is often in direct conflict with the Western American value that “time is money” or that time is something we possess. Sometimes value conflicts take place within individuals—for example, in Indians who leave reservations or villages to live in cities or urban areas. Even among such urban Indians, however, many have a strong desire to retain their “Indianness” while they struggle with daily contact in nonIndian lifeways and thoughtways (Witko, 2006). Thornton (1996) suggests that urban Indians can internalize typical Native values, with some modifications, and tend to become characterized by panIndian ideologies. While pan-Indian ideologies can and do occur in urban areas, value orientation conflicts do not necessarily occur for those who have relocated to or were born in urban settings. Affiliation, maintenance of traditional ceremonies, and opportunities to visit ancestral homes may reinforce the retention of traditional values. For example, some of the best drum groups and dancers at powwows have their homes in the cities. Many Natives exhibit a pattern of movement back and forth from the city to the reservation, often staying for extended periods of time that may even necessitate changes in employment. This pattern has often been interpreted as a way of avoiding stressful life events and in that sense has been seen as a negative behavioral response. Although this is always a possibility and must be assessed as part of the counseling process, it is also very likely that this type of mobility is adaptive. The essential lesson here is that counselors must be sure to examine any value differences with Native clients. A careful analysis of client worldview and value system may allow both client and counselor to discover whether it is a value conflict that is leading to the client’s difficulty. Counseling Approaches While we have provided some basic information and suggestions thus far for counselors working with Native clients, we cannot offer a simple and specific recommendation regarding which counseling style, orientation, or technique is most effective. There is an ongoing debate in Native communities and the mental health profession on whether traditional healing methods or Western counseling methods should be used with Native clients (for some discussions in this debate, see Duran, 2006; Duran et al., 2008; Gone, 2010; Gone & Trimble, 2012; LaFromboise, Trimble, & Mohatt, 1990). There are philosophical, professional, practical, and ethical reasons for such a debate, but a thorough and in-depth discussion of these reasons is beyond the scope of this chapter. A quick example may help. Many in the Native community believe that mental health (all health) has a spiritual component, such that any treatment or healing needs to be embedded within the culture by means of some type of ceremony or traditional healing process that should be performed only by a person who has the power and authority to do so. While there is surely some validity to this, where does this leave the non-Native counselor or practitioner who does not have the power or authority to perform such treatments or ceremonies? Instead of attempting to provide a recommendation regarding the most effective counseling approach for work with Native clients, we present below a review of the limited literature on counseling and mental health services with Native clients and communities by means of both Western and traditional healing methods, offering our own suggestions and examples when appropriate. As noted above, in the section on counselor characteristics, the foundation for any counseling approach utilized must include some basic skill sets and the ability to show warmth, empathy, genuineness, and respect for the Native client’s cultural values and beliefs. Arguably the most frequently cited work recommending a specific approach to counseling with Native clients is that of LaFromboise et al. (1990). These scholars strongly advocate the use of a directive style, presumably in the form of more cognitive or behavioral brief counseling. This position matches with clinical experience: The directive style seems to be more effective because many Indian clients, especially more culturally traditional ones, are likely to be reticent and taciturn during the early stages of counseling, if not throughout the entire course of treatment. Quite often, traditional Indian clients are very reluctant to seek conventional counseling because they may perceive the experience as intolerable and inconsistent with their understanding of a helping relationship. At that point, they may feel very helpless and burdened. It is important to note that traditional Native clients’ initial expectation of the counseling experience may be that it will offer them an opportunity to obtain advice from elders (those with greater wisdom and knowledge). For this reason, by beginning with brief, directive therapy, counselors may be more apt to meet such clients’ expectations concerning the helping relationship. Similarly, Renfrey (1992) and McDonald and Gonzalez (2006) provide evidence that cognitivebehavioral approaches can be effective with Native clients. These directive approaches appear to be effective when the counselor relies on the cultural context of the client’s thoughts and behavioral patterns. This blends well with aspects of the indigenous worldview discussed above, those concerning balance, harmony, and all things being related, including thoughts, behaviors, and the environments or situations in which they occur. In these studies, the clinicians did not rigidly apply Beck’s or Ellis’s frameworks in a manualized manner. For example, if a client has thoughts that “others” are always watching him or her, the counselor does not simply discount this as irrational. Perhaps there is a cultural and spiritual nature to these “others,” thus the counselor engages in a discussion with the client on whether this is a thought that needs to be changed and/or how this fits within the client’s worldview and can potentially have positive influences on other aspects of his or her life. Given that clients’ problems are often situational and contextual, Trimble and Hayes (1984) recommend that non-Indian counselors of American Indians attempt to understand the cultural contexts in which their clients’ problems are embedded. Familial patterns, peer group relationships, and community relationships are a few of the ecological processes that counselors need to understand and incorporate into their intervention plans (Trimble & LaFromboise, 1985). Family counseling, thus, is an approach that makes a good deal of sense. Attneave (1969, 1977), McWhirter and Ryan (1991), and C. Johnson and Johnson (1998) recommend that counselors and therapists account for the social and network characteristics of Indian families and involve family members in the counseling process. Napoli and Gonzalez-Santin (2001) describe an intensive home-based wellness model of care for families living on the reservation. This four-phase model seeks input and assistance not only from nuclear family members but also from extended family and community members. While this approach can certainly apply to non-Indian families and communities, a counselor would greatly benefit from acknowledging this cultural factor when working with Indian clients. The use of counseling strategies and techniques that resonate with Indian traditions and customs can be effective. Herring (1994) recommends that counselors use humor, especially in the form of storytelling. M. T. Garrett, Garrett, Torres-Rivera, Wilbur, and Roberts-Wilbur (2005) provide a brief discussion of humor in Native cultures and offer recommendations for incorporating humor into counseling sessions with Native clients. Others note the importance of art for Indian clients and its role in promoting well-being and healing (Appleton & Dykeman, 1996; Dufrene & Coleman, 1994). Humor and art are important parts of many traditional healing practices. Thus, these recommendations make good sense because they tie counseling procedures to the clients’ traditions and customs. The majority of recommendations proffered by the scholars cited above and others tend to be based on a view of Indian clients taken together; that is, they make no distinctions based on individual Indians’ unique psychological conditions and physical characteristics. Degree of ethnic identity and acculturation, residential situation, and tribal background are but a few of the areas that counselors must account for in determining suitable counseling techniques. In addition to these client descriptors, counselors must consider gender, sexual orientation, disability, and history of sexual and physical abuse. Black Bear (1988) draws attention to the special case of counseling with Indian women, whose situations often include child-care and family responsibilities as well as additional layers of oppression. For example, in researching Native ethnic identity, Gonzalez and Bennett (2000) found that Native women reported feeling less valued by mainstream society than their male counterparts. This finding is highlighted by Malone (2000), who discusses the importance of counselors’ integrating feminist theory with multicultural counseling perspectives when working with Native women, in large part because these clients’ presenting problems have as much to do with gender issues as with cultural ones. Mangelson-Stander’s (2000) work with Indian women in recovery from personal trauma amplifies this recommendation. Mangelson-Stander also found differences between urban and reservation women in their participation in traditional spiritual practices, activities provided by recovery centers, and in the value of family members’ providing care for the women’s children while they were in recovery. Finally, Indian clients with alcohol and drug abuse problems also may require unique attention (Moran & Reaman, 2002; Oetting & Beauvais, 1990; Trimble, 1984, 1992; Trimble & Beauvais, 2000). Intervention and treatment techniques that follow the recommendations made earlier in this chapter may be effective in many cases, but because of the complexity of the problem of substance abuse among Native populations, treatment effectiveness may be compromised. An example of the unique attention this problem may require is that substance abuse counselors may need to develop a respect and appreciation for the spirituality that is strongly entrenched in indigenous communities. Research has shown that infusing spirituality in alcohol recovery programs for Natives, coupled with a multicultural counseling perspective, can enhance outcome effectiveness (M. T. Garrett & Carroll, 2000; Hazel & Mohatt, 2001; Navarro, Wilson, Berger, & Taylor, 1997; Noe, Fleming, & Manson, 2003). Native Healing Approaches Related to the discussion above on substance use and alcohol treatments with Native clients is the emphasis that “culture as treatment” should be the paradigm of choice for counseling with Native individuals and communities (Gone, 2008, 2011; Gone & Calf Looking, 2011; Herring, 1999; Pedersen, 1999). The argument is that counselors should not focus on how to adapt or use Western models of therapy; rather, they should use traditional healing methods from the Native perspective (M. T. Garrett, Garrett, & Brotherton, 2001; Lewis, Duran, & Woodis, 1999; Tafoya, 1989; Thomason, 1991). As we noted earlier, this leaves non-Native counselors in a conundrum, as they are not knowledgeable in such healing methods or authorized to conduct them. We recommend that nonNative counselors establish working relationships with traditional healers and spiritual advisers in Native communities. Such collaboration with an indigenous healing system can take several forms: The counselor may (a) support the viability of traditional healing as an effective treatment system, (b) actively refer clients to indigenous healers, or (c) actively work together with indigenous healers. Increasingly, researchers have been examining the worth of introducing Native beliefs and ceremonies into the conventional counseling setting (Dufrene & Coleman, 1992; M. T. Garrett et al., 2001; Gray, 1984; Heilbron & Guttman, 2000; Roberts, Harper, Tuttle-Eagle Bull, & HeidemanProvost, 1998). In general, the recommendations and examples arising from this research follow the wisdom and advice offered by LaFromboise et al. (1990) concerning the importance of blending culturally unique and conventional psychological interventions to advance the goal of Native empowerment. A few counselors working with Native clients have achieved a modicum of success by incorporating spirituality in counseling sessions. J. T. Garrett and Garrett (1998) describe the use of the “sacred circle” and its related symbolism in an “inner/outer circle” form of group therapy and discuss how the Native perspective can facilitate client progress. Lewis et al. (1999) used a variant of processoriented training grounded in spirituality and found that the technique can allow therapists to enter into a non-Western-based reality with their clients, thus enhancing their sensitivity to and respect for Native worldviews. Heilbron and Guttman (2000) used a traditional aboriginal “healing circle” with nonaboriginal and First Nations women who were survivors of child sexual abuse and found that both groups responded favorably to the approach. Hodge and Limb (2010a, 2010b) discuss a set of tools that counselors may use to assess the spirituality of Indian clients as well as the processes counselors should consider before, during, and after such assessment. Simms (1999) describes the use of a blended counseling approach in which an integrated relational behavioral-cognitive strategy was combined with traditional healing approaches, including talking circles, sweats, and participation in cultural forums. The client that Simms describes was experiencing cultural identity, self-confidence, and academic problems that could not be resolved through the use of a straightforward conventional counseling technique. Similarly, McDonald and Gonzalez (2006) describe the weaving of cognitive-behavioral therapy with traditional Lakota healing practices for a veteran experiencing posttraumatic stress disorder. Here again, there were cultural circumstances related to war and battle that necessitated the inclusion of Native ways of knowing and healing. The use of sweat lodges and talking circles as means for promoting client participation and retention has received some attention in the multicultural counseling literature (M. T. Garrett & Osborne, 1995). Specifically, Colmant and Merta (1999) describe the effectiveness of incorporating a sweat lodge ceremony in the treatment of Navajo youths who were diagnosed with behavioral disruptive disorders. They show how the ceremony has considerable overlap with conventional forms of group therapy and thus merits consideration in the treatment of Native youths. Although incorporating traditional spiritual and healing methods such as the sweat lodge and talking circles can facilitate counselor effectiveness, client retention, and progress under controlled circumstances, counselors must exercise a high degree of caution in deciding to use such techniques. LaDue (1994) strongly recommends that non-Indian counselors abstain from participating in and using such practices, asserting that they should not promote or condone the stealing and inappropriate use of Native spiritual activities. Doing so may invoke ethical considerations, as Native spiritual activities and practices are the sole responsibility of recognized and respected Native healers and elders. Indeed, there is currently high interest in spirituality worldwide, and part of this growing interest involves the exploitation and appropriation of traditional Native ceremonies without the consent of indigenous communities. Matheson (1986) maintains that non-Native individuals who use traditional American Indian spiritual healing practices are under mistaken, even dangerous, impressions and, as a consequence, are showing grave disrespect for the indigenous origins, contexts, and practices of these traditions by Native peoples. If the essence of the counseling relationship is built on trust, rapport, and respect, then the exploitation and appropriation of indigenous traditional healing ceremonies and practices for use in counseling sessions will undoubtedly undermine a counselor’s efforts to gain acceptance from the Indian community and the client. These last points are not meant to discourage the non-Native counselor from exploring and learning about Native ways of knowing and healing. Rather, they are meant to bring us full circle to how we began this chapter, with a discussion of the historical trauma and spiritual loss that many Native communities have experienced. To close out this section, we quote Gone and Trimble (2012), who reviewed the past years of literature on the provision of mental health services to AI/AN clients. Their summative observations capture the current state of affairs: The effort to remedy evident disparities in AI/AN mental health status through clinical interventions has not been well studied for these culturally distinctive populations. Although AI/ANs can, in theory, avail themselves of the usual array of mental health programs and treatments, disproportionate levels of impairment, poverty, lack of insurance coverage, and limited availability of treatment options ensure that far too many AI/ANs with diagnosable distress—like most Americans with these problems—do not obtain effective help in times of need. (p. 149) Summary The literature on counseling with American Indian and Alaska Native clients yields a number of themes. First and foremost, when working with Indian clients counselors need to be adaptive and flexible. This is usually true for counseling in any setting, but it is especially so in Indian country. Herring (1999) says it best in making the following recommendations: “(1) Address openly the issue of dissimilar ethnic relationships rather than pretending that no differences exist; (2) schedule appointments to allow for flexibility in ending the session; (3) be open to allowing the extended family to participate in the session; (4) allow time for trust to develop before focusing on problems; (5) respect the uses of silence; (6) demonstrate honor and respect for the client’s culture(s); and (7) maintain the highest level of confidentiality” (pp. 55–56). As a Native clinician who has lived and worked in Indian country his whole life, the first author of this chapter would like to add to and elaborate on a few of Herring’s recommendations. First, counselor and client should discuss racial and cultural differences early; this relaxes the client and tells him or her that the counselor has put some thought into the matter—the counselor may not be an expert, but he or she cares enough to learn. Second, the idea of flexibility extends beyond time and encompasses relationships and how the counselor conducts him- or herself in the community. Boundaries and ethics that are taught in graduate school may not apply the same way in Native communities. It is important for the counselor to get out of the office and be “seen” in the community —this is how relationships and trust are developed. Only when trust has been established will clients and community members begin to tell the counselor what they really think and feel. Third, culture and context are important—this cannot be emphasized enough (Duran, 2006; Gone, 2004, 2008; Salzman, 2001). Counselors should respect Native cultures and worldviews as superseding psychology and psychological conditions; without culture there would be no psychology. As Salzman (2001) notes, counselors should (a) promote interventions emphasizing meaning construction at the community level and support the collective (community) and individual construction of meaning that sustains adaptive action; (b) support and assist individuals and communities in the identification of standards and values within the cultural worldview they identify with that promote adaptive action in current realities; and (c) support and assist communities in cultural recovery through collaborative content analysis of traditional stories (pp. 189–190). Finally, counselors need to assess acculturation and ethnic identity levels with every Native client (and sooner rather than later). How a client responds (or does not respond) is not necessarily a function of his or her being Native; it may instead be a function of that person’s Nativeness. Where and how the person grew up and was raised are very important factors. Does the person speak his or her Native language? How active is the person in ceremonies and other spiritual activities? What is the ethnic and cultural makeup of the individual’s social environment? The answers to these and other questions can give the counselor a sense of what counseling approaches and treatments might be appropriate. Like the members of other ethnic minority and cultural groups, Indians experience a full range of acculturation. Critical Incident Case Study of Donna Little Donna Little is a 39-year-old Indian woman who has a history of substance misuse and has struggled with reunification with her adolescent children over the last 6 years. She was in residential school from the age of 6 to 16 years old. She has a history of domestic violence in her previous relationships. Donna was the youngest of four children in her family. Her parents, siblings, and herself were raised in the same small northern reservation. Both her parents had gone to residential school in the early 1950s, as did her grandfathers and grandmothers on both sides of her family system in the late 1910s. Donna was raised in an environment of violence and mayhem in her early childhood, which she has talked about quite extensively in counseling. Although her parents abused alcohol, she emphasizes repeatedly that her family was quite ceremonial and participated in the big drum feast and singing within the community. When Donna was 6, an Indian agent wearing a red, white, and black checkered jacket gave her candy and took her to the residential school. She never had the opportunity to say good-bye to her mom and dad, who died of tuberculosis while she was in the residential school. Donna reflects on her residential school experience with a despondent look. While in the residential school, she had only one friend she could count on. Her siblings, who were also at the school, were older and thus not allowed to play with her or sleep near her at the residence dorms. This created an incredible loneliness that Donna did not know how to fill, and often she would use alcohol to help numb that pain. She did not like to drink, but it helped her to stop her thinking badly about the past. Donna was a victim of sexual abuse in the residential school, primarily by the Roman Catholic priest who was in charge. The first time she was assaulted she was 7; the last assault occurred right before she ran away at age 16. When Donna had attempted to tell the head nun in charge of her dorm what was happening to her, she was beaten severely, to the point of unconsciousness. Donna recalls it was her friend, Sue, who nursed her back to health. Donna describes her life as difficult. She went home to her community, only to find a partner who turned out to be as violent toward her as her father was to her mother. She loves her children and cares for them deeply. She breast-fed her three children and still today can feel that connection to them. When her children were taken from her home after the last time her husband beat her, she spiraled out of control. Donna has had long periods of abstinence, has a home in her community that is well cared for, and now has a partner who loves her deeply. Donna is on welfare but hunts and fishes to help with sustenance. Donna and her partner have been together for 10 years, however, they both misuse alcohol on occasion. Donna’s present partner is nonviolent and a former residential school survivor as well. Note: Special thanks to Estelle Simard, MSW, director of the Institute for Culturally Restorative Practices and a member of the Couchiching First Nation, for providing this case study. Discussion Questions 1. What is the culturally relevant history a therapist needs to understand when working with a client such as Donna? 2. What are some of the culturally relevant techniques a counselor can use when working with Native clients who have been abused by people in positions of power, such as priests? 3. How can a therapist connect a Native client back to his or her culture and its various institutions and practices? 4. How might Donna’s therapist help her to reconnect with her family in a manner that promotes wellness for everyone? References Anderson, M., & Ellis, R. (1995). On the reservation. In N. Vacc & S. DeVaney (Eds.), Experiencing and counseling multicultural and diverse populations (pp. 179–197). Muncie, IN: Accelerated Development. Appleton, V., & Dykeman, C. (1996). Using art in group counseling with Native American youth. Journal for Specialists in Group Work, 21, 224–231. Attneave, C. L. (1969). Therapy in tribal settings and urban network intervention. Family Process, 8, 192–210. Attneave, C. L. (1977). The wasted strength of American Indian families. In S. Unger (Ed.), The destruction of American Indian families (pp. 29–33). New York: Association on American Indian Affairs. Attneave, C. L. (1985). Practical counseling with American Indian and Alaska Native clients. In P. B. Pedersen (Ed.), Handbook of cross-cultural counseling and therapy (pp. 135–140). Westport, CT: Greenwood. Bennett, S., & BigFoot-Sipes, D. (1991). American Indian and White college students’ preferences for counselor characteristics. Journal of Counseling Psychology, 38, 440–445. Berry, J. W. (1980). Acculturation as varieties of adaptation. In A. Padilla (Ed.), Acculturation: Theory, models, and findings (pp. 9–25). Boulder, CO: Westview Press. Berry, J. W. (2002). Conceptual approaches to acculturation. In K. M. Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 17–37). Washington DC: American Psychological Association. Black Bear, T. (1988). Native American clients. In A. Horton & J. Williamson (Eds.), Abuse and religion: When praying isn’t enough (pp. 135–136). Lexington, MA: Lexington Books. Brave Heart, M. Y. H., & DeBruyn, L. (1998). The American Indian holocaust: Healing unresolved grief. American Indian and Alaska Native Mental Health Research, 8(2), 56–78. Chrisjohn, R., & Young, S. (1997). The circle game: Shadows and substance in the Indian residential school experience in Canada. Penticton, BC: Theytus. Colmant, S., & Merta, R. (1999). Using the sweat lodge ceremony as group therapy for Navajo youth. Journal for Specialists in Group Work, 24, 55–73. Coyhis, D., & Simonelli, R. (2008). The Native American healing experience. Substance Use & Misuse, 43, 1927–1949. Darou, W. G. (1987). Counseling and the northern Native. Canadian Journal of Counselling, 21, 33–41. Dauphinais, P., Dauphinais, L., & Rowe, W. (1981). Effects of race and communication style on Indian perception of counselor effectiveness. Counselor Education and Supervision, 21(1), 72–80. Deloria, V. (1969). Custer died for your sins: An Indian manifesto. New York: Macmillan. Deloria, V. (2003). God is red: A native view of religion. Golden, CO: Fulcrum. Dufrene, P., & Coleman, V. (1992). Counseling Native Americans: Guidelines for group process. Journal for Specialists in Group Work, 17, 229–234. Dufrene, P., & Coleman, V. (1994). Art and healing for Native American Indians. Journal of Multicultural Counseling and Development, 22, 145–152. Duran, E. (1999). Aniongwea Native American health center: Original people. San Francisco: Fast Forward. Duran, E. (2006). Healing the soul wound. New York: Teachers College Press. Duran, E., & Duran, B. (1995). Native American postcolonial psychology. Albany: State University of New York Press. Duran, E., Duran, B., Brave Heart, M. Y. H., & Yellow Horse-Davis, S. (1998). Healing the American Indian soul wound. In Y. Danieli (Ed.), International handbook of multigenerational legacies of trauma (pp. 341–354). New York: Plenum. Duran, E., Firehammer, J., & Gonzalez, J. (2008). Liberation psychology as the path toward healing cultural soul wounds. Journal of Counseling & Development, 86, 288–295. Fryberg, S. A. (2003). Really? You don’t look like an American Indian: Social representations and social group identities. Dissertation Abstracts International, 64(1549), 3B. Fryberg, S. A., & Markus, H. R. (2003). On being American Indian: Current and possible selves. Journal of Self and Identity, 2(4), 325–344. Garrett, J. T., & Garrett, M. T. (1998). The path of good medicine: Understanding and counseling Native American Indians. In D. R. Atkinson, G. Morten, & D. W. Sue (Eds.), Counseling American minorities (5th ed., pp. 183–192). New York: McGraw-Hill. Garrett, M. T., & Carroll, J. J. (2000). Mending the broken circle: Treatment of substance dependence among Native Americans. Journal of Counseling & Development, 78, 379–388. Garrett, M. T., Garrett, J. T., & Brotherton, D. (2001). Inner circle/outer circle: A group technique based on Native American healing circles. Journal for Specialists in Group Work, 26, 17–30. Garrett, M. T., Garrett, J. T., Torres-Rivera, E., Wilbur, M., & Roberts-Wilbur, J. (2005). Laughing it up: Native American humor as spiritual tradition. Journal of Multicultural Counseling and Development, 33(4), 194–204. Garrett, M. T., & Osborne, W. L. (1995). The Native American sweat lodge as a metaphor for group work. Journal for Specialists in Group Work, 20, 33–39. Garrett, M. T., & Pichette, E. F. (2000). Red as an apple: Native American acculturation and counseling with or without reservation. Journal of Counseling & Development, 78, 3–13. Gone, J. P. (2004). Keeping culture in mind: Transforming academic training in professional psychology for Indian country. In D. A. Mihesuah & A. C. Wilson (Eds.), Indigenizing the academy: Transforming scholarship and empowering communities (pp. 124–142). Lincoln: University of Nebraska Press. Gone, J. P. (2006). Mental health, wellness, and the quest for an authentic American Indian identity. In T. M. Witko (Ed.), Mental health care for urban Indians: Clinical insights from Native practitioners (pp. 55–80). Washington, DC: American Psychological Association. Gone, J. P. (2007). “We never was happy living like a Whiteman”: Mental health disparities and the postcolonial predicament in American Indian communities. American Journal of Community Psychology, 40(3–4), 290–300. Gone, J. P. (2008). “So I can be like a Whiteman”: The cultural psychology of space and place in American Indian mental health. Culture & Psychology, 14(3), 369–399. Gone, J. P. (2010). Psychotherapy and traditional healing for American Indians: Exploring the prospects for therapeutic integration. The Counseling Psychologist, 38(2), 166–235. Gone, J. P. (2011). The red road to wellness: Cultural reclamation in a Native First Nations community treatment center. American Journal of Community Psychology, 47(1–2), 187–202. Gone, J. P. (2013). Redressing First Nations historical trauma: Theorizing mechanisms for indigenous culture as mental health treatment. Transcultural Psychiatry, 50(5), 683–706. Gone, J. P., & Calf Looking, P. E. (2011). American Indian culture as substance abuse treatment: Pursuing evidence for a local intervention. Journal of Psychoactive Drugs, 43(4), 291–296. Gone, J. P., & Trimble, J. E. (2012). American Indian and Alaska Native mental health: Diverse perspectives on enduring disparities. Annual Review of Clinical Psychology, 8, 131–160. Gonzalez, J., & Bennett, R. (2000, February). Self-identity in the indigenous peoples of North America: Factor structure and correlates. Poster session presented at the meeting of the Society for Personality and Social Psychology, Nashville, TN. Gonzalez, J., Simard, E., Baker-Demaray, T., & Iron Eyes, C. (2014). The internalized oppression of North American indigenous peoples. In E. J. R. David (Ed.), Internalized oppression: The psychology of marginalized groups (pp. 31–56). New York: Springer. Gray, L. (1984). Healing among Native American Indians. PSI-Research, 3, 141–149. Hartmann, W. E., & Gone, J. P. (2012). Incorporating traditional healing into an urban American Indian health organization: A case study of community member perspectives. Journal of Counseling Psychology, 59(4), 542–554. Hazel, K. L., & Mohatt, G. V. (2001). Cultural and spiritual coping in sobriety: Informing substance abuse prevention for Alaska Native communities. Journal of Community Psychology, 29(5), 541–562. Heilbron, C., & Guttman, M. (2000). Traditional healing methods with First Nations women in group counseling. Canadian Journal of Counselling, 34, 3–13. Helms J., & Cook, D. (1999). Using race and culture in counseling and psychotherapy: Theory and practice. Boston: Allyn & Bacon. Herring, R. D. (1992). Seeking a new paradigm: Counseling Native Americans. Journal of Multicultural Counseling and Development, 20, 35–43. Herring, R. D. (1994). The clown or contrary figure as a counseling intervention strategy with Native American Indian clients. Journal of Multicultural Counseling and Development, 22, 153–164. Herring, R. D. (1999). Counseling with Native American Indians and Alaska Natives: Strategies for helping professionals. Thousand Oaks, CA: Sage. Hodge, D. R., & Limb, G. E. (2010a). Conducting spiritual assessments with Native Americans: Enhancing cultural competency in social work practice courses. Journal of Social Work Education, 46(2), 265–285. Hodge, D. R., & Limb, G. E. (2010b). A Native American perspective on spiritual assessment: The strengths and limitations of a complementary set of assessment tools. Health and Social Work, 35(2), 121–131. Johnson, C., & Johnson, D. (1998). Working with native American families. New Directions for Mental Health Services, 77, 89–96. Johnson, M., & Lashley, K. (1989). Influence of Native Americans’ cultural commitment on preferences for counselor ethnicity and expectations about counseling. Journal of Multicultural Counseling and Development, 17, 115–122. LaDue, R. (1994). Coyote returns: Twenty sweats does not an Indian expert make. Women and Therapy, 5(1), 93–111. LaFromboise, T. D., Berman, J., & Sohi, B. (1994). American Indian women. In L. Comas-Díaz & B. Greene (Eds.), Women of color: Integrating ethnic and gender identities in psychotherapy (pp. 30–71). New York: Guilford Press. LaFromboise, T. D., Trimble, J. E., & Mohatt, G. V. (1990). Counseling intervention and American Indian tradition: An integrative approach. Counseling Psychologist, 18, 628–654. Lee, S. (1997). Communication styles of Wind River Native American clients and the therapeutic approaches of their clinicians. Smith College Studies in Social Work, 68(1), 57–81. Lewis, E., Duran, E., & Woodis, W. (1999). Psychotherapy in the American Indian population. Psychiatric Annals, 29, 477–479. Lockhart, B. (1981). Historic distrust and the counseling of American Indians and Alaskan Natives. White Cloud Journal, 2(3), 31–43. Lowrey, L. (1983). Bridging a culture in counseling. Journal of Applied Rehabilitation Counseling, 14, 69–73. Malone, J. (2000). Working with Aboriginal women: Applying feminist therapy in a multicultural counseling context. Canadian Journal of Counselling, 34, 33–42. Mangelson-Stander, E. (2000). Strategies for survival through healing among Native American women: An urban case study. Dissertation Abstracts International, 61(2-A), 780. Marsiglia, F., Cross, S., & Mitchell-Enos, V. (1998). Culturally grounded group work with adolescent American Indian students. Social Work With Groups, 21(1–2), 89–102. Matheson, L. (1986). If you are not an Indian, how do you treat an Indian? In H. P. Lefley & P. B. Pedersen (Eds.), Cross-cultural training for mental health professionals (pp. 115–130). Springfield, IL: Charles C Thomas. McDonald, J. D., & Gonzalez, J. (2006). Cognitive-behavioral therapy with American Indians. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive-behavioral therapy: Assessment, practice, and supervision. Washington, DC: American Psychological Association. McWhirter, J., & Ryan, C. (1991). Counseling the Navajo: Cultural understanding. Journal of Multicultural Counseling and Development, 19, 74–82. Millar, J. (1996). Shingwauk’s vision: A history of Native residential schools. Toronto: University of Toronto Press. Mohatt, G., & Eagle Elk, J. (2000). The price of a gift: A Lakota healer’s story. Lincoln: University of Nebraska Press. Moran, J. R., & Reaman, J. A. (2002). Critical issues for substance abuse prevention targeting American Indian youth. Journal of Primary Prevention, 22(3), 201–233. Morrissette, P. (1994). The holocaust of First Nation people: Residual effects on parenting and treatment implications. Contemporary Family Therapy, 16, 381–392. Napoli, M., & Gonzalez-Santin, E. (2001). Intensive home-based and wellness services to Native American families living on reservations: A model. Families in Society, 82(3), 315–324. Navarro, J., Wilson, S., Berger, L., & Taylor, T. (1997). Substance abuse and spirituality: A program for Native American students. American Journal of Health Behavior, 21(1), 3–11. Noe, T., Fleming, C., & Manson, S. (2003). Healthy nations: Reducing substance abuse in American Indian and Alaska Native communities. Journal of Psychoactive Drugs, 35(1), 15–25. Oetting, E. R., & Beauvais, F. (1990). Adolescent drug use: Findings of national and local surveys. Journal of Consulting and Clinical Psychology, 58, 385–394. Pedersen, P. B. (Ed.). (1999). Multiculturalism as a fourth force. Philadelphia: Brunner/Mazel. Peregoy, J. (1999). Revisiting transcultural counseling with American Indians and Alaskan Natives: Issues for consideration. In J. McFadden (Ed.), Transcultural counseling (2nd ed., pp. 137–170). Alexandria, VA: American Counseling Association. Reimer, C. S. (1999). Counseling the Inupiat Eskimo. Westport, CT: Greenwood. Renfrey, G. (1992). Cognitive-behavior therapy and the Native American client. Behavior Therapy, 23, 321–340. Roberts, R., Harper, R., Tuttle-Eagle Bull, D., & Heideman-Provost, L. (1998). The Native American medicine wheel and individual psychology. Journal of Individual Psychology, 54, 135–145. Sage, G. (1997). Counseling American Indian clients. In C. C. Lee (Ed.), Multicultural issues in counseling: New approaches to diversity (2nd ed., pp. 35–52). Alexandria, VA: American Counseling Association. Salzman, M. (2001). Cultural trauma and recovery: Perspectives from terror management theory. Trauma, Violence, & Abuse, 2, 172–191. Simms, W. (1999). The Native American Indian client: A tale of two cultures. In Y. Jenkins (Ed.), Diversity in college settings: Directives for helping professionals (pp. 21–35). New York: Routledge. Sue, D. W., Ivey, A. I., & Pedersen, P. B. (1996). A theory of multicultural counseling and therapy. Pacific Grove, CA: Brooks/Cole. Tafoya, T. (1989). Circles and cedar: Native Americans and family therapy. Journal of Psychotherapy and the Family, 6(1–2), 71–98. Thomason, T. (1991). Counseling Native Americans: An introduction for non–Native American counselors. Journal of Counseling & Development, 69, 321–327. Thomason, T. (2011). Recommendations for counseling Native Americans: Results of a survey. Journal of Indigenous Research, 1(2), article 4. Retrieved from http://digitalcommons.usu.edu/kicjir/vol1/iss2/4 Thornton, R. (1996). Tribal membership requirements and the demography of “old” and “new” Native Americans. In G. D. Sandefur, R. R. Rindfuss, & B. Cohen (Eds.), Changing numbers, changing needs: American Indian demography and public health (pp. 103–112). Washington, DC: National Academy Press. Trimble, J. E. (1984). Drug abuse prevention research needs among American Indians and Alaskan Natives. White Cloud Journal, 3(3), 22–34. Trimble, J. E. (1988). Stereotypic images, American Indians and prejudice. In P. Katz & D. Taylor (Eds.), Towards the elimination of racism (pp. 181–202). New York: Pergamon. Trimble, J. E. (1992). A cognitive-behavioral approach to drug abuse prevention and intervention with American Indian youth. In L. A. Vargas & J. D. Koss (Eds.), Working with culture: Psychotherapeutic interventions with ethnic minority children and adolescents (pp. 246–275). San Francisco: Jossey-Bass. Trimble, J. E., & Beauvais, F. (Eds.). (2000). Health promotion and substance abuse prevention among American Indian and Alaska Native communities: Issues in cultural competence (CSAP Cultural Competence Series 9). Rockville, MD: U.S. Department of Health and Human Services. Trimble, J. E., & Hayes, S. A. (1984). Mental health intervention in the psychological contexts of American Indian communities. In W. A. O’Connor & B. Lubin (Eds.), Ecological models: Applications to clinical and community mental health (pp. 293–321). New York: John Wiley. Trimble, J. E., & LaFromboise, T. D. (1985). American Indians and the counseling process: Culture, adaptation, and style. In P. B. Pedersen (Ed.), Handbook of cross-cultural counseling and therapy (pp. 127–134). Westport, CT: Greenwood. Uhlemann, M., Lee, D., & France, H. (1988). Counselor ethnic differences and perceived counseling effectiveness. International Journal for the Advancement of Counseling, 11, 247–253. Wendt, D. C., & Gone, J. P. (2012). Urban-indigenous therapeutic landscapes: A case study of an urban American Indian health organization. Health & Place, 18(5), 1025–1033. Wexler, L. M., & Gone, J. P. (2012). Culturally responsive suicide prevention in indigenous communities: Unexamined assumptions and new possibilities. American Journal of Public Health, 102(5), 800–806. Witko, T. M. (Ed.). (2006). Mental health care for urban Indians: Clinical insights from Native practitioners. Washington, DC: American Psychological Association. Yurkovich, E. E., Clairmont, J., & Grandbois, D. (2002). Mental health care providers’ perception of giving culturally responsive care to American Indians. Perspectives in Psychiatric Care, 38(4), 147–156. 6 Counseling Asian Americans Client and Therapist Variables Frederick T. L. Leong D. John Lee Zornitsa Kalibatseva Primary Objective ■ To inform the reader about some cultural factors related to client and therapist variables that may play a significant role in the provision of effective counseling for Asian American clients Secondary Objectives ■ To expand and update the earlier literature review provided by Leong (1986) ■ To contribute to the process of bridging the gap between research and clinical practice in the existing knowledge base With the growing cultural diversity in the United States, it is inevitable that mental health service providers will increasingly encounter clients with widely varying cultural backgrounds who may also present with clinical issues that are different from those generally seen among members of the mainstream culture. In response to this demographic shift, it is important for counselors and psychotherapists to increase their levels of cultural awareness and competency in working with a diverse clientele. The development of cross-cultural counseling is a continual process, and the purpose of the present chapter is to contribute to that process by updating and bridging gaps within the knowledge base on counseling across cultures. In 1986, Leong published a comprehensive review of the literature related to counseling Asian Americans that covered client and therapist variables as well as counseling process and outcome variables. Since that review appeared, the field has seen a substantial increase in research efforts with attention focused on Asian Americans. For example, in a bibliography on Asians in the United States published by the American Psychological Association in 1992, 1,057 relevant studies were identified (Leong & Whitfield, 1992), compared with more than 10,699 studies identified in a recent search on PsycINFO regarding Asians in the United States. Three particular research trends are evident in this burgeoning literature: (1) research on specific Asian ethnic groups, (2) research on specific psychological issues (e.g., severe psychopathology) as these relate to Asian Americans, and (3) international research comparing Asians in the United States with Asians in other nations. These trends indicate that researchers are making appropriate efforts to gain deeper understanding of how therapists can best meet the mental health care needs of Asian Americans, especially given the heterogeneity within this population. Due to space limitations, the current review will cover only client and therapist variables as they relate to the counseling of Asian Americans. (For an updated review of counseling process and outcome variables concerning Asian Americans, see Leong, Chang, & Lee, 2007.) While we use the term Asian Americans throughout this chapter, we acknowledge that this general term encompasses many Asian ethnic subgroups, and the information provided may not always be generalizable across all Asian ethnic groups and all Asian individuals. We use this broad term primarily because of the space limitations of this survey chapter, but it is also important to note that our use of the term mirrors the limitations of the current research literature. We incorporate research findings on specific Asian ethnic subgroups throughout the chapter to enhance the applicability of the information to clinical practice. Client Variables It has long been recognized that client characteristics interact significantly with therapist characteristics and theoretical orientations to influence psychotherapy outcomes (Lambert, 2013). Therefore, understanding the personality characteristics and worldviews of Asian Americans from the cultural perspective is critical for an accurate understanding and assessment of how Asian Americans may respond to counseling and psychotherapy. Personality Characteristics Within Cultural Context Research has found that Asian Americans exhibit distinct personality characteristics that are often different from those exhibited by European Americans and members of other racial ethnic minority groups (Uba, 1994; Vernon, 1982). Asian Americans’ personality characteristics are influenced not only by their heritage cultures but also by the interactions of those cultures with the cultures of Western society (D. Sue, 1998). The Asian American worldview emphasizes humility, modesty, treating oneself strictly while treating others more leniently, obligation to family, conformity, obedience, and subordination to authority. Other factors that are important in the cultural context of Asian Americans include familial relations and emphasis on interpersonal harmony versus honesty, role hierarchy versus egalitarianism, and self-restraint versus self-disclosure (Chien & Banerjee, 2002). Asian Americans’ tendency to exhibit lower levels of verbal and emotional expressiveness than do Euro-Americans, for example, can be accounted for by the cultural context as described (Uba, 1994; Vernon, 1982). Recognizing and understanding the cultural context of these characteristics can enhance therapists’ appreciation for why Asian Americans may respond to psychotherapy differently from those with different worldviews. Given this culturally different worldview, which emphasizes role hierarchy and respect for authority, Asian Americans often exhibit greater respect for counselors than do Euro-Americans, whose worldview places less emphasis on deference based on role hierarchy (D. W. Sue & Kirk, 1973). As such, Asian Americans have shown strong preference for a counselor who is an authority but is not authoritarian (Exum & Lau, 1988). For example, Chinese Americans have been found to be more likely than their European American counterparts to expect counselors to make decisions for them and to provide immediate solutions (Mau & Jepsen, 1990). Research shows that not only do Asian Americans prefer structured situations and immediate solutions to problems, but they also prefer directive counseling styles because they exhibit lower tolerance for ambiguity than Euro-Americans. Given this, Asian Americans are likely to have some difficulty with the Western model of counseling and psychotherapy, which is filled with ambiguity by design and is typically conducted as an unstructured process. It has been observed that Asian clients tend to prefer crisis-oriented, brief, and solution-oriented approaches rather than insight- and growth-oriented approaches (Berg & Jaya, 1993). The mismatch of Asian Americans, who tend to be less tolerant of ambiguity, with insightoriented psychotherapy may account for the high rates of early termination and underutilization found among these clients. Underutilization and premature termination of therapy are the twin problems of mental health care for Asian Americans (Leong & Lau, 2001). When using an appropriate cultural lens with Asian Americans, researchers and counselors are vulnerable to making false assumptions and inappropriate comparisons across populations. More specifically, Western worldviews and perspectives should not be used as the norms against which characteristics and behaviors of Asian Americans are interpreted. Without taking the Asian cultural context into account, counselors may potentially view as negative any characteristics of Asian Americans that differ from those of Euro-Americans. For example, Asian values of reserve, restraint of strong feelings, and subtleness in approaching problems may come into conflict with the values of Western counselors who expect their clients to exhibit openness, psychological-mindedness, and assertiveness. A Western counselor may assume that an Asian American client is repressed, inhibited, or shy rather than simply exhibiting characteristics aligned with his or her culture (S. Sue, 1981). Such an ethnocentric and culturally biased approach, sometimes offered under the rubric of “culture blindness,” tends to contribute to the two problems of underutilization and premature termination from mental health services. Etics are defined as universals, but sometimes pseudoetics are imposed on Asian Americans. This can result in erroneous inferences about Asian Americans when their personality characteristics are interpreted with the Euro-American culture viewed as the norm. Such errors can also be found in the arena of career counseling. For example, Asian Americans historically report significantly higher parental career expectations and parental involvement in the career decision-making process than Euro-Americans (Castro & Rice, 2003). When making career decisions, Asian Americans are more likely than Euro-Americans to be influenced by their families and cultural values (Tang, 2002). From an Asian cultural perspective, involving family in career decisions is congruent with cultural norms and values, whereas from a Western perspective, an individual’s concern with parental expectations and wishes regarding career choices may be interpreted as immature and maladaptive. In a study by Hardin, Leong, and Osipow (2001), career decision-making measures indicated that Asian Americans exhibit less mature career choice attitudes than do European Americans. As the authors note, the results may not be accurate indicators of maturity because the measures designed to assess maturity in career decision making were biased toward the cultural norms and expectations of the Western culture. Again, it is important for counselors to consider the worldview of Asian Americans and use that worldview as the normative measuring rubric rather than a biased measure from another worldview. Therapeutic errors result from the application of culturally incongruent worldviews, values, norms, beliefs, and expectancies. Consistent with the cultural congruence model (Leong & Kalibatseva, 2011), the complexity of how cultural values affect the lives of Asian Americans is being explored continuously. Research suggests that gender and racial identity have influenced the cultural values held by Asian Americans (Yeh, Carter, & Pieterse, 2004). A strong preference for distinct cultural value orientations could reflect both traditional Asian and European American cultural values. The unique personality characteristics of Asian American women (True, 1990) and Asian American men (D. Sue, 2001) have also constituted an area of intensive research focus. Factors such as socialization of gender roles, societal pressures, acculturation, and traditional Asian cultural values have been explored for how they relate to the personality development of Asian American women and men. For example, for traditionally oriented Asian American males, reframing and discussing culture conflicts can help resolve issues of living up to cultural expectations. For acculturated Asian American males, a more didactic presentation that includes a discussion of Asian males in American society might be a better first step than introspective techniques in the consciousness-raising process. Understanding the unique characteristics of the two sexes provides context for which psychologists can offer therapeutic assistance. Emotion of Shame—Loss of Face Emotions are important to our understanding of human behaviors because they provide energy for and guide behaviors. Because emotions serve these motivational and communicative functions, understanding cultural variations in the meaning, experience, and expression of emotions in the therapeutic relationship is critical to effective cross-cultural counseling. Shame and shaming are the mechanisms that traditionally help reinforce societal expectations and proper behavior in Asian culture. The fear of losing face can be a powerful motivational force pushing individuals to conform to family and societal expectations. Losing face and the resulting shame are especially salient for Asian American clients because loss of face is often a dominant interpersonal dynamic in Asian social relations, particularly when the relationship involves seeking help for personal issues (Zane & Yeh, 2002). In Asian American culture, the emotion of shame and the experience of losing face involve not only the exposure of the individual’s actions for all to see but also the withdrawal of the family’s, community’s, or society’s confidence and support. Feelings of shame are painful for members of collectivistic cultures (e.g., Asian cultures) because of the social consequences (Yeh & Huang, 1996). The web of obligation and fear of shame are frequently crucial parts of the lives of East Asian and Asian Americans who seek or are referred for treatment. These feelings can affect their behavior and perceptions of the world and their presentation of material in therapy. Such feelings can envelop the relationship with the therapist in ways that the therapist does not understand unless he or she is familiar with the cultural relevance of shame for the client’s particular Asian American group. In a study by Peng and Tjosvold (2011) concerning behavioral strategies in conflict avoidance and how they are related to social face concerns, Chinese employees were asked to recall an incident where they avoided a conflict with their supervisors. Confirmatory factor analysis of the responses revealed yielding, outflanking, delay, and passive aggression as approaches to avoiding conflict. Interestingly, the associations of social face concerns and avoidance were stronger among employees who interacted with Chinese managers compared with those working for Western managers. This study provides some important indications of how Asian American clients may manage conflict and face concerns with European American versus Asian American counselors. Language From the early days of the Whorfian hypothesis (Carroll, 1956) regarding language and thought, cross-cultural psychologists have pointed to the constraining effects of language in cross-cultural communication and understanding. It is therefore not surprising that many investigators have identified language as an important client variable to attend to when counseling Asian Americans. Language may be the source of several kinds of barriers to effective cross-cultural counseling, including misinterpretations and false assumptions. For example, Asian Americans with bilingual backgrounds may be perceived as uncooperative, sullen, and negative (D. W. Sue & Sue, 1972). Asian Americans who speak little or no English may be misunderstood by their counselors. The use of dialects or nonstandard English may interfere with the effective exchange of information or even stimulate bias on the part of the therapist. Given such language-related problems, Asian Americans may attempt to communicate their concerns nonverbally, which in turn may be misinterpreted by counselors (Tseng & McDermott, 1975). The use of interpreters with non-English-speaking Asian clients can result in interpreter-related distortions (Marcos, 1979). Consistent with the Whorfian hypothesis (Carroll, 1956), problems with intercultural communication are not limited to the use of different languages but also stem from differences in thought patterns, values, and communication styles (Chan, 1992). The communication styles of Asian Americans are significantly different from those of Euro-Americans. Asian Americans tend to communicate in a high-context style, with context as the primary channel for communication. Direct and specific references to the meaning of the message are not given. In interpreting the meaning of the message, receivers are expected to rely on their knowledge and appreciation for nonverbal cues and other subtle affects. The Euro-American culture tends to focus on communication through a low-context style, in which words are the primary channel for communication. Direct, precise, and clear information is delivered verbally. Receivers can expect to take what is said at face value. The high-context communication style can be seen as an elaborate, subtle, and complex form of interpersonal communication. This communication style enables Asian Americans to avoid causing shame or loss of face to themselves and others, and thus to maintain harmonious relations. In fact, Asian Americans might consider any form of direct confrontation and verbal assertiveness to be rude and disrespectful. The use of direct eye contact may be limited because direct eye contact may imply hostility and aggression and be taken as a rude gesture. Mental health service providers must be aware of and sensitive to these communication style differences to prevent cross-cultural misunderstandings. An individual’s preferential communication style (high or low context) could influence how he or she perceives others who use the opposite style. Those who prefer high-context communication may perceive those who use low-context communication to be too direct, insensitive to context, and minimally communicative. Those who use a low-context communication style may, in turn, perceive high-context communicators as indirect, lacking in verbal skills, and even untrustworthy. Cultural awareness and accommodation of different communication styles has positive impacts on the therapy process and on the therapeutic alliance between therapist and client. More recent work on culture and cognition by Nisbett and colleagues, as exemplified by Nisbett’s 2003 book The Geography of Thought, provides additional insights into how Asians and Westerners think and reason differently. The research Nisbett summarizes in his book warrants careful study by counselors and therapists working with Asian American clients. Related to the role of language in counseling is a study by Hall, Guterman, Lee, and Little (2002), who examined children’s and adolescents’ counseling outcomes to determine if clients of different backgrounds benefit from being matched with counselors on ethnic, gender, and language factors. The multivariate analyses performed by the investigators found that general psychological functioning and other variables differed between groups in which clients and counselors were matched on these factors and nonmatched groups. The researchers concluded that ethnicity, language, and gender matches led to improvements in treatment outcomes. Language has also come to play a significant role in recent approaches to cultural adaptations in psychotherapy (Bernal & Domenech Rodríguez, 2012). For example, in a review of cultural adaptation of treatment, Bernal, Jiménez-Chafey, and Domenech Rodríguez (2009) point to the growing interest in whether and how psychotherapies can be adapted to take into account the cultural, linguistic, and socioeconomic contexts of diverse ethnocultural groups. According to these scholars, the root of the debate is whether evidence-based treatments (EBTs) developed within particular linguistic and cultural contexts are appropriate for ethnocultural groups that do not share the same language, cultural values, or both. Bernal et al. review the considerable evidence regarding the relationships between cultural contexts and various aspects of the diagnostic and treatment process. They also review the available published frameworks for cultural adaptations of EBTs and various conceptual models for adapting existing interventions to produce more positive therapeutic outcomes. Family Whereas anthropological research has found the family to be a common kinship organization across most cultures, the meaning and importance of the family may vary. Given Asian Americans’ collectivistic value orientation, it has long been observed that the family plays a critical role in Asian American culture. As such, the family and its cultural dynamics are considered to constitute another important client variable, especially in relation to the mental health of Asian Americans. While Asian families may emphasize connectedness among family members, Western norms prioritize separateness and clear boundaries in relationships, individuality, and autonomy (Tamura & Lau, 1992). Mental health service providers should note that the preferred direction of change for Asian American clients may be toward a process of integration rather than a process of differentiation. Within the Asian American cultural context, family constancy, equilibrium, duty, obligation, and appearance of harmonious relations are important factors. Family dynamics and related factors that practitioners should also consider when working with Asian Americans include immigration history, adaptation experiences, cultural values, and generational differences related to acculturation experience (e.g., B. S. K. Kim, Brenner, Liang, & Asay, 2003; J. M. Kim, 2003). More specifically, immigrant families may face problems with social isolation, adjustment difficulties, and cultural and language barriers. Issues such as language and cultural barriers may contribute to parent–child conflicts within immigrant families. Family organization, roles and functioning, and cultural values across generations are also important to explore within Asian American families. Studies have shown that for Asian Americans, immediate and extended family are important loci of identity formation, social learning, support, and role development. Asian culture also places higher value on males than on females, which could result in boys and men holding a disproportionate share of power within the family (Cimmarusti, 1996). Parenting styles received may also explain personality development and life experiences of Asian Americans (Lim & Lim, 2004). In a study of Korean American families, H. Kim and Chung (2003) found that authoritative parenting behaviors were most common, followed by authoritarian behaviors, then permissive behaviors. They also found that authoritative parenting style and greater number of years lived in the United States were predictive of higher academic competence. Authoritarian and permissive parenting styles were predictive of lower self-reliance, whereas greater number of years lived in the United States was related to higher self-reliance. As with any population, among Asian Americans families have the potential not only to facilitate mental health but also to serve as potential mental health stressors. It is important to note that not all families are alike, and clinicians should expect as much variation among Asian American families as among families in other ethnic groups. In a study examining family influences on mental health, Leu, Walton, and Takeuchi (2010) used data from the first nationally representative psychiatric survey of immigrant Asians in the United States (N = 1,583) to demonstrate the importance of understanding acculturation domains within the social contexts of family, community, and neighborhood. They found that among immigrant Asian women, the association between family conflict and mental health problems is stronger for those with higher ethnic identity. For immigrant Asian men, community reception (e.g., high everyday discrimination) is more highly associated with increases in mental health symptoms among those with poor English fluency. Leu et al. conclude from their findings that it is important for practitioners to consider both individual and social domains of acculturation and adaptation. Moreover, these relationships between acculturation and mental health may vary by gender and context. Given the critical need for more culture-specific measures, Wang (2010) describes the development and psychometric evaluation of the Family Almost Perfect Scale (FAPS), which measures the perceived level of perfectionistic standards and evaluation from an individual’s family. In the first study, which used a sample 283 college students, Wang conducted exploratory factor analysis to determine the FAPS scale items. In the second study, the FAPS was cross-validated through confirmatory factor analyses with an Asian/Asian American sample (N = 252) and a European American sample (N = 386). These two samples were compared on various target variables, and Asians/Asian Americans reported modestly higher personal and family discrepancy and lower selfesteem. Wang also grouped the participants into different perceived perfectionistic family types. Those participants who perceived themselves as having maladaptively perfectionistic families reported greater depression and lower self-esteem. The FAPS appears to be a promising new measurement tool that will help increase understanding of the role of family dynamics in mental health among Asian Americans. The personal and family discrepancies revealed in the FAPS may prove to be valuable foci for counseling with Asian Americans with mental health problems. Acculturation Broadly, acculturation is a multidimensional construct that involves adaptation to the norms (i.e., values, attitudes, and behaviors) in a new culture and maintenance of the norms of the indigenous culture (e.g., Berry, Trimble, & Olmeda, 1986). We use the term acculturation here to represent the degree to which Asian Americans are identified with and integrated into the Euro-American majority culture. Acculturation has important implications for Asian Americans’ physical and mental health, academic performance, and response to counseling and psychotherapy (Suinn, 2010). In general, low levels of acculturation have been associated with more psychological symptoms, assuming that low acculturation is also related to academic and financial difficulties and social isolation. However, high levels of acculturation have been linked to difficulties in psychological adjustment in the presence of family conflict and acculturative family distancing (Hwang & Wood, 2009). Asian American families often experience generational differences as later generations internalize Western norms and values more than their parents or grandparents do (third versus first generation; Connor, 1974). A few studies of Asian American families have found that intergenerational discrepancy in acculturation, especially as perceived by the adolescent children, is associated with higher depression scores (Ying & Han, 2007). Caught between Western standards and the traditional cultural values of their parents, Asian Americans may experience mental health problems related to the acculturation process as well as interpersonal conflicts. Based on their clinical experience with Asian Americans, D. W. Sue and Sue (1972) developed a conceptual model for understanding how Asian Americans adjust to culture conflicts. They observed that Asian Americans exhibit three distinct ways of resolving the culture conflicts they experience. First, the traditionalist is one who remains loyal to his or her own ethnic group by retaining traditional Asian values and living up to expectations of the family. Second, the marginal person is one who becomes overly Westernized and rejects traditional Asian values; this individual’s pride and self-worth are defined by his or her ability to acculturate into Euro-American society. Third, the Asian American is one who rebels against parental authority but at the same time attempts to integrate bicultural elements into a new identity by reconciling viable aspects of his or her heritage with the present situation. Asian Americans may attempt to resolve the cultural conflicts associated with acculturation by integrating into both cultures and developing a sense of ethnic identity (Cheryan & Tsai, 2007). Level of acculturation has been associated with Asian Americans’ likelihood of seeking mental health services, therapy duration, and therapy outcome. More acculturated individuals tend to seek professional psychological help more often, whereas less acculturated individuals may rely more on community elders, religious leaders, student organizations, and church groups (Solberg, Choi, Ritsma, & Jolly, 1994). Individuals who are more acculturated are most likely to recognize the need for professional psychological help because they are more open to discussing problems and more tolerant of the stigma often associated with seeking psychological assistance (Atkinson & Gim, 1989). In more recent research, enculturation to Asian values has been found to be inversely associated with professional help-seeking attitudes (B. Kim, 2007), and higher values of acculturation paired with lower values of enculturation have been found to predict more positive attitudes toward seeking professional psychological help (Miller, Yang, Hui, Choi, & Lim, 2011). It is important for clinicians to be cognizant of the impact of acculturation and provide services that address the impact of acculturation in conjunction with other factors, such as acculturative stress, acculturative family distancing, and enculturation. Counseling Expectations The counseling expectations and conceptions of mental health of Asian Americans are important client variables that have been examined empirically. Studies of the effects of Asian students’ cultural conceptions of mental health on expectations of counseling found that Asians generally tended to view counseling as a directive, paternalistic, and authoritarian process (Arkoff, Thaver, & Elkind, 1966) or an advice-and-information-giving process (Tan, 1967). Consequently, Asian Americans were more likely to expect a counselor to provide advice and recommend a specific course of action. Studies of counseling expectations found that, compared with U.S. students, Asian international students reported more expectations for directiveness, empathy, nurturance, and flexibility from counselors (Yoon & Jepsen, 2008; Yuen & Tinsley, 1981). A group of Chinese students also expected more expertise from the counselor and believed that clients should possess lower levels of responsibility, openness, and motivation. These findings suggest that mental health clinicians may need to examine Asian American clients’ expectations for therapy openly and address them in the beginning of treatment as one way to prevent the premature termination that can result from differing expectations. Help-Seeking Attitudes Asian Americans have continuously underutilized mental health services (U.S. Department of Health and Human Services, 2001). Explanations for the low utilization rates include deterrents to participation such as cognitive barriers (e.g., stigma), affective barriers (e.g., shame), Asian value orientation (e.g., collectivistic nature), and physical barriers (e.g., access to resources; Leong & Lau, 2001). Furthermore, in some cultures, psychological therapy may not exist as a concept; therefore, utilization of mental health services may not be viewed as a treatment option. In recent years, researchers have begun to explore ways in which mental illness might be appropriately explained to Asian Americans to increase understanding of the concept and reduce stigma among this population (Yep, 2000). Stigma and lack of understanding can account for the low frequency of mental health care self-referrals among Asian Americans; studies have shown that Asian Americans are more likely than Euro-Americans to be referred to therapists by friends and through health and social service agencies (Akutsu, Snowden, & Organista, 1996). A recent study found that Asian American students’ most preferred methods of addressing their mental health concerns were, in order of preference, taking classes on mental health issues, visiting the health center, finding information online, and visiting the counseling center (Ruzek, Nguyen, & Herzog, 2011). These help-seeking preferences may be associated with the students’ fear of losing face and desire to maintain group harmony and their perception of reporting physical problems as more appropriate than reporting mental health problems. Preferred use of traditional Asian healing practices can also account for underutilization of professional psychological services. Level of acculturation also plays an important role in Asian Americans’ attitudes toward mental health services (Zhang & Dixon, 2003), such that Asian Americans with high acculturation levels are more willing to seek help than those less acculturated. One study found that Chinese, Japanese, and Korean individuals with high acculturation levels were more likely to recognize the need for professional psychological help, more tolerant of stigma, and more open to discussing problems with a psychologist than were individuals who were less acculturated (Atkinson & Gim, 1989). Additionally, Asian American women have been found to be more willing than Asian American men to seek psychological services (Gim, Atkinson, & Whiteley, 1990). To reduce service underutilization and premature termination among Asian Americans, mental health providers must recognize the influences of the Asian cultural context on these clients’ cultural values, attitudes, beliefs, and help-seeking behaviors. Finally, service providers should identify cultural gaps and blind spots in existing Western models of psychotherapy and accommodate treatment to their Asian American clients’ needs (Leong, 2007). Health professionals should openly explore their own vulnerabilities to ethnocentrism and cultural uniformity myths that may hinder their full appreciation of the worldviews of their ethnically different clients. Experiences of Psychological Distress and Coping Mechanisms Asian Americans can experience mental health issues similar to those experienced by members of other racial and ethnic groups (Takeuchi, Mokuau, & Chun, 1992). Despite the “model minority” stereotype, prevalence rates of mental health problems among Asian Americans are noteworthy. A large amount of literature and research attention has been devoted to understanding and describing the unique mental health needs and experiences of Asian Americans (Cheng, 2012; Yang & WonPatBorja, 2007). Awareness of cultural context and appropriate person–environment fit may facilitate mental health practitioners’ understanding of Asian Americans’ experiences and expression of symptoms of distress, enabling them to provide culturally congruent treatment (Leong & Kalibatseva, 2011). One of the most widely circulated claims in cross-cultural psychopathology has been that people of Asian descent tend to somatize psychological distress. Some of the characteristics cited in support of this claim are the denial or suppression of emotions, stigma toward mental disorders, and lack of body–mind dualism in Asian cultures. However, recent studies suggest that Asians and Asian Americans may tend to report somatic symptoms initially, employing a widely used cultural idiom of distress, but they acknowledge the presence of emotional issues, too (Ryder et al., 2008). Thus, clinicians need to pay particular attention to initial symptom reports in assessment, diagnosis, and treatment. The worldview of Asian Americans is further contextualized by an understanding of their ethnic identity. Experiences of racism and discrimination can have negative impacts on Asian Americans’ mental health and coping strategies. In addition, experiences of racial discrimination may hinder the therapeutic process, especially if the counselor is Euro-American and the client has had a negative cultural experience. One study found that racial discrimination stress significantly predicted depressive symptoms over and beyond perceived general stress and perceived racial discrimination among Asian American college students (Wei, Heppner, Ku, & Liao, 2010). Furthermore, immigration experiences may be a source of mental health problems as Asian Americans seek to adjust to living in the United States (F. K. Cheung, 1980). Acculturative stress, for example, is a direct result of the acculturation adaptation process for first-generation immigrants, and bicultural stress is a response to the pull of maintaining ethnic ties in second and later generations and has significant predictive effects on mental health symptoms (Yeh, 2003). Research findings about the need for psychological and social support among Asian Americans have been mixed. Some studies have found that Asian Americans in general may have less of a need for psychological and social support than do Euro-Americans (Wellisch et al., 1999), whereas others have found that Asian American adolescents specifically have higher levels of depressive symptomatology, withdrawn behavior, and social problems than Euro-American adolescents (Chang, 2001). Social support from friends, family, and even international student offices can buffer the stress related to racism and cultural adjustment (Chen, Mallinckrodt, & Mobley, 2002). It is well documented that social support is an instrumental tool for coping among many Asian Americans. Understanding the cultural worldview of Asian Americans can help mental health providers recognize the coping strategies their Asian American clients use when experiencing psychological distress. These strategies may tend to emphasize sharing with family and friends rather than with professionals such as counselors and doctors. Collectivistic coping may be prevalent among Asian Americans, given that it emphasizes the importance of close relationships and family bonds in dealing with stress. More specifically, among the ethnic groups examined in one study (Chinese, Korean, Filipino, and Indian), Korean Americans were found to be more likely than those in other groups to cope with problems by engaging in religious activities (Yeh & Wang, 2000). Finally, Asian Americans may use coping resources based in their heritage cultures. For example, traditional folk healing practices, spiritual identification, and religious practices such as Buddhism are primary resources for support among Asian American communities. Therapist Variables What therapist characteristics affect the provision of mental health services to Asian Americans? Generally speaking, Asian American clients prefer therapists who have attitudes and personalities similar to their own, who have more education than they have, and who are older than them (Atkinson, Wampold, Lowe, Matthews, & Ahn, 1998). Zhang and Dixon (2003) have also found that counselors who respect and are open to learning how to relate to people from different cultures are rated by Asian international students as more expert, attractive, and trustworthy than counselors who are not culturally responsive. Regardless of the specialization or discipline, it is a professional expectation that therapists develop competencies to work with people from different cultures (American Psychological Association, 2003). The actual nature of such competencies is being debated, but it is obvious that the mastery of culturally sensitive skills is imperative for mental health service providers in today’s shrinking world and global economy. To work successfully with clients who are perceived or identify as Asian American, clinicians should be proficient in three areas: (1) knowledge of Asian cultures and ethnicities, (2) awareness of race and racialization among Asian Americans, and (3) skills to respond appropriately to or to broach the subjects of culture, ethnicity, and race during the counseling process. Knowledge of Cultures and Ethnicities Therapists who work with Asian Americans should be familiar with the variety of cultures and ethnicities that exist under the umbrella of the U.S. government’s Equal Employment Opportunity Commission (EEOC) category “Asian.” Learning about cultures and ethnicities from Asia and India and their history in the United States is essential for counselors’ development of cultural competency. The similarities among “Asian” ethnicities have been outlined earlier in this chapter, but the differences are very important to individuals. Therapists who do not know the differences between Chinese, Japanese, Korean, Vietnamese, East Indian, and other Asian cultures and their separate histories in America are susceptible to ethnic and racial stereotyping, which can disrupt the therapeutic alliance and discredit the therapists’ credibility (Berg & Miller, 1992). Unfortunately, one study found that practicing counselors showed degrees of cultural stereotyping similar to those found in the general population (Bloombaum, Yamamoto, & James, 1968). Therapists are not immune to the ethnocentric and racist attitudes that are a part of American educational systems and popular culture (Loewen, 1995; Mok, 1998). An often-cited example of how cultural knowledge can be important for therapists working with Asian Americans is how Euro-American clinicians who make a firm split between body and mind can underestimate the presence of psychological and relational stress in their Asian American clients. Due to philosophical, religious, and familial traditions, Asian Americans may tend to focus more on physical discomforts than on emotional symptoms. This somatization of psychological stress can result in the underestimation of the amount and degree of anxiety and depression among Asian Americans (Okazaki, 2002). In a study that examined the degree to which primary care physicians recognize psychiatric distress in Asian and Latino patients, Chung et al. (2003) found that while 42% of the Asian patients exhibited depressive symptoms, only 24% of them were diagnosed with psychiatric conditions. Such discrepancies can lead to the underestimation of both the incidence and the degree of mental health problems among Asian and Asian American communities, thus affecting public funding of mental health services and service delivery (see Omi, 2010). A therapist’s ability to utilize interventions that match a client’s needs or circumstances is essential in most clinical settings. As noted earlier in this chapter, some studies have suggested that Asian American clients expect and respond more favorably to directive modes of counseling. Therapists who see Asian American clients should also appreciate that there are several traditional healing practices in Asia. The Thai Pa Sook model of counseling (Pinyuchon, Gray, & House, 2003), the Filipino practice of Santo Niño (Lin, Demonteverde, & Nuccio, 1990), and forms of the Japanese and Morita and Naikan therapies (Morita, 1928; Yoshimoto, 1981) can be found in the United States. Sandhu (2004) describes a synergetic collaboration between South Asian Sikh religious healing resources and modern medicine. Counselors should be cautioned to stay within their ethical boundaries of competence and recognize any liabilities that they incur when working with or making referrals to practitioners who utilize methods other than those recognized by American licensing bodies. Awareness of Race and Racialization Therapists who work with Asian Americans should also be aware of how people of a variety of cultures and ethnicities who immigrated to the Americas from Asia, India, and the islands of the Pacific came to be thought of and treated as “Asians” in the United States. This process of “racialization” differs for each group, and the degree of racialization varies from person to person (see Omi & Winant, 1994; Takaki, 1998). Racism, or the institutionalization of the belief in White supremacy, is a crucial element in the histories of all Asians in America—Chinese, Japanese, Koreans, Cambodians, East Indians, and others (see Lopez, 1997). That is, in addition to being aware of the role of racism in the histories of Asian American groups, therapists need to be aware of how the Chinese, Japanese, Filipinos, and others began to think of themselves and their experience in America using racial constructs. Awareness of the events and conditions that led to Chinese, Japanese, Vietnamese, and other groups marching together as “Asian Americans” and adopting the label that the U.S. government used to classify them is important (see Wu, 2001). Counselors who work with Asian Americans can increase their understanding of their clients and the probability that their clients will perceive them as credible if they know these narratives. It is important to note that developing this awareness involves making firm distinctions among the constructs of culture, ethnicity, and race (see Fish, 2000; Helms, Jernigan, & Mascher, 2005; Helms & Talleyrand, 1997; Lee et al., 2013). Being aware of how the different “Asian” cultures have negotiated ethnocentrism and racism in the United States enables counselors to appreciate the sociopolitical contexts of the presenting problems Asian Americans bring to counseling. Understanding how individual clients are negotiating culture and race can help therapists gain insight into their family dynamics, socialization and acculturation, political postures, and religious beliefs. That is, Asian American clients’ cultural (D. W. Sue & Sue, 1972) and racial identities (West-Olatunji et al., 2007) can inform clinical conceptualizations and intervention strategies, especially for clients who may be perceived as “Asian” but identify as mixed or multiracial (Suyemoto, 2004). Probably more important than the client’s racial identity is how the therapist navigates culture and race in his or her own life. Day-Vines and colleagues (2007) have proposed that a therapist’s racial identity is predictive of his or her ability to broach the subjects of race, ethnicity, and culture appropriately during the counseling process. Skills to Broach the Subjects of Culture, Ethnicity, and Race The therapist and the client are both human beings. It is clear from anthropological and genetic research that human beings are similar, different, and unique. The challenges for a therapist are to establish rapport with a client based on similarities between therapist and client, to take into account the differences that exist between them, and to honor the fact that they are both unique individuals. It is the therapist’s responsibility to acknowledge and, when appropriate, address the similarities and differences between therapist and client. These similarities and differences may be cultural (e.g., language, religion, socioeconomic class), ethnic (e.g., dialect, denomination, region), and racial (i.e., identities and positionalities). A therapist raised in a rural American culture would be wise to pay attention to the culture of a client raised in Beijing, China. A gay male counselor from Chicago might have to consider what ethnic differences are operative when he is working with a heterosexual female from Los Angeles. And a White-identified therapist should be attentive to when it may be helpful to broach the topic of race when working with a client who identifies as Asian or Asian American. Certainly, the therapist must recognize the intersections of an individual’s multiple identities. For example, in a counseling relationship between a White, Euro-American, middle-class, heterosexual Christian female therapist from Kansas and an Asian American, upper-class, gay Jewish male from New York, there will probably be interactions worth discussing. A body of research has emerged that demonstrates that the acknowledgment of cultural and racial differences during the counseling process enhances counselor credibility, client satisfaction, the depth of client disclosure, the working alliance, and client willingness to return for follow-up sessions (Zhang & Burkard, 2008). The research findings on the impact of race on the counseling process are mixed. A racial match exists when the counselor and client are both perceived to be from the same racial group.1 Racial matches have been found to be associated with increased utilization, favorable treatment outcomes (i.e., global assessment scores), lower treatment dropout, and increased counselor credibility and empathy (Flaskerud & Lui, 1991; Gamst, Dana, Der-Karabetian, & Kramer, 2001; Gim, Atkinson, & Kim, 1991). Other studies, however, have demonstrated no effect of racial match on treatment processes (Watkins, Terrell, Miller, & Terrell, 1989) or outcomes (Gamst, Dana, Der-Karabetian, & Kramer, 2004). This research is controversial, because the popular view of race is that it should not matter in interpersonal relationships. The notions that the United States is a “postracial” society and that people should be “color-blind” have been argued by scholars and popular media (see Vo, 2010). However, research on the counseling dyad has repeatedly demonstrated that race can matter in this relationship. Meyer, Zane, and Cho (2011) offer an explanation for why and how racial match can have positive impacts on the counseling process for Asian Americans. Using an analog experimental design and a large sample of Asian American undergraduate students born in the United States, they found that when a counselor and client had similar racial characteristics (i.e., skin tone, facial features, and hair texture), the participants assumed that the counselor and client also had similar attitudes and experiences. That is, individuals’ racial phenotypes were assumed to reflect culture or background. Meyer et al. summarize: Racial match produces greater therapist credibility and this effect was mediated by life experience similarity. This suggests that racially matched Asian American clients may perceive that their counselor has undergone similar life experiences and/or has come from a similar culture, and this leads them to evaluate the therapist to be more credible. Thus, racial match could be considered a viable therapeutic possibility when this option is possible at a counseling center. (p. 342) However, Asian American counselors are not always available, and the therapeutic relationship involves much more than race. Language, culture, ethnicity, class, religion, age, size, disability, gender, sexual orientation, educational background, geographic location, marital or relationship status, work experience, military service, and hobbies/recreational activities are all variables that influence the client’s and counselor’s perceptions and behavior. Experienced therapists take all these variables into account when doing therapy. Just because race is only one of many factors in a counseling relationship, however, that does not mean that it can be denied or ignored. The research suggests that to neglect the meaning that therapists and their clients give to race could be to omit an important element from the therapeutic process. When therapists who are not racially identified as “Asian” work with clients who identify as “Asian” or “Asian American,” they should have not only some knowledge of the clients’ ethnicities and racial identities but also the skills to develop rapport and establish some credibility across racial lines. Having similar attitudes and life experiences can go a long way toward bridging a racial divide, but members of different racial groups in the United States do not always have similar experiences and values. For therapists, knowing how to respond appropriately to how they are perceived by clients because of their phenotypes associated with race is an important skill. How counselors negotiate how they are racially perceived has been referred to as “racial responsiveness” (Lee et al., 2013). Discerning when and how to broach the topic of racial differences during the counseling process can be difficult and confusing. Therapists need to develop this skill through the processes of experienced supervision and the understanding of their own cultural, ethnic, and racial identities. Summary and Conclusions As an update to Leong’s (1986) review of the literature on counseling Asian Americans, this chapter has highlighted the culturally relevant client and therapist variables that shape the counseling relationship. A growing body of psychological research on Asian Americans has demonstrated the ways in which clients’ subjective experiences and expressions of distress, openness to formal mental health services, expectations of providers, therapeutic goals, and interpersonal and communication styles are shaped by culture and context. Specifically, the cultural socialization of many Asian Americans has contributed to the salience of an interpersonal orientation that values interdependence, conformity, emotional self-restraint, humility, and respect for authority. Research studies with an indigenous measure of Chinese personality found a Chinese factor of personality above and beyond the Big Five (F. M. Cheung, Cheung, Leung, Ward, & Leong, 2003). Originally labeled the “Chinese tradition factor,” it was renamed “interpersonal relatedness” following expansion of the research program beyond Chinese samples (F. M. Cheung, Cheung, Wada, & Zhang, 2003). This factor points to the existence of a relational self among Asians that is consistent with research on individualism– collectivism (Triandis, 1995) and independent–interdependent self-construal (Markus & Kitayama, 1991). Given this relational self, it is not surprising that studies have shown that Asian Americans expect a counselor to play the role of an authority figure who provides structured guidance in problem solving as well as empathy, nurturance, and flexibility. However, individual differences are also important to acknowledge, particularly with regard to how Asian Americans reconcile the conflicting norms and values of their cultures of origin and those of mainstream U.S. society. Individuals who are more culturally identified with Western norms and values may be more responsive to mainstream helping approaches, whereas more traditionally oriented individuals may require culturally modified approaches. The impact of acculturation on Asian American clients’ mental health may need to be addressed in relation to acculturative stress, acculturative family distancing, and enculturation. Regardless, the literature suggests that the tensions inherent in resolving different cultural expectations may affect the majority of Asian Americans, many of whom find themselves straddling two (or more) different cultural worlds, often within their own families. As highlighted in the present chapter, the worldview of a traditional Asian American client may differ quite dramatically from that of a Euro-American therapist or a therapist of color who has been trained primarily in Western models of psychotherapy. The greater the cultural distance between client and therapist, the greater the potential for inaccurate assessment of the presenting problem and difficulties in establishing a strong working relationship. These interpersonal barriers are thought to contribute to the tendency of Asian Americans to underutilize mental health services and to terminate treatment prematurely once it is initiated. Specifically, counselors’ lack of culturally relevant knowledge and susceptibility to popular ethnic stereotypes have been linked to inaccurate assessment and misdiagnosis. Moreover, counselors may need to identify cultural blind spots (e.g., assumptions about individualism or Western ways to communicate distress) in existing Western models of psychotherapy and accommodate treatment to individual clients’ needs. Because many Asian Americans are hesitant to seek formal mental health services, those who do may be particularly sensitive to therapists’ failure to meet their help-seeking expectations. By now, there is convergent evidence that Asian Americans as a whole tend to favor more structured and problemfocused interventions over unstructured, exploratory approaches. The good news is that modifications of mainstream therapeutic approaches as well as culturally grounded interventions are being developed to complement traditional Asian American clients’ cultural values and illness constructs. Therapists working predominantly with Asian clients may seek training in newly developed culturally grounded approaches that respect the hierarchical structure of traditional Asian families and integrate religious healing rituals with psychological interventions. Therapists who are sensitive to the acculturative stressors faced by recent immigrants and their children may also achieve greater credibility due to their ability to empathize and recommend specific coping strategies. In addition, awareness of the cultural roots of traits such as modesty, conformity, and emotional self-control may minimize the risk of overpathologization and improve therapists’ ability to connect with their Asian clients. Finally, given space limitations, we have restricted our coverage in this chapter to the recent literature on client and therapist variables affecting Asian Americans in counseling and therapy. Readers who are interested in a review of research studies concerning the therapy process and outcomes involving Asian Americans are referred to Leong et al. (2007). Future Directions Despite the rapid growth of research in Asian American mental health to include children and families, college students, and community members, more research is needed to capture the cultural diversity of the Asian American community. As discussed, the field is showing favorable signs of representing the complexity of the Asian American identity by exploring how racial and ethnic identity, generational status, and gender interact to shape mental health and mental health care. Another exciting development is that the field is now moving beyond studies of individual-level acculturation to examine the processes by which families and communities change as a result of exposure to diverse cultural systems. This is an important new research area given the bidirectional nature of acculturation; immigration flows are dramatically changing the social and cultural landscape of American society just as immigrants themselves are changed in the resettlement process. Leong and Kalibatseva (2011) have proposed a cultural congruence model for integrating the various strands of research on counseling and psychotherapy among Asian Americans. They posit that cultural congruence can serve as an integrative framework for accommodating the heterogeneity within the Asian American population. In essence, effective psychotherapy for Asian Americans will have to take into account cultural differences in beliefs, values, needs, and norms. Leong and Kalibatseva propose that the underlying principle of effective psychotherapy for clients of color, including Asian Americans, is a culturally congruent approach that matches the client and therapist in terms of a variety of cultural variables and individual differences. To the extent that cross-cultural psychotherapy is a complex process, Leong and Kalibatseva (2011) propose their cultural congruence model as a bridging element to be joined to the cultural accommodation process outlined by Leong and Lee (2006). An important factor in effective psychotherapy for Asian Americans is therapists’ understanding of the unique cultural values, beliefs, needs, and expectations of Asian American clients. Whereas Leong and Lee’s cultural accommodation model has delineated the need for therapists to accommodate cultural differences in order to provide effective psychotherapy for Asian Americans, the cultural congruence model provides a theoretical rationale for making such accommodations. Borrowing from the field of interactional psychology and person–environment fit models, the cultural congruence approach is predicated on the hypothesis that culturally congruent (versus incongruent) processes and goals will lead to positive therapeutic outcomes. Of course, the proposal that cultural congruence underlies effective psychotherapy for Asian Americans or members of other racial/ethnic minority groups will need to be subjected to research in terms of effectiveness and efficacy (Leong & Kalibatseva, 2011). Finally, in light of recent efforts to develop clinical training models that are flexible enough to address the needs of diverse client populations, empirical studies are needed to examine the effects of such curricula on therapists’ ability to meet the needs of their Asian American clients. Critical Incident Failing a Course Simon Ho is a 19-year-old Chinese American sophomore attending a midwestern university. He has a good academic record, with a 3.25 grade point average, but he is having difficulty understanding various concepts in his advanced chemistry class. With a big exam approaching, Simon is not only increasingly worried but also experiencing headaches and stomach troubles. Fearing the possibility of failing the exam and disappointing his family, Simon decides to seek assistance from his chemistry professor. Upon approaching the professor, he is greeted happily and courteously. His professor spends more than an hour with him, reviewing some of the material for the exam. After this review, Simon feels a bit more confident about his understanding of the concepts. Unfortunately, Simon receives a D on the exam. Disappointed by his poor performance, he begins to skip class to avoid his professor and never seeks his professor’s assistance again. Discussion Questions 1. Why does Simon not ask his professor for further assistance or guidance? Choose the best answer: 1. Simon thinks that the professor would have written on the test that it was necessary to see him, if he really cared. 2. Simon feels that chemistry is no longer important in his life. 3. Simon is too ashamed to see his professor again. 4. Simon is upset with his professor for not reviewing the necessary material with him. 2. How might Simon’s cultural context help to explain his headaches and stomach troubles? 3. What other cultural factors could also account for Simon’s experience? Note 1. A racial match does not necessarily mean a cultural or ethnic match. For example, a Chinese American counselor working with a Korean international student is a racial match, but not a cultural or ethnic match. A cultural match would be a counselor and client who were both born and raised in the United States. An ethnic match might be a counseling dyad in which both people (regardless of skin tone or phenotypes) are middle-class Christian Korean Americans who grew up in Seattle. References Akutsu, P. D., Snowden, L. R., & Organista, K. C. (1996). Referral patterns in ethnic-specific and mainstream programs for ethnic minorities and Whites. Journal of Counseling Psychology, 43(1), 56–64. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402. Arkoff, A., Thaver, F., & Elkind, L. (1966). Mental health and counseling ideas of Asian and American students. Journal of Counseling Psychology, 13(2), 219–223. Atkinson, D. R., & Gim, R. H. (1989). Asian-American cultural identity and attitudes toward mental health services. Journal of Counseling Psychology, 36(2), 209–212. Atkinson, D. R., Wampold, B. E., Lowe, S. M., Matthews, L., & Ahn, H. (1998). Asian American preferences for counselor characteristics: Application of the Bradley–Terry–Luce model to paired comparison data. Counseling Psychologist, 26(1), 101–123. Berg, I. K., & Jaya, A. (1993). Different and same: Family therapy with Asian-American families. Journal of Marital and Family Therapy, 19(1), 31–38. Berg, I. K., & Miller, S. D. (1992). Working with Asian American clients: One person at a time. Families in Society, 73(6), 356–363. Bernal, G., & Domenech Rodríguez, M. M. (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: American Psychological Association. Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40, 361–368. Berry, J. W., Trimble, J. E., & Olmeda, E. (1986). Assessment of acculturation. In W. J. Lonner & J. W. Berry (Eds.), Field methods in cross-cultural research (pp. 291–324). Beverly Hills, CA: Sage. Bloombaum, M., Yamamoto, J., & James, Q. (1968). Cultural stereotyping among psychotherapists. Journal of Consulting and Clinical Psychology, 32(1), 99. Carroll, J. B. (1956). Language, thought, and reality: Selected writings of Benjamin Lee Whorf. Cambridge: MIT Press. Castro, J. R., & Rice, K. G. (2003). Perfectionism and ethnicity: Implications for depressive symptoms and self-reported academic achievement. Cultural Diversity & Ethnic Minority Psychology, 9(1), 64–78. Chan, S. (1992). Families with Asian roots. In E. W. Lynch & M. J. Hanson (Eds.), Developing crosscultural competence: A guide for working with young children and their families (pp. 181–257). Baltimore: Paul H. Brookes. Chang, E. C. (2001). Cultural influences on optimism and pessimism: Differences in Western and Eastern construals of the self. In E. C. Chang (Ed.), Optimism and pessimism: Implications for theory, research, and practice (pp. 257–280). Washington, DC: American Psychological Association. Chen, H.-J., Mallinckrodt, B., & Mobley, M. (2002). Attachment patterns of East Asian international students and sources of perceived social support as moderators of the impact of U.S. racism and cultural distress. Asian Journal of Counseling, 9, 27–48. Cheng, E. C. (2012). Handbook of adult psychopathology in Asians: Theory, diagnosis, and treatment. New York: Oxford University Press. Cheryan, S., & Tsai, J. L. (2007). Ethnic identity. In F. T. L. Leong, A. G. Inman, A. Ebreo, L. Yang, L. Kinoshita, & M. Fu (Eds.), Handbook of Asian American psychology (2nd ed., pp. 125–139). Thousand Oaks, CA: Sage. Cheung, F. K. (1980). The mental health status of Asian Americans. Clinical Psychologist, 34, 23–24. Cheung, F. M., Cheung, S. F., Leung, K., Ward, C., & Leong, F. T. L. (2003). The English version of the Chinese Personality Assessment Inventory. Journal of Cross-Cultural Psychology, 34, 433–452. Cheung, F. M., Cheung, S. F., Wada, S., & Zhang, J. (2003). Indigenous measures of personality assessment in Asian countries: A review. Psychological Assessment, 15, 280–289. Chien, W. W., & Banerjee L. (2002). Caught between cultures: The young Asian American in therapy. In E. D. Russell (Ed.), The California School of Professional Psychology handbook of multicultural education, research, intervention, and training (pp. 210–220). San Francisco: Jossey-Bass. Chung, H., Teresi, J., Guarnaccia, P., Meyers, B., Holmes, D., & Bobrowitz, T. (2003). Depressive symptoms and psychiatric distress in low income Asian and Latino primary care patients: Prevalence and recognition. Community Mental Health Journal, 39, 33–46. Cimmarusti, R. A. (1996). Exploring aspects of Filipino-American families. Journal of Marital and Family Therapy, 22(2), 205–217. Connor, J. W. (1974). Acculturation and family continuities in three generations of JapaneseAmericans. Journal of Marriage and the Family, 36, 159–165. Day-Vines, N. L., Wood, S. M., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K., & Douglass, M. J. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85, 401–409. Exum, H. A., & Lau, E. Y. (1988). Counseling style preference of Chinese college students. Journal of Multicultural Counseling and Development, 16(2), 84–92. Fish, J. M. (2000). What anthropology can do for psychology: Facing physics envy, ethnocentrism, and a belief in “race.” American Anthropologist, 102, 552–563. Flaskerud, J. H., & Liu, P. Y. (1991). Effects of an Asian client–therapist language, ethnicity and gender match on utilization and outcome of therapy. Community Mental Health Journal, 27, 31–42. Gamst, G., Dana, R. H., Der-Karabetian, A., & Kramer, T. (2001). Asian American mental health clients: Effects of ethnic match and age on global assessment and visitation. Journal of Mental Health Counseling, 23, 57–71. Gamst, G., Dana, R. H., Der-Karabetian, A., & Kramer, T. (2004). Ethnic match and treatment outcomes for child and adolescent mental health center clients. Journal of Counseling & Development, 82, 457–465. Gim, R. H., Atkinson, D. R., & Kim, S. J. (1991). Asian-American acculturation, counselor ethnicity and cultural sensitivity and rating of counselors. Journal of Counseling Psychology, 38, 57–62. Gim, R. H., Atkinson, D. R., & Whiteley, S. (1990). Asian-American acculturation, severity of concerns, and willingness to see a counselor. Journal of Counseling Psychology, 37, 281–285. Hall, J., Guterman, D. K., Lee, H. B., & Little, S. G. (2002). Counselor-client matching on ethnicity, gender, and language: Implications for counseling school-aged children. North American Journal of Psychology, 4, 367–381. Hardin, E. E., Leong, F. T. L., & Osipow, S. H. (2001). Cultural relativity in the conceptualization of career maturity. Journal of Vocational Behavior, 58(1), 36–52. Helms, J. E., Jernigan, M., & Mascher, J. (2005). The meaning of race in psychology and how to change it: A methodological perspective. American Psychologist, 60, 27–36. Helms, J. E., & Talleyrand, R. M. (1997). Race is not ethnicity. American Psychologist, 52, 1246–1247. Hwang, W., & Wood, J. (2009). Acculturative family distancing: Link with self-reported symptomatology among Asian Americans and Latinos. Child Psychiatry & Human Development, 40, 123–138. Kim, B. (2007). Adherence to Asian and European American cultural values and attitudes toward seeking professional psychological help among Asian American college students. Journal of Counseling Psychology, 54, 474–480. Kim, B. S. K., Brenner, B. R., Liang, C. T. H., & Asay, P. A. (2003). A qualitative study of adaptation experiences of 1.5-generation Asian Americans. Cultural Diversity & Ethnic Minority Psychology, 9(2), 156–170. Kim, H., & Chung, R. H. (2003). Relationship of recalled parenting style to self-perception in Korean American college students. Journal of Genetic Psychology, 164(4), 481–492. Kim, J. M. (2003). Structural family therapy and its implications for the Asian American family. Family Journal, 11(4), 388–392. Lambert, M. J. (Ed.). (2013). Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed.). New York: John Wiley. Lee, D. J., Sina, T., Taylor, J. R., Bilyeu, A., Bryan, A., Grzegorek, J., Miller, E., & Rath, S. (2013, February). Multicultural counseling and social justice: Critiques and responses. Paper presented at the 22nd Annual Big Ten Counseling Center Conference, University of Iowa. Leong, F. T. L. (1986). Counseling and psychotherapy with Asian-Americans: Review of the literature. Journal of Counseling Psychology, 33(2), 196–206. Leong, F. T. L. (2007). Cultural accommodation as method and metaphor. American Psychologist, 62, 916–927. Leong, F. T. L., Chang, D., & Lee, S.-H. (2007). Counseling and psychotherapy with Asian Americans: Process and outcomes. In F. T. L. Leong, A. G. Inman, A. Ebreo, L. Yang, L. Kinoshita, & M. Fu (Eds.), Handbook of Asian American psychology (2nd ed., pp. 429–447). Thousand Oaks, CA: Sage. Leong, F. T. L., & Kalibatseva, Z. (2011). Effective psychotherapy for Asian Americans: From cultural accommodation to cultural congruence. Clinical Psychology: Science and Practice, 18, 242–245. Leong, F. T. L., & Lau, A. S. L. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3, 201–214. Leong, F. T. L., & Lee, S.-H. (2006). A cultural accommodation model for cross-cultural psychotherapy: Illustrated with the case of Asian Americans. Psychotherapy: Theory, Research, Practice, Training, 43, 410–423. Leong, F. T. L., & Whitfield, J. R. (1992). Asians in the United States: Abstracts of the psychological and behavioral literature, 1967–1991. Washington, DC: American Psychological Association. Leu, J., Walton, E., & Takeuchi, D. (2010). Contextualizing acculturation: Gender, family, and community reception influences on Asian immigrant mental health. American Journal of Community Psychology, 48, 168–180. Lim, S. L., & Lim, B. K. (2004). Parenting style and child outcomes in Chinese and immigrant Chinese families: Current findings and cross-cultural considerations in conceptualization and research. Marriage and Family Review, 35(3–4), 21–43. Lin, K. M., Demonteverde, L., & Nuccio, I. (1990). Religion, healing, and mental health among Filipino Americans. International Journal of Mental Health, 19, 40–44. Loewen, J. W. (1995). Lies my teacher told me: Everything your American history textbook got wrong. New York: New Press. Lopez, I. F. H. (1997). White by law: The legal construction of race. New York: New York University Press. Marcos, L. R. (1979). Effects of interpreters on the evaluation of psychopathology in non-Englishspeaking patients. American Journal of Psychiatry, 136(2), 171–174. Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98, 224–253. Mau, W. C., & Jepson, D. A. (1990). Help-seeking perceptions and behaviors: A comparison of Chinese and American graduate students. Journal of Multicultural Counseling and Development, 18(2), 9–104. Meyer, O., Zane, N., & Cho, Y. (2011). Understanding the psychological processes of the racial match effect in Asian Americans. Journal of Counseling Psychology, 58, 335–345. Miller, M. J., Yang, M., Hui, K., Choi, N.-Y., & Lim, R. H. (2011). Acculturation, enculturation, and Asian American college students’ mental health and attitudes toward seeking professional psychological help. Journal of Counseling Psychology, 58, 346–357. Mok, T. A. (1998). Getting the message: Media images and stereotypes and their effect on Asian Americans. Cultural Diversity and Mental Health, 4, 185–202. Morita, S. (1928). Morita therapy. Tokyo: Kenshusho. Nisbett, R. E. (2003). The geography of thought: How Asians and Westerners think differently... and why. New York: Free Press. Okazaki, S. (2002). Self–other agreement on affective distress scales in Asian Americans and White Americans. Journal of Counseling Psychology, 49(4), 428–437. Omi, M. (2010). “Slippin’ into darkness”: The (re)biologization of race. Journal of Asian American Studies, 13, 343–358. Omi, M., & Winant, H. (1994). Racial formation in the U.S. from the 1960s to 1980s. New York: Routledge. Peng, C., & Tjosvold, D. (2011). Social face concerns and conflict avoidance of Chinese employees with their Western or Chinese managers. Human Relations, 64, 1031–1050. Pinyuchon, M., Gray, L. A., & House, R. M. (2003). The Pa Sook model of counseling Thai families: A culturally mindful approach. Journal of Family Psychotherapy, 14, 67–93. Ruzek, N. A., Nguyen, D. Q., & Herzog, D. C. (2011). Acculturation, enculturation, psychological distress and help-seeking preferences among Asian American college students. Asian American Journal of Psychology, 2, 181–196. Ryder, A. G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S., et al. (2008). The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America? Journal of Abnormal Psychology, 117, 300–313. Sandhu, J. S. (2004). The Sikh model of the person, suffering, and healing: Implications for counselors. International Journal for the Advancement of Counseling, 26, 33–46. Solberg, V. S., Choi, K. H., Ritsma, S., & Jolly, A. (1994). Asian-American college students: It is time to reach out. Journal of College Student Development, 35, 296–301. Sue, D. (1998). The interplay of sociocultural factors on the psychological development of Asians in America. In D. R. Atkinson, G. Morten, & D. W. Sue (Eds.), Counseling American minorities (5th ed., pp. 205–213). New York: McGraw-Hill. Sue, D. (2001). Asian American masculinity and therapy: The concept of masculinity in Asian American males. In G. E. Good & G. R. Brooks (Eds.), The new handbook of psychotherapy and counseling with men: A comprehensive guide to settings, problems, and treatment approaches (Vol. 2, pp. 780–795). San Francisco: Jossey-Bass. Sue, D. W., & Kirk, B. A. (1973). Differential characteristics of Japanese-American and ChineseAmerican college students. Journal of Counseling Psychology, 20(2), 142–148. Sue, D. W., & Sue, S. (1972). Counseling Chinese-Americans. Personnel & Guidance Journal, 50, 637–644. Sue, S. (1981). Programmatic issues in the training of Asian-American psychologists. Journal of Community Psychology, 9(4), 293–297. Suinn, R. M. (2010). Reviewing acculturation and Asian Americans: How acculturation affects health, adjustment, school achievement, and counseling. Asian American Journal of Psychology, 1, 5–17. Suyemoto, K. L. (2004). Racial/ethnic identities and related attributed experiences of multiracial Japanese European Americans. Journal of Multicultural Counseling and Development, 32, 206–221. Takaki, R. (1998). Strangers from a different shore: A history of Asian Americans. Boston: Little, Brown. Takeuchi, D. T., Mokuau, N., & Chun, C. A. (1992). Mental health services for Asian Americans and Pacific Islanders. Journal of Mental Health Administration, 19, 237–245. Tamura, T., & Lau, A. (1992). Connectedness versus separateness: Applicability of family therapy to Japanese families. Family Process, 31(4), 319–340. Tan, H. (1967). Intercultural study of counseling expectancies. Journal of Counseling Psychology, 14, 122–130. Tang, M. (2002). A comparison of Asian American, Caucasian American, and Chinese college students: An initial report. Journal of Multicultural Counseling and Development, 30(2), 124–134. Triandis, H. C. (1995). Individualism and collectivism. Boulder, CO: Westview Press. True, R. H. (1990). Psychotherapeutic issues with Asian American women. Sex Roles, 22(7–8), 477–486. Tseng, W. S., & McDermott, J. F. (1975). Psychotherapy: Historical roots, universal elements, and cultural variations. American Journal of Psychiatry, 132(4), 378–384. Uba, L. (1994). Asian Americans: Personality patterns, identity, and mental health. New York: Guilford Press. U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity— A supplement to mental health: A report of the surgeon general. Rockville, MD: Author. Vernon, P. E. (1982). The abilities and achievements of Orientals in North American. New York: John Wiley. Vo, L. T. (2010). Beyond color-blind universalism: Asians in a “postracial America.” Journal of Asian American Studies, 13, 327–342. Wang, K. T. (2010). The Family Almost Perfect Scale: Development, psychometric properties, and comparing Asian and European Americans. Asian American Journal of Psychology, 1, 186–199. Watkins, C. E., Terrell, F., Miller, F. S., & Terrell, S. L. (1989). Cultural mistrust and its effects on expectational variables in Black client–White counselor relationships. Journal of Counseling Psychology, 36, 447–450. Wei, M., Heppner, P. P., Ku, T., & Liao, K. Y. (2010). Racial discrimination stress, coping, and depressive symptoms among Asian Americans: A moderation analysis. Asian American Journal of Psychology, 1, 136–150. Wellisch, D., Kagawa-Singer, M., Reid, S. L., Lin, Y. J., Nishikawa-Lee, S., & Wellisch, M. (1999). An exploratory study of social support: A cross-cultural comparison of Chinese-, Japanese-, and Anglo-American breast cancer patients. Psycho-Oncology, 8, 207–219. West-Olatunji, C., Frazier, K., Guy, T., Smith, A., Clay, L., & Breaux, W. (2007). The use of the racial/cultural identity development model to understand a Vietnamese American: A research case study. Journal of Multicultural Counseling and Development, 35, 40–50. Wu, F. H. (2001). Yellow: Race in America beyond Black and White. New York: Basic Books. Yang, L. H., & WonPat-Borja, A. J. (2007). Psychopathology among Asian Americans. In F. T. L. Leong, A. G. Inman, A. Ebreo, L. Yang, L. Kinoshita, & M. Fu (Eds.), Handbook of Asian American psychology (2nd ed., pp. 379–405). Thousand Oaks, CA: Sage. Yeh, C. J. (2003). Age, acculturation, cultural adjustment, and mental health symptoms of Chinese, Korean, and Japanese immigrant youths. Cultural Diversity & Ethnic Minority Psychology, 9, 34–48. Yeh, C. J., Carter, R. T., & Pieterse, A. L. (2004). Cultural values and racial identity attitudes among Asian American students: An exploratory investigation. Counseling and Values, 48, 82–95. Yeh, C., & Huang, K. (1996). The collectivistic nature of ethnic identity development among AsianAmerican college students. Adolescence, 31, 645–661. Yeh, C., & Wang, Y. W. (2000). Asian American coping attitudes, sources, and practices: Implications for indigenous counseling strategies. Journal of College Student Development, 41, 94–103. Yep, G. A. (2000). Explaining illness to Asian and Pacific Islander Americans: Culture, communication, and boundary regulation. In B. B. Whaley (Ed.), Explaining illness: Research, theory, and strategies (pp. 283–297). Mahwah, NJ: Lawrence Erlbaum. Ying, Y., & Han, M. (2007). The longitudinal effect of intergenerational gap in acculturation on conflict and mental health in Southeast Asian American adolescents. American Journal of Orthopsychiatry, 77, 61–66. Yoon, E., & Jepsen, D. A. (2008). Expectations of and attitudes toward counseling: A comparison of Asian international and U.S. graduate students. International Journal for the Advancement of Counselling, 30, 116–127. Yoshimoto, I. (1981). The way of Naikan. Nara: Naikan Kenshusho. Yuen, R. K., & Tinsley, H. E. (1981). International and American students’ expectancies about counseling. Journal of Counseling Psychology, 28, 66–69. Zane, N., & Yeh, M. (2002). The use of culturally-based variables in assessment: Studies on loss of face. In K. S. Kurasaki, S. Okazaki, & S. Sue (Eds.), Asian American mental health: Assessment theories and methods (pp. 123–138). New York: Kluwer Academic/Plenum. Zhang, N., & Burkard, A. (2008). Client and counselor discussions of racial and ethnic difference in counseling: An exploratory investigation. Journal of Multicultural Counseling and Development, 36, 77–87. Zhang, N., & Dixon, D. N. (2003). Acculturation and attitudes of Asian international students toward seeking psychological help. Journal of Multicultural Counseling and Development, 31, 205–222. 7 Counseling Persons of Black African Ancestry1 Ivory Achebe Toldson Kelechi C. Anyanwu Casilda Maxwell Primary Objective ■ To teach counselors how to identify and make reasonable accommodations for the unique psychological traits and sociocultural background of persons of Black African ancestry Secondary Objectives ■ To describe psychological, cultural, and sociopolitical issues that counselors might consider before working with clients of Black African ancestry ■ To propose enhanced techniques and strategies for providing effective counseling services to African Americans and other clients of African descent The purpose of this chapter is to help counselors explore practices and procedures that appreciate the culture, nomenclature, history, and clinical preferences of clients and counselor trainees of Black African ancestry. The chapter emphasizes ways in which counselors can enhance the quality and integrity of their services by developing a better understanding of (1) specific cultural norms and folkways, (2) how sociocultural power differentials manifest within a therapeutic context, and (3) how Black/African psychology tenets can shape clinical practice. In many counseling settings, routine practices and compliance standards often diminish the quality of care for Black clients. Some counselors report that they often alter standards and bend rules, not only to enhance Black clients’ services but also to protect them from maltreatment (Williams, 2005). For example, one Black counselor reported that he instructs his Black adolescent clients to use the title of “Brother” instead of “Mr.” when addressing him. Another counselor described the dissonance she felt when she frankly told her client to “just ignore that label... that’s not who you really are,” when referring to her client’s treatment plan diagnosis. Yet another counselor encouraged her client to call out the name of a deceased loved one to keep his memory alive and not merely to “let go” of the past. Finally, a counselor admitted that he applauded his client’s tough confrontation of her son’s drug use. When used in traditional counseling settings, all of the above interventions may appear refractory and audacious, yet a body of literature supports their legitimacy for Black clients (Ayonrinde, 2003; Bhugra & Bhui, 1999; Brody et al., 2006; Harvey & Coleman, 1997; Herrick, 2006; Leavitt, 2003; Reiser, 2003; Toldson & Toldson, 1999; Wills et al., 2007). Notably, nothing heretofore stated should be casually considered a counseling strategy for African Americans or any other client of Black African ancestry. Throughout this chapter, the authors will resist the impulse to directly suggest counseling strategies and hope that readers will not intuit counseling methods that they will “try out” on a Black client. The literature is replete with novel techniques to address the unique counseling needs of persons of African descent—too many to reiterate in this chapter but no less deserving of consideration. However, counseling strategies are not the primary problem when working with Black clients. No counseling strategy offers a recipe for healing all persons of African descent. Several articles have warned against using a “cookie cutter” approach to working with Black clients (Bowie, Cherry, & Wooding, 2005; Estrada, 2005; Respress & Lutfi, 2006; Taylor-Richardson, Heflinger, & Brown, 2006). Helpers must be self-aware and able to use themselves as agents of change (Sheely & Bratton, 2010). Moreover, the millions of Black people who exist are more different from one another than they are collectively different from other races (Jackson et al., 2004). In fact, the practice of force fitting Black people into a category reflects a Eurocentric paradigm that relies heavily on taxonomies to understand complex material (Leong & Wong, 2003). Afrocentric approaches de-emphasize classification systems and guidelines and highlight relativity and rhythm (Cokley, 2005; Washington, Johnson, Jones, & Langs, 2007). In this view, counseling strategies are not rules that match a specific taxonomy of clients and their problems. Rather, the relative importance of a counselor’s strategy depends on the rhythm and context of a session. The purpose of this chapter is to help counselors use their strategies within a context that appreciates Black people’s common folkways and collective struggle. In North America and abroad, persons of Black African ancestry share common folkways that evince their African origin, cultural adaptations to colonial autocracies (e.g., language and religion), and a collective struggle against racism and discrimination. History and Nomenclature Persons of Black African ancestry live as citizens, foreign nationals, and indigenous populations on every continent as a result of immigration, colonialism, and slave trading. With an estimated population of 38.9 million, 12.6% of the total population of the United States, African Americans constitute the second largest non-White ethnic group in the country (Ruggles et al., 2009). According to the American Community Survey, in the United States, 80% of Black males and 83% of Black females age 25 and older have completed high school or obtained a GED. Forty-five% of Black males and 53% of Black females have attempted college, and 16% of Black males and 19% of Black females have completed college (Ruggles et al., 2009). Today, most Black people in the Americas are the progeny of victims of the transatlantic slave trade. From 1619 to 1863, millions of Africans were involuntarily relocated from various regions of West Africa to newly established European colonies in the Americas. Many different African ethnic groups, including the Congo, Yoruba, Wolof, and Ibo, were victims of the transatlantic slave trade. The Black American population is the aggregate of these groups, consolidated into one race, bound by a common struggle against racial oppression, and distinguished by cultural dualism (Toldson, 1999). Importantly, the historic legacy of Black people in the Western Hemisphere is not limited to slavery. The Olmec heads found along the Mexican Gulf Coast is evidence of African colonies in the Americas centuries before Columbus arrived in the Caribbean (Van Sertima, 2003). Black people were also responsible for establishing the world’s first free Black republic, and only the second independent nation in the Western Hemisphere, with the Haitian Revolution (Geggus, 2001). In the United States, almost 500,000 African Americans were free prior to the Civil War and were immensely instrumental in shaping U.S. policy throughout abolition and beyond. Post-Civil War, African Americans influenced U.S. arts, agriculture, foods, textile industry, and language and invented technological necessities such as the traffic light and elevators as well as parts necessary to build the automobile and personal computer. All of these contributions were necessary for the United States to become a world power by the 20th century. Racism and oppression are forces that have shaped the experiences and development of Black people worldwide. Although European colonialists initially enslaved Black people because of their agricultural expertise and genetic resistance to diseases, they used racist propaganda to justify their inhumane practices (Loewen, 1996). During periods of slavery and the “Scramble for Africa,” European institutions used pseudoscience and religion (e.g., the Hamitic myth) to dehumanize Black people. The vestiges of racism and oppression survived centuries after propaganda campaigns ended and influence all human interactions, including counseling relationships. Today, racism is perpetuated most profoundly through the educational system. Loewen (1996) pointed out that students are taught to revere Columbus, who nearly committed genocide against the native population of the Dominican Republic, and Woodrow Wilson, who openly praised the Ku Klux Klan. Although many of these facts are not well known and purposefully disguised in history texts, children often leave traditional elementary and secondary education with the sense that aside from a few isolated figures (e.g., Martin Luther King and Harriet Tubman), Black people had a relatively small role in the development of modern nations (May, Willis, & Loewen, 2003). Contemporary literature on the health and economic status of Black people, especially in the United States, is dismal. Evidence is often presented indicating that African Americans have the highest incidence of any given mental or physical disorder, are more deeply impacted by social ills, and generally have the lowest economic standing. While most of the statistics are accurately presented, rationales are usually baseless and findings typically lack a sociohistorical context. In addition, studies on African Americans unfairly draw social comparisons to the social groups that historically benefited from their oppression. Historical distortions accompanying dismal statistics have resulted in many counselors perpetually using a deficit model when working with Black clients (Jamison, 2009). The deficit model focuses on clients’ problems, without exploring sociohistorical factors or institutional procedures. Persons of Black African ancestry have a distinguished history, are immeasurably resilient, and have developed sophisticated coping mechanisms throughout centuries of oppression. Appreciating and celebrating a client’s legacy, contextualizing problems, and building on strengths instead of focusing on deficits are universally appreciated counseling strategies that merit greater attention when working with Black clients (Amatea, Smith-Adcock, & Villares, 2006). Barriers to Cross-Cultural Counseling With Persons of Black African Ancestry Before a person, particularly those who are not familiar with Black culture, can successfully work with Black people in counseling settings, he or she needs to be aware of a range of cultural and cognitive dispositions. This section explains common barriers to effective counseling with persons of Black African ancestry. Cultural encapsulation is the practice of disregarding the influence of culture on therapeutic processes, which can lead to ineffectiveness with connecting with Black clients. Several authors have noted the effects of cultural encapsulation in psychotherapy (Estrada, Frame, & Williams, 2004; Leuwerke, 2005). Culturally encapsulated counselors may (a) define reality with one set of cultural assumptions and stereotypes about Black people, (b) be insensitive to cultural variation and view only one culture as legitimate, (c) have unfounded and unreasoned assumptions about other cultures, (d) overemphasize clinical techniques that they apply rigidly across cultures, and (e) interpret behaviors from their own personal reference (Ponterotto, Pedersen, & Utsey, 2006). White privilege, or conferred dominance, describes the unearned societal rewards that Whites receive based on skin color (McIntosh, 1998). Unrecognized or poorly understood White privilege can diminish counseling relationships with Black clients. According to McIntosh, most White people are unaware of privileges because they are maintained across generations through denial. Neville, Worthington, and Spanierman (2001) posited that White privilege is an insidious and complex network of relationships among individuals, groups, and systems that operates in a racial social hierarchy. On the surface, it would appear that Whites reap only benefits from unearned racial privilege. However, there are a number of social and emotional consequences associated with receiving White privilege (Helms, 1995; Neville et al., 2001; Pinderhughes, 1989; Thompson & Neville, 1999). For example, Thompson and Neville (1999) reported that a group of White counseling psychology graduate students who had become aware of their unearned racial advantage experienced feelings of guilt, shame, and sadness. According to Pinderhughes (1989), people who realize White privilege may experience uncertainty and a sense of entrapment. In cross-cultural counseling supervision, White privilege is associated with many racial issues, such as White supervisors being culturally unresponsive to African American supervisees and White supervisees becoming insubordinate with African American supervisors. In counselor training, Utsey, McCarthy, Eubanks, and Adrian (2002) observed that White privilege often manifests as White trainees speaking for themselves, in contrast to Black trainees who are often called on to speak for their entire race. In addition, Helms and Cook (1999) found that supervisors often attribute clinical errors to a client’s pathology rather than to a White trainee’s clinical skills in cross-racial counseling relationships. White trainees who have an enhanced sense of their White privilege are more effective in negotiating cross-racial counseling situations (Utsey, Gernat, & Hammar, 2005). Helms (1997) posited that White counselor trainees can develop a “nonracist” White identity by accepting their “Whiteness” and acknowledging ways in which they benefit from White privilege. Therefore, the task for counselor trainees is to become aware of how subtle White privileges are relevant to their experiences and impact their clinical work with African American clients (Utsey et al., 2002). Color-blindness refers to racism that is reflected in color-blind racial attitudes typified by ignorance, denial, and a distortion of the reality that race plays a role in people’s lived experiences (Neville et al., 2001). Bonilla-Silva (2002) identified the following four major schematic characteristics of color-blind racism: (a) principles of liberalism are extended to racial matters, (b) social and economic racial disparities are explained in societal terms (e.g., dysfunctional family structure, deficient environmental conditions, etc.), (c) racial stratification (e.g., residential and school segregation) is viewed as a naturally occurring phenomena, and (d) racism is asserted to be a thing of the past. In the context of counselor training, White counselor trainees’ color-blind racial attitudes are often manifest in the attitude that Black clients are no different from racial majority group clients (Utsey et al., 2005). When using color-blind attitudes, the White counselor trainee risks overlooking the role of racism and discrimination in relation to the client’s presenting problem. Utsey et al. (2005) noted that color-blindness is unethical, since the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2010) mandates that practitioners address issues related to racism and discrimination as potential sources of distress for racial minority clients. White counselor trainees who adopt a color-blind posture toward their racial minority clients also tend to minimize the influence of their Whiteness on the counselor-client relationship. In addition, color-blindness is a major cause of the disproportionate number of Black people being diagnosed with severe pathology (Ridley, 1995). Psychological Development of Persons of Black African Ancestry Essentially, three forces make up the identity of persons of Black African ancestry: (a) expressions of African consciousness, (b) resistance to racism and oppression, and (c) adaptations to colonialism (Toldson, 2008). These three forces are omnipresent among continental and diasporic Black Africans. Within each force, there are countless manifestations through Black persons’ personality, psyche, and behavior. Expressions of African Consciousness African consciousness embodies archetypal and ancestral wisdom in Black people’s collective memory. Predisposition toward vital emotionalism, spontaneity, rhythm, naturalistic attitudes, physical movement, style, and creativity with the spoken word are cultural expressions that form the core of African consciousness. These characteristics interact to produce human behavior that registers images, sounds, aromas, and euphoria to the senses (Toldson & Toldson, 2001). Expressions of African consciousness heavily influence Black people’s subjective worldview. As a construct, African consciousness helps persons of African descent to attain optimal self-concept, selfesteem, and self-image (Constantine, Myers, Kindaichi, & Moore, 2004). African consciousness is the archetypal background from which diasporic Africans must formulate answers to questions of identity: Who am I? How do I see myself? Who defined my image, and was my image defined in a way to help me challenge, confront, and overcome adversity? Who do I come from? What can I do? What do I believe about my lineage and myself? Where am I going in life? And what does it mean when I become ill (sick, fail, transgress, addicted)? (Toldson & Toldson, 2001, p. 405) Black communities use elements of African consciousness as an essential influence to serve as a balance or counterpart to the mind and body (Cervantes & Parham, 2005). This balance secures harmony, proportion, and symmetry with nature, self, and others. Spirituality is the basic underlining or constituting entity of the African conscious, embodying essential properties, attributes, and elements indispensable to their subjective worldview. The spirit is an immaterial sentient part of Black persons, providing inward structure, dynamic drive, and creative response to life encounters or demands. Recognition of the African consciousness, and the distinct way it manifest under various circumstances, is essential to African-centered therapeutic interventions. This holistic perspective makes healing a collective undertaking. Accordingly, the construction of reality is inseparably spiritual and material is essential to the African consciousness (Hatter & Ottens, 1998; Mphande & James-Myers, 1993; Tyehimba, 1998). Contrarily, Western psychology emphasizes a material view of reality that focuses on awareness through the five senses. The Eurocentric perspective sees the world as an infinite number of discreetly different manifestations presenting as observable, material phenomena. Simply stated, while the Eurocentric paradigm might suggest, “Seeing is believing,” the Afrocentric paradigm would suggest, “There is more than meets the eye.” Consistent with Afrocentric perspectives, many contemporary physicists and psychologists believe that a material conception of reality is outmoded (Cunliffe, 2006; Davis, 2005; Nelson, 2006). Spirit, in the African cosmos, rhythmically shapes things, ideals, animals, and human beings together in a representative whole of its essence (Cervantes & Parham, 2005; Constantine et al., 2004; Herrick, 2006; Toldson & Pasteur, 1972). When this rhythm is disturbed, the spirit is unsettled and manifests in the individual as anxiety, depression, or other mental or physical disorders (Blackett & Payne, 2005). Restoring this rhythm to achieve an integrative harmony within the self is the goal of African-centered approaches to therapy. These approaches form the backdrop to culturally appropriate therapeutic services delivered in the African American community (Vontress, 1991, 1999). The absence of a “balanced focus” in modern-day medicine places the typical African American client in an etiological dilemma with respect to acquired illnesses. Finch (1990) insists that among traditional African people, “Without the psycho-spiritual cure—without reestablishing this sensitive harmony—the medicinal cure is considered useless” (p. 129). Finch goes on to say that African medicine has baffled scholars because it completely integrates the “magico-spiritual” and “rational” elements. The spiritual aspect of healing has been discredited among the modern-day scientificminded scholars (Finch, 1990). However, Finch explains, modern medicine acknowledges that 60% of illnesses treated by physicians have a psychological basis, and interventions quite often involve pharmacologically inactive drugs—placebos. In the Afrikan and Zulu worldview, one’s values and purpose is placed on their “being” in the community/world rather than obtaining possessions. The quality of one’s “inner essence” is determined by evaluating his or her behaviors and spirituality—ultimately defining his or her worth to the community. Afrikan worldview psychologists’ (Ubuntu psychologist), overall function would be to (1) recognize Spirit in all aspects of life, (2) appreciate people’s spiritual journey, (3) facilitate movement towards becoming one with the Creator, (4) help increase people’s strength from their experiences, (5) keep people aligned with their purpose, and (6) acknowledge that people have purpose. (Washington, 2010, p. 37) Zulu thought also suggests that certain disorders can specifically occur in Afrikans and they must be understood within context in order for balance and harmony of the self and community to exist (Washington, 2010). Resistance to Racism and Oppression Kessler, Mickelson, and Williams (1999) conducted a telephone survey that explored the impact of racism on mental health. The study revealed that the lifetime prevalence of “major discrimination” was 50% for African Americans, in contrast to 31% for Whites. In addition, major discrimination was associated with psychological distress. The authors concluded that racism and oppression adversely affect mental health and place African Americans at risk for mental disorders such as depression and anxiety. The influences of racism and oppression on the psychological development of Black people are twofold. First, racism and oppression contribute to behavioral responses that signal concern about survival, which can either increase psychological distresses or promote unconventional survival mechanisms (Clark, Anderson, & Clark, 1999). In this view, Black people are not collectively injured by racism and oppression. Using ego defense mechanisms to illustrate, when responding to racism and oppression, some Black people might take a “middle-of-the-road” stance such as denial, intellectualization, or humor. A more harmful mechanism might be displacement, where a Black person will unconsciously redirect resentment for the oppressor to less threatening targets such as the family and community. Contrarily, sublimation is a healthy and productive reaction to racism, which involves refocusing negative feelings into healthy outlets of expression, allowing for creative solutions to problems. In addition to extrapolations of psychoanalytic theory, several African theories have emerged to explain the impact of racism and oppression on Black people’s psychological functioning. Cultural trauma, for example, describes slavery, lynching, and legal discrimination beyond their past institutional manifestations and asserts that these experiences are embedded in the collective memory of present-day Black people (Alexander, 2004; Eyerman, 2001). The legacy of cultural trauma is manifested in the destructive activities that occur in African American communities, including violence and substance abuse, which are also associated with symptoms of posttraumatic responses (Whaley, 2006). Post-traumatic slave syndrome asserts that positive and negative adaptive behaviors survived throughout generations of Black people from the transatlantic slave trade and other atrocities. Leary (2005) suggests reevaluating those adaptive behaviors and replacing maladaptive ones to promote healing in Black culture. Other models of racism and oppression focused on more contemporary manifestations of racism. Invisibility syndrome for example is a more subtle form of racism and White privilege that engenders race-related stress (Franklin & Boyd-Franklin, 2000; Franklin, Boyd-Franklin, & Kelly, 2006). Finally, the presence of historical hostility resulting from slavery and discrimination is reported to contribute to a “unique psychology” among African Americans that may result in tension and mistrust of non-Black counselors (Vontress & Epp, 1997). The second consequence of racism and oppression is more directly related to postcolonial institutions, including organizations that provide counseling services (Fairchild, 1991; Fairchild, Yee, Wyatt, & Weizmann, 1995). Mental health in American has roots in racism and oppression. During slavery, mental health professionals diagnosed runaways with drapetomania, meaning “flight from home mania” (Fernando, 2003). Black people who were content with subservience were considered mentally healthy. Today, the attitude that persons of Black African ancestry should have psychomotor restrictions continues to pervade mental health systems. African American patients are more frequently involuntarily committed to psychiatric hospitals and administered psychotropic drugs (Schwartz & K. Feisthamel, 2009). In addition, persons of Black African ancestry continue to receive labels of borderline intellectual functioning and mental retardation on the basis of psychometric scales that were constructed based on a Eurocentric paradigm and normed primarily on persons of European descent (Hilliard, 1976, 1980). Many conscious counselors are aware that current mental health systems are failing Black clients. In a counseling psychology doctoral class at an urban university, a professor asked his students in a Black psychology class to “raise your hand if you’ve ever oppressed your client.” More than half of the students dejectedly raise their hands. With remarkable insight, the students realized that by simply following the rules of their employers, they were participating in less than optimal practices that contributed to their clients’ oppression. Ways in which counselors and other mental health professionals routinely oppress their clients include (1) using biased psychological tests to inform counseling decisions, (2) writing or endorsing reports that emphasize deficits, (3) endorsing the use of psychotropic medication to suppress culturally or developmentally appropriate behaviors, (4) using the majority culture as the basis for behavioral norms, and (5) adhering to diagnostic classification systems without regard to cultural considerations (Toldson, 2008). Adaptations to Colonialism Persons of Black African ancestry have had to adapt to the language, customs, religious practices, educational pedagogy, economic philosophies, and geopolitical systems of European colonial tyrants (Loomba, 2005; Lyons & Pye, 2006; Turner-Musa, 2007; Valls, 2005). For centuries, European colonial empires extended its sovereignty over territory beyond its homeland, using Black African slave labor to cultivate the Americas and native Black Africans to build dependencies, trading posts, and plantation colonies. The colonizers imposed their sociocultural mores, religion, and language on Black people and adopted a corrupt set of values, including racism, ethnocentrism, and imperialism, which aim to justify the means by which colonial settlements were established. In the relatively recent history of Black people achieving equal rights under the law in the Americas (i.e., 1964) and sovereign nationhood in Africa (i.e., 1950s–1970s), Black people have adapted, mastered, and innovated traditional European systems. Black people have added words and dialects to European languages, established educational institutions based on Eurocentric pedagogy, and maintained financial institutions based on lassie faire capitalism. A Eurocentric mind-set will lead many to assert that Black people are obliged to adapt and that adaptation should be effortless. In reality, adaptation is a cultural imposition to Black people worldwide. Imagine White Americans having to adapt to a system in which oratory mastery was required for college admission, bartering was the primary method of exchange, and laws were determined by a council of elders. In the postcolonial era, there have been many critiques of the impact of colonialism and whether colonialism exists today. Colonialism permanently changed the social-cultural, geographic, political, and economic landscape of the world. Persons of Black African ancestry in Africa and the Americas continue to live as second-class citizens, whereas generations-old businesses and banks that financed acts of genocide and other atrocities reap residual benefits from the legacy of colonialism. Colonialism has implications for counseling practice and research on Black people. First, the psychological impact of colonialism and survival of indigenous values among colonialized people influences counseling relationships. Second, cultural imperialism is a natural by-product of colonialism, leading many counselors to make assumptions about a client’s traditions and values that are shaped by the majority culture. In addition to cultural imperialism, ethnocentrism, racism, White supremacy, and pseudo-scientific theories used to justify colonialism have lingered well past decolonialism and influence counseling research and practice. Understanding the impact of colonialism requires investigating the environmental, historical, political, and social contexts to determine how Black psychology has developed over time (Jamison, 2009). Afrocentric and Eurocentric approaches, even with their contrasting views, provide insight into understanding African Americans (Belgrave & Allison, 2006). Collectively, the three forces of Black peoples’ psychological development embody the infinite diversity and the omnipotent potential of persons of Black African ancestry. These are the archetypal forces providing definition to their inner structures, mechanisms of endurance, dynamic drive, and ability to adapt to foreign environments. They represent the whole of Black people, illustrating past preeminence, and ensuring present perseverance and future consummation. Mental Health Conceptualizing Mental Health Problems Successful treatment of a psychiatric disorder ushers in an accurate conceptualization and assessment of the problem. Difficulties conceptualizing Black peoples’ mental health problems typically arise from the tendency of mental health professionals to assume individual autonomy, which suggests that individuals’ problems originate and are perpetuated within each individual (Atkinson, Morten, & Sue, 1997). This assumption undermines the complexity of Black peoples’ mental health problems. A competent assessment of Black problematic behavior should not be limited to a description of mental and emotional deficits or to observations of externalized abnormal behaviors. Instead, an accurate assessment should extend to describe inherent responses to social and environmental conditions, in which the abnormal behavior might be a “normal” reaction. In other words, Black behavioral pathology is sometimes best explained as a consequence of dynamic ecological systems rather than the result of intrapsychological deficits. On a basic level, when considering the mental health status of Black people, one must be mindful of the universality of diagnoses, aware of biases in mental health procedures, and sensitive to diversity. Universality is the idea that disorders found in some cultures may manifest differently or be obsolete in other cultures (Lee, 2002). However, to achieve true authenticity in conceptualizing the mental health status of Black people, professionals must relate to their subject with the holism that is consistent with African-centered perspectives and its Western adaptations, such as existentialism (De Maynard, 2006; Epp, 1998) and positive psychology (Strümpfer, 2005, 2006). Nontraditional approaches might require clinicians to grasp a clients’ mental health using insight and intuition, intellectual creativity, and abstract reasoning. This might sound irrational to a staunch adherent to the scientific method. However, in practice, using strict logic to understand mental health often reduces the client to a blunder of fragmented inferences, rent asunder from the whole in which he or she belongs. The mental health status of Black people should be viewed within the context of their history and nomenclature and of the complex of forces that influence their cultural identity. Specific Mental Health Challenges Prevalence of Mental Health Disorders. The Epidemiological Catchment Area studies (ECA) and the National Comorbidity Survey (NCS) have been used to assess the prevalence rate of mental health disorders across cultures (Galea & Cohen, 2011). The ECA indicated that Black people have an overall higher prevalence of mental health disorders; however, when controlling for socioeconomic factors, most differences are statistically eliminated. Both the ECA and NCS found that African Americans were less likely to suffer from depression. The ECA indicated that African Americans are more likely to suffer from phobia than were Whites. Using several studies, the Department of Health and Human Services concluded that African Americans are overdiagnosed with schizophrenia and underdiagnosed for depression and anxiety (Snowden, 2012). Schwartz and Feisthamel (2009) found 27% of African American clients were diagnosed with psychotic disorders, compared with 17% of all European American when presenting for treatment. Schizophrenia and affective disorders specifically are uniquely associated with forces that shape Black people’s psychological development and must be carefully examined within a cultural context. Fernando (2003) revealed that reports suggesting high rates of schizophrenia among African Americans began to appear in the 19th century. By the mid-1900s, the overdiagnosis of schizophrenia was firmly established, while the diagnosis of bipolar disorders began to decline. Interestingly, British studies during the same time period revealed similar diagnostic trends, although reports of schizophrenic behavior in Africa were rare (Fernando, 2003). Recent findings suggest that the overrepresentation of Black people with schizophrenia is primarily due to diagnostic biases rather than to true differences in the population. Today, the excessive and inaccurate diagnosis of schizophrenia may be attributed to Black people’s nonmaterial conception of reality, spirituality or religiosity, and/or “healthy paranoia,” originally defined as a generalized reaction to racism, which is perceived as necessary for normal adaptive functioning in oppressive environments (Metzl, 2009; Whaley & Hall, 2009). Racial biases that permeate mental health systems may also contribute to the underdiagnosis of depression. Fernando (2003) noted that in the past, the lower incidence of depression among African Americans has been attributed to frontal lobe idleness, which caused Black people to lack higherorder emotional functions (Carothers, 1953) and resulted in a tendency for Black people to respond to adversity with “cheery denial” (Bebbington, Hurry, & Tennant, 1981). These blatantly racist explanations are comparable to recent findings that clinicians tend to minimize emotional expressions by African Americans (Das, Olfson, McCurtis, & Weissman, 2006), which leads to fewer Black people being diagnosed with depression. Das et al. (2006) suggested that clinicians circumvent cultural influences by examining “somatic and neurovegetative symptoms rather than mood or cognitive symptoms” (p. 30). This approach undermines Black people’s psychological functioning and implies that clinicians should ignore symptoms that they do not understand rather than broaden their cultural lenses. Suicide. Research on suicide within the African American community has continued to increase. African Americans generally have lower suicide rates when compared to Caucasians, despite significant economic and social disparities within the Black community (Davidson & Wingate, 2011; U.S. Department of Health and Human Services, 2001). Recent research found that African Americans significantly indicated higher levels of protective factors against suicidal behavior than did Caucasian counterparts (Davidson & Wingate, 2011). However, after a review of literature, Spates (2011) concluded that in African American women who suffered a history of particular mental disorders, depression, physical and emotional abuse, and alcohol and substance abuse have all demonstrated to considerably increase the risk of suicidal behaviors. Walker, Alabi, Roberts, and Obasi (2010) found that college students who were more African centered along with experiencing depressive symptoms disclosed having fewer reasons to live. Additional findings, contradicting previous literature, indicated that hopelessness was not associated with suicidal behaviors among African American young adults (Walker et al., 2010). Exposure to Violence and Posttraumatic Stress. African Americans are more likely to be a victim of a violent crime than any other ethnic or racial group. McDevitt-Murphy, Neimeyer, Burke, Williams, and Lawson (2012) found that a disproportionate number of murder victims in the United States are African American, which compounds other public health concerns such as grief, loss, and trauma. African Americans significantly experience clinical outcomes such as posttraumatic stress disorder (PTSD), complicated grief, depression, and anxiety (McDevitt-Murphy et al., 2012). Extended social supports, properly strict parents, and a hearty self-assurance contribute to resiliency among Black youth (Thompson, Briggs-King, & LaTouche-Howard, 2012). Vulnerable Segments of the Population. Persons of Black African ancestry are susceptible to a variety of mental health problems because they are overrepresented in the most vulnerable segments of the population. Although only 13.8% of the U.S. population, African Americans make up between 38% and 44% of the homeless population (Cortes, Henry, de la Cruz, & Brown, 2012) and nearly half of state and federal inmates (Carson & Sabol, 2011). In addition, African Americans are at a greater risk for mental health care disparities because they are less likely to have health insurance and less likely to obtain proper mental health treatment (Simning, Wijngaarden, & Conwell, 2011). Simning et al. (2011) found that African Americans residing in public housing had a higher lifetime prevalence of mental illness than African Americans not residing in public housing. Results also indicated that African Americans residing in public housing had higher levels of anxiety and substance use disorders than African American non-public housing residents (Simning et al., 2011). Additionally, a recent study found that among African American sexual assault survivors, there is increased poverty linked to discriminating negative mental health outcomes such as depression, PTSD, and illicit drug use (Bryant-Davis, Ullman, Tsong, Tillman, & Smith, 2010). Furthermore, there is increasing evidence that persons who experience discrimination have an elevated risk for psychological distress and mental issues; researchers have found higher percentages among African Americans who have experienced discrimination than among other minorities (McLaughlin, Hatzenbuehler, & Keyes, 2010). Moreover psychiatric disorders constitute another important factor that exposes African Americans to adverse social situations (Jin et al., 2008). Schwartz and Feisthamel (2009) indicated that African American participants had a significantly greater chance of being diagnosed with childhood disorders than did European American participants. Results of this study also demonstrated that counselors disproportionately diagnose African Americans with psychotic and childhood disorders (Schwartz & Feisthamel, 2009). Educational Issues. Education is the key to correcting longstanding social and economic racial disparities in the United States. One in three African Americans without a high school diploma lives below poverty, and less than 10% achieve a middle-class income (Jackson, 2010). If black male ninth graders follow current trends, about half of them will not graduate with their current ninth-grade class (Jackson, 2010), and about 20% will reach the age of 25 without obtaining a high school diploma or GED (Ruggles et al., 2009). The High School Longitudinal Survey asked parents a variety of questions that related to their ninthgrade child’s potential to complete high school (LoGerfo, Christopher, & Flanagan, 2011). When comparing each variable across race and gender, Black students are at the greatest risk for not completing high school. Specifically, Black males are more than twice as likely to repeat a grade and be suspended or expelled from school as White males. Black males were also more likely to receive special education services and have an individualized education plan (IEP) and the least likely to be enrolled in honors classes. Parents of Black students were the most likely to have the school contact them because of problems with their son’s behavior or performance (Toldson & Lewis, 2012). Healing Practices and Experiences With Mental Health Treatment Community-Based Treatment. Comprehensive mental health treatment programs endorse rendering services in the clients’ homes, schools, and communities (Bennett, 2006; Teicher, 2006; Toldson & Toldson, 2001). Communitybased approaches could address Black people’s reluctance to seek professional mental health care in traditional settings, reduce the ethnocentric biases among care providers, and help care providers to have a better context for clients’ problems. From an African-centered perspective, community-based interventions could represent a progressive step toward communalizing the process of mental health delivery. Group Therapy. Group therapy and community-based interventions are more consistent with the African values of collectivism and communalism (Toldson & Toldson, 1999; Vaz, 2005). The group combats the sense of isolation that is a product of individualism, while it promotes a sense of oneness, consistent with the African ethos of oneness of being. The idea of universality (Yalom & Leszcz, 2005) comes close to the African idea of oneness of being, and creating this sense within the group requires culturally appropriate interventions and procedures. Collectivism in Counseling. Black peoples’ collectivist orientation is evident in their healing preferences. Specifically, persons of Black African ancestry are more likely to rely on family and friends to cope with personal difficulty (Logan, 1996; Ruiz, 1990). The “brotherhood/sisterhood” concept among African Americans elevates family extensions to the status of core family members, and solutions to personal difficulties often involve meaningful exchange throughout the extended family. Thus, Black people in therapy may feel compelled to elevate the status of the clinician to an extended family member before actively engaging in the therapeutic process. Naturalistic Healing. This is another value evident in mental health healing practices among Black people. In a review of the literature, U.S. Department of Health and Human Services (2001) found that African Americans prefer counseling to drug therapy and are more likely to have concerns about the side effects, effectiveness, and addiction potential of medications (Cooper-Patrick et al., 1997; Dwight-Johnson, Sherbourne, Liao, & Wells, 2000). Research has also revealed that African Americans tend to take an active approach to facing personal problems and are less likely than Whites to use any professional services to deal with mental health issues (Bean, Perry, & Bedell, 2002). In this view, Black people might prefer a process of healing that feels more natural, emphasizing normal adjustments to life transitions and less intrusive or “technical” approaches, such as medication or a formal brand of therapy. Summary and Conclusions Psychological health care must begin to affirm a biomedical ethic that is sensitive to perspectives of Africans and diasporic descendants. The process can be enhanced by making accommodations for the expression of belief patterns, thoughts, and sociocultural customs indicative of the presence of an African identity in the behavior of African people. These must be woven into theoretical points of departure in the provision of quality psychological health care. The impact of the interrelationships among environmental conditions and sociopolitical dynamics on the definitions of normal mentally healthy behavior of oppressed Africans must be accounted for in diagnostic decision making relative to clients of African descent. It is essential to increase the presence of psychological health care providers, who embrace the understanding that it is therapeutically relevant, if not necessary, to develop an African identity in the psyches of African people. These providers should understand the sociopolitical influences of the dominant perspective of psychology in order to help affirm a bioethical perspective that is sensitive to the African ethos. Recognizing group identity and collective responsibility as real and deducible phenomena within the culture of African American people is consistent with the embrace of an African ethos. This can be made operational by soliciting consent for biomedical involvement of the individual from relevant groups, including the family, church, social/civic organizations, associations, friends, fraternal and sorority societies, and/or sociopolitical organizations (the tribe) with which the individual affiliates in the manifestation of his or her identity as a group member. Such a procedure is advisable, not only out of respect for these African values but also in recognition of the low power quotient afforded the ordinary citizen of African descent. Additionally, it is important to recognize that most African Americans have to be, at least to some extent, bicultural and that this status creates a unique set of mental health issues related to self-esteem, identity formation, and role behavior to which systems of psychological health care must appropriately respond. Differentiating between the symptoms of intrapsychic stress and stress arising from sociopolitical powerlessness and limited economic resources is an essential clinical skill of the psychologist who claims sensitivity to a biomedical perspective that is consistent with the African ethos. Learning the culturally different indicators for depression, anxiety, attachment and loss, identity confusion, and other less inflammatory diagnostic indicators to more accurately replace those that are excessively used such as schizophrenic, borderline personality, oppositional defiant, conduct, and attention deficit disorders in African American clients is a diagnostic imperative. Moreover, subscribing to diagnostic nomenclature introduced by African American psychologists, which also defines accommodationist behavior of the acculturated African American as maladaptive, must be considered in diagnostic formulations about the mental health of African Americans. Accepting spirit and unseen forces as meaningful phenomena in the life realm and decision-making processes of the majority of African people is significantly important. Spirit is an entity that has to be reconciled and/or accommodated in formulas for clinical insight and understanding. In behavioral, as in biomedical research, there is a tendency to recruit participants disproportionately from particular groups within the social system (Toldson & Toldson, 2001). Groups that are dependent or powerless by virtue of their age, their physical and mental condition, their minority status, their social deviance, or their condition of captivity within various institutions are heavily recruited as research participants. Given the African American power deficiency within the social system, the truly voluntary nature of consent becomes problematic for Black research participants. The exploitation of Black research participants, usually to demean the Black community, is a situation that must be brokered at the sociopolitical level. Power bases in the Black community to sign off on matters of consent would rightfully bring the control of such research within the bounds of the African American community in concurrence with its collective nature. The medical-based professions emanate from Africa, brought to excellence in antiquity by the Egyptians (Finch, 1990). Racism within the biomedical sphere of intelligence must be confronted and purged. Purgation should be followed by an impregnation with the spirit of Africa. The degree of confrontation, purgation, and impregnation will be measured by the degree of African consciousness that is cultivated within the African American community. African and diasporic scholars, and others of goodwill, who are possessed with the ethos of doing what is good, right, fair, and just in the interest of the physical and mental health of African people everywhere must cultivate clinical procedures that promote comfort with the existence and therapeutic desirability of an African consciousness in the psyches of African descendants. Cultivating its expression is consistent with good and right action in the delivery of quality mental health care to citizens of African descent. Note 1. In this chapter, the terms persons of Black African ancestry or Black people are used to describe persons worldwide whose ancestors were indigenous to sub-Saharan Africa. The term African Americans is used to describe Black people in America, usually the United States of America. References Alexander, J. C. (2004). Cultural trauma and collective identity. Berkeley: University of California Press. Amatea, E. S., Smith-Adcock, S., & Villares, E. (2006). From family deficit to family strength: Viewing families’ contributions to children’s learning from a family resilience perspective. Professional School Counseling, 9(3), 177–189. American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Washington, DC: American Psychological Association. Atkinson, D. R., Morten, G., & Sue, D. W. (1997). Counseling American minorities (5th ed.). Dubuque, IA: McGraw-Hill. Ayonrinde, O. (2003). Importance of cultural sensitivity in therapeutic transactions: Considerations for healthcare providers. Disease Management & Health Outcomes, 11(4), 233–248. Bean, R. A., Perry, B. J., & Bedell, T. M. (2002). Developing culturally competent marriage and family therapists: Treatment guidelines for non-African-American therapists working with AfricanAmerican families. Journal of Marital & Family Therapy, 28(2), 153–164. doi:10.1111/j.17520606.2002.tb00353.x Bebbington, P. E., Hurry, J., & Tennant, C. (1981). Psychiatric disorder in selected immigrant groups in Camberwell. Social Psychiatry, 16, 43–51. Belgrave, F. Z., & Allison, K. W. (2006). African American psychology: From Africa to America. Thousand Oaks, CA: Sage. Bennett, Jr., M. D. (2006). Cultural resources and school engagement among African American youths: The role of racial socialization and ethnic identity. Children & Schools, 28(4), 197–206. Bhugra, D., & Bhui, K. (1999). Racism in psychiatry: Paradigm lost—paradigm regained. International Review of Psychiatry, 11(2/3), 236. Blackett, P. S., & Payne, H. L. (2005). Health rhythms: A preliminary inquiry into group-drumming as experienced by participants on a structured day services programme for substance-misusers. Drugs: Education, Prevention & Policy, 12(6), 477–491. Bonilla-Silva, E. (2002). The linguistics of color blind racism: How to talk nasty about Blacks without sounding “racist.” Critical Sociology, 28(1/2), 41. Bowie, S. L., Cherry, D. J., & Wooding, L. H. (2005). African American MSW students: Personal influences on social work careers and factors in graduate school selection. Social Work Education, 24(2), 169–184. Brody, G. H., McBride Murry, V., McNair, L., Brown, A. C., Molgaard, V., Spoth, R. L.,... Yi-fu, C. (2006). The strong African American families program: Prevention of youths’ high-risk behavior and a test of a model of change. Journal of Family Psychology, 20(1), 1–11. Bryant-Davis, T., Ullman, S. E., Tsong, Y., Tillman, S., & Smith, K. (2010). Struggling to survive: Sexual assault, poverty, and mental health outcomes of African American women. American Journal of Orthopsychiatry, 80(1), 61–70. doi:10.1111/j. 1939-0025.2010.01007.x Carothers, J. C. (1953). The African mind in health and disease: A study in ethnopsychiatry. Geneva, Switzerland: World Health Organization. Carson, E. A., & Sabol, W. J. (2011). Prisoners in 2011. Washington, DC: U.S. Department of Justice, Office of Justice Programs, & Bureau of Justice Statistics. Cervantes, J. M., & Parham, T. A. (2005). Toward a meaningful spirituality for people of color: Lessons for the counseling practitioner. Cultural Diversity & Ethnic Minority Psychology, 11(1), 69–81. Clark, R., Anderson, N. B., & Clark, V. R. (1999). Racism as a stressor for African Americans: A biopsychosocial model. American Psychologist, 54(10), 805–816. doi:10.1037/0003066X.54.10.805 Cokley, K. O. (2005). Racial(ized) identity, ethnic identity, and afrocentric values: Conceptual and methodological challenges in understanding African American identity. Journal of Counseling Psychology, 52(4), 517–526. Constantine, M. G., Myers, L. J., Kindaichi, M., & Moore, J. L. III. (2004). Exploring indigenous mental health practices: The roles of healers and helpers in promoting well–being in people of color. Counseling and Values, 48(2), 110–125. Cooper-Patrick, L., Powe, N. R., Jenckes, M. W., Gonzales, J. J., Levine, D. M., & Ford, D. E. (1997). Identification of patient attitudes and preferences regarding treatment of depression. Journal of General Internal Medicine, 12, 431–438. Cortes, A., Henry, M., de la Cruz, R., & Brown, S. (2012). 2012 annual homeless assessment report to Congress. Philadelphia, PA: Abt Associates and the University of Pennsylvania. Cunliffe, E. (2006). Without fear or favour? Trends and possibilities in the Canadian approach to expert human behaviour evidence. International Journal of Evidence & Proof, 10(4), 280–315. Das, A. K., Olfson, M., McCurtis, H. L., & Weissman, M. M. (2006). Depression in African Americans: Breaking barriers to detection and treatment. Journal of Family Practice, 55(1), 30–39. Davidson, C. L., & Wingate, L. R. (2011). Racial disparities in risk and protective factors for suicide. Journal of Black Psychology, 37(4), 499–516. doi:10.1177/0095798410397543 Davis, A. (2005). Learning and the social nature of mental powers. Educational Philosophy & Theory, 37(5), 635–647. De Maynard, V. A. (2006). Philosophy, “race” and mental health: Another existential perspective. Internet Journal of World Health & Societal Politics, 3(1), 4. Dwight-Johnson, M., Sherbourne, C. D., Liao, D., & Wells, K. B. (2000). Treatment preferences among primary care patients. Journal of General Internal Medicine, 15, 527–534. Epp, L. R. (1998). The courage to be an existential counselor: An interview of Clemmont E. Vontress. Journal of Mental Health Counseling, 20(1), 1–12. Estrada, D. (2005). Multicultural conversations in supervision: The impact of the supervisor’s racial/ethnic background. Guidance & Counseling, 21(1), 14–20. Estrada, D., Frame, M. W., & Williams, C. B. (2004). Cross–cultural supervision: Guiding the conversation toward race and ethnicity. Journal of Multicultural Counseling & Development, 32, 307–319. Eyerman, R. (2001). Cultural trauma: Slavery and the formation of African American identity. New York, NY: Cambridge University Press. Fairchild, H. H. (1991). Scientific racism: The cloak of objectivity. Journal of Social Issues, 47(3), 101–115. Fairchild, H. H., Yee, A. H., Wyatt, G. E., & Weizmann, F. M. (1995). Readdressing psychology’s problems with race. American Psychologist, 50(1), 46–47. Fernando, S. (2003). Cultural diversity, mental health and psychiatry: The struggle against racism. New York: Brunner-Routledge. Finch, C. (1990). The African background to medical science: Essays on African history, science & civilizations. London: Karnak House. Franklin, A. J., & Boyd-Franklin, N. (2000). Invisibility syndrome: A clinical model of the effects of racism on African-American males. American Journal of Orthopsychiatry, 70(1), 33. Franklin, A. J., Boyd-Franklin, N., & Kelly, S. (2006). Racism and invisibility: Race-related stress, emotional abuse and psychological trauma for people of color. Journal of Emotional Abuse, 6(2/3), 9–30. Galea, S., & Cohen, N. L. (2011). Population mental health: Evidence, policy, and public health practice. Abingdon, Oxon, England: Routledge. Geggus, D. P. (2001). The impact of the Haitian revolution in the Atlantic world. Columbia: University of South Carolina. Harvey, A. R., & Coleman, A. A. (1997). An Afrocentric program for African American males in the juvenile justice system. Child Welfare, 76(1), 197–211. Hatter, D. Y., & Ottens, A. J. (1998). Afrocentric world view and Black students’ adjustment to a predominantly White university: Does worldview matter? College Student Journal, 32(3), 472. Helms, J. E. (1995). An update on Helms’ White and people of color racial identity models. In J. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 181–198). Thousand Oaks, CA: Sage. Helms, J. E. (1997). Implications of Behrens (1997) for the validity of the White Racial Identity Attitude Scale. Journal of Counseling Psychology, 44, 13–16. doi:10.1037/0022-0167.44.1.13 Helms, J. E., & Cook, D. A. (1999). Using race and culture in counseling and psychotherapy: Theory and process. Boston, MA: Allyn & Bacon. Herrick, K. E. (2006). Spirituality legitimized... almost. Journal of Spirituality & Paranormal Studies, 29(4), 227–236. Hilliard, A. G. (1976). A review of Leon Kamin’s The Science and Politics of I.Q. Journal of Black Psychology, 2(2), 64–74. Hilliard, A. G. (1980). Cultural diversity and special education. Exceptional Children, 46(8), 584–588. Jackson, J. H. (2010). Yes we can: The Schott 50 state report on public education and Black males. Cambridge, MA: Schott Foundation for Public Education. Jackson, J. S., Torres, M., Caldwell, C. H., Neighbors, H. W., Nesse, R. M., Taylor, R. J.,... Williams, D. R. (2004). The national survey of American life: A study of racial, ethnic and cultural influences on mental disorders and mental health. International Journal of Methods in Psychiatric Research, 13(4), 196–207. Jamison, D. (2009). Returning to the source: An archeology and critical analysis of the intellectual foundations of contemporary Black psychology. Journal of African American Studies, 13(3), 348–360. doi:10.1007/s12111-009-9092-7 Jin, R., Ge, X., Brody, G., Simons, R., Cutrona, C., & Gibbons, F. (2008). Antecedents and consequences of psychiatric disorders in African-American adolescents. Journal of Youth & Adolescence, 37(5), 493–505. doi:10.1007/s10964-007-9202-6 Kessler, R. C., Mickelson, K. D., & Williams, D. R. (1999). The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. Journal of Health & Social Behavior, 40(3), 208–230. Leary, J. D. (2005). Post traumatic slave syndrome: America’s legacy of enduring injury and healing. Milwaukie, OR: Uptone Press. Leavitt, R. L. (2003). Developing cultural competence in a multicultural world: Part II. PT: Magazine of Physical Therapy, 11(1), 56. Lee, S. (2002). Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems. Psychopathology, 35(2), 152–157. Leong, F. T., & Wong, P. T. (2003). Optimal human functioning from cross-cultural perspectives: Cultural competence as an organizing framework. In W. B. Walsh (Ed.), Counseling psychology and optimal human functioning (pp. 123–150). Mahwah, NJ: Lawrence Erlbaum. Leuwerke, W. (2005). Fostering the development of multicultural counselling competencies: Training, growth and development for White counsellors. Guidance & Counseling, 21(1), 21–29. Loewen, J. W. (1996). Lies my teacher told me: Everything your American history textbook got wrong (1st Touchstone ed.). New York: Simon & Schuster. Logan, S. L. (1996). The Black family: Strengths, self-help, and positive change. Boulder, CO: Westview Press. LoGerfo, L., Christopher, E. M., & Flanagan, K. D. (2011). High school longitudinal study of 2009 (HSLS:09). A first look at Fall 2009 ninth-graders’ parents, teachers, school counselors, and school administrators (NCES 2011–355). Washington, DC: U.S. Department of Education, National Center for Education Statistics. Loomba, A. (2005). Colonialism/postcolonialism (2nd ed.). New York, NY: Routledge. Lyons, T., & Pye, G. (2006). Africa on a global stage. Trenton, NJ: Africa World Press. May, N., Willis, C., & Loewen, J. W. (2003). We are the people: Voices from the other side of American history. New York: Thunder’s Mouth Press. McDevitt-Murphy, M. E., Neimeyer, R. A., Burke, L. A., Williams, J. L., & Lawson, K. (2012). The toll of traumatic loss in African Americans bereaved by homicide. Psychological Trauma: Theory, Research, Practice, and Policy, 4(3), 303–311. doi:10.1037/a0024911 McIntosh, P. (1998). White privilege: Unpacking the invisible knapsack. In M. McGoldrick (Ed.), Revisioning family therapy: Race, culture, and gender in clinical practice (pp. 147–152). New York: Guilford. McLaughlin, K. A., Hatzenbuehler, M. L., & Keyes, K. M. (2010). Responses to discrimination and psychiatric disorders among Black, Hispanic, female, and lesbian, gay, and bisexual individuals. American Journal of Public Health, 100(8), 1477–1484. doi:10.2105/AJPH.2009.181586 Metzl, J. (2009). The protest psychosis: How schizophrenia became a Black disease. Boston, MA: Beacon Press. Mphande, L., & James–Myers, L. (1993). Traditional African medicine and the optimal theory: Universal insights for health and healing. Journal of Black Psychology, 19(1), 25–47. Nelson, J. M. (2006). Missed opportunities in dialogue between psychology and religion. Journal of Psychology & Theology, 34(3), 205–216. Neville, H. A., Worthington, R. L., & Spanierman, L. B. (2001). Race, power, and multicultural counseling psychology: Understanding White privilege and color-blind racial attitudes. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 257–288). Thousand Oaks, CA: Sage. Pinderhughes, E. (1989). Understanding race, ethnicity, and power: The key to efficacy in clinical practice. New York: Free Press. Ponterotto, J. G., Pedersen, P., & Utsey, S. O. (2006). Preventing prejudice: A guide for counselors, educators, and parents. Thousand Oaks, CA: Sage. Reiser, M. (2003). Why should researchers care about culture? Canadian Journal of Psychiatry, 48(3), 154. Respress, T., & Lutfi, G. (2006). Whole brain learning: The fine arts with students at risk. Reclaiming Children & Youth, 15(1), 24–31. Ridley, C. R. (1995). Overcoming unintentional racism in counseling and therapy. Thousand Oaks, CA: Sage. Ruggles, S., Sobek, M., Alexander, T., Fitch, C. A., Goeken, R., Hall, P. K.,... Ronnander, C. (2009). Integrated public use microdata series: Version 4. 0 [machine–readable database]. Ruiz, D. S. (1990). Handbook of mental health and mental disorder among Black Americans. New York: Greenwood Press. Schwartz, R. C., & Feisthamel, K. P. (2009). Disproportionate diagnosis of mental disorders among African American versus European American clients: Implications for counseling theory, research, and practice. Journal of Counseling & Development, 87(3), 295–301. Sheely, A. I., & Bratton, S. C. (2010). A strengths-based parenting intervention with low-income African American families. Professional School Counseling, 13(3), 175–183. Simning, A., Wijngaarden, E., & Conwell, Y. (2011). Anxiety, mood, and substance use disorders in United States African-American public housing residents. Social Psychiatry & Psychiatric Epidemiology, 46(10), 983–992. doi:10.1007/s00127-010-0267-2 Snowden, L. R. (2012). Health and mental health policies’ role in better understanding and closing African American-White American disparities in treatment access and quality of care. American Psychologist, 67(7), 524–531. doi:10.1037/a0030054 Spates, K. (2011). African-American women and suicide: A review and critique of the literature. Sociology Compass, 5(5), 336–350. doi:10.1111/j.1751-9020.2011.00372.x Strümpfer, D. J. W. (2005). Standing on the shoulders of giants: Notes on early positive psychology (psychofortology). South African Journal of Psychology, 35(1), 21–45. Strümpfer, D. J. W. (2006). Positive emotions, positive emotionality and their contribution to fortigenic living: A review. South African Journal of Psychology, 36(1), 144–167. Taylor-Richardson, K. D., Heflinger, C. A., & Brown, T. N. (2006). Experience of strain among types of caregivers responsible for children with serious emotional and behavioral disorders. Journal of Emotional & Behavioral Disorders, 14(3), 157–168. Teicher, S. A. (2006). An African-centered success story. Christian Science Monitor, 98(135), 14–17. Thompson, C. E., & Neville, H. A. (1999). Racism, mental health, and mental health practice. The Counseling Psychologist, 27, 155–223. Thompson, R., Briggs-King, E. C., & LaTouche-Howard, S. A. (2012). Psychology of African American children: Strengths and challenges. In E. C. Chang & C. A. Downey (Eds.), Handbook of race and development in mental health (pp. 27–43). New York, NY: Springer Science + Business Media. Toldson, I. A. (1999). Black American. In J. S. Mio, J. E. Trimble, P. Arredondo, H. E. Cheatham, & D. Sue (Eds.), Key words in multicultural interventions (pp. 32–34). Westport, CT: Greenwood. Toldson, I. A. (2008). Counseling persons of Black African ancestry. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (6th ed., pp. 161–179). Thousand Oaks, CA: Sage. Toldson, I. A., & Lewis, C. (2012). Challenge the status quo. Washington, DC: Congressional Black Caucus Foundation. Toldson, I. A., & Toldson, I. L. (1999). Esoteric group therapy: Counseling African American adolescent males with conduct disorder. Journal of African American Men, 4(3), 73. Toldson, I. L., & Pasteur, A. B. (1972). Soul music: Techniques for therapeutic intervention. Journal of Non-White Concerns in Personnel and Guidance, 1(1), 31–39. Toldson, I. L., & Toldson, I. A. (2001). Biomedical ethics: An African-centered psychological perspective. Journal of Black Psychology, 27(4), 401–423. Turner-Musa, J. (2007). African American psychology: From Africa to America. Western Journal of Black Studies, 31(1), 74–75. Tyehimba, K. A. (1998). The relationship between an Afrocentric world view and perceived psychological distress among African-Americans. (Dissertation Abstracts International: Section B: The Sciences & Engineering, 58(8), 4476. Retrieved from http://search.ebscohost.com/login.aspx? direct=true&db=psyh&AN=1998–95004–091&site=ehost–live U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity, a supplement to mental health: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. Utsey, S. O., Gernat, C. A., & Hammar, L. (2005). Examining White counselor trainees’ reactions to racial issues in counseling and supervision dyads. The Counseling Psychologist, 33(4), 449–478. Utsey, S. O., McCarthy, E., Eubanks, R., & Adrian, G. (2002). White racism and suboptimal psychological functioning among White Americans: Implications for counseling and prejudice prevention. Journal of Multicultural Counseling & Development, 30(2), 81. Valls, A. (2005). Race and racism in modern philosophy. Ithaca, NY: Cornell University Press. Van Sertima, I. (2003). They came before Columbus: The African presence in ancient America. New York: Random House Trade Paperbacks. Vaz, K. M. (2005). Reflecting team group therapy and its congruence with feminist principles: A focus on African American women. Women & Therapy, 28(2), 65–75. doi:10.1300/J015v28n02_05 Vontress, C. E. (1991). Traditional healing in Africa: Implications for cross-cultural counseling. Journal of Counseling & Development, 70(1), 242–249. Vontress, C. E. (1999). Interview with a traditional African healer. Journal of Mental Health Counseling, 21, 326. Vontress, C. E., & Epp, L. R. (1997). Historical hostility in the African American client: Implications for counseling. Journal of Multicultural Counseling & Development, 25(3), 170–184. Walker, R. L., Alabi, D., Roberts, J., & Obasi, E. M. (2010). Ethnic group differences in reasons for living and the moderating role of cultural worldview. Cultural Diversity and Ethnic Minority Psychology, 16(3), 372–378. doi:10.1037/a0019720 Washington, G., Johnson, T., Jones, J., & Langs, S. (2007). African-American boys in relative care and a culturally centered group mentoring approach. Social Work With Groups, 30(1), 45–68. Washington, K. (2010). Zulu traditional healing, Afrikan worldview and the practice of ubuntu: Deep thought for Afrikan/Black psychology. Journal of Pan African Studies, 3(8), 24–39. Whaley, A. L. (2006, April). Cultural trauma, compound trauma, and posttraumatic growth: Relevant concepts for survivors of chattel slavery, Jim Crow racism, and Hurricane Katrina. Paper presented at the 3rd Annual National Black Counseling Psychologist Conference, Howard University, Washington, DC. Whaley, A. L., & Hall, B. N. (2009). Effects of cultural themes in psychotic symptoms on the diagnosis of schizophrenia in African Americans. Mental Health, Religion & Culture, 12(5), 457–471. doi:10.1080/13674670902758273 Williams, O. (2005, April). The Black student who sat by the door: Agents of social justice. Paper presented at the 2nd Annual National Black Counseling Psychologist Conference, Howard University, Washington, DC. Wills, T. A., Murry, V. M., Brody, G. H., Gibbons, F. X., Gerrard, M., Walker, C., & Ainette, M. G. (2007). Ethnic pride and self-control related to protective and risk factors: Test of the theoretical model for the strong African American families program. Health Psychology, 26(1), 50–59. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books. 8 Counseling the Latino/a From Guiding Theory to Practice ¡Adelante! J. Manuel Casas A. Pati Cabrera Melba J. T. Vasquez Primary Objective ■ To assist counselors and practitioners in becoming more competent in their efforts to work with persons who are ethnically, racially, and/or culturally different from themselves, particularly those identified as Latino/a Secondary Objectives ■ To provide a brief demographic overview of the diverse Latino/a population in the United States ■ To provide the outlines of a theoretical approach that would unify theories of person, environment, and the counseling situation ■ To present a framework that practitioners can use to direct and drive their work with Latino/a clients, including identifying likely sources of both friction and possibility The subtitle of this chapter— “¡Adelante!”—translates loosely as “Moving forward!” The decision to include this subtitle was not made arbitrarily. After much thought, we decided that this term best conveys the major spirit that underlies our purpose in this chapter, which is to portray Latino/as, the largest ethnic “minority group” in the United States, as a significant and resilient portion of the American population; Latino/as continue to move forward in their efforts to overcome challenging social and economic living conditions. With this spirit as a driving force, this chapter is intended to help mental health practitioners, educators, and researchers become more culturally competent in their efforts to understand accurately and, in turn, work more effectively with members of this population. Underscoring a major challenge associated with such efforts, we first provide a demographic overview of Latino/as in the United States. We pay selective attention to educational and economic issues because of the important socially determining roles that these play in the mental health and well-being of Latino/a individuals and communities. Throughout the chapter we make every effort to steer clear of suggesting cookbook or cookie-cutter approaches. Instead, we provide a theoretical perspective, guidelines, and a framework that can help counselors to conceptualize presenting challenges and problems and, in turn, facilitate the identification and use of the most culturally appropriate and clinically effective strategies and interventions with Latino/a clients. Finally, we note that Latino/as have many different ways of describing their identities—including pan-ethnic terms like Hispanic and Latino, the term American, and terms that refer to their families’ countries of origin. Given this fact, and in line with the prevailing literature, we have opted to use the gender-responsive term Latino/a to refer to individuals of diverse Hispanic-based national origins, including Mexico, the countries of Central America (e.g., Guatemala, Honduras, Costa Rica, El Salvador, Nicaragua, and Panama), the Spanish-speaking countries of South America (e.g., Colombia, Venezuela, Peru, Chile, Ecuador, Uruguay, Paraguay, and Argentina), the Spanish-speaking countries of the Caribbean (e.g., Cuba, the Dominican Republic), and the U.S. territorial island of Puerto Rico. Having made this caveat, we alert the reader to the fact that in referring to works by varied authors on Latino/as in this chapter, we have made an effort to retain the original terminology used by these authors. General Attributes and Trends According to the U.S. Census Bureau, as of May 2011 Latino/as numbered 50.5 million, or almost 16% of the total population. Latino/as make up the fastest-growing racial/ethnic group in the United States (Ennis, Ríos-Vargas, & Albert, 2011). Given this rate of growth, it is likely that by the year 2050, Latino/as will number 102.6 million (U.S. Census Bureau, 2004, 2006). While the Latino/a population continues to grow, it bears noting that since 2009, the rate of growth of this population has decreased significantly. According to the Pew Hispanic Center (2012a), this decrease has been primarily the result of plunging immigration from Mexico, the birthplace of more U.S. immigrants than any other country. At this time, more Mexicans may be leaving the United States than arriving for the first time since the Great Depression, due to weakness in the U.S. job market, a rise in deportations, and a decline in Mexico’s birthrate (Pew Hispanic Center, 2012a). In spite of the decrease, two phenomena are largely expected to account for the continued growth of the Latino/a population: the relative youth of the U.S. Latino/a population in general and the prevalence of high birthrates among several Latino/a subgroups (e.g., Mexican Americans and Puerto Ricans) (Martin et al., 2006; U.S. Census Bureau, 2004, 2006). The Latino/a population is significantly younger than its non-Latino/a White counterpart (U.S. Census Bureau, 2006). The U.S. Census Bureau (2012) indicates that the overall fertility rate among this young population is approximately 40% greater than the rate among non-Hispanic Whites. It should be noted that this rate of growth is already having an impact in the political arena. In the 2012 presidential election, Latino/as gave the significant majority of their votes (71%) to help reelect President Barack Obama, and political analysts spoke with surprise at how Latino/as will shape the political landscape across the country for the next few years (Mixner, 2012). Sociocultural Common Ground In a recent survey that focused on Hispanics and their views of identity, the Pew Hispanic Center (2012c) found that when asked whether Latino/as in the United States share a common culture, just 29% of Latino/as agreed; 69% said that Latino/as in the United States have many different cultures. Depending on the definitional parameters (e.g., historical versus regional ethnic) placed on the term culture, there is evidence to support both perspectives. With respect to this chapter, we are working from the widely accepted perspective that the majority of Latino/as share a common sociohistorical cultural experience and Spanish as a heritage language. In addition, they also share pervasive psychosocial characteristics that reflect their Hispanic origins. Such characteristics include but are not limited to the following: familismo, a close-knit sense of family within a hierarchical structure (Coohey, 2001); personalismo, a very intense sense of privacy and protectiveness (Rosselló, Bernal, & Rivera-Medina, 2008); a profound religious faith (Farley, Galves, Dickinson, & Perez, 2005); and machismo, men’s sense of leadership, loyalty, and the responsibility to provide for and protect their families (in comparison to the negative attributes commonly associated with this cultural factor) (Crockett, Brown, Iturbide, Russell, & Wilkinson-Lee, 2009). Although much more could be said about these and other characteristics, we mention them only briefly here for illustrative purposes. (For more details regarding these characteristics, see Villarruel et al., 2009.) Most of the information on Latino/as in the United States focuses on the three largest ethnic/national groups within the U.S. Latino/a population: Mexican Americans, Puerto Ricans, and Cuban Americans. Latino/as of Mexican origin are clearly the largest national subgroup, accounting for 64% of the total Latino/a population (Pew Hispanic Center, 2012a, 2012b; U.S. Census Bureau, 2006). Representation among the other national and/or geographically designated subgroups is as follows: Central and South Americans, 13.1%; Puerto Ricans, 9.0%; Cubans, 3.4%; and “other Latinos/as,” who listed census identification labels such as Spanish, Spanish American, and Latino, 7.7% (this group includes many Latino/as of Mexican origin who live in the Southwest, especially New Mexico; U.S. Census Bureau, 2006). Diversity among Latino/a groups and individuals can vary across numerous mutually nonexclusive and frequently interacting variables that can affect the mental and physical well-being of members of the subgroups. These include but are not limited to the following: (1) demographic variables (e.g., racial makeup, age, family size and composition, geographic distribution); (2) sociohistorical variables (e.g., length of time in the United States, impetus for immigration to the United States, experiences with racism); (3) sociopolitical variables (e.g., immigrant/citizen status, level of political participation); (4) socioeconomic variables (e.g., educational attainment, labor force participation, individual and family income); (5) social-psychological variables (e.g., acculturation level, actual and perceived power and self-entitlement, intragroup similarity and cohesion); and (6) physical and mental health status variables (e.g., prevalence of illnesses and problems, access to health insurance and treatment facilities). It is noteworthy that, although differences along these variables are evident across the Latino/a population as a whole, the data clearly show that it is frequently possible to differentiate particular ethnic or national groups along many of these variables (e.g., fertility rate, age, educational attainment, income, geographic distribution) (Ennis et al., 2011). A subgroup within the Latino/a population that, given its size and the prevailing social political times, merits specific attention is the immigrant population. Approximately 55% of the entire immigrant population in the United States (39.9 million) is from Latin America. More specifically, one-third of the foreign-born population in the United States is from Mexico (U.S. Census Bureau, 2011a), and most documented and undocumented immigrants are from Mexico (Passel & Cohn, 2012). Until recently, the prevalent trend had been that inflow of undocumented immigrants exceeded arrivals of legal permanent residents. This is no longer the case (Pew Hispanic Center, 2012a). While the geographic distribution of Latino/a immigrants has traditionally been concentrated in states such as California, New York, Florida, Texas, and Illinois (Congressional Budget Office, 2011), this too is no longer true; immigrants are currently settling throughout the rest of the country (Passel & Cohn, 2012). Contrary to negative depictions of Latino/a immigrants in the media (Massey, 2010) and, in particular, in political discourse (Carter, Lawrence, & Morse, 2011), Latino/a immigrants continue to demonstrate pervasive culturally based resilience factors that assist them in overcoming risks and adversity (American Psychological Association [APA], 2007; Chiswick, 2011). (For more detailed information on Latino/a immigrants, see APA, 2012b.) Educational and Economic Well-Being Given the significant socially determining role that educational and economic factors play relative to the social and psychological development and well-being of both individuals and their communities (Center on the Developing Child, 2010), we focus attention here on selective facts that are integral parts of these two factors. However, before doing so, we would like to reiterate that while the information provided is applicable to the vast majority of Latino/as, given the diversity that exists within this population, it may not be so for certain Latino/a subgroups. (For greater detail on the applicability of the information to specific subgroups, see Ennis et al., 2011.) Educational Well-Being The number of Latino/as graduating from high schools across the United States increased by 20% from 1972 to 2009 (Chapman, Laird, Ifill, & KewalRamani, 2011). Concomitantly, while their school dropout rate has also decreased nationally, Latino/as continue to drop out of high school at rates that are higher than those of any other major group in the United States (Chapman et al., 2011; Pew Hispanic Center, 2010; U.S. Census Bureau, 2008). Taking gender into account, researchers for the U.S. Department of Education found that Latinas have higher high school dropout rates than do girls in any other racial or ethnic groups (Chapman et al., 2011). From available evidence, the high dropout rate is primarily attributed to immigrants, who drop out at the alarming rate of 46.2% (APA, 2012a). Consequently, Latino/as in general remain the second least formally educated and least economically successful Americans (when compared to non-Hispanic African Americans) (DeNavas-Walt, Proctor, & Smith, 2011). While low rates of high school completion account significantly for the underrepresentation and poor performance of Latino/as in higher education (Aud et al., 2010), there is evidence that the representation of Latino/as in higher education is improving, which may suggest that those graduating from high school are continuing to further their education. According to the Pew Hispanic Center (2011), college enrollment among young Hispanics increased by 24% in the period 2009–2010. To put this increased enrollment rate into perspective, note that it reflects the fact that a significant portion of such enrollment occurs at community or two-year colleges. Another statistic that bears noting is the Latino/a college dropout rate, which continues to exceed 50% (U.S. Census Bureau, 2008). Recent data suggest that only 57% of Latino/a college students nationwide complete a bachelor’s degree, compared to 81% of White American college students (Pew Hispanic Center, 2004). Given these college dropout rates, it is not surprising that only 7.9% of Latino/as hold bachelor’s or higher degrees, whereas 71.8% of non-Latino/a Whites hold such degrees (Aud et al., 2010). Unfortunately, at the graduate level, in the period 2007–2008, Latino/as received only 5.9% and 3.6% of master’s and doctoral degrees, respectively. The same figures for non-Latino/a Whites were 65.5% and 57.1%, respectively (Aud et al., 2010). Thus, with the exception of Native Americans and Alaska Natives, Latino/as have the lowest rates of representation at the graduate level (Aud et al., 2010). (For more information regarding the variables associated with the educational disparities between Latino/as and other racial/ethnic groups, see APA, 2012a.) Economic Well-Being Latino/as represent a large and growing segment of the labor force in the United States. At nearly 23 million, they represented 15% of the labor force in 2010. By 2018, they are expected to constitute 18% of the labor force (U.S. Department of Labor, 2012). However, they concomitantly continue to face elevated unemployment levels compared to other workers. In March 2011, the unemployment rate for Hispanics was 11.3%, which was greater than that of the total U.S. population (8.8%). Given the educational statistics presented above, it is not surprising that Latino/a employees are disproportionately employed in service and support occupations. The fact of the matter is that most Latino/as are employed in construction (24.4%), health and social services (10.9%), and educational services (9.5%), with only 7.1% employed in professional, scientific, and technical services (U.S. Department of Labor, 2012). With respect to economic well-being, in 2009, the Latino/a median household income was $38,039. In comparison, the median household income for White families was $54,461. According to the U.S. Census Bureau (2011b), 12 million Latino/as were counted as poor in 2009. Unfortunately, to the detriment of the future economic advancement of the United States, children make up a significant segment of the Latino/a population living in poverty. The share of all U.S. children who are Hispanic has grown steadily, from 7.5% in 1976 to 22.7% in 2009. Over the same period, the share of all poor children who are Hispanic grew from 14.1% to 36.7%. It is estimated that by 2030 Hispanic children will make up 44% of all poor children in the United States (U.S. Census Bureau, 2010). Theory of Person and Environment We now direct attention to a theory that seeks to understand the behaviors of persons as being the products of the interactions that occur between persons and the diverse culturally imbued environments in which they find themselves at any given time. More specifically, we begin with the idea that any individual is embedded in a life space comprising the individual in interaction with a specific environment or environments; the individual and the environment(s) are interdependent and mutually constitutive. This theory rests heavily on the foundations laid by Kurt Lewin (1935, 1936), whose field theory tells us that all psychological events are differentially and interactively dependent on both psychological states and environmental factors. Lewin’s famous equation, depicted in rough mathematical terms, presents this idea of “life space” as a contention that individual behavior (B) is a function (f) of the individual person (P) in interaction with his or her psychological environment (E), so B = f(P, E). The reality is, of course, always more complicated than formulas and figures can represent. Individuals live and grow within and across multiple environments. In describing his theory of the ecology of human development, Bronfenbrenner (1977) refers to the “progressive, mutual accommodation, throughout the life span, between a growing human organism and the environments in which it lives” (p. 514). In addition to noting the self-evident fact that people interact with different environments over a life span and even over the course of a single day, Bronfenbrenner proposes that the human experience is a result of reciprocal interactions between the individual and his or her environments, varying as a function of the individual, his or her contexts and culture, and time (Bronfenbrenner & Morris, 2006). Giving greater specificity and clarity to his theory, he describes the various levels of systems and structures that make up these environments. These include a hierarchy of the following: the microsystem, consisting of the immediate physical setting and its collection of individual actors (e.g., workplace, schools, family, peers); the mesosystem, comprising the interrelations among settings; the exosystem, an extension of the mesosystem “embracing other specific social structures, both formal and informal... that impinge upon or encompass the [individual’s] immediate settings” (e.g., public policies such as pathways to legal immigrant status, health care and educational policies); and the macrosystem, which includes the overarching and historical patterns of the culture or subculture (e.g., economic, historical, and cultural context, xenophobia) (p. 515). Working from the foundation laid by Bronfenbrenner, we suggest that these various systems be understood as levels of context, preliminarily defined as follows: 1. Interpersonal contexts, including both the number and quality of relationships, as well as the more immediate contexts built up of ongoing emergent interactions 2. Social contexts, where individuals must manage their lives in multiple social systems and networks (For a discussion of the interrelated peer, family, and school “social worlds” of children, see Hartup, 1979.) 3. Institutional contexts, including schools, local governments, and the maze of everyday bureaucracies 4. Economic and political contexts, where the individual’s place in the larger economic system and relative access to resources are deeply consequential The interdependent relationships among these contexts are more important than their independent influences on individual behavior and experience. While we may consider them separately in many phases of our research and practice, we must keep in mind that these contexts never in fact exist independent of each other. Figure 8.1 offers one way of depicting these multiple, overlapping contextual environments. We hope to capture the following points in our graphic/visual representation. First, the individual person still rests at the center of the figure, and he or she is always already embedded in a set of contexts. These contexts are depicted as nested circles, all of which share a side. By presenting these circles as sharing a side, we intend to convey our understanding that contexts are mutually constituted, as parts of each other. Figure 8.1 A Person in Interaction With His or Her Multiple Mutually Constituted Environments What about culture? We work from the presumption that any individual is continuously situated in culture (e.g., personal, local, global). This “cultural situatedness” of person and mind means that a person’s individual history as a member of various ethnic, linguistic, national, class, or other groups always colors the person’s experience within and across multiple contexts and, most important, the way those various contexts are interdependent. Reflecting this perspective, Comas-Díaz (2012) directs attention to the ever-present nature of culture within the social context of counseling. She contends that culture is like the proverbial elephant sitting in the middle of the counseling setting; it cannot be ignored. On the contrary, if culture permeates the entire therapeutic process, it must be understood and directly addressed throughout the process. In support of this perspective, Comas-Díaz strongly argues that “culture influences how people become distressed, interpret their maladies, seek help, and eventually heal. Similarly, culture shapes how clinicians view themselves, their clients, and their clinical practice” (p. 3). Comas-Díaz contends that when clinicians recognize this all-encompassing role of culture they develop an approach to clinical care that examines the impact of context(s) on clients, themselves, and the world. For the purposes of this book and chapter, the theory we have outlined already requires elaboration: How might we think of these persons-in-environments (including the counseling environment) within a counseling frame? A person experiences these environments in the dynamic ebb and flow of everyday life, in relations with other persons, and in practical efforts to get things done. Said another way, these person-environment relations are only ever potential and must be activated and reconstructed and transformed in real-life situations. Which person-environment relations or experiences are immediately relevant depend on the dynamic, unfolding situations in which persons find themselves. The counseling session is one such situation in which the person-in-environment phenomenon occurs simultaneously for the counselor and the client (see Figure 8.2). With respect to the counselor, seeing the client from this perspective constitutes a move away from an essentializing and trait view of person/personality (e.g., “She is Latina and Latinas experience the world in such and such a way”) to a situated state view (e.g., “While she is Latina, the problems that she is presenting are not solely reflective of her culture but are also tied to other social factors with which she is currently dealing”). A Guiding Framework for Counseling Practice As a preface to this section, we underscore the fact that in order to maximize the effectiveness of using the framework described below, it is imperative that the counselor have some training in multicultural counseling. More specifically, at minimum, the counselor should be culturally competent in the following areas: He or she should be able to identify the varied sociocultural environments that have affected and/or may continue to affect the client; should have strong cultural self-awareness (e.g., being aware of how he or she reacts to culturally different individuals); and should be able to listen to clients with a “multicultural ear” (e.g., allowing the clients to tell their stories—starting where they want to start and ending where they want to end) and see clients through a multicultural lens (i.e., recognizing and gathering all relevant information from which to understand the clients’ culturally situated stories) (see Comas-Díaz, 2012). Figure 8.2 A Situated Perspective on a Person’s Interaction With His or Her Environment The practical framework we offer here builds on the theoretical approach outlined above, describing in more concrete terms those particular concerns that contextually cut across interacting environments and that are most likely to be relevant to cross-cultural counseling. The framework represents an evolution of thinking from the framework initially proposed by Casas and Vasquez (1989). Figure 8.3 depicts this framework. We have placed “the counseling situation” at the upper center of the figure. On the far-left and farright sides of the figure, we list a small collection of “person-environment” factors that may influence or be activated in a given counseling situation. Their location at the far edges of the figure reflects our understanding that these person-environment factors are relatively distal to the actual counseling situation. These factors take shape in the counselor’s and client’s “orientations to the counseling situation.” We locate these orientations closer to the situation, as they are relatively proximal. For both counselor and client, “person-environment factors” and “orientation to the counseling situation” are uniquely and integrally related. The double-sided arrows near the tops of these sections are designed to represent this relationship. Figure 8.3 A Framework for Approaching Cross-Cultural Counseling Extending below the counseling situation, we have listed as “situational variables” a few of those variables that are undetermined until both counselor and client mutually construct the counseling situation. Although we have been temped to characterize these variables as “matters within the counselor’s control,” we realize that both counselor and client have control over their own behavior. The point, in fact, is not who has control over these variables but that these variables remain variables throughout a counseling situation. That is, they vary in ways that are responsive to and constructive of the live, unfolding situation. Although we are convinced of the general usefulness of this framework, we have not provided an exhaustive list of all the person-environment factors that could be relevant to the counseling situation. Nor have we described in detail all the various orientations or identified all possible situational variables. We have identified only those factors and orientations that are most likely to be sources of both friction—positive or negative—and possibility in cross-cultural counseling. In the sections that follow, we describe in greater detail the orientations of counselor and client as likely sources of friction (and possibility) for cross-cultural counseling. It is in these descriptions that we draw out specific implications for the counseling of Latino/as. The Counselor Many clinicians believe that theirs is an impartial helping profession in which practitioners relate to the essential humanity in each client. This is a dangerous and most often plainly false belief (ComasDiáz, 2012). In fact, the practice of counseling in the United States is anything but impartial (ComasDíaz, 2012; D. W. Sue & Sue, 2008). Like all other human beings, counselors are encapsulated by the beliefs inherent in the diverse environmental contexts (e.g., social, ethnic) in which they were nurtured and/or currently exist (Wrenn, 1962). To this point, Comas-Díaz (2012) contends that while counselors may have been trained to be aware of the monocultural assumptions in the mainstream society, they tend to be much less aware of the assumptions prevalent in the counseling profession. When all is said and done, the fact of the matter is that counseling is a cultural activity replete with dominant cultural assumptions and beliefs. To counsel Latino/a clients effectively, counselors must develop an awareness of how their acceptance of and adherence to specific personal, mainstream, and professional assumptions, beliefs, and values may have significant impacts on their interactions with such clients as well as clients from other diverse backgrounds. After all, many Latino/as from diverse backgrounds may find such assumptions, beliefs, and values to be at odds with their own thinking and experience. Concomitantly, a counselor’s interpretation of a client’s behavior in terms of the counselor’s own assumptions, beliefs, and values, whether personal and/or professional, can lead to poor assessment and diagnosis (e.g., continued use of ethnocentric diagnostic tools), which, in turn, can result in ineffective or even destructive interventions (Comas-Díaz, 2012; Marsella & Yamada, 2007). In the paragraphs that follow, we selectively identify and discuss a few value-based assumptions and beliefs that are rooted in mainstream U.S. society and more specifically in the norms of typical contemporary professional training that serve as sources for potential client–counselor friction. (For additional discussion of such assumptions and beliefs, see Comas-Díaz, 2012.) What counts as “normal” is widely understood and universally accepted. Many counselors accept a more or less universal definition of “normal” behavior. This assumption can lead counselors to assume that describing a person’s behavior as inherently “normal” is meaningful and implies a recognizable pattern of behaviors by the “normal” person. However, what is considered normal is better evaluated and understood within the context of that behavior, including the cultural background(s) of the persons involved, the time during which the behavior is being displayed and observed, and preceding and subsequent actions. Rather than ask if an observed belief or behavior is “normal,” we ought to examine the circumstances of that belief or behavior so that we can determine how reasonable and sensible it is (Marsella & Yamada, 2007). Individuals are the building blocks of society; everyone is autonomous; the individual person is the unit of change; everyone has his or her own identity; individualism is more appropriate than collectivism. It is not surprising that a good number of the beliefs and assumptions identified herein focus on the construct of individualism. Contemporary U.S. culture makes a hero of the independent, self-sufficient person, deliberately freed from the limitations of family, community, and circumstances. Counselors who share this assumption have as a primary goal the development of the individual as an independent person. This assumption works to the detriment of many Latino/as who have learned to give greater importance to the external self, the “other-directed” and interdependent individual (i.e., those from cultures that put family or other designated social units above the individual), a self that is best understood through its contextual and historical linkages (Vasquez, 2007). Complementing the high value placed on individualism in traditional counseling theories and practice is the assumption that independence has value and dependence does not. Closeness and dependence must be understood within specific cultural contexts and not merely as pathological forms of enmeshment. Counselors who attempt to assess the appropriateness of relationships among and between Latino/a clients must consider other possibilities, including the positive health functions served by an individual’s reliance on others (Niemann, 2001). More specifically, effective counselors of Latino/as must understand the value of connecting, supporting, and cooperating within a group. Many counselors perceive the individual person as the unit of change and as such understand their duty to be that of changing individuals to fit society rather than changing society to fit individuals (for details, see Cushman, 1992). Counseling interventions tend to focus on the individual and how the individual should take the initiative to change, regardless of the possibility that the individually experienced problem may have more to do with the person’s environment (D. W. Sue & Sue, 2008). Latino/as in the United States experience second-class citizenship, oppression, and discrimination to varying degrees (Gallardo, 2012). Given such experiences, the effective counselor may need to assume nontraditional roles to actively validate and support Latino/a clients’ efforts to change the environmental factors that prevent them from attaining their personal goals (see Atkinson, Thompson, & Grant, 1993; Freire, 1973). History is irrelevant; what matters is the “here and now.” As Pedersen (1987) has observed, some counselors are most likely to focus on the immediate events that created crises in their clients’ lives. When clients begin talking about their own histories or the histories of “their people,” such counselors are likely to stop listening and wait for the clients to “catch up” to current events. For many Latino/as, the past and the present interrelate in such a complex manner that it is impossible for anyone to understand a total individual without also understanding and appreciating his or her sociohistorical experience (Comas-Diáz, 2012; McNeill et al., 2001). The Client Latino/a clients are neither blank slates nor mere extrapolations of the statistically derived “average” Latino/a found in the literature. In line with the person-environment theory described above, the Latino/a client brings with him or her unique personal and social cultural characteristics and a trove of life experiences in and with multiple, overlapping, and interacting environments. Such characteristics and experiences might be as mundane and “normal” as family size, birth order, childhood illnesses, and family mobility. Or, as is the case with many Latino/as, they can include such stressful and often devastating experiences as racism, segregation, xenophobia, discrimination (Pew Hispanic Center, 2009), poverty, psychological trauma associated with the immigration process and/or immigration status (APA, 2012b), significant educational disadvantages (Suárez-Orozco, Suárez-Orozco, & Todorova, 2008; Fuligni, 2012), unequal access to health and social services (APA, 2012b; McNeill & Cervantes, 2008; Rodríguez, Valentine, Son, & Muhammad, 2009), unfair employment (or unemployment) practices, and political disenfranchisement. Unfortunately, there is no question that stressful experiences such as those noted above have a high potential for causing negative psychological consequences (i.e., mental health–related problems) (APA, 2006, 2012b). Given the high propensity to encounter such experiences within the Latino/a community, there is a pressing need for counselors to understand and address them in a culturally competent manner within the counseling process. In the paragraphs that follow, we describe a few of the person-environment factors identified in the framework presented above that are especially relevant to counseling Latino/as. Experience with racism and/or discrimination. When the client is a member of an ethnic or linguistic minority group, she or he is likely to have had some personal experience with racism or other forms of discrimination (APA, 2012c; Pew Hispanic Center, 2009). For Latino/as in particular, experience with linguistic discrimination, or “linguistic profiling” (Vinokurov, Trickett, & Birman, 2002), may be as common as discrimination on the basis of race or class. Personal experience is often but need not be firsthand experience; the stories a person hears from family and other minority group members can build a sense of an experienced history that includes shared—and therefore personal—instances of discrimination. Frequently, these experiences are formative for the client, carried forward as personal orientations to everyday encounters. Unfortunately, from a more severe perspective, there is evidence to show that they are frequently associated with mental health problems, including depression, anxiety, substance abuse, and suicidal ideation (Cheng et al., 2010; Tummala-Narra, Alegría, & Chen, 2012). (For more information regarding the toll exacted by systematic biases, stereotypes, and discrimination, as well as strategies to reduce those mechanisms, see APA, 2012c.) Acculturation pressures. Acculturation is a major factor that contributes to the dynamic, ever-changing nature of the Latino/a population. In its original and still quite acceptable definition, the term acculturation refers to the phenomena that result when groups of individuals from two different cultures come into continuous firsthand contact and experience subsequent changes in the original patterns of either or both groups (Redfield, Linton, & Herskovits, 1936). Although originally perceived from the perspective of the group, acculturation occurs both in groups and in individuals. A variety of factors determine the direction and rate of acculturation, as well as the pressures an individual may experience as a result of acculturation processes. Among these are contextual changes in the racial or ethnic demographics of a community or region, proximity to the individual’s native homeland, prevailing sociopolitical attitudes and policies (e.g., segregation), economic conditions and practices (e.g., means and opportunities for improving employment and economic status), and access to high-quality, advanced education. According to Kurtines and Szapocznik (1996), differentially available opportunities and the continued prevalence of traditionally prescribed gender roles cause acculturation rates to vary by generation and gender. The rate is faster for younger generations (Birman, 2006). Acculturation pressures can constitute a risk factor for an individual when they occur in an environment that lacks relevant support networks among family, teachers, friends, and counselors; these pressures can and often do create conflict, stress, and loss of self-esteem as the individual struggles with an inevitable clash of values. When acculturation pressures confront especially strong ethnic identification, a person’s mental health may be put at increased risk (Torres, Driscoll, & Voell, 2012). In relation to resilience, Yeh, Arora, and Wu (2006) contend that, with support from significant others, an individual’s choice to maintain important aspects of his or her sociocultural background can create a “healthy aware” individual who can function effectively across cultures and settings. (For thorough coverage of the acculturation process from a psychological perspective, see Torres et al., 2012.) Role expectations. Every client enters the counseling situation with expectations about the roles she or he and the counselor might take up. These roles are often organized around questions of authority and trust. For many clients, the mere act of sitting down with a counselor involves handing over an uncomfortable level of authority for their own well-being. Progress through one or more counseling sessions requires that the counselor and client establish (and consistently reestablish) trust. To the extent that Latino/as from various backgrounds learn to value discretion in personal matters, they may be especially disinclined to take their personal struggles public. In such cases, the counselor’s careful management of authority relations and constant work to establish trust are extraordinarily important. Credibility given to the counseling process. General attitudes toward counseling and the credibility given to the counseling process among Latino/as remain largely unexplored areas of research on multicultural counseling. That said, anecdotal evidence from a broad spectrum of counselors and caregivers encourages, at least, a question about widely held skepticism regarding psychological treatment, including counseling, among Latino/as. That a particular individual may carry this skepticism into the counseling situation is only one possibility. Whether or not a client is skeptical her- or himself, she or he may be having to deal with skepticism from a spouse or partner, family members, or friends. Strengths and resilience. One of the most important strategies for counselors to employ in working with persons of color is to identify their clients’ strengths and areas of resilience. Fortunately, the psychotherapeutic process generally provides counselors with ample opportunities to become intimately acquainted with the strengths and resilience of their clients. Latino/as have a wide range of strengths and resilience. For example, a 2012 report issued by the National Center for Health Statistics indicates that Hispanics live longer than White or Black Americans (Miniño & Murphy, 2012). Generally, mortality is correlated with income, education, and health care access, so we would expect the Hispanic population to have a higher mortality, similar to the Black population. This unique resilience of Latino/as given the usual negative health outcomes of poverty and other psychosocial challenges, such as infant mortality and low birth weight, as seen in non-Latino Whites and other groups, has been called the “Latino/a paradox.” The specific “pathways” or protective factors that may buffer Latino/as and enhance their mental health have not yet been identified, but they are hypothesized to include familismo and spirituality. Both these factors may foster positive social support that protects individuals against depression, even in the face of substantial environmental risk. The Counseling Situation The central category of our framework focuses on variables within the counseling situation itself. The way we conceive this category includes those behaviors and positionings that are most clearly in the direct control of both counselor and client. Rather than prescribe an appropriate sequence of behaviors, organization of physical space, or proximity, we turn to Atkinson et al.’s (1993) description of the diverse roles that a counselor may assume in the counseling situation. (For information on the aforementioned variables, see Ponterotto, Casas, Suzuki, & Alexander, 2010; D. W. Sue & Sue, 2008; S. Sue, Zane, Hall, & Berger, 2009; Vasquez, 2007.) Before we address the diverse roles that a counselor may assume, we should note that, given the space limitations here, our focus is on generic counseling roles and not on specific therapeutic theories and approaches. (Readers interested in such information should see Casas, Raley, & Vasquez, 2008.) Atkinson et al. (1993) propose a three-dimensional model that focuses on the diverse roles that counselors may have to assume when counseling racial/ethnic minority clients. Within the proposed model, Atkinson et al. suggest that in the process of selecting roles and strategies when working with these clients, counselors need to take into consideration three factors, each of which exists on a continuum: (1) client level of acculturation to the dominant society (high to low), (2) locus of problem etiology (external to internal), and (3) goals of helping (prevention, including education/development, to remediation). Just as the roles themselves are interactionally constituted, so are the clients’ particular locations on any of these continua. That is, the extent to which acculturation pressures matter, the location of the problem, and the specific goal for counseling may vary from one moment to the next and will certainly vary over the long haul of multiple sessions. The point bears repeating: The appropriate counselor role may vary even within a single counseling session, as the counselor works with every available sense to decide how to think and act for the client’s well-being. Atkinson et al. (1993) identify eight therapist roles that interact with each of the three continua extremes. Specifically, the therapist serves as the following: 1. Advisor: When the client is low acculturation, the problem is externally located, and prevention is the goal of treatment. 2. Advocate: When the client is low in acculturation, the problem is external in nature, and the goal of treatment is remediation. 3. Facilitator of indigenous support systems: When the client is low in acculturation, the problem is internal in nature, and prevention is the goal of treatment. 4. Facilitator of indigenous healing systems: When the client is low in acculturation, the problem is internal in nature, and remediation is the treatment goal. 5. Consultant: When the client is high in acculturation, the problem is external in nature, and prevention is the treatment goal. 6. Change agent: When the client is high in acculturation, the problem is external in nature, and remediation is the goal of treatment. 7. Counselor: When the client is high in acculturation, the problem is internal in nature, and prevention is the primary goal of treatment. 8. Psychotherapist: When the client is high in acculturation, the problem is internal in nature, and remediation is the goal of therapy. As is evident, the framework we have presented does not attempt to identify and describe specific counseling strategies and interventions that have been shown through research and/or practice to be effective with Latino/a adults and children. We believe that at this point in time such interventions are too numerous for us to address adequately within the parameters of this chapter. (For examples of such strategies and interventions, see Kataoka et al., 2003; Santisteban & Mena; 2009; Smokowski & Bacallao, 2009.) However, wishing to help readers select those interventions that may be most clinically effective and culturally appropriate, we highlight the following guiding principles: (1) Use an ecological perspective (Bronfenbrenner & Morris, 2006) to develop and guide interventions, (2) integrate evidence-based practice (Kazdin, 2008) with practice-based evidence (Birman et al., 2008), (3) provide culturally competent treatments (APA, 2002), (4) use comprehensive communitybased services (Birman et al., 2008), and (5) use a social justice perspective as a driving force for all services (Corey, Corey, & Callanan, 2011). (For more details relative to these principles, see APA, 2012b.) Conclusion In this chapter we have asserted the essential importance of counselors’ cultural knowledge and awareness of the social, institutional, political, and economic experience of clients who are members of ethnic minority groups. If counselors understand the relevant cultural values, norms, and behaviors of their clients, as well as the unique stresses that the clients face, they may propose interpretations of their clients’ behaviors that are different from those they might otherwise apply. In addition to culturally sensitive or modified approaches to counseling and therapy with Latino/as, counselors must employ other frameworks and perspectives beyond those traditionally used, many of which have been based on remedial models (i.e., treating the client after a specific problem has surfaced). Romano and Hage (2000) strongly assert the need for a much greater emphasis on and commitment to the science and practice of prevention in counseling psychology. Preventive interventions forestall the onset of problems or needs through anticipation of the risks and challenges faced by persons across their multiple environments. To this end, we suggest the incorporation of such interventions for enhancing the quality of life of Latino/a groups. Following the outlines of the theory described in this chapter, preventive environmental interventions (Banning, 1980) designed for members of ethnic minority groups may be included. A business-as-usual mentality will not work with Latino/as or other minority clients. The challenges that such clients bring to counseling sessions demand that counselors employ careful ways of thinking that are regularly refreshed through explorations into new theoretical, cross-national, and crossdisciplinary terrains (see Díaz-Guerrero, 1995) as well as genuine contact with the dynamic, diverse “real world.” We have provided a road map for such exploration, including the outline of a framework that identifies a range of possibly relevant variables. In the journeys that counselors may take with their clients, we have anticipated a few likely challenges and encouraged a preventive, resilience-based orientation that will help Latino/a clients to move forward in their efforts to overcome challenging psychological, social, and economic living conditions—adelante. Critical Incident We present the counseling situation below in order to outline some potential implications of our work for counselors’ real-life practice. Although hypothetical, the situation draws on an actual case described in greater detail elsewhere (Raley, Casas, & Corral, 2004). The Case of Liliana Liliana, who is 24 years old, is voluntarily seeking counseling for “relationship issues.” She has lived in California’s San Francisco Bay Area for most of the time since her family emigrated with undocumented status from Mexico. Recently married, Liliana currently lives within a few miles of her mother and sisters. Liliana’s family of origin is economically poor. She has met but does not have ongoing contact with her biological father, who is “somewhere in Mexico.” Her mother and two older sisters are deeply committed to the Apostolic Christian Church, but Liliana does not attend services regularly. Liliana speaks reverently of her grandmother, although relations between the two were tense for a time. Liliana and her grandmother were not speaking to each other because of her grandmother’s rejection of Liliana’s younger sister. According to Liliana, her grandmother could not accept that her sister’s biological father was African American. Despite a very difficult time in public school, Liliana was able to succeed at a small private high school, and she was accepted by an Ivy League university. She left the university after her sophomore year to raise her own family. She is currently working for a successful technology firm as she completes her degree. Liliana’s sense of humor engages young people and adults, her penetrating insights guide conversations, and she is well liked by those who know her well. She continues to defy authority when she feels that it is unjustifiably imposed, is occasionally impatient with what she perceives to be the irrelevance of other people’s emotions or reasoning, and sometimes balks at what she sees as unnecessary or unimportant work. How might the framework described in this chapter be useful to a counselor’s efforts to improve Liliana’s mental health? The framework does not provide a script that Liliana’s counselor might follow. In fact, the framework is designed to discourage a search for solutions, pointing instead to better questions to guide a counselor’s practice. Some of these guiding questions might become actual questions that the counselor could ask Liliana. Others could guide the counselor’s attention during their meetings, helping the counselor discern those important ecological factors, identify the particulars of Liliana’s orientation to the counseling situation, and design and cocreate a safe physical and social space. The discussion questions that follow provide a limited example of guiding questions, organized according to the broad categories of variables described in our framework. Discussion Questions Person-Environment Factors 1. What sorts of experiences, if any, has Liliana had with racism and other kinds of discrimination? How have these contributed to the way Liliana sees herself and her lived world? How do race, language, class, gender, and so on matter to Liliana’s beliefs? 2. What are Liliana’s own conceptions and explanations of her economic situation and that of her family? 3. What is Liliana’s “take” on her experiences as an immigrant? Orientation to the Counseling Situation 1. Has Liliana been in counseling therapy before? What was the experience like? Have any of her family members been in therapy? For what reason, and with what perceived results? 2. What concerns does Liliana bring to the present counseling situation? 3. How, if at all, does the ethnic, racial, linguistic, or economic background of the counselor matter to Liliana’s orientation to the counseling situation? Situational Variables 1. What is the most neutral arrangement of space and materials? 2. What are Liliana’s observable responses (linguistic, behavioral, and so on) to the counseling situation, including especially the specific behaviors of the counselor? 3. Given what the counselor is learning about Liliana’s environment and orientation, what roles might the counselor take on to best meet Liliana’s needs? And under what conditions might such roles usefully vary? References American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. American Psychological Association. (2006). Resolution on prejudice, stereotypes, and discrimination. Retrieved from http://www.apa.org/about/governance/council/policy/prejudice.pdf American Psychological Association. (2007, March). Psychological perspectives on immigration. Communiqué. Retrieved from http://www.apa.org/pi/oema/resources/communique/2007/03/mar.pdf American Psychological Association. (2012a). Report of the APA Presidential Task Force on Educational Disparities. Ethnic and racial disparities in education: Psychology’s contribution to understanding and reducing disparities. Washington, DC: Author. American Psychological Association. (2012b). Report of the APA Presidential Task Force on Immigration. Crossroads: The psychology of immigration in the new century. Washington, DC: Author. American Psychological Association. (2012c). Report of the APA Presidential Task Force on Reducing and Preventing Discrimination. Dual pathways to a better America: Preventing discrimination and promoting diversity. Washington, DC: Author. Atkinson, D. R., Thompson, C. E., & Grant, S. K. (1993). A three-dimensional model for counseling racial/ethnic minorities. The Counseling Psychologist, 21, 257–277. Aud, S., Hussar, W., Planty, M., Snyder, T., Bianco, K., Fox, M., Frohlich, L., Kemp, J., & Drake, L. (2010). The condition of education 2010 (NCES 2010-028). Washington, DC: National Center for Education Statistics, Institute of Education Sciences, U.S. Department of Education. Retrieved from http://nces.ed.gov/pubs2010/2010028.pdf Banning, J. (1980). The campus ecology manager role. In U. Delworth & G. Hanson (Eds.), Student services: A handbook for the profession (pp. 209–227). San Francisco: Jossey-Bass. Birman, D. (2006). Measurement of the “acculturation gap” in immigrant families and implications for parent–child relationships. In M. H. Bornstein & L. R. Cote (Eds.), Acculturation and parent– child relationships: Measurements and development. Mahwah, NJ: Lawrence Erlbaum. Birman, D., Beehler, S., Harris, E. M., Everson, M. L., Batia, K., Liataud, J.,... Capella, E. (2008). International family adult and child enhancement services (FACES): A community-based comprehensive services model for refugee children in resettlement. American Journal of Orthopsychiatry, 78, 121–132. Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513–531. Bronfenbrenner, U., & Morris, P. A. (2006). The bioecological model of human development. In W. Damon & R. M. Lerner (Series Eds.) & R. M. Lerner (Vol. Ed.), Handbook of child psychology: Vol. 1. Theoretical models of human development (6th ed.). Hoboken, NJ: John Wiley. Carter, A., Lawrence, M., & Morse, A. (2011). 2011 immigration-related laws, bills, and resolutions in the states: Jan. 1-March 31, 2011. Washington, DC: National Conference of State Legislatures. Retrieved from: http://www.ncsl.org/issues-research/immig/immigration-laws-and-bills-spring2011.aspx Casas, J. M., Raley, J. D., & Vasquez, M. J. T. (2008). Adelante! Counseling the Latina/o from guiding theory to practice. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (6th ed., pp.129–146). Thousand Oaks, CA: Sage. Casas, J. M., & Vasquez, M. J. T. (1989). Counseling the Hispanic client: A theoretical and applied perspective. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (3rd ed., pp. 153–175). Honolulu: University of Hawaii Press. Center on the Developing Child, Harvard University. (2010). The foundations of lifelong health are built in early childhood. Cambridge, MA: Author. Retrieved from http://www.developingchild.harvard.edu Chapman, C., Laird, J., Ifill, N., & KewalRamani, A. (2011). Trends in high school dropout and completion rates in the United States: 1972–2009 (NCES 2012-006). Washington, DC: National Center for Education Statistics. Retrieved from http://nces.ed.gov/pubs2012/2012006.pdf Cheng, J. K., Fancher, T. L., Ratanasen, M., Conner, K. R., Duberstein, P. R., Sue, S., & Takeuchi, D. (2010). Lifetime suicidal ideation and suicide attempts in Asian Americans. Asian American Journal of Psychology, 1, 18–30. Chiswick, B. (Ed.). (2011). High-skilled immigration in a global market. Washington, DC: AEI Press. Comas-Díaz, L. (2012). Multicultural care: A clinician’s guide to cultural competence. Psychologists in independent practice. Washington, DC: American Psychological Association. Congressional Budget Office. (2011). A description of the foreign-born population: An update. Washington, DC: Author. Coohey, C. (2001). The relationship between familism and child maltreatment in Latino and Anglo families. Child Maltreatment, 6, 130–142. Corey, G., Corey, M., & Callanan, P. (2011). Issues and ethics in the helping professions. Belmont, CA: Brooks/Cole. Crockett, L. J., Brown, K. R., Iturbide, M. I., Russell, S. T., & Wilkinson-Lee, A. M. (2009). Conceptions of good parent–adolescent relationships among Cuban American teenagers. Sex Roles, 60, 575–587. Cushman, P. (1992). Psychotherapy to 1992: A historically situated interpretation. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change (pp. 21–64). Washington, DC: American Psychological Association. DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2011, September). Income, poverty, and health insurance coverage in the United States: 2010 (Current Population Reports No. P60-239). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/2011pubs/p60239.pdf Díaz-Guerrero, R. (1995). Origins and development of Mexican ethnopsychology. World Psychology, 1(1), 49–67. Ennis, S. R., Ríos-Vargas, M., & Albert, N. G. (2011, May). The Hispanic population: 2010 (Census Brief No. C2010BR-04). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-04.pdf Farley, T., Galves, A., Dickinson, L. M., & Perez, M. J. D. (2005). Stress, coping, and health: A comparison of Mexican immigrants, Mexican-Americans, and non-Hispanic Whites. Journal of Immigrant Health, 7, 213–220. Freire, P. (1973). Pedagogy of the oppressed. New York: Continuum. Fuligni, A. J. (2012). The intersection of aspirations and resources in the development of children from immigrant families. In C. García Coll & A. K. Marks (Eds.), The immigrant paradox in children and adolescents: Is becoming American a developmental risk? (pp. 299–308). Washington, DC: American Psychological Association. Gallardo, M. E. (2012). Context and culture: The initial clinical interview with the Latina/o client. Journal of Contemporary Psychotherapy, 39(3). doi:10.1007/s10879-012-9222-8 Hartup, W. W. (1979). The social worlds of childhood. American Psychologist, 34, 944–950. Kataoka, S. H., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., Zaragoza, C., & Fink, A. (2003). A school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 311–318. Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146–159. Kurtines, W. M., & Szapocznik, J. (1996). Family interaction patterns: Structural family therapy in contexts of cultural diversity. In E. D. Hibbs & P. L. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 671–697). Washington, DC: American Psychological Association. Lewin, K. (1935). A dynamic theory of personality. New York: McGraw-Hill. Lewin, K. (1936). Principles of topological psychology. New York: McGraw-Hill. Marsella, A. J., & Yamada, A. M. (2007). Culture and psychopathology: Foundations, issues, and directions. In K. Shinobu & C. Dov (Eds.), Handbook of cultural psychology (pp. 797–818). New York: Guilford Press. Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: Final data for 2004 (National Vital Statistics Reports, vol. 55, no. 1). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_01.pdf Massey, D. S. (2010). New faces in new places: The changing geography of American immigration. New York: Russell Sage Foundation. McNeill, B. W., & Cervantes, J. M. (2008). Latina/o healing practices: Mestizo and indigenous perspectives. New York: Routledge. McNeill, B. W., Prieto, L. R., Niemann, Y. F., Pizarro, M., Vera, E. M., & Gomez, S. P. (2001). Current directions in Chicana/o psychology. The Counseling Psychologist, 29, 5–17. Miniño, A. M., & Murphy, S. L. (2012, July). Death in the United States, 2010 (NCHS Data Brief No. 99). Washington, DC: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db99.pdf Mixner, D. (2012). The top five best constituencies for President Obama on election day! [Web log post]. Retrieved from http://www.davidmixner.com/2012/11/the-top-five-best-constituencies-forpresident-obama-on-election-day.html Niemann, Y. F. (2001). Stereotypes about Chicanas and Chicanos: Implications for counseling. The Counseling Psychologist, 29, 55–90. Passel, J. S., & Cohn, D. (2012). U.S. foreign-born population: How much change from 2009 to 2010? Washington, DC: Pew Hispanic Center. Retrieved from http://www.pewhispanic.org/2012/01/09/u-s-foreign-born-population-how-much-change-from-2009to-2010/?src=prc-headline Pedersen, P. B. (1987). Ten frequent assumptions of cultural bias in counseling. Journal of Multicultural Counseling and Development, 15, 16–24. Pew Hispanic Center. (2004). Latino youth finishing college: The role of selective pathways. Washington, DC: Author. Pew Hispanic Center. (2009). Between two worlds: How young Latinos come of age in America. Washington, DC: Author. Pew Hispanic Center. (2010). Latino/a high school dropouts and the GED. Washington, DC: Author. Pew Hispanic Center. (2011). Hispanic college enrollment spikes, narrowing gaps with other groups. Washington, DC: Author. Pew Hispanic Center. (2012a). Net migration from Mexico falls to zero—and perhaps less. Washington, DC: Author. Pew Hispanic Center. (2012b). The 10 largest Hispanic origin groups: Characteristics, rankings, top counties. Washington, DC: Author. Pew Hispanic Center. (2012c). When labels don’t fit: Hispanics and their views of identity. Washington, DC: Author. Ponterotto, J. G., Casas, J. M., Suzuki, L. A., & Alexander, C. M. (Eds.). (2010). Handbook of multicultural counseling (3rd ed.). Thousand Oaks, CA: Sage. Raley, J., Casas, J. M., & Corral, C. (2004). Quality de vida: “Browning” our understanding of quality of life. In R. J. Velasquez, L. M. Arellano, & B. W. McNeill (Eds.), The handbook of Chicana/o psychology and mental health (pp. 455–468). Mahwah, NJ: Lawrence Erlbaum. Redfield, R., Linton, R., & Herskovits, M. J. (1936). Memorandum for the study of acculturation. American Anthropologist, 38, 149–152. Rodríguez, M., Valentine, J. M., Son, J. B., & Muhammad, M. (2009). Intimate partner violence and barrier to mental health care for ethnically diverse populations of women. Trauma, Violence, & Abuse, 10, 358–374. Romano, J. L., & Hage, S. M. (2000). Prevention and counseling psychology: Revitalizing commitments for the 21st century. The Counseling Psychologist, 22, 733–763. Rosselló, J., Bernal, G., & Rivera-Medina, C. (2008). Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms. Cultural Diversity & Ethnic Minority Psychology, 14, 234–245. Santisteban, D. A., & Mena, M. P. (2009). Culturally informed and flexible family-based treatment for adolescents: A tailored and integrative treatment for Hispanic youth. Family Process, 48, 253–268. Smokowski, P. R., & Bacallao, M. (2009). Entre dos mundos/Between two worlds: Youth violence prevention, comparing psychodramatic and support group delivery formats. Small Group Research, 40, 3–27. Suárez-Orozco, C., Suárez-Orozco, M. M., & Todorova, I. (2008). Learning a new land: Immigrant students in American society. Cambridge, MA: Harvard University Press. Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5th ed.). Hoboken, NJ: John Wiley. Sue, S., Zane, N., Hall, G. C. N., & Berger, L. K. (2009). The case for cultural competency in psychotherapeutic intervention. Annual Review of Psychology, 60, 525–548. Torres, L., Driscoll, M. W., & Voell, M. (2012). Discrimination, acculturation, acculturative stress, and Latino psychological distress: A moderated meditational model. Cultural Diversity & Ethnic Minority Psychology, 18, 17–25. Tummala-Narra, P., Alegría, M., & Chen, C.-N. (2012). Perceived discrimination, acculturative stress, and depression among South Asians: Mixed findings. Asian American Journal of Psychology, 3, 3–16. U.S. Census Bureau. (2004). U.S. interim projections by age, sex, race, and Latino/a origin: 2000– 2050. Retrieved from http://www.census.gov/population/www/projections/usinterimproj U.S. Census Bureau. (2006). Latino/a population in the United States: July 1, 2000, to July 1, 2006. Retrieved from http://www.census.gov/population/www/socdemo/Latino.html U.S. Census Bureau. (2008). 2006–2008 American Community Survey 3-year estimates. American FactFinder. Retrieved from http://www.factfinder.census.gov/servlet/DatasetMain=PageServlet? program=ACS&submenuId=datasets2&lang=en U.S. Census Bureau. (2010). Historical poverty tables. Retrieved from http://census.gov/hhes/www/poverty/data/historical/people.html U.S. Census Bureau. (2011a). Selected characteristics of the native and foreign-born populations: 2010 American Community Survey 1-year estimates. American FactFinder. Retrieved from http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml? pid=ACS_10_1YR_S0501&prodType=table U.S. Census Bureau. (2011b). Statistical abstract of the United States: 2011. Washington, DC: Author. Retrieved from http://www.census.gov/compendia/statab U.S. Census Bureau. (2012). Table 78. Live births, deaths, marriages, and divorces: 1960 to 2008. In Statistical abstract of the United States: 2012. Washington, DC: Author. Retrieved from: http://www.census.gov/compendia/statab/2012/tables/12s0079.pdf U.S. Department of Labor. (2012). The Latino labor force at a glance. Washington, DC: Author. Retrieved from http://www.dol.gov/_sec/media/reports/HispanicLaborForce/HispanicLaborForce.pdf Vasquez, M. J. T. (2007). Cultural difference and the therapeutic alliance: An evidence-based analysis. American Psychologist, 62, 878–885. Villarruel, F. A., Carlo, G., Grau, J. M., Azmitia, M., Cabrera, N. J., & Chahin, T. J. (Eds.). (2009). Handbook of U.S. Latino psychology: Developmental and community-based perspectives. Thousand Oaks, CA: Sage. Vinokurov, A., Trickett, E. J., & Birman, D. (2002). Acculturative hassles and immigrant adolescents: A life-domain assessment for Soviet Jewish refugees. Journal of Social Psychology, 142, 425–445. Wrenn, C. G. (1962). The culturally encapsulated counselor. Harvard Educational Review, 32, 444–449. Yeh, C. J., Arora, A. K., & Wu, K. A. (2006). A new theoretical model of collectivistic coping. In P. Wong & L. Wong (Eds.), Handbook of multicultural perspectives on stress and coping (pp. 55–72). New York: Springer. 9 Counseling Arab and Muslim Clients Marwan Dwairy Fatimah El-Jamil Primary Objective ■ To assist counselors in understanding the historical and cultural background they need to be effective in professional encounters with Arab and/or Muslim clients Secondary Objectives ■ To encourage counselors to revise or modify psychological theories and practices related to the development and assessment of mental health to fit Arab/Muslim beliefs and cultures ■ To aid in the development or conceptualization of new mental health assessment and intervention tools that are suited to Arab/Muslim clients A psychotherapist or counselor who works with Arab and Muslim clients may notice that these clients are more family or community oriented and therefore less individually oriented than most Western clients. Terms such as self, self-actualization, ego, opinion, and feeling have a collective meaning for them. These clients may be preoccupied by family issues, duties, expectations, and the approval of others; as such, in conversing with them, counselors may find it difficult to distinguish between their personal needs and opinions and those of their families. These primary psychocultural differences between Arab and Muslim clients and Western clients will be expanded upon in this chapter. While taking these differences into consideration, readers are advised to keep in mind both the large diversity that exists among Arabs and Muslims and the fact that they share many characteristics and features with members of other collectivistic cultures. Before we discuss these commonalities and differences, however, we offer a brief overview of the historical, cultural, and religious background of Arabs and Muslims. Such knowledge will help to clear up some of the many misunderstandings Arabs and Muslims have faced since the infamous attacks on New York City and Washington, D.C., on September 11, 2001. Arab and Muslim History, Culture, and Religion Arabs are the descendants of Arabic tribes who lived in the deserts located in what are now known as the Saudi peninsula, Iraq, and Syria. In the early 7th century (ad 610), Islam emerged in Mecca and became one of the great monotheistic religions. At this time, the Prophet Muhammad began to exhort men and women to reform themselves morally and to submit to the will of God, as expressed in the divine messages revealed to the Prophet. These revelations were later embodied in the holy book called the Qur’an. About 285 million Arabs are spread over 22 Arab countries in North Africa and the Middle East today (Encyclopædia Britannica Almanac, 2003). Although the majority of Arabs are Muslims, Christian and Druze minorities exist in Arab populations. Muslims today number about 1.3 billion people worldwide, living in more than 100 countries on all continents. The largest Muslim populations are found not in Arab countries but rather in Asian countries such as Indonesia, India, Malaysia, Pakistan, and Bangladesh (Encyclopædia Britannica Almanac, 2003). Despite the fact that Islam has been adopted by many non-Arab nations, the Arabic language and history remain central to Muslims because Islam was revealed in the Arabic language to Muhammad in Mecca, a city in Arabia (Dwairy, 2006). The word Islam means “submission” and comes from the Arabic root that means “peace” (Kobeisy, 2004). The five fundamental tenets of Islam that are shared by all Islamic groups are as follows: 1. 2. 3. 4. 5. Shahada: The profession of faith (“There is no God but Allah, and Muhammad is His Prophet.”) Siyam: Fasting in the holy month of Ramadan Salah: Prayer five times a day Zakah: A tax devoted to providing financial help to the poor Hajj: The pilgrimage to Mecca These tenets direct Muslims to submit and pray to one God (shahada, salah, and hajj), to learn to control their instincts (siyam), and to empathize with the poor and offer them help (zakah). A true believer is expected to adhere to and fulfill these five principles, which are meant to promote a greater connectedness to God and to other believers. Antagonism and hostility directed toward the West are far divorced from any true Islamic fundamental beliefs. On the contrary, Islam is very clear about the need to accept and respect others, including those who practice other monotheistic religions, such as Christianity and Judaism. In fact, the same spiritual source, Abraham, is considered the father of these three monotheistic religions, as they all emerged from his descendants. After the death of the Prophet Muhammad, the issue of who should be his successor became a most pressing problem. Ali, who was the Prophet’s cousin and son-in-law, presented himself as the person most eligible for the job, but he was turned down by the majority at the time. After the death of the third Rashidi caliph, Othman, Ali appeared as the first among many contestants, but again he was opposed bitterly by many groups. This issue of leadership ended in fierce battles and divisions among Muslims. This era in Islamic history, called the “greatest civil strife,” resulted in the death of Ali and later his son, Hussein. Ali’s followers and all those opposed to the winning groups were deeply and tragically moved by their losses and gathered themselves together. That was the beginning of the Shia sect of Islam, the name of which literally means “the supporters.” The majority group was called the Sunni, or “the followers of the way of the Prophet” (Badawi, 1996). All Muslims, whether Sunni or Shia, follow the main pillars of Islam and the Qur’an, with minor differences in their interpretations of the Qur’an that developed over the years. Even though the Islamic empire disintegrated over time into different nationalities and countries, the two main sects of Islam remain, along with their struggle for authority in the Islamic world, the same struggle that began in the 14th century. A set of very strict laws called the Shari’aa was later developed. These laws are based on specific interpretations of the Qur’an and on what is known about the Prophet’s life, the Sunna. The Shari’aa provides directives according to which an individual’s personal, familial, social, economic, and political life must be led. The Shari’aa is practiced in almost every Arab country, although in some countries (such as Saudi Arabia and Qatar) it is fully enforced as law, while in others (such as Lebanon) it is only partially enforced and then only on Muslim citizens. Therefore, Islam not only involves faith and prayer to God but also provides legislation pertaining to almost every aspect of life. Islam can be described as a social religion that attempts to promote a balanced order in society, since it encompasses all the needs of the human being from the spiritual to the physical. The impression that the West has of sexuality in Arab Muslim societies has received much attention and debate in the media, particularly given the very conservative dress known as the abaya and the veil known as the hijab, which are often shown in the media. Sexuality is one of the many aspects of day-to-day life that Islam addresses. For example, Islam directs both male and female believers to avert their gaze from members of the opposite sex and to safeguard their gender, as this is more decent for them (Khalidi, 2008). Islam also describes grave punishments that believers will endure for engaging in sex outside of wedlock, and adultery is considered the greatest of sexual transgressions (Khalidi, 2008). Islam, however, also provides legal sexual vents for men within the context of wedlock. Polygamy, which is a concession that is not predominant in today’s Arab cultures, serves as one of those legal vents. Divorce is another example of a legal vent that permits both women and men the practical means to deal with irreconcilable conflicts associated with changing physical or emotional needs. The hijab, as well as other conservative dress as currently practiced by Muslim women, is an expression of Islamic identity and faith and serves to protect women from the sexual advances of men. However, among more moderate-minded Muslims, it is also viewed as a form of control imposed by Islamic institutions to limit the sexual appeal of women. Among Islamic countries today, only Saudi Arabia and Iran enforce the veiling of women, and in countries such as Tunisia and Turkey, state laws prohibit veiling. Regardless of societal laws, however, the dress code in Islam is conservative. Arabs and Muslims also have a very specific political history that shapes the way they experience the West. For many decades, Arab Muslims were acquainted with Westerners as colonialists or occupiers in Africa and Asia. Their biggest and most devastating defeat, however, was the Zionist movement in Palestine, backed by the West. More recently, they know the West as supporting or condoning the Israeli occupation of Palestinian land and launching the war on Iraq without clear indication of threat. In the past few decades, particularly since the “war on terrorism” began, the relationships between Arab Muslim societies and the West have become particularly tense, with the West often seen as a threat to the Arab and Muslim societies’ sovereignty and their collective character. While these views are not shared by all Arabs and Muslims, many do remain apprehensive about Western regimes and foreign policies, particularly after having endured decades of political instability in their home countries (Erickson & Al-Timimi, 2001). Furthermore, because of sociopolitical issues, including the dictatorships and monarchies in various Arab countries of North Africa and Asia and poverty within rural areas, religious “fundamentalism” grew as a result of people’s disempowerment. Some Muslims thought that they could improve their lives by returning to their religion the way it was practiced during the “golden age” of Islam. Otherwise they would have to follow in the steps of the powerful nations that defeated them. This was the beginning of what the West has termed “Islamic fundamentalism.” However, the fundamentalists’ reactions to world events have become more desperate and hate-fueled with time, veering away from the tenets of Islam and toward political ends. The events of the Arab Spring, initially motivated by the masses, were also reactions to these sociopolitical issues, but fundamentalist religious groups have further taken advantage of these revolutionary movements that began during the Arab Spring to gain power in countries such as Tunisia, Egypt, Syria, Iraq, and Libya. Despite having negative feelings toward the West, many Arabs are also fascinated by Western culture, technology, and science. They consume Western products and watch and listen to Western media, and Arab scholars often adopt Western theories. There is no doubt that exposure to Westerners, through travel, media, science, and technology, has introduced many Arab Muslims to new individualistic values that challenge their collectivist traditions and beliefs. Attitudes toward the West are therefore often a mixture of rage and antagonism on one hand and identification and glorification on the other. Arab and Muslim immigrants of course vary in the proportion of their resentment versus their identification with the West (Dwairy, 2006), as we will discuss in the following sections. Arab Americans Estimates of the population of Arab Americans residing in the United States range from 1.7 million to 5.1 million. Arab and Muslim Americans are found in all social classes, at all education levels, and in urban and rural settings. Their levels of education and income are usually higher than the averages for the total U.S. population (Arab American Institute, 2012), in part because educational achievement and economic enhancement are highly valued in Arab cultures (Abraham, 1995). Many are also multinational and multilingual, with the Arabic language as their mother tongue and usually English or French as their second language. Arabs may travel to and settle in Western countries for higher education and employment opportunities, or they may be seeking refuge from war, political instability, economic hardship, or, in some cases, religious persecution (Abi-Hashem, 2008, 2011). In general, Arab Americans integrate well into mainstream U.S. society, but some Arabs and Muslims do remain separate and unable to integrate into the American social system (Abi-Hashem, 2011). They may consciously or unconsciously resist assimilation into the American culture. Many factors play roles in facilitating or inhibiting acculturation and/or the development of a cohesive, individual, Arab ethnic identity (Erickson & Al-Timimi, 2001). First, there is great religious and political heterogeneity among Arabs. Some Arab Americans align themselves with conservative Republican values, while others, particularly immigrants, who tend to be dissatisfied with American foreign policy, lean toward more left-wing liberal values (Abraham, 1995). Islamic religious identification also varies greatly: Some Arab Muslims adhere to all the fundamental beliefs, tenets, and practices of Islam; some identify as believers without strict practice; and still others consider themselves Muslim solely for purposes of identity or sense of belonging. Second, the lack of recognition by the United States of Arab Americans as an ethnic minority group greatly affects their identity. Some Arabs, for this reason, identify as “White,” while others insist on placing themselves in an “other” category in order to assert their separate ethnicity. Third, Arab Americans have experienced racism, discrimination, and social stigma to varying degrees, with some reporting direct harm and others completely unacknowledged as Arabs or Muslims (Abi-Hashem, 2011; Erickson & Al-Timimi, 2001). Such realities challenge Arab Muslims’ ease of assimilation or acculturation to the host American culture. Authoritarian and Collective Culture The social systems in both the traditional Arab and the Muslim worlds tend to be collective and authoritarian: The individual and family are interdependent, and the family is ruled by a patriarchal, hierarchical authority. Despite some progress in the past few decades, democratic values and political rights remain limited in most Arab Muslim countries, and the citizens still, for the most part, rely on the family rather than on the state for their survival, including in matters related to child care, education, jobs, housing, and protection (United Nations Development Programme, 2002). In the absence of a state system that provides for the needs of the citizens, the individual and family continue to be interdependent. Individuals depend on their families for survival, and family cohesion, economy, status, and reputation are in turn dependent on individuals’ behavior and achievements. The individual is expected to serve the collective (family or community) in order to receive the familial support needed for his or her survival. In such a social system, two polarized options are open to individuals: (1) to be submissive in order to gain vital collective support or (2) to relinquish the collective support in favor of self-fulfillment. Arabs and Muslims are split in terms of the choices that they make between these two poles and can be roughly divided into three societal categories: authoritarian/collectivistic, mixed, and individualistic. The majority of Arabs and Muslims are found in the first two categories. The individualistic minority is typically made up of those who were raised in educated, middle- to upperclass urban families and have had much exposure to Western culture. Of course, these categories are dynamic and contextual: An Arab person’s orientation can be more collective in terms of one issue, such as family life, and less collective in terms of another, such as business activities and related issues. For most Arab and Muslim individuals, choices in life are collective matters, and therefore the family is always involved in major decision making. Decisions concerning clothing, social activities, education, career, marriage, housing, size of the family, and child rearing are often made within the family context, and at times the individual has only minimal space for personal choice. Within this system, an individual learns to be more reliant on others and consistently assesses whether personal initiatives and challenges are worth embarking on if they counter the wishes of the family. To maintain its cohesion, the collective system may not welcome authentic self-expression of feelings; instead, individuals are often expected to express what others anticipate. This way of communicating within the collective is directed by values of showing respect (ihtiram), fulfilling social duties (wajib), and pleasing others and avoiding confrontations (mosayara). Given that societal, cultural, and religious norms as described above greatly affect an individual’s psychological development, counselors and psychotherapists who work with Arab and Muslim clients may need to revise their theoretical understanding of mental health and adapt their methods of assessment and therapy to the specific needs of this population. Psychosocial Development Western theories of development emphasize a separation–individuation process that normally ends with the individual developing an independent identity after adolescence. While they may use different terminology, all theories of development agree that normal development starts with symbiosis or complete dependence and ends with independence and autonomy. Freud claimed that after the fifth year of life, children already possess, through a process of identification with the samesex parent, an almost independent personality structure. After age 5, children unconsciously repeat and transfer their early relationships with their parents to their present interpersonal relationships (Freud, 1900, 1940/1964). Erikson (1950) asserted that the formation of an independent ego identity is a necessary stage in the normal development of children. He described the stages that lead to autonomous ego identity: First, children attain basic trust (birth to 1 year), then seek autonomy (1–3 years) and move toward initiation (3–6 years) and industry (6–12 years), until they achieve ego identity in late adolescence. Object relations theory also focuses on analyzing the process of separation–individuation in the first 3 years of life (Mahler, Bergman, & Pine, 1975) and its continuance into adolescence (Blos, 1967), until the individuation of the self is achieved. These theories of development actually describe the ideal development in Western society. Accordingly, the mentally healthy adult is independent, autonomous, individuated, internally controlled, and responsible for him- or herself. In an individualistic society, dependence in an adult may be considered a disorder (e.g., dependent personality disorder) or a sort of fixation or regression. Conversely, in societies where collective/authoritarian norms and values continue to be the major generators of behavior, personal development does not occur in the same way as it does in primarily individualistic societies. Assuming complete autonomy and independence is inappropriate, because individuals remain embedded in the larger family context and society (Hofstede, 1986; Sue & Sue, 1990). Adolescents continue to be emotionally and socially dependent on their environment; only later, as older adults, do individuals become more interdependent with their environment. In fact, in societies that adopt authoritarian parenting styles, Arab adolescents are not expected to act out, become egocentric, or engage in nonconformist or rebellious behavior (Racy, 1970). Indeed, Timimi (1995) has postulated that Arab youth do not experience identity crises in adolescence or achieve individual autonomy because their individual identities are part of the larger family identities to which they are always loyal. When the ego identity of Arab Palestinian adolescents was measured, it was found to be more foreclosed and diffused than that of American youth (Dwairy, 2004a). Foreclosed or diffused adolescents do not experience a crisis period but rather adopt commitments from others (usually parents) and accept them as their own without shaping, modifying, or testing them for personal fit. These adolescents do not experience a need or desire to explore alternatives and/or deal with the question of their identity. Furthermore, the identity of male Arab Palestinian adolescents was found to be even more foreclosed than that of their female counterparts. Additionally, the interconnectedness with their parents was of a higher level than that found among American youth. Arab Palestinian adolescents, for instance, displayed higher levels of emotional, financial, and functional dependence on their parents than did American adolescents (Dwairy, 2004a). Authoritarian parenting and psychological dependence and interdependence are frequently misunderstood by Western counselors working with Arab and Muslim clients. Some studies indicate that Arab children and youth are satisfied with authoritarian parenting (Hatab & Makki, 1978). Additionally, other studies indicate that authoritarianism is not associated with any detriment to the mental health of Arab youth (Dwairy, 2004b; Dwairy & Menshar, 2006). Examining these psychocultural features among Turkish families, Fisek and Kağitçibaşi (1999) commented that authoritarianism should not be considered as oppression, emotional connectedness as enmeshment or fusion, or the collective familial self as constriction or developmental arrest. Similarly, Western counselors and therapists who work with Arab and Muslim families should be attentive to psychosocial dependence and interdependence as appropriate and functional behavior that is based on correct reality testing and the understanding of the social reality in Arab and Muslim societies, and not as a fixation, regression, or sign of immaturity. Personality The concept of personality emerged along with the development of individualism in the West. Personality theories arose to explain the internal dynamics that rule the individual’s behavior. Most personality theories assume an intrapsychic construct (ego, self, trait, drives) and processes (conflicts, repression, self-actualization) according to which behavior is explained (Dwairy, 2002). In contrast, in most collectivistic societies, where the personality continues to be other-focused (Markus & Kitayama, 1998), norms, values, rules, and familial authority can largely explain the behavior of the individual. In these societies, such as Arab Muslim ones, the concept of personality must therefore go beyond the intrapsychic constructs and processes and focus on the social layer, because the intrapsychic structures are dependent on the external, social layer of personality. The main dynamic in the personal life of the Arab Muslim individual is in the interpersonal or intrafamilial domain rather than the intrapsychic. Most sources of struggle are primarily external, a conflict between personal needs and social and familial control. To contend with and manage this common conflict, individuals require specific social coping skills. Central to these skills, which prevail naturally in Arab societies, are mosayara (or mojamala) and istighaba. Mosayara is to align oneself with others’ needs by verbalizing what is expected and concealing one’s true feelings and attitudes. It is an essential expectation in Arab Muslim societies because it helps maintain harmony within the family and society. Istighaba, on the other hand, allows feelings, attitudes, and needs that are not expressed because of mosayara to be expressed in the absence of familial or social knowledge. Socially unacceptable behavior is expressed in solitude, away from the “eyes of the society,” to avoid punishment or isolation. These are two complementary skills often used to cope within the collective Arab society (Dwairy, 1997b, 1998). Therefore, the two main entities of the collective personality are the social layer of personality versus the private layer. The social layer is the component that is exposed to others and communicates with them according to norms and values while using coping skills such as mosayara. The private layer is the component that enables ventilation of unacceptable needs or expressions away from the scrutiny of social control, while using coping skills such as istighaba. Neither layer is independent, but rather is or is not conveyed according to the presence or absence of social, external control. Thus, the collectivistic personality, as compared to the individualistic one, tends to act contextually rather than consistently across social situations. Individual differences among Arabs and Muslims may be displayed within two main factors: (1) the individuation of the person (the more individuated the person, the less dominated by the social layer he or she is), and (2) the social status (individuals behave differently according to their social roles, gender, age, and profession). These two factors help explain and predict differences in behavior among Arabs and Muslims (for further discussion of these factors, see Dwairy, 2002). Assessment Since the typical intrapsychic structures of personality, such as ego, self-concept, and conflict, are interpersonal rather than individual among many Arab and Muslim clients, to understand a client’s personality, the clinician needs to assess its other, more relevant components. Most important, the clinician should assess the client’s level of individuation to understand whether the social or the private layer predominates, to know the context in which each component is activated, and to know how effectively the client uses his or her social coping skills. The conventional battery of tests that focuses on intrapsychic components of personality does not meet this need; therefore, the clinician needs to seek out additional assessment tools that can assess the client’s level of individuation, values, adherence to norms, coping skills, and need to be understood within the family context. A structured interview such as the Person-in-Culture Interview (Berg-Cross & Chinen, 1995) is one example of a tool that could provide the therapist or counselor with the information he or she requires to understand the needs, attitudes, and values of the individual as opposed to those of his or her family. In such an interview, the client is asked to identify his or her attitudes and feelings concerning a certain issue and then to identify his or her family’s reaction to that same issue. This enables the therapist to better understand similarities and differences between the client’s values and attitudes and those of the client’s family. Talking about a significant object (TASO) is another innovative technique that directs the client to talk about him- or herself through a significant object the client identifies from his or her home. This technique is based on the understanding that people in traditional cultures have strong emotional attachments to their physical environments; therefore, talking about a significant item brought from the home environment reveals significant memories and events pertaining to the client’s life and family (see Dwairy, 1999, 2001). Psychopathology Psychopathology, according to Western personality theories, is considered a dysfunction within the intrapsychic domain that causes suffering, impairment in functioning, somatic complaints, or detachment from reality (American Psychiatric Association, 1994). Arabs and Muslims, however, may display these symptoms because of a dysfunction within the individual-family relationship. The main sources of psychopathology are often dysfunction between the social and private layers of personality and the failure or misuse of social coping skills. For instance, an imbalance between mosayara and social approval or the discovery of the istighaba by the family may cause severe psychosomatic and social distress. Furthermore, since the individual and the family, the mind and the body, and, at times, reality and illusion are not easily distinguishable entities among many Arabs and Muslims, a disorder is displayed in all of these domains in a diffused rather than stylistic way. Patterned disorders that are described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV-TR) are not displayed clearly among Arabs and Muslims. For instance, major depression, considered in the West to be a mood disorder characterized by sad feelings, hopelessness, and helplessness, may be manifested among Arabs and Muslims only physically in somatic complaints, frequently with no feelings of sadness, hopelessness, and helplessness (Al-Issa, 1989; Baasher, 1962; Racy, 1980). Additionally, many Arabs and Muslims have a different concept of reality from that of Westerners. They may at times consider visions and dreams to be the true reality (Al-Issa, 1995; Dwairy, 1997a), and on the basis of dreams and visions, they may make crucial decisions in their lives. This difference in the concept of reality challenges reality testing as a criterion for mental disorder, as adopted by the Western nosology. In addition, in the diagnosis of schizophrenia, the conventional DSM-IV nosology does not aid in differentiating between cultural hallucinations and psychotic ones. A typical psychotic disorder among Arabs and Muslims is acute, precipitated by familial or social distress, and polymorphic, involving a large range of symptoms. Many recover mental health within a year, even without any medication, and typically have no family history of psychosis (Okasha, Seif El Dawla, Khalil, & Saad, 1993). There is also an increasingly debated issue around the prevalence and quality of posttraumatic stress in the Arab region. An epidemiological study conducted in Lebanon highlighted the fact that despite ongoing wars, political turmoil, and civil unrest, rates of posttraumatic stress disorder, based on DSM-IV-TR diagnostic criteria, are low and similar to rates found in the United States (Karam, Noujeim, Saliba, & Chami, 1996). PTSD symptomatology such as intrusive flashbacks or nightmares may not be the central problem area that Arabs present with. Other studies conducted in Lebanon and Palestine have found higher rates of depression, anxiety, aggression, and socially avoidant behaviors after exposure to sustained, repeated, or multiple war traumas (Cloitre et al., 2009; Karam, 1997; Khamis, 2008). These symptoms may more adequately describe the traumatic reactions of Arabs in the region. Therapists in the West must be careful not to assume a diagnosis of PTSD based on past trauma alone, as there may be other, more pertinent, issues and symptoms that need direct attention. Psychotherapy and Counseling Working with Arab and Muslim clients requires careful attention and sensitivity to the major psychological, social, and cultural issues described above. Each phase of therapy has its own particular set of challenges and concerns. Choosing a Psychotherapist or Counselor Although research has found that matching therapist and client on gender and ethnicity does not change therapy outcome (Zane, Hall, Sue, Young, & Nunez, 2004), these two factors should be considered with Arab and Muslim clients. Among very religious or conservative Arabs and Muslims, there are limitations to how freely the opposite sexes can interact with one another, particularly with strangers (Kobeisy, 2004). In addition to the individual’s own religious, cultural, and social beliefs, the issue for which counseling is sought is a very important consideration (Kobeisy, 2004). Arab and Muslim clients sitting with therapists of the opposite sex may find it very challenging to discuss certain personal issues, and this may facilitate resistance to the process. Matching therapist and client on cultural or religious background needs careful attention also. Some Arabs and Muslims prefer therapists of the same ethnic identity in order to ensure a process free of stereotypic judgments. However, some Arabs and Muslims who particularly value the confidentiality that comes with the therapy process may want to avoid having someone from their own community becoming aware of their personal secrets. They may fear being judged or blamed by an Arab Muslim “authority” as they may be in their own families. Such clients actually prefer therapists whose backgrounds are different from their own (Kobeisy, 2004). Thus, Arab and Muslim clients seeking services should be asked directly about their preferences in this area before psychotherapy begins. The Beginning Phase Before embarking on a specified therapeutic path, the therapist should consider several aspects of the client’s experience. The therapist should demonstrate a thorough understanding of the client’s background before deciding on the treatment plan. First, the therapist must assess the client’s comfort with communicating in English. Arabic is a rich language with many words that refer to varying intensities of the same emotions, and Arabic speakers make frequent use of metaphors. Speaking in one’s mother tongue naturally elicits a wider emotional response and complexity. Just because clients may be able to communicate rather well in English does not mean that they can express themselves in that language with the same level of clarity as they can in Arabic (Sayed, 2003b). In such cases, therapists need to exercise patience in communication and ask their clients questions that facilitate both interest in and acceptance of what the clients are saying and how they are saying it. The use of an interpreter can be an option when the struggle to articulate appears to interfere with the therapy process and emotional expression. However, the therapist must assess the need to use an interpreter carefully, because doing so can lead to complications. While a client may initially welcome the idea of having an interpreter in session, later the presence of a third party who is similar to the client in cultural and/or linguistic background may create increased feelings of shame or unease for the client. Thus, in order to save face, the client may form a coalition with the interpreter that interferes with an honest and open therapy process (Sayed, 2003b). Second, the therapist should assess the client’s level of acculturation to Western society and norms, as there is much heterogeneity among Arab and Muslim communities and within individual families in terms of acculturation (Abi-Hashem, 2011; Al-Krenawi & Graham, 2000; Erickson & Al-Timimi, 2001). An immigration history may also be pertinent, particularly if the client has endured any psychological trauma, such as armed conflict or persecution, in his or her country of origin, or if the client has experienced any discrimination or prolonged mourning in the host country (Abi-Hashem, 2008; Nassar-McMillan & Hakim-Larson, 2003). In addition, immigration to the West challenges the cultural features mentioned earlier. After emigration, a fundamental cultural revision and change may take place in the mind of the Arab and Muslim individual. The Western, liberal, individualistic life may seem too permissive and therefore threatening to traditional Arab and Muslim values concerning family, women, and child rearing. While Arab and Muslim immigrants may want to be part of the Western society, they may be afraid of becoming enmeshed and losing their values and identity. Therefore, at some initial stage after arrival in the host country, Arabs and Muslims may become more committed to certain cultural norms and values that had only a marginal position in their way of life before emigration. Many may find refuge in their cultures of origin and become more nationalistic or religiously fundamentalist than before. Other first-generation Arab and Muslim immigrants live in two polarized worlds and are torn between two conflicting cultures, struggling to define themselves. Counselors and psychotherapists need to be sensitive to these two seemingly contradictory goals of Arab and Muslim clients: the need to adapt to Western society and the need to retain their own cultures (Abi-Hashem, 2011). Third, the therapist or counselor should assess the internal resources available to the client versus the power the social environment exerts on her or him. Level of individuation from the family, ego strength, and the control of the family are three major factors that should be assessed before any therapy takes place (Dwairy, 2006). On the basis of this assessment, the counselor may decide whether to apply therapies that reveal unconscious contents and end in greater self-actualization or to apply therapies that focus on basic problem-solving and communication skills. The higher the level of the client’s individuation, the stronger the ego, the greater the flexibility of the family, the more apposite it is for the counselor to apply insight-oriented interventions. With a client who is unindividuated, has weak ego strength, and lives in a strict and traditional family, the counselor will want to adopt short-term and problem-focused interventions. The Psychotherapy Process Because the distresses of clients from collective cultures are commonly related to intrafamilial disorder, counselors and therapists need to work on restoring this order. With more traditional Arab Muslim clients, working on revealing unconscious contents and helping the clients align themselves with their own personal needs and values can be counterproductive, in that it may change the clients’ behaviors in ways that clash with the clients’ social and religious environments and meet with family disapproval. Assuming also that clients are typically the most vulnerable members of their families, it seems unrealistic to expect that they will be able to endure the conflicts within their families or communities that would result from their expressing forbidden feelings and needs. At the same time, children of Arab Americans who were born in the West may experience increased tension between the demands of their families and those of the society of their host country. In some cases, severe power struggles emerge between these children and their parents. It is sensible in such cases for counselors to determine if any differences in religiosity and cultural identity exist between parents and children (Springer, Abbott, & Reisbig, 2009). Therapists working with such families need to support both the parents’ demands and their children’s struggles while aiming for increased communication, understanding of positions, and compromises between parents and children. Counselors and therapists should try to understand the rationale of these families’ systems from within, to listen to both the stresses and anxieties that the parents experience and the stresses of their children, to express empathy with their conflicts, to harness resources that exist from within Islam and their beliefs, and to encourage and empower those progressive components in the parents’ value system and religion that may facilitate therapeutic changes. Counselors should remember that their role is to serve the needs of their clients within the clients’ own families and value systems rather than to serve only the clients’ individual needs and values. Integrating positive religious coping strategies into therapy with Arab and Muslim clients has been demonstrated to yield positive clinical outcomes (Abu-Raiya & Pargament, 2010, 2011), particularly because for most of these clients religious identity is a primary source of comfort. Pargament, Koenig, and Perez (2000) define positive religious coping strategies as methods an individual uses to develop a safe and secure relationship with God, a higher meaning to his or her life, and a sense of spiritual connection to others; as such, therapists may find it useful to encourage their Arab and Muslim clients to draw on their religious coping resources. Another study found that integrating knowledge of the Qur’an and the Hadith (sayings and customs of the Prophet) into an evidence-based therapy program, such as cognitive-behavioral therapy, rapidly improved anxiety symptoms in Muslim patients with strong religious backgrounds (Razalli, Aminah, & Khan, 2002). In general, because evidence-based therapies disregard individual and cross-cultural differences, it is imperative that counselors working with Arab and Muslim clients modify such therapies so that they are culturally sensitive. Another important aspect of therapy with Arab and Muslim clients is the need to improve clients’ communication with their families. Even though a counselor or therapist may be working individually with a client, family sessions or direct work with some members of the client’s family may prove essential (Al-Krenawi & Graham, 2000), despite the fact that such an approach is contraindicated in traditional individual therapy. A therapist may misconstrue a client’s wish to involve his or her family, or the family’s wish to be involved, as codependency, overinvolvement, overprotection, or enmeshment, whereas the client may see the therapist’s failure to understand the need for family involvement as professional neglect (Al-Krenawi & Graham, 2000). Thus, counselors and therapists who work with Arab and Muslim clients should give special attention to understanding the relationship dynamics of the family (conflicts, coalitions, and force balances) and the status of the client within the family in order to restore the family order. A counselor who ignores the influence of the family and focuses instead on the client’s personal issues may miss the point and make a client who appears enmeshed in the family feel misunderstood. In addition, a counseling approach that threatens familial authority or the client’s faith may result in premature termination of the counseling process and leave the client to suffer the consequences. Drawing on family systems theory allows the therapist to embrace all the significant subsystems that make up the client’s world without placing blame on any one element of the system (Nichols, 2012). Problems of Transference and Countertransference Arab and Muslim clients may manifest ambivalence toward the West explicitly or implicitly in therapy with Western counselors, and this ambivalence may be displayed through transference and countertransference processes. Many Arab and Muslim clients bring their cultures to their counseling sessions and consider Western counselors to be representative of all that the West means for Arabs and Muslims. An Arab and Muslim client may express submissiveness and idealization to a Western counselor not only as transference of the child–parent relationship but also as transference of the Arab and Muslim–West relationship. Expressions of anger and rage on one hand and feelings of inferiority or fear on the other are expected components of an Arab and Muslim client’s transference toward a Western counselor. For some Arab and Muslim clients, the American therapist may represent the whole American regime and its attitude toward the Arabic and Islamic nations. This transference may be expressed in terms of we (the Arabs) and you (the Americans). The therapist should not take any accusation personally but rather should help the client to differentiate among the therapist, “Americans” in general, and American foreign policy. An inquiry such as “When you say you, do you mean we the Americans or me the therapist?” may help the Arabic client to be aware of the differences between Americans in general and the therapist as a particular person. An open and honest discussion of the impressions the client carries about the United States and other Western countries may prove helpful in facilitating the therapeutic alliance, and this process may demand similar disclosure on the part of the therapist before the patient can truly trust the therapist. The Arab client’s perception of the therapist can also affect the transferential relationship. The client may appear submissive as a result of his or her perception of the therapist as all-knowing, someone to be afforded the highest status and respect. Such a client may place all trust in the therapist and initially give him or her full control over treatment and decision making (Sayed, 2003a). Other Arab and Muslim clients, in contrast, may generally mistrust counselors or therapists altogether and tend to prefer to seek psychological help from family members, elders, or clergy (Abi-Hashem, 2011). Part of this mistrust has to do with the fear of being labeled as “crazy,” and this fear is compounded by the notion among some Arabs and Muslims that people who suffer from mental illness have a weak self and weak faith (Sayed, 2003a). Western counselors need also to be aware of their own biases and assumptions regarding Arabs and Muslims, as these will affect their countertransference toward Arab and Muslim clients and families. They need to be open to listening to and learning about the client and family, divesting themselves of any stereotypic notions and prejudices they may have absorbed from the Western media (AbiHashem, 2011; Sayed, 2003b). For example, Western counselors may find it difficult to understand the rationale of the traditional Arab and Muslim parenting style, not having experienced the vital individual-family interdependence that exists where state-provided care is absent. Counselors may easily find themselves opposing the authority of Arab and Muslim families and employing therapeutic or even legal means in attempts to create a liberal, egalitarian order in these families. They may need to make a great conscious effort to avoid judging the behaviors and attitudes of their Arab and Muslim clients and their families according to Western norms and values. Arab and Muslim clients can be helped best by counselors or therapists who empathize with their collective cultural, political, and social values. By manifesting acceptance, tolerance, and unconditional positive regard toward clients’ families, their traditions, and their beliefs, counselors may help these clients trust and relinquish anger, mistrust, or feelings of inferiority. Empathy and acceptance that are limited to the individual client and do not encompass the family and culture do not suffice and, in some cases, may be counterproductive or threatening. Additionally, pushing a client to confront her or his family may prematurely place the client in an irresolvable familial conflict. Culturanalysis A therapist working with an Arab and Muslim client may want to apply a within-culture therapy and employ culture to facilitate therapeutic change. In order to achieve this, the therapist must identify subtle contradictions within the belief system of the client and employ cultural aspects that may facilitate change. Similarly to how a psychoanalyst analyzes the intrapsychic domain and brings conflicting aspects to consciousness (e.g., aggression and guilt) to mobilize change, a culturanalyst analyzes the client’s belief system and brings contradicting aspects to consciousness to create a revision in attitudes and behavior. The assumption that underlies culturanalysis is that culture influences people’s lives on an unconscious level. When a therapist inquires and learns about a client’s culture, he or she may find some unconscious aspects that are dissociated from the client’s conscious attitudes with which a conflict exists. Once the therapist brings these aspects to the awareness of the client, the client starts to revise his or her conscious attitudes, and a significant change may be effected. Culturanalysis can be understood from different theoretical perspectives. In the same way that a humanistic (Rogersian) therapist establishes an unconditional positive regard for and empathy with the individual to facilitate the expression of the authentic self, a culturanalyst establishes positive regard for and empathy with the culture and facilitates the recognition of more and more aspects of the culture that were denied and that may be employed to accomplish change. Alternatively, one can understand this process in terms of generating a cognitive dissonance within the client’s belief system that necessitates change. For example, Samer, a 22-year-old religious Muslim client struggling with depression, was, as many individuals with depression do, focusing on negative events in his life and denying many positive ones. He tried with no success to protect himself from negative events by praying more frequently. When confronted with his own religion’s beliefs, he was prompted to examine the ways in which he truly appreciated the grace of God as a Muslim man. The therapist’s employment of the client’s religious belief system made change for Samer easier and more stable. (For more examples, see Dwairy, in press.) Indirect Therapies Arabs and Muslims, like members of many other cultures, have a concept of reality that differs from that of Westerners. The positivistic concept of reality in the West is associated with a literal reality. The Arabic language, in contrast, is very metaphoric (Hourani, 1983, 1991), and therefore many Arab and Muslim clients may express their problems through metaphors and images. Given these cultural characteristics, therapists should facilitate these clients’ use of imaginative and metaphoric conceptions over positivistic conceptions. Approaches such as metaphor therapy may be especially useful with Arab and Muslim clients. Since more traditional Arab and Muslim clients are likely to feel uncomfortable with addressing their family lives directly, and because they primarily use metaphoric language to express distress, therapists and counselors should enter these clients’ metaphoric world and facilitate metaphoric solutions. When a client who is trying to say that her family does not understand her suffering expresses herself using a proverb such as “Elli eidu belmay mesh methl elli eidu bennar” (The one whose hand is in water is not like the one whose hand is in fire), the therapist can work through this metaphor without addressing the familial relationship directly. Kopp (1995) describes a three-stage approach to metaphor therapy in which, first, the client is asked to select a metaphor that describes the problem in concrete terms; next, the client is asked to change the metaphor in such a way that it describes the solution to the problem; and finally, the client is asked what she or he has learned from the metaphoric solution and what practical implications can be deduced from it that she or he can use to cope with the problem. Bresler (1984) describes a metaphoric technique designed to help chronic pain sufferers control their pain by controlling images in their minds. First, the client is guided to draw a picture of the pain, then to draw the state of no pain, and then to draw the pleasure state. In the second stage, the client learns to control the images in his or her mind and to retain the pictures (images) of no pain and pleasure. Through these three images, the client processes the pain experience metaphorically. Let us return to our example about the feeling of a hand in water versus the feeling of a hand in fire. If this metaphor describes the problem, the therapist may suggest that the client draw (or imagine) the metaphor and then create a new picture that describes the relief of finding a solution. The fact that the client is involved in imagining a metaphor-based solution influences his or her real experience. Metaphor therapy is a suitable intervention when the aim of the therapist is to avoid dealing directly with repressed contents. Other indirect therapies that may be useful with Arab and Muslim clients include guided imagery therapy, art therapy, and bibliotherapy (Dwairy & Abu Baker, 1992). In all these therapies, the client processes the problem and finds solutions or new coping strategies on a symbolic, imaginative level, influencing the psychosocial level of experience. (For more discussion of the metaphor model of therapy, see Dwairy, 2006, Chapter 11.) Conclusion Arabs are the descendants of Arabic tribes who once lived in the deserts of the Saudi peninsula, Iraq, and Syria and today number about 285 million living in 22 Arab countries. The Islamic religion appeared in one of the main Arabic tribes in the 7th century and has now been adopted by 1.3 billion Arab and non-Arab people worldwide. The Arab and Muslim worlds share the ethos of tribal collectivism and Islamic values, but they are also influenced by their exposure to Western culture. The social systems in both worlds tend to be collective and authoritarian: The individual and family are interdependent, and the family is ruled by a patriarchal, hierarchical authority. Within this collective system, many Arab and Muslim youth do not become psychologically individuated from their families. Their personalities continue to be collective and directed by external norms and values rather than by internal structures and processes. These Arabs and Muslims often come from traditional and religious families where collective values are highly enforced and the standards or expectations placed on males of the household differ from those placed on females. The clinical picture of Arab and Muslim clients may differ from that described in the DSM-IV-TR. Counselors and therapists who work with these clients should be aware of the challenges of dealing with unconscious, personal, and/or repressed contents without acknowledging the importance of the family belief system and the real restrictions that may be placed on the individual. Arab Americans face the additional struggle of managing the demands of their families along with the demands of the culture of their host country. Individuals often require assistance in allowing themselves to adopt new values from the host country without feeling that their cultural identity is being threatened. Throughout this process, clients’ family members also require assistance in communicating their needs and fears to one another so that the family system itself does not feel threatened either. Therapists and counselors who work with Arab and Muslim clients should modify their therapies by incorporating cultural and religious norms and beliefs and by including the use of family therapy, metaphor therapy, and other indirect therapies. Critical Incident Self-Fulfillment Within the Family Culture Sawsan, a 17-year-old girl, was brought by her father to counseling because she had withdrawn herself from family meetings and activities during the past 2 months, instead spending most of her time listening to music in her bedroom. Lately, she had complained about headaches that lasted all day with no relief, despite the use of painkillers. The family’s medical doctor had told Sawsan’s parents that she may be passing through a stressful period and referred them to counseling. At the initial intake meeting with Sawsan and her father, the father dominated the conversation, and Sawsan displayed approval of his views. The father described her as a perfect girl who always met her parents’ expectations in school and in social behavior. The change in her behavior made her seem to him as “not her.” He tried to attribute this change to “bad friends” or “bad readings.” He also denied that Sawsan was experiencing any stress and emphasized how much the family loves Sawsan and cares for her needs. He said, “Nothing is missing in her life. We’ve bought her everything she wants. She couldn’t be passing through any stress.” Knowing that most Arab girls find it very difficult to express their feelings in front of their fathers (or both parents), after listening to the father the counselor asked to be allowed to have a private conversation with Sawsan, and the father agreed. At the beginning of this conversation, Sawsan continued to go along with her father’s views, describing how much her parents love and support her and denying any stress. Only after the counselor validated to her that she indeed has good parents was she ready to reveal a conflict that had been raised recently concerning her desire to study at a university located far from her village, which would necessitate her living in the student dorms. Her father rejected the idea of his daughter living away from the house, far away from his immediate control. In an attempt to compensate for this, he bought her a new computer and suggested that she study at a nearby college. She insisted that she wanted to study at the university and tried to push until her father became angry, claiming that she was imitating “bad girls” who sleep away from their homes. As she described this conflict, she continued to remove any accusation from her father, saying, “He did this because he is worried about my future,” and “He is right and I should understand this.” The counseling process lasted for five sessions, during which the counselor met with only the father three times in order to establish a positive “joining” with his position and worries. The counselor then revealed to the father some contradictions within his belief system regarding the importance of education, as described in culturanalysis. After that, the counselor met with both father and daughter and encouraged Sawsan to explain to her father why she felt she needed to study at the university and to express her commitment to her family values. The counselor also encouraged the father to express his care and worry to Sawsan and then to discuss a compromise that may be accepted by both of them. He agreed to allow his daughter to study at another university, in a city where she could live with her uncle’s family. In a follow-up meeting, Sawsan and her father expressed satisfaction. Sawsan had returned to normal interaction with the family and no longer complained of headaches. Discussion Questions Sawsan’s case illustrates several issues that are typical of those facing Arab Muslim youth and their parents: 1. Arab Muslim clients usually approach counseling or psychotherapy after they have visited medical doctors. How might this affect the counseling process? 2. Young Arab Muslim clients are typically brought to counseling by their parents and take a passive and submissive role in the first meeting, when their parents are present and dominate the conversation. Should a non-Muslim counselor try to alter this interaction? If so, what steps might the counselor take? 3. Sawsan had expressed her distress passively (withdrawal) and somatically (headaches). How central are these forms of expression for her case? 4. Traditional Arab Muslim parents are typically not sensitive and empathic to their children’s emotional needs and do not understand why their children are distressed as long as their materialistic needs (e.g., Sawsan’s new computer) are supplied. How might the counselor deal with the parents if and when such beliefs and attitudes emerge? 5. For Arab Muslim parents, traditions and values are more important for decision making than their children’s feelings. Can or should the counselor try to ameliorate this tendency? 6. Arab Muslim parents tend to attribute bad behavior to external entities such as “bad friends” or “bad readings” or, in some cases, bad spirits. Is this something that the counselor may want to address with the parents? 7. The behavior of Arab children in the presence of their parents (external control) is often extremely different from their behavior when they are away from external control. It is not that one behavior is real and the other is false; rather, the two behaviors represent two different yet real components of the children’s personalities. As a counselor, how would you deal with this? 8. It is often difficult for Arab children to criticize their parents in conversations with foreigners, such as Western counselors, and they typically feel the need to emphasize that the intentions of their parents are good. Should the counselor avoid discussing the client’s parents with the client? 9. The main conflict that needed resolution in the above case was an intrafamilial rather than an intrapsychic one; therefore, counseling was focused on the family relationship in order to accomplish change in the relationship that fits the needs of both the identified patient (Sawsan) and the family belief system. Do you agree that change was possible only after the counselor had established a positive relationship with the father? 10. Counseling with Arab and Muslim families should not seek to change or confront the family culture or the family structure; rather, it should be aimed at finding better solutions within the fabric of that culture. Explain how the counselor might use a family’s internal resources and strengths to change this situation for the better. References Abi-Hashem, N. (2008). Arab Americans: Understanding their challenges, needs, and struggles. In A. J. Marsella, J. L. Johnson, P. Watson, & J. Gryczynski (Eds.), Ethnocultural perspectives on disasters and trauma: Foundations, issues, and applications (pp. 115–173). New York: Springer. Abi-Hashem, N. (2011). Working with Middle Eastern immigrant families. In A. Zagelbaum & J. Carlson (Eds.), Working with immigrant families: A practical guide for counselors (pp. 151–180). New York: Routledge. Abraham, N. (1995). Arab Americans. In R. J. Vecoli, J. Galens, A. Sheets, & R. V. Young (Eds.), Gale encyclopedia of multicultural America (Vol. 1, pp. 84–98). New York: Gale Research. Abu-Raiya, H., & Pargament, K. (2010). Religiously integrated psychotherapy with Muslim clients: From research to practice. Professional Psychology: Research and Practice, 41(2), 181–188. Abu-Raiya, H., & Pargament, K. (2011). Empirically based psychology of Islam: Summary and critique of the literature. Mental Health, Religion & Culture, 14(2), 93–115. Al-Issa, I. (1989). Psychiatry in Algeria. Psychiatric Bulletin, 13, 240–245. Al-Issa, I. (1995). The illusion of reality or the reality of illusion: Hallucination and culture. British Journal of Psychiatry, 166, 368–373. Al-Krenawi, A., & Graham, J. R. (2000). Culturally sensitive social work practice with Arab clients in mental health settings. Health and Social Work, 25(1), 9–22. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Arab American Institute. (2012). Demographics. Retrieved August 3, 2012, from http://www.aaiusa.org/pages/demographics Baasher, T. (1962). Some aspects of the history of the treatment of mental disorders in the Sudan. Sudan Medical Journal, 1, 44–47. Badawi, A. (1996). Mazahib al-Islamiyeen [Sects of Islam]. Beirut, Lebanon: Dar El-Ilm Lilmalayin. Berg-Cross, L., & Chinen, R. T. (1995). Multicultural training models and person-in-culture interview. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 333–356). Thousand Oaks, CA: Sage. Blos, P. (1967). The second individuation process of adolescence. Psychoanalytic Studies of the Child, 22, 162–186. Bresler, D. (1984). Mind-controlled analgesia: The inner way to pain control. In A. A. Sheikh (Ed.), Imagination and healing (pp. 211–230). New York: Baywood. Cloitre, M., Stolbach, B., Herman, J., Van Der Kolk, B., Pynoos, R., & Wang, J. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22, 399–408. Dwairy, M. (1997a). A biopsychosocial model of metaphor therapy with holistic cultures. Clinical Psychology Review, 17(7), 719–732. Dwairy, M. (1997b). Personality, culture, and Arabic society. Jerusalem: Al-Noor (in Arabic). Dwairy, M. (1998). Cross-cultural counseling: The Arab-Palestinian case. New York: Haworth. Dwairy, M. (Ed.). (1999). Cross-cultural psychotherapy [Special issue]. Clinical Psychology Review, 19(8). Dwairy, M. (2001). Therapeutic use of the physical environment: Talking about a significant object. Journal of Clinical Activities, Assignments & Handouts in Psychotherapy Practice, 1(1), 61–71. Dwairy, M. (2002). Foundations of psychosocial dynamic personality theory of collective people. Clinical Psychology Review, 22, 343–360. Dwairy, M. (2004a). Individuation among Bedouin versus urban Arab adolescents: National, ethnic and gender differences. Cultural Diversity & Ethnic Minority Psychology, 10(4), 340–350. Dwairy, M. (2004b). Parenting styles and psychological adjustment of Arab adolescents. Transcultural Psychiatry, 41(2), 233–252. Dwairy, M. (2006). Counseling and psychotherapy with Arabs and Muslims: A culturally sensitive approach. New York: Teachers College Press. Dwairy, M. (in press). From psychoanalysis to culture analysis. London: Palgrave Macmillan. Dwairy, M., & Abu Baker, K. (1992). The use of stories in psychotherapy. Al-Thaqafa, 1, 34–37 (in Arabic). Dwairy, M., & Menshar, K. E. (2006). Parenting style, individuation, and mental health of Egyptian adolescents. Journal of Adolescence, 29, 103–117. Encyclopædia Britannica Almanac. (2003). Chicago: Encyclopædia Britannica. Erickson, C. D., & Al-Timimi, N. R. (2001). Providing mental health services to Arab Americans: Recommendations and considerations. Cultural Diversity & Ethnic Minority Psychology, 7(4), 308–327. Erikson, E. H. (1950). Childhood and society. New York: W. W. Norton. Fisek, G. O., & Kağitçibaşi, Ç. (1999). Multiculturalism and psychotherapy: The Turkish case. In P. B. Pedersen (Ed.), Multiculturalism as a fourth force (pp. 75–92). Philadelphia: Brunner/Mazel. Freud, S. (1900). The interpretation of dreams. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vols. 4–5). London: Hogarth. Freud, S. (1964). An outline of psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 23). London: Hogarth. (Original work published 1940) Hatab, Z., & Makki, A. (1978). Al-solta el-abawia wal-shabab [Parental authority and youth]. Beirut: Ma’had El-Inmaa’ El-Arabi (in Arabic). Hofstede, G. (1986). Cultural differences in teaching and learning. International Journal of Intercultural Relations, 10, 301–320. Hourani, A. (1983). Arabic thoughts in the liberal age. Cambridge: Cambridge University Press. Hourani, A. (1991). A history of the Arab peoples. New York: Warner. Karam, E. G. (1997). Comorbidity of posttraumatic stress disorder and depression. In C. S. Fullerton & R. J. Ursano (Eds.), Posttraumatic stress disorder: Acute and long-term responses to trauma and disaster (pp. 77–90). Washington, DC: American Psychiatric Press. Karam, E. G., Noujeim, J. C., Saliba, S. E., & Chami, A. H. (1996). PTSD: How frequently should the symptoms occur? The effect on epidemiologic research. Journal of Traumatic Stress, 9(4), 899–905. Khalidi, T. (2008). The Qur’an: A new translation. London: Penguin Books. Khamis, V. (2008). Post-traumatic stress and psychiatric disorders in Palestinian adolescents following intifada-related injuries. Social Science & Medicine, 67, 1199–1207. Kobeisy, A. N. (2004). Counseling American Muslims: Understanding the faith and helping the people. Westport, CT: Praeger. Kopp, R. R. (1995). Metaphor therapy: Using client-generated metaphors in psychotherapy. New York: Brunner/Mazel. Mahler, M., Bergman, A., & Pine, F. (1975). The psychological birth of the infant: Symbiosis and individuation. New York: Basic Books. Markus, H. R., & Kitayama, S. (1998). The cultural psychology of personality. Journal of CrossCultural Psychology, 29(1), 63–87. Nassar-McMillan, S., & Hakim-Larson, J. (2003). Counseling considerations among Arab Americans. Journal of Counseling & Development, 81(2), 150–159. Nichols, M. P. (2012). Family therapy: Concepts and methods (10th ed.). Boston: Pearson. Okasha, A., Seif El Dawla, A., Khalil, A. H., & Saad, A. (1993). Presentation of acute psychosis in an Egyptian sample: A transcultural comparison. Comprehensive Psychiatry, 34(1), 4–9. Pargament, K. I., Koenig, H. G., & Perez, L. M. (2000). The many methods of religious coping: Development and initial validation of the RCOPE. Journal of Clinical Psychology, 56, 519–543. Racy, J. (1970). Psychiatry in Arab East. Acta Psychiatrica Scandinavica, 221, 160–171. Racy, J. (1980). Somatization in Saudi women. British Journal of Psychiatry, 137, 212–216. Razalli, S. M., Aminah, K., & Khan, U. A. (2002). Religious-cultural psychotherapy in the management of anxiety patients. Transcultural Psychiatry, 39(1), 130–136. Sayed, M. A. (2003a). Conceptualization of mental illness within Arab cultures: Meeting challenges in cross-cultural settings. Social Behavior and Personality, 31(4), 333–342. Sayed, M. A. (2003b). Psychotherapy of Arab patients in the West: Uniqueness, empathy, and otherness. American Journal of Psychotherapy, 57, 445–459. Springer, P. R., Abbott, D. A., & Reisbig, A. M. (2009). Therapy with Muslim couples and families: Basic guidelines for effective practice. Family Journal, 17(3), 229–235. Sue, D. W., & Sue, D. (1990). Counseling the culturally different: Theory and practice. New York: John Wiley. Timimi, S. B. (1995). Adolescence in immigrant Arab families. Psychotherapy, 32, 141–149. United Nations Development Programme. (2002). Arab human development report 2002: Creating opportunity for future generations. New York: Oxford University Press. Zane, N., Hall, G. C. N., Sue, S., Young, K., & Nunez, J. (2004). Research on psychotherapy with culturally diverse populations. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 767–804). New York: John Wiley. Part III Counseling Issues in Broadly Defined Cultural Categories Major shifts have occurred in the United States and around the world within the past decade that relate to the four chapters in this section. The global economic recession has adversely affected most countries, and the United States is experiencing a widening income gap that is increasing the number of people displaced to the margins. Tensions around immigration have increased globally as well, as many people are leaving their countries of origin to seek employment and other opportunities. The landscape of U.S. demographics has been significantly affected by these trends: By 2050, it is projected that Whites will no longer be a numerical racial majority in the United States, and the 2010 census results suggest that more than half of the growth in the total population within the previous decade resulted from the increase in the Latino population. As a result of all these changes, the need to address the diversity and inequalities in American school systems has become even more pressing, with educational disparities still on the rise despite numerous so-called educational reforms and accountability initiatives. In addition, the LGBQ and trans* communities have increased their visibility, and struggles for LGBTQ rights have gained traction, with some advances in legislation to protect people from discrimination based on sexual orientation, gender identity, and gender expression across the United States and around the world. We have also seen the extension of marriage benefits to same-sex couples in some locations. These changes have not been uniform, however; constitutional bans on the recognition of same-sex marriages have proliferated, and some countries have officially criminalized the LGBTQ community. Given these changing realities, we need to rethink how we approach our work with clients from diverse cultural populations. Thus, Part III of this edition of Counseling Across Cultures includes many new authors and addresses new approaches to the topics of gender, sexual orientation, marginalization, and school counseling. Michi Fu, Joe Nee, and Yin-Chen Shen (Chapter 10) are new contributors who discuss current gender issues in counseling from a nonbinary, transinclusive, and intersectional perspective. They begin by examining relevant definitions and deconstructing the prevalent binaries that continue to perpetuate privilege (e.g., hegemonic masculinity, cisgender privilege) and oppression (e.g., sexism, heterosexism) around gender. They present different types of sexism and briefly explore gender at the intersections of race/ethnicity, social class, and sexual orientation. They finish their discussion of this important topic with a series of recommendations for counselors and clinicians who are dealing with gender issues in their practice. Returning to Counseling Across Cultures is Melanie M. Domenech Rodríguez, joined on this occasion by Melissa Donovick and Kee J. E. Straits, with a revised and updated chapter on counseling marginalized populations (Chapter 11). These authors discuss the process and politics that lead to marginalization and examine how the definitions and the experience of marginalization are relative to context. They also highlight the importance of context in counseling with people who have intersecting marginalized identities. The authors consider the interplay among privilege, power, and marginalization. They challenge counselors to shift their conceptualizations and reframe their practice by “centering the margins,” and they provide a set of guiding questions for an approach that counselors can use in working with clients from marginalized populations. The authors illustrate this approach using undocumented immigrants as a case example. Cheryl Holcomb-McCoy and Ileana Gonzalez, new contributors, present the chapter on school counseling (Chapter 12). They propose “a shift in school counseling practice and policy that is rooted in cultural competence and social justice principles” and where advocacy is central to the school counselor’s role. They discuss some of the challenges of 21st-century school counseling, which include multiple dimensions of inequality and violence that many public school students face: mental health disparities, achievement inequalities, college access and dropout disparities, lack of access to STEM (science, technology, engineering, and mathematics) preparation, and peer victimization, among others. The authors describe the profession’s standards for multiculturally competent practice and present various frameworks for approaching school counseling from a social justice stance. Eliza A. Dragowski and María R. Scharrón-del Río bring a new approach to the discussion of sexual orientation to this edition of Counseling Across Cultures. This shift is reflected in the revamped title to Chapter 13, “Reflective Clinical Practice With People of Marginalized Sexual Identities.” The authors use marginalized sexual identities as an umbrella term to refer to the identities of people who fall outside heteronormativity, many of whom identify as lesbian, gay, bisexual, and/or queer (LGBQ). From these authors’ perspective, in order to engage in multiculturally competent practice, mental health practitioners need to engage in critical self-reflection, personal examination of their social locations, and the deconstruction of dominant norms. Dragowski and Scharrón-del Río emphasize the importance of counselors’ being aware of the intersectionality of identities, privileges, and oppressions, and they elaborate on the intersection of sexism and heterosexism and its significance to counseling work with marginalized sexual identity populations. Moreover, they argue that counselors should develop an advocacy position with regard to the social inequalities and oppression faced by marginalized sexual identity populations. The four chapters in Part III consider issues of systematic privilege and oppression and emphasize how important it is for mental health professionals to engage in critical self-reflection on their own identities and examination of their own areas of privilege and oppression. These chapters also address issues of intersectionality of identities and present various approaches that counselors might use to engage in multiculturally competent practice with the populations discussed. Finally, all of the chapters stress the importance of counselors’ adopting an advocacy position as part of multiculturally competent practice with these populations. These elements are all important and necessary to counseling in increasingly diverse environments. 10 Gender, Sexism, Heterosexism, and Privilege Across Cultures Michi Fu Joe Nee Yin-Chen Shen Primary Objective ■ To discuss the impacts of gender, sexism, and heterosexism on privilege across cultures Secondary Objectives ■ To introduce a discussion of various forms of privilege (e.g., male privilege, nontransgender privilege) ■ To explore gender at the intersections (e.g., race, social class, and sexual orientation) In this chapter we aim to explore the intersections of gender with other aspects of identity, such as social class, sexual orientation, and race. How do these variables influence privilege? We begin by offering terminology consistent with the expanded framework. We then invite the reader to consider how different forms of privilege are viewed from both the marginalized and the privileged perspectives. We also consider and examine multiple intersections of gender with other aspects of identity. Finally, we address the clinical implications of privilege and offer recommendations to counselors working with clients who are dealing with the issues raised in this chapter. Defining Gender-Related Concepts When first embarking on a discussion of gender and different forms of privilege, it is useful to develop a common understanding of operating definitions. Therefore, we offer definitions of sex, gender, gender identity, gender role, and transgender at the outset to reduce potential confusion, as these are the basic terms we use throughout this chapter. Sex refers to physical markers that are typically used to define humans as male or female. The specialized reproductive cells of a developing embryo begin to develop into specific organs (e.g., penis, clitoris, vagina, testes, and ovaries) based on X and Y chromosomal makeup as well as the combination of testosterone or estrogen hormonal interactions in uterus (Blackless et al., 2000). Gender, in contrast, is a learned behavior and social construct influenced by gender role, personality traits, attitudes, values, and the relative power that society assigns in a specific culture (Looy & Bouma, 2005). As a social construct, gender is an acquired identity and set of behaviors that are learned over time, and is independent of sex (Mar, 2010). In other words, “sex is fixed and based in nature; gender is arbitrary, flexible, and based in culture” (Goldstein, 2001, p. 2). Gender identity is one’s perception of one’s own gender (e.g., man, woman, boy, girl, nongendered, bigendered, transgender, genderqueer), and such perception may or may not be congruent with the sex assigned at birth. Money (1994) defines gender identity as “the sameness, unity, and persistence of one’s individuality as male or female or androgynous, in greater or lesser degree, especially as it is experienced in self-awareness and behavior. Gender role is everything that a person says and does to indicate to others or to the self the degree that one is either male or female or androgynous” (p. 169). Hence, gender identity is expressed through gendered behaviors and is connected to one’s sense of affiliation to a gender group such as male or female. At the core of the work that Sennott and Smith (2011) do is the awareness that gender goes beyond the traditional binary, and that there is a continuum of identities ranging from more feminine to more masculine. Furthermore, “one’s identity can only be named by the person claiming the identity” (Sennott & Smith, 2011, p. 220). The Identity Continuums are tools created to educate people about the differences among phenotypic sex, gender identity, gender expression, and sexual practices (Sennott & Smith, 2011, p. 221). First on the Identity Continuums, the sex continuum denotes that phenotypical sex goes beyond the penis (male) and vagina (female) and expands across more than 40 different intersex conditions, of which three-fourths can be distinguished as separate using genetic, chromosomal, or hormonal testing (Sennott & Smith, 2011).The second continuum, the gender continuum, is experienced internally and cannot be labeled by persons other than the individual. As Mandlis (2011) points out, “The deeming of someone male or female is based on a single doctor’s individual discretion through a brief genital examination; the deeming of man or woman occurs many times a day through interactions between people that depend on the interpretation and discretion of the individuals involved” (p. 233). The third Identity Continuum is gender expression, which has a number of different levels between the distinct end points of feminine and masculine. Femininity or masculinity can be conveyed through choices of clothing, gestures, verbal communication, and body language, and can be expressed differently throughout the day depending on whom the individual is interacting with. Similarly, the interpretation of gender expression by others can vary from moment to moment, as it “depends on the interpretation and discretion of the individuals involved” (Mandlis, 2011, p. 233). Transgender (trans, trans*) is an umbrella term often used to refer to people who experience their gender identities as being different in some way from the sexes they were assigned at birth (Gay, Lesbian & Straight Education Network, 2013). Transgender identity can be claimed by a very diverse group of people, some of whom may or may not want to alter their bodies permanently to match their gender identities and presentation. Expanding Beyond a Binary Framework When considering gender identity in relation to many of their clients, it is critical that mental health professionals move beyond the binary framework, although this can be challenging because the framework is so deeply ingrained in many societies. Traditional notions of sex and gender promote the belief that gender is determined genetically and is recognized at birth based on the appearance of the external genitalia. This belief rests on the assumption that an individual’s visible sex organs are the exclusive determinant of that person’s gender identity, and that only two valid gender identities exist. Based on the social categorization framework, the categories of male and female are viewed as representing a “fundamental divide of the natural world” (Macrae & Bodenhausen, 2000, p. 113) and serve as norms to help people maneuver and function. With the establishment of these norms, those who fall outside them are often seen as in violation or are categorized as part of the outgroup, and therefore are subject to discrimination, prejudice, and even condemnation. Such division not only creates restrictions on the diversity of gender identities people experience (e.g., transgender, genderqueer, or bigendered), but it also limits all other gender expressions that lie within the feminine-to-masculine continuum (Sennott & Smith, 2011). Since society provides few opportunities for variations in gender expression, gendervariant/nonconforming/questioning and transgender youth often experience enormous pressure to conform to social expectations. This conformity may lead to feelings of confusion and isolation (Gagne & Tewksbury, 1998). Discrimination and prejudice are major contributing factors to gendervariant and transgender people’s experience of psychological distress and other negative life outcomes. These can include depression, anxiety, and other emotional and behavioral difficulties; family and peer relationship problems (Di Ceglie, 2000); inability to perform at school or at work; low self-esteem and negative self-image (Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005); campus and classroom bias rejection (Case, Stewart, & Tittsworth, 2009); and school dropout (Sausa, 2005). Privilege and Oppression Within gender, there are two areas of social and institutional privilege: the privilege of the masculine over the feminine and the privilege of nontransgender (or “cisgender”) individuals over those who are gender variant or nonconforming or who identify as transgender. Sexism and Male Privilege Individuals’ experiences of gender and gender-based oppression are largely determined by their cultural roots as well as by the mainstream societies in which they find themselves. The latter may or may not diverge significantly from the former. These systems are inherently difficult to identify, and often the first step toward addressing problems of gender-based oppression is to develop an awareness of them. While racism and discrimination are usually easily recognizable as acts committed among individuals, the concept of privilege is less visible (McIntosh, 1988). Privilege, according to McIntosh, occurs when “one group has something of value that is denied to others simply because of the groups they belong to rather than because of anything they’ve done or failed to do” (quoted in Johnson, 2001, p. 23). An example of male privilege is the fact that a man can travel crosscountry alone with less fear of being sexually assaulted than a female traveler would face. Another example might be that it is legal for men to be in public shirtless, whereas in most jurisdictions in the United States it is a criminal offense for a woman to do the same. An additional example is that men are expected to be competent in the fields of science and mathematics, while it is assumed that competence in these areas is unusual for women. The fact that privilege is unearned and afforded to the dominant social group at the cost of denying the same to the oppressed group makes it a difficult topic to address. Identifying privilege for what it really is, an unearned advantage, is often difficult for those who have long enjoyed the benefits of privilege and, as a result, are unaware of the nature of the problem (Coston & Kimmel, 2012; McIntosh, 1988). Male privilege is a power structure that exists across most cultures and multicultural populations. An example is the influence of Confucianism in many East Asian cultures, which dictates that males possess the power in their families. Men and women tend to be socialized differently in the world. In the United States, boys and girls are oversaturated with guidelines and expectations based on gender, even before birth. What it means to grow up as a male is very different from what it means to grow up as a female. For example, the saying “Boys don’t cry” may mean that males grow up learning not to express their emotions freely. It may also mean that an individual’s value as a person is determined by how much he or she embodies the masculinized ideal, such that even girls who cry are subject to ridicule. Privilege is encountered and experienced at the individual level, but it is maintained and facilitated at the institutional level. Individuals experience socially constructed privileges, which are socially constructed discourses or guidelines followed by the majority of individuals and which arrange individuals relative to others in power relations (Winslade, Monk, & Drewery, 1997). Discourses are formal ways of thinking that provide the basis for how societal messages are interpreted, endorsed, and maintained by the dominant group. These discourses lay the foundation for the ways people act in the world and the ways in which the world, in turn, acts towards people. Robinson (1999) notes that even though individuals may not have specific membership in privileged or oppressed groups, they mistakenly perceive themselves to be immune to the effects of oppression. While individuals may not be aware of the results of privilege or in fact consider themselves to be neutral, they occupy the same physical space and face the same societal ills as those who are marginalized. Men are socialized as gendered beings to embrace and/or be influenced by rigid and sexist discourses in which they are oriented toward success and competition (Coston & Kimmel, 2012). This orientation is positively reinforced or rewarded for males but punished or discouraged for females. Recognition of privilege due to anticipated benefit and shame/fear in admitting the privilege is a potential barrier to addressing the impact of male privilege on men and women (Robinson, 1999). Individuals who enjoy the benefits of privilege often do not recognize that their benefit is unearned or feel that their privilege is a source of guilt, particularly as they have something to lose. Gender privilege can thus be invisible to those who benefit from it (Good & Moss-Racusin, 2010). Individuals who believe strongly in the ideal of gender equality may be blind to the privilege they enjoy (i.e., men, cisgender people) or to the privilege denied to others (women, gender-variant people, trans* people). Males are taught not to recognize male privilege, as whites are taught not to recognize white privilege (McIntosh, 1988). Men may stand to acknowledge that women are disadvantaged, but this may not necessarily mean that they are able to acknowledge their own status of being more privileged. These individuals may work to promote the rights of women and advocate on women’s behalf, all without suggesting that they should limit or relinquish their own privilege (McIntosh, 1988). By understanding and confronting male privilege, men can become assets in the process of changing social inequalities. Men cannot become partners in this process if they refuse to engage in dialogue, reject diversity efforts, and are never challenged about their privilege (Vaccaro, 2010). Privilege occurs whether people are consciously aware of it or not: In working against sexism and for gender equality, it is not enough for men to claim that they do not directly take part in the oppression process; they must acknowledge the advantages awarded to males. Privilege may also have unintended negative consequences for men in regard to their emotional development and perception of roles. Mankowski and Maton (2010) define male privilege as an unearned advantage granted to men that entails both potential benefits and potential damages. Positive consequences for males include social, economic, and political benefits because of their gender. Negative consequences may include the inability of males to express a full range of emotions (Robinson, 1999). Men are traditionally socialized to be the breadwinners, to fulfill the role of being financially responsible for their families. Emotional expression is often discouraged in males, with the exceptions of anger and aggression. With societal and individual pressures to compete and succeed, males are increasingly at risk for high rates of psychological distress. Compared to women, men tend to be limited in their ability to express a range of emotions (Robinson, 1999). The argument could be made that women are more in tune with their emotions not because of biological differences but because of differences in socialization and societal discourses for females and males. Males differ among themselves in their access to the power afforded through male privilege based on race, sexual orientation, social class, and other identities (Coston & Kimmel, 2012; Mankowski & Maton, 2010). Mankowski and Maton (2010) found that men who tended to strongly endorse or were more conflicted about gender expectations generally scored lower on measures of well-being and had increased problem behaviors. Adhering to gendered norms could be a source of continual psychological distress for men, which could affect their quality of life. For example, McLeod and Owens (2004) found that African American boys who experienced expectations of hypermasculinity may have had greater psychological burdens that presented a challenge for healthy identity development. These researchers also found that persons in lower status positions tended to experience more negative feedback from others and compared themselves less favorably to others. Males are generally privileged in relation to females, but they can be marginalized in other aspects of their identities. Men who experience such marginalization include, but are not limited to, disabled men, gay men, and working-class men (Coston & Kimmel, 2012). Male privilege may not be an absolute and uniform advantage, as other factors influence the extent of a person’s power over others. Furthermore, male privilege may even be overshadowed by other aspects of marginalization. For example, a White heterosexual male may experience privileges not experienced by an African American gay male. Disabled men may not meet the idealized standards of attractiveness, which may influence their social position, and their relative lack of agency over their physical capabilities may be perceived as a reduction of masculinity (Coston & Kimmel, 2012). Male homosexuality has long been considered “effeminate” and “deviant” from traditional concepts of masculinity. Similarly, the concept that gay men are not “real” men is rooted in sexism (Coston & Kimmel, 2012). Working-class men, on the other hand, fit within the expectations of strength and are acclaimed for their physical prowess, but they may be considered “dumb brutes” (Coston & Kimmel, 2012). Among men, working-class status has implications for mental health, well-being, and family life. There is a stereotype that working-class men “produce hypermasculinity by relying on blatant, brutal, and relentless power strategies in their marriages, including spousal abuse” (Pyke, 1996, p. 545). The combination of multiple minority statuses may exacerbate an individual’s feelings of oppression and privilege. Studies indicate that members of racial and ethnic minority groups experience higher levels of psychological distress than do members of the majority group. Specifically, minority women are exposed to disproportionately high levels of stress and have access to fewer resources than do their nonminority counterparts (Beale, 1970; Essed, 1991; McLeod & Owens, 2004). This has been referred to as “double minority status” or “double jeopardy” (Beale, 1970). Social distance may exist between individuals of different socioeconomic statuses within races as well as between members of different races (Yancey & Kim, 2008). Potentially furthering the power structure within socioeconomic status, some individuals may adopt strong racial identities as a means of distinguishing themselves from others. Individuals with multiple minority statuses may be at risk for mental health difficulties as they struggle to come to terms with the many different aspects of their identity. For example, a Latino gay male experiences forms of oppression that a White gay male may not have to face, such as racial barriers, language barriers, and cultural differences. Men’s gender socialization may contribute to high-risk sexual behavior, reduced involvement in parenting, violence toward intimate partners, and alcohol abuse—all behaviors supported by the pressure for men to distance themselves from anything perceived to be feminine. Scholars have long recognized that race, class, and gender inequalities are linked through underlying factors (Yancey & Kim, 2008). Aosved and Long (2006) examined various forms of discrimination and their relation to the endorsement of the rape myth. They found that higher levels of racism, sexism, homophobia, ageism, classism, and religious intolerance were associated with higher acceptance of the myth among both men and women, with sexism and attitudes toward gender accounting for the greatest variation in acceptance. Further analyses revealed that all of the examined constructs were related to one another: Prejudice against one group increased the likelihood that an individual would be found to have rigid and intolerant cognitive perspectives overall. It is important to understand how attitudes and cultural norms permeate everyday life to facilitate the tolerance of sexual violence and oppressive beliefs. Greater awareness of male privilege may lead individuals to actions based on their increased awareness, as seen with how individuals respond to awareness of White privilege (Case, 2007). Transphobia and Cisgender Privilege As Scott-Dixon (2006) writes, “Gender privilege, the privilege of being normatively and unambiguously placed within a mainstream gender system, despite its constraints, is a great social privilege enjoyed by most people who are not trans” (p. 20). Transphobia is defined as “societal discrimination and stigma of individuals who do not conform to traditional norms of sex and gender” (Sugano, Nemoto, & Operario, 2006, p. 217). Transphobia ranges from fear, disgust, or hatred toward transgender or transsexual persons to fear, disgust, or hatred toward “cross-dressers, feminine men, and masculine women” (Nagoshi et al., 2008, p. 521). Using the analogy of investment, Mandlis (2011) explains the privileges associated with being a nontranssexed individual. First and foremost, “the authenticity of the transsexed body requires an authority figure from within the juridical regime, such as a doctor or government official, to vouch for it” (p. 222). Transgender persons thus appear to have little agency to determine their own identities and even less agency over their bodies. For example, a nontransgender woman does not need to present a letter from a psychologist or a psychiatric diagnosis in order to undertake breast augmentation surgery, nor does she have to undergo counseling to ensure that she is of sound mind and body to make such a decision. But a transgender woman seeking the same surgery does have to obtain such “validation” from external entities. Furthermore, regardless of whether or not she receives a medical diagnosis, a transgender woman’s breast surgery is not covered by Medicaid and is almost never covered by private insurance. Moreover, traditional notions of gender (which subscribe to a hierarchical binary) are subsidiary to biological sex; whether an individual opts for (or has access to) any form of gender reassignment surgery or hormone replacement, the trans individual is “deemed devious, in that s/he is deceiving people in regards to his/her ‘true’ sex” (Mandlis, 2011, p. 222). Indeed, results from studies of gender differences and transphobia suggest that one of the possible reasons for transphobia in men is anger toward the “deceiving” genitals of female-to-male transgender individuals and the change of power relationship in the male-to-female body (Bettcher, 2007; Nagoshi et al., 2008). Bailey (2003) perpetuates the stereotype that many male-to-female transgender individuals are in fact gay men who became women as a way to attract straight men. The view that Bailey depicts suggests that trans women are “sexual deceivers” and that the gender identities of trans people are mere forms of sexual preference. Ultimately, transgender individuals pay the price for the perpetuation of the “deception” stereotype. The 1984 case of Ulane v. Eastern Airlines exemplifies how transsexual individuals are dehumanized as a result of such stereotyping. As Lloyd (2005) observes, “In the court’s eyes, Karen Ulane was not a man or a woman, but rather a transsexual—a sort of monstrous, repulsive intermediate deemed all the more appalling because she chose this embodiment” (p. 163). Mandlis (2011) notes: In embodying her transsexed body, Karen Ulane not only excludes herself from responsible citizenship, justifying the court’s lack of protection toward her, but she also becomes a monster —not because of an incongruence between the sex she was natally assigned and the sex she currently embodies, but because her choice to live her sex in the flesh is understood as her own invocation of a sovereign exclusion that renders her abject. (p. 225) On a societal level, since ancient times women have held a lower position than men in the status hierarchy, and this status differential between males and females is still evident in many cultures, places, and situations. According to Morrison (2010), within this gender hierarchy there lies a sacred space established solely for female empowerment, which does not wish to be “tainted” by male presence: “Some consider this threat of male infringement to be presented by transwomen, believing that even when identifying as female, transwomen will carry inextricable maleness into an otherwise purely female place of safety” (p. 652). Along the same line of safety, Mizock and Lewis (2008) observe that many shelters for the homeless are designed for the convenience of a gender-binary population, with group showers, open restrooms, and bunk beds available to segregated male and female groups; such arrangements place transgender people at risk of “nonconsensual disclosure” (p. 346) and can also expose transgender individuals, particularly adolescents, to physical assaults and even rape. Before the recent inclusion of transgender people under the protection of health care reform legislation, transgender persons in the United States who sought care often experienced refusal or termination of treatment, inappropriate documentation, inadequate privacy protection, and offensive and dehumanizing statements. Such a health care system failed to protect the well-being of transgender individuals. Mizock and Lewis (2008) found that “transgender individuals report difficulty deciding on the timing and process by which to disclose their gender identity to doctors, partially due to concerns with health insurance coverage and prejudice and discrimination on the part of medical providers and staff at medical facilities” (p. 344). Other health care challenges faced by trans people include privacy concerns, stigma, and inadequate care due to lack of knowledge by providers, which often forces trans* clients to become experts in the health care system and take up to role of educators to their medical providers in order to receive adequate services (Mizock & Lewis, 2008). Finally, it is important to note that 32 U.S. states still have no laws preventing employers from discriminating against employees or potential employees in hiring and firing decisions based on gender identity and gender expression (Human Rights Campaign, 2014). Further, in many states, legal forms of identification do not allow for changes to gender designations for individuals who are transsexual but have not undergone sex reassignment surgery; this creates concerns among these trans persons when they are involved in such activities as “attending bars and clubs, navigating airports, and interfacing with the police” (Mizock & Lewis, 2008, p. 346). Gender at the Intersections Race and Gender Racism is a systematic process of societal subjugation that includes the interaction of racial stereotypes (i.e., beliefs and opinions), racial prejudice (i.e., attitudes and evaluations), and discrimination or unfair treatment on the basis of race (Greer, Brondolo, & Brown, 2014; Whitley & Kite, 2010). Members of a target group may perceive discrimination as unjustified negative behaviors toward them (Kim, Anderson, Hall, & Willingham, 2010). Lykes (1983) defines racial prejudice in relation to discrimination as “[biased] attitudes held by individuals of another race, and actions and behaviors which are based on these views” (p. 80). Institutional discrimination can occur when institutional policies facilitate the unequal distribution of benefits across groups or the restriction of opportunities for members of a target group (Kim et al., 2010). Racism is one of the most commonly described types of discrimination. Media exposure and discourses on cultural diversity have highlighted the effects of racism and the recognition of racism within modern society. Individuals who take a neutral position (i.e., claim to be “color-blind”) and those who believe that race and gender are not factors in how individuals are treated underscore the importance of recognizing that racism and sexism are still prevalent. That some people express the belief that racism and sexism do not exist is not an indication that oppressed individuals are experiencing less discrimination. At the university level, female faculty members and administrators are promoted at slower rates than their male counterparts, and their earnings are lower than those of their male colleagues (Johnsrud & DesJarlais, 1994). Such inequities are the results of institutional practices that give benefits to White males at the expense of females and people of color. Females and people of color working in universities experience stereotypes about their cognitive abilities as well as differential treatment by students, administrators, and other faculty (Blakemore, Switzer, DiLorio, & Fairchild, 1997). In race relations, as in gender relations, those in the dominant position possess the power to classify, name, and “construct the Other” (Delphy, 2008)—those who are within marginalized groups: women, people of color, and LGBTQ people. Men and women are designated positions and gender roles based on socially constructed expectations; men and masculinity are associated with productive activities and the public arena (leadership), while women and femininity are associated with reproductive activities and the private sphere (family, caring roles, and so on) (Swim, Aikin, Hall, & Hunter, 1995). Modern concepts of interlocking systems of domination in racism and sexism have been explored extensively by female scholars of color (Gianettoni & Roux, 2010). Black and Latina feminists have highlighted the sexism inherent in the U.S. civil rights movement (Combahee River Collective, 1979; hooks, 1981; Hull, Scott, & Smith, 1982; Moraga & Anzaldúa, 1983) and the racism in the dominant (White) feminist movement of the 1970s (Gianettoni & Roux, 2010). They have argued that an overemphasis on either racism or sexism allows the domination to continue in the other domain. To address this predicament appropriately, it is necessary to utilize a process that fights both racism and sexism. Racism and sexism are also prevalent in the popular media and in athletic events. Relative to their male counterparts, female athletes struggle to achieve respectful, high-quality coverage of their sports in the mainstream news media (Cooky, Wachs, Messner, & Dworkin, 2010). Only 3% to 8% of the sports coverage on national television and local news programs is focused on women’s sports (Messner, Duncan, & Willms, 2006). Even when such coverage is offered, it often trivializes women’s athleticism and heterosexualizes female athletes (Heywood & Dworkin, 2003). Female athletes are not praised for their abilities; rather, they are often negatively portrayed in the media as masculine. In commenting on the Rutgers University women’s NCAA basketball team, Don Imus, a controversial radio personality, described team members as “nappy-headed hoes,” a clear example of explicit racism and sexism on national radio. The term ho has been “part of pop culture vernacular, commonly heard in certain forms of rap and hip-hop music, on daytime talk shows such as Jerry Springer” (Cooky et al., 2010, p. 146). Imus’s comments reflect a dominant discourse in American society. Nappy is a derogatory and racist stereotype used to describe the hair texture of African and African American women, and ho is the shortened version of the word whore (Cooky et al., 2010). African American women in athletics have been negatively portrayed as both hypersexualized and less feminine (Banet-Weiser, 1999; McPherson, 2000). Successful female athletes experience sexism that minimizes their physical skills, and many are marginalized due to their gender. The Women’s National Basketball Association’s marketing strategy focuses on portraying the league’s athletes as models, mothers, or the girl next door, roles that act as reminders of heterosexual aspects of their identity (Banet-Weiser, 1999; McPherson, 2000), while male athletes enjoy the privilege of being recognized for their athletic abilities. The strategy implemented by the WNBA also highlights the hardships that female athletes endure, as if society requires a reminder of the gender of these athletes. Male athletes do not experience such marginalization, and their physical prowess is praised rather than ridiculed. Research in multicultural psychology and studies of issues relevant to communities of color have been increasing over the years, but little research has looked specifically at the concurrent multiple oppressions that are associated with multiple minority identities (Szymanski & Stewart, 2010). According to the American Psychological Association (2007), racial/ethnic minority women both in the United States and abroad often live in racist and patriarchal cultures, where they are exposed to various forms of racism and sexism that come from a variety of places, including interpersonal relationships, workplaces, media, and legal systems. Multicultural feminist psychology focuses on the potentially mentally harmful consequences of multiple oppressions in racism and sexism for African American women, referred to as double (or multiple) jeopardy (Comas-Díaz & Greene, 1994; King, 1988; Klonoff & Landrine, 1995). Double, or multiple, jeopardy occurs when someone holds membership in more than one group that has been historically marginalized, referred to as a minority group. For example, an African American woman who identifies as lesbian experiences three different marginalized minority identities: race, gender, and sexual orientation. Other forms of minority status exist, including, but not limited to, those related to disability, class, socioeconomic status, religion, language, and nationality. Two multicultural feminist theoretical approaches to conceptualizing the relationship between multiple oppressions and African American women’s psychological distress are the additive approach and the interactionist perspective. The additive approach is concerned with how the individual oppression experiences of a person with more than one minority status (e.g., racism and sexism) have direct effects that combine to produce negative impacts on psychological health (Beale, 1970; Shields, 2008; Warner, 2008). According to the interactionist perspective, in addition to direct effects on mental health, one form of oppression may amplify the impact of another form of oppression experienced by a person of more than one minority status, which may lead to more psychological distress symptoms (Greene, 1994; Landrine, Klonoff, Alcaraz, Scott, & Wilkins, 1995). Class and Gender Class and gender intersect in various ways for working-class and poor women and trans people. The foundation for representation by the government assumes that the individuals who govern should have knowledge of those for whom they govern (McIntyre-Mills, 2003); however, only the majority will have their needs met. The process of governance does not take into account those who constitute “the other” (Young, 2009)—that is, those who are not in privileged positions and are denied benefits that others are granted. One example of “classed sexism” can be seen in the gendered notions of labor and work. Such ideas have historically limited women’s access to employment opportunities and fair wages. The gendered idea that males are to be breadwinners, able to support their families through their earning potential, influenced the shift in many countries’ populations from rural to urban areas. In Britain, this process of gendered thinking was utilized to attract migrant workers in the years following World War II (Young, 2009). While men relocated to urban areas for work, women were left with the household responsibilities and the care of the children. The gendered norms of the migrant family were the result of economic necessity combined with defined gender roles. Although considerable progress has been made in many countries toward negotiating the underlying processes of power relations and oppression of women in occupational sectors, inequities still exist. For example, the retail industry has traditionally hired individuals for particular positions based on gender (Mujtaba & Sims, 2011). Men are hired and trained for positions that are typically managerial; such jobs pay more than the positions that women more commonly occupy. Women are more likely to recognize glass ceilings and unfair consequences (Mujtaba & Sims, 2011). The expectation that men or women are more appropriate for certain jobs is an example of gender bias. Members of the dominant culture (White, male, and middle- and upper-class) possess and maintain their dominance over others through power and the development of policy (Harley, Jolivette, McCormick, & Tice, 2002). Those in control exert their influence over others through a variety of domains—psychological, societal, and interpersonal—and through systematic institutions. The psychological implications of being working-class include the recognition of having limited resources, the stigma of being poor, social exclusion, and classism. Smith (2005) discusses the effects of poverty on emotional well-being, which research has consistently found to be devastating (Carr & Sloan, 2003). Classism is the assignment of individual qualities of value and worth based on social class and “the systematic oppression of subordinated groups (people without endowed or acquired economic power, social influence, or privilege) by the dominant groups (those who have access to control of the necessary resources by which other people make their living)” (Collins & Yeskel, 2005, p. 143). It is perpetuated by institutions that facilitate the processes that separate the haves from the have-nots and extends beyond income, intersecting with other factors such as race, religious affiliation, culture, sexual orientation, and gender. Classism is similar to the other isms—sexism, racism, and heterosexism—in that it is an interlocking system that includes concepts of domination, control, and resources, where one group has privilege and the others are oppressed (Hardiman & Jackson, 1997; Smith, 2005). The discourse underlying male privilege is not based solely on gender differences or success: Essential to male privilege is to be in a position of power over others, “to be a real man” (Coston & Kimmel, 2012). Gendered roles in occupations are delineated, and those who go against these roles are often marginalized. Nevertheless, even in professions that are considered to be mostly female (e.g., nursing), men are likely to earn more and to be promoted into leadership roles more quickly than women (Brown, 2009). Parental expectations regarding what their children should do and excel at can affect the development of the children themselves. Many parents tend to have higher expectations for their sons than for their daughters in math, science, computers, and sports, and these beliefs are further reinforced by children’s peer groups (Leaper & Brown, 2008). Individuals are socialized according to gender from a young age to be proficient in certain academic subjects. A young female who is not expected to do well in math and science could have difficulty believing in her capacity to become an engineer or a physicist. Males are often discouraged from taking positions that could be considered to be feminine or beyond the scope of traditionally male-gendered occupations, such as nursing (Brown, 2009). Young females who experience negative comments about their academic abilities at home from their parents and siblings often find little comfort at school, as teachers are among the most common sources of such comments (Brown, 2009). Older girls are more likely than younger girls to report such sexism, perhaps because of the cumulative effect of hearing negative comments over time (Brown, 2009). The exposure to negative comments regarding academic abilities is not isolated to early development; it is a continual process that females are subjected to in multiple facets of their lives. Sexual Orientation and Gender Sexism and heterosexism. Sexism stems from beliefs and behaviors that privilege men over women. Whether at the cultural, societal, institutional, or individual level, sexism is the mechanism that ensures that women occupy subordinate roles compared with men and that women-identified values are disparaged (Matzner, 2004). Traditional forms of sexism entail discriminatory, hostile, and violent actions that directly threaten the well-being of women. Such actions arise from men’s efforts to maintain a patriarchal society that centers on male dominance, thus placing women, gender-variant, and transgender people in less powerful positions. In order to keep women bound by traditional gender roles, men often devalue or punish with hostility those women who strive to control men or show signs of masculinity (such as assertiveness) (Shepherd et al., 2011). As a result of the women’s rights movement and feminist activism, earlier forms of sexism have evolved to produce a modern version in which the assumption is made that women no longer experience discrimination, hostility, or unequal treatment, and women are expected to be content with their current treatment (Cunningham & Melton, 2013). Along with this modern form of sexism is another that Glick and Fiske (2001) call “benevolent sexism.” It comes into women’s daily lives subtly and is perhaps the most invisible form of sexism. Benevolent sexism often takes the form of helping women with certain activities, such as carrying items or holding doors open. The rationale behind such acts is the belief that women are “pure” and “dependent”; therefore, women should conform to the feminine characteristics of purity and goodness. Benevolent sexism occurs when men perform tasks “for” women without seeking their consent. Underlying these actions is the assumption that women either need or desire assistance from men in performing certain tasks. Benevolent sexism perpetuates the stereotype that women are in need of male protection. Despite the apparently chivalrous nature of benevolent sexism, studies have shown that this form of sexism can be more harmful than the traditional hostile sexism. Seemingly gracious gestures can cause confusion as the recipient of the gestures often cannot identify the reason for intrusive thoughts or the source of discomfort, mainly because the underlying discrimination is not as salient as direct hostility. Such confusion can often lead to self-doubt and low self-esteem, and thus to decreased task performance (Dardenne, Dumont, & Bollier, 2007). According to Sibley and Wilson (2004), hostile and benevolent sexism can occur simultaneously, depending on the group of women and the situation in which they are interacting with men. For example, men may carry heavy items and open doors for women who conform to traditional gender roles but behave and speak hostilely to women they perceive as stepping out of “their place” by being assertive or by appearing more masculine in dress. Because benevolent sexism is masked as “chivalry,” it often goes unchecked; such sexism is an example of the invisibility of male privilege. Wise (2001) offers the following definition of heterosexism for social work: Heterosexism reflects the dominance of a worldview in which heterosexuality is used as the standard against which all people are measured; everyone is assumed to be naturally heterosexual unless proven otherwise, and anyone not fitting into this pattern is considered to be abnormal, morally corrupt and inferior. The assumption of heterosexuality and its superiority is perpetuated through its institutionalization within laws, media, religions, and language, which either actively discriminates against non-heterosexuals or else renders them invisible through silence. Just as the concepts of racism and sexism have helped us to understand the oppression of black people and women, so the concept of heterosexism has assisted us in theorizing lesbian and gay oppression. (p. 154) Old-fashioned heterosexism is grounded in the belief that everyone should be heterosexual—the heterosexual relationship is normal and superior to relationships of other gender configurations, including same-sex relationships and relationships in which one or more of the partners are transgender. Similar to traditional hostile sexism, old-fashioned heterosexism is characterized by name-calling (e.g., homo, faggot) and discrimination, hostility, and violence toward nonheterosexual persons. The modern version of heterosexism comes in a more subtle form that asserts that “gay and lesbian people make excessive demands for change; that discrimination toward gay and lesbian people is a thing of the past; and that gay and lesbian people prevent their own acceptance by the dominant culture by exaggerating the importance of sexual orientation” (Eldridge & Johnson, 2011, p. 384). Along with modern heterosexism is yet another more subtle form of oppression known as heteronormativity, which Martin (2009) describes as “the mundane, everyday ways that heterosexuality is privileged and taken for granted as normal and natural. Heteronormativity includes the institutions, practices, and norms that support heterosexuality (especially a particular form of heterosexuality—monogamous and reproductive) and subjugate other forms of sexuality, especially homosexuality” (p. 190). Martin further notes that heteronormativity includes parents’ assumption that their children are heterosexual. With this assumption, parents limit the family’s discussions of love, attraction, commitment, and marriage to heterosexuality, leaving the LGBTQ community absent and invisible in children’s social world and their understanding, and thus perpetuating heteronormativity from a very early age. Marginalization of gender-nonconforming LGB people. The LGB community is part of larger society, and thus members of this community also struggle with perpetuating systematic oppressions (e.g., racism, sexism, classism, ableism). Researchers have documented multiple instances of sexism and transphobia in the LGB community. Weiss (2004) quotes a lesbian writer who describes trans* inclusion in a pejorative way: “Gays and lesbians have struggled for decades to be able to name ourselves and to BE ourselves. But now in our own community we are expected to applaud Dykes rejecting womanhood and embrace men taking it over” (p. 49). Dobkin (2000) quotes another writer who would say to a trans man, “You are not a transsexual man, you are a lesbian woman who has mutilated herself in order to change a woman- loving woman into a more acceptable figure.” At the core of both statements is the assumption that gender is binary, which excludes and vilifies those whose gender identity and expression challenge that assumption. Cultural variations in sexual orientation and gender identification definitions. Not all cultures subscribe to the gender binary: the hijras in South Asia and the fa’afafine in Samoa are examples of gender categories that go beyond the binary. Many American Indian/First Nations groups also recognize a “third gender” often denominated as two-spirit, whereby a gendernonconforming person—whether nonconforming in gender presentation, role, or sexual orientation— is considered to have a sacred or elevated role in the community (Williams, 2010). Experiences of homophobia and transphobia among members of these indigenous nations are inextricably connected to racism and colonization. As stated earlier, an individual’s cultural background can influence his or her concepts of sexual orientation, gender identification, and gender expression. For example, according to Confucianism, it is the responsibility of the son to bring into the family a daughter-in-law, and it is the daughter’s responsibility to marry into a family and give birth to children, preferably males (Chow & Cheng, 2010). Same-sex attraction is a disgrace to the family, and acting on such attraction clashes with the Confucian notion of filial piety. Transgender individuals, especially those who transition hormonally or surgically, are viewed as posing a greater threat to deeply rooted Confucian family values in a public way; they may be perceived as bringing shame to the family. For some Asian gays, lesbians, and trans people, living a dual life (keeping same-sex attraction privately but fulfilling the obligations of husband, wife, parent) may be more tolerable than coming out publicly (Winter & Webster, 2008). Since culture mediates many of an individual’s identities, counselors working with Asian gay, lesbian, bisexual, or transgender clients should keep in mind that family harmony and filial piety are two important factors that may influence a client’s decision making regarding coming out versus passing with a heterosexual union. Clinical Implications What are the clinical implications of taking privilege into account when addressing gender and its interactions with other aspects of identity? We offer the following suggestions concerning gender and sexual orientation, class, race, and other variables for counselors working with clients from marginalized populations: 1. Develop your awareness of your own racial, gender, and sexual identities, as well as your notions of privilege. This may be the single most important thing a counselor can do when working with marginalized populations, since failing to explore these areas of the self can result in a regressive relationship with clients, in which the clients remains stagnant and unable to fully develop their racial (and other) identities and maintain a limited understanding of power and privilege (Carter & Helms, 1992). 2. Use inclusive language. If you are uncertain about how a client self-identifies, ask the person what his or her preferred pronoun is. If you are uncertain about words a client is using in session, it is important that you attempt to educate yourself before asking your client. For 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. example, saying to a client, “I know what transgender means but I want to know what it means to you” may fall flat if the client senses that you feel uncomfortable or that you are quite unfamiliar with the concept. Educate yourself. Never pretend to understand an issue with which you are unfamiliar, and realize that it is not sufficient to learn about sexism from one female client, to learn about racism from one client of color, and so on. Read books, explore websites, and actively engage sources beyond your clients to learn more about marginalized communities. Admit to your clients when you do not know something and let them know you are open to learning from them, or from outside sources. Ask them what it is like for them to hear you say that you do not know about something they brought up. Help clients to explore aspects of their identities by actively bringing the topics of gender, race, and other identities into the room. Clients are not likely to assume that you are cognizant of these issues unless you explicitly make it known. Keep a list of safe, knowledgeable, and affirming resources to refer clients to (e.g., physicians). Examine your own unearned privileges related to gender, or your own experience of gender oppression. Consider your own gender role and gender identity. How did you come to self-identify the way you do with regard to gender? How did you decide you were a man or woman, for example? Be prepared to refer clients to reliable sources of information regarding their rights related to gender identity and sexual orientation. These rights vary from place to place depending on local laws and ordinances. Include prompts during intake to invite discussion regarding gender or sexual orientation. For example, refer to significant others without using gender-specific pronouns to leave open the possibility of same-sex attraction. During the onset of therapy, open the door for future exploration of aspects of either the client’s identities or your own. Serve as an advocate for trans* individuals when working with others who have power over your trans clients with regard to transition (e.g., health care providers, legal systems). While it is important to be knowledgeable and open regarding patients’ explorations of their gender identities and the evolution of those identities, do not assume that gender is a relevant issue for a given trans* patient. For many trans* patients, exploring gender identity is unnecessary in the therapy room, or is less of a priority than other concerns. Find multiple ways (explicit and subtle) to convey your knowledge, awareness, and attitudes about gender and sexual orientation. For many LGBT people, listening for language and looking for visible cues that a person is not homophobic are key survival strategies, allowing them to stay safe when dealing with health care systems that have often been very discriminatory against LGB and especially transgender people. Critical Incidents Case 1 Jamie is a 31-year-old Korean American female who works in a law firm as a paralegal. She was referred to counseling by her employee assistance program counselor because of job-related stress. During the intake session, she disclosed that she feels devalued at work. Her supervisor is a 48-yearold Caucasian male who sometimes makes her feel uncomfortable with statements that he casually makes about her appearance and work performance. For example, once when she wore a blazer to the office he told her that he prefers that she wear apparel that highlights her feminine features. During her last performance appraisal, she was marked down for speaking up in meetings, which confused her because she feels she usually defers to others in the predominantly male group. She has begun to wonder if she will ever be recognized for her work performance since some of her male counterparts have boasted about raises that she has not been offered, despite the fact that she often produces work that is more accurate than theirs, and she works more quickly than they do. She reported that she has begun to have difficulty sleeping and wonders if she should quit the firm. Through therapy, Jamie started to recognize that her supervisor’s behavior toward her has made her feel marginalized and devalued based on her gender. She began to focus on empowering herself to determine whether or not she would be able to make an impact with her immediate supervisor, and ultimately she decided to speak with her firm’s human resources department to seek a transfer to another supervisor. Case 2 Nikki is a 17-year-old male-to-female transgender client. She was sent to counseling by her parents because of their concern that she has become more withdrawn in the past few months. They noticed that she spends much of her time alone in her room and sometimes does not go to school. They are fearful that she will not be able to graduate and go on to college. Nikki disclosed to the counselor that she began to be bullied by her classmates after she asked a friend to the Sadie Hawkins dance. Since then, her classmates have shunned her and she has not felt safe going to school. She mentioned that she would prefer to be homeschooled or to drop out of school. During the course of therapy, the counselor spent time validating Nikki’s experiences, providing psychoeducation to her parents about the effects of bullying, and advocating with school administrators to provide a safe learning environment for her. Nikki eventually was allowed to pursue independent studies while taking select classes with supportive educators who were able to provide her a safe space on campus so that she could work steadily toward graduating with honors. Discussion Questions 1. What are some of the messages you received while you were growing up about the “places” of men and women in society? What are some of the messages you have received about transgender women? Transgender men? What impacts might these messages about gender have on your clinical work? 2. How might you create space for your clients to explore their gender identities and expressions? 3. How might you convey to a new client during the intake process that you are aware of, open to, and knowledgeable about the existence of genders beyond male and female? 4. How might you convey to a new client early on in your work together that you are aware of and knowledgeable about systemic sexism, heterosexism, homophobia, and transphobia? How might 5. 6. 7. 8. 9. you convey to a client that you are not overtly biased against gender-variant people? Have you ever encountered a situation in which you did not know another person’s gender? If so, what was this like for you? What internal reactions did you have? How did you respond to the individual? What might you do if you are unsure about a patient’s gender? What types of countertransference might you have when working with clients of various genders? How do you respond differently to men? Women? Trans men? Trans women? Gendervariant and genderqueer people? What are some ways in which you could obtain ongoing information to continue to develop your knowledge and awareness of sexism and gender privilege? How might you better incorporate issues of gender and privilege in your clinical work? How do race and ethnicity affect the way you respond to persons of various genders? Notice what feelings come up for you during your interactions with men, women, gender-variant, and trans people of various racial and ethnic backgrounds. References American Psychological Association. (2007). Guidelines for psychological practice with girls and women. American Psychologist, 62, 949–979. Aosved, A. C., & Long, P. J. (2006). Co-occurrence of rape myth acceptance, sexism, racism, homophobia, ageism, classism, and religious intolerance. Sex Roles, 55, 481–492. doi:10.1007/s11199-006-9101-4 Bailey, J. M. (2003). The man who would be queen: The science of gender-bending and transsexualism. Washington, DC: Joseph Henry Press. Banet-Weiser, S. (1999). Hoop dreams: Professional basketball and the politics of race and gender. Journal of Sport and Social Issues, 23, 403–422. Beale, F. (1970). Double jeopardy: To be Black and female. In T. Cade (Ed.), The Black woman: An anthology (pp. 90–100). New York: Signet. Bettcher, T. M. (2007). Evil deceivers and make-believers: On transphobic violence and the politics of illusion. Hypatia, 22(3), 43–65. Blackless, M., Charuvastra, A., Derryck, A., Fausto-Sterling, A., Lauzanne, K., & Lee, E. (2000). How sexually dimorphic are we? Review and synthesis. American Journal of Human Biology, 12, 151–166. Blakemore, J. E., Switzer, J. Y., DiLorio, J. A., & Fairchild, D. L. (1997). Exploring the campus climate for women faculty. In N. V. Benokraitis (Ed.), Subtle sexism: Current practice and prospects for change (pp. 54–71). Thousand Oaks, CA: Sage. Brown, B. (2009). Men in nursing: Re-evaluating masculinities, re-evaluating gender. Contemporary Nurse, 33(2), 120–129. Carr, S. C., & Sloan, T. S. (2003). Poverty and psychology: From global perspective to local practice. New York: Kluwer Academic/Plenum. Carter, R., & Helms, J. (1992). The counseling process as defined by relationship types: A test of Helms’s interactional model. Journal of Multicultural Counseling and Development, 20(4), 181–201. Case, K. A. (2007). Raising male privilege awareness and reducing sexism: An evaluation of diversity courses. Psychology of Women Quarterly, 31, 426–435. Case, K. A., Stewart, B., & Tittsworth, J. (2009). Transgender across the curriculum: A psychology for inclusion. Teaching of Psychology, 36, 117–121. Chow, P. K-Y., & Cheng, S-T. (2010). Shame, internalized heterosexism, lesbian identity, and coming out to others: A comparative study of lesbians in mainland China and Hong Kong. Journal of Counseling Psychology, 57, 92–104. Collins, C., & Yeskel, F. (2005). Economic apartheid in America: A primer on economic inequality and insecurity. New York: New Press. Comas-Díaz, L., & Greene, B. (Eds.). (1994). Women of Color: Integrating ethnic and gender identities in psychotherapy. New York: Guilford Press. Combahee River Collective. (1979). Collective statement. In Z. Eisenstein (Ed.), Capitalist patriarchy and the case for socialist feminism (pp. 362–372). New York: Monthly Review Press. Cooky, C., Wachs, F. L., Messner, M. A., & Dworkin, S. L. (2010). It’s not about the game: Don Imus, race, class, gender, and sexuality in contemporary media. Sociology of Sport Journal, 27, 139–159. Coston, B. M., & Kimmel, M. (2012). Seeing privilege where it isn’t: Marginalized masculinities and the intersectionality of privilege. Journal of Social Issues, 68(1), 97–111. Cunningham, G. B., & Melton, E. N. (2013). The moderating effects of contact with lesbian and gay friends on the relationships among religious fundamentalism, sexism, and sexual prejudice. Journal of Sex Research, 50, 401–408. Dardenne, B., Dumont, M., & Bollier, T. (2007). Insidious dangers of benevolent sexism: Consequences for women’s performance. Journal of Personality and Social Psychology, 93, 764–779. Delphy, C. (2008). Classer, dominer. Qui sont “les autres”? [Classify, dominate. Who are “the others”?]. Paris: La Fabrique. Di Ceglie, D. (2000). Gender identity disorder in young people. Advances in Psychiatric Treatment, 6, 458–466. Dobkin, A. (2000, January 26). Come back, little butches. Outlines. Retrieved from http://www.suba.com/~outlines/alix12600.html Eldridge, J., & Johnson, P. (2011). The relationships between old-fashioned and modern heterosexism to social dominance orientation and structural violence. Journal of Homosexuality, 58, 382–401. Essed, P. (1991). Understanding everyday racism: An interdisciplinary theory. Newbury Park, CA: Sage. Gagne, P., & Tewksbury, R. (1998). Conformity pressures and gender resistance among transgendered individuals. Social Problems, 45, 81–101. Gay, Lesbian & Straight Education Network. (2013). Safe space kit: A guide to supporting lesbian, gay, bisexual, and transgender students in your school. New York: Author. Retrieved from http://glsen.org/sites/default/files/SSK_2013_book.pdf Gianettoni, L., & Roux, P. (2010). Interconnecting race and gender relations: Racism, sexism, and the attribution of sexism to the racialized other. Sex Roles, 62, 374–386. Glick, P., & Fiske, S. T. (2001). An ambivalent alliance: Hostile and benevolent sexism as complementary justifications for gender inequality. American Psychologist, 56, 109–118. Goldstein, J. S. (2001). War and gender: How gender shapes the war system and vice versa. Cambridge: Cambridge University Press. Good, J., & Moss-Racusin, C. (2010). Teaching briefs. Psychology of Women Quarterly, 34, 418–424. Greene, B. (1994). African American women. In L. Comas-Díaz & B. Greene (Eds.), Women of color: Integrating ethnic and gender identities in psychotherapy (pp. 10–29). New York: Guilford Press. Greer, T. M., Brondolo, E., & Brown, P. (2014). Systematic racism moderates effects of provider racial biases on adherence to hypertension treatment for African Americans. Health Psychology, 33(1), 35–42. Hardiman, R., & Jackson, B. (1997). Conceptual foundations for social justice courses. In M. Adams, L. A. Bell, & P. Griffin (Eds.), Teaching for diversity and social justice (pp. 16–29). New York: Routledge. Harley, D. A., Jolivette, K., McCormick, K., & Tice, K. (2002). Race, class, and gender: A constellation of positionalities with implications for counseling. Journal of Multicultural Counseling and Development, 30(4), 216–238. Hepp, U., Kraemer, B., Schnyder, U., Miller, N., & Delsignore, A. (2005). Psychiatric comorbidity in gender identity disorder. Journal of Psychosomatic Research, 58, 259–261. Heywood, L., & Dworkin, S. L. (2003). Built to win: The female athlete as cultural icon. Minneapolis: University of Minnesota Press. hooks, b. (1981). Ain’t I a woman: Black women and feminism. Boston: South End Press. Hull, G. T., Scott, P. B., & Smith, B. (Eds.). (1982). All the women are White, all the Blacks are men, but some of us are brave: Black women’s studies. Old Westbury, NY: Feminist Press. Human Rights Campaign. (2014, June 2). Employment Non-Discrimination Act. Retrieved from http://www.hrc.org/resources/entry/employment-non-discrimination-act Johnson, A. G. (2001). Privilege, power, and difference. Mountain View, CA: Mayfield. Johnsrud, L. K., & DesJarlais, C. D. (1994). Barriers to tenure for women and minorities. Review of Higher Education, 17(4), 335–353. Kim, C. L., Anderson, T. L., Hall, E. L. H., & Willingham, M. M. (2010). Asian and female in the White God’s world: A qualitative exploration of discrimination in Christian academia. Mental Health, Religion & Culture, 13(5), 453–465. King, D. K. (1988). Multiple jeopardy, multiple consciousnesses: The context of African American feminist ideology. Signs: Journal of Women in Culture and Society, 14, 42–72. Klonoff, E. A., & Landrine, H. (1995). The schedule of sexist events: A measure of lifetime and recent sexist discrimination in women’s lives. Psychology of Women Quarterly, 19, 439–470. Landrine, H., Klonoff, E. A., Alcaraz, R., Scott, J., & Wilkins, P. (1995). Multiple variables in discrimination. In B. Lott & D. Maluso (Eds.), The social psychology of interpersonal discrimination (pp. 183–224). New York: Guilford Press. Leaper, C., & Brown, C. S. (2008). Perceived experiences with sexism among adolescent girls. Child Development, 73(3), 685–704. Lloyd, A. W. (2005). Defining the human: Are transgender people strangers to the law? Berkeley Journal of Gender, Law & Justice, 20, 150–195. Looy, H., & Bouma, H. (2005). The nature of gender: Gender identity in persons who are intersexed or transgendered. Journal of Psychology & Theology, 33, 166–178. Lykes, M. B. (1983). Discrimination and coping in the lives of Black women: Analyses of oral history data. Journal of Social Issues, 39(3), 79–100. Macrae, C. N., & Bodenhausen, G. V. (2000). Social cognition: Thinking categorically about others. Annual Review of Psychology, 51, 93–120. Mandlis, L. (2011). Whose crazy investment in sex? Journal of Homosexuality, 58, 219–236. Mankowski, E. S., & Maton, K. I. (2010). A community psychology of men and masculinity: Historical and conceptual review. American Journal of Community Psychology, 45, 73–86. doi:10.1007/s10464-009-9288-y Mar, K. (2010). Female-to-male transgender spectrum people of Asian and Pacific Islander descent. (Doctoral dissertation). Retrieved from Dissertation Abstracts International. (3417144) Martin, K. A. (2009). Normalizing heterosexuality: Mother’s assumptions, talk, and strategies with young children. American Sociological Review, 74, 190–207. Matzner, A. (2004). Sexism. In C. J. Summers (Ed.), glbtq: An encyclopedia of gay, lesbian, bisexual, transgender, and queer culture. Retrieved from http://www.glbtq.com/social-sciences/sexism,2.html McIntosh, P. (1988). White privilege and male privilege: A personal account of coming to see correspondences through work in women’s studies. Wellesley, MA: Wellesley College Center for Research on Women. McIntyre-Mills, J. (2003). Critical system praxis for social and environmental justice: Participatory policy design and governance for a global age. New York: Kluwer Academic/Plenum. McLeod, J. D., & Owens, T. J. (2004). Psychological well-being in the early life course: Variations by socioeconomic status, gender, and race/ethnicity. Social Psychology Quarterly, 67(3), 257–278. McPherson, T. (2000). Who’s got next? Gender, race and the meditation of the WNBA. In T. Boyd & K. Shropshire (Eds.), Basketball Jones: American above the rim (pp. 184–197). New York: New York University Press. Messner, M. A., Duncan, M. C., & Willms, N. (2006). This revolution is not being televised. Contexts, 5(3), 34–38. Mizock, L., & Lewis, T. K. (2008). Trauma in transgender populations: Risk, resilience, and clinical care. Journal of Emotional Abuse, 8, 335–354. Money, J. (1994). The concept of gender identity disorder in childhood and adolescence after 39 years. Journal of Sex & Marital Therapy, 20, 163–177. Moraga, C., & Anzaldúa, G. (1983). This Bridge Called My Back: Writings by Radical Women of Color. New York: Kitchen Table/Women of Color Press. Morrison, E. G. (2010). Transgender as ingroup or outgroup? Lesbian, gay, and bisexual viewers respond to a transgender character in daytime television. Journal of Homosexuality, 57, 650–665. Mujtaba, B. G., & Sims, R. L. (2011). Gender differences in managerial attitudes towards unearned privilege and favoritism in the retail sector. Employee Responsibilities and Rights Journal, 23, 205–217. Nagoshi, J. L., Adams, K. A., Terrell, H. K., Hill, E. D., Brzuzy, S., & Nagoshi, C. T. (2008). Gender differences in correlates of homophobia and transphobia. Sex Roles, 59, 521–531. Pyke, K. D. (1996). Class-based masculinities: The interdependence of gender, class, and interpersonal power. Gender & Society, 10(5), 527–549. Robinson, T. L. (1999). The intersections of dominant discourses across race, gender, and other identities. Theory, Practice, Research, & Counselor Training, 77, 73–78. Sausa, L. A. (2005). Translating research into practice: Trans youth recommendations for improving school systems. Journal of Gay & Lesbian Issues in Education, 3(1), 15–28. Scott-Dixon, K. (2006). Trans/forming feminisms: Trans-feminist voices speak out. Toronto: Sumach Press. Sennott, S., & Smith, T. (2011). Translating the sex and gender continuums in mental health: A transfeminist approach to client and clinician fears. Journal of Gay & Lesbian Mental Health, 15, 218–234. Shepherd, M., Erchull, M. J., Roser, A., Taoubenberger, L., Queen, E. F., & McKee, J. (2011). “I’ll get that for you”: The relationship between benevolent sexism and body self-perceptions. Sex Roles, 64, 1–8. Shields, S. A. (2008). Gender: An intersectionality perspective. Sex Roles, 59, 301–311. Sibley, C. G., & Wilson, M. S. (2004). Differentiating hostile and benevolent sexist attitudes toward positive and genative sexual female subtypes. Sex Roles, 51, 687–696. Smith, L. (2005). Psychotherapy, classism, and the poor: Conspicuous by their absence. American Psychologist, 60(7), 687–696. Sugano, E., Nemoto, T., & Operario, D. (2006). The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS and Behavior, 10, 217–225. Swim, J. K., Aikin, K. J., Hall, W. S., & Hunter, B. A. (1995). Sexism and racism: Old-fashioned and modern prejudices. Journal of Personality and Social Psychology, 68, 199–214. Szymanski, D. M., & Stewart, D. N. (2010). Racism and sexism as correlates of African American women’s psychological distress. Sex Roles, 63, 226–238. doi:10.1007/s11199-010-9788-0 Vaccaro, A. (2010). What lies beneath seemingly positive campus climate results: Institutional sexism, racism, and male hostility toward equity initiatives and liberal bias. Equity & Excellence in Education, 43(2), 202–215. doi:10.1080/10665680903520231 Warner, L. R. (2008). A best practices guide to intersectional approaches in psychological research. Sex Roles, 59, 454–463. Weiss, J. T. (2004). GL vs. BT: The archaeology of biphobia and transphobia within the U.S. gay and lesbian community. Journal of Bisexuality, 3, 25–55. Whitley, B. E., Jr., & Kite, M. E. (2010). The psychology of prejudice and discrimination (2nd ed.). Belmont, CA: Wadsworth. Williams, W. L. (2010, October 11). The “two-spirit” people of indigenous North Americans. Guardian. Retrieved from http://www.theguardian.com/music/2010/oct/11/two-spirit-people-northamerica Winslade, J., Monk, G., & Drewery, W. (1997). Sharpening the critical edge: A social constructionist approach in counselor education. In T. Sexton & B. Griffin (Eds.), Constructivist thinking in counseling practice, research, and training (pp. 228–245). New York: Teacher’s College Press. Winter, S., & Webster, B. (2008). Measuring Hong Kong undergraduate students’ attitudes towards transpeople. Sex Roles, 59, 670–683. Wise, S. (2001). Heterosexism. In M. Davies (Ed.), The Blackwell encyclopaedia of social work (p. 154). Oxford: Blackwell. Yancey, G., & Kim, Y. J. (2008). Racial diversity, gender equality, and SES diversity in Christian congregations: Exploring the connections of racism, sexism, and classism in multiracial and nonmultiracial churches. Journal for the Scientific Study of Religion, 47(1), 103–111. Young, J. (2009). Migration, ethnicity and privilege: An exploration of representation and accountability. Systemic Practice and Action Research, 23, 101–113. Authors’ Note: We would like to thank the editors for including this topic in this publication. We would also like to thank the reviewers, especially Mr. Avy A. Sloknik, for their expertise and feedback. 11 Counseling the Marginalized Melanie M. Domenech Rodríguez Melissa Donovick Kee J. E. Straits Primary Objective ■ To broaden the conceptualization of marginalization to go beyond the limited range of groups that currently receive clinical/research attention Secondary Objectives ■ To present an approach to counseling people from marginalized groups ■ To highlight the particular flexibility needed in the application of mainstream counseling techniques and skills to populations other than the ones they were intended for Our survival depended on an ongoing public awareness of the separation between margin and center and an ongoing private acknowledgment that we were a necessary, vital part of that whole. —bell hooks, Feminist Theory: From Margin to Center (2000, p. xvi) In her introduction to the second edition of Feminist Theory: From Margin to Center, bell hooks (2000) wrote about the frustrating contrast between Black Americans’ marginalized status and their critical importance to the broader U.S. community. By serving as the periphery of a given entity, the margin demarcates the boundary of that entity. Typically, researchers have focused their work on the “center,” the means, the averages. Anything outside the average tends to be considered unusual, aberrant, or abnormal. By taking this approach, scientists have participated in the creation and/or perpetuation of perceptions of what is average and what is not (see various essays in Rothenberg, 2011). In the absence of a complex understanding of what places individuals or groups at the center or the margins, the practice of focusing on a norm can serve unwittingly to mask privilege and create an illusion of marginality. For example, examining the mental health outcomes of ethnic minorities in contrast to those of Whites is commonplace practice. White is average, ethnic minority is not. Rather than examining two groups, comparative research promotes the creation and maintenance of hierarchies wherein one group is better and another worse. Mental health researchers have questioned this practice for some time and have called for research focusing on particular groups without contrasting outcomes with those of Whites or a majority population (Bernal & Scharrón-del Río, 2001; Cauce, Coronado, & Watson, 1998). Conducting noncomparative research with traditionally marginalized persons is a way to challenge the notion that those persons exist only “in relation” to a majority group, and that their outcomes are judged also “in relation.” Yet the practice of comparative research continues. In this chapter we seek to inform ethical practice in order to contribute to the clinical competence of mental health practitioners working with marginalized populations generally. The populations that are marginalized are many, especially when the intersections of multiple identities are considered. For illustrative purposes, we provide a case in point—a discussion of undocumented immigrants in the United States who have intersecting identities (e.g., ethnicity, nationality, socioeconomic status) that place them among the most marginalized. We also present discussion of a case in which the intersection of ethnicity (i.e., multiracial) and age (i.e., adolescent) creates a particular context of marginalization. Defining the Margin Marginalization is defined in this chapter as the social process through which individuals, groups, or communities are excluded from the center (of society) or relegated to the periphery or margins on the basis of some characteristic (e.g., race, ethnicity, class, gender, sexual orientation) or combination of characteristics (i.e., intersecting identities). Marginalization by definition is a dynamic concept that occurs in relation to others. For example, the mentally ill are at the margins of the broader community from which mental health is defined. Migrants are at the margins of the broader community into which they have migrated. The obese are at the margins of a group where there is a mean and standard deviation for weight set within a given geographical boundary. This last example is of interest because it underscores the importance of going beyond a statistical average to define marginalization; social reactions toward obese individuals exemplify the social contracts present in the dynamic of marginalization. Social expectations for behavior and beauty ideals in the United States are such that it is punishing to be overweight but often desirable to be underweight. This knowledge of cultural context is of critical importance in defining and understanding marginalization. A context is created by the people who populate it. So, who defines the center and the margins? Using poverty as an example, marginalization can be defined in relation to broad social standards. By U.S. government accounts, a family of four (two adults and two children under age 18) with an annual family income of $23,050 is considered to be poor (U.S. Department of Health and Human Services [U.S. DHHS], 2012). In the international arena, poverty for an individual has been defined as living with earnings of $1.25 a day (World Bank, 2012). However, it is critical for counselors to understand that such institutional definitions can be quite irrelevant to the daily lives of individuals, who are likely to define themselves in relation to others in a more tangible way (e.g., all of my neighbors have televisions and I don’t, therefore I am poorer). Institutional definitions may be more relevant for their consequences. For example, government assistance programs provide goods and/or services on the bases of federal definitions of poverty. A mother who is enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has access to goods that may affect how she sees herself, her family, and her community. Depending on the context, she may feel marginalized in relation to women who do not qualify for WIC because of higher earnings, but less marginalized than a recent immigrant who is not receiving the needed assistance for fear of deportation. An awareness of the definition of margin (whether self- or other-generated) is critical in a counseling relationship for a variety of reasons: It places the person(s) and the relationship in a broader sociopolitical context, and it focuses on external sources of impact on the person(s). Additionally, knowledge of context can present a first line of intervention in a counseling relationship. Indeed, the “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” published by the American Psychological Association (APA, 2003) state: Psychologists are in a position to provide leadership as agents of prosocial change, advocacy, and social justice, thereby 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. (p. 382) Living at the Margins Living at the margins places people in a unique situation. There are two dynamics that are critical to address in the context of the counseling relationship as it pertains to marginalization: how persons see themselves and how they are perceived by others (e.g., Trimble, 2000). Specifically, does a person see her- or himself as marginalized? Do others see her or him that way? If so, which others? Some have termed marginalization from the viewpoint of the individual subjective marginalization and that from the viewpoint of those around the individual objective marginalization. A therapist attempting to understand whether a client is marginalized will want to understand whether the client is in a position of exclusion, removed from some socially defined center (objective). In addition, does the client want to be a more central participant (subjective)? A third perspective, contextual marginalization, takes into account the lens of the larger social, cultural, and political context. The therapist must be aware of the larger social, cultural, and political lens of the time and where a client may be perceived from this broader perspective. And finally, in a fourth perspective, reflexivity, the therapist evaluates his or her own subjective, objective, and contextual marginalization and considers how that position might influence his or her perspective on and perpetuation of the client’s marginalization. Seeking answers to these questions can help tremendously to inform practice. For example, a middleclass, well-educated, professional African American woman may be perceived by a counselor to be a member of a marginalized group by virtue of her “African American-ness,” yet she may not perceive herself as marginalized at all. How does the counselor proceed? The next steps have serious practice, ethical, and social implications. If the counselor decides the client is marginalized and that the intervention should focus on creating more awareness of the marginalization (i.e., the client is in denial), the counselor could not only be pursuing an unfruitful course but could also be engaging in potentially unethical behavior (e.g., APA, 2010, 2.01, “Boundaries of Competence”). This example serves as a reminder that people are members of many social groups and that the same person may be at the margin of one social group and concurrently be in the “center” of another group. The intersection of identities leads to a separate set of questions: Which margins? And how relevant are they to the people who would be categorized? The same African American professional may feel more marginalized in a context where the majority of African Americans have a low level of education (and may perceive her as “selling out” or “acting White”; Murray, Neal-Barnett, Demmings, & Stadulis, 2012; Neal-Barnett, 2001; Ogbu, 1991) than in a professional setting where her peers have the same level of education and income but few are African American. The predominant stereotypes highlight certain group characteristics while rendering other segments of the population invisible (Jones, 2003). In the latter situation, the professional may feel more marginalized by her educational status than by her race. An awareness of the intersection of identities as well as self- and other-perception of relative placement in (or out of) marginalized groups is critical in a counseling relationship. Dimensions of Marginalization The most commonly identified dimension of potential marginalization is sociocultural status: age, gender, sexual orientation, race/ethnicity, nationality, class, religion, and so on. Outward manifestations may include skin color, language, family structure, mannerisms, and clothing, although sociocultural status is not always visible. For example, an American Indian man with strong indigenous phenotype who is gay is a visible ethnic minority with a sexual orientation that may or may not be visible. There are many other dimensions along which we may judge our fellow humans in relation to the average or acceptable norm. Low economic status, another dimension of marginalization, is sometimes evident; for example, a person may be on welfare, may be homeless, or may have limited food access. Other dimensions include educational/occupational status (e.g., dropout, unemployed), legal status (criminal history, legality of work/living, incarceration), developmental status (youth/elder, intellectual disability, helplessness/victimization), geographic location (rural, reservation, remote), physical and mental health status (disability, mental illness, chronic or infectious disease), community status (relative to community norms, e.g., music, food, hobbies, hair, language), and social justice status (experiences of discrimination, oppression). The intersection of identities must be understood as cumulative and integrated (Lowe & Mascher, 2001), such that individuals are increasingly marginalized the further away they are from the valued “center” and the more dimensions along which they are marginalized. Figure 11.1 depicts this relationship. Persons at the center or mainstream of a particular social group have the utmost privilege. With every move away from the center, a layer of privilege is removed, and persons who are at the very edges of the margin (which becomes thinner or less populated at the edges) may be marginalized by people who are themselves marginalized by others. Power, Privilege, and Marginalization Marginalization—or the social, political, geographical, psychological placement away from a center —places persons away from sources of privilege. If enfolded within the embrace of inclusion, individuals gain access to the necessities of life, such as material, instrumental, social, emotional, financial, and safety resources. One aspect of being at the center and exercising or being the recipients of power is that individuals are often unaware of the power in which they reside. For those relegated to the fringes, the absence of power and privilege makes both more readily identifiable. The multiple dimensions in which an individual experiences marginalization are likely to vary depending on the depth (e.g., lack of privilege results in loss of essential resources) and breadth (i.e., the cumulative effect of lacking privilege in multiple areas) of the marginalization experienced. In a counseling relationship, a thorough understanding of both depth and breadth of marginalization is essential. Figure 11.1 Cumulative and Integrated Marginalization Risk, Resilience, and Marginalization Marginalization is associated with negative health outcomes, including lower life expectancy, increased child mortality, and increased rates of diabetes, cancer, obesity, and heart disease (e.g., Christopher & Simpson, 2014; Doubeni et al., 2012; Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013). Marginalization is also associated with negative mental health outcomes (e.g., Araújo & Borrell, 2006; Seng, Lopez, Sperlich, Hamama, & Meldrum, 2012). Studies of marginalized populations, including LGBTQ and Native American groups, have found higher rates of depression and suicide among these groups. Other marginalized groups, such as prison populations, have been found to experience high rates of substance abuse, past victimization (e.g., child abuse), learning disorders, and trauma-related mental health issues. Racial/ethnic minorities who have anomic ethnic identities (versus strong ethnic or bicultural identities) are at higher risk for substance abuse, depression, and anxiety. Having multiple marginal social identities increases an individual’s risk for negative physical and mental health outcomes. Current evidence-based mental health interventions may neglect this complex dynamic. Clinicians must be aware of the specific risk factors associated with clients’ social contexts in order to assess and treat clients appropriately. At the same time, therapists cannot rely on assumptions or negative expectations regarding clients’ perceived marginalized status. The literature on resilience demonstrates that moderate amounts of adversity may benefit our mental health in the long run if we can also access appropriate supports to overcome adversity. Hall, Stevens, and Meleis (1994) summarize some of the strengths that may be associated with a marginalized position, including the following: greater awareness of boundaries and their ability to protect, cultural and personal uniqueness, access to resources through collective awareness and organization, access to and control of protective information, survival skills and insights gained through forced reflection regarding one’s relative position to the center, and exposure to experiences that may foster greater empathy. Several investigations have pointed to the potential for individuals to gain strength by reframing personal marginalization in the context of collective action toward social justice. Often, being positioned at the margin provides individuals with license for creativity and innovation, stimulating talents that may be less likely to grow in those who conform to social norms. A broader position between identities or social worlds can provide greater reflexivity, mental and social flexibility, and multiple perspectives from which to interpret the world. Marginalized populations may foster resilient families and communities through strong familial and interpersonal ties, spirituality, cultural knowledge and traditions, shared language and values, and mutual affirmation/validation. The case discussion in the next section provides a framework for therapists to use in approaching the counseling relationship with clients who are marginalized. This framework requires that the counselor acquire important knowledge about the individual client and the group or groups to which the client belongs or with which he or she identifies. The counselor must also acquire self-knowledge and knowledge of the available tools for engaging effectively in the counseling relationship with a marginalized client. The following general questions can guide the counselor’s knowledge acquisition about the client: (1) Who is the individual and how does he or she identify? How would the individual be identified by others? (2) Which dimensions of marginality might the individual perceive for him- or herself, and which appear to be most prominent? (3) Of the groups and/or dimensions the individual identifies as most salient, who defines them? (4) What is known about the group? (5) What are the specific challenges to counseling and/or the counseling relationship? What are other relevant challenges? Further questions can guide the counselor’s acquisition of knowledge about him- or herself: (1) How do I identify? How do others identify me? (2) To which dimensions of marginality might I belong or not? What privilege do I hold or not hold based on these dimensions? (3) How do my identification and levels of privilege influence my values and beliefs about the group(s) salient to my client? How do my skills and knowledge potentially apply (or not) to this group? Finally, to acquire the tools needed to take part effectively in the counseling relationship, the counselor must engage with institutions and individuals outside the agencies in which the counselor operates. Case in Point: Undocumented Immigrants How is the group defined? Who defines it? Undocumented immigrants are citizens of other countries who have entered the United States without following official routes and/or procedures for entrance that would render them documented, or traceable, by the U.S. government. Some undocumented immigrants may have entered the country with the proper documentation for time-limited visits and remained in the United States past the allotted time; others may have received visas for specific purposes but are engaged in activities not permitted by those visas (e.g., working full-time after being admitted to the country on a student visa). Various kinds of visas are available; they generally fall into one of two categories—nonimmigrant (e.g., visitors, students) and immigrant (e.g., lawful permanent residency, or “green cards”). Other terms used to describe undocumented immigrants are illegal aliens (or simply illegals) and migrant workers (or migrants). Exceedingly pejorative terms such as wetback also continue to be used by important political and media figures (e.g., Carr, 2003), and open displays of hostility toward undocumented immigrants are not uncommon at the community level (such as a bumper sticker recently seen in Oregon that read “This is Oregon, not Mexico”). Undocumented status may be temporary, as for immigrants who are in the process of obtaining the necessary documents to remain in the United States legally, or it may be of a more permanent nature, as is the case for many lowwage and/or seasonal immigrant workers who would not qualify for visas (called “inadmissibles” by the U.S. Citizenship and Immigration Services, 2006). In this particular case the group— undocumented immigrants—is defined by the U.S. government. What is known about the group? In 2010 it was estimated that there were approximately 10.8 million undocumented immigrants living in the United States—the same number as estimated for 2009, but lower than the 11.8 million estimated in 2007. The decline of 1 million in the undocumented population from the peak of 11.8 million in 2007 was likely due to the economic recession in the United States (Hoefer, Rytina, & Baker, 2011). The U.S. Department of Homeland Security (U.S. DHS) reported that in 2010, 62% of the undocumented population was of Mexican origin (Hoefer et al., 2011). The United States experienced a 27% growth in the population of undocumented immigrants during 2007–2010. Undocumented adults and children constitute about 4% of the U.S. population (Passel & Taylor, 2010). Many undocumented immigrants, especially those of Mexican origin, migrate to the United States looking for work (Berk, Schur, Chavez, & Frankel, 2000; Passel, Capps, & Fix, 2004), and, as workers, they contribute to social programs such as Social Security (Porter, 2005, 2006). Of the many undocumented immigrants who are in the United States, a sizable proportion are identified by the U.S. government for deportation. Over the decade ending in 2009, the immigrant parents of more than 100,000 U.S. citizen children were deported (U.S. DHS, 2009). In 2010, 516,992 undocumented immigrants were identified by the U.S. Border Patrol and processed (Hoefer et al., 2011). While these persons hailed from many countries around the globe, the overwhelming majority were of Mexican origin (83%) and were identified for processing in the Southwest (86.6%). The vast majority of the persons identified by the Border Patrol chose to return to their countries of origin voluntarily. The statistics on national origin of those identified for deportation (i.e., 83% from Mexico) are striking in comparison to the relative number of immigrants from Mexico (i.e., 33%) and the total of 55% from Latin America (Grieco & Trevelyan, 2010). Awareness of these data is important for counselors seeking to understand the unique context of Mexican immigrants in comparison to immigrants from other countries. The visibility of undocumented immigrants varies greatly. Geographically, undocumented immigrants are unevenly distributed in the United States, with 2.6 million estimated to reside in California in 2010 (Hoefer et al., 2011). According to the same report, in that year 1.8 million undocumented immigrants were estimated to reside in Texas, and 760,000 in Florida. The majority of the undocumented population resided in seven states: California, Texas, New York, Florida, Illinois, New Jersey, and Arizona. Another report suggests that there has been significant dispersion of the undocumented population in the past decade; as of 2009, sizable numbers of undocumented immigrants were living in the states listed above plus North Carolina, Georgia, and other southeastern states (Passel & Cohn, 2009). Although specific statistics are not available concerning the workforce participation of undocumented immigrants, according to the U.S. Department of Labor (2012) 15.9% of the nation’s labor force in 2011 was foreign-born. A 2011 study by the National Center for Children in Poverty found that 75.9% of children of recent immigrants had a parent who was employed (Wight, Thampi, & Chau, 2011). Such high employment rates, however, do not protect immigrants from living in poverty (Wight et al., 2011). What are the specific challenges to counseling and the counseling relationship? The first major challenge is access to care. Undocumented immigrants are likely to face tremendous obstacles in obtaining publicly funded health care services, both because of policies creating barriers to access (Kullgren, 2003) and because of the fear of being identified as undocumented (Berk & Schur, 2001). Indeed, research shows that undocumented immigrants tend to underutilize health services, especially preventive services (Chavez, Cornelius, & Jones, 1986). Families may find themselves in a very challenging position when seeking services is imperative, as in the case of children with chronic conditions (Rehm, 2003). Further complicating this matter, undocumented immigrants are significantly less likely than legal residents and native-born Americans to have health insurance, or to have health care providers they see consistently (K. J. Marshall, Urrutia-Rojas, Mas, & Coggin, 2005; Prentice, Pebley, & Sastry, 2005). In terms of mental health, research has found a significant relationship between undocumented status and poor mental health outcomes for different ethnic groups (Eisenman, Gelberg, Liu, & Shapiro, 2003; Law, Hutton, & Chan, 2003; G. N. Marshall, Schell, Elliott, Berthold, & Chun, 2005). These findings are often associated with prior exposure to violence, and, indeed, mental health outcomes have been found to vary across national origins (Salgado de Snyder, Cervantes, & Padilla, 1990). The children of immigrants are also at high risk of exposure to violence. Jaycox and colleagues (2002) found that 32% and 16% of the children in their sample (ages 8–15) reported posttraumatic stress disorder and depressive symptoms, respectively, in the clinical range. These numbers are substantially higher than would be expected for a national sample. It is important also to understand that there are areas of health and mental health wherein immigrants experience great resilience. For example, first-generation Latino teens have been found to engage in fewer risky sexual behaviors than their nonimmigrant counterparts (Guarini, Marks, Patton, & García Coll, 2011). A better health outcome for immigrants than for those in later generations has been termed the immigrant paradox, a phenomenon that may or may not operate depending on context. For example, in one study, first-generation immigrants had the lowest rates of asthma in neighborhoods with a high density of immigrants but the highest rates of asthma in low-density neighborhoods. One context (high density of immigrants) provided protection, while the other (low density) augmented risk (Cagney, Browning, & Wallace, 2007). Immigrants also have to deal with the negative attitudes of others toward them (Hovey, Rojas, Kain, & Magaña, 2000) and the negative climate that these attitudes create. Undocumented immigrants who have experienced discrimination or negative social climate may find it difficult to disclose information to or form a productive alliance with a counselor. Negative attitudes toward immigrants have been documented in the United States and abroad. For example, Suro (2005) found negative attitudes toward immigrants in the United States across ethnic groups, with the exception of Latinos, who had relatively positive attitudes toward migration. Internationally, Fetzer (2000) studied antiimmigration sentiment in the United States, France, and Germany, testing the economic self-interest and cultural marginality theories. He found weak support for the economic self-interest theory, which suggests that anti-immigration attitudes are directly tied to material self-interest. In contrast, he found strong evidence in all three countries for the cultural marginality theory, which posits that experiencing marginality engenders sympathy or support for members of other marginalized groups, even outside one’s own. Fetzer found that when other factors were controlled for, belonging to an ethnic, racial, or religious minority group decreased anti-immigration sentiment, as did being female and being foreign-born. Similar research has found support for anti-immigration policies as tied to ingroup and outgroup biases (Lee & Ottati, 2002). These negative attitudes toward immigration policy and immigrants are a particular challenge because the variables implicated in creating change in attitudes would require targeting at a broad social level. Another specific challenge for undocumented immigrants lies in the intersections of social and individual issues. For example, one study found that husbands of undocumented women in domestic violence situations used the women’s undocumented status to control their behavior (Dutton, Orloff, & Hass, 2000), highlighting the intersection of gender and immigration status. Another author suggests that the intergenerational transmission of violence may begin for children and adolescents with the violence of the border crossing (Solis, 2003), potentially signaling a relationship between susceptibility to aggression and undocumented status. Through participation in an e-mail discussion group that includes the first author of this chapter, a clinician asked for recommendations regarding the case of a Latina who was lesbian and partnered. The woman was undocumented, and her family would not allow her to move out of the family house to cohabit with her partner; they threatened to report her to immigration authorities if she chose to move out. In situations such as these, individuals’ struggles are affected by broader social issues of power and legitimacy. Overall, the literature shows that undocumented immigrants are vulnerable—both socially and instrumentally. Contextual information is critical to the counselor’s approach to the counseling relationship. For example, a counselor who detects reluctance to disclose on the part of an undocumented immigrant client could make internal attributions about this behavior (e.g., the client doesn’t like me, the client is being excessively guarded), or the counselor could understand the behavior in context and attempt to create an environment that maximizes the possibility of establishing a positive, productive relationship. The counselor must consume information about the client’s context with care to avoid creating stereotypes or “glosses” (Trimble & Dickson, 2005). The counselor’s aim should be to gain a sense of the complexity of the client’s group’s circumstances, which may provide a good indication of areas of assessment and potential intervention. However, information is only one important dimension of the counseling relationship. In addition to the information gathered, clinician variables are of critical importance. The Purpose of Counseling Before we move on to discuss what a counselor should do in a counseling relationship with a marginalized person, we want to focus briefly on the purpose of the counseling relationship. The American Counseling Association (ACA, 1997) defines counseling as “the application of mental health, psychological, or human development principles, through cognitive, affective, behavioral, or systematic intervention strategies, that address wellness, personal growth, or career development, as well as pathology” (p. 1). Similarly, Pipes and Davenport (1999) provide the following insight: Presumably one of the characteristics of all human cultures is that within the culture, there are certain people, at certain times, who exhibit and/or report an undesirable (to them) state of affairs in terms of their perceptions, thoughts, behavior, or emotions, or some combination thereof. These may or may not be undesirable to others. Presumably, it is also a characteristic of each culture that certain processes, procedures, and structures are both made available to and at times imposed upon the individuals in order to deal with these perceived problems.... one such process... [is] psychotherapy or counseling. (p. 4) Both of these definitions include the notion of counseling as a relationship that serves to effect change in the life of the person receiving the counseling services. What is of interest is that the definitions do not specify type, location, or duration of intervention, or point of intervention. Indeed ACA’s definition does not even specify a client per se, lending flexibility to the application and definition of counseling. This flexibility is consistent with the APA (2003) guidelines, which issue a call to action at the individual as well as social level. We offer the following discussion of counselor considerations in the context of a call to flexible yet life-improving interventions. Counselor Considerations The APA (2003) “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” provide an excellent frame from which counselors can inform their practice of counseling the marginalized. We urge counselors who work with marginalized persons to read and/or review these guidelines in their entirety. For the purposes of this section, we discuss in detail guideline 1, “psychologists as cultural beings,” and guideline 5, “application of culturally appropriate skills in practice.” We also address ethical considerations, especially in light of the difficulty of integrating theoretical/applied knowledge for use with populations for which it was not originally designed. The first APA (2003) guideline states, “Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves” (p. 382). In the context of the case of undocumented immigrants, the counselor’s personal beliefs and values about immigration will likely affect the counseling relationship. In addition to understanding perceptions of “the other” in a cultural frame, it is important for the counselor to examine him- or herself in a cultural context. Specifically, to meet this first guideline the counselor must have personal awareness of his or her own privilege (see Rothenberg, 2011) as well as the cultural lenses of his or her professional knowledge (see Pfaffenberger, 2006). Rothenberg (2011) writes: “White privilege is the other side of racism. Unless we name it, we are in danger of wallowing in guilt or moral outrage with no idea of how to move beyond them. It is often easier to deplore racism and its effects than to take responsibility for the privileges some of us receive as a result of it” (p. 1). Counselors must turn attention to themselves as cultural beings and make the invisible (e.g., privilege derived from racism) visible. This is not only responsible professional action but also an ethical mandate (e.g., ACA, 2014, C.2.a., “Boundaries of Competence”). Couching personal exploration as an examination of privilege might be unpalatable to some counselors (as it is to some of the students in our own undergraduate and graduate diversity-focused courses). A counselor may consider using his or her own counseling skills in this process of exploration. Where a counselor feels attacked or negatively engaged by the language of “White privilege,” reframing might be a powerful ally. Exploring White privilege can also be understood as exploring and challenging cultural assumptions or cultural programming. The word privilege may sound as though it connotes something intentional, unearned, an accusation to be rebutted. Cultural programming is unintentional, covert, something to be challenged by counselors who hope to achieve further professional and personal growth. Knowing the language of White privilege is important also because many writings have been published using these key words, some of which are difficult to find without explicit searches employing these words. The fifth APA (2003) guideline states, “Psychologists are encouraged to apply culturally appropriate skills in clinical and other applied psychological practices” (p. 390). The application of appropriate skills requires that the counselor be mindful of how previously learned skills are implemented and does not necessarily require the development of an entirely new repertoire of skills (APA, 2003). For example, during parent training, the lead author of this chapter works with immigrant Latino/a families in teaching skills building, problem solving, positive involvement, effective discipline, and effective monitoring/supervision. The concepts remain the same (especially since there is crosscultural evidence of their utility), but the presentation of the skills and the counseling relationship with these parents is noticeably different from what it would be with White, middle-class parents. Indeed, there is accumulating evidence that empirically supported approaches to treatment work across ethnic groups (for an excellent review, see Miranda et al., 2005), and that they work optimally if cultural adaptations are made to fit clients’ cultures and contexts (Benish, Quintana, & Wampold, 2011; Bernal & Domenech Rodríguez, 2012; Smith, Domenech Rodríguez, & Bernal, 2011). Finally, counselors must have intimate knowledge of the codes of ethics of the counseling profession (e.g., ACA, 2014; APA, 2003). When applying interventions flexibly and appropriately to various cultural contexts, counselors may find themselves having to examine their ethics codes carefully, with a special focus on understanding the rationale behind each element of the codes. For example, the American Psychological Association (2003) code of ethics presents mandates for ethical delivery of psychological services but does not present a definition of therapy. Counselors who find themselves in unusual settings may be hard-pressed to understand the scope of what they need to do in order to engage in ethical delivery of services. It is likely that they will gain a full understanding only after beginning service delivery and working through potential problems as they arise. Resources are available to help counselors understand ethics codes beyond the written mandates (e.g., Fisher, 2003; Ford, 2006), and specific resources are available concerning the application of ethics to work in culturally diverse communities (e.g., Trimble & Fisher, 2006). Conclusions Our focus in this chapter has been on counseling the marginalized. There is no single clear course of action for counselors working with marginalized populations. We recommend that counselors develop familiarity with theories of multicultural counseling (see Fuertes & Gretchen, 2001). Because “the marginalized” can be broadly defined, it is important for a counselor to have a clear definition (by self and others) of the group or groups involved, have knowledge about the group’s context, and understand the areas of challenge, especially related to the counseling relationship. Knowledge alone does not suffice. We emphasize that it is the approach to the counseling relationship that is most important to successful outcomes. The challenge for counselors is to be flexible and to increase their self-awareness, especially as it pertains to privilege (or cultural programming). In counseling the marginalized, counselors must not only practice their trade but also apply the knowledge they have received in settings for which it was not conceptualized (e.g., a cognitive-behavioral therapist who now runs groups with undocumented immigrants can use the technical skills associated with CBT but also needs to do many other things in order to have truly fruitful counseling relationships). Overall, the challenges are many, but they are easily surpassed by the rewards. A counselor who works with marginalized persons is indeed heeding the call to action for social justice (APA, 2003; Sue, 2005) by providing services to groups that are often underserved (U.S. DHHS, 2001). Critical Incident Sean, a 15-year-old multiracial (Native American, White, and Black) male, initiated services of his own accord to manage symptoms of depression, including suicidal ideation. Sean was academically advanced for his age and excelled as an artist and skateboarder. He prided himself most on his academic success, and he aimed to graduate from high school early and attend college. Sean had poor self-esteem and lacked a strong cultural identity. In the state where Sean resided, he could consent to treatment. He did so, stating that his father, who was his legal guardian, would not consent. The counselor developed a strong rapport with Sean. Sean was raised in a single-parent household. Sean’s father had a severe and chronic mental illness for which he received sporadic treatment, and he was currently stable. According to Sean, during his childhood he was placed in state custody for a year due to his father’s alcoholism and physical abuse toward him. Sean also spent a year living in a homeless shelter with his father. During this time, he was required to attend therapy, which he found unhelpful to his family. Sean’s father believed it was yet another example of the “White man trying to destroy the Indian.” Sean’s siblings were all incarcerated. His grandparents experienced relocation, boarding school abuse, and slavery. Sean’s immediate family was relatively isolated because of his father’s outrageous behavior. Sean reported that his father would often denigrate him. One day, Sean was limping when he arrived for a therapy session. When asked what had happened, he stated that his father had been angry with him for not doing well in his Native language class and had taken a belt to his legs and then shoved him through the screen door, breaking it. Sean further reported that his father’s fits of rage were a rare occurrence (every few months) and Sean had learned to manage them by accepting the abuse. The counselor reminded Sean of his duty to report child abuse or neglect. Sean then attempted to downplay the story, reporting that he had fallen through the door himself. Sean asked that the counselor not report the incident because he feared being taken away from his father again; Sean felt that his father depended on his care. He was also concerned that any type of investigation would disrupt his schooling and cause his grades to suffer. The counselor was conflicted about whether to report. He considered the following points: (a) client safety, including assessment of the severity, frequency, and impact of the abuse and the vulnerability of the client; (b) obligation to report given the state laws around child abuse and neglect; (c) psychological benefit versus harm to the client as a consequence of reporting, including betraying the client’s trust, potential family fragmentation, and loss of stability, predictability, and family social supports in the client’s environment; (d) client level of independence and maturity; and (e) concern regarding the client, family, and community perceptions of social services as a systemic enactment of violence on families. Sean’s family had experienced generations of marginalization and victimization enacted through systems meant to uphold social policies. The counselor consulted with several colleagues. In addition to emphasizing the legal and ethical obligations of the profession, one colleague asked, “What if something more violent or lethal were to happen to this child and you did not report? Would you be able to live with that?” The counselor decided that he could not. He talked with Sean about the need to report, encouraging Sean to report with him, but ultimately the counselor made the call. The counselor had plans to work closely with the family if the case was investigated, to ensure that the caseworker considered the family’s context and culture. He also hoped to help the adolescent develop a safety plan and build broader networks of social and cultural support while also continuing to support him in his academic strengths. However, after the counselor reported the abuse, Sean did not return to counseling. Discussion In this case, the reported child abuse dictated a course of action. However, as the counselor was attuned to the cultural context of the marginalized client, the course of action was complex. The primary ethical dilemma was between APA ethical standard 3.04, “Avoiding Harm,” and state legal standards that mandated the reporting of child abuse. Given the client’s cultural context and previous history with social services, the counselor was aware that reporting the abuse might cause harm and a disruption in the client’s family and school functioning. Within the therapeutic relationship, reporting the child abuse might be perceived as rupturing therapeutic trust and breaking confidentiality. The counselor made a judgment to report the child abuse and abide by state legal standards. This decision was guided by the following APA principles: beneficence and nonmaleficence, justice, and respect for people’s rights and dignity. The counselor intended to ensure the client’s welfare and minimize future harm by reporting the child abuse while also promoting social justice. Discussion Questions 1. What are the different contexts of marginalization that may have been at play in this situation? Do we know anything about the therapist’s understanding or experiences of marginalization that may have influenced his perspective and choice to report (what would yours be)? 2. How well did the therapist behave in accordance with: (a) the legal standards, (b) the ethical standards of conduct in psychology, (c) the ethical standards of conduct with racial/ethnic minorities and marginalized groups, and (d) personal ethics? Where do the standards conflict or align in regard to this case? 3. How do you think the therapist’s choice to report affected the client’s marginalization and other issues for which he sought help in counseling? How do you think the client might have been affected if the therapist had not reported? 4. What possible alternative courses of action could the therapist have taken? How appropriate or inappropriate would each of these alternatives have been? References American Counseling Association. (1997). Definition of professional counseling. Retrieved from http://www.counseling.org/publications American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author. Retrieved from http://www.counseling.org/Resources/aca-code-of-ethics.pdf American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402. American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Washington, DC: Author. Retrieved from http://www.apa.org/ethics/code/principles.pdf Araújo, B. Y., & Borrell, L. N. (2006). Understanding the link between discrimination, mental health outcomes, and life chances among Latinos. Hispanic Journal of Behavioral Sciences, 28, 245–266. doi:10.1177/0739986305285825 Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58, 279–289. Berk, M. L., & Schur, C. L. (2001). The effect of fear on access to care among undocumented Latino immigrants. Journal of Immigrant Health, 3, 151–156. Berk, M. L., Schur, C. L., Chavez, L. R., & Frankel, M. (2000). Health care use among undocumented Latino immigrants. Health Affairs, 19(4), 51–64. Bernal, G., & Domenech Rodríguez, M. M. (Eds.). (2012). Cultural adaptations: Tools for evidencebased practice with diverse populations. Washington, DC: American Psychological Association. doi:10.1037/13752-000 Bernal, G., & Scharrón-del Río, M. R. (2001). Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research. Cultural Diversity & Ethnic Minority Psychology, 7, 328–342. Cagney, K. A., Browning, C. B., & Wallace, D. M. (2007). The Latino paradox in neighborhood context: The case of asthma and other respiratory conditions. American Journal of Public Health, 97, 919–925. Carr, D. (2003, February 10). Gaffes on Hispanics, from 2 well-known mouths. New York Times, p. C9. Cauce, A. M., Coronado, N., & Watson, J. (1998). Conceptual, methodological, and statistical issues in culturally competent research. In M. Hernandez & M. R. Isaacs (Eds.), Promoting cultural competence in children’s mental health services: Systems of care for children’s mental health (pp. 305–329). Baltimore: Paul H. Brookes. Chavez, L. R., Cornelius, W. A., & Jones, O. W. (1986). Utilization of health services by Mexican immigrant women in San Diego. Women & Health, 11(2), 3–20. Christopher, G., & Simpson, P. (2014). Improving birth outcomes requires closing the racial gap. American Journal of Public Health, 104(S1), S10–S12. Doubeni, C. A., Schootman, M., Major, J. M., Torres Stone, R. A., Laiyemo, A. O., Park, Y.,... Schatzkin, A. (2012). Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health–AARP Diet and Health Study. American Journal of Public Health, 102, 680–688. Dutton, M. A., Orloff, L. E., & Hass, G. A. (2000). Characteristics of help-seeking behaviors, resources and service needs of battered immigrant Latinas: Legal and policy implications. Georgetown Journal on Poverty Law and Policy, 7, 245–305. Eisenman, D. P., Gelberg, L., Liu, H., & Shapiro, M. F. (2003). Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. Journal of the American Medical Association, 290, 627–634. Fetzer, J. S. (2000). Economic self-interest or cultural marginality? Anti-immigration sentiment and nativist political movements in France, Germany and the USA. Journal of Ethnic and Migration Studies, 26, 5–23. Fisher, C. B. (2003). Decoding the ethics code: A practical guide for psychologists. Thousand Oaks, CA: Sage. Ford, G. G. (2006). Ethical reasoning for mental health professionals. Thousand Oaks, CA: Sage. Fredriksen-Goldsen, K. P., Kim, H.-J., Barkan, S. E., Muraco, A., & Hoy-Ellis, C. P. (2013). Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. American Journal of Public Health, 103, 1802–1809. Fuertes, J. N., & Gretchen, D. (2001). Emerging theories of multicultural counseling. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 509–541). Thousand Oaks, CA: Sage. Grieco, E. M., & Trevelyan, E. N. (2010, October). Place of birth of the foreign-born population: 2009 (American Community Survey Brief ACSBR/09-15). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/2010/pubs/acsbr09-15.pdf Guarini, T. E., Marks, A. K., Patton, F., & García Coll, C. (2011). The immigrant paradox in sexual risk behavior among Latino adolescents: Impact of immigrant generation and gender. Applied Developmental Science, 15, 201–209. Hall, J. M., Stevens, P. E., & Meleis, A. I. (1994). Marginalization: A guiding concept for valuing diversity in nursing knowledge development. Advances in Nursing Science, 16(4), 23–41. Hoefer, M., Rytina, N., & Baker, B. C. (2011, February). Estimates of the unauthorized immigrant population residing in the United States: January 2010 (Population estimates). Washington, DC: U.S. Department of Homeland Security, Office of Immigration Statistics. Retrieved from http://www.dhs.gov/xlibrary/assets/statistics/publications/ois_ill_pe_2010.pdf hooks, b. (2000). Feminist theory: From margin to center (2nd ed.). Cambridge, MA: South End Press. Hovey, J. D., Rojas, R. S., Kain, C., & Magaña, C. (2000). Proposition 187 reexamined: Attitudes toward immigration among California voters. Current Psychology: Developmental, Learning, Personality, Social, 19, 159–174. Jaycox, L. H., Stein, B. D., Kataoka, S. H., Wong, M., Fink, A., Escuedero, P., & Zaragosa, C. (2002). Violence exposure, posttraumatic stress disorder, and depressive symptoms among recent immigrant schoolchildren. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 1104–1110. Jones, S. J. (2003). Complex subjectivities: Class, ethnicity, and race in women’s narratives of upward mobility. Journal of Social Issues, 59, 803–820. Kullgren, J. T. (2003). Restrictions on undocumented immigrants’ access to health services: The public health implications of welfare reform. American Journal of Public Health, 93, 1630–1633. Law, S., Hutton, M., & Chan, D. (2003). Clinical, social, and service use characteristics of Fuzhounese undocumented immigrant patients. Psychiatric Services, 54, 1034–1037. Lee, Y., & Ottati, V. (2002). Attitudes toward U.S. immigration policy: The role of ingroup–outgroup bias, economic concern, and obedience to law. Journal of Social Psychology, 142, 617–634. Lowe, S. M., & Mascher, J. (2001). The role of sexual orientation in multicultural counseling: Integrating bodies of knowledge. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 755–778). Thousand Oaks, CA: Sage. Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M., & Chun, C. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. Journal of the American Medical Association, 294, 571–579. Marshall, K. J., Urrutia-Rojas, X., Mas, F. S., & Coggin, C. (2005). Health status and access to health care of documented and undocumented immigrant Latino women. Health Care for Women International, 26, 916–936. Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W.-C., & LaFromboise, T. (2005). State of the science on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology, 1, 113–142. Murray, M. S., Neal-Barnett, A. M., Demmings, J. L., & Stadulis, R. E. (2012). The acting White accusation, racial identity, and anxiety in African American adolescents. Journal of Anxiety Disorders, 26, 526–531. Neal-Barnett, A. M. (2001). Being Black: New thoughts on the old phenomenon of acting White. In A. M. Neal-Barnett, J. M. Contreras, & K. A. Kerns (Eds.), Forging links: African American children clinical developmental perspectives (pp. 75–88). Westport, CT: Greenwood. Ogbu, J. U. (1991). Minority coping responses and school experience. Journal of Psychohistory, 18, 433–456. Passel, J. S., Capps, R., & Fix, M. (2004, January 12). Undocumented immigrants: Facts and figures (Urban Institute fact sheet). Retrieved from http://www.urban.org/UploadedPDF/1000587_undoc_immigrants_facts.pdf Passel, J. S., & Cohn, D. (2009). A portrait of unauthorized immigrants in the United States. Washington, DC: Pew Hispanic Center. Retrieved from http://pewresearch.org/pubs/1190/portraitunathorized-immigrants-states Passel, J. S., & Taylor, P. (2010). Unauthorized immigrants and their U.S.-born children. Washington, DC: Pew Hispanic Center. Retrieved from http://pewhispanic.org/files/reports/125.pdf Pfaffenberger, A. H. (2006). Critical issues in therapy outcome research. Journal of Humanistic Psychology, 46, 336–351. Pipes, R. B., & Davenport, D. S. (1999). Introduction to psychotherapy: Common clinical wisdom (2nd ed.). Boston: Allyn & Bacon. Porter, E. (2005, April 5). Illegal immigrants are bolstering Social Security with billions. New York Times, p. A1. Porter, E. (2006, June 19). Here illegally, working hard, and paying taxes. New York Times, p. A1. Prentice, J. C., Pebley, A. R., & Sastry, N. (2005). Immigration status and health insurance coverage: Who gains? Who loses? American Journal of Public Health, 95, 109–116. Rehm, R. S. (2003). Legal, financial, and ethical ambiguities for Mexican American families: Caring for children with chronic conditions. Qualitative Health Research, 13, 689–702. Rothenberg, P. S. (2011). White privilege: Essential readings on the other side of racism (4th ed.). New York: Worth. Salgado de Snyder, V. N., Cervantes, R. C., & Padilla, A. M. (1990). Gender and ethnic differences in psychosocial stress and generalized distress among Hispanics. Sex Roles, 22, 441–453. Seng, J. S., Lopez, W. D., Sperlich, M., Hamama, L., & Meldrum, C. (2012). Marginalized identities, discrimination burden, and mental health: Empirical exploration of an interpersonal-level approach to modeling intersectionality. Social Science & Medicine, 75, 2437–2445. doi:10.1016/j.socscimed.2012.09.023 Smith, T. B., Domenech Rodríguez, M. M., & Bernal, G. (2011). Culture. Journal of Clinical Psychology, 67, 166–175. doi:10.1002/jclp.20757 Solis, J. (2003). Re-thinking illegality as a violence against, not by, Mexican immigrants, children, and youth. Journal of Social Issues, 59, 15–31. Sue, D. W. (2005). Racism and the conspiracy of silence: Presidential address. The Counseling Psychologist, 33, 101–114. Suro, R. (2005). Attitudes toward immigrant and immigration policy: Surveys among Latinos in the U.S. and in Mexico. Washington, DC: Pew Hispanic Center. Trimble, J. E. (2000). Social psychological perspectives on changing self-identification among American Indians and Alaska Natives. In R. H. Dana (Ed.), Handbook of cross-cultural and multicultural personality assessment (pp. 197–222). Mahwah, NJ: Lawrence Erlbaum. Trimble, J. E., & Dickson, R. (2005). Ethnic gloss. In C. B. Fisher & R. M. Lerner (Eds.), Encyclopedia of applied developmental science (Vol. 1, pp. 412–415). Thousand Oaks, CA: Sage. Trimble, J. E., & Fisher, C. B. (2006). The handbook of ethical research with ethnocultural populations and communities. Thousand Oaks, CA: Sage. U.S. Citizenship and Immigration Services. (2006). Glossary and acronyms. Retrieved from http://www.uscis.gov/graphics/glossary2.htm#I U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity. Rockville, MD: Government Printing Office. U.S. Department of Health and Human Services. (2012). 2012 poverty guidelines for the 48 contiguous states and the District of Columbia. Retrieved from http://www.aspe.hhs.gov/poverty/12poverty.shtml#guidelines U.S. Department of Homeland Security, Office of Inspector General. (2009). Removals involving illegal alien parents of United States citizen children (OIG-09-15). Washington, DC: Author. Retrieved from http://www.oig.dhs.gov/assets/Mgmt/OIG_09-15_Jan09.pdf U.S. Department of Labor. (2012). Labor force characteristics of foreign-born workers summary (Economic news release). Retrieved from http://www.bls.gov/news.release/forbrn.nr0.htm Wight, V. R., Thampi, K., & Chau, M. (2011, April). Poor children by parents’ nativity: What do we know? New York: National Center for Children in Poverty. Retrieved from http://www.nccp.org/publications/pub_1006.html World Bank. (2012, February 29). World Bank sees progress against extreme poverty, but flags possibilities (Press release no. 2012/297/DEC). Retrieved from http://www.worldbank.org/en/news/2012/02/29world-bank-sees-progress-against 12 Counseling in Schools Issues and Practice Cheryl Holcomb-McCoy Ileana Gonzalez Primary Objective ■ To provide insight into a number of disparities and barriers that racially and socioeconomically diverse students face in today’s schools and how multiculturally competent counselors can transform these challenges through various aspects of their practice Secondary Objectives ■ To highlight several challenges diverse students face in schools, such as mental health concerns; achievement inequities; lack of preparation for college and career readiness; peer victimization; lack of preparation in the fields of science, technology, engineering, and mathematics; and linguistic concerns ■ To provide a framework for social justice–focused school counseling ■ To describe multiculturally competent approaches to school counseling, including empowerment-focused and strengths-based counseling techniques and consultation practices Schools in the United States are more racially segregated now than they have been at any time in the past 40 years (Orfield & Lee, 2007): The typical White student attends school where almost 80% of the students are White, and the typical African American or Latino student attends school where at least two-thirds of the students are from that student’s racial/ethnic group. This alarming reality is at odds with the fact that overall the national student body is becoming more diverse every year (Humes, Jones, & Ramirez, 2010), in large part due to the increasing percentage of Latino students in public schools. As the student population becomes increasingly diverse, efforts mount to identify effective methods and strategies for counseling the individuals who make up this population. School-based counselors are currently called upon not only to conduct effective and culturally sensitive counseling but also to facilitate and enhance the educational and career development of students who vary widely in cultures, languages, abilities, and many other characteristics. To meet this challenge, more counseling preparation programs are addressing diversity and cultural competence, as evidenced by the accreditation standards set by the Council for the Accreditation of Counseling and Related Educational Programs (2009) and the guidelines of the American Psychological Association (1990). Moreover, there is a dire need for school counselors who are trained and ready to collaborate with other educators and community stakeholders on school reform efforts. With the needs described above as a backdrop, we propose a shift in school counseling practice and policy that is rooted in cultural competence and social justice principles (e.g., justice, advocacy). This shift involves revisiting the school counseling professional’s historical role as advocate for change and focusing on preparing youth to be successful in their postsecondary endeavors (e.g., university/college, apprenticeships, career choices). We believe the profession is poised to bring forth practices and strategies that will help empower culturally diverse students and their families to be successful and productive citizens of the 21st century. In this chapter we will discuss what we believe are the profession’s challenges and offer possible counseling strategies for implementation at the K–12 school level. We will present brief descriptions of factors that ultimately impede the academic and social development of all students but have disproportionate impacts on culturally diverse students. In addition, we will address culturally appropriate counseling interventions for school counselors and programs from a social justice framework. Challenges of 21st-Century School Counseling Mental Health Disparities A distinct body of literature describes the deficits in the provision of mental health care services to racial and ethnic minority children and families of lower socioeconomic status, and it has become increasingly apparent that ethnically and racially diverse children are underserved relative to their White counterparts in the areas of prevention, access, quality treatment, and outcomes of care (National Center for Health Statistics, 2012). The presence of psychiatric disorders in childhood has been linked to negative outcomes, including poor social mobility and reduced social capital. For example, childhood depression has been associated with increased welfare dependence and unemployment. Many of these identifiable risk factors for mental illness (e.g., poverty, exposure to violence) disproportionately affect students of color. According to the U.S. census, in 2007 approximately 18% of children in the United States were poor, and among these, Black and Latino children were disproportionately affected. High rates of isolation of ethnically and racially diverse children can have significant adverse effects on these children’s mental health, including depression and behavior problems, anxiety disorders such as posttraumatic stress disorder, and a range of other adjustment difficulties (Flannery, Wester, & Singer, 2004). Many racial and ethnic minority children and adolescents also experience “compounded community trauma,” which has been defined as trauma resulting from witnessing violence in their homes and neighborhoods (Horowitz, Weine, & Jekel, 1995). Compounded community trauma has been linked to high rates of mental illness, including posttraumatic stress disorder, depression, and externalizing behaviors. Additional factors that increase the risk of mental illness for low-income youth are neighborhood exposure to violence, neighborhood social disorganization, repeated experiences of discrimination, and chronic exposure to discrimination. Early interventions such as the CognitiveBehavioral Intervention for Trauma in Schools (CBITS; Kataoka et al., 2003) have been shown to be advantageous for addressing traumatic stress and maximizing students’ effective coping strategies in at-risk environments. Thus, it is essential that school counseling programs engage in early prevention and intervention to reduce the burden of mental disorders for low culturally and ethnically diverse students. Other community-based interventions that show promise include school-based services, mentoring programs, family support and education programs, and wilderness programs. Many of these have demonstrated effectiveness with African American, Latino, and American Indian children and families (Alegria, Vallas, & Pumariega, 2010). Achievement Inequities In addition to the mental health disparities that racial and ethnic minority children and adolescents disproportionately face, a nationwide education crisis is profoundly affecting the social and economic fabric of American communities (A. Duncan, 2009). In 2002, the sweeping education reform known as No Child Left Behind was signed into law, representing the first mechanism for closely monitoring student and school achievement through measurement against national and state standards. Through this accountability lens, gaps in achievement, attainment, and opportunities between students of varying geographic locations, races, and socioeconomic statuses are highlighted. Recent statistics indicate that substantial gaps exist between African American and Latino students and their White and Asian peers (National Center for Education Statistics [NCES], 2009, 2011). On average, African American and Latino students are 2 to 3 years behind White students of the same age across the nation, while more pronounced racial achievement gaps exist in most large urban school districts (McKinsey & Company, 2008). The National Assessment of Educational Progress (NAEP) reveals racial achievement gaps in both reading and mathematics. For example, in 2009 and 2011, African American and Latino students in fourth and eighth grades scored an average of 20 points lower than their White peers on NAEP math and reading assessments, a difference of about two grade levels (NCES, 2011; Planty et al., 2009). The racial achievement gap increases as children progress in school: between fourth and twelfth grades, for example, the disparity in math scores grows 41% for Latinos and 22% for African Americans as compared to White students (McKinsey & Company, 2008). Scores in 2011 showed gains among White, Latino, and African American students in reading and mathematics, demonstrating that the achievement gaps are slowly narrowing, but they still remains significant (NCES, 2011). Gaps are also apparent in the low representation of students of color in rigorous curricula (NCES, 2007). A small proportion of African American students have access to challenging programs such as advanced placement. Many of those who do have access to these courses have not excelled: less than 4% of African American students score a 3 or higher on an advanced placement test at some point in high school, compared to 15% of students nationwide (McKinsey & Company, 2008). African American and Latino students have lower academic achievement in high school and less access to rigorous courses compared to their White counterparts (Nunn, 2011). As opposed to their more affluent, White peers, these students are consequently less likely to attain a high school diploma or to enter a postsecondary institution with the skills and knowledge needed to be successful in college (House & Hayes, 2002). African American and Latino students and students from low socioeconomic backgrounds continue to be underprepared for, and underrepresented in, 4-year colleges and universities (Holland & Farmer-Hinton, 2009; Kena et al., 2014, pp. 148–150). Data also show that there is a significant achievement gap between affluent and low-income children (Education Trust, 2008). Low-income students are roughly 2 years of learning behind more affluent students of the same age (McKinsey & Company, 2008). At the individual school level, schools with populations comprising mostly low-income students perform much worse than those with fewer lowincome students. The U.S. Department of Education reports that student and school poverty adversely affects student achievement (Aud et al., 2010). In a longitudinal study conducted with third- through fifth-grade students from 71 high-poverty schools, the U.S. Department of Education (2001) found that students who live in poverty scored below norms in all years and in all grades as measured by the Stanford Achievement Test, ninth edition (SAT-9); schools with the highest percentages of poor students performed significantly worse than other students at the same grade levels. Low-income African American students suffer from the largest achievement gap of any cohort, and data suggest that the average low-income White student is about 3.5 years ahead in learning compared to the average low-income African American student (Aud et al., 2010). College Access and Dropout Disparities Similar to differences in achievement, there are stark disparities in college enrollments across groups of students. Low-income students, students whose parents have never attended college, and students of color (i.e., African American, Latino/Hispanic) are less likely to attend college than are their more affluent White and Asian peers (Perna et al., 2008). Although college enrollments have increased across all groups, there is still a persistent enrollment gap. Moreover, according to the National Center for Education Statistics, when students from underrepresented groups do enroll in college, they tend to enroll in public 2-year colleges or 4-year colleges and universities with less selective admissions policies and fewer resources than the institutions attended by their more privileged counterparts. The lack of college preparatory counseling in high schools has been noted as an explanation for these disparities in college access and choice; consequently, school counselors have been blamed for lack of engagement and gatekeeping practices related to college advising (Rosenbaum, Miller, & Krei, 1996). Obviously, school-based counselors are a logical source of assistance for African American, Latino, and low-income students, as well as students whose parents do not have direct experience with college (Perna et al., 2008). In addition to the disparities in college access and admissions, students of color are disproportionately represented in the nation’s dropout statistics. Of the more than 1.2 million students who fail to graduate from high school on time each year, more than half are students of color, despite the fact that these students make up less than 40% of the high school population. Only 57.8% of Latino students, 53.4% of African American students, and 49.3% of American Indian and Alaska Native students entering ninth grade receive high school diplomas 4 years later. Although the graduation rate for Asian American students is 80% (roughly four percentage points higher than the White student average), students from some Asian ethnic subgroups, including Southeast Asians and Pacific Islanders, do not fare as well academically as their peers from other subgroups. Peer Victimization Another challenge in education today that has generated attention from many groups is the increase in reports of peer victimization, also known as bullying. Peer victimization is defined as physical, verbal, or psychological abuse that takes place in and around school, especially in places where adult supervision is minimal (Graham, 2006). Hitting, name-calling, intimidating gestures, racial slurs, spreading of rumors, and exclusion from the group by perceived “powerful others” are all examples of behaviors that constitute peer victimization. Research on the consequences of peer victimization has documented that students who experience such victimization have higher incidence of depression, suicide, poor school performance, low self-esteem, absenteeism, psychiatric care and hospitalization, substance abuse, and high-risk sexual behavior than students who are not victimized (Juvonen & Graham, 2001). Research has also found that ethnicity, sexual orientation, gender identity, gender conformity, and culture are important contextual variables related to student victimization by peers. For instance, in a 2011 survey of LGBTQ students conducted by the Gay, Lesbian & Straight Education Network, 64% reported feeling unsafe, 82% reported being verbally harassed, and 38% reported being physically harassed because of their sexual orientation (Kosciw, Greytak, Bartkiewicz, Boesen, & Palmer, 2012). Some research suggests that approximately 28% of gay and lesbian youth drop out of high school because of feeling unsafe (due to verbal and physical abuse) in the school environment (Remafedi, 1987). Research also indicates that lesbian, gay, bisexual, transgender, and questioning youth report experiencing significantly more at-school victimization (e.g., bullying, harassment) than do their heterosexual peers (Kosciw et al., 2012; Williams, Connolly, Pepler, & Craig, 2005). Graham (2006) found that no one ethnic group is more or less at risk for being the target of peer abuse. However, she notes that an ethnic or cultural group’s numerical power in a school can be a critical factor affecting a victim’s propensity to self-blame. For instance, if a victimized student’s own ethnic group is the numerical majority that holds the balance of power in the school, then the student’s construal about the causes of victimization are more likely to implicate the self. Lack of Preparation in Science, Technology, Engineering, and Mathematics Another important factor that calls for a shift in the role of school counselors is the continuing achievement gap between African American and Latino students and their White counterparts in the areas of science, technology, engineering, and mathematics, the so-called STEM fields (Harper, 2010). The importance of increasing the numbers of underrepresented students in STEM courses, and eventually STEM careers, has heightened dramatically in the past decade because of the impending growth in jobs/careers in these fields. College graduation statistics for 2007 show that African Americans received only 7–8% of STEM bachelor degrees bestowed by U.S. institutions, compared with 64% of the White cohort. Nestor-Baker and Kerka (2009) list seven challenges to the recruitment and retention of underrepresented students in STEM college majors: lack of academic preparation, low confidence levels, the imposter syndrome (e.g., everyone understands but me), unrealistic expectations (e.g., passing with little effort), lack of community, environmental alienation, and financial need. Teacher and classroom efforts have received attention in the literature; however, the role of the school counselor in providing career counseling and social/emotional assistance has received limited attention. Feller (2003) and other counseling professionals continue to call for counselors to take a more active role in promoting STEM careers. Schmidt, Hardinge, and Rokutani (2012) recommend that school counselors use the following strategies to increase the participation of diverse students in STEM coursework: course advisement and selection, promotion of academic rigor, strategic emphasis on achievement and goal orientation, commitment to parental inclusion, and attention to underrepresented populations. Linguistic Diversity Another factor that has significant impacts on the practice of school counseling today is the linguistic diversity found in schools. In 2010, about 10% of U.S. students were identified as English language learners (Aud et al., 2010). According to a study conducted by the Pew Hispanic Center, English language learner (ELL) students tend to go to public schools that have low standardized test scores (Fry, 2008). However, these low levels of assessed proficiency are not solely attributable to poor achievement by ELL students. These same schools report poor achievement by other major student groups as well and share a number of characteristics associated generally with poor standardized test performance, such as high student–teacher ratios, high student enrollments, and high levels of students living in or near poverty. When ELL students are not isolated in these low-achieving schools, the gap between their test score results and those of other students is considerably narrower. These data have significant implications for school counselors. In addition to the language barriers present in counseling, the heterogeneity of the ELL student population presents challenges to school counselors in the form of numerous different behavioral norms, cultural customs, and previous schooling practices across language groups. Moreover, given that a significant number of ELL students are from first- and second-generation immigrant families, it is important for counselors to recognize that the parents of these children may not understand how American schools operate or be aware of the various educational programs available to assist their children. Multicultural School Counseling Competence and Practice Perhaps one of the greatest challenges confronting school counselors today is that of becoming “culturally competent,” or having the ability to counsel students of varying cultural backgrounds effectively. For many years, a growing body of literature has addressed the need for multicultural competence in counseling and in the training of future school counselors (Ali & Ancis, 2005; Collins & Pieterse, 2007). Multicultural theorists have defined cultural competence as a specific area of competence that includes (1) cultural awareness and beliefs, (2) cultural knowledge, and (3) cultural skills. A counselor has achieved cultural competence when he or she possesses the skills necessary to work effectively with clients from various cultural backgrounds. Hence, a school counselor with a high level of multicultural counseling competence acknowledges student–counselor cultural differences and similarities as significant to the counseling process. In contrast, a counselor with a low level of multicultural competence provides counseling services with little or no regard for the counselor’s or the student’s cultural background. Given the school setting and the educational outcomes that must be addressed in schools, the multicultural competence of school counselors includes more than focusing on individual student emotional and/or social concerns alone. School counselors, in general, are expected to have knowledge of the educational landscape—including school norms and practices and education terminology. A multiculturally competent school counselor would be expected to have knowledge of educational systemic factors that influence students’ success. For instance, “tracking” has been documented as a practice and policy that perpetuates gaps in achievement and attainment among students. Therefore, advocating for the dismantling of tracking practices is an example of an intervention that would be expected of a multiculturally competent school counselor. In response to the need for a shift in the practice of school counselors, the American School Counselor Association (ASCA, 2009) adopted the following position on cultural diversity: Professional school counselors promote academic, career, and personal/social success for all students. Professional school counselors collaborate with stakeholders to create a school and community climate that embraces cultural diversity and helps to remove barriers that impede student success. (p. 1) In addition, the 2010 revision of ASCA’s Ethical Standards for School Counselors addresses multiculturalism, diversity, and anti-oppression competencies as follows in Section E.2, “Multicultural and Social Justice Advocacy and Leadership”: Professional school counselors: 1. Monitor and expand personal multicultural and social justice advocacy awareness, knowledge and skills. School counselors strive for exemplary cultural competence by ensuring personal beliefs or values are not imposed on students or other stakeholders 2. Develop competencies in how prejudice, power and various forms of oppression, such as ableism, ageism, classism, familyism, genderism, heterosexism, immigrationism, linguicism, racism, religionism and sexism, affect self, students and all stakeholders. 3. Acquire educational, consultation and training experiences to improve awareness, knowledge, skills and effectiveness in working with diverse populations: ethnic/racial status, age, economic status, special needs, ESL or ELL, immigration status, sexual orientation, gender, gender identity/expression, family type, religious/spiritual identity and appearance. 4. Affirm the multiple cultural and linguistic identities of every student and all stakeholders. Advocate for equitable school and school counseling program policies and practices for every student and all stakeholders including use of translators and bilingual/multilingual school counseling program materials that represent all languages used by families in the school community, and advocate for appropriate accommodations and accessibility for students with disabilities. 5. Use inclusive and culturally responsible language in all forms of communication. 6. Provide regular workshops and written/digital information to families to increase understanding, collaborative two-way communication and a welcoming school climate between families and the school to promote increased student achievement. 7. Work as advocates and leaders in the school to create equity-based school counseling programs that help close any achievement, opportunity and attainment gaps that deny all students the chance to pursue their educational goals. Social Justice–Focused Counseling in Schools At the core of ASCA’s position on the ethical mandates as they relate to diversity is the adoption of an advocacy position. While the multicultural counseling movement has maintained its significance and momentum in the field of counseling (Ponterotto, Casas, Suzuki, & Alexander, 2010), the notion of a social justice counseling movement has also gained significance (Hook & Davis, 2012). Social justice counseling, according to the Counselors for Social Justice division of the American Counseling Association, is a multifaceted approach to counseling in which practitioners strive to promote human development and the common good simultaneously by addressing challenges related to both individual and distributive justice. Social justice counseling includes empowerment of the individual as well as active confrontation of injustice and inequality in society as they affect clientele and in their systemic contexts. Social justice counselors direct attention to the four critical principles that guide their work: equity, access, participation, and harmony. They conduct their work with a focus on the cultural, contextual, and individual needs of those served. Within the context of school counseling, Holcomb-McCoy (2007) offers a social justice framework specifically for school counselors that includes six key counselor functions: 1. 2. 3. 4. 5. 6. Counseling Consultation Connecting schools, families, and communities Collecting and using data Challenging bias Coordinating student services and support Table 12.1 presents examples of counselor activities for each of these functions. When using a social justice approach to counsel students, it is critical for school counselors to consider the historical oppression and discrimination that racial and ethnic minority students and their families have endured and currently endure in their communities. Getting past classism, racism, sexism, heterosexism, and other isms is a challenge for many students and their families, and, as a result, feeling that they are not valued or respected, many have drifted into dysfunctional and counterproductive school behavior (Franklin & Franklin, 2000). School counselors, therefore, must not avoid or ignore the implications of race, gender, class, language, sexual orientation, religion, and/or culture when working with students. Students are very much aware of prejudice and discrimination and the meanings of their cultural backgrounds to other persons. For instance, Malik, a 15-year-old African American gay high school student in a predominantly African American school reported to his counselor, “Mr. Freeman doesn’t like me because he knows that I’m gay. That’s why I don’t go to his class anymore. I heard that he doesn’t like sissies.” Bonita, a 10-year-old student from El Salvador, told her counselor about her observations of the gifted group: “I don’t want to be in that group.... It’s just for the smart, White kids.” Both of these students’ statements signify discriminatory problems in their schools that should be explored by their school counselors. Addressing equality as well as equity is an important aspect of a social justice approach to counseling. Attempts to ensure equality focus on the use of the same policies and procedures for all students, but such an approach can hinder a school’s ability to reach students individually. The “equality” principle is manifested through the belief that schools must remain neutral, with every student receiving the same consequences for the same behaviors; this principle ignores the long-term effects of oppression and discrimination on some groups. To ensure equity, on the other hand, educators treat students on the basis of their individual needs. Social justice counseling urges educators to “strike a balance between equity and equality in their school practices because both are critical to promoting success to all students” (Holcomb-McCoy, 2007, p. 21). In a recent survey of middle and high school counselors, counselors were more likely to demonstrate a commitment to equality than to equity when working in schools with larger percentages of minority students and larger percentages of students from lower socioeconomic statuses (Bridgeland & Bruce, 2011). Source: Holcomb-McCoy, C. (2007). School counseling to close the achievement gap: A framework for success. Thousand Oaks, CA: Corwin. Multicultural School Counseling Approaches We believe that school counselors who work within a social justice framework use strategies that enhance students’ self-worth, improve students’ academic and personal self-efficacy, and ultimately enhance students’ feelings of empowerment. The challenge for school counselors is to initiate counseling with an understanding of the environmental barriers that are impeding students’ academic and social development, an ability to build on students’ strengths, and a keen understanding of equity and empowerment in the context of education. Below we provide more detailed descriptions of empowerment-based counseling, strengths-based counseling, group counseling, and school culture interventions as they apply to the work of school counselors. Empowerment-based counseling. The concept of empowerment originated in the social sciences as early as the 1970s, but it is a relatively new concept in the field of education (Perkins & Zimmerman, 1995). Hipolito-Delgado and Lee (2007) describe empowerment-focused counseling as twofold, involving (1) the student’s ability to make grounded choices inclusive of his or her critical consciousness of how issues of oppression may affect personal and community well-being in educational, social, economic, political/civic, and health domains; and (2) the student’s acquisition of knowledge and skills to eradicate barriers and social injustices when the student observes these in his or her life or community. It is important to note that school counselors who utilize empowerment-focused counseling advocate for students’ selfempowerment rather than attempt to empower students themselves. According to Hawley and McWhirter (1991), professionals utilizing empowerment-focused counseling highlight their clients’ current assets and strengths in relation to how those positive traits can foster a greater internal locus of control in their personal lives and their community lives. Empowerment-focused counseling can be a powerful approach for school counselors and other helping professionals to utilize with students in traditionally marginalized groups. These students and their families often experience injustices or inequities in multiple domains—educational, social, economic, political/civic, and health. For example, in the domain of education, national data show that gatekeeping practices over time limit African American students’ access to rigorous academic courses that can facilitate high achievement (Rowan, Hall, & Haycock, 2010); this in turn creates barriers to economic success and ultimately leads to negative health outcomes (e.g., depression, heart disease). School counselors can integrate an empowerment-focused approach into their practice by implementing the following types of activities: 1. Creating environments in which students can share their stories/experiences while also doing positive asset searches 2. Acknowledging the impacts of systemic oppression and marginalization on students who are members of racial/ethnic minority groups 3. Facilitating dialogue with students about their desired choices or goals with critical awareness of how concepts of “power” play a role in oppression 4. Exploring with students how they can use their assets/strengths to access their own power to make choices and address barriers and injustices in their lives and communities Hipolito-Delgado and Lee (2007) emphasize that before school counselors can advocate effectively for students’ empowerment, the professionals must first reflect on their own attitudes, biases, assumptions, and beliefs about the students’ abilities to make choices in their own lives and communities. Additionally, school counselors must take the time to reflect on and process their views of systemic oppression and marginalization of diverse groups of students within the educational system in which they work. A final component of empowerment-focused counseling is the knowledge of how race plays a significant role in the daily lives of all persons of color in the United States. Broaching the topics of race, ethnicity, and culture as these may affect the student’s presenting issue is an integral factor in the effectiveness of empowerment-focused counseling with African American students (Day-Vines et al., 2007). Day-Vines and colleagues (2007) constructed a continuum of broaching behavior by the counselor as it relates to his or her ability to keep a racial and cultural context in consideration effectively. At one extreme of the broaching continuum is “the avoidant counselor,” who does not acknowledge or address the notion that race, ethnicity, and culture may play a role in the presenting issue. Day-Vines and colleagues suggest that with clients of color, lack of skill or refusal to broach racial topics leads to early termination of counseling by the client. At the advanced end of the sixpoint continuum is “the infusing counselor,” who both integrates race within the counseling setting and advocates for the client’s empowerment to address social justice issues outside the counseling setting in collaboration with the counselor. Strengths-based counseling. Strengths-based counseling focuses on student assets and “positive messages,” in contrast to the deficit model or framework that is typically used in school settings (Galassi & Akos, 2007). Strengths-based counseling is a positive approach that highlights the student as the expert of his or her life in the counseling dynamic in addition to exploring how strengths and resilience traits have encouraged both coping skills and success in areas of the student’s life. The approach has two goals: (1) problem prevention and reduction and (2) skills acquisition. Strengths-based counseling emphasizes a developmental asset framework; research has indicated that students’ strengths, protective factors, and resources are positively correlated with their success in school and life domains (Scales, 2005). The developmental assets are aligned to actions school counselors and other helping professionals can take to advocate for student success. For example, Scales (2005) suggests that high expectations are developmental assets, and therefore helping professionals should promote a challenging curriculum for all students by working to remove tracking and gatekeeping practices that have traditionally limited access to rigorous courses (e.g., honors and advanced placement classes) for students of color. Consultation. Consultation, unlike counseling, is an indirect service delivery approach, that can be used to influence change in entire classrooms, schools, or families. School counselors typically use consultation as a means to assist parents and/or teachers as they grapple with various types of student problems or difficulties. One of the most important shifts in the field of consultation concerns the increasingly apparent influence that culture and other environmental aspects have on the process of consultation (Ingraham, 2000, 2003; Tarver-Behring & Ingraham, 1998). Most of the literature on multicultural issues in consultation has been published in school psychology journals and books; little discussion of multicultural consultation has been found in the school counseling literature. Clearly, when consulting with parents and teachers from culturally diverse backgrounds, school counselors need to consider the impacts of culture not only on their clients (i.e., students) but also on the consultation process (Moseley-Howard, 1995). In a classic article on multicultural consultation, Gibbs (1980) focused on the differences in the consultation process between African American and White teachers. Her model reflected her observation of African American and White teacher consultees’ initial responses to the use of consultation in an inner-city school setting. Gibbs concluded that the African American teachers—due to a combination of historical, cultural, and social patterns—responded minimally and indicated little interest in the initial stages of consultation. She described the White teachers, on the other hand, as being much more attentive and asking questions related to the methods and goals of the project. Gibbs asserted that African American consultees preferred an interpersonal consultant style that focused on trust and building rapport between consultant and consultee. White teachers, according to Gibbs, preferred an instrumental consultant style that was task driven. As a result of her observations, Gibbs recommended that consultants should be genuine and “down-to-earth,” and that they should establish nonhierarchical relations with African American consultees (teachers or parents). The research examining Gibbs’s conclusions, however, has resulted in contradictory findings. For instance, C. F. Duncan and Pryzwansky (1993) found that African American teachers preferred the instrumental rather than the interpersonal style of consultation. This issue of preferred and effective consultation styles with diverse groups of consultees, particularly diverse parents, is an area of research that still warrants more extensive research. It is important to note that in many cases, school counselors/consultants may view cultural differences as “the problem.” Sheridan (2000) notes that status or demographic variables such as race, class, and parental factors (e.g., mother’s marital status) are often perceived as the sources of students’ problems (e.g., a consultant may believe that a child’s problem is rooted in the fact that the child lives in a single-parent household). Davies (1993) found that educators believed that parents who were less educated, poor, and ethnic minorities were deficient in their abilities to help their children with school work and uninterested in their children’s education. However, research has indicated that in most instances, poor, less educated, and minority parents are interested in their children’s education, want the best for them, and have the capacity to support their children’s learning (Henderson, Mapp, Johnson, & Davies, 2007). Regarding parent consultation, the strategies used in consultation can be roughly divided into two types: those that focus on the presentation of new information or ideas as the primary change agent and those that focus on the relationship between the consultee and the consultant as the source of change. Many consultants influenced by the “information as change agent perspective” view the consultant–parent relationship as important only to the extent that it facilitates the dissemination of knowledge regarding appropriate parenting practices and family functioning. Such consultants generally adhere to behavioral or cognitive-behavioral theories, and they typically subscribe to a psychoeducational approach to altering what they view as maladaptive patterns of behavior through the use of behavioral strategies (Sheridan, 1992). This approach can create several problems if consultants fail to take cultural factors into account when consulting with parents of diverse backgrounds. Turner (1982), for instance, notes the problems that African Americans may have with certain behavior modification techniques and with terminology such as aversive conditioning, behavior control, extinction, and stimulus–reward. From a cultural perspective, these techniques and their accompanying terminology focus heavily on controlling or changing behavior, which is reminiscent of many marginalized groups’ oppressive histories. Consultation based solely on education and imparting information may also fail to consider the importance of psychosocial influences such as family structure, cultural value systems, interactional patterns, and adaptive coping strategies on behavior and functioning in culturally diverse families and instead may focus on factors that play a more important role in middle-income White American families (Boyd-Franklin, 2003). For example, consultants who use this approach may ignore the fact that in some cultures families traditionally involve extended family members, such as grandparents, in family decision making and child-rearing practices to a greater extent than do many White families (Holcomb-McCoy & Bryan, 2010). In addition to differences in family structure, consultation may be influenced by the adaptive coping strategies of diverse cultural groups. Marginalized groups have developed particular coping strategies (e.g., suspicion of outsiders, group unity) to deal with hostile environments, and members of these groups may be misdiagnosed as pathological if they are not examined within the appropriate cultural context. For instance, the literature is replete with evidence documenting the misclassification of African American and Latino students as having behavior problems (Losen & Orfield, 2002). Thus, consultants must not assume that all students have been accurately classified or identified. Attempts to change what are assumed to be maladaptive behaviors through the use of consultation may lead to ineffective interventions that fail to address the true source of difficulty, such as frustration with teachers’ low expectations, anger associated with a family situation, or inability to feel safe. Consultants’ failure to address the real sources of students’ problems can result in resistance and hostility from parents. Consultants’ attitudes and actions may also affect working alliances or relationships in parent consultation. For example, Kalyanpur and Rao (1991) identified three qualities that were related to low-income African American mothers’ negative perceptions of outreach agency professionals. First, the consultants’ perceived lack of respect for the parents and failure to trust them were significant barriers to fostering collaborative relationships. Second, the professionals’ tendency to focus on children’s deficits while ignoring their strengths also undermined the relationships. The third factor leading to impaired relationships was the consultants’ perceived lack of appreciation for the mothers’ parenting styles, which were often blamed for children’s behavior problems at school. Utilization of data. Data on dropout rates, standardized test scores, graduation rates, and so on can provide tremendous impetus for change in schools where low expectations lead to low results for large numbers of students—particularly low-income students and students of color (Johnson, 2002). We believe that school counselors should examine such data to absorb the troubling implications of status quo practices (e.g., tracking) that have worked against students rather than in favor of them and then lead “data discussions” in their schools and communities to advocate for changes in practice. These discussions might occur in meetings of departmental teams, case management teams, and school improvement teams, as well as in general faculty meetings and school–community focus groups. Collaborative teaming among school and community stakeholders can produce meaningful results and a broader awareness of data trends concerning culturally diverse students’ progress. For example, the Montgomery County Public Schools in Maryland use a program called Study Circles to create dialogue around race, ethnicity, and barriers to student achievement and parental involvement. Here, parents, teachers, administrators, and school counselors collaborate with trained facilitators to work on students’ achievement-related issues (for more information, see the school system’s website at http://www.montgomeryschoolsmd.org/departments/studycircles). We believe that school counselors are critical participants in these types of teams because counselors often have information about the “whole child” and, in turn, can serve as advocates for parents and students who are often “silent” at these meetings. Over the past decade, school counseling professionals have developed several data templates to help practicing school counselors use data in their programs. For instance, Kaffenberger and Young (2008) offer step-by-step implementation strategies, along with examples and information on a variety of resources, to help school counselors develop plans for collecting data, make sense of the data collected, and share the findings with key stakeholders. Their approach to utilizing data enables school counselors to connect their programs to the mission of equity and social justice and also provides them with a framework for analyzing existing strategies to determine which should be replicated, redesigned, or discarded. In regard to counselors’ utilization of academic and social data, Ford, Grantham, and Whiting (2008) warn that analyzing student data can also be an inhibitor to shifting student achievement. Frequently, education professionals look at data solely through the lens of deficits, gaps, and underrepresentation (Whiting, Ford, Grantham, & Moore, 2008). Ford and colleagues assert that quite often culturally diverse students who do achieve are overlooked and are thus left out of challenging courses, special programming, and other opportunities that could engage them more in the schooling process. School culture. School culture includes the values, beliefs, and norms that lay the foundation for a school’s climate, programs, and practices. Unfortunately, in today’s schools, many teachers and other school professionals believe that culturally diverse students come to school with cultural deficits. This belief gets translated into assumptions about students’ cognitive abilities and is reflected in common educational practices, such as assigning racial and ethnic minority students to special education classes at disproportionately higher rates than their peers in other ethnic and cultural groups. Therefore, for many students, the school’s negative perception of their ethnic group creates a climate of low expectations and low performance that can lead to self-degrading feelings (Denbo, 2002). To create nurturing school cultures that support feelings of inclusion and the learning of all students, school counselors must initiate programs and practices that result in the elimination of harmful institutional practices. For more than a decade, researchers have worked to identify the characteristics of schools that promote resilience in ethnically diverse students as well as overall student success (Somers, Owens, & Piliawsky, 2008; Werner & Smith, 1992). They have found that such schools do the following: ■ Promote close bonds ■ Value and encourage education ■ Use high-warmth, low-criticism styles of interaction ■ Set and enforce clear boundaries (rules, norms, and laws) ■ Encourage supportive relationships with many caring others ■ Promote the sharing of responsibilities, service to others, and “required helpfulness” ■ Provide access to resources for meeting basic needs of housing, nutrition, employment, health care, and recreation ■ Set high and realistic expectations for success ■ Encourage goal setting and mastery ■ Encourage the development of prosocial values (such as altruism) and life skills (such as cooperation) ■ Provide opportunities for leadership, decision making, and other meaningful ways to participate ■ Support the unique talents of each individual School counselors and other school professionals can work together to promote these and other characteristics to create school cultures that provide students with safe places to learn and cultivate student achievement and resilience. One underexamined social and cultural feature of schools is the impact of student–adult relationships on students’ experiences in school. Despite the challenges associated with large schools, it has been argued that personalized student–teacher relationships can promote student engagement and achievement and mediate against dropping out (Bryk & Schneider, 2002). For example, such relationships have been found to be linked to learning (Nieto, 1999), especially when they are driven by care and respect (Rodríguez, 2008). Conversely, negative student-adult relationships have been associated with dropping out and academic failure (McHugh, Horner, Colditz, & Wallace, 2013). Student–adult relationships have also been found to be particularly significant for low-income students (Noguera, 2004). In describing some common characteristics of care among 13 teachers in his study, Brown (2003) reported that the teachers showed genuine interest in their students by being assertive in explicitly stating expectations for appropriate student behavior and academic growth. Milner (2007) found that teachers and other school personnel demonstrated their interest in students by offering students compliments, by allowing students to make up work and to work for extra credit at the end of the school term when students were at risk of receiving failing grades, by volunteering to serve as sponsors/advisers to clubs and organizations, and by attending after-school activities (such as basketball games). The demonstration of care by teachers and other education professionals is particularly important for the success of culturally diverse students, who often report feeling isolated and not valued in the school setting. Enrollment in rigorous courses. More than 20 years ago, a national report by the College Board, Changing the Odds: Factors Increasing Access to College (Pelavin & Kane, 1990), examined the relationship between enrollment in college prep–level courses and college-going rates among high school students and whether African American, Latino, and White students participated equally in those courses related to college going. The researchers found that low-income African American and Latino students did not enroll in courses in geometry and foreign languages and did not aspire to a bachelor’s degree at the same rates as White students. However, when African American and Latino students had the opportunity to enroll in and completed such courses, the likelihood of their college enrollment increased, and the gap between minority students and Whites decreased. A more recent report published by the College Board found that students who took challenging courses such as precalculus, calculus, and physics had significantly higher average SAT scores than those students who did not take rigorous courses (Wiley, Wyatt, & Camara, 2010). Gamoran and Hannigan (2000) found support for the contention that higher-level coursework improves academic achievement of all students in their analysis of data from more than 12,500 students in the National Assessment of Educational Progress. Typically, school counselors develop students’ schedules, and in high schools, counselors implement college counseling and advisement related to college readiness. Unfortunately, many school counselors make decisions about who goes to college and who does not. All too often, low-income, African American, Latino, and Native American students are sent the message that they are not “college material” and are subsequently advised to take courses that do not prepare them for college admission. In order to ensure that diverse students have the opportunity to pursue college degrees, it is imperative that school counselors create cultures in which students expect that college can be a reality in their future. In conducting college admissions counseling with culturally diverse students, school counselors should address the many concerns that these students might have, including issues such as the availability of financial aid, the diversity of university/college student populations, and students’ fears about leaving home and entering the new cultural environments of university campuses. Muhammed (2008) found that school counselors’ expectations for students’ future education positively influenced students’ college predisposition at a high magnitude. Clearly, school counselors hold a powerful position in the college admissions process for all students. For first-generation college students, school counselors are even more important—they may be the key to whether or not students apply to college or take the courses that are necessary for college admission. Conclusions There is no doubt that school counselors can play a transformative role in schools. Education reform aimed at addressing the needs of culturally diverse students requires educators who understand and embrace cultural diversity, advocate for change, and recognize cultural conflict. These three skills, among others, are imperative for the 21st-century school counselor. Given the dramatic changes in school demographics and the need for a skilled workforce in the future, the United States is in dire need of school counselors who are culturally competent, ready to promote social justice principles, and able to articulate the linkages among mental health, education, and community building. We believe that the collective work of school counselors, teachers, parents, administrators, and other school and community stakeholders must be characterized by social justice principles. Critical Incident Achievement data at High School X consistently show a sizable gap between students of color and White students in math and language arts. High School X is situated in a metropolitan suburban community where the majority of students are White and affluent. The school’s student enrollment, however, is ethnically mixed—35% African American, 20% Latino, 30% White, 5% Asian, and 10% other ethnicities. Of the total student body, 30% qualify for free and reduced-price lunches; African American and Latino students make up a majority of the free and reduced-price lunch population. The percentage of White students at High School X has decreased steadily over the past 5 years, causing community and school district concern. Parental involvement is high among White parents but low among low-income parents and parents of color. African American and Latino parents have complained (consistently) to the principal that the teachers are not “sensitive” to their children’s cultural differences. In addition, numerous students have come to the guidance office complaining about “racial tension” between groups of students (ethnic groups, economic groups, and so on). The principal has asked the school counseling team to assist with these problems. Discussion Questions 1. What are at least three significant factors that affect the achievement of culturally diverse students in schools? Discuss the impacts of these factors on overall student development and wellness. 2. What is the difference between equality and equity? Why may some people disagree with an “equity” perspective in school counseling? 3. What does taking a social justice approach to counseling mean to you? What are some possible challenges to using a social justice-based ap-proach in schools? 4. List skills that you need to be an effective, culturally competent school counselor. Are these skills that you have mastered, need to improve, or do not possess? 5. Discuss your strengths and your needs for improvement in multicultural school counseling. References Alegria, M., Vallas, M., & Pumariega, A. (2010). Racial and ethnic disparities in pediatric mental health. Child and Adolescent Psychiatric Clinics of North America, 19, 759–774. Ali, S., & Ancis, J. R. (2005). Multicultural education and critical pedagogy approaches. In C. Enns & A. L. Sinacore (Eds.), Teaching and social justice: Integrating multicultural and feminist theories in the classroom (pp. 69–84). Washington, DC: American Psychological Association. doi:10.1037/10929-004 American Psychological Association. (1990). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. Retrieved from http://www.apa.org/pi/oema/resources/policy/provider-guidelines.aspx American School Counselor Association. (2009). The professional school counselor and cultural diversity. Alexandria, VA: Author. American School Counselor Association. (2010). Ethical standards for school counselors. Alexandria, VA: Author. Aud, S., Hussar, W., Planty, M., Snyder, T., Bianco, K., Fox, M., Frohlich, L., Kemp, J., & Drake, L. (2010). The condition of education 2010 (NCES 2010-028). Washington, DC: U.S. Department of Education, National Center for Education Statistics. Retrieved from http://nces.ed.gov/pubs2010/2010028.pdf Boyd-Franklin, N. (2003). Race, class, and poverty. In F. Walsh (Ed.), Normal family processes: Growing diversity and complexity (3rd ed., pp. 260–279). New York: Guilford Press. Bridgeland, J., & Bruce, M. (2011). 2011 national survey of school counselors: Counseling at a crossroads. New York: College Board. Retrieved from http://media.collegeboard.com/digitalServices/pdf/nosca/11b_4230_NarReport_BOOKLET_WEB_11 Brown, K. (2003). From teacher-centered to learner-centered curriculum: Improving learning in diverse classrooms. Education, 124(1), 49–54. Bryk, A., & Schneider, B. (2002). Trust in schools: A core resource for improvement. New York: Russell Sage Foundation. Collins, N. M., & Pieterse, A. L. (2007). Critical incident analysis based training: An approach for developing active racial/cultural awareness. Journal of Counseling & Development, 85(1), 14–23. Council for the Accreditation of Counseling and Related Educational Programs. (2009). CACREP standards. Retrieved from http://www.cacrep.org/wp-content/uploads/2013/12/2009-Standards.pdf Davies, D. (1993). Benefits and barriers of parent involvement. In N. Chavkin (Ed.), Families and schools in a pluralistic society (pp. 205–216). Albany: State University of New York Press. Day-Vines, N. L., Wood, S., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K., & Douglass, M. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85, 401–409. Denbo, S. J. (2002). Why can’t we close the achievement gap? In S. J. Denbo & L. Moore Beaulieu (Eds.), Improving schools for African American students: A reader for educational leaders (pp. 13–16). Springfield, IL: Charles C Thomas. Duncan, A. (2009, February). Speech delivered at the 91st Annual Meeting of the American Council on Education, Washington, DC. Duncan, C. F., & Pryzwansky, W. B. (1993). Effects of race, racial identity development, and orientation style on perceived consultant effectiveness. Journal of Multicultural Counseling and Development, 21, 88–96. Education Trust. (2008). Core problems: Out-of-field teaching persists in key academic courses and high-poverty schools. Washington, DC: Author. Retrieved from http://www.edtrust.org/sites/edtrust.org/files/publications/files/SASSreportCoreProblem.pdf Feller, R. W. (2003). Aligning school counseling, the changing workplace, and career development assumptions. Professional School Counselor, 6(4), 262–271. Flannery, D. J., Wester, K. L., & Singer, M. I. (2004). Impact of exposure to violence in school on child and adolescent mental health and behavior. Journal of Community Psychology, 32, 559–573. Ford, D. Y., Grantham, T. C., & Whiting, G. W. (2008). Culturally and linguistically diverse students in gifted education: Recruitment and retention issues. Exceptional Children, 74(3), 289–306. Franklin, A. J., & Franklin, N. (2000). Invisibility syndrome: A clinical model of the effects of racism on African-American males. American Journal of Orthopsychiatry, 70(1), 33–41. Fry, R. (2008). The role of schools in the English language learner achievement gap. Washington, DC: Pew Hispanic Center. Retrieved from http://files.eric.ed.gov/fulltext/ED502050.pdf Galassi, J. P., & Akos, P. (2007). Strengths-based school counseling: Promoting student development and achievement. New York: Taylor Francis. Gamoran, A., & Hannigan, E. C. (2000). Algebra for everyone? Benefits of college-preparatory mathematics for students with diverse abilities in early secondary school. Education Evaluation and Policy Analysis, 22(3), 241–254. Gibbs, J. T. (1980). The interpersonal orientation in mental health consultation: Toward a model of ethnic variation in consultation. Journal of Community Psychology, 8, 195–207. Graham, S. (2006). Peer victimization in school: Exploring the ethnic context. Current Directions in Psychological Science, 15, 317–321. Harper, S. R. (2010). An anti-deficit achievement framework for research on students of color in STEM. New Directions for Institutional Research, 2010(148), 63–74. Hawley, E., & McWhirter, E. (1991). Empowerment in counseling. Journal of Counseling & Development, 69, 222–230. Henderson, A. T., Mapp, K. L., Johnson, V. R., & Davies, D. (2007). Beyond the bake sale: The essential guide to family–school partnerships. New York: New Press. Hipolito-Delgado, C. P., & Lee, C. C. (2007). Empowerment theory for the professional school counselor: A manifesto for what really matters. Professional School Counseling, 10, 327–332. Holcomb-McCoy, C. (2004). Assessing the multicultural competence of school counselors: A checklist. Professional School Counseling, 7, 178–186. Holcomb-McCoy, C. (2007). School counseling to close the achievement gap: A framework for success. Thousand Oaks, CA: Corwin. Holcomb-McCoy, C., & Bryan, J. (2010). Advocacy and empowerment in parent consultation. Journal of Counseling & Development, 88, 259–268. Holland, N., & Farmer-Hinton, R. (2009). Leave no schools behind: The importance of a college culture in urban public high schools. High School Journal, 92(3), 24–43. Hook, J. N., & Davis, D. E. (2012). Integration, multicultural counseling, and social justice. Journal of Psychology & Theology, 40(2), 102–106. Horowitz, K., Weine, S., & Jekel, J. (1995). PTSD symptoms in urban adolescent girls: Compounded community trauma. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1353–1361. House, R., & Hayes, R. (2002). School counselors: Becoming key players in school reform. Professional School Counseling, 5(4), 249–256. Humes, K. R., Jones, N. A., & Ramirez, R. R. (2010, March). Overview of race and Hispanic origin: 2010 (Census Brief No. C2010BR-02). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf Ingraham, C. L. (2000). Consultation through a multicultural lens: Multicultural and cross-cultural consultation in schools. School Psychology Review, 29, 320–343. Ingraham, C. L. (2003). Multicultural consultee-centered consultation: When novice consultants explore cultural hypotheses with experienced teacher consultees. Journal of Educational and Psychological Consultation, 14, 329–362. Johnson, R. S. (2002). Using data to close the achievement gap: How to measure equity in our schools. Thousand Oaks, CA: Corwin. Juvonen, J., & Graham, S. (Eds.). (2001). Peer harassment in school: The plight of the vulnerable and victimized. New York: Guilford Press. Kaffenberger, C., & Young, A. (2008). Making DATA work. Alexandria, VA: American School Counselor Association. Kalyanpur, M., & Rao, S. S. (1991). Empowering low-income Black families of handicapped children. American Journal of Orthopsychiatry, 61(4), 523–532. Kataoka, S. H., Stein, B. D., Jaycox, L. H., Wong, M., Escudero, P., Tu, W., Zaragoza, C., & Fink, A. (2003). A school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 311–318. Kena, G., Aud, S., Johnson, F., Wang, X., Zhang, J., Rathbun, A., Wilkinson-Flicker, S., & Kristapovich, P. (2014). The condition of education 2014 (NCES 2014-083). Washington, DC: U.S. Department of Education, National Center for Education Statistics. Retrieved from http://nces.ed.gov/pubs2014/2014083.pdf Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & Palmer, N. A. (2012). The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York: Gay, Lesbian & Straight Education Network. Retrieved from http://www.glsen.org/sites/default/files/2011%20National%20School%20Climate%20Survey%20Full Losen, D. J., & Orfield, G. (Eds.). (2002). Racial inequity in special education. Cambridge, MA: Harvard Education Press. McHugh, R., Horner, C., Colditz, J. B., & Wallace, T. (2013). Bridges and barriers: Adolescent perceptions of student–teacher relationships. Urban Education, 48(1), 9–43. McKinsey & Company. (2008). The economic impact of the achievement gap in America’s schools. New York: Author. Retrieved from http://mckinseyonsociety.com/downloads/reports/Education/achievement_gap_report.pdf Milner, R. H. (2007). Race, narrative inquiry, and self-study in curriculum and teacher education. Education and Urban Society, 39(4), 584–609. Moseley-Howard, G. S. (1995). Best practices in considering the role of culture. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology (3rd ed., pp. 337–345). Washington, DC: National Association of School Psychologists. Muhammed, C. G. (2008). African American students and college choice: A consideration of the role of school counselors. NASSP Bulletin, 92(2), 81–94. National Center for Education Statistics. (2007). Urban education in America. Table C.1.a.-1. Number and percentage distribution of public elementary and secondary school teachers, by locale and selected characteristics: 2007–08. Retrieved from http://nces.ed.gov/surveys/ruraled/tables/c.1.a.-1.asp?refer=urban National Center for Education Statistics. (2009). The Nation’s Report Card: Trial urban district assessment mathematics 2009 (NCES 2010-452). Washington, DC: Institute of Education Sciences, U.S. Department of Education. Retrieved from http://nces.ed.gov/nationsreportcard/pdf/dst2009/2010452rev.pdf National Center for Education Statistics. (2011). The Nation’s Report Card, summary of major findings. Retrieved from: http://nationsreportcard.gov/math_2011/summary.asp National Center for Health Statistics. (2012). Health, United States, 2011: With special feature on socioeconomic status and health. Hyattsville, MD: Author. Retrieved from http://www.cdc.gov/nchs/data/hus/hus11.pdf Nestor-Baker, N., & Kerka, S. (2009, October). Recruitment and retention of underrepresented students in STEM fields. Columbus: Ohio State University. Retrieved from http://www.osu.edu/documents/STEM_recruitment_retention.doc Nieto, S. (1999). Critical multicultural education and students’ perspectives. In S. May (Ed.), Critical multiculturalism: Rethinking multicultural and antiracist education (pp. 209–235). London: Falmer Press. Noguera, P. (2004). Racial isolation, poverty, and the limits of local control in Oakland. Teachers College Record, 106(11), 2146–2170. Nunn, L. M. (2011). Classrooms as racialized spaces: Dynamics of collaboration, tension, and student attitudes in urban and suburban high schools. Urban Education, 46(6), 1226–1255. Orfield, G., & Lee, C. (2007). Historic reversals, accelerating resegregation, and the need for new integration strategies. Cambridge, MA: Civil Rights Project at Harvard University. Pelavin, S. H., & Kane, M. B. (1990). Changing the odds: Factors increasing access to college. New York: College Entrance Examination Board. Perkins, D. D., & Zimmerman, M. A. (1995). Empowerment theory, research, and application. American Journal of Community Psychology, 23(5), 569–579. Perna, L., Li, C., Rowan-Kenyon, H. T., Thomas, S. L., Bell, A., & Anderson, R. (2008). The role of college counseling in shaping college opportunity: Variations across high schools. Review of Higher Education, 31, 131–159. Planty, M., Hussar, W., Snyder, T., Kena, G., KewalRamani, A., Kemp, J., Bianco, K., & Dinkes, R. (2009). The condition of education 2009 (NCES 2009-081). Washington, DC: U.S. Department of Education, National Center for Education Statistics. Retrieved from http://nces.ed.gov/pubs2009/2009081.pdf Ponterotto, J. G., Casas, J. M., Suzuki, L. A., & Alexander, C. M. (Eds.). (2010). Handbook of multicultural counseling (3rd ed.). Thousand Oaks, CA: Sage. Remafedi, G. (1987). Male homosexuality: The adolescent’s perspective. Pediatrics, 79, 326–337. Rodríguez, L. F. (2008). Struggling to recognize their existence: Examining student–adult relationships in the urban high school context. Urban Review, 40, 436–453. Rosenbaum, J., Miller, S. R., & Krei, M. S. (1996). Gatekeeping in an era of more open gates: High school counselors’ views of their influence on students’ college plans. American Journal of Education, 104, 257–279. Rowan, A. H., Hall, D., & Haycock, K. (2010). Gauging the gaps: A deeper look at student achievement. Washington, DC: Education Trust. Retrieved from http://www.edtrust.org/sites/edtrust.org/files/publications/files/NAEP%20Gap_0.pdf Scales, P. C. (2005). Developmental assets and the middle school counselor. Professional School Counseling, 9(2), 104–111. Schmidt, C. D., Hardinge, G. B., & Rokutani, L. J. (2012). Expanding the school counselor repertoire through STEM-focused career development. Career Development Quarterly, 60(1), 25–35. Sheridan, S. M. (1992). Consultant and client outcomes of competency based behavioral consultation training. School Psychology Quarterly, 7, 245–270. Sheridan, S. M. (2000). Considerations of multiculturalism and diversity in behavioral consultation with parents and teachers. School Psychology Review, 29, 344–353. Somers, C. L., Owens, D., & Piliawsky, M. (2008). Individual and social factors related to urban African American adolescents’ school performance. High School Journal, 91(3), 1–11. Tarver-Behring, S., & Ingraham, C. L. (1998). Culture as a central component of consultation: A call to the field. Journal of Educational and Psychological Consultation, 9, 57–72. Turner, S. M. (1982). Behavior modification and Black populations. In S. M. Turner & R. T. Jones (Eds.), Behavior modification and Black populations: Psychosocial issues and empirical findings (pp. 1–19). New York: Plenum Press. U.S. Department of Education. (2001). The longitudinal evaluation of school change and performance (LESCP) in Title 1 schools. Washington, DC: Government Printing Office. Werner, E. E., & Smith, R. S. (1992). Overcoming the odds: High risk children from birth to adulthood. Ithaca, NY: Cornell University Press. Whiting, G. W., Ford, D. Y., Grantham, T. C., & Moore, J. L. (2008). Multicultural issues: Considerations for conducting culturally responsive research in gifted education. Gifted Child Today, 31(3), 26–30. Wiley, A., Wyatt, J. N., & Camara, W. J. (2010). The development of a multidimensional college readiness index. New York: College Board. Retrieved from http://www.cascadeeducationalconsultants.com/resources/Blog/College-Readiness-Index.pdf Williams, T., Connolly, J., Pepler, D., & Craig, W. (2005). Peer victimization, social support, and psychosocial adjustment of sexual minority adolescents. Journal of Youth and Adolescence, 34(5), 471–482. Appendix Professional School Counselor Multicultural Competence Checklist Directions: Check whether you are competent or not competent on each of the following items. Source: Holcomb-McCoy (2004). 13 Reflective Clinical Practice With People of Marginalized Sexual Identities Eliza A. Dragowski María R. Scharrón-del Río Primary Objective ■ To contribute to the development of awareness, knowledge, and skills of mental health professionals around issues surrounding the marginalization of people whose sexual identities defy heteronormative norms Secondary Objectives ■ To analyze historical, contextual, societal, and conceptual issues that are relevant to counselors’ work with people of marginalized sexual identities ■ To present and critically analyze the intersections of privilege and oppression around heteronormativity, heterosexism, and sexism as they relate to counseling with people of marginalized sexual identities ■ To present and discuss several guidelines for reflective practice with this client population In our society, the prevailing cultural ethos of heteronormativity privileges heterosexuality (Nadal, 2013; Sue, 2010) as the “default category to which people are assumed to fit” unless they break these values and norms and “make a conscious effort to adopt a different classification... or... [reject] the classification system entirely” (Hicks & Milton, 2010, p. 258). When we began writing this chapter, we were aware of the many excellent reviews of research and practice that address developmental, vocational, parenting, and health issues among people whose identities and lives are marginalized and disrupted by heteronormativity and heterosexism (e.g., Chung, Szymanski, & Markle, 2012; Croteau, Bieschke, Fassinger, & Manning, 2008). Therefore, we decided that our contribution to this topic would be most valuable if we focused on a critical analysis of the prevailing constructs surrounding people of marginalized sexual identities.1 Our aim in this chapter, then, is to contribute to the development of awareness, knowledge, and, ultimately, skills of mental health professionals (MHPs) concerned with issues surrounding marginalization of people who defy heteronormative norms.2 We will analyze the salient historical, contextual, societal, and conceptual issues that affect MHPs’ work with this client population. We will also offer several guidelines for reflective practice, highlighting the need for MHPs to (1) cultivate self-awareness with respect to social norms and social locations, (2) understand that people’s sexual identities exist in synergy and can be understood only in relation to other identities (such as gender, race, ethnicity, religion, class), and (3) promote a social advocacy stance. We begin by asking the reader to reflect on what it means when we call someone or ourselves gay, lesbian, or bisexual. Although, as Hicks and Milton (2010) note, human sexuality is “one of the richest and most universal of human experiences, while also being one of the most nebulous, complicated, and personal” (p. 257), “gay,” “lesbian,” and “bisexual” categories are often assumed to be self-evident. The reality, however, can be more complex. Categories Versus Lived Experiences Discussions of sexual orientation and sexual identity usually rely on categorizations of people as straight/heterosexual, gay, lesbian, or bisexual. Our society, with its affinity for certainty and categorization, appears to “accept gay/lesbian and to a lesser extent bisexuality as viable alternatives to heterosexuality, provided one easily subscribes to a single identity and stereotypical characteristics of each” (Hicks & Milton, 2010, pp. 258–259). Nevertheless, people’s interpretations of their lives and experiences do not always fit neatly into fixed identity labels (Diamond, 2008; Hicks & Milton, 2010; Rust, 2003). Fausto-Sterling (2012) describes a television show about mature women who, after years of sustaining relationships with husbands, “discovered” that they were attracted to women and, therefore, identified as lesbians. The show’s narrative created an assumption of fundamentality about sexual identity: These women were inherently lesbian, which is why their midlife “discoveries” were presumed to erase years of heterosexual and often satisfying relationships. While it is possible that some of these women had always been attracted to women and engaged in heterosexual relationships in order to avoid stigma, female sexuality has been shown to be fluid and context dependent. For example, Espín (1999) found that the dynamics of immigrant lesbian and heterosexual women’s sexual behaviors transformed along with their migration experiences. Diamond’s (2008) study of women who initially identified as lesbian, bisexual, or otherwise nonheterosexual also showed that, over the course of 10 years, many of these women moved across the boundaries of sexual identities, sometimes repeatedly. What about men’s sexual fluidity? Although the literature shows that men’s gender and sexual identities and expressions can be flexible in some indigenous cultures (e.g., Hutchings & Aspin, 2007; Jacobs, Thomas, & Lang, 1997), in current Western societies men’s sexualities tend to be more stable than women’s (Baumeister, 2000; Connell & Messerschmidt, 2005; Fausto-Sterling, 2012). Nonetheless, Alfred Kinsey’s seminal study with White American participants revealed a prevalent variability in men’s sexual behaviors, with 46% of the studied male population sexually engaging with both men and women (Kinsey, Pomeroy, & Martin, 1948/1998). While various arguments persist, the current state of our knowledge does not fully explain how cultural, biological, and psychological processes interact to influence the development of human sexuality and desire (Fassinger & Arseneau, 2007; Fausto-Sterling, 2012). People construct their sexual identities in myriad ways, according to cultural norms and ways of understanding sexuality, intimate preferences, sexual behaviors, fantasies, arousal patterns, attractions, and self-identifications (Fassinger & Arseneau, 2007; Hutchings & Aspin, 2007). For example, Rust (1992) found that for some of the lesbians in her study sample, self-identification was based on the dominance of homosexual feelings and behaviors. However, women who experienced sexual feelings toward men for up to 50% of the time also claimed lesbian identity. Comparatively, some self-identified bisexual women claimed this identity while acknowledging that 80% to 90% of their sexual experiences were with other women. We, along with other authors (e.g., Fassinger & Arseneau, 2007; Hicks & Milton, 2010; L. C. Smith, Shin, & Officer, 2012), acknowledge that categorizing people according to exclusive groupings is problematic. These limiting categories create artificial distinctions and narrow lenses for understanding people’s experiences. More insidiously, they can “become instantiated as essential identities rather than as neutral social markers and, as such, become regulatory mechanisms of the dominant culture” (L. C. Smith et al., 2012, p. 390). At the same time, however, the terms lesbian, gay, bisexual, and heterosexual/nonheterosexual are not only ubiquitous in social and clinical dialogue but also vital to civil rights protections, which are granted based on defined group status (Fassinger & Arseneau, 2007). Moreover, the almost universal oppression and victimization experienced by people because of their (often assumed) nonnormative sexuality cannot be overlooked. Das Nair and Thomas (2012) describe two Iranian boys who were killed after a publicly discovered sexual encounter. Although no evidence suggested that they self-identified as gay, “irrespective of what they called themselves or how they identified... the outcome was death” (p. 64). In another recent example, two Ecuadorian brothers who expressed familial affection toward each other on a New York City street were brutally attacked by men shouting antigay and anti-Latino slurs; the attack left one of the brothers battered and the other one dead (Fahim, 2010). Therefore, dissociating the content of this chapter from the language permeating clinical, social, and political discourse would reduce it to a pure theoretical exercise, and that would run contrary to our goal of helping MHPs to work with members of this population. As L. C. Smith et al. (2012) observe: Socially constructed identity categories not only structure how persons think about and position themselves relative to power and privilege in society but simultaneously supply a foothold from which to critically analyze inequities inherent in such positioning. At this time, without social identity categories, critically conscious counselors have no way to speak to the inequitable experiences of millions. The utilization of socially constructed identity categories is, paradoxically, part of the problem and part of the solution. (p. 390) People describe themselves using a variety of terms, including gay, lesbian, straight, bisexual, queer, questioning, asexual, and pansexual, depending on how they perceive their sexual identities at particular moments in their lives (Galupo, 2011; Hicks & Milton, 2010). Since these labels may not be appropriate for people who resist or do not recognize these categories, we will use the term LGB judiciously (e.g., when referencing studies using LGB categories or when referring specifically to people with lesbian, gay, and bisexual identities), while acknowledging these terms’ limitations. We will use the term people of marginalized sexual identities when discussing people whose sexual identities fall outside norms prescribed by heteronormativity.3 We use these terms to describe populations that are diverse, fluid, and represent a wide range of realities and experiences. Moreover, we understand the term sexual orientation to refer to romantic, emotional, and/or erotic attractions to others that are expressed through behaviors, affectionate bonds, and romantic relationships (American Psychological Association [APA], 2008). We understand sexual identity to refer to the way people understand themselves with regard to sexual orientation and acknowledge that sexual identity can be fluid and may intersect with other identities, such as race, class, and gender (das Nair & Butler, 2012). In the next section, we present a historical and cultural review of the concept of homosexuality. After all, “if we know the past, then perhaps we can improve our understanding of the present and move toward a future that includes those who have not always been considered previously” (Strickland, 2001, p. 365). Historical Context Sexual behavior between people of the same gender has been documented across various historical, cultural, and geographic contexts (Crompton, 2006; Nussbaum, 2002). Historians and anthropologists disagree, however, about the interpretation of these apparent homosexual behaviors. Various cultures have constructed sexuality according to their own standards, as “bodily experiences are brought into being by our development in particular cultures and historical periods” (Fausto-Sterling, 2012, p. 78). For example, a person’s sexuality could be regulated by the individual’s class, gender role, or age as opposed to the gender of his or her partner (Rust, 1992). The present conceptualizations of homosexuality and heterosexuality are popularly believed to have emerged in 19th-century Europe based on the binary model of femininity and masculinity (Drescher, 2010; Fausto-Sterling, 2012; Foucault, 1980; Rust, 1992). The practice of assigning people to distinct and exclusive categories facilitated the policing of gender and lent itself to measurements in the service of the medical and psychological sciences (Fausto-Sterling, 2012). Soon after the introduction of the concept of homosexuality into the lexicon and medical literature, people began to use this knowledge to understand themselves. According to Hansen (1992), “By helping to give large numbers of people an identity and a name, medicine also helped to shape these people’s experience and change their behavior, creating . . . a new species of person, ‘the modern homosexual’ ” (p. 125). Shortly after the concept of homosexuality was introduced to the United States, heterosexuality was assigned the “normal” status. This view, supported by medical, religious, and legal institutions, quickly became the natural state of being (Fausto-Sterling, 2012). The construction of homo- and heterosexuality also formed the possibility for bisexuality, although this sexual orientation and identity remained largely ignored by the medical and social sciences for many years (Rust, 1992, 2003). The American Psychiatric Association defined homosexuality as a mental disorder in the first (1952) and second (1968) editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I and DSM-II). Facilitated by the civil rights movement, the climate began to change in the early 1970s. Social activists and some health professionals began to question a pathological view of homosexuality, focusing instead on the effects of social stigma caused by homosexual identity as well as the stigma of the “homosexuality” diagnosis. Eventually, in 1973, the American Psychiatric Association agreed that homosexuality was not a mental disorder. After working through the opposition of those who disagreed, and after failing to remove homosexuality entirely from DSM-III (1980; the diagnosis was removed and replaced with “ego dystonic homosexuality”), the association finally eliminated the diagnosis from the next edition, DSM-III-R, in 1987 (Drescher, 2010).4 With time, psychotherapeutic efforts designed to reframe same-gender desires, sexual arousal, and behavior came under a great amount of scrutiny, and supportive treatment approaches began to proliferate (APA Task Force, 2009). Research conducted as early as the 1950s found that homo- and heterosexual people do not differ significantly in terms of mental health (Hooker, 1957). A plethora of subsequent studies have shown that LGB and straight populations are comparable across measures of adaptation, mental health, cognitive abilities, and self-esteem (APA, 2012; APA Task Force, 2009; Chung et al., 2012; Hooker, 1957). Currently, scientists agree that the stress of being a member of a socially oppressed group is a major contributor to increased incidence of mental health issues, and an extensive body of research shows this phenomenon among people of marginalized sexual identities (e.g., Balsam, Beauchaine, & Rothblum, 2005; Dragowski, Halkitis, Grossman, & D’Augelli, 2011; Gonsiorek & Weinrich, 1991; Huebner, Rebchook, & Kegeles, 2004; N. Smith & Ingram, 2004; Stevenson, 2007; Szymanski, 2005). In fact, the minority stress model is one of the most influential theoretical and explanatory frameworks used to understand how stigma, prejudice, and discrimination create distinctive stressors that contribute to negative health outcomes among people who defy heteronormativity (Meyer, 2003). The rise of the modern gay and lesbian movement in the late 20th century paved the way for sociopolitical communities that shared common sexual identity and political interests (Rust, 1992). As these communities developed, they had to negotiate their positionality within the larger society. Social Construction of Sexual Inequality In this section, we review some of the important societal structures that facilitate oppression and marginalization. While we concentrate on heterosexism and sexism, our thinking is based in the belief that all oppressive structures are based on (1) simplifying complex phenomena by dividing them into two separate extremes, (2) positioning some groups of people as superior to “others,” and (3) classifying the values and beliefs of the dominant group as superior (and therefore normal) rather than appreciating the values of all people equally (Jun, 2010). Heterosexism and Heteronormativity Heteronormativity is a dominant social norm that promotes the presumed superiority and naturalness of heterosexuality. Within this ethos, heterosexual people are celebrated, recognized, and positioned as the only legitimate members of the “people” category, while those who deviate are stigmatized (Kitzinger, 2005; L. C. Smith et al., 2012). Sexual stigma refers to “the negative regard, inferior status, and relative powerlessness” that are attached to “nonheterosexual behaviors, identity, relationships, or communities” (Herek, Gills, & Cogan, 2009, p. 33). Structural sexual stigma is also known as heterosexism, an oppressive ideological system “embodied in institutional practices that work to the disadvantage of sexual minority groups” (Herek et al., 2009, p. 33). Maintaining the dominance of heterosexuality involves the pervasive practice of othering: dichotomizing human diversity, marking those who are perceived as different, and problematizing the marked group (Canales, 2000; Coston & Kimmel, 2012; Greene, 2005). Through othering, one way of being is superior while the “opposite” way is rendered inferior; one is exaggeratedly celebrated and visible while the other becomes unacknowledged. Ultimately, every person existing outside the norm represents an “alternative” to or a “variation” on the norm (Kitzinger, 2005). And so, with implicit support from sociopolitical structures, people who do not embody heteronormativity “are presumed to be abnormal, unnatural, requiring explanation, and deserving of discriminatory treatment and hostility” (Herek et al., 2009, p. 33). Whether seen as unfortunate victims or solicitors of oppression by way of sexual aberrance, people of marginalized sexual identities are targeted as the ones with the problem (Diangelo, 1997). That is how the cycle of dominance is not only established but also naturalized, legitimated, and, ultimately, considered to be justified. Gender and Sexism Compulsory heterosexism and heteronormativity are intertwined with implicit assumptions about gender and gender inequality. Traditional gender structures are maintained by the “production of discrete and asymmetrical oppositions between ‘feminine’ and ‘masculine,’ where these are understood as expressive attributes of ‘male’ and ‘female’” (Butler, 1990, p. 24). This binary discourse creates assumptions, expectations, and stereotypes about each gender and marginalizes those who transgress gender norms (Serano, 2007; L. C. Smith et al., 2012). This phenomenon, known as oppositional sexism, operates to legitimize feminine expressions in women and to delegitimize feminine expressions in men (and vice versa for masculinity). So, while all people are capable of expressing feminine traits, oppositional sexism ensures that such expression will appear natural when produced by women and unnatural when produced by men. (Serano, 2007, p. 326) Oppositional sexism, in turn, is an active arm of cisnormativity, the idea that people who are born as biological males will become men who will naturally express masculinity, and people who are born as biological females will become women who will naturally express femininity (Bauer et al., 2009; Serano, 2007). In this social norm, cisgender people—those who express and identify with the genders that were assigned to them at birth—are privileged and normalized, as opposed to people who are transgender or genderqueer (Tate, 2012). Since the idea of the “opposite sexes” interlinks gender and sexuality through the “compulsory practice of heterosexuality” (Butler, 1990, p. 208), people with nonheterosexual identities are also seen as violating gender norms. Additionally, all (including heterosexual) people who do not rigidly subscribe to traditional gender norms are problematized by cisnormativity (McInnes & Couch, 2004; Ueno & McWilliams, 2010). The binary and oppositional gender norms also create traditional sexism, in which femininity, generally associated with women, is subordinated to masculinity, which is seen as belonging to men (Connell, 1987; Schilt & Westbrook, 2009; Serano, 2007). The assumption [is] that masculinity is strong while femininity is weak, that masculinity is tough while femininity is fragile, that masculinity is rational while femininity is irrational, that masculinity is serious while femininity is frivolous, that masculinity is functional while femininity is ornamental, that masculinity is natural while femininity is artificial and that masculinity is sincere while femininity is manipulative. (Serano, 2014) In addition, femininity is often cast in the role of pleasuring and benefiting masculinity (ObradorsCampos, 2011; Serano, 2007). Through early socialization, most people tend to conform to the rules of sexism and gender inequality, as most girls implicitly learn to accommodate the interests and desires of men (Connell, 1987) and typical boys learn how to distance themselves from femininity (which is seen as subjugated and weak) while embodying strength, domination, and power (Dragowski & Scharrón-del Río, 2014; Kimmel, 2005). Strickland (2001) notes that MHPs often do not know how to provide answers to people of marginalized communities because they “do not even understand the question” (p. 372). We hope that the above review of conceptual, historical, social, and systemic issues supports readers’ understanding of the life contexts of persons within this client population. In the next section, we provide a brief analysis of some tangible clinical concerns that are important for MHPs to keep in mind when working with people of marginalized sexual identities. Thoughts on Reflective Counseling Recent advances in social, political, and civil rights in the United States have helped to alter the therapeutic approaches used in counseling work with people of marginalized sexual identities (APA Task Force, 2009). A significant shift from “corrective” to “affirmative” treatment approaches is certainly a welcome change. But, like most changes, this one might be experiencing growing pains. While LGB civil rights have progressed significantly, in the words of President Obama (2007), “we still have a lot of work to do.” Similarly, the current level of clinical work with this population has been described as “oversimplified, noninclusive,” and carried out under the general banner of “it’s okay to be gay” (Bieschke, Perez, & DeBord, 2007, p. 3). Sexual stigma is internalized by everyone, regardless of sexual identity (Herek et al., 2009). All MHPs have been raised and trained in a culture steeped in oppressive ideologies, including heterosexism, sexism, and heteronormativity, that shape biased views of clients and their struggles (Greene, 2007). These societal biases become part of MHPs’ individual and collective psyches and, when left unexamined, reinforce themselves as natural phenomena (Bieschke et al., 2007; Greene, 2007; Herek et al., 2009; Sue, 2010). While the subjugation of marginalized communities regularly takes overt forms, oppressive ideologies also operate outside conscious awareness and are frequently accepted and perpetrated by well-meaning people (including MHPs and educators) who explicitly champion democratic and egalitarian principles (Athanases & Larrabee, 2003; McCabe, Dragowski, & Rubinson, 2012; L. C. Smith et al., 2012). Recent research reveals the pervasiveness and deleterious effects of these covert forms of oppression, called microaggressions (Nadal, 2013; Sue, 2010). Self-Awareness and Examination of Social Locations Like all systems of inequality, heterosexism and heteronormativity legitimate marginalization, ostracism, degradation, and even violence against those whose behaviors and identities are not in accord with the prevailing ideology (Herek et al., 2009; Obradors-Campos, 2011). While it is relatively easy to detect overt cases of heterosexism, focusing only on extreme examples allows people to avoid examination of their own subtle, and often unintentional, behaviors that perpetuate this ideology. This complicity (intrinsic to heterosexual privilege) allows oppression to thrive, as “the ‘problem’ is externalized, while the sense of normalcy in our status is internalized” (Diangelo, 1997, p. 9). Consequently, while activists battle overt discrimination, the “heteronormative social fabric [continues to be] unobtrusively rewoven, thread by thread, persistently, without fuss or fanfare, without oppressive intent or conscious design” (Kitzinger, 2005, p. 478). It is partly for this reason that some scholars have called for abandoning the use of the word homophobia when speaking about negative attitudes toward people of marginalized sexual identities (Dermer, Smith, & Barto, 2010; Herek, 2004; L. C. Smith et al., 2012). The term was coined by Weinberg in 1972 to denote irrationally negative attitudes toward, fear of, and hatred of gays and lesbians by straight people (Dermer et al., 2010). However, the connection of the word phobia to the field of psychiatry situates the term homophobia within the realm of medicine, thus absolving the people who propagate such discrimination of moral responsibility and failing to accentuate the structural inequities nested within marginalization and oppression (L. C. Smith et al., 2012). An attitude of reflective practice with people of marginalized identities must begin not only with MHPs’ understanding of the established oppressive norms but also with an acknowledgment of their own part in perpetuating the inequality (Ferfolja, 2007). Heterosexism and heteronormativity, although functioning tacitly within all of us, are rarely discussed (Greene, 2005). Why? Partly because these systems are normalized to the point of becoming natural and invisible (Cole, Avery, Dodson, & Goodman, 2012; Kitzinger, 2005). Moreover, dismantling their own biases and privileges requires that MHPs deconstruct and question the norms that benefit them simply for being born into a dominant group—a process that stimulates intense discomfort and defensiveness (Diangelo, 1997). Although difficult, MHPs’ self-examination of their privileged gender and sexual identities is necessary for effective practice with this client population. In addition to locating sources of privilege, MHPs must scrutinize their beliefs and feelings about their own expressions of sexual identity, whether they belong to privileged or marginalized communities. For example, although heterosexual identity development has been relegated to the “natural” position (Hicks & Milton, 2010), a close examination of heterosexual identity enables practitioners to recognize and examine their own sexual identities and social positioning. Worthington, Savoy, Dillon, and Vernaglia’s (2002) model of heterosexual identity development offers the possibility of examining people’s individual and societal heterosexual identities, including their positions as members of a privileged and oppressive majority. Meaningful self-application of this model is likely to result in respect for sexual diversity; self-identification of sexual needs, values, and behaviors; and development of “conscious, coherent perspectives on dominant/nondominant group relations, privilege, and oppression” (Worthington et al., 2002, p. 519) around issues of sexual identity.. Similar processes must also take place with respect to the analysis of gender. MHPs must be conscious of how they express their genders and assess their level of comfort with diversity of gender expression. In addition, (especially) MHPs who identify with and express cisnormativity and binary gender ideology must critically examine their often subconscious participation in traditional and oppositional sexism. Such examination can result in a deconstruction of gender entitlement, described as “the arrogant conviction that one’s own beliefs, perceptions, and assumptions regarding gender and sexuality are more valid than those of other people,” and gender anxiety, “the act of becoming irrationally upset or being made uncomfortable by the existence of those people who challenge or bring into question one’s entitlement” (Serano, 2007, p. 89). MHPs who neglect the process of cultivating self-awareness and self-analysis run the risk of engaging in therapeutic microaggressions. These behaviors are subtle forms of heterosexism, often perpetrated by well-meaning clinicians who consciously align themselves with principles of social justice (Nadal, 2013; Sheldon & Delgado-Romero, 2011; Sue, 2010). Some examples of sexual orientation microaggressions include the avoidance or minimization of the client’s sexual identity, orientation, or behavior; the assumption that all presenting mental health issues are related to the client’s sexual identity, orientation, or behavior; overidentification based in the assumption of similarity and/or familiarity with people of marginalized sexual identities; the assumption of universal experience among members of this client population; and the denial of heterosexism (Nadal, 2013; Sheldon & Delgado-Romero, 2011). Conversely, the ongoing and lifelong practice of self-analysis of gender and sexuality identity will lead MHPs to a new level of critical consciousness. Such self-analysis is an important part of becoming a truly reflective clinician who is not only aware but also purposely observes and resists oppressive systems in self and in society (L. C. Smith et al., 2012). The previously described heterosexism and heteronormativity are two such societal systems of oppression that warrant careful scrutiny. Awareness of Heterosexism and Heteronormativity While oppressive to people of marginalized sexual and gender identities, heterosexism, heteronormativity, and strict gender norms also create specific challenges for self-identified men or women of all sexual identities. Because of societal veneration of masculinity, men of marginalized sexual identities tend to be more vilified and to encounter stronger negative societal reactions than women who violate gender and sexual norms (Britton, 1990; Otis & Skinner, 1996). In the pervasive climate of dominant masculinity, these men are likely to be seen as flagrant violators of the established norms of masculinity and (in a show of misogyny) belittled for being perceived as womanlike (Connell & Messerschmidt, 2005; Coston & Kimmel, 2012; Ellis, 2012; Herek, 2002). In comparison to men, women (in Western secular societies) tend to be allowed more flexibility to move across gendered spaces (Ellis, 2012). However, this “paradoxical benefit” comes at the cost of invisibility and the discounting of female sexuality and women overall (Fassinger & Arseneau, 2007; Otis & Skinner, 1996). Due to the intersection of oppressions targeting gender and sexual orientation/identity, women of marginalized sexual identities are exposed to multiple negative effects created by their double-subjugated status (Firestein, 2007). As we will discuss later, if these women’s sexual identities are interlocked with other marginalized social identities (e.g., race, ethnicity, economic standing, or ability) their lives can be marked by additional burdens (Collins, 1990; Greene, 1996, 2007). The dualistic discourse framing gender and sexuality creates particular challenges for people who identify as bisexual. A binary discourse views people as either gay or straight (L. C. Smith et al., 2012) and renders bisexual persons unacknowledged, even within the gay and lesbian communities (Firestein, 2007; Potoczniak, 2007). Although, in our society, bisexual men tend to be more stigmatized than bisexual women (in accordance with the greater importance assigned to men and men’s sexuality), all bisexual persons face stigmatization from both general and gay/lesbian communities (Potoczniak, 2007). For example, the prevalent belief that bisexuality is a failure to achieve a stable (monosexual) sexual identity ascribes higher moral status to heterosexuals, as well as to lesbians and gay men, than to bisexuals (Firestein, 2007; Obradors-Campos, 2011). The pervasiveness of heterosexism and heteronormativity perpetuates stigma, which forces people to understand themselves and others according to those systems (Herek et al., 2009). For straight/heterosexual people, this process translates into discomfort, judgment, hatred, and/or violence toward persons who challenge heteronormativity. For people of marginalized sexual identities, such stigma is internalized and can translate into self-directed devaluation as well as stigmatization of others within their community. Negative mental health and relational correlates of internalized sexual stigma (also known as internalized homophobia or internalized homonegativity) are well documented in the literature (e.g., Frost & Meyer, 2009; Herek, Cogan, Gills, & Glunt, 1997). One example of internalized stigma can be seen among some gay and bisexual men who, in response to having their masculinity devalued and threatened, adhere to hypermasculine ideology, which, in turn, is linked to increased depression and anxiety (Connell, 1992; Fischgrund, Halkitis, & Carroll, 2012; Halkitis, 2001). Finally, we must acknowledge the pernicious effects of heterosexism and heteronormativity on every member of society, regardless of sexual identity. The common denominator for all those who are oppressed is the “inhibition of their ability to develop and exercise their capacities and express their needs, thoughts and feelings” (Obradors-Campos, 2011, p. 215). As people navigate the rules of the heterosexual matrix and avoid being targets of sexual stigma, they tend to restrict certain behaviors and to control the full expression of their emotions and needs (Butler, 1990; Herek et al., 2009; Obradors-Campos, 2011). Consider, for example, what Serano (2007) calls effemimania, which she defines as our societal obsession with critiquing and belittling feminine traits in males... [, which] encourages those who are socialized male to mystify femininity and to dehumanize those who are considered feminine,... thus form[ing] the foundation of virtually all male expressions of misogyny. (p. 342) Since others can easily undermine a typical boy’s masculinity by calling him a “sissy” or a “girl,” boys commonly engage in elaborate exhibitions of their masculinity and heterosexuality. In the process, they inhibit the parts of themselves that they perceived as feminine (which they equate with weakness), thus eschewing emotionality, vulnerability, and interconnectedness. Ultimately, boys and men not only perniciously deny themselves full participation in the human experience but also absorb and reinforce denigration of women (Dragowski & Scharrón-del Río, 2014; Kimmel, 2005; Klein, 2012; Nakkula & Toshalis, 2006; Pascoe, 2007; Way, 2011). Another example of self-censoring can be seen in going underground, the process described by Gilligan wherein adolescent girls transition from assertive self-expression to a more “‘appropriate’ feminine behavior [that] is neither loud nor aggressive” (Nakkula & Toshalis, 2006, p. 102) in order to make themselves more acceptable socially and to preserve social relationships. Deconstructing the societal structures and systems of privilege and oppression that relate to heterosexism and heteronormativity is but one part of the process of becoming a reflective and culturally aware clinician. MHPs must also examine all of their social locations as they relate to race, ethnicity, ability, socioeconomic status, and other social identities, especially if they belong to societally privileged groups. Although, as Coates (2013) observes, “in modern America we believe racism to be the property of the uniquely villainous and morally deformed, the ideology of trolls, gorgons and orcs,” racism, along with many other oppressive ideologies, can be perpetuated by wellintentioned people who have never examined their privileged standing in society. Through the process of critical self-awareness MHPs can understand, acknowledge, and begin to resist the social forces that shape their acceptance of and (often unwitting) participation in complex systems of privilege and oppression.5 Awareness of Intersectionality of Identities Well it’s hard for me to separate [my identities]. When I’m thinking of me, I’m thinking of all of them as me. Like once you’ve blended the cake you can’t take the parts back to the main ingredients. (study participant quoted in Bowleg, 2012, p. 758) Systems of inequality pose additional challenges for people whose multiple identities are stigmatized. A growing body of research demonstrates that MHPs’ meaningful consideration of the intersectionality of clients’ identities is integral to the provision of effective clinical services (Greene, 2005, 2007; Riggs & das Nair, 2012) and, therefore, represents an important area of MHPs’ clinical competence. The intersectional approach to understanding people is not a simple analysis of the addition of identities; rather, it involves the examination of an intricate set of interrelating identities that concurrently interact and can become differently prominent in various developmental phases and contexts (Greene, 2005; Riggs & das Nair, 2012). Depending on temporal and spatial contexts, some of these identities may be socially privileged while others are oppressed, creating a unique mosaic of dynamics that often bring these clients to seek assistance from MHPs (Greene, 2007). Since the understanding of sexuality is culturally contingent, MHPs can help clients of various ethnocultural groups only if they are knowledgeable about those groups’ norms and practices. For example, it is not unusual for people whose sexual and ethnocultural identities are marginalized to be confronted with conflicting social norms and familial demands and to prioritize one identity over the other (Greene, 2007). Among individuals in these populations, identification with mainstream LGB communities (usually perceived as White) is often made cautiously if at all, as such identification may appear to be a rejection of ethnocultural values (Fassinger & Arseneau, 2007; Liddle, 2007). This is especially true if a person’s particular culture has a history of racial and/or ethnic oppression/colonization. For example, in the recollections of a British Arab woman, coming out to her family led to abuse and accusations that she had made the family appear “modernized, westernized, [and] filthy” (Goldberg, 2010, as cited in das Nair & Thomas, 2012, p. 68). Moreover, a positive stance toward public coming out, with its emphasis on individuality, may be in conflict with cultures that value collective identity, thus creating tensions between loyalty and allegiance (Bieschke et al., 2007). MHPs should never discount their clients’ concerns about affirmation from their ethnocultural communities. People of marginalized sexual and ethnocultural identities can struggle with accusations of being inauthentic to themselves if they choose not to come out (das Nair & Thomas, 2012). Although they may be perceived as exclusionary, ethnocultural communities also provide people of marginalized sexual identities with comfort, support, and a shield from societal racism (Liddle, 2007). Cultural proscriptions and community bonds may be so strong that some people will choose not to come out publicly in order to maintain these ties. For example, many African Americans and Latino/as are well integrated into their ethnocultural communities if they do not explicitly align with marginalized sexual identities and communities. Similarly, the Midwest has its own version of a “don’t ask, don’t tell” policy that is maintained between rural lesbians and their communities (Liddle, 2007). Moreover, various cultures prescribe particular rules designating who is and is not gay. For example, in some Mediterranean and Latino/a cultures, only the receptive (“bottom”) sexual partners label themselves gay, not the insertive (“top”) ones; in some indigenous cultures people who engage in sexual relations with people of all genders are known as two-spirit and are held in high regard (Fassinger & Arseneau, 2007). Becoming knowledgeable and competent scholars of cultural diversity also enables MHPs to help their clients reflect on instances when invoked cultural loyalties are profoundly hurtful and damaging to the clients’ health. As Greene (2007) notes, “It may be difficult for [some LGB] client[s] to appreciate the fact that cultural values are being used selectively and in ways that may depart from the manner in which the family or group generally adheres to them” (p. 188). Religion, which is often intricately linked with people’s ethnocultural heritage, can also be a source of tensions and discord in families of this client population (das Nair & Thomas, 2012; Shannahan, 2010). Although secularity is often assumed of people of marginalized sexual identities, religious affiliation can be important, and even primary, to these clients’ understanding of self and fundamental to their experience of life as meaningful (Shannahan, 2010; Yip, 2010). However, historically, many religious doctrines have been used selectively to support social inequalities, including subjugation of women, laws against miscegenation, and racial segregation. Even in contemporary religious institutions, men’s voices are usually given more credence than women’s (Rios et al., 2011; Shannahan, 2010). As Greene (2007) argues, “While ethical practice requires practitioners to be sensitive to cultural and religious norms, this does not mean that such norms should be accepted blindly without regard for whether or not they are causing harm” (p. 188). One of the most controversial topics of debate concerning ethical practice is the issue of so-called conversion therapy. Such treatment is championed by some religious groups and is sometimes requested by people of marginalized sexual identities who believe themselves to be sinners and hope to be cured of their desires toward people of the same gender (das Nair & Thomas, 2012). MHPs who conduct conversion therapy claim to do so out of respect for their clients’ religious beliefs. However, ethical practice, which demands respect for human diversity (including religious beliefs), also dictates that MHPs do no harm. Although conversion therapy has been shown to contribute to initial feelings of hope and acquisition of skills needed to assimilate a heterosexual identity, it has also been linked with the reinforcement of negative self-stereotypes, beliefs in unrealistic outcomes, intensification of self-hatred, intimacy difficulties, helplessness, and suicidal ideation (Beckstead & Israel, 2007). Most important, however, although many conversion therapists believe in the treatment’s effectiveness, even Robert Spitzer, whose well-publicized study has been used as proof that same-gender desires can be converted to other-gender desires through therapeutic interventions, recently apologized to “the gay community.” In a formal letter, he admitted to the study’s “fatal flaws,” which invalidated its results (Becker, 2012). Following a large-scale review of the scientific literature on efforts to change sexual orientation, the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation (2009) deemed such efforts ineffective and potentially harmful. The APA, along with most other professional associations, recommends supportive therapy approaches that encourage identity exploration and active coping without the imposition of any explicit sexual orientation identity outcomes. It has also been recommended that people of marginalized sexual identities who have strong religious beliefs be supported in their exploration of the possibility of integrating their two identities (APA Task Force, 2009; Beckstead & Israel, 2007; Glassgold, 2008). Religion and spirituality can be sources of comfort and support for such individuals if they can successfully integrate these aspects of identity with sexual identity (das Nair & Thomas, 2012). MHPs can aid clients in accomplishing this integration by helping them find compassionate and egalitarian religious communities, which exist within every major religious group (e.g., Browne, Munt, & Yip, 2010; Robinson, 2012; Shannahan, 2010). MHPs who facilitate these negotiations must be mindful of the intersectionality and specificity of the religious and ethnocultural identities of the clients, especially if they are not identities that are privileged in our society. As Yip (2008) notes, it would be naive to assume that for ethnocultural people of marginalized sexual identities the reconciliation of identities would mirror the trajectory of such reconciliation for their White Christian counterparts: Such an expectation of homogeneity and assimilation would be limiting and insensitive to cultural diversity within the LGB community. The assumption that there is one “developmental model” for all LGB identity and politics—led by the precedent set by “white” and LGB Christians—is unsound, since identity is socially and culturally grounded. (p. 283) Just as Judeo-Christian religious identities can be privileged, hierarchical divisions based on the interplay of other identities exist within LGB communities, mirroring society at large (Greene, 2005). In 2010, Judith Butler declined to accept the Berlin Civil Courage Prize, protesting the gay and lesbian community’s failure to challenge the Whiteness of the majority of its constituents as well as its failure to actively challenge the marginalization of people based on their intersecting identities, including social class, race, and gender variance (Riggs & das Nair, 2012). As Greene (2005) notes: All members of disadvantaged groups are not equally disadvantaged and all do not automatically learn to be any more tolerant of differences than members of the majority. Like members of dominant groups, members of disadvantaged groups with privileged identities may often deny those privileged identities, preferring to focus on their locus of disadvantage. It is usually the majority voices that are most privileged and often deemed to speak for the entire culture. (p. 304) Several scholars have written about the experiences of ethnocultural people of marginalized sexual identities (e.g., das Nair & Thomas, 2012; Firestein, 2007; Greene, 1996, 2007; Liddle, 2007). However, it is important to note that social class, religion, physical and mental (dis)ability, age, and other client identities exist and interact continuously with each other and with the societal structures. As such, they represent important areas of exploration for MHPs.6 For example, among people of marginalized sexual identities, working-class status (das Nair & Hansen, 2012) often interacts with ethnocultural identities, exacerbating negative health burdens and disabilities (Halkitis et al., 2011; Krehely, 2009; Mays, Cochran, & Zamudio, 2004). Becoming a Judicious Scholar of the Literature MHPs need to become discerning students of the literature concerning people of marginalized sexual identities. As Greene (2007) observes, working with this client population requires that MHPs have specific knowledge and skills that are often neglected in mental health–related graduate programs. For example, sexual identity development and coming out are important processes that have been described and conceptualized extensively since the 1970s (e.g., Cass, 1979; Coleman, 1981–1982; Troiden, 1979). While the early models introduced linear, stage progressions from sexual identity unawareness to coming out and gay/lesbian identity integration (Liddle, 2007), recent models are more inclusive in their attention to younger people, gender, and sexual diversity (attending to experiences of nonheterosexual women and bisexual people), as well as racial and ethnic diversity (for reviews, see Bilodeau & Renn, 2005; Chung et al., 2012). Coming out has been acknowledged as a positive and healthy process for people of marginalized sexual identities, and these models are considered important in that they provide essential frameworks for addressing issues commonly encountered during sexual identity development. At the same time, however, these models have been criticized for being simplistic, promoting linear and gradual trajectories that do not fit the experiences of many, endorsing a specific end point as the healthiest outcome of identity development, and ignoring human diversity and intersecting identities (Bilodeau & Renn, 2005; das Nair & Thomas, 2012; Diamond, 2006; Liddle, 2007; Matthews, 2007; Rust, 2003). As noted earlier, depending on the client’s identifications and appropriated hierarchy of cultural values, that individual’s coming-out process, or its end point, may not look like the ones described in the widely accepted sexual identity development models (das Nair & Thomas, 2012). While it is important for MHPs to keep abreast of health, vocational, developmental, family, and other issues pertaining to people of marginalized sexual identities, they must also remember that scholarly work concerning these populations is beset with myriad shortcomings. These include methodological issues, such as use of retrospective data collected from small samples of socially privileged populations; varying assignments of participants to the gay, lesbian, and bisexual categories; and the historical lack of attention to the experiences of women, bisexual people, and other people (e.g., pansexual, asexual) of marginalized sexual identities (Fassinger & Arseneau, 2007; Fausto-Sterling, 2012; Hicks & Milton, 2010). Adopting an Advocacy Position History (“his story”), including the history of psychology, is written by the “winners.” An old African proverb notes that the tale of the hunters would be quite different if written by the lions. (Strickland, 2001, p. 365) Mental health institutions have a history of othering, problematizing, diagnosing, marginalizing, hospitalizing, and even incarcerating “women, minorities, and those who do not fit a White, Western European patriarchic hegemony” (Strickland, 2001, p. 365). When compared with contemporary attitudes, past treatment of people who were deemed to behave in an “unnatural” ways is clearly oppressive. However, we are always at risk of falling into oppressive ideologies (Jun, 2010; Strickland, 2001). Although today oppression and marginalization can be more subtle and shrouded in empiricism, they still pervade the society as well as mental health establishments (Dragowski, Scharrón-del Río, & Sandigorsky, 2011; Strickland, 2000, 2001). As Greene (2005) states, “When psychotherapy paradigms legitimize the social status quo rather than examine it critically, they become instruments of social oppression and control and by definition contribute to social injustice” (p. 300). Therefore, in order to work competently with people representing the full spectrum of diversity, MHPs must continually guard against subtle tactics preventing the analysis of dominant ideologies. We believe that the adoption of a social justice advocacy position is a necessary component of the reflective therapeutic stance. We agree with Glassgold (2007), who asserts that MHPs must “make [their] work a liberatory experience, to be among those who offer solutions to problems of social justice” (p. 38). Martín-Baró (1998) also recommends that, in order to understand the realities they seek to study, MHPs need to clarify their locations within these realities both personally and as individuals and members of social classes. Therefore, in addition to analyzing prevalent ideologies, cultivating self-awareness/self-social locations, and understanding the intersectionality of people’s social identities, MHPs should become actively involved in resisting dominant oppressive norms and visibly supporting the rights of marginalized people (Glassgold, 2007; Jun, 2010; Larson, 2008). As they openly stand with people of marginalized sexual identities, MHPs will not only support these clients but also actively witness oppression. As Stevenson (2007) notes, in any situation of unfairness, “in addition to a victim and perpetrator there is often a witness who can highlight the reactions of others to the victimization” (p. 389). Effective witnessing has the potential to validate that injustice has taken place, create a source of resilience, and offer sociopolitical and personal support to the oppressed, as well as demonstrate refusal to conspire with the oppressor. Ultimately, people whose distress is pathologized are like canaries in coal mines. Their distress is not a symptom of pathology but rather a warning that there is ‘‘‘poison in the air’ in the form of toxic social conditions,” which, if left unchanged, will affect each and every person in the society (Greene, 2005, p. 302). Reflective clinical practice must concentrate on helping people to survive these toxic conditions while simultaneously attempting to eradicate social inequalities. Conclusions The advocacy position helps to reinforce a stable reflective therapeutic stance in which imbalances of power—in the society as well as in the therapeutic environment—are recognized and equalized (Larson, 2008). The deconstruction of social inequalities alerts MHPs to the many health burdens resulting from these inequalities, but the story of reflective clinical practice does not end here. While MHPs should remain acutely aware of the systems of inequality, they should not lose sight of the countless pathways to resilience, suffering, joy, apprehension, loss, and recovery. Every clinical engagement should be marked by a multilayered and multidimensional stance, as MHPs must treat all clients as people with “emotion and intellect, multiple identities, rich sociocultural and familial history, a particular relationship to oppression and privilege, and particular thinking patterns” (Jun, 2010, p. 378). It is clinically competent to see a client’s circumstances as an interplay of intrapersonal (e.g., individual differences, personality, trauma history, internalized oppression, unexamined privilege), interpersonal (e.g., family dynamics, community affiliation), and social dimensions (e.g., experience with the “isms,” systematic location of privilege and oppression, personal history of discrimination). At various times some of these dimensions will be more relevant to a client’s distress than others, but most of the time the client’s experiences will reflect the synergy of all dimensions. Critical Incident Laura is a counselor at a small, private, progressive, and predominantly White university in the northeastern United States. Laura is a White, straight, U.S.-born cisgender woman of Dutch descent who graduated from an Ivy League university. She has been a mental health practitioner for the past 8 years and considers herself to be an effective and competent clinician. For the past 2 months, Laura has been working with Eduardo, a 19-year-old cisgender man, a freshman at the university, who initially presented with a depressed mood, inability to concentrate, and general anhedonia. Eduardo is an immigrant from the Dominican Republic; he was 5 years old when he arrived in the United States with his family. He grew up in the Southeast, which he considers home and where his family still lives. He is the eldest of four siblings (María, Carmen, and Lissette are 14, 12, and 6, respectively) and the first one in his family to go to college. Eduardo’s parents, who are extremely proud of their “college boy,” worked multiple jobs while he was growing up and now own a small neighborhood restaurant. Eduardo works there during school breaks and is studying business so that he can take over the management of the restaurant and allow his parents to retire. In the course of treatment, Eduardo discloses that for the past 6 months he has been having erotic encounters with men. He discounts these encounters as “just playing” and, after a recollection of every encounter, he tells Laura about his plans to get married to a woman and to have a large family. He tells Laura that he is not gay, because he is “very masculine” (un tigre) and always the “top” during sex, which he considers comparable to having sex with a woman. Lately, Eduardo has been talking a lot about one particular young man, Clive, with a lot of tenderness and affection. Eduardo talks about Clive wanting to go on “real dates” and finds these requests “ridiculous,” as he does not date men. At the same time, Laura notes Eduardo’s worsening mood and apathy turning into passive suicidal ideation. She is familiar with research linking closeted homosexuality with negative psychological consequences. Since coming out is empirically correlated with improved mental and general health functioning, Laura is convinced that Eduardo’s worsening mental health is related to his inability to come out and decides that she will assist Eduardo with this process. Laura’s therapeutic goals are not easy to implement, however. No matter how gently she brings it up, Eduardo becomes angry and, at times, leaves sessions prematurely. At one point, Laura shares her experience of being the only nonlegacy student among her friends at her Ivy League university in order to show Eduardo that she knows what it means to feel different and not always accepted. She also shares the story of her gay cousin, who came out about 10 years ago. She states that she knows how hard it is to come out, but she imagines that things must be so much easier for gay people now than they were for her cousin. Laura’s disclosure is met with a blank stare from Eduardo. One day, Laura looks around her office and notices that none of the books or pamphlets she has available relate to “gay issues.” She makes an effort and brings in pamphlets advertising the university’s Gay, Lesbian, Bisexual, and Queer Student Union. At Eduardo’s next session, she asks him if he would be willing to go with her to the organization’s open house the next week. Eduardo’s eyes well up with tears. He says, “I cannot believe you. You have no idea who I really am.” He storms out of the room and does not come back for his next three scheduled appointments. Discussion Questions 1. What assumptions does Laura appear to be making about the etiology of Eduardo’s symptoms? 2. What factors from Eduardo’s background and present situation may be contributing to his current mental health? 3. What are some of the important intersectional issues (in terms of gender, sexuality, and ethnocultural background) at play for Eduardo? What are some of the important intersectional issues at play for Laura? 4. How are Laura’s actions the result of her lack of self-awareness and privilege as it relates to working with people of oppressed identities? 5. What sexual orientation microaggressions can you identify in Laura’s interactions with Eduardo? 6. What do you think Laura should do to reengage Eduardo in meaningful, respectful, and reflective psychotherapeutic work? Notes 1. In this chapter, the conceptual phrase people of marginalized sexual identities denotes people who, in the scholarly literature reviewed and utilized here, are referred to as lesbian, gay, bisexual, and/or queer (LGBQ). People who identify as asexual or pansexual also live with marginalized sexual identities and can be subject to the same oppressions that we elaborate in this work, but we do not specifically address the lived experiences or needs of these populations, as that is beyond the scope of the literature referenced and, thus, of this chapter. 2. We use mental health professionals as an umbrella term that includes counselors, psychologists, social workers, psychiatrists, and other professionals who engage in counseling and psychotherapy. 3. Since gender norms are interconnected with heteronormativity, people who fall outside the heteronormative paradigm also fall outside gender normativity. In this chapter, we do not specifically address issues related to transgender and transsexual people. Although trans people share some history and oppressive societal treatment with people of marginalized sexual identities, there is increasing evidence of the need to understand the experiences of these populations separately (Pyne, 2011). While trans people—like everyone else—can identify as straight, gay, bisexual, or queer (and therefore have marginalized sexual identities in addition to marginalized gender identities and expressions), we understand trans issues to be connected primarily to gender rather than to sexual identity. These issues are addressed in detail in Chapter 10 of this book. 4. Notably, the possibility of conceptualizing sexuality as causing distress remained in the DSM-IVTR (fourth edition, text revision, published in 2000) with the diagnosis of “sexual disorder not otherwise specified.” It was removed in 2013, with the publication of the fifth edition, DSM-5. 5. Various models of deconstructing privilege are available in published literature. Deconstructing privilege: Teaching and learning as allies in the classroom by K. Case is one example of a book aimed at analysis and confrontation of systemic privilege. 6. A full review of the topic of intersectionality of identities is beyond the scope of this chapter; for a comprehensive analysis of the topic, see das Nair and Butler (2012). References American Psychological Association. (2008). Answers to your questions: For a better understanding of sexual orientation and homosexuality. Washington, DC: Author. Retrieved from www.apa.org/topics/sorientation.pdf American Psychological Association. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Washington, DC: American Psychological Association. American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders. Washington, DC: Author. American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Athanases, S. Z., & Larrabee, T. G. (2003). Toward a consistent stance in teaching for equity: Learning to advocate for lesbian- and gay-identified youth. Teaching and Teacher Education, 19(2), 237–261. doi:10.1016/S0742-051X(02)00098-7 Balsam, K. F., Beauchaine, T. P., & Rothblum, E. D. (2005). Victimization over the life span: A comparison of lesbian, gay, bisexual, and heterosexual siblings. Journal of Consulting and Clinical Psychology, 73(3), 477–487. Bauer, G., Hammond, R., Travers, R., Kaay, M., Hohenadel, K. M., & Boyce, M. (2009). “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. Journal of the Association of Nurses in AIDS Care, 20, 348–361. Baumeister, R. F. (2000). Gender differences in erotic plasticity: The female sex drive as socially flexible and responsive. Psychological Bulletin, 126, 347–374. Becker, J. M. (2012, April 25). Exclusive: Dr. Robert Spitzer apologizes to gay community for infamous “ex-gay” study. Truth Wins Out. Retrieved from http://www.truthwinsout.org/news/2012/04/24542 Beckstead, L., & Israel, T. (2007). Affirmative counseling and psychotherapy focused on issues related to sexual orientation conflicts. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 221–244). Washington, DC: American Psychological Association. doi:10.1037/11482-009 Bieschke, K. J., Perez, R. M., & DeBord, K. A. (2007). Introduction: The challenge of providing affirmative psychotherapy while honoring diverse contexts. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 3–11). Washington, DC: American Psychological Association. doi:10.1037/11482-000 Bilodeau, B. L., & Renn, K. A. (2005). Analysis of LGBT identity development models and implications for practice. New Directions for Student Services, 111, 25–39. Bowleg, L. (2012). “Once you’ve blended the cake, you can’t take the parts back to the main ingredients”: Black gay and bisexual men’s descriptions and experiences of intersectionality. Sex Roles, 68(11/12), 754–767. doi:10.1007/s11199-012-0152-4 Britton, D. M. (1990). Homophobia and homosociality: An analysis of boundary maintenance. Sociological Quarterly, 31(3), 423–439. Browne, K., Munt, S. R., & Yip, A. K. T. (2010). Queer spiritual spaces: Sexuality and sacred places. Farnham, England: Ashgate. Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. New York: Routledge. Canales, M. K. (2000). Othering: Toward an understanding of difference. Advanced Nursing Science, 22(4), 16–31. Cass, V. C. (1979). Homosexuality identity formation: A theoretical model. Journal of Homosexuality, 4, 219–235. doi:10.1300/j082v04n03_01 Chung, Y. B., Szymanski, D. M., & Markle, E. (2012). Sexual orientation and sexual identity: Theory, research, and practice. In N. A. Fouad (Ed.), Handbook of counseling psychology: Vol. 1. Theories, research, and methods (pp. 423–451). Washington, DC: American Psychological Association. Coates, T. (2013, March 6). The good, racist people. New York Times. Retrieved from http://www.nytimes.com/2013/03/07/opinion/coates-the-good-racist-people.html?_r=0 Cole, E. R., Avery, L. R., Dodson, C., & Goodman, K. D. (2012). Against nature: How arguments about the naturalness of marriage privilege heterosexuality. Journal of Social Issues, 68(1), 46–62. Coleman, E. (1981–1982). Developmental stages of the coming out process. Journal of Homosexuality, 7(2–3), 31–43. doi:10.1300/j082v07n02_06 Collins, P. H. (1990). Black feminist thought: Knowledge, consciousness, and the politics of empowerment. New York: Routledge. Connell, R. (1987). Gender and power: Society, the person, and sexual politics. Stanford, CA: Stanford University Press. Connell, R. W. (1992). A very straight gay: Masculinity, homosexual experience, and the dynamics of gender. American Sociological Review, 57(6), 735–751. Connell, R. W., & Messerschmidt, J. W. (2005). Hegemonic masculinity: Rethinking the concept. Gender & Society, 19, 829–859. doi:10.1177/0891243205278639 Coston, B. M., & Kimmel, M. (2012). Seeing privilege where it isn’t: Marginalized masculinities and the intersectionality of privilege. Journal of Social Issues, 68(1), 97–111. Crompton, L. (2006). Homosexuality and civilization. Cambridge, MA: Belknap Press. Croteau, J. M., Bieschke, K. J., Fassinger, R. E., & Manning, J. L. (2008). Counseling psychology and sexual orientation: History, selective trends, and future directions. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (4th ed., pp. 194–211). Hoboken, NJ: John Wiley. das Nair, R., & Butler, C. (Eds.). (2012). Intersectionality, sexuality and psychological therapies: Working with lesbian, gay and bisexual diversity. Chichester, England: John Wiley. das Nair, R., & Hansen, S. (2012). Social class. In R. das Nair & C. Butler (Eds.), Intersectionality, sexuality and psychological therapies: Working with lesbian, gay and bisexual diversity (pp. 137–162). Chichester, England: John Wiley. das Nair, R., & Thomas, S. (2012). Race and ethnicity. In R. das Nair & C. Butler (Eds.), Intersectionality, sexuality and psychological therapies: Working with lesbian, gay and bisexual diversity (pp. 59–87). Chichester, England: John Wiley. Dermer, S. B., Smith, S. D., & Barto, K. K. (2010). Identifying and correctly labeling sexual prejudice, discrimination, and oppression. Journal of Counseling & Development, 88, 325–331. Diamond, L. M. (2006). What we got wrong about sexual identity development: Unexpected findings from a longitudinal study of young women. In A. M. Omoto & H. S. Kurtzman (Eds.), Sexual orientation and mental health: Examining identity and development in lesbian, gay, and bisexual people (pp. 73–94). Washington, DC: American Psychological Association. Diamond, L. M. (2008). Sexual fluidity: Understanding women’s love and desire. Cambridge, MA: Harvard University Press. Diangelo, R. (1997). Heterosexism. Journal of Progressive Human Services, 8(1), 5–21. doi:10.1300/J059v08n01_02 Dragowski, E. A., Halkitis, P. N., Grossman, A. H., & D’Augelli, A. R. (2011). Sexual orientation victimization and posttraumatic stress symptoms among lesbian, gay, and bisexual youth. Journal of Gay & Lesbian Social Services, 23(2), 226–249. doi:10.1080/10538720.2010.541028 Dragowski, E. A., & Scharrón-del Río, M. R. (2014). The importance of challenging hegemonic masculinity in preventing school violence. School Psychology Forum, 8(1), 10–27. Dragowski, E. A., Scharrón-del Río, M. R., & Sandigorsky, A. (2011). Childhood gender identity... disorder? Developmental, cultural, and clinical concerns. Journal of Counseling & Development, 89, 360–366. Drescher, J. (2010). Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual. Archives of Sexual Behavior, 39, 427–460. doi:10.1007/s10508-009-9531-5 Ellis, S. J. (2012). Gender. In R. das Nair & C. Butler (Eds.), Intersectionality, sexuality and psychological therapies: Working with lesbian, gay and bisexual diversity (pp. 31–57). Chichester, England: John Wiley. Espín, O. M. (1999). Women crossing boundaries: A psychology of immigration and the transformations of sexuality. New York: Routledge. Fahim, K. (2010, April 22). Brother of victim in baseball-bat killing testifies in the hate-crime trial. New York Times. Retrieved from http://www.nytimes.com/2010/04/23/nyregion/23hate.html?_r=0 Fassinger, R. E., & Arseneau, J. R. (2007). “I’d rather get wet than be under that umbrella”: Differentiating the experiences and identities of lesbian, gay, bisexual, and transgender people. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 19–49). Washington, DC: American Psychological Association. doi:10.1037/11482-001 Fausto-Sterling, A. (2012). Sex/gender: Biology in a social world. New York: Routledge. Ferfolja, T. (2007). Schooling cultures: Institutionalizing heteronormativity and heterosexism. International Journal of Inclusive Education, 11, 147–162. doi:10.1080/13603110500296596 Firestein, B. A. (2007). Cultural and relational contexts of bisexual women: Implications for therapy. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 91–117). Washington, DC: American Psychological Association. doi:10.1037/11482-004 Fischgrund, B. N., Halkitis, P. N., & Carroll, R. A. (2012). Conceptions of hypermasculinity and mental health states in gay and bisexual men. Psychology of Men and Masculinity, 13, 123–135. doi:10.1037/a0024836 Foucault, M. (1980). The history of sexuality (Vol. 1). New York: Vintage. Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56(1), 97–109. Galupo, M. P. (2011). Bisexuality: Complicating and conceptualizing sexual identity. Journal of Bisexuality, 11(4), 545–549. doi:10.1080/15299716.2011.620866 Glassgold, J. M. (2007). “In dreams begin responsibilities”: Psychology, agency and activism. Journal of Gay and Lesbian Psychotherapy, 11(3/4), 37–57. Glassgold, J. M. (2008). Bridging the divide: Integrating lesbian identity and Orthodox Judaism. Women and Therapy, 31, 59–73. Goldberg, A. (2010, October 24). Tale of gay woman forced to marry to protect “honour.” BBC News. Retrieved from http://www.bbc.co.uk/news/us-11613992 Gonsiorek, J., & Weinrich, J. (1991). Definition and scope of sexual orientation. In J. Gonsiorek & J. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 1–12). Newbury Park, CA: Sage. Greene, B. (1996). Lesbian women of color. Journal of Lesbian Studies, 1(1), 109–147. doi:10.1300/J155v01n01_09 Greene, B. (2005). Psychology, diversity and social justice: Beyond heterosexism and across the cultural divide. Counselling Psychology Quarterly, 18(4), 295–306. doi:10.1080/09515070500385770 Greene, B. (2007). Delivering ethical psychological services to lesbian, gay, and bisexual clients. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 181–199). Washington, DC: American Psychological Association. doi:10.1037/11482-007 Halkitis, P. N. (2001). An exploration of perceptions of masculinity among gay men living with HIV. Journal of Men’s Studies, 9(3), 413–429. Halkitis, P. N., Brockwell, S., Siconolfi, D. E., Moeller, R. W., Sussman, R. D., Mourgues, P. J., Cutler, B., & Sweeney, M. M. (2011). Sexual behaviors of adolescent emerging and young adult men who have sex with men ages 13–29 in New York City. Journal of Acquired Immune Deficiency Syndromes, 56(3), 285–291. doi:10.1097/QAI.0b013e318204194c Hansen, B. (1992). American physicians’ “discovery” of homosexuals, 1880–1900: A new diagnosis in a changing society. In C. Rosenberg & J. Golden (Eds.), Framing disease (pp. 104–133). New Brunswick, NJ: Rutgers University Press. Herek, G. M. (2002). Gender gaps in public opinion about lesbians and gay men. Public Opinion Quarterly, 66(1), 40–66. Herek, G. M. (2004). Beyond “homophobia”: Thinking about sexual prejudice and stigma in the twenty-first century. Sexuality Research & Social Policy, 1(2), 6–24. Herek, G. M., Cogan, J. C., Gills, J. R., & Glunt, E. K. (1997). Correlates of internalized homophobia in a community sample of lesbian and gay men. Journal of the Gay and Lesbian Medical Association, 1(2), 17–25. Herek, G. M., Gills, J. R., & Cogan, J. C. (2009). Internalized stigma among sexual minority adults: Insights from a social psychological perspective. Journal of Counseling Psychology, 56(1), 32–43. doi:10.1037/a0014672 Hicks, C., & Milton, M. (2010). Sexual identities: Meanings for counselling psychology practice. In R. Woolfe, S. Strawbridge, B. Douglas, & W. Dryden (Eds.), Handbook of counselling psychology (3rd ed., pp. 257–275). London: Sage. Hooker, E. (1957).The adjustment of the male overt homosexual. Journal of Projective Techniques, 21, 18–31. Huebner, D. M., Rebchook, G. M., & Kegeles, S. M. (2004). Experiences of harassment, discrimination, and physical violence among young gay and bisexual men. American Journal of Public Health, 94(7), 1200–1203. Hutchings, J., & Aspin, C. (2007). Sexuality and the stories of indigenous people. Wellington, New Zealand: Huia. Jacobs, S. E., Thomas, W., & Lang, S. (1997). Two-spirit people: Native American gender identity, sexuality, and spirituality. Urbana: University of Illinois Press. Jun, H. (2010). Social justice, multicultural counseling, and practice: Beyond a conventional approach. Thousand Oaks, CA: Sage. Kimmel, M. S. (2005). Masculinity as homophobia: Fear, shame, and silence in the construction of gender identity. In M. S. Kimmel (Ed.), The gender of desire: Essays on male sexuality (pp. 25–42). Albany: State University of New York Press. Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1998). Sexual behavior in the human male. Philadelphia: W. B. Saunders. (Original work published 1948) Kitzinger, C. (2005). Heteronormativity in action: Reproducing the heterosexual nuclear family in after-hours medical calls. Social Problems, 52, 477–498. Klein, J. (2012). The bully society: Shootings and the crisis of bullying in America’s schools. New York: New York University Press. Krehely, J. (2009). How to close the LGBT health disparities gap. Washington, DC: Center for American Progress. Retrieved from http://www.americanprogress.org/wpcontent/uploads/issues/2009/12/pdf/lgbt_health_disparities_race.pdf Larson, G. (2008). Anti-oppressive practice in mental health. Journal of Progressive Human Services, 19(1), 39–54. doi:10.1080/10428230802070223 Liddle, B. J. (2007). Mutual bonds: Lesbian women’s lives and communities. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 51–69). Washington, DC: American Psychological Association. doi:10.1037/11482-002 Martín-Baró, I. (1998). Psicología de la liberación. Madrid: Editorial Trotta. Matthews, C. R. (2007). Affirmative lesbian, gay, and bisexual counseling with all clients. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 201–220). Washington, DC: American Psychological Association. doi:10.1037/11482-008 Mays, V. M., Cochran, S. D., & Zamudio, A. (2004). HIV prevention research: Are we meeting the needs of African American men who have sex with men? Journal of Black Psychology, 30(1), 78–105. doi:10.1177/0095798403260265 McCabe, P. C., Dragowski, E. A., & Rubinson, F. (2012). What is homophobic bias anyway? Defining and recognizing microaggressions and harassment of LGBTQ youth. Journal of School Violence, 12(1), 7–26. doi:10.1080/15388220.2012.731664 McInnes, D., & Couch, M. (2004). Quiet please! There’s a lady on the stage—Boys, gender and sexuality non-conformity and class. Discourse: Studies in the Cultural Politics of Education, 25(4), 431–443. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. Nadal, K. L. (2013). That’s so gay! Microaggressions and the lesbian, gay, bisexual, and transgender community. Washington, DC: American Psychological Association. Nakkula, M. J., & Toshalis, E. (2006). Understanding youth: Adolescent development for educators. Cambridge, MA: Harvard Education Press. Nussbaum, M. C. (2002). Other times, other places: Homosexuality in ancient Greece. Annual of Psychoanalysis, 30, 9–22. Obama, B. (2007). Plan to strengthen civil rights. Change.gov: The Office of the President-Elect. Retrieved from http://change.gov/agenda/civil_rights_agenda Obradors-Campos, M. (2011). Deconstructing biphobia. Journal of Bisexuality, 11(2–3), 207–226. doi:10.1080/15299716.2011.571986 Otis, M. D., & Skinner, W. F. (1996). The prevalence of victimization and its effect on mental wellbeing among lesbian and gay people. Journal of Homosexuality, 30(3), 93–117. doi:10.1300/J082v30n030 Pascoe, C. J. (2007). Dude, you’re a fag: Masculinity and sexuality in high school. Berkeley: University of California Press. Potoczniak, D. J. (2007). Development of bisexual men’s identities and relationships. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 119–145). Washington, DC: American Psychological Association. doi:10.1037/11482-005 Pyne, J. (2011). Unsuitable bodies: Trans people and cisnormativity in shelter services. Canadian Social Work Review, 28(1), 129–137. Riggs, D. W., & das Nair, R. (2012). Intersecting identities. In R. das Nair & C. Butler (Eds.), Intersectionality, sexuality and psychological therapies: Working with lesbian, gay and bisexual diversity (pp. 9–30). Chichester, England: John Wiley. Rios, L. F., Luciana de Aquino, F., Muñoz-Laboy, M., Murray, L. R., Oliveira, C., & Parker, R. G. (2011). The Catholic Church, moral doctrine, and HIV prevention in Recife, Brazil: Negotiating the contradictions between religious belief and the realities of everyday life. Culture and Religion, 12(4), 355–372. Robinson, G. (2012). God believes in love: Straight talk about gay marriage. New York: Alfred A. Knopf. Rust, P. C. (1992). The politics of sexual identity: Sexual attraction and behavior among lesbian and bisexual women. Social Problems, 4, 366–386. Rust, P. C. (2003). Finding a sexual identity and community: Therapeutic implications and cultural assumptions in scientific models of coming out. In L. D. Garnets & D. C. Kimmel (Eds.), Psychological perspectives on lesbian, gay, and bisexual experiences (2nd ed., pp. 227–269). New York: Columbia University Press. Schilt, K., & Westbrook, L. (2009). Doing gender, doing heteronormativity: “Gender normals,” transgender people, and the social maintenance of heterosexuality. Gender & Society, 23, 440–464. doi:10.1177/0891243209340034 Serano, J. (2007). Whipping girl: A transsexual woman on sexism and the scapegoating of femininity. Berkeley, CA: Seal Press. Serano, J. (2014, July 28). Empowering femininity. Ms. Magazine. Retrieved from http://msmagazine.com/blog/2014/07/28/empowering-femininity Shannahan, D. S. (2010). Some queer questions from a Muslim faith perspective. Sexualities, 13(6), 671–684. Sheldon, K., & Delgado-Romero, E. A. (2011). Sexual orientation microaggressions: The experience of lesbian, gay, bisexual, and queer clients in psychotherapy. Journal of Counseling Psychology, 58, 210–221. Smith, L. C., Shin, R. Q., & Officer, L. M. (2012). Moving counseling forward on LGB and transgender issues: Speaking queerly on discourses and microaggressions. The Counseling Psychologist, 40, 385–408. doi:10.1177/0011000011403165 Smith, N., & Ingram, K. M. (2004). Workplace heterosexism and adjustment among lesbian, gay, and bisexual individuals: The role of unsupportive social interactions. Journal of Counseling Psychology, 51(1), 57–67. doi:10.1037/0022-0167.51.1.57 Stevenson, M. R. (2007). Public policy, mental health, and lesbian, gay, bisexual, and transgender clients. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed., pp. 379–397). Washington, DC: American Psychological Association. doi:10.1037/11482-0016 Strickland, B. R. (2000). Misassumptions, misadventures, and the misuse of psychology. American Psychologist, 55, 331–338. Strickland, B. R. (2001). Including the other in psychology. Ethics and Behavior, 11, 365–373. Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. Hoboken, NJ: John Wiley. Szymanski, D. M. (2005). Heterosexism and sexism as correlates of psychological distress in lesbians. Journal of Counseling & Development, 83, 355–360. Tate, C. C. (2012). Considering lesbian identity from a social-psychological perspective: Two different models of “being a lesbian.” Journal of Lesbian Studies, 16(1), 17–29. Troiden, R. R. (1979). Becoming homosexual: A model of gay identity acquisition. Psychiatry: Journal for the Study of Interpersonal Processes, 42, 362–373. Ueno, K., & McWilliams, S. (2010). Gender-typed behaviors and school adjustment. Sex Roles, 63, 580–591. doi:10.1007/s11199-010-9839-6 Way, N. (2011). Deep secrets: The hidden landscape of boys’ friendships. Cambridge, MA: Harvard University Press. Weinberg, G. H. (1972). Society and the healthy homosexual. New York: St. Martin’s Press. Worthington, R. L., Savoy, B. H., Dillon, F. R., & Vernaglia, E. R. (2002). Heterosexual identity development: A multidimensional model of individual and social identity. The Counseling Psychologist, 30, 496–531. Yip, A. K. T. (2008). Researching lesbian, gay, and bisexual Christians and Muslims: Some thematic reflections. Sociological Research Online, 13(1). Retrieved from http://www.socresonline.org.uk/13/1/5.html Yip, A. K. T. (2010). Coming home from the wilderness: An overview of recent scholarly research on LGBTQI religiosity/spirituality. In K. Browne, S. R. Munt, & A. K. T. Yip (Eds.), Queer spiritual spaces: Sexuality and sacred places (pp. 35–50). Farnham, England: Ashgate. Part IV Counseling Individuals in Transitional, Traumatic, or Emergent Situations All too often, cultural psychology proceeds from the unspoken assumption that culture is a monolithic, constant entity to which individuals need to adapt at a fixed point in time. The chapters in this section call that assumption into question by dealing with situations in which the apparently unbreakable bond between the person and culture is severed or loosened. International students, immigrants, and refugees leave their cultures behind and move to different cultures. In the case of survivors of natural and physical disasters, the seemingly solid link with culture is suddenly strained, weakened, or ruptured, and poor, homeless, and lower-class individuals are, to varying degrees, excluded or marginalized from their cultures. The final chapter in this section is devoted to acculturation, the process through which a person acquires competence for coping with a new or different cultural environment. In Chapter 14, Nancy Arthur invites the reader to follow two recently arrived international students as they come to terms with the social, academic, and practical challenges of life in North America. She describes international students as learners in the course of a protracted, multiphasic cross-cultural transition. In the early stages of this progression, curiosity and excitement mingle with culture shock, and a complex, often uneven, process of personal and social adaptation is initiated that, in the optimal case, leads to a state of stability and balance. At the various stages of this process disruption may occur, and counseling is a major resource for those so affected, helping them to restore functioning or attain improved functioning. International students are subject to various “pull,” or attraction, and “push,” or pressure, factors in seeking to pursue their educational goals in North America, and Arthur describes some of the frustrations, conflicts, and stresses they frequently encounter in this pursuit. She recommends that, in intervening, counselors employ flexibility in technique, format, and modality, and she cautions that traditional verbal approaches to counseling may not be appropriate or effective with some international student clients, nor should these be considered the only modes of helping. In some cases, counseling may be compressed into a single session and yet may produce beneficial results. The culturally sensitive experience and communication of the counselor’s empathy is a major factor in enhancing the effectiveness of counseling with international students, and empirically supported techniques are favored for intervention, subject to two caveats: First, empirically demonstrated treatments should be adapted to and validated in populations similar to the clients’; and second, counselors should not automatically or rigidly limit themselves to empirically validated procedures, especially with a culturally diverse clientele, lest they artificially restrict the range of potentially useful approaches. Room must be allowed for improvisation and for learning from new experience. Chapter 15, by Fred Bemak and Rita Chi-Ying Chung, deals with counseling immigrants and refugees. Its central feature is the multiphase model (MPM) of psychotherapy, social justice, and human rights with migrant populations, which is based on the recognition that merely providing psychotherapy (or counseling) for immigrant and refugee clients is often not enough. Most refugees and many immigrants arrive in the United States in a highly traumatized state. Their condition is not conducive to quick and effortless culture learning. Many of these newcomers may be baffled by verbal counseling services, rooted as they are in the values, traditions, and assumptions of the American culture and geared to the rapid pace of modernization currently experienced in this country. Specifically, they may be bewildered and alienated by the expectation that they share their private concerns with benevolent but somewhat mysterious strangers. To help overcome these obstacles, the first step in the MPM is focused on mental health education, communicated to immigrant and refugee help seekers in an understandable medium and in a meaningful manner. The road is then clear for individual, group, and family therapy, which may be considerably modified to increase its fit with the clients’ expectations and experiences. In particular, the one-to-one format of the prototypical American counseling encounter may not be appropriate for persons from many immigrant and refugee cultures. Rather, sharing and processing traumatic experiences and their aftermath in group settings may be more congenial, and dealing with family problems within the family group may appear to be more natural. It is important to emphasize that Bemak and Chung do not promote a “different” mode of counseling for culturally distinct newcomers. Specifically, they consider the entire gamut of behavioral, cognitive, and affective techniques applicable and potentially beneficial. However, they are convinced that reducing psychic distress and promoting subjective well-being are but two components of helping immigrants and refugees function productively and efficiently in their new society. In their recent contributions, they emphasize a more comprehensive, holistic approach that prominently includes assisting persons who have fled or migrated from their cultures of origin to overcome powerlessness and secure their human rights, a task that overlaps with the major concerns addressed in Chapter 17. Moreover, in keeping with their orientation of relying on the newcomers’ cultural resources as much as possible, Bemak and Chung recommend actively incorporating clients’ indigenous healing practices and traditions. They also provide examples of successfully implementing this objective, on both individual and group levels, with refugees from Southeast Asia and elsewhere. Chapter 16, by Beth Boyd, is devoted to the cultural aspects of counseling the survivors of natural and human-made disasters. Such catastrophic events have occurred with appalling frequency in the first two decades of the 21st century. Concurrently, experientially based knowledge has accrued on culturally sensitive ways of helpfully intervening with the diverse populations traumatized by disasters. Boyd takes the reader through the succession of phases of apprehending the traumatic event and coping with its immediate impact and its long-range aftermath, identifying the emotional, cognitive, behavioral, physiological, and spiritual effects associated with each. With the exception of a small number of purportedly universal reactions, cultural variation is expected in all of these aspects of responding. Of special interest in the present context is the author’s observation that the experience of disaster is often associated with the fraying of the individual’s ties to his or her community. The resulting social isolation intensifies the survivor’s sense of helplessness and augments feelings of hopelessness. Boyd emphasizes that, in intervening, counselors must demonstrate flexibility and improvisation. Within this orientation, she advocates active listening, promotion of problem solving, facilitation of personal empowerment, and promotion of personal and social competence. A specific model of wide potential applicability and usefulness is that of psychological first aid, which Boyd describes as a grassroots public health program of providing psychological support here and now, with prominent participation by primary care providers. The consensus on recent advances in providing psychosocial support in emergencies is expressed in the guidelines disseminated by the Inter-Agency Standing Committee, which are included in the chapter. These guidelines emphasize the human rights of disaster victims, the importance of victims’ participation in mental health interventions, as well as building on available resources and capacities, and the provision of multilayered support. In Chapter 17, Laura Smith and Melanie E. Brewster guide the reader through the complexities of current conceptualizations of poverty. They focus on the implications of the evolving understanding of poverty as a condition of living for the development of empathetic and effective counseling and psychotherapy. Poverty greatly overlaps with low social class, although the two categories are not coextensive. Both of these social categories are closely associated with marginalization and exclusion from the benefits and resources that are readily available to members of the dominant culture. Being poor intersects with a number of other social identities based on culture, ethnicity, race, gender, sexual orientation, and disability. Classism is the process of privileging higher social status and maintaining the low status of the poor through stigma, stereotyping, and discrimination. Poverty can be considered both a determinant of poor mental health and its consequence, and counseling and clinical interventions have an important role to play in improving the well-being and coping skills of poor people. To this end, counseling approaches need to be substantially modified. Mental health practitioners are not necessarily free of classist misconceptions and attitudes. They may distance themselves from poor clients and may create discomfort and provoke feelings of being misunderstood and rejected even as they strive to promote acceptance and comfort. Yet, as Smith and Brewster contend, it is not enough to adapt counseling techniques for a socioeconomically disadvantaged clientele. Rather, the authors recommend that counselors engage with these clients in collaborative quests not only to help overcome clients’ distress and enhance their coping skills but also to address social justice issues and pathogenic conditions in disadvantaged communities. In this context, Smith and Brewster discuss anti-oppression advocacy, an ingenious, innovative, and promising, but as yet little-known, approach to tackling poor persons’ problems on the societal and community levels, and not just within individuals. In Chapter 18, Jaimee Stuart and Colleen Ward present a comprehensive ecological model of acculturation and extend it to the domain of counseling. They introduce four intercultural strategies for helping individuals chart their course of acculturation. The first of these is designed explicitly to promote assimilation, and the counselor is tasked with expediting this process on the basis of his or her expertise. Not surprisingly, Stuart and Ward reject the rationale of this encapsulated assimilationist strategy as being contrary to the multicultural and pluralistic ethos and thereby violating the counselee’s autonomy and integrity. The second strategy emphasizes the counselee’s individuality and uniqueness and allows the counselee to pursue his or her own choices. The counselor becomes a facilitator, which is in keeping with her or his established role in the counseling process. In the third strategy described by the authors, the counselor shares his or her expertise and experience to introduce innovative ways of dealing with the challenges of acculturation and thus broaden the counselee’s repertoire of choices. In the fourth strategy, the counselor becomes a “translator,” or a bridge, between the counselee and his or her new culture. In this capacity, the counselor not only helps the counselee learn to function more effectively in the new environment but also assumes the task of educating local people about the newcomers’ characteristics and concerns. Thus, this ambitious objective is simultaneously targeted at the individual, relational, and contextual levels. In the process, this strategy transcends the boundaries of counseling. Counselors may have little power or opportunity to reduce discriminatory attitudes and practices within their communities, but they can and must deal with the effects of discrimination in the lives of their immigrant and refugee clients, especially as these affect and deflect the acculturation process. Stuart and Ward emphasize that a major goal of counseling with these clients is to increase counselees’ resilience in the face of the stresses and frustrations they encounter in their new environments. Chapter 18 also includes a wealth of empirically substantiated information on the factors within individuals’ personalities as well as within their families and communities that facilitate or impede acculturation. 14 Counseling International Students in the Context of CrossCultural Transitions Nancy Arthur Primary Objective ■ To provide foundational knowledge about international students in the context of their experience of cross-cultural transitions Secondary Objectives ■ To help counselors enhance their professional skills for working with international students through inclusive cultural empathy ■ To help counselors facilitate the integration of international students on the campuses of their host countries Counseling international students involves counseling across cultures. Counselors’ worldviews may be relatively similar to or profoundly different from those of international students from many countries and many cultures. The primary aims of this chapter are threefold. First, the chapter provides foundational knowledge about international students in the context of their experiences of cross-cultural transitions. Second, the chapter is intended to help counselors enhance their professional skills for working with international students through inclusive cultural empathy (Pedersen, Crethar, & Carlson, 2008). Cultural empathy is defined as “the learned ability of counselors to accurately understand and respond appropriately to each culturally different client” (Pedersen et al., 2008, p. 44). Counselors are invited to go further in their understanding about the role of empathy in counseling international students to an inclusive perspective that “incorporates functions and modes of counseling that may fall outside conventional definitions of who a counselor is, what roles he or she plays, who a client is, and what her or his goals in help-seeking are” (Pedersen et al., 2008, p. 3). The third goal of this chapter is to discuss how counselors can support the positive integration of international students on campus. Counselors are integral members of student support services and have important roles in designing formal and informal delivery of services to address the transition need of international students. The terms foreign student and international student are often used interchangeably. The term foreign student, however, has negative connotations, as it positions international students as outsiders to educational institutions and local communities. Anyone might be a foreigner, depending on one’s cultural point of view (Pedersen, 1991). International students are individuals who are accepted into academic programs in many different countries around the world. The term international student is reflective of these individuals’ efforts, through education, to increase their understanding and experiences of other countries and cultures. The terms home country and host country are used to represent the contexts across which international students experience cross-cultural transitions. Home country refers to the student’s country of origin or source country; host country refers to the destination country where the international student is enrolled for an educational program. This chapter is organized into five major sections. First, background information is provided about enrollment trends and the contributions of international students to higher education. Next, readers are introduced to students’ motivations to leave their home countries to study elsewhere, as a starting point for understanding the nature of cross-cultural transitions. The third section of the chapter focuses on culture shock as a learning process that is part of the experience of living in a new cultural context. Some of the common issues that international students experience in the academic, interpersonal, and career domains are described in the fourth section, and the fifth section focuses on recommendations for counseling with these students. Throughout the chapter, the discussion focuses on six key areas related to the enhancement of inclusive cultural empathy for counseling practices and for counselor roles (Arthur, 2004, 2010): 1. 2. 3. 4. 5. 6. Knowledge about models and concepts related to cross-cultural transitions Knowledge about common transition demands Multicultural competencies, including self-awareness, knowledge, and skills Enhancement of access to and usage of counseling services Advocacy to overcome systemic and institutional barriers Facilitation of positive integration into the campus and local communities Modalities of service delivery are considered, and suggestions for improving access to counseling services are offered. Critical incidents are integrated into the chapter to help readers connect key concepts with applied practice. These critical incidents, which are composites of real-life counseling situations with international students, describe the experiences of Ling, a 20-year-old female from a country in Southeast Asia, and Mohammed, a 25-year-old graduate student from a country in the Middle East. Before turning to the core content of the chapter, readers are invited to reflect about their views of international students. Do you know any international students? What previous interactions have you had with international students? What are the main source countries of international students at your local educational institutions? How would you go about making connections with international students to support them in accessing counseling services? What kinds of competencies (e.g., attitudes, knowledge, skills) would help you to increase inclusive cultural empathy for working with international students? These questions are intended to help readers begin a process of reflection that not only focuses on international students but also encourages readers’ reflection on their own personal worldviews, including their values and beliefs. Although this chapter emphasizes knowledge about international students, the content is also designed to support readers in exploring their own attitudes, knowledge, and skills as a foundation for building inclusive cultural empathy. The Growing International Student Population Because of the higher tuition fees charged to international students in comparison with students from universities’ home countries, international education provides a substantial base of funding to institutions of higher education. It is estimated that international students and their dependents contributed more than $21 billion to the economy of the United States during the 2010–2011 academic year (Institute of International Education, 2012). Beyond financial resources, international students bring a wealth of experience from their home cultures and countries, including contacts for future partnership and trade. Although many international students want to engage in the exchange of knowledge and friendships, it is incumbent on the host institutions to prepare their local educational communities, including students and faculty, regarding ways to foster positive integration. One perspective is that all learners, from home and host countries, are international students. The idea of encouraging local students to see themselves as global learners and join international students in their learning journeys is controversial, however. Unfortunately, international students remain a relatively untapped human resource for fostering the academic and cultural literacy of local students. There has been substantial growth in the numbers of international students worldwide, from 0.8 million in 1975 to 3.7 million in 2009—a more than fourfold increase (Organisation for Economic Co-operation and Development, 2011). During the 2010–2011 academic year, more than 700,000 international students were enrolled in colleges and universities in the United States (Institute of International Education, 2012). Most educational institutions have increased their targets for the numbers of international students they accept for undergraduate and graduate education, typically allowing for such students to make up around 10% of the undergraduate student population and around 25% of graduate students, although there is considerable variation among schools. Nonetheless, there are major implications for educational institutions when one-tenth or one-fourth of students enrolled are from other countries. Educational institutions have to consider what helps them to be competitive in the global marketplace as they focus their internationalization efforts to recruit new students. Beyond recruitment, educational institutions need to be equipped with infrastructure to retain and support international students with their personal learning goals. The Journeys of Two International Students Ling arrived at the counselor’s office after the physician on campus referred her. She went to see the physician for symptoms of fatigue and headaches, saying that she was having difficulty concentrating on her schoolwork and had recently failed an exam. The physician could not find any apparent cause of her symptoms beyond muscle tension but did notice that Ling seemed to be experiencing a high level of stress. The physician suggested that Ling talk to a counselor about her experiences. Ling did not really know what that would be like, as she had never seen a counselor before. When the physician told Ling to come back if she had any more problems, she thought she had better see the counselor, or she might get into trouble with the doctor. During the first appointment, the counselor noticed that Ling had written “academic difficulties” on the intake card. When Ling began to describe her issues, the counselor noticed that she seemed very nervous. To help establish rapport, the counselor expressed some interest in how Ling had decided to become an international student. Ling described that it was not really her idea; her parents had insisted that she study in another country. She said that was what a lot of families in her country were doing, and her parents wanted to make sure she received a good education. Mohammed initiated the first appointment with a counselor because he wanted to ask about changing his academic program. He won a scholarship from his home country to study in the United States, but he had quickly found out during his work for his undergraduate degree that he preferred subjects in a program other than the one he originally applied for. Mohammed asked that the counselor call him “Mo” and was reluctant to talk about other topics with the counselor, stating that he just needed information about what he could do to change his program. The counselor asked him if he would describe the terms of his sponsorship and what flexibility he might have to change his program. Mohammed stated, “That is the problem, I am not sure if I will be able to keep my scholarship and change programs. I was hoping that you would write a letter on my behalf so that I could give it to my sponsor.” Ling’s and Mohammed’s situations represent different motivations for becoming an international student. Counselors working with such students should assess the degree of voluntariness of their participation, the pressures for mobility they may be experiencing, and their perceptions about the permanence of studying abroad. These factors have been linked to the acculturation process, or the psychological changes that result from efforts to adapt during cross-cultural transition (Berry, 2001). In Ling’s case, her parents were in charge of the decision. International education represented a source of family honor, and Ling felt a huge burden to be successful for her family. Ling was an average student who had to study very hard to achieve the marks expected of her by her family. She was the elder of two children, and she felt that the family was counting on her to be a good role model for her younger brother. Although she was excited about the opportunity to study in the United States, she also was troubled about leaving her family and friends behind. In contrast, Mohammed viewed international education as opening doors that would allow him to move to another country and pursue permanent immigration. Mohammed’s strong academic abilities resulted in a scholarship that paid his tuition and living expenses. The conditions in his home country were a strong motivating factor for Mohammed, as uncertain economic and political conditions were threatening stability in the region. He was very concerned that if conditions deteriorated, he would be drafted for military service. His acceptance as an international student was a primary means through which he was attempting to secure a more stable future for himself. What these students have in common is that conditions in both their home countries and the host country weighed heavily on their early experiences as international students. Their immigration status is contingent on enrollment and proof of academic progress. Their journeys as international students will unfold through the discussion below about the nature of cross-cultural transitions. Understanding International Student Transitions International students do not go through fixed or predetermined stages of adjustment. However, their experiences may be framed by phases in the transition process, from the initial decision to entering the host culture, living and learning in the host culture, and preparing to end the experience as an international learner. Push and Pull Factors The process of cross-cultural transition for international students begins not when they arrive in their host countries but in the decision making and planning to become international students. As noted in the previous discussion, both push and pull factors may be relevant to the decision to become an international student (Mazzarol & Soutar, 2002). For example, numerous push factors in the home country may prompt an individual to look for opportunities in other countries. These factors might include a lack of educational or employment opportunities, family pressures, and unfavorable political, social, or economic conditions (Arthur, 2004). The perceived benefits of studying in the destination country serve as pull factors (Mazzarol & Soutar, 2002). The primary pull factor is the belief that international education will enhance the marketability of a student’s skills and future employment options (Brooks, Waters, & Pimlott-Wilson, 2012; Shih & Brown, 2000). Related factors include the perceived quality of education, standard of living, lifestyle considerations such as personal safety (in some countries) and/or family reunification, and opportunities to gain knowledge of foreign languages or local economies (Gu, Schweisfurth, & Day, 2010). Counselors may find it useful to explore the decision to become an international student to assess how the student is managing the journey between the home country and the destination country. Reasons for becoming an international student vary among individuals, and reasons may shift in their importance over time. Generally, students’ reasons are connected to their experiences of adjustment in later phases of cross-cultural transition. Learners in Cross-Cultural Transition A key characteristic of international students is that they are learners during their cross-cultural transitions (Arthur, 2004; Pedersen, 1991). These transitions involve a process over time during which individuals discover the assumptions they hold regarding who they are, as well as their assumptions about other people and/or the world around them (Schlossberg, 1992, 2011). The emphasis on learning is a key for drawing on international students’ strengths and resources. During the course of cross-cultural transition, international students inevitably encounter new cultural contexts that require adjustments in their understanding and behavior. It is the contrasts between home and host cultures that challenge international students to learn new ways of responding. International experience is a catalyst for personal learning, but it may be accompanied by varying emotional reactions, such as excitement, confusion, or a sense of overwhelming dissonance about prior beliefs and novel experiences in the host culture. The learning for international students is not just about the host culture; their experiences help them to gain new perspectives about their lives back home. Counselors can support international students to see positive implications in the more difficult or negative aspects of their cross-cultural experiences (Pedersen et al., 2008). Conversely, counselors can help these students to anticipate any potential negative implications of their positive experiences of cross-cultural transitions. Culture Shock During Transition Adjustment difficulties are inevitable during cross-cultural transition, particularly when there are great differences in practices between the home and host cultures (Pedersen, 1991). The term culture shock refers to “a more or less sudden immersion into a nonspecific state of uncertainty where the individuals are not certain what is expected of them or of what they can expect from the persons around them” (Pedersen, 1995, p. 1). Essentially, culture shock is the reaction that people experience when their previous learning does not equip them for unfamiliar situations across cultures. Culture shock is usually most severe at the point when the individual enters a new cultural environment; however, it is commonly experienced in various levels of intensity during the process of adjustment. International students typically experience culture shock that manifests in physical or physiological symptoms (Oberg, 1960; Ward, Bochner, & Furnham, 2001). One of the earliest models of culture shock portrayed it as a U-curve to represent the initial contact with the host culture, a growing sense of conflict over cultural differences, and adaptation over time (Lysgaard, 1955). A W-curve model of culture shock expanded on the upward and downward shifts in morale over time and added the stage of adjustment when the person returns to his or her home culture (Gullahorn & Gullahorn, 1963). Pedersen (1995) has outlined a four-phase model of culture shock. The first phase is akin to being a tourist, when new discoveries about cultural contrasts seem exciting. The second phase is a turning point of disintegration, when cultural contrasts may lead to a sense of disorientation and dissatisfaction. Ling seemed to hit the stage of disorientation immediately when she landed in the United States. She was overwhelmed by the physical space, the change in living habits from home to campus residence with roommates, changes in food, and feeling like she often did not know what to say to people, and she experienced intensive loneliness. In contrast, Mohammed seemed more prepared, and he enjoyed the novelty of learning about new lifestyles. He did not have any noticeable signs of culture shock, and he was able to be proactive about finding his way around campus and the city. He joined in some of the extracurricular activities on campus and seemed to embrace the host culture with a thirst for new learning. In the third phase of culture shock, known as adjustment or reorientation (Pedersen, 1995), international students typically cope better as they begin to integrate new learning and try new strategies. Positive integration may be related to international students’ capacity to develop empathy in new cultural contexts (Draguns, 2007). For example, some international students may have better skills than others for understanding expectations and communicating those expectations through their behavior; they seem to “hit the ground running” with minimal culture shock. Other international students may struggle with heightened culture shock if they lack the capacity to empathize with the behavior of people in the host culture. Some international students may experience more culture shock when they are excluded or their behavior does not seem to help them gain acceptance in the host culture (Draguns, 2007). It may take some international students longer than others to understand what is expected of them and to be able to interact effectively with other people in the host culture. Ling’s first year was characterized more by crisis than by reorientation. Her grades were negatively affected, and she had to deal with a lot of shame and self-doubt as she went from being one of the top students academically in her home country to barely passing some of her courses. It was only after she returned home during the summer semester break that things seemed to turn the corner toward a positive experience. Ling realized that not everything in her home culture was as ideal as she had portrayed it in her mind when she was feeling lonely and homesick. In fact, she found herself missing some of her new friends and some of the independence that she had gained through living on her own. Ling returned to the United States with a renewed sense of commitment and motivation to succeed. She was more prepared to enter the fourth phase of culture shock, which reflects a higher degree of adaptation in managing cross-cultural transitions. It seemed that Ling was internalizing learning about both home and host cultures, and this learning helped to increase her capacity to demonstrate empathy during interactions with people in the country where she was studying. Although models of culture shock have heuristic value, the process is not always linear, and counselors need to pay attention to individual differences. For some international students, the pattern of culture shock follows very closely the progression suggested in the models. For others, the experience is more cyclical in nature. As they gain success at managing some transition demands, they may find other aspects of their situation to be more overwhelming, and vice versa. Although all students who face cultural contrasts between home and host cultures are likely to experience some initial culture shock, the degree to which this subsides or intensifies over time is related primarily to the students’ perceptions of the new demands and of their own coping resources (Chen, 1999). Culture shock may manifest in physical symptoms such as fatigue, headaches, cognitive impairment, reduced energy, gastrointestinal problems, and muscle aches and pains. As noted in the introduction to Ling, some of these symptoms were what led her to seek assistance from a physician. Ling had never experienced such severe headaches, and they were interfering with her sleep and her capacity to function during the day. It is important to note that such symptoms are experienced as real for the individual and not just psychosomatic; intense symptoms, particularly if new, can be very alarming. It is important that counselors consider these symptoms as valid and that they work with interdisciplinary teams of student services professionals to find the best diagnostic and treatment approaches for students. Culture shock may also manifest in psychological symptoms such as anxiety, depression, and a general sense of stress. Counselors may want to explore international students’ understandings of such symptoms and how they would be treated in their home cultures. Typical Western counseling interventions such as talk therapy may not be the usual course of treatment in students’ home cultures, as many alternative methods of healing are practiced across cultures (Pedersen et al., 2008). Counselors need to orient international students to the nature of counseling and discuss their clients’ preferred approaches. Interventions to address culture shock may include helping students by providing concrete suggestions about ways to manage perceived demands such as the pace of change, academic issues, loss of typical support systems, and change of routines. When students are feeling overtaxed, they may react in survival mode and not be able to muster coping resources. Counselors can help students to recognize the coping resources they can draw upon and can determine where students might benefit from skills training or other kinds of interventions. The transactional model of stress and coping (Lazarus & Folkman, 1984) can provide a foundation for helping international students to sort out where they are gaining mastery in the new cultural environment and where there is an imbalance between their perceived demands and their coping strategies. Counselors may also act in the capacity of cultural interpreters to help international students gain a better understanding about local cultural expectations. From this direction, counseling can be an intervention to help international students develop empathy for understanding expectations and demonstrating appropriate behavior in a new cultural context (Draguns, 2007). There are many positive aspects to the transitions that international students experience (Moores & Popadiuk, 2011). Culture shock is a catalyst for individuals to learn from cultural contrasts and internalize that learning into their unique cultural identities. The counselor listened to Ling’s description of her symptoms and how they were interfering with her health and academic focus. The counselor asked Ling how her symptoms would be perceived in her home culture. Ling described the herbs that her mother would give her and how she would be assigned to bed rest until the symptoms were relieved. However, Ling said that she did not want to tell her parents, particularly her mother, about her symptoms, as she knew that it would cause her parents to worry about her. The counselor asked Ling if she would be interested in learning about how these symptoms might be addressed through counseling, and then she could make a choice about whether to continue counseling or not. Ling agreed, saying that she would be grateful for any kind of advice the counselor could offer. The counselor showed Ling a chart of symptoms related to culture shock and explained how many international students experience similar symptoms. Ling stated that it was a relief to know that she was not “going crazy.” The counselor invited Ling to work with her to draw a map of the transition demands that she was experiencing, which ones she was managing, and which ones she was struggling with in her adjustment to school and to living in the local community. The counselor then invited Ling to talk about some of the beliefs that felt like heavy weights of parental expectations and academic success. The counselor also invited Ling to try some mindfulness training in which she could learn meditation and relaxation skills that she could use to help relieve some of the physical symptoms that she was experiencing. Connections Between Common Transition Issues International students experience many of the same issues all students face, such as adjusting to the demands of a new academic environment, moving to a new city, and leaving friends and family behind (Hayes & Lin, 1994; Popadiuk & Arthur, 2004). However, the demand for rapid learning across cultures adds layers of complexity to the experiences of international students. The types of common issues affecting international students include (a) interpersonal factors related to their environments and surroundings, and (b) intrapersonal factors related to internal processes (Johnson & Sandhu, 2007). When adjustment issues surface in one domain, there are often overlapping issues in other domains (Hwang, Wang, & Sodanine, 2011); conversely, when international students are able to increase their capacity for managing issues in one area of cross-cultural transition, their adaptation in other areas often improves. Academic Issues Academic concerns may be connected to the degree of prior academic preparation, changes in teaching and learning approaches, workload issues, or satisfaction with the content of curriculum. Capacity to manage academic issues may be highly influenced by language proficiency. In fact, language proficiency has been noted as the most critical influence for both academic and social adjustment of international students (Hayes & Lin, 1994). Students’ language proficiency may affect their understanding of instruction and class discussion, the degree to which they feel comfortable offering answers in class, and how confident they feel about approaching local students in class or participating in group assignments. Language proficiency includes both students’ actual ability to speak in the language of the host country and their confidence about their language skills (Swagler & Ellis, 2003). When an international student indicates “academic issues” on an intake card as the reason for seeking counseling, this may be the tip of the iceberg, signaling underlying concerns about academic, linguistic, and/or social competency. Students’ capacities to resolve intercultural stressors often go beyond academic learning performance to include career aspirations and career outcome expectations (Reynolds & Constantine, 2007; Zhou & Santos, 2007). After the initial counseling interview, Mohammed made another appointment in the second semester. The counselor asked how he was doing, and he said that things were going generally well, but he had some questions about his academic program. When the counselor invited Mohammed to explain, he said that he was surprised at some of the things that were happening in class. He said that he had expected that the quality of academic instruction would be higher and that his classmates and instructors would be more motivated to engage in discussion about current issues in his field. He said that he had tried to approach his academic supervisor but found that the supervisor was really busy and had little time for him. Mohammed was hoping for more of a mentorship relationship with his supervisor, although he was appreciative of the time and expertise that his supervisor was able to offer. When the counselor asked about interactions with his classmates, Mohammed stated that he had made two close friends, both of whom had traveled a lot and seemed to be more open-minded than other students. The counselor inquired about what was going on with Mohammed in relation to other students and people he had met in the community, and Mohammed seemed hesitant about whether or not to answer. After some silence, he stated, “It has been difficult.” The counselor gave him time to tell a story that contained examples of how he had been ignored and shut out of group assignments, even though he was confident that he could make a contribution or take the lead on an assignment. He also provided the counselor with examples of incidents in which he had overheard racial slurs and comments about why “they let people like him” study in the United States. Counselors must consider what it might be like to move to another country for an extended period of time, away from friends and family and other usual sources of support. Although advances in technology have made it much easier for international students to communicate with those they have left behind in their home countries, these students still experience the loss of support systems. International students are faced with the need to develop new social connections and build strong support systems. Instrumental types of support they need include having someone to go to for assistance and concrete advice about where to find things and how local systems work. International students are often keen to develop friendships with local students as part of their learning journeys. However, there are wide variations in the ways that local students are prepared for or open to widening their social networks to include people whose countries and cultural backgrounds are different from their own. In Ling’s case, she had a roommate who befriended her and encouraged her to join her for some social activities. It was her roommate who suggested that Ling see a physician, and she accompanied Ling to the first counseling appointment. In Mohammed’s case, interactions with peers were more challenging. His efforts to engage with others were initially viewed in negative ways by many of his classmates. What was striking in the conversation that he had with the counselor was that, despite his outward appearance of confidence and his academic success, Mohammed was experiencing profound loneliness. Although his determination to complete his academic program never wavered, he was struggling to make the kinds of social and academic connections that he believed were important for the achievement of his long-term goals. The counselor also noted Mohammed’s comments that suggested he was possibly experiencing racism from his colleagues. He recounted specific incidents in which his nationality and assumed religious practices were joked about and commented on in a hostile manner. Mohammed felt that he was being judged not because of who he was but because of world events such as the terrorist attacks of September 11, 2001, which resulted in bias against international students from the Middle East (Henry & Fouad, 2007). Despite these difficulties, Mohammed made two trusted friends in his academic program and was able to expand his personal and professional network through his colleagues and his academic supervisor. Gender Roles Gender-role expectations are an important part of social relations. It is often assumed that the migration flow of international students is from cultures that are more traditional in nature to more liberal cultural contexts. In such cases, some international students may find that they enjoy the freedom associated with new lifestyles. However, it should not be assumed that such freedoms are necessarily desirable or even seen in a positive light. Rather, some students may find that contrasts in gender-role behaviors help them to appreciate the strengths of their home cultures (Arthur & Popadiuk, 2010). The migration flow of international students also occurs from more liberal cultures to more traditional cultures, where expectations for norms of behavior, dress, and ways of interacting are more socially scripted and the social expectations for males may differ from those for females. Counseling can be an effective process through which international students are supported to reflect about gender norms in both the home and host cultures as part of values clarification. Career Issues A key reason for pursuing international education is to improve employment prospects for the future (Brooks et al., 2012). However, the career-related needs of international students may change at different phases of cross-cultural transition (Arthur, 2007). Similar to the experiences of many local students, exposure to new ideas and new academic subjects can lead international students to question whether they have selected academic majors that are appropriate for them. It should not be assumed that the career and academic plans of international students are consolidated or realistic (Singaravelu, White, & Bringaze, 2005). Depending on the terms of sponsorship, international students may be restricted to the academic programs they declared at the time they accepted their sponsorships. Some students may also feel pressured to pursue the academic routes approved and financially supported by their parents. Counselors can assist with the design and delivery of career planning services that address international students’ needs during various phases of cross-cultural transition (Arthur, 2007). Initially, students may request help to investigate study-abroad opportunities, educational institutions and programs, or student visa information, or they may seek help in selecting an academic major. Counseling services for international students may include a focus on initial transition demands and students’ possible needs for career exploration. New issues may surface through cultural learning that either confirms students’ original choices of academic interests or triggers dilemmas about what other options might be available (Singaravelu et al., 2005). Counselors must be aware that decisions made in one cultural context may have profound effects on an international student’s life in another cultural context. Ling was struggling academically in her core courses for a science major. She had to work long hours to understand the course content and prepare for the laboratory portions of her program. When she discussed her academic program, the counselor noticed that her affect seemed flat. Ling did not seem to have a sense of direction about what she would do with her science degree other than that she hoped it would help her to find a good job. The counselor asked Ling how she decided to pursue a science degree. Ling stated that science was the degree that her parents wanted her to take. The counselor was initially surprised by this answer, and she paused to reflect about its meaning. She asked Ling what she would like to study. Ling lowered her eyes and quietly said that she had also decided to study science. The counselor then faced a dilemma: Should she probe Ling about her other possible interests, noting the discrepancies between what Ling was saying and her nonverbal behavior? Ling seemed to be feeling overly pressured about following her parents’ wishes and not her personal career interests. It is important for counselors to include assessment of perceived influences from both home and host cultures when working with international students on career planning and decision making. Career counseling may not be a familiar intervention for international students, and counselors may need to provide education about how it is linked to helping students with their current and future career choices (Shih & Brown, 2000; Yi, Lin, & Kishimoto, 2003). The career-related needs of undergraduate and graduate students may differ according to whether they are seeking specialist skills or planning to enter the workforce for the first time postgraduation (Shen & Herr, 2004). The majority of the research on international students’ cultural adjustment has focused on the initial phase of transition and the kinds of issues that surface during students’ first few months of living and learning in the host culture. However, international students’ experiences of cross-cultural transition extend well beyond the initial period of adjustment. As students approach the end of their international education, they may face a critical question: whether to return home or, instead, try to stay in the host country to gain employment experience and possibly pursue permanent immigration. It has been reported that approximately 70% of international students studying in the United States say that they would like to stay in the country permanently following the completion of their academic programs (Spencer-Rodgers, 2000). Research with international graduate students at one large U.S. university found that 22% of the respondents stated a preference to begin their careers in their home countries, 51% preferred staying in the United States, and 27% were not sure (Musumba, Jin, & Mjelde, 2009). Whereas international students have historically been viewed as temporary sojourners (Pedersen, 1991), shortages of skilled labor in many developed countries have shifted the view, and international students are now often seen as desirable human capital (Arthur & Nunes, 2014). Students’ decisions to pursue permanent immigration appear to be influenced by perceptions of employment opportunities, lifestyle options (such as safety and employer expectations), and expectations for a better future (Arthur & Flynn, 2011). Relationships in both home and host cultures have a strong influence on international students’ career decision making, in fostering career opportunities, in providing support for staying in the country, and in helping to build new support networks (Arthur & Nunes, 2014; Popadiuk & Arthur, 2014). Career counseling can provide international students with opportunities to discuss their future options and perceived opportunities in both home and host cultures. International students who are planning to pursue employment in the host country may need assistance in their job searches and help in understanding the cultural nuances of the job search process. International students may benefit from assistance in making connections with employers, practicing interviewing skills, and learning the best ways to represent their international experience to employers. In one study, international students reported several barriers in their job searches, including lack of language proficiency, lack of understanding of networking and interview expectations, and concerns about whether or not employers actually valued their unique international experience (Sangganjanavanich, Lenz, & Cavazos, 2011). Mohammed’s academic program included the option of an unpaid placement with a local employer. Mohammed completed a semester working for that employer and expressed his interest in staying with the company. However, the employer was not in a position financially to hire him. This set up a spiral of events in which Mohammed found himself approaching a deadline for employment to satisfy immigration requirements, and he had no offers of employment. He had been so certain that things would work out in his favor that he was not prepared for the rigorous nature of the job search process. He returned to talk to the counselor and request advice about what he could do to secure employment. When the counselor inquired about his experience in interviews, Mohammed stated, “It is as if the employers really don’t care about my international experience and what I might bring that would add to their company. The last employer actually interrupted me when I was telling him about my experience back home and kept asking me if I had worked in the U.S. I felt that my chances were finished then.” The counselor explored with Mohammed what it would mean for him if, indeed, his chances of staying in the United States were limited. Mohammed showed a lot of emotion as he said he could not imagine returning to his home country. When he departed to begin his international studies, in his mind he was saying goodbye to his life at home. Even though many international students wish to pursue permanent employment in their host countries, the reality is that most return home after completing their academic studies, whether by personal choice, because they lack suitable employment, or because of immigration restrictions. A key consideration that counselors should keep in mind about the reentry transition is that it is more than just a physical relocation—it is a process of reacculturation to life back home. Counselors need to consider students’ reentry transition issues in relation to the entirety of the students’ cross-cultural experiences, including their motives to become international students, their academic and interpersonal experiences, their acquisition of academic qualifications, and their perceived employment opportunities. International students bring their cross-cultural experiences home. Many international students and their significant others, including friends and families, are unprepared for reverse culture shock (Gaw, 2000). International students may not expect to go through any adjustments when they are returning to familiar cultures. Some international students find the constancy or lack of change in their home cultures to be reassuring and an anchor of familiarity for their reentry. Others find the lack of change to be unsettling as they feel forced to set their new learning aside to fit in at home. When provided with feedback by friends and family members, international students may realize how much they have personally changed. Some of the common issues that may surface during the reentry transition include pressure to find employment and concerns about career mobility, the transferability of international education, maintaining language skills, maintaining relationships, and gender-role conflicts (Arthur, 2003). Students may benefit from learning about the reentry transition before they leave the host country; such information can help them to anticipate and prepare for returning home. Counselors might offer services through workshops designed for students in the final year of their academic programs, or they might arrange for reentry transition to be a featured topic in the international students’ newsletter on campus. Material on reentry transition could also be featured in an online workshop for students. The key here is for services to be offered using multiple delivery formats so that international students can self-select preferred formats for learning. Ling was reading an e-mail message from the international student services center when she noticed that the center was offering a workshop on the topic of job search and returning home. She decided to register for the workshop, as she knew that she would be expected to find employment shortly after returning to her home country, and she was concerned about making contacts with employers. When Ling went to the workshop, she was surprised when the facilitators talked about some of the issues that other international students had reported when they returned home. She knew that she had mixed feelings about returning home. She really missed her family and friends and was looking forward to some basic things, like eating the food that she enjoyed and going out to places in her home city. However, Ling had started to realize that she would also miss her life in the United States. She had grown accustomed to making more of her own decisions. She liked the informality of relationships between people. She had been dating another student, even though they both knew that Ling would be returning to her home country. After the workshop, Ling began to realize that she would really miss parts of her life as an international student. Counseling International Students At the beginning of this chapter, readers were invited to reflect about their own attitudes and knowledge about international students as a foundation for inclusive cultural empathy (Pedersen et al., 2008). This is an important starting place from which to consider practices for counseling international students. Unfortunately, most counselor education programs offer little, if any, content focusing on work with international students. Some of the existing counseling literature portrays international students as problematic and problem laden (Pedersen, 1991; Popadiuk & Arthur, 2004). Counselors may want to begin by expanding their knowledge about the main source countries of international students on their campuses and making contacts with other student services professionals to collaborate on methods of service delivery. To state a fundamental point, counseling international students requires competencies for counseling across cultures. Counselors should examine their own multicultural counseling competencies for supporting international students throughout their experiences of living and learning in the host culture, and as they prepare to make the transition to employment in the host country or the transition home. Counselors can use multicultural counseling frameworks (Arredondo et al., 1996; Collins & Arthur, 2010a, 2010b; Sue et al., 1998) to identify their current strengths and areas for competency development toward increasing inclusive cultural empathy (Pedersen et al., 2008). Diversity of International Students The overarching categorization of international students often obscures the cultural diversity found within this student population. It is prudent for counselors to remember that international students come from many countries and many cultures, and there can be major differences in the worldviews of students from the same country (Arthur & Nunes, 2014). For example, within any country there are many subcultures with social, religious, and political beliefs that influence behavior. Gender issues may be associated with family expectations and role obligations, with greater or lesser distinctions made between males and females. Depending on the norms of the home country, some international students may be studying in a more liberal environment while for others the destination country is a more traditional or conservative environment. Some students may also experience major shifts in economic conditions and standards of living between their home and host countries. Such economic disparities mean that some students may find the cost of living in the host country affords them good value for their spending on education and daily living needs. In contrast, international students from emerging countries and families where financial resources are limited may feel considerable financial strain in meeting the costs of living in the host country. The demographic distribution in the home country may be considerably different from that in the host country in terms of population density and ethnicity. Some international students may have their first experiences of being identified as members of a visible minority in the host culture, or they may engage in religious or other social practices that are different from those of the majority of people in the host culture. The experience of shifting from a dominant to a nondominant ethnic identity can have a profound impact on international students in terms of their personal identities and understandings of interpersonal relations. Social attitudes toward identities need to be inclusive of international students whose sexual identities may be constrained or liberated, depending on prevailing attitudes in the home or host country (Pope, Singaravelu, Chang, Sullivan, & Murray, 2007). Unfortunately, the new experience of “difference” leads some international students also to experience racism and other forms of oppression that may be part of the social nuances of the host culture. Whether the actions associated with such forms of oppression are intentional or unintentional (Pedersen et al., 2008), they may have devastating effects on international students’ health and on their sense of integration into the local culture. These examples illustrate the plurality found within the international student population and the importance of counselors’ taking into account the multiple influences on cultural identity during cross-cultural transitions. Growing numbers of younger students are being sent to other countries for their education, with or without a parent (Popadiuk, 2009). The developmental needs of such children differ considerably from those of adult international students. Although this chapter has focused primarily on international students, it should be noted that the health and well-being of accompanying partners and/or children are strongly interconnected in the cross-cultural transition experience (Techome & Osei-Kofi, 2012). Regardless of the ages or life experiences of international students, counselors working with this population should take a strengths-based approach and focus on the needs of individuals who are learning while living in new cultural contexts. Culture Shock Versus Serious Mental Health Issues The demands of adjusting to new cultural contexts may trigger international students to experience serious mental health concerns or may exacerbate preexisting mental health issues. For some students, preexisting mental health issues may surface with the added risk factors and demands of crosscultural adjustment. It should be expected that some psychiatric issues and serious psychological problems will occur in the international student population, given that these issues are estimated to be present in as much as 20% of the local population (Leong & Chou, 2002). Counselors need to be prepared to address serious mental health issues—including psychosis, suicide ideation and attempts, schizophrenia, depression, and anxiety—in any student population (Oropeza, Fitzgibbon, & Baron, 1991) and should be skilled at assessments and interventions that take into account cultural diversity. There is a risk that international students’ symptoms may be misunderstood or that inadequate resources may be allocated if serious symptoms are minimized or misinterpreted as only manifestations of culture shock. Improving the Cultural Validity of Counseling Counselors should be aware that there are wide variations in the ways in which helping relationships are constructed in countries around the world, including the ways in which counseling is understood and practiced (Arthur & Pedersen, 2008; Hohenshil, Amundson, & Niles, 2013). Counselors need to consider how they can build positive profiles so that international students consider counseling to be a viable and valuable campus resource. It is critical that counselors build partnerships with other student services personnel, such as international student advisers, residence staff, careers services staff, medical personnel, and chaplains. The people with whom international students interact on a regular basis, including academic faculty, are key sources of referrals to counseling services. Interprofessional collaboration is premised on the idea that the combined expertise of professionals from different disciplines leads to improved service delivery and outcomes (Mellin, Hunt, & Nichols, 2011). The literature on counseling international students in previous decades tended to focus on international student problems, usage rates, and difficulties with accessing counseling (Popadiuk & Arthur, 2004). Counselors may want to consider providing education to international students about the purposes and functions of counseling, as pretherapy orientation may help students to derive greater benefit from counseling services (Leong & Chou, 2002). Counselors should not assume that all international students prefer a particular counseling style (e.g., directive or nondirective), as such preferences may depend on cultural norms pertaining to hierarchical relationships and expressions of respect to the counselor as a person who is a perceived expert. It is important for counselors to consider the cultural norms of each student and also how acculturated the individual is to the local norms and ways of communicating. When students are more familiar with the counseling process, they are more likely to appreciate a collaborative and informal counseling style. Counselors need to be intentional about adjusting their counseling styles to respond appropriately to their clients’ needs as they unfold over time (Pedersen et al., 2008). International students may first present to counseling seeking immediate solutions to issues that they are experiencing as crisis or they feel ill equipped to manage (Hayes & Lin, 1994). A single session may be all that is required to help a student link with relevant resources. However, in my experience, that single session may also be a time when multiple layers of interaction occur between the counselor and the international student. For example, first, the counselor can validate the student’s choice to seek help. Second, the counselor can provide orientation to counseling and what it might offer for the student’s immediate or future needs. Third, the counselor can offer problem solving to address the student’s immediate concerns. Fourth, the counselor can assess the student’s overall functioning and offer assistance with any identified concerns. Fifth, the counselor can help to normalize the student’s experience of cross-cultural transition while addressing the individual’s unique needs. Sixth, the counselor can begin to establish a trusting relationship that may set the stage for the student to return to counseling or encourage peers to do so. Seventh, the counselor can link the student with available resources on campus and in the local community. Eighth, the counselor can listen for issues that the student has in common with other international students and consider whether advocacy or systems intervention may be a viable direction. As with every client, it is the choice of any international student whether or not to continue with counseling. However, the counselor’s capacity to build a positive therapeutic alliance in a first session sets the stage for future counseling. Theoretical notes. The universality of Western theories of counseling has been questioned (Hohenshil et al., 2013). Counselors need to guard against assuming that mental health and healing practices in one part of the world are valued by people who have lived in other cultural contexts. It is important for counselors to understand international students’ views regarding the causes of their current issues or challenges and to consider culturally responsive interventions. Counselors should be skilled in performing cultural auditing processes that help them to assess their conceptualizations of client issues and appropriate directions for interventions, developed in a collaborative process (Collins, Arthur, & Wong-Wylie, 2010). Clients are the experts on their own cultural identities, and counselors should collaborate with them in determining the change processes that are the best fit for addressing their presenting concerns. Empirically supported treatments. There is a long-standing debate in the field of counseling and psychotherapy regarding the preferential use of empirically supported treatments (ESTs) (e.g., Hunsley, Dobson, Johnston, & Mikhail, 1999; King, 1999). Essentially, one side of the debate calls for treatment efficacy to be demonstrated through experimental design, the use of manualized treatment protocols, the specification of demographic characteristics, and study by two different research teams (Hunsley et al., 1999). Concerns have been raised about the emphasis on approaches that are more amenable to empirical validation (e.g., cognitive-behavioral therapies) versus constructivist approaches (e.g., narrative therapies). Those on the other side of the debate assert that just because an approach does not meet the criteria for inclusion as an empirically validated treatment, that does not mean it is ineffective as a treatment method. Within the multicultural counseling literature there are pressures to adopt ESTs (D’Andrea & Heckman, 2008), but there are also concerns about how well the criteria for ESTs incorporate the languages, cultural identities, and practices of people from diverse cultural backgrounds (Atkinson, Bui, & Mori, 2001). Widely adopting any one treatment modality is counterintuitive to the recognition of multiple worldviews and the call for counselors to take into consideration the unique contextual influences on client concerns. It seems that there is a risk of either harm or good when any one approach is universally applied across diverse populations. We need more examples of counseling practices and interventions that support counseling international students, particularly research that focuses on therapist and counseling process variables (Leong & Chou, 2002). Formal and informal methods. Counselors are encouraged to be involved in service design that incorporates both formal and informal methods and takes place in both formal and informal contexts (Pedersen et al., 2008). For example, services might be marketed through information delivered online, information on topics related to health promotion might be delivered electronically for students to self-serve, and counselors might participate in the design and delivery of group interventions. With the increasing use of social media, some counselors may need to upgrade their skills for connecting with students. It is important for counselors to consider that talk-based counseling may not be the only method for reaching out to international students. Educational and preventive information can be delivered through electronic formats that support international students to learn about common issues, access online resources, and follow up with counseling if they feel they need more in-depth exploration of helping resources. The involvement of international students in designing online resources is critical for ensuring the relevance of these resources. Newer students seem to appreciate testimonials and role modeling by international students about their personal experiences and what helped them to cope. Counselors who are involved with designing service delivery modalities need to be cognizant of the best ways to incorporate the perspectives of more experienced international students. There are advantages to counselors’ offering some services in a psychoeducational format directly with international students; in such settings students gain awareness about transition issues while having the opportunity to discuss strategies. Group interventions offer the added advantages of sharing among international students and the development of additional support systems (Arthur, 2003). Group interventions also allow students to make initial contact with counselors, which likely helps them to feel more comfortable about requesting future counseling. Accountability for results. There is growing pressure for counselors in a variety of practice settings to be accountable for the results of their professional work. This poses challenges both for the practice of counseling and for the roles that counselors might take in health promotion, illness prevention, and campus internationalization. For example, there is no straightforward answer to the question, What counts as counseling with international students? It is not only the work that counselors perform in formal counseling sessions that international students might rate as most helpful. Outreach and advocacy efforts on campus, both formal and informal, lead to some of the most effective interventions. However, counselors are challenged to account for the effectiveness of service delivery that is focused on prevention and health promotion or is delivered in new and innovative ways. Conclusion Counseling international students means counseling individuals who have unique and diverse cultural identities. There is no single method or theoretical framework that is recommended as being superior to others. Rather, counselors who work with international students need to consider the worldviews of their clients and how they can design and deliver interventions to meet the clients’ needs during the process of cross-cultural transition. That is not to say that all of the presenting issues raised by international students are caused by cross-cultural transition. However, the experiences of these students are often especially complex because of the challenges of navigating local cultural norms, academic demands, communication issues, relationships in both home and host countries, and implementation of career plans. Counselors play an important role in helping international students with their journeys of living and learning across cultures and across educational contexts. It is important that counselors consider their own attitudes and awareness about international students, including their personal assumptions and biases. A growing number of resources about international students are available in both the educational literature and the counseling literature. Counselors who work in campus settings should access those resources to increase their level of inclusive cultural empathy for working with international students. It is important for counselors to remember that this is not just one population; international students are clients with multiple cultural identities from around the world. Discussion Questions 1. What opportunities do you see for counselors to have an influence on campus internationalization, to help foster the integration of international students in the educational institution and in the local community? 2. What are the cultural assumptions that underpin the theoretical approaches that you use in your counseling? How can you make sure that those assumptions are appropriate for the worldviews of your clients? 3. What competencies would help you to increase inclusive cultural empathy for counseling international students? 4. Given the information on Ling provided in this chapter, as Ling’s counselor, how would you attempt to strengthen the working alliance by helping her to surface some of her “culture teachers” (Pedersen et al., 2008) and their influences on her decisions and experiences? 5. What ethical issues might surface in the referral of international students from student advisers or academic faculty, and how might you manage those issues? 6. How would you evaluate the impacts of services on international students, including direct counseling, outreach activities, and psychoeducational approaches aimed at health promotion? 7. Given the information on Mohammed provided in this chapter, what hypotheses do you make regarding his reluctance to focus on his home country? What do these hypotheses imply about the similarities or differences between your worldview and Mohammed’s? 8. What ethical responsibilities do counselors have for addressing racism and other forms of oppression directed toward international students? 9. How might counselors incorporate a stronger focus on career planning and decision making in interventions with international students? 10. What areas for your continued professional learning have you identified from reading this chapter? References Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalization of the multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24(1), 42–78. Arthur, N. (2003). Preparing international students for the re-entry transition. Canadian Journal of Counselling, 37(3), 173–185. Arthur, N. (2004). Counseling international students: Clients from around the world. New York: Kluwer Academic/Plenum. Arthur, N. (2007). Career planning and decision-making needs of international students. In M. Pope & H. Singaravelu (Eds.), A handbook for counseling international students in the United States (pp. 37–56). Alexandria, VA: American Counseling Association. Arthur, N. (2010). Learners in cross-cultural transition: Counselling international students. In N. Arthur & S. Collins (Eds.), Culture-infused counselling (2nd ed., pp. 423–446). Calgary, AB: Counselling Concepts. Arthur, N., & Flynn, S. (2011). Career development influences of international students who pursue permanent immigration to Canada. International Journal of Education and Vocational Guidance, 11(3), 221–237. doi:10.1007/s10775-011-9212-5 Arthur, N., & Nunes, S. (2014). Should I stay or should I go home? Career guidance with international students. In G. Arulmani, A. J. Bakshi, F. T. L. Leong, & A. G. Watts (Eds.), Handbook of career development: International perspectives (pp. 587–606). New York: Springer. Arthur, N., & Pedersen, P. B. (Eds.). (2008). Case incidents in counseling for international transitions. Alexandria, VA: American Counseling Association. Arthur, N., & Popadiuk, N. (2010). A cultural formulation approach to career counseling with international students. Journal of Career Development, 37(1), 423–440. doi:10.1177/0894845309345845 Atkinson, D. R., Bui, U., & Mori, S. (2001). Multiculturally sensitive empirically supported treatments—an oxymoron? In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 542–574). Thousand Oaks, CA: Sage. Berry, J. (2001). A psychology of immigration. Journal of Social Issues, 57, 615–631. Brooks, R., Waters, J., & Pimlott-Wilson, H. (2012). International education and the employability of UK students. British Educational Research Journal, 38, 281–298. doi:10.1080/01411926.2010.544710 Chen, C. P. (1999). Common stressors among international college students: Research and counseling implications. Journal of College Counseling, 2, 49–65. Collins, S., & Arthur, N. (2010a). Culture-infused counselling: A fresh look at a classic framework of multicultural counselling competencies. Counselling Psychology Quarterly, 23(2), 203–216. doi:10.1080/09515071003798204 Collins, S., & Arthur, N. (2010b). Culture-infused counselling: A model for developing cultural competence. Counselling Psychology Quarterly, 23(2), 217–233. doi:10.1080/09515071003798212 Collins, S., Arthur, N., & Wong-Wylie, G. (2010). Enhancing reflective practice in multicultural counseling through cultural auditing. Journal of Counseling & Development, 88(3), 340–347. doi:10.1002/j.1556-6678.2010.tb00031.x D’Andrea, M., & Heckman, E. F. (2008). A 40-year review of multicultural counseling outcome research: Outlining a future research agenda for the multicultural counseling movement. Journal of Counseling & Development, 86, 356–363. Draguns, J. G. (2007). Empathy across national, cultural, and social barriers. Baltic Journal of Psychology, 8(1–2), 5–20. Gaw, K. F. (2000). Reverse culture shock in students returning from overseas. International Journal of Intercultural Relations, 24(1), 83–104. Gu, Q., Schweisfurth, M., & Day, C. (2010). Learning and growing in a “foreign” context: Intercultural experiences of international students. Compare: A Journal of Comparative and International Education, 40(1), 7–23. doi:10.1080/03057920903115983 Gullahorn, J. T., & Gullahorn, J. E. (1963). An extension of the U-curve hypothesis. Journal of Social Issues, 19(3), 33–47. Hayes, R. L., & Lin, H. (1994). Coming to America: Developing social support systems for international students. Journal of Multicultural Counseling and Development, 22, 7–16. Henry, C. G., & Fouad, N. A. (2007). Counseling international students from the Middle East. In H. Singaravelu & M. Pope (Eds.), A handbook for counseling international students in the United States (pp. 223–236). Alexandria, VA: American Counseling Association. Hohenshil, T., Amundson, N., & Niles, S. (2013). Counseling around the world: An international handbook. Alexandria, VA: American Counseling Association. Hunsley, J., Dobson, K. S., Johnston, C., & Mikhail, S. F. (1999). Empirically supported treatments in psychology: Implications for Canadian professional psychology. Canadian Psychology, 40, 289–302. Hwang, K. P., Wang, M., & Sodanine, S. (2011). The effects of stressors, living support, and adjustment on learning performance of international students in Taiwan. Social Behavior & Personality, 39, 333–344. Institute of International Education. (2012). Open doors 2012: Report on international educational exchange. New York: Author. Retrieved from http://www.iie.org/en/Research-andPublications/Open-Doors Johnson, L., & Sandhu, D. S. (2007). Isolation, adjustment, and acculturation issues of international students: Intervention strategies for counselors. In H. Singaravelu & M. Pope (Eds.), A handbook for counseling international students in the United States (pp. 13–36). Alexandria, VA: American Counseling Association. King, M. C. (1999). Realpolitik and the empirically validated treatment debate. Canadian Psychology, 40, 306–308. Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Leong, F. T. L., & Chou, E. L. (2002). Counseling international students and sojourners. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th ed., pp 185–207). Thousand Oaks, CA: Sage. Lysgaard, S. (1955). Adjustment in a foreign society: Norwegian Fulbright grantees visiting the United States. International Social Science Bulletin, 10, 45–51. Mazzarol, T., & Soutar, G. N. (2002). “Push–pull” factors influencing international student destination choice. International Journal of Educational Management, 16(2), 82–90. doi:10.1108/09513540210418403 Mellin, E. A., Hunt, B., & Nichols, L. M. (2011). Counselor professional identity: Findings and implications for counseling and interprofessional collaboration. Journal of Counseling & Development, 89, 140–147. doi:10.1002/j.1556-6678.2011.tb00071.x Moores, L., & Popadiuk, N. (2011). Positive aspects of international student transitions: A qualitative inquiry. Journal of College Student Development, 52(3), 291–306. doi:10.1353/csd.2011.0040 Musumba, M., Jin, Y. H., & Mjelde, J. W. (2009). Factors influencing career location preferences of international graduate students in the United States. Education Economics, 19(5), 501–517. doi:10.1080/09645290903102902 Oberg, K. (1960). Cultural shock: Adjustment to new cultural environments. Practical Anthropology, 7, 177–182. Organisation for Economic Co-operation and Development. (2011). Education at a glance 2011: Highlights. Paris: Author. Retrieved from http://www.oecd.org/edu/skills-beyondschool/48631550.pdf Oropeza, B. A., Fitzgibbon, M., & Baron, A. J. (1991). Managing mental health crises of foreign college students. Journal of Counseling & Development, 69, 280–284. Pedersen, P. B. (1991). Counseling international students. The Counseling Psychologist, 19, 10–58. Pedersen, P. B. (1995). The five stages of culture shock: Critical incidents around the world. Westport, CT: Greenwood. Pedersen, P. B., Crethar, H. C., & Carlson, J. (2008). Inclusive cultural empathy: Making relationships central in counseling and psychotherapy. Washington, DC: American Psychological Association. Popadiuk, N. E. (2009). Unaccompanied Asian secondary students in Canada. International Journal for the Advancement of Counselling, 31(4), 229–243. Popadiuk, N. E., & Arthur, N. (2004). Counseling international students in Canadian schools. International Journal for the Advancement of Counselling, 26(2), 125–145. Popadiuk, N. E., & Arthur, N. (2014). Key relationships for international student university-to-work transitions. Journal of Career Development, 41(2), 122–140. Pope, M., Singaravelu, H., Chang, A., Sullivan, C., & Murray, S. (2007). Counseling gay, bisexual, and questioning international students. In H. Singaravelu & M. Pope (Eds.), A handbook for counseling international students in the United States (pp. 57–86). Alexandria, VA: American Counseling Association. Reynolds, A., & Constantine, M. (2007). Cultural adjustment difficulties and career development of international college students. Journal of Career Assessment, 15(3), 338–350. doi:10.1177/1069072707301203 Sangganjanavanich, V. F., Lenz, A. S., & Cavazos, J., Jr. (2011). International students’ employment search in the United States: A phenomenological study. Journal of Employment Counseling, 48, 17–26. doi:10.1002/j.2161-1920.2011.tb00107.x Schlossberg, N. (1992). Adult development theories: Ways to illuminate the adult development experience. In H. D. Lea & Z. B. Leibowitz (Eds.), Adult career development: Concepts, issues, and practices (2nd ed., pp. 2–16). Alexandria, VA: National Career Development Association. Schlossberg, N. (2011). The challenge of change: The transition model and its application. Journal of Employment Counseling, 48, 159–162. Shen, Y., & Herr, E. L. (2004). Career placement concerns of international graduate students: A qualitative study. Journal of Career Development, 31(1), 15–29. doi:10.1177/089484530403100102 Shih, S., & Brown, C. (2000). Taiwanese international students: Acculturation level and vocational identity. Journal of Career Development, 27(1), 35–47. doi:10.1177/089484530002700103 Singaravelu, H., White, L., & Bringaze, T. (2005). Factors influencing international students’ career choice: A comparative study. Journal of Career Development, 32(1), 46–59. doi:10.1177/0894845305277043 Spencer-Rodgers, J. (2000). The vocational situation and country of orientation of international students. Journal of Multicultural Counseling and Development, 28(1), 32–49. Sue, D. W., Carter, R. T., Casas, J. M., Fouad, N. A., Ivey, A. E., Jensen, M.,... Vazquez-Nutall, E. (1998). Multicultural counseling competencies: Individual and organizational development. Thousand Oaks, CA: Sage. Swagler, M. A., & Ellis, M. V. (2003). Crossing the distance: Adjustment of Taiwanese graduate students in the United States. Journal of Counseling Psychology, 50, 420–437. Techome, Y., & Osei-Kofi, N. (2012). Critical issues in international education: Narratives of spouses of international students. Journal of Studies in International Education, 16(1), 62–74. doi:10.1177/1028315311403486 Ward, C., Bochner, S., & Furnham, A. (2001). The psychology of culture shock (2nd ed.). Hove, England: Routledge. Yi, J., Lin, G., & Kishimoto, Y. (2003). Utilization of counseling services by international students. Journal of Instructional Psychology, 30, 333–342. Zhou, D., & Santos, A. (2007). Career decision-making difficulties of British and Chinese international university students. British Journal of Guidance & Counselling, 35(2), 219–235. doi:10.1080/03069880701256684 15 Counseling Immigrants and Refugees Fred Bemak Rita Chi-Ying Chung Primary Objective ■ To assist mental health practitioners in understanding and providing effective multicultural counseling and psychotherapy with refugees and migrants by providing a model of treatment and psychotherapy (the multiphase model of psychotherapy, social justice, and human rights) Secondary Objectives ■ To provide an understanding of the sociopolitical and historical contexts of mental health for refugees and migrants ■ To promote awareness and understanding of the impacts of premigration trauma on postmigration adjustment ■ To sensitize mental health practitioners regarding acculturation, cultural belief systems, and associated adjustment issues that affect the psychological well-being of refugees and migrants Immigrant and refugee migration is not a new phenomenon. People have moved from place to place since the beginning of humankind. However, in recent years, with increasing globalization, advances in technology, growing aspirations for a “better life,” improved access to international travel, and frequent widespread devastation from natural disasters, the rates of migration have increased worldwide. In the United States alone there are approximately 40 million immigrants (U.S. Census Bureau, 2011). It is estimated that one in five persons living in the United States is a first- or secondgeneration immigrant (Mather, 2009). It is critical that mental health professionals be trained to provide culturally responsive services for this growing population. To understand migrant populations fully, it is essential to understand the differences between those who have migrated involuntarily, or were forced to do so, and those who chose to migrate to another country or region. The forced migration group consists mainly of refugees who have left their home countries or regions due to war, political instability, regional and national conflicts, genocide, social and economic upheaval, poverty, or natural disasters (Bemak & Chung, 2008). Others in the forced migration group are those who have migrated because of coercion, fraud, physical force, deception, or threat of exploitation, such as persons working in factories, as maids, or in the commercial sex industry (Chung, 2005, 2009). It is estimated that approximately 2.5 million trafficked persons fall into this category (Chung, 2005, 2009). Although refugees and others who are forced to migrate generally experience more difficult adaptation than voluntary migrants because of their circumstances, immigrants in both groups encounter similar postmigration challenges. Given these commonalities, we use the term migrants in referring to people from both groups in this chapter. We begin the chapter with a brief description of refugees and immigrants, present demographics and salient issues encountered by migrants, and then discuss the challenges facing this population as a foundation for understanding the migrant experience. We will then address a number of issues related to providing culturally responsive mental health services to migrants, laying the groundwork for a discussion of the multiphase model (MPM) of psychotherapy, social justice, and human rights. Migration Demographics Over the decade ending in 2010, the number of international migrants increased from 150 million to 214 million, and it is estimated that migrants make up 3.1% of the world’s population, or 1 of every 33 people (International Organization for Migration, 2010). The United States has witnessed a rapid increase in immigration, especially between 1990 and 2009, when the immigrant population nearly doubled, from 20 million to 38.5 million. As of 2011, 39.9 million people in the United States, or 13% of the population, were immigrants (U.S. Census Bureau, 2011). It is estimated that one in five persons in the United States is a first- or second-generation immigrant, and nearly one-fourth of children younger than 18 have an immigrant parent (Mather, 2009). By 2020 immigrant children and adolescents will account for one-third of the U.S. population (Mather, 2009). In addition, it is estimated that 11.5 million undocumented immigrants are living in the United States (Hoefer, Rytina, & Baker, 2012), with the number increasing as the result of human smuggling and trafficking (Chung, 2009). Dispelling the Myths About Migrants In the United States immigration has generated political polarization, and in this politically charged climate many myths about migrants have been created and perpetuated. Below, we dispel four common myths. 1. Migrants have few skills and are using available resources without making any contribution. Immigrants to the United States come with a variety of educational and skill levels. They constitute 47% of U.S. scientists with PhDs, almost one-quarter of bachelor’s degree–level college graduates working in engineering and science, and 25% of physicians (Portes & Rumbaut, 2006). Those who have little or no education and fill unskilled manual labor and service jobs make up 75% of U.S. farm and fruit and vegetable workers (Kandel, 2008). What is not widely known is that undocumented migrants in 2005 (the most recent figures available) contributed approximately $9 billion in federal taxes and generated $75 billion in earnings, but they are not entitled to benefits such as Social Security (Loller, 2008; Massey, 2010). 2. Migrants are taking jobs from American workers. Migrants make up 13% of the U.S. population and constitute 15% of the workforce (Meissner, 2010). Their overrepresentation in the workforce is largely the result of the aging of the U.S. population and the relatively young age of the migrant population, which has accounted for 58% of the growth of the U.S. population since 1980. Furthermore, migrants tend to be grouped in high-skilled and low-skilled occupations, which means these workers complement rather than compete with native-born U.S. workers. 3. Most immigrants are undocumented. Two-thirds of migrants in the United States are in the country legally. It is estimated that there are almost 11 million undocumented immigrants in the United States (Hoefer et al., 2012; Passel & Taylor, 2010), most of whom hold low-paying and unsteady jobs (Yoshikawa, 2011). Approximately 40% of these undocumented migrants arrived legally but overstayed their visas (Hoefer et al., 2012). The largest proportion (three-quarters) of undocumented immigrants in the United States are from nearby regions (Canada, the Caribbean, Central America, and Mexico), with the second-largest group from Asia, followed by South America (Hoefer et al., 2012). Approximately 1.1 million of the undocumented immigrants in the United States arrived as young children and have been educated in U.S. schools (Passel & Taylor, 2010). 4. Strengthening the borders and reducing illegal border crossings will make the United States safer. After the terrorist attacks on New York City and Washington, D.C., on September 11, 2001, the United States undertook concerted efforts to strengthen border security. The U.S. Border Patrol has nearly doubled in size, to more than 20,000 agents, and the Department of Homeland Security is on schedule to meet congressional mandates for southwestern border enforcement that includes fence building (Meissner, 2010). However, given the enormous lengths of the borders separating the United States from Mexico and Canada (totaling nearly 7,500 miles of land and 12,380 miles of coastline) and the vast network of seaports and international airports through which people pass daily, guarding and securing all border ports of entry is a major challenge. It has been suggested that, rather than emphasizing security measures on borders, the United States should focus on distributing more work visas to reduce illegal border crossings (Meissner, 2010). The Refugee Experience It is estimated that there are 42 million refugees worldwide (United Nations High Commissioner for Refugees, 2010) due to ongoing political instability, regional and national conflicts, wars, genocide, social and economic upheaval, poverty, natural disasters, and population growth (Bemak & Chung, 2008). The majority of refugees come from developing countries, and refugee populations consist mainly of women, children, and people with disabilities, many of whom lack the mental, physical, and economic resources to survive under harsh conditions (Bemak, Chung, & Pedersen, 2003). Environmental refugees—persons forced to migrate because of the effects of climate change and environmental racism—have increased in number (Chung, Bemak, & Kudo Grabosky, 2011); the United Nations Environment Programme (UNEP, 2010) has estimated that there are 25 million such refugees around the world. Examples of this group include persons displaced by the 2011 floods and tornadoes in the U.S. Midwest, the 2011 earthquake and tsunami in Japan, the 2010 earthquake in Haiti, Cyclone Nargis in Myanmar (Burma) in 2008, and Hurricane Katrina in Mississippi and New Orleans in 2005. UNEP (2010) has projected that, with environmental degradation such as deforestation, rising sea levels, and the rapid melting of ice caps, 200 million people will become environmental refugees by 2050. Regardless of why refugees migrate, there is a high prevalence of serious mental health problems within this population, often related to struggles to escape from intolerable and chaotic conditions. Worrying about family members who remain in danger in the home country, being held for prolonged periods in detention facilities, and being subjected to torture are all conducive to the development of more pronounced mental health problems (Nickerson, Bryant, Steel, Silove, & Brooks, 2010; Robjant, Hassan, & Katona, 2009). Refugee migration is extremely difficult and frequently dangerous, resulting in loss of family, identity, community, and culture; a downgrade in socioeconomic status and employment; the need to learn a new language; dramatic shifts in social, familial, and gender roles; and acculturation, adjustment, and adaptation problems in the new country (Bemak & Chung, 2008). Premigration Trauma The involuntary flight premigration experience plays an important part in the postmigration adjustment of refugees. It is critical for mental health professionals to consider the impacts of often highly stressful and/or traumatic premigration events and to understand their influence on postmigration adjustment and adaptation (Bemak et al., 2003). Many refugees have been subjected to war atrocities and refugee camp living; many have experienced and witnessed torture, killing, incarceration, starvation, rape and other sexual abuse, physical beatings, and injuries. Many who managed to escape to refugee camps faced problems of overcrowding, poor nutrition, unsanitary conditions, inadequate medical care, and continued violence that often compounded already existing psychological problems. Therefore, it is not surprising that numerous studies have found refugees to be more prone to psychological problems than members of other populations (e.g., American Psychological Association [APA], 2010; Bemak & Chung, 2008). Refugees’ traumatic experiences have been categorized into four major types: (a) deprivation (e.g., food and shelter), (b) physical injury and torture, (c) incarceration and reeducation camps, and (d) the witnessing of torture and killing (Mollica, Wyshak, & Lavelle, 1987). In addition, refugees have experienced the loss, through death or separation, of nuclear and extended family members as well as their communities and countries. Premigration trauma puts refugees at high risk for developing serious mental health problems, including depression, dissociation, anxiety, posttraumatic stress disorder (PTSD), and psychosis (APA, 2010; Keyes, 2000), and higher rates of psychopathology compared to the general U.S. population (e.g., Vickers, 2005). Some refugee groups are at higher risk than others for developing serious mental health disorders. Older refugees may experience more difficulties in adjusting to new environments, and single men (under 21 years old) may also be at risk because of lack of familial and social supports (Bemak et al., 2003). Unaccompanied minors—children and adolescents with no adult family members present during resettlement—are another vulnerable group. Also susceptible to mental health problems are refugee women and girls who experienced rape and other sexual abuse before migration (Chung & Bemak, 2002b; Morash, Bui, Zhang, & Holtreter, 2007) and refugee women whose husbands were killed during war. For example, Cambodian refugee women who had experienced their country’s genocidal conflict had significant difficulties in postmigration adjustment (Chung, 2001), similar to refugee women from Rwanda and Somalia. In the sections that follow we discuss some of the challenges that migrant populations encounter and present major themes related to counseling this population. Although some of the constructs discussed are similar to those in other cross-cultural counseling situations, we emphasize that the cultural dynamics and the historical and sociopolitical backgrounds of migrant populations present unique characteristics that are traceable to respective cultures of origin and cultures of resettlement. Mental health professionals must understand these differences clearly and incorporate that understanding into therapeutic relationships with migrant clients at multiple levels, including individual, family, group, and community. Impact of Culture on Mental Health Cultural Belief Systems Understanding cultural differences and cultural belief systems as they relate to psychological problems and healing is important in providing effective services for migrant populations. Historically, Western models of psychotherapy have been based on a worldview that emphasizes individual psychotherapy as a means to enhance optimal independent functioning, coping abilities, and adaptation. This is in direct contrast to the cultural contexts of many migrants, who often come from collectivistic cultures that focus on interpersonal relationships and social networks and may take a holistic approach to mental health. In collectivistic cultures the family, the community, and the social network define personal identity and cultivate interdependence. The members of many migrant groups may perceive being individually oriented and independent as contrary to their cultural beliefs. As a result, standard clinical interventions based on Western European American practices are frequently in conflict with migrants’ beliefs and value systems. Providing psychological services for migrants requires the use of assessment and treatment methodologies that are consistent with these clients’ cultural values and beliefs. For example, refugees from Asia or Africa who believe that emotional imbalance is caused by animism or spirits may report visualizing and hearing deceased relatives. Traditional Western psychotherapists attribute such symptoms to psychosis and employ counseling techniques and medication that focus on the symptomatology (the “hallucination”) to treat the underlying psychosis. Indigenous healing methods approach the same symptoms from a different cultural framework, incorporating the deceased relatives and spirits as important and relevant forms of personal and spiritual communication that may help stabilize the individual and possibly the entire family. The need to understand and validate the client’s conceptualization of problems within the context of culture has been strongly emphasized (e.g., Kleinman, Eisenberg, & Good, 1978). The cultural conceptualization of mental illness encompasses symptom manifestation (Chung & Kagawa-Singer, 1995), help-seeking behavior (Chung & Lin, 1994), and expectations of treatment and outcome. For example, African refugees who believe deceased ancestors provide wisdom and guidance may have symptoms of head pain or insomnia that is caused by upsetting ancestral spirits. By seeking help from individuals who respect and honor their cultural belief system, such as traditional healers, these refugees believe they can gain assistance in communicating with ancestors to establish the cause of the problem and subsequent solution. Similar complaints and symptoms are found across cultures, but they may take different forms and be attributed to different causes (e.g., Kirmayer, 1989; Phillips & Draguns, 1969); thus, it is important for the therapist to understand and accept the impact of culture and the complexity of the cultural construction of mental illness/mental health as it relates to migrant clients. Therapists must be knowledgeable and employ culturally sensitive therapeutic interventions and skills (Bemak & Chung, 2008; Pedersen, 2000) while also maintaining an awareness of crosscultural errors in under- or overdiagnosing symptomatology. It is critical for therapists to bring diagnosis and intervention in line with their migrant clients’ cultural belief systems, values, and healing practices, acknowledging the clients’ cultural conceptualizations of their problems. Effectively counseling across cultures requires a deep and nurturing inclusive cultural empathy, a concept introduced by Pedersen, Crethar, and Carlson (2008). Cultural Influence on the Utilization of Mainstream Mental Health Services Although there is a need for mainstream mental health services for migrants, several factors contribute to the historical reluctance of members of this population to seek help. First, consistent with their cultural belief systems and practices, members of migrant groups are likely initially to explore traditional healing methods with elders, family members, friends, and religious leaders. Only after failing to locate or receive help from such customary support networks do migrants seek out mainstream mental health professionals. (Noteworthy is the fact that more than 75% of people in the world use complementary or alternative treatments; Micozzi, 1996.) The situation is further complicated because by the time migrants finally enter into psychotherapeutic treatment, their problems have often grown more severe, with more serious symptoms. A second reason migrants often avoid using mainstream mental health services is the cultural insensitivity of many mental health professionals, which includes failure to understand cultural differences in the expression of symptomatology (Chung & Bemak, 2012). The lack of cultural responsiveness by mainstream services has been found to account for low utilization rates, high dropout rates, and premature client termination among ethnic groups (S. Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Mainstream service providers may not accommodate cultural differences related to such issues as time or language, and they may not understand the impacts of their own behaviors, such as voice tone, speaking volume, and nonverbal communication. For example, in some cultures direct eye contact, shaking hands with a member of the opposite sex, or pointing the soles of one’s feet at someone is considered offensive. Thus, migrants often view mental health service systems as “insensitive.” Additionally, many encounter “offensive” receptionists or other staff members, and these interactions trigger recollections of negative experiences with authority figures. Such encounters heighten migrants’ negative reactions to mainstream mental health services. Third, there is the problem of language (Bemak & Chung, 2008; Kim et al., 2011). Not knowing the language of the host country may be an obstacle to migrants’ interaction with mainstream mental health services, either because translators are not available or because the translators provided are not effective within the mental health domain. That is, even when translators are available, skill deficiencies may cause problems; some translators are unable to move beyond literal translation and understand more subtle yet essential issues that provide the contexts of clients within their cultures. Effective translators working with mental health service providers can assist in interpreting the innuendoes of tonal changes, the meanings of nonverbal behavior, and cultural frameworks that provide context for social relationships and definitions of self. Children are sometimes asked to act as translators for families, but it should be noted that in traditional hierarchical families this practice creates difficulties in relation to the actual context of the conversation and the lack of verbatim translations, and it can lead to changes in family dynamics (Bemak et al., 2003). To overcome language and cultural barriers in the treatment of migrant clients, translators must be carefully trained and able to establish well-defined partnerships with clinical professionals. A promising technique for reducing the language barrier is for the therapist to invite the client to name important feelings or issues in the client’s first language (Draguns, 1998). A fourth reason for migrants’ low utilization of mainstream mental health services is inaccessibility (Wu, Kviz, & Miller, 2009). Clinics and private offices are frequently located in areas that are difficult for migrants to reach and that they may perceive as culturally removed. Public transportation systems may be complicated and difficult to use, and travel on such systems is time-consuming. Furthermore, particularly in urban areas, community-based mental health facilities may be located in poorer sections that migrants perceive as unsafe. Challenges in Psychosocial Adjustment and Adaptation The first 1–2 years of resettlement constitute a crucial period when migrants attempt to meet basic needs such as housing and employment (Tayabas & Pok, 1983). Bemak (1989) has outlined a threephase development model of acculturation affecting psychosocial adjustment. The first phase is a period of security and safety, when migrants attempt to use existing skills to master the new environment and achieve psychological safety. Successful completion of this phase leads to the second phase, during which skills from the culture of origin and the new culture are integrated in the process of acculturation. The third phase follows successful adaptation and is highlighted by a growing sense of the future. In this developmental model, it is only after they have achieved a basic mastery of culture and language and a sense of psychological safety that migrants begin to contemplate and plan for realistic and attainable future goals and implement strategies for achieving these objectives. Migrant adaptation in the resettlement country includes learning new coping skills and new behavioral and communication patterns. This can present challenges, especially for migrants who are accustomed to using certain survival strategies. For example, a migrant may use “acting dumb”—that is, remaining numb and unresponsive—as a survival skill to cope with psychological, physical, and sexual trauma. In the resettlement country, such survival strategies may appear to be strange and inappropriate. For refugees another important factor in adaptation to a new country is a marked ambivalence about relocation. Unlike their immigrant counterparts who chose to migrate, refugees have experienced the loss of decision-making control related to essential life questions, such as geographic location, job opportunities, and social networks. Furthermore, refugees may be resentful toward the host country. For example, some refugees in Africa, Asia, and Latin America have felt abandoned by relocation countries that they believed would protect and take care of them. These feelings contribute to obstacles in adaptation. Survivor’s guilt is another problem that has commonly been associated with refugees (Bemak et al., 2003) and may have implications for other migrant groups. Many refugees are haunted by feelings of guilt because they escaped from dangerous conditions in their home countries but left behind family, friends, and loved ones. Awareness that the people who remained in their countries of origin are alive and not ill or suffering may partially relieve survivor’s guilt, while knowledge about them living in unpleasant conditions causes added emotional distress. Migrants who have little or no information about those they left behind may be plagued with feelings of intense stress and guilt, and cycles of pain and sadness may affect their happiness, success, and well-being. Acculturation Acculturation models generally include the concepts of assimilation, integration or biculturalism, rejection, and deculturation (Berry, 2002). As migrants interact with resettlement country cultures they are challenged to learn the rules, beliefs, values, and attitudes of the countries’ dominant cultures, some of which may conflict with their traditional cultures. Acculturation depends on how migrants accept, integrate, or reject these new rules and worldviews. Research has concluded that biculturalism or integration produces the healthiest acculturation outcomes (Berry, 2002). Migrants may experience culture shock accompanied by a sense of helplessness and disorientation, since resettlement introduces them to new reference groups that are frequently more individualistic than collectivistic (Bemak & Greenberg, 1994) and present the difficulties of moving from a sociocentric to an egocentric society (Bhugra, 2004). Individual and cultural differences play an important role in migrants’ abilities to integrate their cultures of origin with their relocation cultures, along with factors such as desire and willingness to adapt, ability to identify with a new reference group, acceptance of new norms and values, social and family support, and resolution of past trauma. In addition, elements of acculturation such as cultural identity, social customs, language acquisition, preferred music, social network choices, and preferred food all contribute to adaptation and adjustment to a new culture (Yoon, Langrehr, & Ong, 2011). For refugees, difficult premigration experiences that link with psychosocial maladjustment may hinder acculturation. Language Barriers Language plays an important role in adjustment and acculturation. Research has shown a correlation in the United States between proficiency in English and academic success (Goldenberg, 2008). English as a second language (ESL) programs in the United States offer language training yet fall short of addressing associated issues. Learning a new language may symbolize abandoning one’s homeland and can be a catalyst for feelings of cultural identity loss. An example of this is provided by an El Salvadoran migrant who struggled learning English. In a painful moment she explained in Spanish, “To learn English is to forget my country. I don’t want to lose myself and speak English!” A Cambodian adolescent whose mother had been executed during mass genocide under the Khmer Rouge regime had similar difficulties. One night after she migrated to the United States, the girl had a dream in which her mother angrily exhorted her to “stop speaking English. You must speak Khmer! Remember you are Cambodian!” Experiencing the frustration of trying to learn a new language may also bring back memories of “better times and easier communication” with neighbors, friends, and family. The struggle with language may exacerbate emotional problems and the frustrations of living in the new environment, contributing to culture shock. ESL classes may also create feelings of helplessness and cause regressive behavior similar to that seen in earlier developmental years, as when a child’s attempts to learn to master the environment sometimes lead to questions about selfworth, feelings of inadequacy, low self-esteem, and loss in social status. Furthermore, learning the language of the new culture may stimulate a redefinition of family relationships, causing dysfunction, conflicts, role confusion, and subsequent painful social restructuring. An example is the child who acquires language skills more quickly than his parents, thereby causing a reversal of roles when the parents become dependent on the child for cultural and language translation. Differences in rates of language acquisition among family members can be particularly difficult for highly structured matriarchal or patriarchal families, where the ensuing role confusion affects established family patterns. For example, an Ethiopian wife took ESL classes at night, which required her to leave home in the evenings and fall short on fulfilling her traditional household duties. As she became more proficient in English, she identified with the customs and practices of the new culture, felt more independent, and rejected her traditional role as a wife, which in turn, triggered marital disequilibrium and conflict. Employment Gaining employment and becoming economically self-sufficient are major factors that influence adaptation. Financial independence is seen as a primary marker for successful adjustment, but for refugees the ability to attain such independence is inhibited by resettlement policies. For example, the United States and Canada require refugees to pay back airfare and other transportation costs (they are the only two countries to do so) (Alexander, 2010). This means that a family of four flying from Africa to the United States would arrive with a debt exceeding $10,000, or the cost of four airline tickets. This policy creates an added burden and stress on refugees who are already struggling to find gainful employment while adapting to a new environment. In addition to the social and economic readjustment problems that challenge migrants, many also have difficulties finding employment that matches their training and education. Migrants often experience downward vocational mobility and underemployment (Davila, 2008) as well as a dramatic decrease in employability (Yakushko, Backhaus, Watson, Ngaruiya, & Gonzalez, 2008). Educational qualifications earned in migrants’ countries of origin are often not transferable to resettlement countries, and jobs in technologically advanced societies may require specialized skills. Thus, migrants are often forced to “begin again” or “start from scratch.” The search and struggle for gainful employment may result in feelings of hopelessness, poor self-esteem, and a decrease in status. Downward occupational mobility in a fluctuating competitive employment market and barriers to licensure and credentialing may be especially painful for migrants who achieved professional status in their countries of origin, and this may cause additional family tension, with changes in familial and gender roles. Unemployment or underemployment of men commonly forces wives to work and may produce conflict between the gender-role values of migrants’ cultures of origin and those of the host country (Bemak et al., 2003). Paradoxically, migrant men may experience downward occupational mobility while migrant women may experience upward occupational mobility. Changes in Family Dynamics Relocation may have dramatic effects on families. Migrants may face new rules that are contradictory to their traditional child-rearing practices, including methods of child discipline and punishment; they may find that their traditional practices are illegal in the resettlement country, which can create confusion and adjustment difficulties. As children acculturate faster than adults, uncertainty and conflict may arise concerning traditional customs in areas such as dating, marriage, parties, curfews, and school extracurricular activities, making formerly well-established parent-dictated norms into topics of negotiation. Thus, adaptation to the host culture may potentially lead to intergenerational conflicts around traditional values and result in a loss of authority for adults. Migrant youth witness the transformation of their parents from autonomous and culturally competent caretakers to depressed, overwhelmed, and dependent individuals. Their confidence in their parents, who struggle with new language and customs, is often undermined, while the parents experience anxiety over the loss of authority and control. Education In 2011, of the almost one-fourth (23.7%) of U.S. migrant school-aged children (Migration Policy Institute, 2011), 23% were foreign-born (Mather, 2009). Although large numbers of migrant students excel in school, many face problems (García Coll & Marks, 2012), some of which are related to the emphasis on high-stakes testing (Suárez-Orozco, Suárez-Orozco, & Todorova, 2008). Rules for classroom and school behavior are different from those in migrants’ home countries, social and extracurricular activities are not easily accessible for newly enrolled migrants, and expectations for academic success may not fit with family-determined goals. Furthermore, expectations for academic success in Western resettlement countries—with their emphasis on test scores, grades, early course and vocation choices, and rankings—may contradict cultural norms for migrant students (Bemak & Chung, 2003). For example, a 10th grader who is a refugee from Somalia, who is already dealing with the difficulty of figuring out a new school environment, is expected to choose classes that will have a significant impact on her vocation. This career-defining moment is based on the student’s previous grades and predictions regarding whether she can succeed in more demanding classes. Selecting one’s career at age 15 is quite different from the practice in Somalia schools, where attendance past a certain age is uncommon and classes taken in 10th grade are not regarded a road map for a future vocation. In addition, migrant students whose languages, modes of dress, ways of socially interacting, habits, and foods are different from those of their resettlement country peers may illicit prejudicial responses from peers and staff. They may become targets of physical and emotional abuse, verbal harassment, assault, or robbery. Historically, school personnel and mental health professionals have misdiagnosed the aggressive behaviors of migrant children who have been exposed to sustained trauma. As Van der Kolk (1987) notes: “Traumatized children have trouble modulating aggression. They tend to act destructively against others or themselves” (p. 16). (For more in-depth discussion of issues related to migrants and schools, see Bemak & Chung, 2003.) Racism and Xenophobia as Barriers in Psychosocial Adjustment In addition to the psychosocial adjustment challenges described above, migrants often encounter negative discriminatory attitudes in the resettlement country. These attitudes have been identified as natural by-products of the Western focus on individualism (Pedersen, 2000), which contributes to a lack of understanding of life in collectivistic cultures. Discriminatory attitudes toward migrants may be manifested overtly or covertly. Examples include laws that limit the number of cars individual households can have in their driveways or how many people may live in a single house or apartment dwelling. An example of more overt prejudice is the anti-Arab sentiment since 9/11 in Australia, France, the United Kingdom, and the United States, which has resulted in fear and hatred toward foreigners and those who look different from Anglo-Saxon Europeans and has led to hate crimes, riots, and beatings (Bemak & Chung, 2014; Chavez, 2008). Migrants of color who look different from members of the majority culture find themselves at higher risk of experiencing racism and discrimination than those migrants who are racially similar to the majority culture (Berry & Sabatier, 2010). Migrant experiences of racism and discrimination are related to psychosocial adjustment and adaptation (Kira et al., 2010). The degree and overt nature of racist behavior may correlate with antagonism toward perceived political enemies, such as Iranians and Arabs. Additionally, the economic stability in the resettlement country influences job opportunities, resource availability, and policies and practices and defines community and social behaviors toward culturally different migrant newcomers. Immigration policies coupled with the economic stress and changing demographics of communities may precipitate hostility and prejudice, leading to migrants being blamed for unemployment or underemployment among native-born workers. We have coined the term political countertransference to characterize this type of negative reaction toward migrants (Chung et al., 2011). Recent public political disagreements focusing on immigrants, and specifically undocumented people, have fueled xenophobia in the United States. Corporate media frequently portray immigrants in a negative manner, promoting myths and stereotypes of this group as being a burden on the U.S. economy, taking jobs from U.S. citizens, and misusing resources and services (Chung et al., 2011). Immigrants have been the targets of negative media reports (Massey, 2010), and undocumented migrants have been equated to criminals because they are in the country illegally (Chung et al., 2011). There has been speculation about the contribution of such media coverage and political controversy to the rise in hate crimes against immigrants (Holthouse & Potok, 2008; Hsu, 2009; Leadership Conference on Civil Rights Education Fund [LCCREF], 2009; Michels, 2008). For example, FBI data show that hate crimes against Latino/as increased approximately 40% from 2003 to 2007 (LCCREF, 2009). Economic difficulties foster increased xenophobia and fear of newcomers (Bemak & Chung, 2014). Debates about restrictions on immigrants and immigration laws have led to mixed reactions that typify the controversy—for example, 12 U.S. states have passed legislation that allows anyone who graduates from a state high school to qualify for state-resident tuition rates at state colleges and universities, while 6 states have barred undocumented immigrant students from eligibility for such instate tuition rates, even if they graduate from state high schools (Morse, Binbach, & National Conference of State Legislatures, 2012). In Arizona, restrictive laws sanction racial profiling and legalize police questioning of all Latino/as regardless of their official immigration status (Kennedy, 2010). Alabama laws require schools to determine whether any students are undocumented and stipulate that it is a crime to give an undocumented immigrant a ride in a car. On a national level, legislators’ resistance to passing the long-debated Dream Act (formally the Development, Relief, and Education for Alien Minors Act), which would provide a path to legal residency for immigrants who may have lived most of their lives in the United States with undocumented parents, may be rooted in long-standing principles of racism, discrimination, and xenophobia. Migrants experience discrimination in numerous other areas as well. Housing inequities (including differential mortgage lending practices), systematic profiling by security and law enforcement workers, inadequate access to health care, reduced employment opportunities based on language skills, and poor educational access are some of the barriers to social, employment, and professional advancement that migrants face as a result of racial and ethnic background (Chung, Bemak, Ortiz, & Sandoval-Perez, 2008). Such discrimination was evident after Hurricane Katrina in 2005, when Latino/a Americans in areas affected by the storm were asked to provide proof of residency to ensure that they were not undocumented immigrants trying to access the hurricane relief resources and take advantage of the services and food provided for survivors (Bemak & Chung, 2011). In addition to institutional racism, immigrants and refugees encounter racial microaggressions— subtle forms of individual racism (D. W. Sue et al., 2008)—that affect their adaptation and psychological well-being. For example, as noted above, media coverage of immigration issues and political attention to undocumented people have created suspicions that Latino/as are undocumented. Similarly, Asian Americans are often viewed as “perpetual foreigners” (Chung et al., 2008). An illustration of this is the case of U.S.-born figure skater Michelle Kwan. When Kwan, a favorite to win the goal medal in figure skating at the 1988 Winter Olympics, was defeated by another U.S. skater, the MSNBC headline stated, “American Beats Out Kwan” (Chung et al., 2008). Similarly, a Seattle Times headline during the 2002 Salt Lake City Winter Olympics read, “American Outshines Kwan” (Chung et al., 2008). Such headlines reinforce the assumption that Asian Americans are not “real” Americans but rather foreigners who are in the United States competing for American jobs and taking resources and services meant for U.S. citizens. Political Countertransference Countertransference is a well-established concept that mental health professionals study during training to become competent therapists. Among the unique challenges that therapists face in working with migrants is the need to understand their countertransference while also maintaining heightened awareness about the complexity and impact of their political countertransference (Chung et al., 2011). Mental health professionals, similar to all citizens, are exposed to political messages through public media (e.g., television, newspapers, cinema), and these messages become incorporated into the professionals’ worldviews. With the current heated public disagreements about immigration, undocumented people, and the economy, fueled by fears of terrorist attacks, mental health professionals need to recognize that they may be influenced by these media messages, and that influence may, in turn, affect their work with migrant clients and create political countertransference (Chung et al., 2011). Given that immigration is a highly charged issue that receives substantial media coverage, mental health professionals must be aware that certain messages about migrants may become subtly and subliminally embedded in their own attitudes. For example, media portrayals of undocumented people as taking resources and jobs from U.S. citizens in economically difficult times promote prejudice, racism, and discriminatory behavior in the general public. A mental health professional who is having difficulty securing a coveted job in the health sector may feel resentment toward a foreign-born client who comes to counseling for anxiety but has an ideal job working in a nearby public health agency. Mental health professionals must be aware of their own reactions to politically charged issues related to migrants. Family Reunification Challenges A dramatic issue for migrants is the reunification of family members. Often, parents (or one parent) may migrate first and then, once established, send for their children and other family members. Specific to refugees is forced migration, which often causes family separation as some members escape while others remain in the home country. Serial migration occurs when the migration and reunification of family members happen at different times that may extend over several years. For example, one parent might migrate first, followed by the other parent a few years later. Once the parents are established older children may join them, followed by other children at a later time, then grandparents, aunts, and uncles over the next several years. Consequently, family reunification can take many years for both voluntary and involuntary migrants. After periods of separation a major challenge is the reintegration of family members as a unit (Chung, Quiros, Bemak, & Ortiz, 2014). Reuniting children with parents who migrated before them requires adaptation of the children to a new culture and way of life in the resettlement country, children’s adjustment to parents that they may not remember, and perhaps children’s becoming acquainted with siblings they do not know, if the parents had more children after settling in the United States. The longer the separation, the greater the likelihood that the children will exhibit psychological problems (Suárez-Orozco, Bang, & Kim, 2011). Adding to the difficulty of reunification is the children’s grief over the loss of their home country and of family members, friends, and caretakers back home who have been looking after them since their parents departed. It is critical for mental health professionals to be aware of this complex migration process. Multiphase Model of Psychotherapy, Social Justice, and Human Rights With Migrant Populations Migrants to the United States and globally are more diverse than ever before, creating tremendous challenges for mental health professionals. Providing psychotherapy and counseling to migrants requires unique skills based in an understanding of and sensitivity to the historical, sociopolitical, cultural, and psychological realities of migrants’ lives and their experiences of deeply rooted trauma, change, and loss. Displaying cross-cultural empathy when working with this population is also essential. Empathetic responses are understood to be different from culture to culture and yet have the potential to enhance the richness of the therapeutic relationship (Draguns, 2007). Furthermore, empathy must incorporate an understanding of the larger ecological and sociopolitical contexts and backgrounds of migrant clients (Chung & Bemak, 2002a). Cross-cultural empathy also requires multicultural competencies and skills that focus on relationship-centered connections that go beyond individualistic perspectives and evolve into inclusive cultural empathy (Pedersen et al., 2008). Inclusive cultural empathy has been identified as essential for effective counseling across cultures and relates to counseling with migrants. It is essential that mental health professionals understand differences in symptom manifestation based on culture and cultural biases using assessment instruments. Because therapist training and supervision rarely address multiculturalism, social justice, and human rights themes relevant to migrant experiences, mental health professionals must reconceptualize responsive clinical interventions. This is especially important when they are working within Western-based psychotherapeutic frameworks that rely on trust, reciprocal understanding, and open and free communication, which can become strained when cultural barriers exist (Draguns, 1998). Given the complexity of the migrant experience, therapists must consider numerous issues carefully when providing clinical interventions. It is with an understanding of the distinctness of migrant experiences that we propose the multiphase model (MPM) of psychotherapy, social justice, and human rights for migrant populations (Chung & Bemak, 2012). The MPM incorporates the APA (2003) guidelines on multicultural practice, which promote cultural competence for psychologists. Therapists must take into account the complexity of each migrant client’s historical background, past and present stressors, the acculturation process, psychosocial issues in adaptation, and cultural influences regarding the conceptualization of mental illness, healing, and worldviews. Using the MPM, mental health professionals should be able to culturally adapt their individual, family, and group counseling skills and techniques to migrant populations while utilizing inclusive cultural empathy. These culturally responsive interventions are based on a comprehensive understanding, awareness, and acceptance of the cultural, sociopolitical, and historical backgrounds of migrant clients, as well as the ability to experience and communicate empathy across cultures (Chung & Bemak, 2002a; Pedersen et al., 2008). Fundamental in employing the MPM is personal awareness and understanding of the ethnic/racial identity process for migrant clients, insight into one’s own identity (Helms, 1995), and understanding of the interaction of that identity with migration. Therapists’ lack of awareness about these issues frequently leads to misdiagnoses, premature termination by clients, and even harmful treatment. Unlike traditional mental health precepts that were originally rooted in psychodynamic constructs, the MPM is a psychosocial model that includes cognitive, affective, and behavioral interventions, inclusive of cultural foundations and their relationships to community and social processes, and incorporates resilience and prevention. The MPM includes five phases: Phase I, mental health education; Phase II, individual, group, and/or family psychotherapy; Phase III, cultural empowerment; phase IV, indigenous healing, and Phase V, social justice and human rights. There is no fixed sequence to employing the MPM phases, and phases may be implemented concurrently or sequentially. Emphasis on and utilization of any one phase or combination of phases is determined by the psychotherapist. Use of the MPM does not require additional resources or funding; rather, the model represents a reconceptualization and diversification of the role of the psychotherapist as a helper. Phase I, mental health education, focuses on educating the client about mental health practices and interventions. Migrants may not be aware of or have expectations for how to behave as clients. Basic elements of counseling such as intake assessments, professional and interpersonal dynamics in the counseling process, the interpreter’s role, and time boundaries may be strange and unfamiliar to migrants. Thus, in Phase I the psychotherapist informs the individual, family, or group about the MPM, the process of psychotherapy, and the mental health encounter, clearly explaining respective roles and expectations. Although Phase I is always introduced at the beginning of any mental health intervention, it may be reintroduced at later points in psychotherapy if clarification is needed and expectations need to be redefined. It is important during this phase for the therapist to introduce and employ inclusive cultural empathy, which incorporates affective acceptance, intellectual understanding, and cross-cultural empathy and counseling skills (Chung & Bemak, 2002a; Pedersen et al., 2008). Phase II is based on more traditional Western individual, group, and family therapy interventions while incorporating the migrant client’s cultural norms and practices in healing. Traditional techniques rooted in Western psychodynamic practices are alien to many migrants, resulting in the need for therapists to be more directive and active during therapy with some groups (Kinzie, 1985). Further, the focus on independence as a goal in Western psychotherapy contrasts directly with the reliance and strength many immigrants gain from their families and communities (Hong & DomokosCheng Ham, 2001). Specific therapeutic techniques have been identified that are effective in working with migrants. Draguns (1996) has identified salient issues in cross-cultural therapy for PTSD, including the interpretation of actions, feelings, and experiences; the quality and nature of verbal interactions between client and psychotherapist; the role of verbal communication; role expectations for both professional and client; the interrelationship of somatic and physical symptoms with psychological distress; the use of metaphor, imagery, myth, ritual, and storytelling; and the nature of the relationship between client and psychotherapist. Cognitive-behavioral interventions have also been recognized as helpful with migrants (Bemak & Greenberg, 1994; Schottelkorb, Doumas, & Garcia, 2012), as has existential counseling (Parthasarthi, Durgamba, & Murthy, 2004). Duarte-Velez, Bernal, and Bonilla (2010) note the compatibility of cognitive-behavioral therapy with Buddhist tenets and Latino cultures. Storytelling, projective drawing, and play therapy have been found to help children regain control over traumatic events they have experienced (Pynoos & Eth, 1984; Schottelkorb et al., 2012), and Charles (1986) found the use of cultural characteristics to be effective in counseling with Haitian refugees who held strong moral values (e.g., honesty). Bemak and Timm (1994) have shown how dream work was important in a therapeutic intervention with a Cambodian refugee. Other techniques that may be employed in counseling include narrative therapy, gestalt interventions, relaxation, role-playing, and psychodrama. In using these different theories and techniques, it is critical for therapists to ensure that they are employing cultural empathy (Chung & Bemak, 2002a; Draguns, 2007; Pedersen et al., 2008), which has been identified as being key to establishing trusting and effective cross-cultural relationships. Mental health professionals must also consider migrants’ backgrounds in relationship to their current psychological functioning. Many refugees were politically forced to migrate. Forcible and invasive intrusions into their personal lives and behaviors by governments and authority figures have likely resulted in fear and distrust. Their daily survival has depended on hypersensitivity about the motives of those seeking personal information. Such migrants may experience being asked very personal questions by mental health professionals as highly threatening and inappropriate. Since counseling requires self-disclosure and social intimacy, psychotherapists must be sensitive when establishing trust with migrant clients. They must work to create trust while keeping in mind the clients’ personal experiences and subsequent worldviews, which affect the therapeutic relationship. For example, in her home country a Bosnian student had hidden and watched as several men beat and raped her mother, feeling powerless and knowing that she would face the same fate if she tried to defend her mother. When this young woman first met a psychotherapist in her resettlement country, her affect was blunted, she was reluctant to express any feelings or opinions, and she was highly mistrustful. It is our belief that group psychotherapy is essential for fostering interdependence, healing, and acculturation among migrant clients. Even though group psychotherapy has not yet been a prominent mode of therapeutic intervention with migrants, it is viewed as a key element in the MPM. Therapeutic factors in group work that are applicable for migrants include universality, altruism, and corrective emotional experiences (Yalom & Leszcz, 2005), as well as love (Bemak & Epp, 1996). Ehntholt, Smith, and Yule (2005) have reported on the benefit of refugee children sharing common experiences of trauma in group counseling. Other scholars have also extolled the merits of group therapy with migrants (e.g., Friedman & Jaranson, 1994). The emphasis on group psychotherapy is highlighted in Phase II, with the use of the group format expanded upon in Phase I, where psychoeducational information sessions are incorporated, and Phase III, where groups meet to discuss cultural empowerment. Strong family bonds and the demands on migrant families to adapt hold the promise of making family therapy an important intervention for addressing systemic problems. Therefore, the MPM also embodies family counseling as a major therapeutic intervention through which the psychotherapist helps the family examine interpersonal dynamics, communication, relationships, and roles. Family therapists must clearly understand and be knowledgeable about the backgrounds and traditional family relationships in their migrant clients’ cultures of origin. MPM’s Phase III, cultural empowerment, helps migrants gain environmental mastery. Many mental health professionals are faced with migrant clients whose motivation for seeking counseling is to gain help in understanding and adapting to the world around them, rather than delving into psychological problems. Thus, it is important for therapists first to work with these clients to resolve practical problems that will relieve the frustrations associated with accessing services and support related to education, language training, social services, housing, medical care, employment, and transport. This requires being attuned to the challenges of adapting to a new culture and providing case management– type assistance that helps empower migrant clients. Using the MPM, the psychotherapist is not expected actually to become the migrant client’s case manager; rather, the therapist takes on the role of “cultural systems information guide,” assisting the client in finding relevant information to help adjust to a new culture. For example, the psychotherapist might review bus schedules with the client, role-play with the client in preparation for a meeting with a social service official, or practice with the client what to say during a phone call responding to a help-wanted advertisement. The therapist may need to function in this capacity over a prolonged period, with the longer-term goal of developing the client’s skills in dealing with multifaceted aspects of the system in the new culture, which in turn creates the conditions for cultural mastery and empowerment (Bemak, 1989). One aspect of cultural empowerment in the MPM relates to experiences of discrimination and racism that migrants may encounter in the resettlement country (Dietz, 2010). As mentioned previously, some migrants come from racially homogeneous cultures and have had no previous exposure to racial, ethnic, or cultural diversity or experiences as members of ethnocultural minorities. They may encounter an upsurge of hostility to migrants by individuals, local communities, and state and federal governments that correlates with economic and political trends, resulting in scapegoating. It is important that psychotherapists understand the effects of individual and institutional racism and discrimination and explore coping strategies, skills, and deeper psychological problems related to these hostile acts as part of Phase III. Phase IV of the MPM, indigenous healing, is the part of the model that combines Western traditional healing methodologies with nontraditional healing practices. The World Health Organization (1992) has described how an integration of indigenous and Western healing practices can result in more effective therapeutic outcomes. Even so, Western mental health professionals often disregard successful indigenous practices from their migrant clients’ cultures of origin. It is essential that psychotherapists remain open to the use of non-Western culturally healing methodologies that support and enhance the psychotherapeutic process. Simultaneously, they must be mindful that not all indigenous persons offering services are legitimate healers, nor are all indigenous healing practices effective or relevant. Assessing the capabilities of potential indigenous healers and incorporating them in “treatment partnerships” offers a rich integration of healing practices from both clients’ cultures of origin and their resettlement cultures. An example of such cooperative treatment is the case of a Vietnamese adolescent who was having problems with anger. Because the adolescent was a practicing Buddhist, the psychotherapist referred him to a Buddhist monk to supplement counseling. The adolescent spent weekend retreats with the monk while maintaining weekly sessions with the therapist. In therapy the adolescent described how the monk would sit with him, share stories about angry people that were relevant to his situation, and sometimes laugh with him about his problem. The adolescent found his time with the monk extremely helpful and became more open and trusting with the psychotherapist, expressing appreciation for the therapist’s understanding of “his” culture. The psychotherapist and monk maintained contact, working together to help the adolescent. The willingness of the therapist to collaborate with the monk was instrumental in the adolescent’s healing and fostered credibility through the acknowledgment and acceptance of the client’s cultural belief system. Phase V, social justice and human rights, addresses social injustices and potential human rights violations encountered by resettled migrants. Similar to the other MPM phases, Phase V is not discrete; rather, it is infused throughout the various MPM phases. Phase V requires the psychotherapist to assume a social advocacy role, emphasizing basic human rights that affect psychological well-being. In this phase, the psychotherapist is proactive regarding social injustices and human rights violations experienced by the client. As discussed previously, migrants may experience daily social injustices such as unequal access to resources, services, and opportunities; discrimination in health, housing, and employment; and unfair treatment in the legal and educational systems. The premise of MPM Phase V is that psychotherapists must address ecological social justice and human rights factors that affect migrant clients’ mental health and assist them in changing life conditions that contribute to their situation (Chung & Bemak, 2012). For example, exploring coping strategies related to workplace discrimination without discussing approaches to changing or eliminating the ongoing intolerance leaves the client in a perpetual situation of coping with this problem. Examples of social justice work in Phase V include educating clients about their rights; assisting clients, their families, and their communities in standing up for equal treatment and access to resources and opportunities; writing to legislators to advocate for changes in policies and legislation; and educating helping professionals regarding migrants’ experiences and cultural influences. This kind of work on social justice and human rights is an integral component of the MPM and important for the psychological well-being of migrant clients. Conclusion Counseling and psychotherapy with migrants is complex. To assist mental health professionals in providing effective care for migrant clients, we have proposed the multiphase model of psychotherapy, social justice, and human rights. This five-phase intervention approach integrates Western psychotherapy with indigenous healing methods, cultural empowerment, psychosocial interventions, and social justice/human rights advocacy. The MPM takes into account cultural belief systems, acculturation, psychosocial adaptation, cross-cultural empathy, and the influence of resettlement policy on mental health, providing a holistic framework that conceptualizes an integrated strategy to meet the wide-ranging needs of the migrant population. Critical Incident Zewditu came to Chicago from rural Sudan, where her husband and brothers disappeared after they were captured by soldiers and taken away to fight in the war. Zewditu was then incarcerated, and during that time she was raped. She recently remarried; her new husband is a Sudanese man she met in a language class in Chicago. Zewditu is upset with herself for being argumentative and impatient with her husband, and she also feels overwhelmed being in the city. She is highly anxious as she tries to figure out how to survive in the confusing urban environment, especially since she was rudely treated and dismissed at the social services office where she went to inquire about services. Zewditu is afraid to sleep at night and is distrustful of men in authority. Applying the MPM Zewditu does not know about Western counseling. Utilizing Phase I of the MPM, mental health education, the therapist helps Zewditu to gain a clear understanding of what happens during counseling. Using Phase II, individual, group, and/or family psychotherapy, the therapist carefully analyzes how and where to include Zewditu’s husband in therapy, given that Zewditu comes from a collectivistic culture where interdependence is very important. The therapist decides that creative and culturally appropriate counseling techniques that may be useful with Zewditu include narrative therapy, role-playing, gestalt techniques, and psychodrama; the therapist takes care to employ inclusive cultural empathy skills in using these techniques. Using Phase III, cultural empowerment, the therapist helps Zewditu master her new culture and gain the strategies and skills she needs to reduce her anxiety about living in Chicago. Using Phase IV, the therapist contacts traditional healers and religious leaders from the Sudanese community, who collaborate with the therapist to help Zewditu address the difficult issues of rape and her conflicts with her new husband. Finally, using Phase V, social justice and human rights, the therapist works with Zewditu to ascertain if her treatment at the social services office involved any social justice issues or human rights violations that require greater support from the therapist. (It is important to note that, as previously stated, the MPM phases need not be introduced in any specific order or sequence.) Discussion Questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. What are four common myths about migrants? What are the causes of refugee migration? In what ways do refugees differ from other immigrants? What are some of the impacts of premigration trauma on refugee mental health? What is the relationship between premigration trauma and postmigration adjustment? How does culture affect immigrant and refugee mental health? How do expectations for treatment outcomes affect psychological interventions with migrants? Discuss the appropriateness of using Western diagnoses with immigrant and refugee populations. What difficulties might arise from such an approach? What are some of the reasons for the underutilization of mainstream mental health services by migrants? Discuss the four major types of trauma that refugees experience. What factors contribute to successful immigrant and refugee acculturation? What are the impacts of racism and xenophobia on psychosocial adjustment for migrants? How does survivor’s guilt contribute to mental health problems? What are the implications of access to education and employment for migrant mental health? How do changing family dynamics contribute to mental health problems for migrants? What are some of the ways in which U.S. schools have not met the needs of migrant students? Describe the family reunification process. What are the effects of racism and discrimination on migrant mental health? Describe the importance of cross-cultural empathy in therapists’ work with immigrant and refugee populations. Describe the impact of political countertransference on the effectiveness of counseling and psychotherapy with immigrants and refugees. Describe the importance of Phase I in the MPM. How can therapists creatively adapt the Western model of psychotherapy (e.g., MPM Phase II) to work effectively with refugees? Why is cultural empowerment an essential component of the MPM? Why should mental health practitioners collaborate with indigenous healers when working with migrant clients? How could such collaboration be incorporated into mainstream practice? How are issues of human rights and social justice important to migrants and related to the MPM? References Alexander, C. (2010, November 30). Who pays the airfare to transport refugees to the U.S., and how does it work? Immigrant Connect. Retrieved from http://www.immigrantconnect.org/2010/11/30/who-pays-the-airfare-to-transport-refugees-to American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58(5), 377–402. American Psychological Association. (2010). Resilience and recovery after war: Refugee children and families in the United States. Washington, DC: Author. Retrieved from http://www.apa.org/pubs/info/reports/refugees-full-report.pdf Bemak, F. (1989). Cross-cultural family therapy with Southeast Asian refugees. Journal of Strategic and Systemic Therapies, 8, 22–27. Bemak, F., & Chung, R. C.-Y. (2003). Multicultural counseling with immigrant students in schools. In P. B. Pedersen & J. Carey (Eds.), Multicultural counseling in schools (2nd ed., pp. 84–101). Needham Heights, MA: Allyn & Bacon. Bemak, F., & Chung, R. C.-Y. (2008). Counseling refugees and migrants. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (6th ed., pp. 307–324). Thousand Oaks, CA: Sage. Bemak, F., & Chung, R. C.-Y. (2011). Post-disaster social justice group work and group supervision. Journal for Specialists in Group Work, 36(1), 3–21. Bemak, F., & Chung, R. C.-Y. (2014). Immigrants and refugees. In F. T. L. Leong (Ed.), APA handbook of multicultural psychology: Vol. 1. Theory and research (pp. 503–517). Washington, DC: American Psychological Association. Bemak, F., Chung, R. C.-Y., & Pedersen, P. B. (2003). Counseling refugees: A psychosocial approach to innovative multicultural interventions. Westport, CT: Greenwood. Bemak, F., & Epp, L. (1996). The 12th curative factor: Love as an agent of healing in group psychotherapy. Journal of Specialists in Group Work, 21(2), 118–127. Bemak, F., & Greenberg, B. (1994). Southeast Asian refugee adolescents: Implications for counseling. Journal of Multicultural Counseling and Development, 22(4), 115–124. Bemak, F., & Timm, J. (1994). Case study of an adolescent Cambodian refugee: A clinical, developmental and cultural perspective. International Journal for the Advancement of Counselling, 17, 47–58. Berry, J. W. (2002). Conceptual approaches to acculturation. In K. M. Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 17–38). Washington, DC: American Psychological Association. Berry, J. W., & Sabatier, C. (2010). Acculturation, discrimination and adaptation among second generation immigrant youth in Montreal and Paris. International Review of Psychiatry, 20, 317–329. doi:10.1080/09540260802090363 Bhugra, D. (2004). Migration and mental health. Acta Psychiatrica Scandinavica, 109, 243–258. Charles, C. (1986). Mental health services for Haitians. In H. P. Lefley & P. B. Pedersen (Eds.), Cross-cultural training for mental health professionals (pp. 183–198). Springfield, IL: Charles C Thomas. Chavez, L. (2008). The Latino threat: Constructing immigrants, citizens, and the nation. Stanford, CA: Stanford University Press. Chung, R. C.-Y. (2001). Psychosocial adjustment of Cambodian refugee women: Implications for mental health counseling. Journal of Mental Health Counseling, 23(2), 115–126. Chung, R. C.-Y. (2005). Women, human rights and counseling: Crossing international boundaries. Journal of Counseling & Development, 83, 262–268. Chung, R. C.-Y. (2009). Cultural perspectives on child trafficking, human rights and social justice: A model for psychologists. Counselling Psychology Quarterly, 22(1), 85–96. Chung, R. C.-Y., & Bemak, F. (2002a). The relationship between culture and empathy in crosscultural counseling. Journal of Counseling & Development, 80, 154–159. Chung, R. C.-Y., & Bemak, F. (2002b). Revisiting the California Southeast Asian mental health needs assessment data: An examination of refugee ethnic and gender differences. Journal of Counseling & Development, 80, 111–119. Chung, R. C.-Y., & Bemak, F. (2012). Social justice counseling: The next steps beyond multiculturalism. Thousand Oaks, CA: Sage. Chung, R. C.-Y., Bemak, F., & Kudo Grabosky, T. (2011). Multicultural–social justice leadership strategies: Counseling and advocacy with immigrants. Journal of Social Action in Psychology and Counseling, 3(1), 86–102. Chung, R. C.-Y., Bemak, F., Ortiz, D. P., & Sandoval-Perez, P. A. (2008). Promoting the mental health of migrants: A multicultural/social justice perspective. Journal of Counseling & Development, 86, 310–317. Chung, R. C.-Y., & Kagawa-Singer, M. (1995). An interpretation of symptom presentation and distress: A Southeast Asian refugee example. Journal of Nervous and Mental Disease, 183(10), 639–648. Chung, R. C.-Y., & Lin, K. M. (1994). Helpseeking behavior among Southeast Asian refugees. Journal of Community Psychology, 22, 109–120. Chung, R. C.-Y., Quiros, A., Bemak, F., & Ortiz, D. P. (2014). Reunification challenges of Latino immigrants. Manuscript submitted for publication. Davila, L. T. (2008). Language and opportunity in the “land of opportunity”: Latina immigrants’ reflections on language learning and professional mobility. Journal of Hispanic Higher Education, 7, 356–370. Dietz, J. (Ed.). (2010). Employment discrimination against immigrants [Special issue]. Journal of Managerial Psychology, 25(2). doi:10.1108/02683941011019320 Draguns, J. G. (1996). Ethnocultural considerations in the treatment of PTSD: Therapy and service delivery. In A. J. Marsella, M. J. Friedman, E. T. Gerrity, & R. M. Scurfield (Eds.), Ethnocultural aspects of posttraumatic stress disorder (pp. 459–482). Washington, DC: American Psychological Association. Draguns, J. G. (1998). Transcultural psychology and the delivery of clinical psychological services. In S. Cullari (Ed.), Foundations of clinical psychology (pp. 375–402). Boston: Allyn & Bacon. Draguns, J. G. (2007). Empathy across national, cultural, and social barriers. Baltic Journal of Psychology, 8(1–2), 5–20. Duarte-Velez, Y., Bernal, G., & Bonilla, K. (2010). Culturally adapted cognitive-behavior therapy: Integrating sexual, spiritual, and family identities in an evidence-based treatment of a depressed Latino adolescent. Journal of Clinical Psychology, 66, 895–906. doi:10.1002/jclp.20710 Ehntholt, K. A., Smith, P. A., & Yule, W. (2005). School-based cognitive-behavioural therapy group intervention for refugee children who have experienced war-related trauma. Clinical Child Psychology & Psychiatry, 10, 235–250. Friedman, M., & Jaranson, J. (1994). The applicability of the posttraumatic stress disorder concepts to refugees. In A. J. Marsella, T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain: The mental health and well-being of the world’s refugees (pp. 207–228). Washington, DC: American Psychological Association. García Coll, C., & Marks, A. K. (Eds.). (2012). The immigrant paradox in children and adolescents: Is becoming American a developmental risk? Washington, DC: American Psychological Association. Goldenberg, C. (2008). Teaching English language learners: What the research does—and does not— say. American Educator, 32(2), 8–23, 42–44. Helms, J. E. (1995). An update of Helms’s white and people of color racial identity models. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 199–217). Thousand Oaks, CA: Sage. Hoefer, M., Rytina, N., & Baker, B. C. (2012, March). Estimates of the unauthorized immigrant population residing in the United States: January 2011 (Population estimates). Washington, DC: U.S. Department of Homeland Security, Office of Immigration Statistics. Retrieved from http://www.dhs.gov/xlibrary/assets/statistics/publications/ois_ill_pe_2011.pdf Holthouse D., & Potok, M. (2008). 2007: A year marked by staggering levels of racist hate. Intelligence Report (Southern Poverty Law Center), no. 129 (Spring). Retrieved from http://www.splcenter.org/get-informed/intelligence-report/browse-all-issues/2008/spring/the-yearin-hate Hong, G. K., & Domokos-Cheng Ham, M. (2001). Psychotherapy and counseling with Asian American clients: A practical guide. Thousand Oaks, CA: Sage. Hsu, S. S. (2009, June 17). Immigration debate tied to hate crimes. Washington Post. Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2009/06/16/AR2009061603518.html International Organization for Migration. (2010). World migration report 2010. The future of migration: Building capacities for change. Geneva: Author. Retrieved from http://www.publications.iom.int Kandel, W. (2008). Profile of hired farm workers: A 2008 update. Washington, DC: U.S. Department of Agriculture. Retrieved from http://www.ers.usda.gov/Publications/ERR60/ERR60.pdf Kennedy, H. (2010, July 28). Arizona immigration law SB 1070 has most controversial parts blocked by federal judge. New York Daily News. Retrieved from http://articles.nydailynews.com/2010-0728/news/27071057_1_immigration-law-legal-immigrants-immigration-status Keyes, E. F. (2000). Mental health status in refugees: An integrative review of current research. Issues in Mental Health Nursing, 21, 397–410. doi:10.1080/016128400248013 Kim, G., Loi, C. X. A., Chiriboga, D. A., Jang, Y., Parmelee, P., & Allen, R. S. (2011). Limited English proficiency as a barrier to mental health service use: A study of Latino and Asian immigrants with psychiatric disorders. Journal of Psychiatric Research, 45, 104–110. doi:10.1016/j.jsychires.2010.04.031 Kinzie, J. D. (1985). Overview of clinical issues in the treatment of Southeast Asian refugees. In T. C. Owan (Ed.), Southeast Asian mental health: Treatment, prevention, services, training, and research (pp. 113–135). Washington, DC: National Institute of Mental Health. Kira, I. A., Lewandowski, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2010). The effects of perceived discrimination and backlash on Iraqi refugees’ mental and physical health. Journal of Muslim Mental Health, 5, 59–81. doi:10.1080/1556490100362210 Kirmayer, L. J. (1989). Cultural variation in the response to psychiatric disorders and emotional distress. Social Science & Medicine, 28(3), 327–339. Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness and care. Annals of Internal Medicine, 88, 251–258. Leadership Conference on Civil Rights Education Fund. (2009). Confronting the new faces of hate: Hate crimes in America, 2009. Washington, DC: Author. Retrieved from http://www.protectcivilrights.org/pdf/reports/hatecrimes/lccref_hate_crimes_report.pdf Loller, T. (2008, April 11). Many illegal immigrants pay up at tax time. USA Today. Retrieved from http://www.usatoday.com/money/perfi/taxes/2008-04-10-immigrantstaxes_N.htm Massey, D. S. (2010). New faces in new places: The changing geography of American immigration. New York: Russell Sage Foundation. Mather, M. (2009). Children in immigrant families chart new path. Washington, DC: Population Reference Bureau. Retrieved from http://www.prb.org/pdf09/immigrantchildren.pdf Meissner, D. (2010, May 2). 5 myths about immigration. Washington Post. Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2010/04/30/AR2010043001106.html Michels, S. (2008). Hate crimes tied to immigration debate? Civil rights groups says anti-immigrant rhetoric driving increase in hate crimes. ABC News. Retrieved from http://abcnews.go.com/TheLaw/story?id=4421921&page=1 Micozzi, M. S. (1996). Fundamentals of complementary and alternative medicine. New York: Churchill Livingstone. Migration Policy Institute. (2011). ELL information center. Retrieved from http://www.migrationinformation.org/integration/ellcenter.cfm Mollica, R. F., Wyshak, G., & Lavelle, J. (1987). The psychosocial impact of war trauma and torture on Southeast Asian refugees. American Journal of Psychiatry, 144, 1567–1572. Morash, M., Bui, H., Zhang, Y., & Holtreter, K. (2007). Risk factors for abusive relationships. A study of Vietnamese American immigrant women. Violence Against Women, 13, 653–675. Morse, A., Binbach, K., & National Conference of State Legislatures. (2012, November 7). In-state tuition and unauthorized immigrant students. National Conference of State Legislatures. Retrieved from http://www.ncsl.org/issues-research/immig/in-state-tuition-and-unauthorized-immigrants.aspx Nickerson, A., Bryant, R., Steel, Z., Silove, D., & Brooks, R. (2010). The impact of fear for family on mental health in a resettled Iraqi refugee community. Journal of Psychiatry Research, 44, 229–235. doi:10.1016/j.jpsychires.2009.08.006 Parthasarthi, M. S., Durgamba, V. K., & Murthy, N. S. (2004). Counselling migrant families in southern India. International Journal for the Advancement of Counselling, 26, 363–367. Passel, J. S., & Taylor, P. (2010). Unauthorized immigrants and their U.S.-born children. Washington, DC: Pew Hispanic Center. Retrieved from http://pewhispanic.org/files/reports/125.pdf Pedersen, P. (2000). A handbook for developing multicultural awareness (3rd ed.). Alexandria, VA: American Association for Counseling and Development. Pedersen, P. B., Crethar, H. C., & Carlson, J. (2008). Inclusive cultural empathy: Making relationships central in counseling and psychotherapy. Washington, DC: American Psychological Association. Phillips, L., & Draguns, J. G. (1969). Some issues in intercultural research on psychopathology. In W. Caudill & T. Y. Lin (Eds.), Mental health research in Asia and the Pacific (pp. 21–32). Honolulu: East-West Center Press. Portes, A., & Rumbaut, R. G. (2006). Immigrant America: A portrait. Berkeley: University of California Press. Pynoos, R., & Eth, S. (1984). Children traumatized by witnessing acts of personal violence: Homicide, rape or suicide behavior. In S. Eth & R. Pynoos (Eds.), Post-traumatic stress disorder in children (pp. 17–44). Washington, DC: American Psychiatric Press. Robjant, K., Hassan, R., & Katona, C. (2009). Mental health implications of detaining asylum seekers: Systematic review. British Journal of Psychiatry, 194, 306–312. doi:10.1192/bjp.bp.108.053223 Schottelkorb, A., Doumas, D., & Garcia, R. (2012). Treatment for childhood refugee trauma: A randomized controlled trial. International Journal of Play Therapy, 21, 57–73. Retrieved from http://psycnet.apa.org.mutex.gmu.edu/journals/pla/21/2/57.pdf Suárez-Orozco, C., Bang, H. J., & Kim, H. Y. (2011). “I felt like my heart was staying behind”: Psychological implications of immigrant family separations and reunification. Journal of Adolescent Research, 26, 222–257. doi:10.1177/0743558410376830 Suárez-Orozco, C., Suárez-Orozco, M. M., & Todorova, I. (2008). Learning a new land: Immigrant students in American society. Cambridge, MA: Harvard University Press. Sue, D. W., Nadal, K. L., Capodilupo, C. M., Lin, A. I., Torino, G. C., & Rivera, D. P. (2008). Racial microaggressions against Black Americans: Implications for counselors. Journal of Counseling & Development, 86, 330–338. Sue, S., Fujino, D. C., Hu, L., Takeuchi, D. T., & Zane, N. W. S. (1991). Community mental health services for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal of Consulting and Clinical Psychology, 59(4), 533–540. Tayabas, T., & Pok, T. (1983). The Southeast Asian refugee’s arrival in America: An overview. In Asian American Community Mental Health Training Center, Bridging cultures: Social work with Southeast Asian refugees (pp. 3–14). Los Angeles: Special Services for Groups, Asian American Community Mental Health Training Center. United Nations Environment Programme. (2010). Climate change and environmentally induced migration. Retrieved from http://www.unep.org/conflictsanddisasters/Policy/DisasterRiskReduction/ClimateChangeAndMigration United Nations High Commissioner for Refugees. (2010). Statistical yearbook 2009: Trends in displacement, protection and solutions. Geneva: Author. Retrieved from http://www.unhcr.org/4ce532ff9.html U.S. Census Bureau. (2011). Selected characteristics of the native and foreign-born populations: 2010 American Community Survey 1-year estimates. American FactFinder. Retrieved from http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml? pid=ACS_10_1YR_S0501&prodType+table Van der Kolk, B. A. (1987). Psychological trauma. Washington, DC: American Psychiatric Press. Vickers, B. (2005). Cognitive model of the maintenance and treatment of post-traumatic stress disorder applied to children and adolescents. Clinical Child Psychology & Psychiatry, 10, 217–234. World Health Organization. (1992). Refugee mental health: Draft manual for field testing. Geneva: Author. Wu, M. C., Kviz, F. J., & Miller, A. M. (2009). Identifying individual and contextual barriers to seeking mental health services among Korean American immigrant women. Issues in Mental Health Nursing, 30, 78–85. doi:10/1080/01612840802595204 Yakushko, O., Backhaus, A., Watson, M., Ngaruiya, K., & Gonzalez, J. (2008). Career development concerns of recent immigrants and refugees. Journal of Career Development, 34, 362–396. doi:10.1177/0894845308316292 Yalom, I., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books. Yoon, E., Langrehr, K., & Ong, L. Z. (2011). Content analysis of acculturation research in counseling and counseling psychology: A 22-year review. Journal of Counseling Psychology, 58, 83–96. doi:10.1037/a0021128 Yoshikawa, H. (2011). Immigrants raising citizens: Undocumented parents and their children. New York: Russell Sage Foundation. 16 Counseling Survivors of Disaster Beth Boyd Primary Objective ■ To provide an overview of disaster mental health care and disaster response in diverse communities Secondary Objectives ■ To identify the effects of traumatic stress at both individual and community levels ■ To provide overviews of the disaster mental health interventions and the issues that affect disaster mental health service responses to ethnocultural communities ■ To discuss the ways in which individual and community resilience can be strengthened following a disaster Disasters are often thought of as events that are unusual or outside the range of normal human experience. However, in just the past 10 years, natural events such as floods, earthquakes, hurricanes, mudslides, tornadoes, wildfires, and tsunamis have had devastating consequences, affecting more people worldwide and having greater economic impacts than ever before. In 2011 alone, natural disasters around the globe resulted in 30,773 deaths, 244.7 million people requiring immediate assistance, and estimated financial losses of $355.1 billion (Guha-Sapir, Vos, & Below, 2012). Increasingly, human-made disasters—terrorist attacks, mass shootings, bombings, nuclear accidents, and transportation industry crashes—have also seriously stretched the capacity of disaster response agencies to care for survivors, rescue and recovery personnel, and the loved ones of those who died. Although the number of mental health professionals trained in disaster response has grown enormously since the September 11, 2001, terrorist attacks on the World Trade Center and the Pentagon, there are still not enough such professionals to satisfy the needs for psychosocial support and healing within communities affected by large public health emergencies (Andrulis, Siddiqui, & Purtle, 2009). In addition, well-intentioned mental health response efforts have repeatedly been shown to be ineffective, or even damaging, when disaster responders lack the training, experience, and knowledge they need to understand the complex interplay among their own cultural identities, the cultural contexts of the disaster survivors and communities, and the unique “culture” that evolves from the disaster itself (Fothergill, Maestas, & Darlington, 1999; Marsella, Johnson, Watson, & Gryczynski, 2008). This chapter will describe the key issues relevant to providing mental health services in the aftermath of a disaster, with an emphasis on attending to the cultural contexts of affected people and communities. Types of Disasters Disasters cause widespread community disruption and individual trauma (Marsella et al., 2008), as well as extensive physical damage or destruction, loss of life or property, drastic changes to the environment, and/or serious effects on the economic, social, and cultural lives of communities (Kaniasty & Norris, 1995). Concerns about prolonged health effects, job loss, and socioeconomic deterioration contribute to the damaging effects that disasters have on the mental and behavioral health of those they touch (National Biodefense Science Board [NBSB], 2008). Disasters are typically classified as either “natural” or “human-made,” but it is important to remember that many disasters have both natural and human-made components. For example, heavy flooding may overwhelm a dam, an earthquake may cause damage to a nuclear power plant, and human error or faulty technology may result in the failure of a tsunami warning system. Such combinations of disaster types can complicate the ways in which survivors react to the events or affect their ability to cope in the aftermath (DeWolfe, 2000). Natural disasters. Natural disasters are events that occur as part of the natural world. These include severe weather events (e.g., hurricanes, tornadoes, floods, tsunamis, winter weather, extreme heat), earthquakes, volcanic eruptions, wildfires, and landslides. People generally see these types of disasters as unavoidable and typically are better able to cope with such events than with those that can be blamed on human actions. For some people, it may be comforting to see these types of events as the acts of a “higher power,” whereas for others, such events may make the world seem to be a dangerous and unpredictable place (Yates, 1998). Human-made disasters. The Centers for Disease Control and Prevention breaks down human-made disasters into the following categories: bioterrorism, chemical emergencies, radiation emergencies, and mass casualty incidents. A bioterrorism attack is the deliberate release of a virus, bacteria, or other germs (spread through air, water, or food) with the intent to cause illness or death to people, plants, or animals (e.g., the anthrax attacks of 2001). A chemical emergency is the accidental or deliberate release of a chemical that has the potential to cause harm to people’s health. Industrial accidents and crashes of vehicles carrying hazardous chemicals are the most common accidental releases of chemicals. A radiation emergency occurs when people are exposed to high levels of radiation that may result in death or serious risks to health (e.g., cancer). This type of event may also be accidental (e.g., nuclear power plant accident) or deliberate (e.g., “dirty” bomb or nuclear attack). Mass casualty incidents are situations in which large numbers of injuries and/or deaths occur. Examples of such incidents include transportation industry crashes (e.g., crashes of airplanes or trains), bridge or building collapses, fires, and explosions. Survivors and others affected by these types of disasters often spend a great deal of energy feeling that the events were preventable, feeling betrayed by fellow human beings, and affixing blame. If an incident is followed by a protracted investigation and/or litigation, this may prolong or complicate the natural healing process for survivors (DeWolfe, 2000). Phases of Disasters Disasters occur in phases that may or may not appear to be distinct, depending on the disaster. While there are several models of disaster phases, most contain some variation of the following: warning, period of threat, impact, inventory, rescue, remedy, and recovery (DeWolfe, 2000). Not all disasters have all of the phases. For example, many events do not have a warning phase (e.g., airplane crash, fire). Every disaster has an impact phase, but it is important to recognize that this phase may continue long after the event itself is over (e.g., survivors live in tents for months following a hurricane). The following is a brief overview of the phases of disasters. Warning. Some disasters have distinct warning phases (e.g., hurricanes, which can be tracked for days before they make landfall). However, even with credible information, many people disbelieve, overlook, or simply ignore warnings of impending danger. In order to be effective, messages of warning must be very clear, specific, immediate, personal, and delivered by a credible source. Input from disaster mental health professionals regarding the language, type, and delivery of warning messages can have a significant impact during this phase (NBSB, 2008). Period of threat. Panic is likely to occur when people perceive an immediate severe danger, believe there is only one or a limited number of escape routes from the danger, believe those escape routes may be closing, and lack current information about the danger. As many disaster situations develop very quickly, it is predominantly through careful predisaster planning, training, and action that disaster mental health professionals can have their greatest impact. However, it is important for such professionals to remember that sociocultural issues may influence what people find to be acceptable preparation efforts, the ability of people to evacuate, and the amount of trust people put in official warnings (Marsella & Christopher, 2004). These issues were painfully clear in the aftermath of Hurricane Katrina in New Orleans. Impact. During the period of the impact and the immediate postimpact period, people may be in a state of confusion, feeling dazed, stunned, or disoriented. This is a temporary state from which most people will emerge rather quickly, especially as they begin to provide assistance to family members and others. The most important considerations during this phase are physical safety and meeting basic needs for shelter, food, water, and reconnection with loved ones. Inventory. During the period of inventory, survivors of disaster begin to take stock of their situation. This is a time when survivors may feel conflicting emotions, such as relief at having survived and overwhelming grief for what they have lost. Expressions of emotion can change rapidly and may even be confusing to survivors. Rescue. During the rescue period, survivors must shake themselves from the debilitating effects of shock and act quickly to save loved ones and others around them. It is not unusual for those who participate in rescue efforts to have feelings of euphoria during this time and experience the more common effects of sadness, grief, and fear after everyone else is safe. This can be confusing because they may then express emotions that other survivors have already moved beyond (e.g., shock, disbelief). Remedy. In this phase, survivors begin to take a more realistic, measured look at their situation and planning for the future. Survivors come to understand that there will be long-term consequences of the disaster, and the process of allocating blame or fault for the situation begins. Recovery. During the recovery period, survivors individually and collectively attempt to stabilize and regain their predisaster levels of functioning. This process may happen relatively quickly or may take months, or even years. The emphasis during this phase is on adaptation to the changed conditions, and those survivors with more limited abilities to adapt will begin to show signs of emotional stress during this phase. Individual Reactions to Traumatic Stress Responses to disaster at the individual level are now well understood (DeWolfe, 2000; U.S. Department of Health and Human Services, 2005). Persons exposed to traumatic events may experience the effects in all domains of their lives: emotional, psychological, behavioral, physiological, and spiritual. Emotional effects. A survivor may experience any or all of a variety of emotional reactions, such as denial, anxiety, fear, worry about safety of self or others, anger, irritability, restlessness, sadness, grief, feelings of being overwhelmed, hopelessness that anything will ever be better, feelings of isolation, abandonment, and guilt or “survivor’s guilt.” It is common for survivors to have distressing dreams or nightmares in which they relive the events of the disaster, try to save someone, or simply experience the anxiety or sadness they may be feeling when awake. Sometimes survivors feel they can identify only with other survivors, and sometimes they feel completely alone even though many others have survived the same disaster. There is no specific order to what emotions people might experience, and there is no “normal” pattern of reactions. People in the same family might experience different emotional reactions and thus have a difficult time understanding each other’s responses. Clearly, culture has a big impact on how people express their emotions, what is considered appropriate for grieving or for sharing with outsiders, and how the healing process progresses. Cognitive effects. Cognitive effects of traumatic events include memory problems, disorientation, confusion, slowness of thinking and comprehending, difficulty setting priorities or making decisions, poor concentration, limited attention span, loss of objectivity, inability to stop thinking about the event, and blaming. These reactions are often the most distressing to survivors because, although they expect and understand feelings of sadness or anxiety, the cognitive effects often make them feel as if they are losing their ability to cope, losing their minds, or “going crazy.” In the course of disaster response, survivors are often asked to provide multiple important dates, telephone numbers, names of insurance companies, and so on, and it is quite distressing for them when they cannot remember their own addresses or their children’s birthdates. Survivors often have to set priorities and make significant life decisions (e.g., where to stay, how to talk to children about losses, what task to undertake first) at a time when their cognitive abilities are being overwhelmed by the disaster. Behavioral effects. Behavioral effects of experiencing a disaster include such things as changes in sleep, appetite, and activity level, whether in the direction of increase (e.g., sleeping too much, eating too much, being too active) or decrease (e.g., inability to sleep, loss of appetite, reduction in activity). There may also be decreased efficiency and effectiveness in normal activities, difficulty communicating, outbursts of anger or frequent arguments, inability to rest, changes in patterns of intimacy, changes in job or school performance, periods of crying, hypervigilance about safety, social withdrawal, silence, or increased use of alcohol, tobacco, or drugs (including nicotine and caffeine). Survivors are also more prone to accidents because of inattention to details in their environment. This includes vehicle accidents as well as household accidents. In many cultures, providing food for others during a crisis is an important way of coping, and accidents involving knives, boiling liquids, and stove burns are not unusual. Physiological effects. The physiological effects of traumatic stress include increases in heartbeat, respirations, and blood pressure; upset stomach, nausea, and diarrhea; sweating or chills; tremors (especially hands and lips); muscle twitching; “muffled hearing”; tunnel vision; feeling uncoordinated; headaches; muscle soreness; lower back pain; the feeling of having a “lump in the throat”; exaggerated startle response; fatigue; changes in menstrual cycle; changes in libido or sexual performance; and decreased resistance to infection. Worsening of physical illnesses that tend to be exacerbated by stress (e.g., asthma, diabetes, arthritis, hypertension, allergies) is also common. Significant hair loss may occur 2–3 months after the traumatic event. In cultures were stressors are more likely to be expressed somatically, these types of symptoms may be especially prominent. Spiritual effects. The experience of traumatic stress also has an effect on survivors’ sense of spirituality (Boyd, Quevillon, & Engdahl, 2010). People who have experienced a disaster may feel that “the world has turned upside down,” that they “just can’t make sense of anything,” or that “nothing has meaning anymore.” Traumatic stress tends to make survivors feel isolated, severing important connections to social support systems and cutting them off from those people and things that help them to make meaning of life. Survivors may experience “crises of faith,” where the world no longer makes sense to them and they question their belief systems, wondering how the disaster could have been allowed to happen, how so many could be left suffering, and so on (McCombs, 2010). It is important for mental health professionals to recognize that spiritual and religious beliefs may be expressed in a variety of ways. Depending on their spiritual views, survivors may see a natural disaster as punishment for not living in balance with nature or living in violation of divine laws, as a “rebalancing” event in the natural world, as an opportunity to realize a divine mandate of mercy, or even as something imposed by a divine being that is not for human beings to know or understand. In some cultures questioning divine intention is common; in others, this kind of questioning would never occur. Universal effects. While disaster survivors may experience a wide variety of stressors and effects, the underlying concerns and needs of survivors tend to be consistent across populations and disasters. All people are concerned for the basic survival of themselves and their loved ones, feel grief over the loss of loved ones and the loss of valued and meaningful possessions, and experience fear and anxiety about personal safety and the physical safety of loved ones. The following reactions to disaster are common across all people, regardless of culture: ■ Sleep disturbances, often including nightmares and imagery from the traumatic event ■ Concerns about relocation and the related isolation or crowded living conditions ■ A need to talk about events and feelings associated with the disaster (often repeatedly) ■ A need to feel one is part of the community and its recovery efforts Community Reactions to Traumatic Stress The traumatic effects of a disaster may also be experienced at the community level (Hobfall & deVries, 1995; Williams, Zinner, & Ellis, 1999). A community touched by disaster may experience a period of communal shock, disbelief, anger, or grief (emotional), disorientation (cognitive), and unconstructive behaviors (behavioral), and community members may struggle collectively to make sense of what has happened (spiritual). Ideally, the community can come to see itself as a stronger, more cohesive, resilient version of itself as it learns to heal. But a large part of that ability to heal depends on the degree to which interventions contribute to making the event manageable, whether resources for recovery are sufficient to the need, and whether the community can successfully reframe the traumatic event into a challenge (Zinner & Williams, 1999). Community resilience is the ability of a community to face a threat, survive, and “bounce back” with a newly defined sense of itself that includes the losses and changes it may have sustained (Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008). When people have to be evacuated and relocated from their homes and communities, important community ties, kinship systems, and social support systems can be seriously damaged, leaving people with inadequate support at the time when they need it most (Laborde, Brannock, & Parrish, 2011). This presents a serious threat to a community’s ability to be resilient. The reestablishment of a sense of community (even within a shelter) as quickly as possible can help people to regain a sense of control and stabilization within their social environment, even while acknowledging that this context may be forever changed (Milligan & McGuinness, 2009). The successful reconnection of survivors with their community is an important source of identity, meaning, and resilience, and achieving that reconnection often depends on strong community leadership. For example, just hours after Oklahoma City was hit by an F5 tornado in May 1999, community leaders helped affected residents to reframe the disaster by reminding them of the way the community came together and provided communal support following the bombing of the Murrah Federal Building in 1995 (Boyd et al., 2010). Promoting community resilience and wellness is inextricably connected to the historical and cultural identities of the affected people (Landau, 2007; Walsh, 2007). Just as individuals with histories of previous unresolved losses often have a more difficult time recovering from disaster, a community with a history of similar losses will struggle as well. For those who seek to help, it is important to understand what those losses were, how they were perceived, the overall impacts of the losses, what community actions were helpful or not helpful, what legacy of loss has remained in the community, and how the community has grown or found meaning in the previous events (Williams et al., 1999). Cox and Perry (2011) suggest that communities experience a complex social-psychological disorientation following disasters and that the process of community reorientation must include a consideration of sense of place and its critical role in the development and maintenance of social capital and community resilience. When a community is scattered by dislocation, the resulting disruption in the foundation of home and identity leads to feelings of helplessness, isolation, and loss of sense of community and cultural identity (Laborde et al., 2011). This is reflected in the many examples of African American families relocated to historically White neighborhoods following Hurricane Katrina. Vulnerable Populations in Disaster It has long been known that exposure to predisaster trauma may be higher than average in economically disadvantaged urban environments (Breslau et al., 1998; Selner-O’Hagan, Kindlon, Buka, Raudenbush, & Earls, 1998) and that these populations may also be at greater risk for postdisaster stress and difficulty with resilience. In the United States, people from diverse cultures, individuals with limited English proficiency or who are non–English speaking, individuals with disabilities, elderly persons, children, and individuals who are transportation disadvantaged often have additional risk factors that may affect their ability to recover from a disaster (NBSB, 2008). Those living in rural areas, particularly members of ethnic minority groups and persons with low socioeconomic status, often have preexisting stressors—such as chronic medical issues, severe mental illness, and substance use issues—that may lead to more difficult recovery from disaster (Institute of Medicine, 2003). At the community level, the most economically and culturally marginalized communities are at greater risk for disruptions in the community healing process as well (Cox & Perry, 2011). With fewer resources available to help in the aftermath of a disaster, these communities are often less prepared, more likely to suffer devastating effects, and experience a much slower recovery process than more advantaged communities (Laborde et al., 2011). Further damage may be done when disaster responders lack the requisite awareness, knowledge, and skills to meet the specific cultural and language needs of racially and ethnically diverse communities. This was painfully clear in the aftermath of Hurricane Katrina in 2005, but it is not a new phenomenon. In a review of the literature on natural disasters, Fothergill et al. (1999) found that, compared with other communities, racial and ethnic minority communities are more vulnerable to disaster, less likely to have received disaster education, often left out of preparation activities, less likely to trust official warnings, and disproportionately affected (both physically and psychologically) by natural disasters. It is not surprising, then, that these communities often have greater difficulties in the recovery process due to economic factors (e.g., lower incomes, fewer savings, greater unemployment, less insurance), lack of access to communication channels and information, differences in language, and experience of discriminatory practices. Fothergill et al. point out that the kind of marginalization racial and ethnic minority communities experience in disasters is present in every disaster phase and cannot be explained simply as the result of differences in economic resources and power. The evidence of cultural ignorance, cultural insensitivity, racial isolation, and racial bias in housing, information dissemination, and relief assistance exposed in these scholars’ review of previous studies is difficult to ignore, and similar evidence has continued to be reported since their study appeared in 1999 (Andrulis et al., 2009). Cultural Context Culture provides the overall framework from which we learn how to think, feel, and behave in relation to our environment and to others around us. Even a large-scale disaster that seems to be clearly defined (e.g., river flooding) has to be understood within the cultural contexts of those affected. Culture influences what individuals perceive as traumatic and how they interpret traumatic events (e.g., What relationship does the affected community have with that river?). Culture influences how individuals and communities express traumatic reactions and forms a contextual lens through which survivors view and judge their own responses to events. “Help” is also culturally determined—and it is determined by both the giver and the recipient (Norris & Alegría, 2008). What may seem “helpful” in the giver’s culture may not been seen as anything of the sort in the recipient’s culture. It is important for the giver to keep in mind that the sole reason for being in that “helping” role is to provide aid and support to those affected by the disaster. Thus it is imperative for the giver to understand what is meant by “help” in the recipient’s cultural view, who that help should come from, who else should be there, who can sanction the help, what help would look like, what the expected response would be, how to know when to stop, and so on. As no one is able to know all the nuances of the concept of help in every culture, it also becomes important for the potential giver to find the resources within the affected community that can inform and sanction outside help. The community will also define how “recovery” will eventually look. Culture is reflected in language. Language dictates how ideas are formed, how sensory perceptions are articulated, and how the world is interpreted. While the ability to speak multiple languages is important for those who provide mental health services, it is equally important for service providers to remember that one can know how to speak a language without actually having knowledge of the nuances that convey the culture. Phrasing, silences, speed of delivery, and pitch or tone of voice (even when using the same words) have different meanings across different cultures. Finally, culture has an impact on the expected routines and rituals for special events, for grieving, and for everyday life. For example, eating and sleeping patterns, spiritual practices and beliefs, modes of dress, and social behaviors are all part of a survivor’s culture. Disaster responders need to understand how these rituals and routines may affect a survivor’s ability to cope with the aftermath of a disaster. Something as simple as inappropriate food can become a threat to coping and a sign of cultural insensitivity. Many disasters have provided stories from temporary shelters about survivors becoming ill from eating food to which they were unaccustomed, or conflicts between survivors and relief workers about survivors’ preferences for familiar foods from their own cultures (Phillips, 1993). It is crucial that each individual, family, or community receiving disaster mental health services be viewed within the context of that person’s, family’s, or community’s own cultural group and that group’s specific sociopolitical history. Every community has its own history of difficult times, its own memories of hope and despair, and its own stories of coping in challenging situations. Styles of grieving and understanding losses, coping, and moving forward into the future are all determined by the culture of the community. The communal experience of how outside help has been given and received in the past has an effect on whether help is desired, how it is interpreted, and how it is received in the present. In the ideal disaster response, community experiences of the disaster are understood, community leaders are actively engaged in working with culturally responsive outsiders to identify and manage the effects of the disaster in the community, timely and trustworthy communication is disseminated on a predictable schedule in languages that match those of the community members, and barriers to services are continually assessed and eliminated (DeWolfe, 2000). Disaster Mental Health Care Response What Is Disaster Mental Health Care? Disaster mental health care is a field of practice focused on helping disaster survivors, rescue and recovery workers, and other people affected by disasters to develop the skills necessary to cope with the extreme stress that often occurs after a disaster. Although everyone who experiences a disaster will have some effects, not everyone will require formal mental health services. In fact, with adequate support, the vast majority of people can and will overcome the effects of traumatic stress in the aftermath of disaster without the need for professional services (DeWolfe, 2000). The goal of disaster mental health care is to provide psychological support, information about normal reactions to disaster, and aid in the development of positive coping skills in order to prevent the negative longterm effects of disaster, such as posttraumatic stress disorder. Characteristics of Disaster Mental Health Services Disaster mental health services are more practical than psychological in nature and are often provided in nontraditional places, such as shelters, food distribution centers, churches, hospitals, morgues, and family service centers. These are places embedded in the community where affected people naturally turn for help and where they trust that help will be relevant to them. If the nature of the disaster is such that survivors can remain in their own homes, these services may also be provided in their homes. From a disaster mental health perspective, reactions to traumatic stress are seen as normal responses to a situation that is abnormal (Myers, 1994). Those who have experienced a disaster are seen as active survivors with strengths, resources, and the ability to be resilient, even in times of great stress —rather than as passive victims who are unable to take care of themselves during a time of crisis. Survivors are not diagnosed, and their reactions are not seen as signs of pathology, illness, or disorder. This requires counselors to set aside traditional notions of mental health services, avoid the use of mental health labels, and use an active outreach approach to intervene with survivors effectively. Traditional counseling services take place in a provider’s office at preappointed times. The client expects to be diagnosed and treated for a “disorder” or a “mental illness.” The focus of services is on individual personality and functioning and tends to examine the content that the client brings to the session. The client’s past experiences and their influences on current problems may be explored. There is a psychotherapeutic focus to this type of counseling, and the provider of services keeps records, charts, case files, and so on. In contrast, disaster mental health response occurs “in the field,” or where the survivors are. This might be a shelter, a disaster recovery center set up by the Federal Emergency Management Agency (FEMA) in a community center, a school, a tent, or a place of worship. “Sessions” with survivors may be conducted as they stand in line to access assistance for their material losses, at tables where they are eating meals provided by humanitarian groups, at sites where they will be identifying loved ones’ remains, or on the streets as they view the rubble that was once a familiar place to them. The providers do not have appointments to see the survivors and often do not know if they will ever meet with them again. In such a session, the assessment of the survivor’s strengths and coping skills is the activity of primary interest, and counseling focuses on disaster-related issues rather than on past experiences or pathology. The provider takes the things that the survivor reports at face value and sees the survivor as capable, resilient, and in possession of a range of skills and strengths that have already led to the individual’s survival of the disaster. The counselor focuses on validating the survivor’s common reactions and experiences of the abnormal event of the disaster, helping to normalize reactions that may be quite anxiety-provoking for the survivor and providing education about possible effects of the event on the survivor, his or her children and other loved ones, and the community. Finally, the providers of disaster counseling do not collect identifying information on those they serve. Depending on the organizations they are working with, they may be required to track information such as numbers of contacts, types of contacts (e.g., assistance in finding a service, normalizing reaction, providing psychoeducation, helping to reconnect to others), and ages of contacts (child, adolescent, adult, elderly). Specific Disaster Mental Health Interventions Predisaster Community Connections Clearly, the best way to ensure that appropriate, responsive disaster mental health services will be provided in any community is for disaster mental health professionals to make connections to the community prior to a disaster. Becoming familiar with and forming relationships with community members, particularly in communities that differ from the mainstream, prior to a disaster can help to ensure that providers can deliver help properly should the need arise. Identifying and building relationships with respected “insiders” in the culture can help counselors make connections with the community, identify resources, and gain authorized access in times of need. Before a disaster occurs is also the time for mental health professionals to learn about the sociopolitical history of the community, work to become aware of their own personal biases and misinformation, and learn about the community’s culturally specific communication styles (e.g., eye contact, pace of conversation, nonverbal communication). Attending local community events, learning about access rituals (often involving ceremony, food, expressions of goodwill), learning greetings and other key phrases in the local language, showing a willingness to learn about the ethnocultural group, and expressing appreciation and respect for the strength and resilience of the culture will be invaluable experiences should the community need help in the future. Participating in the community in these ways can also give disaster mental health professionals opportunities to work with community leaders to develop culturally and linguistically appropriate psychoeducational materials, disaster planning documents, and community training materials at a time when the community is not in crisis. Postdisaster Interventions In the immediate postdisaster environment, it is important for mental health professionals to recognize that although any contact with survivors can be potentially therapeutic, many people are not ready or willing to talk about their own feelings or reactions to the event. Survivors need to regain a sense of control over their lives, and respecting their wishes not to talk about their experiences is an important part of empowering them. Recognizing and supporting their coping strengths, providing clear information, and offering choices when appropriate may help survivors regain their sense of control quickly (U.S. Department of Health and Human Services, 2005). In general, most survivors will not feel that they need mental health services and will not seek them out. However, survivors will respond to active, genuine interest and concern, assistance in obtaining needed resources, and help in managing disaster stress (DeWolfe, 2000). Establishing contact. Providing mental health services to survivors of disaster requires the full range of counseling skills needed in other situations, as well as knowledge and skills specifically related to disasters. As with traditional counseling, working with survivors of disaster starts with establishing rapport. This can be particularly difficult because disaster mental health services often take place in public spaces where survivors may be engaged in other activities (e.g., standing in line, filling out forms, sorting through rubble). In order to make contact, it is most helpful for counselors to introduce themselves and briefly explain the role of disaster mental health care. As many people may be put off by the idea of receiving mental health services, it is often useful for counselors to explain their role by talking about “disaster counseling,” “offering help with coping,” or “helping with disaster stress.” Sometimes people do not want to talk about their own reactions but are very interested in learning about ways to respond to their children’s reactions. By offering a warm, caring, and calm presence, conveying feelings of interest, compassion, respect, and nonjudgment, counselors can often help survivors feel comfortable enough to talk about their experience. Providing supportive listening while they stand in line for assistance or while they eat a meal in a shelter can be exactly the help that some survivors need. Survivors may have concerns about what they did or did not do during the disaster, and it is very important for counselors to behave in such a way that survivors do not feel judged. This is easier said than done, because disasters present situations that may be beyond the realm of anything many counselors have experienced. However, these situations are very real for the survivors and are particularly painful if losses of life are involved. Active listening. By using active listening skills as they hear survivors’ stories, counselors can help them begin to express their thoughts, feelings, and memories of what happened. Allowing silence gives survivors time to reflect and become aware of their feelings. Simply “being there” with survivors can help them to feel they are not alone and allow them to feel support. Sometimes survivors are so overwhelmed by their experiences that they do not have the words or the ability to organize those experiences in order to begin talking. Prompts such as “Where were you when this happened?” can be enough to help them begin to talk about it. Counselors can convey concern and understanding by using caring facial expressions and attending to survivors’ nonverbal communication, matching appropriate eye contact, space positioning, and pacing. It is also helpful for counselors to give culturally appropriate occasional signs (e.g., head nodding, vocalizations, facial expressions) to indicate that they are in tune with survivors. Occasional paraphrasing and reflection of feelings can help convey understanding and empathy, check for accuracy and clarification of misunderstandings, and give survivors help in identifying and articulating strong emotions. Demonstrating feelings of interest and understanding conveys respect for survivors and the ways in which they are handling their reactions. Counselors experienced in disaster response may refer to this as “listening with your heart,” as it is often impossible for counselors to understand fully what survivors have been through. It is equally important for counselors to remember that all of the skills described above look different in different cultural contexts (e.g., eye contact and personal space preferences vary greatly across cultural groups). Normalizing reactions. Although most people are able to find ways to cope following a disaster, it is not surprising that survivors’ functioning is generally somewhat diminished as they work to process the events around them emotionally, cognitively, physiologically, and spiritually. Often they just need support and reassurance that their reactions are normal effects of what they have experienced and that they will feel better with time. Being able to identify, label, and put into words the reactions they may be experiencing is very helpful to survivors. Telling people that they are having normal reactions to an abnormal situation can be very comforting to survivors who feel they do not have control of anything —including their reactions. Many times, people who have experienced a disaster believe that they are the only ones who have been affected in particular ways. Disaster tends to isolate people from their support systems, and they may not recognize that even people close to them are experiencing similar reactions. It is helpful for counselors to educate people about the effects of traumatic stress and normalize what they may be experiencing. This may include distributing educational materials about normal reactions for adults, older adults, children, and vulnerable populations within the community; educating people about how to get connected with various services; and helping them to anticipate what they may need in the future. Disaster counseling interventions may also happen in small impromptu groups of people who may be standing in line together, or in more formal groups that have been set up for specific purposes (e.g., church groups, community groups, youth groups, parent groups). The more that survivors can be connected back to their natural support and healing systems, the faster their healing process will begin, and the better they will be able to provide support to others in their communities. Allowing expression of emotion. Survivors often have a need to express intense emotions very early on in their interactions with disaster counselors. In traditional counseling, such expression might not happen until a strong relationship has been established, after many sessions. However, this might be one of the first things to happen in a disaster situation. Expressing intense emotions through tears or angry venting is an important part of healing and can help survivors clear some of the emotion so that they can engage in the problem solving that will be required for them to take the next steps in their lives. While it can be difficult to contain this kind of intense emotional expression, disaster counselors need to be prepared to experience this, feel comfortable enough to allow survivors this important expression, and give them the encouragement to simply feel their emotions. Helpers should stay relaxed, breathe, and let the survivors know it is okay to feel and to express their feelings. If helpers shut down emotions that feel too intense (for the helpers), survivors get the message that they should not express how they feel, or that there is something wrong with what they feel. Problem solving. The stress of experiencing a disaster often causes disorganized thinking and difficulty with planning. Unfortunately, in the immediate aftermath of a disaster, survivors are required to make a lot of decisions, set priorities, and problem solve the next steps in their lives. Sometimes people feel so overwhelmed they cannot move forward and become immobilized, or they may become unproductively active. In either situation, disaster counselors can guide them through problem-solving steps to help them prioritize and focus attention on tasks that need to be addressed first. It is often necessary for counselors to help survivors identify and define the problems and challenges they are facing at the present. This can be an important step because survivors may define their problems differently than how counselors would have guessed. Counselors can assess survivors’ functioning and coping by asking how they have coped with stressful life events in the past and how they are doing now. By helping survivors evaluate available resources—asking who might be able to help with the current problem and what other resources might be helpful—counselors can encourage them to begin to imagine things being different. Helping survivors to develop plans of action and set out the steps that will be necessary for them to enact their plans can be the key to helping them move forward. From a self-care perspective, it is important for disaster counselors to know that it is easy to become overwhelmed by the pain and need that accompanies a disaster and want to overfunction on behalf of survivors. Counselors must, however, stay aware that survivors need to feel empowered to solve their own problems while helpers stay in the background and support. Survivors will feel more capable, competent, and able to tackle the next challenge if they are allowed to remain in control of their own lives. Other postdisaster interventions. Other postdisaster mental health interventions might include case finding, mediation, community outreach, brief counseling (individual and group), case management, public education through the media, and information and referral. Clearly many of these functions take counselors outside the range of usual counseling duties, but this is the norm for work in disaster situations. Psychological First Aid Both the Institute of Medicine (2003) and the National Biodefense Science Board (2008) have recommended the development of a national plan for the implementation of community-based psychological first aid (PFA), a grassroots public health model of psychological support. In the case of disaster mental health care, PFA involves psychological support that is used for self-care and is provided by non–mental health professionals to family, friends, neighbors, coworkers, and students. Such care focuses on education regarding traumatic stress and active listening. PFA also incorporates psychological support provided by primary care providers to their patients and by emergency responders to those they serve. PFA is pragmatic, nonintrusive support rather than formal counseling intervention, and it focuses on providing a sense of safety, calming, self- and communal-efficacy, connectedness, and hope. Community-based PFA is adapted to the specific needs of each community in which it is implemented, making it a genuinely culturally responsive model. Mental health professionals serve as trainers and consultants in adapting the model to individual communities (including special needs and vulnerable populations), supervisors of PFA networks, and bridges to the higher continuum of care for those who may need a professional level of care. A community educated in PFA will help ensure that many people are trained to provide basic psychological support, so that the limited available time of disaster mental health professionals can be reserved for those who are most in need. The adaptation of the PFA model to specific groups is one of the strengths of PFA, providing a responsive model for disaster mental health care with diverse ethnic, religious, and professional groups. Barriers to Effective Service Delivery Communities that differ from the mainstream may experience the effects of long-standing and deeply embedded barriers to disaster services (Andrulis et al., 2009; Bolin & Stanford, 1998; Fothergill et al., 1999). A disaster may actually produce new social problems by separating families, disrupting social networks and community structures, and exacerbating preexisting problems (Inter-Agency Standing Committee [IASC], 2007; NBSB, 2008). Mental health professionals offering disasterrelated services must be aware of these realities and how they affect the people and communities with whom they may work. Some of these barriers are discussed below. Poverty. The combination of trauma, poverty, and ethnic minority status makes a high-risk situation for many communities. For example, substandard housing, which is found on many Native American reservations, is particularly vulnerable to destruction, putting residents at higher risk for becoming homeless in a disaster (Fothergill et al., 1999; Fothergill & Peek, 2005). Culture and language. Help is best given in the native language of the survivor, and in a way that is consonant with the culture (NBSB, 2008). This becomes difficult in light of a shortage of mental health professionals trained in disaster mental health and culturally responsive service provision (Andrulis et al., 2009; Fothergill et al., 1999; Laborde et al., 2011; McCabe et al., 2011). At times, lack of attention to these issues has affected communities’ understanding of warnings or damaged their ability to evacuate unsafe areas. For example, when Hurricane Katrina struck the U.S. Gulf Coast in 2005, evacuation orders were not properly translated into Vietnamese, and this confusion continued well into the recovery period, causing a great deal of stress, fear, and confusion in the region’s Vietnamese immigrant community (Lum, 2005). Some communities may reject any outside help because of past experiences with “help” in which their cultural values were not recognized or incorporated into the system of care. Suspicion about government. Many communities have had negative experiences with government authorities in the past and/or have no expectations of receiving help from such authorities (Bolin & Stanford, 1998; Fothergill et al., 1999). In some cases, suspicions about government intentions or programs preclude survivors from accessing the resources that might be available to them (Wray, Rivers, Whitworth, Jupka, & Clements, 2006). For example, after Hurricane Katrina, many people with property in certain areas of the Gulf Coast were reluctant to go to available shelters, preferring to remain in the ruins of their completely destroyed homes because they feared their property would be seized by the federal government (NASA had reportedly been trying to acquire these properties for years). In Latino communities, rumors circulated of police raids on emergency shelters, and fears of arrest or deportation kept people from seeking assistance (Bourne, 2006). “Cracks” between systems of care. Some communities have had long-standing problems with access to services because of “cracks” between systems of care. For example, many state governments assume that Native Americans will receive services from the federal government in the wake of a disaster and so have not included reservation communities in their state disaster planning. Media attention. Media attention is often the key to obtaining needed resources and services, but communities of color often do not receive this critical attention following disasters, or, worse, they may be portrayed negatively. This was the case in post-Katrina New Orleans when African Americans were portrayed as “looters” while White people behaving in exactly the same ways were portrayed as “finding food and supplies” for their families. Media attention can make a big difference in attracting needed resources to a community, but it can also be damaging (Fothergill et al., 1999). Varying levels of acculturation to the mainstream culture. Those who hope to provide help in a community must be aware that in any community there are varying levels of acculturation to the mainstream culture. When services are provided only for those who adhere to a “traditional” cultural perspective, or only for those who are aligned with a mainstream perspective, many others are left out. When determining whether services will be helpful, disaster mental health professionals must carefully consider who will be included in these services— and who will be left out. Social contexts. For a community with a long history of traumatic events and/or losses, the current disaster may not have the meaning that outsiders might expect. Where poverty, oppression, ongoing violence, and discrimination are present, the experience of prolonged and repeated trauma is likely to supersede the singular effects of the current disaster event (Herman, 1992). Knowledge of the community’s sociopolitical history and experience of traumatic events is critical for those who seek to help. Lack of knowledge about the importance of spiritual foundations. Communities with strong spiritual foundations are better able to cope with the stress and trauma of disaster (McCombs, 2010). The spiritually centered communities of many cultures value connections between the physical and spiritual worlds, and ongoing relationships with ancestors help to guide actions in the present. In many communities, the church, temple, or place of prayer are the first places that people turn to for help in managing disaster stress (Laborde et al., 2011). Those providing psychosocial support should be aware of such important natural resources for coping after a disaster and the central role that spirituality plays in mental health and wellness. Ethnocultural realities. Preexisting racial or cultural tensions are often exacerbated in the stressful postdisaster environment (NBSB, 2008). Especially in times of national insecurity, an “us versus them” mentality is magnified (Dudley-Grant, Comas-Díaz, Todd-Bazemore, & Hueston, 2003). For example, following the terrorist attacks of September 11, 2001, racial profiling of Latinos increased because they “looked Middle Eastern.” Disaster mental health providers need to be aware of these realities, validate those experiences when told of them, and use their relative privilege as “outsiders” to advocate for fairness and social justice. Inter-Agency Standing Committee Guidelines The guidelines on mental health and psychosocial support in emergency settings issued by the InterAgency Standing Committee (2007) identify important areas in which service providers should work with local cultural resources to mobilize communities following disasters. These guidelines provide a useful framework highlighting the essential nature of community participation, capacity building, and attention to human rights issues in disaster response. They emphasize the essential need for culturally responsive psychosocial interventions and include action sheets with suggested activities and process indicators of success. While these guidelines were developed for humanitarian relief operations across the world, they constitute a very useful resource for disaster mental health professionals working with diverse communities within the United States. The guidelines are anchored by a set of basic principles that guide humanitarian response to communities in crisis. These principles are briefly described below. Human rights and equity. This principle directs humanitarian aid workers to protect the human rights of all those involved, especially those who are at increased risk for exploitation or discrimination in the aftermath of a disaster. Disaster response should be inclusive and those involved should be aware of the many ways in which one set of voices can be privileged over others. Participation. All efforts should be made to empower members of the local affected community to participate in their own healing and recovery from the disaster. Disaster responders should recognize that every community, no matter how badly affected, has inherent strengths, resilience, and the capacity to heal itself in its own way. The community has faced other adversities, experienced other crises, and has survived. At the same time, responders must recognize that their very presence is a political act, privileging some groups and not recognizing others. Recovery will be fuller and more sustainable if solutions come from within the community instead of being imposed from the outside. Definitions of problems, determinations of needed help, and forms of solutions should come from different groups within the community. This will allow the community to retain local control rather than become dependent on help from the outside. Do no harm. Disaster responders need to be aware that, even with the best of intentions, giving help can cause unintentional injuries. This is especially hard to acknowledge when people have good intentions for helping, but survivors are in a heightened state of vulnerability. It is recommended that responders take care to design their interventions on sufficient data; coordinate services with groups within the community; commit to openness, evaluation, and transparency; and develop participatory approaches. Building on available resources and capacities. It is critical that disaster responders recognize existing strengths within the community and support the natural healing mechanisms that have sustained the community for many generations. Integrated support systems. Although there is sometimes a temptation to offer stand-alone services for specific populations affected by a disaster (e.g., disaster counseling for women who have been sexually assaulted), it is more helpful to make certain that services are integrated into broader systems of care, such as health care, mental health care, social services, and educational systems. This makes it more likely that services will reach more people, carry less stigma, and be more sustainable overall. Multilayered supports. Services should be multilayered and able to support people who are affected in a variety of different ways. For example, some people just need basic needs met, others need family and community supports, and others might need specialized mental health services. It is important for disaster responders to develop complementary supports that meet the needs of different groups. Conclusions The sheer number of devastating large-scale natural and human-made disasters that continue to occur across the world demands that mental health professionals prepare to respond to communities and cultures where they may have little prior knowledge or experience. Whether or not disaster responders actually provide what is experienced as “helpful” depends on their commitment to cultural responsiveness and unwavering attention to the economic, political, and social contexts in which survivors live. Counseling survivors of disasters requires counselors to step outside their accustomed roles in order to support positive individual and community coping and resilience. Cultural responsiveness requires that disaster response efforts are grounded in affected communities’ concepts of help, healing, and wellness. The most important disaster counseling skill is that of supporting survivors’ natural healing systems. Critical Incident As a member of a team of Native American mental health professionals and traditional spiritual leaders (hereafter called “the Team”), I have had the opportunity to respond to community crises in Native communities. Often these responses have come after communities have experienced clusters of youth suicides. The following is a description of one of those responses. The health director of a remote tribal community of approximately 2,500 contacted and met with the Team leaders (one of the community’s traditional spiritual/cultural leaders and me, a clinical psychologist). She described the occurrence of 17 youth suicides in the community, all by hanging, over a 2-month period. Most members of the community had been affected directly in some way, and some families had lost more than one child. Service providers and first responders in the community were overwhelmed and exhausted as suicide attempts were continuing almost every day. Community leaders had sent the health director to request that the Team respond as soon as possible to help stop the suicide attempts and help the community begin a healing process. Team Activities The Team prepared itself through spiritual ceremony and then traveled to the community within 3 days. The following are some of the activities of the Team over the next several weeks. Meeting with first-line service providers (FLSPs). The Team spent the first day meeting with a group of service providers and first responders from the community, providing training on the effects of traumatic stress and using talking circles to give the FLSPs a chance to talk about the ways they had been affected by the suicides. The FLSPs became the lead group for all the following work and worked closely with the Team for the remainder of the visit. Community meeting. The Team conducted an open community meeting to hear the perceptions and ideas of community members about what had been happening. Meeting with tribal government. The Team met with the tribal government to ensure that community members recognized that the Team had been authorized to be in the community, and to present a report and recommendations to tribal leaders at the end of the visit. The Team maintained contact with tribal leaders as recommendations were implemented over the next several years. Meeting with spiritual leaders. Traditional Native spiritual leaders and church leaders had never met together before but were able to come together to provide united spiritual support to community members. Working with schools. All of the schools serving the reservation children (public, church-based, tribal) were visited. This was facilitated by school counselors who were part of the FLSP group. Team members working with members of the FLSP group held talking circles with children in every grade, all teachers, and all administrators to educate (in grade-appropriate formats) about the effects of traumatic stress and to identify high-risk children. Meeting with affected families and relatives. Team members traveled to families’ homes or met them in places they felt comfortable. In some cases, families had not yet reentered the homes where their children had died. Spiritual leader members of the Team conducted the appropriate ceremonies that would allow them to go into their homes or enter their children’s rooms. Mental health members of the Team worked with the children, adults, and families to help them express their grief, honor their loved ones, and support one another. Meeting with representatives of the judicial system. Some children whose siblings had died were afraid to return to school because they were afraid someone else in their families would die. The schools had started to press charges against the parents for truancy. Team members met with representatives of the judicial system and were able to work out solutions that included in-home schooling for affected children. Building a context. Meetings with the tribal health director over a 2-week period revealed a broader context that included 4 years of massive flooding on the reservation, basements that held 3–4 feet of standing water, increases in respiratory illnesses, deaths of elders, occurrence of hantavirus, and washed-out roads requiring school buses to detour 70 miles (resulting in children going to school in the dark and not returning until dark). Many families had moved to the central district of the reservation, where services and schools were centered, but a severe housing shortage required them to live with friends or relatives. Families were separated, with members scattered among multiple households and their possessions somewhere else. Federal funding cuts meant that service providers were overwhelmed. Overcrowded living conditions led to increases in substance abuse, domestic violence, and gambling. Preexisting racial tensions between the reservation residents and people living in the nearby town were exacerbated. There was a single half-time mental health professional for the reservation, and when the suicide attempts started, young people who attempted to harm themselves were sent off the reservation to hospitals more than 100 miles away for evaluation. Often, their families did not have access to transportation and could not go with them. When the young people returned, their families were not informed about diagnoses, medications, or warning signs, and there was no aftercare in the community. This was the case for many of the young people who had died. People started to believe that when their children were “sent away,” they were put on medicine that contributed to them killing themselves, so now there were many more suicide attempts that went unreported. The young people who had died were actually seen as the youth leaders in the community. Sharing the context. The Team worked with the health director and tribal governance to build the context for the current crisis situation. The tribal chairperson called a mandatory meeting of all community members so that the Team could share the context with community members. People in the community had not connected the long-term stress brought on by the flooding to the suicides. The tribe did not think of the flooding as a “disaster” because it was a part of the natural world (there actually is no word for disaster in the tribal language). Team members had also been working with the young people, developing a new set of youth leaders. These youth shared their grief, feelings of loss, and need for adult guidance at the community meeting. Sharing this context allowed community members to get a “big-picture” view of what had been happening and allowed them to come together and mobilize community resources to support each other and begin a healing process. Developing a community crisis team. The Team worked with the FLSP group to develop a community crisis team with an emergency plan and connection to needed resources. The Team had discovered a pattern of suicide attempts, and planning was done for the community crisis team to use time periods when no suicide attempts were happening to do community education and outreach. Engaging in advocacy. The Team was able to advocate with FEMA to get needed resources to the community. Acknowledging the relationship. The Team maintained contact with the community and its leaders. Follow-up visits focused on further development of the crisis team, the youth leadership, community education, and advocacy for resources. It was important for the Team to acknowledge that its relationship with the community did not end at the end of the crisis. Engaging in self-care. The Team met at the end of every day so that members could debrief and check in with each other. Even when the Team worked late into the night, this meeting was important to make sure that everyone remained healthy. In a situation where children have died and everyone in the community has been affected, it is difficult for helpers not to be overwhelmed as well. Throughout this intervention and the several years that followed, the Team maintained a supportive presence, stayed in the background, and empowered community leaders and service providers to shape and implement their plans. Community members who had felt helpless in the beginning became active leaders for change in their own community. The suicide attempts stopped, the youth leadership asked for representation in tribal governance, and needed resources (including mental health professionals) were received in the community. Discussion Questions 1. What are some of the reactions to traumatic stress seen in the community described above? 2. How did culture play a role in the crisis that occurred in this community? 3. What are some of the considerations for “outsiders” entering a community that has been affected by a disaster? 4. Was the community described above resilient? 5. How do the IASC guidelines apply in this setting? How do they serve to protect a community during a crisis response? References Andrulis, D., Siddiqui, N., & Purtle, J. (2009). California’s emergency preparedness efforts for culturally diverse communities: Status, challenges and directions for the future. Philadelphia: Center for Health Equality, Drexel University School of Public Health. Retrieved from http://www.diversitypreparedness.org Bolin, R., & Stanford, L. (1998). The Northridge earthquake: Community-based approaches to unmet recovery needs. Disasters, 22(1), 21–38. Bourne, D. R. (2006, March). Evacuation patterns of ethnic minority populations affected by Hurricane Katrina. In Hurricane Katrina: A multicultural disaster [Special section]. Communiqué, pp. xiii–xvi. Retrieved from http://www.apa.org/pi/oema/resources/communique/2006/03/katrinaspecial-section.pdf Boyd, B., Quevillon, R. P., & Engdahl, R. M. (2010). Working with rural and diverse communities after disasters. In P. Dass-Brailsford (Ed.), Crisis and disaster counseling: Lessons learned from Hurricane Katrina and other disasters (pp. 149–164). Thousand Oaks, CA: Sage. Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., & Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry, 55, 626–632. Cox, R. S., & Perry, K.-M. E. (2011). Like a fish out of water: Reconsidering disaster recovery and the role of place and social capital in community disaster resilience. American Journal of Community Psychology, 48(3–4), 395–411. DeWolfe, D. J. (2000). Training manual for mental health and human service workers in major disasters (2nd ed.; DHHS Publication No. ADM 90-538). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Dudley-Grant, R. G., Comas-Díaz, L., Todd-Bazemore, B., & Hueston, J. D. (2003). Fostering resilience in response to terrorism: For psychologists working with people of color. Washington, DC: American Psychological Association Task Force on Resilience in Response to Terrorism. Fothergill, A. E., Maestas, E. G., & Darlington, J. D. (1999). Race, ethnicity and disasters in the United States: A review of literature. Disasters, 23(2), 156–173. Fothergill, A. E., & Peek, L. A. (2005). Poverty and disasters in the United States: A review of recent sociological findings. Natural Hazards, 34, 89–110. Guha-Sapir, D., Vos, F., & Below, R., with Ponserre, S. (2012). Annual disaster statistical review 2011: The numbers and trends. Brussels: Centre for Research on the Epidemiology of Disasters. Retrieved from http://www.cred.be/sites/default/files/ADSR_2011.pdf Herman, J. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377–391. Hobfall, S. E., & deVries, M. W. (Eds.). (1995). Extreme stress and communities: Impact and intervention. Dordrecht, Netherlands: Kluwer. Institute of Medicine. (2003). Preparing for the psychological consequences of terrorism: A public health strategy. Washington, DC: National Academies Press. Inter-Agency Standing Committee. (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: Author. Kaniasty, K., & Norris, F. H. (1995). In search of altruistic community: Patterns of social support mobilization following Hurricane Hugo. American Journal of Community Psychology, 23, 447–477. Laborde, D. J., Brannock, K., & Parrish, T. (2011). Assessment of training needs for disaster mental health preparedness in Black communities. Journal of the National Medical Association, 103(7), 624–634. Landau, J. (2007). Enhancing resilience: Families and communities as agents for change. Family Process, 46(3), 351–365. Lum, I. (2005). Swept into the background. Diverse Issues in Higher Education, 22, 22–27. Marsella, A. J., & Christopher, M. A. (2004). Ethnocultural considerations in disaster: An overview of research, issues, and directions. Psychiatric Clinics of North America, 22(30), 521–539. Marsella, A. J., Johnson, J. L., Watson, P., & Gryczynski, J. (2008). Essential concepts and foundations. In A. J. Marsella, J. L. Johnson, P. Watson, & J. Gryczynski (Eds.), Ethnocultural perspectives on disaster and trauma: Foundations, issues, and applications (pp. 3–13). New York: Springer. McCabe, O. L., Perry, C., Azur, M., Taylor, H. G., Bailey, M., & Links, J. M. (2011). Psychological first-aid training for paraprofessionals: A systems-based model for enhancing capacity of rural emergency responses. Prehospital and Disaster Medicine, 26(4), 251–258. McCombs, H. (2010). The spiritual dimensions of caring for people affected by disasters. In P. DassBrailsford (Ed.), Crisis and disaster counseling: Lessons learned from Hurricane Katrina and other disasters (pp. 131–148). Thousand Oaks, CA: Sage. Milligan, G., & McGuinness, T. M. (2009). Mental health needs in a post-disaster environment. Journal of Psychosocial Nursing, 47(9), 23–30. Myers, D. (1994). Disaster response and recovery: A handbook for mental health professionals (DHHS Publication No. SMA 94-3010). Washington, DC: U.S. Department of Health and Human Services. National Biodefense Science Board, Disaster Mental Health Subcommittee. (2008). Initial report. Washington, DC: U.S. Department of Health and Human Services. Retrieved from http://www.phe.gov/Preparedness/legal/boards/nbsb/Documents/nbsb-dmhreport-final.pdf Norris, F. H., & Alegría, M. (2008). Promoting disaster recovery in ethnic-minority individuals and communities. In A. J. Marsella, J. L. Johnson, P. Watson, & J. Gryczynski (Eds.), Ethnocultural perspectives on disaster and trauma: Foundations, issues, and applications (pp. 15–35). New York: Springer. doi:10.1007/978-0-387-73285-5_2 Norris, F. H., Stevens, S. P., Pfefferbaum, B., Wyche, K. F., & Pfefferbaum, R. L. (2008). Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology, 41(1–2), 127–150. doi:10.1007/s10464-007-9156-6 Phillips, B. D. (1993). Cultural diversity in disasters: Sheltering, housing, and long-term recovery. International Journal of Mass Emergencies and Disasters, 11(1), 99–110. Selner-O’Hagan, M. B., Kindlon, D. J., Buka, S. L., Raudenbush, S. W., & Earls, F. J. (1998). Assessing exposure to violence in urban youth. Journal of Child Psychology and Psychiatry, 39(2), 215–224. U.S. Department of Health and Human Services. (2005). Mental health response to mass violence and terrorism: A field guide (DHHS Publication No. SMA 4025). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Retrieved from http://store.samhsa.gov/shin/content/SMA05-4025/SMA05-4025.pdf Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience. Family Process, 46(2), 207–227. Williams, M. B., Zinner, E. S., & Ellis, R. R. (1999). The connection between grief and trauma: An overview. In E. S. Zinner & M. B. Williams (Eds.), When a community weeps: Case studies in group survivorship (pp. 3–22). Philadelphia: Brunner/Mazel. Wray, R., Rivers, J., Whitworth, A., Jupka, K., & Clements, B. (2006). Public perceptions about trust in emergency risk communication: Qualitative research findings. International Journal of Mass Emergencies and Disasters, 24(1), 45–75. Yates, S. (1998). Attributions about the causes and consequences of cataclysmic events. Journal of Personal and Interpersonal Loss, 3(1), 7–24. Zinner, E. S., & Williams, M. B. (1999). Summary and incorporation: A reference frame for community recovery and restoration. In E. S. Zinner & M. B. Williams (Eds.), When a community weeps: Case studies in group survivorship (pp. 237–254). Philadelphia: Brunner/Mazel. 17 Counseling in the Context of Poverty Laura Smith Melanie E. Brewster Primary Objective ■ To explore how the context of poverty affects clinical work in mental health care Secondary Objectives ■ To introduce a discussion of class structures in the United States (e.g., poverty, middle, working, upper-middle, and owning) and biases held by mental health professionals ■ To explore social class at the intersections of identity (e.g., race, gender) Despite the seemingly monolithic impact of social class on personal aspirations, career mobility, educational access, and mental/physical health, clear definitions of the concept of class remain nebulous (Browning & Cagney, 2003; Murali & Oyebode, 2004; Sapolsky, 2005). In near unison, social scientists acknowledge that class is an important predictor of life experiences and well-being, yet these same scholars are problematically scattered in their definitions and conceptualizations of social class (Oakes & Rossi, 2003), with the result that the terms social class, classism, and socioeconomic status (SES) are often used interchangeably. Such scholarly discord likely stems from broader confusion about the meaning(s) of social class. When people think about social class, many different topics likely come to mind that arrange themselves roughly into a hierarchy (Smith, 2010). As such, the phrase upper class may be loosely associated with prestige, status, wealth, corporate executives with jets, NBA players, and the Kardashian family; associations with poverty, on the opposite end of the class spectrum, include “trashiness,” inaccessibility, housing projects in Philadelphia, broken-down trailer homes, and poor dental hygiene. Through this automatic categorization system, the phrase lower class (and all individuals who may be lumped into this category) has become synonymous with negative images of poverty, grime, stupidity, drug use, criminality, low achievement, and worse (Lott, 2002). As such, even the language that we associate with social class often holds power to oppress and marginalize. In this chapter, we provide an overview of social class and poverty that will allow counselors in training to begin to factor class into their conceptualizations of the identities and oppressions that may have shaped their clients’ experiences. It is important to note that such an overview must necessarily be general; thus, we will not address many important dimensions of social class membership as a lived experience. For example, like other dimensions of social identity, social class membership is not a simple, unitary characteristic. Although a number of broad generalizations may be made, social class membership is manifested differently at its intersections with other identities such as race, ethnicity, gender, sexual orientation, immigration status, and (dis)ability. Along these lines, the complexity of social class intersectionality begins with the fact that American racial group identities themselves are deeply intertwined with social class, in that the establishment of separate racial categories for people of color served to rationalize the enslavement of kidnapped Africans and the seizing of Native American lands (e.g., Marable, 2000). The modern legacy of this history is that people of color continue to be overrepresented among Americans living in poverty (U.S. Census Bureau, 2010). Gender-related intersections, which have given rise to the phrase “the feminization of poverty,” operate with the result that women in the United States are 40% more likely than men to live in poverty and 60% more likely to live in extreme poverty (Legal Momentum, 2010). At the intersection of social class and sexual orientation, we encounter the preconception that LGBT people are affluent, childless, and have abundant disposable income. The reality is that the multidimensional layers of institutionalized prejudice experienced by LGBT people—such as unequal access to health care, housing discrimination, and employment discrimination—result in significant economic hardships for many and elevated poverty rates among queer people (Albelda, Badgett, Schneebaum, & Gates, 2009; Redman, 2010). In addition to the works just cited, we encourage interested readers to consult The Color of Wealth (Lui, Leondar-Wright, Brewer, & Adamson, 2006) to learn more about the intersections of race and class, and Marcia Hill and Esther Rothblum’s Classism and Feminist Therapy: Counting Costs (1996) to read about class, gender, and their implications for psychotherapy. Lustig and Strauser (2007) and Stapleton, O’Day, Livermore, and Imparato (2006) are among those who have written about the intersections of poverty and (dis)ability. Talking About Social Class Properly identifying an individual’s social class membership often proves to be an elusive task, and researchers frequently use demographic information such as income, occupation, and level of education as proxies for social class identification. Utilizing these three demographic characteristics is problematic because there is no evidence that these indicators consistently predict social class position (American Psychological Association Task Force on Socioeconomic Status, 2008; Smith, 2010). For example, a sanitation worker, a high school English teacher, a small business owner, and a security guard may all earn approximately $50,000 per year, placing them in a middle-class category according to median income levels in the United States, yet assumptions about the people who occupy each of these jobs (education level, blue- or white-collar), the benefits and flexibilities of these jobs, and the upward mobility (or not) associated with each of these positions all translate into differential levels of social power for those who occupy them (Smith, 2010). In distinguishing social class from related variables like income, theorists vary greatly in their class designations, though a few commonalities can be found among these definitions. The following organizational structure presents basic language for social class groupings that draws heavily from works by Gilbert (2008), Leondar-Wright (2005), Smith (2010), and Zweig (2000): ■ Poverty: Persons in this group occupy low-wage positions or are currently unemployed. Individuals living in poverty often used to hold working-class status, but, due to economic crises, health conditions, or other serious life circumstances, are now unable to garner enough income to meet basic needs. In 2012, the U.S. Department of Health and Human Services defined the “poverty line” as an annual income of $11,170 for a single person (add $3,960 for each additional person in a family). Approximately 13% of the U.S. population is believed to fall below this line. At the same time, this figure is widely interpreted as underestimating the costs of supporting a family, and therefore the numbers of Americans living in poverty. Relatedly, a numerical cutoff such as this one implies that a person attempting to live on $11,170 per year is technically not poor. ■ Working class: Individuals in this group generally work in lower-income positions (e.g., janitorial staff, people in food service, factory workers) and generally have little power or agency in the workplace compared with individuals in more privileged classes. In other words, working-class people often do not participate in workplace policy making, do not hire or fire other people, and have few options for autonomy or input regarding the pace and content of their workdays. ■ Middle class: The people in this group are typically college educated and have slightly more economic security than working-class individuals. Middle-class individuals, such as teachers, managers, office workers, and accountants, often receive salaries rather than hourly wages. Their jobs frequently allow them some degree of autonomy in the workplace, in that they may create workplace policy or participate in its creation. Persons in this group also typically exercise greater workplace autonomy with regard to the precise allocation of their time to particular tasks, the option to create or modify aspects of their workload, the freedom to make phone calls and take bathroom breaks during the workday, and so forth. ■ Upper-middle class: Like other middle-class people, individuals in this class must work for a living, but those in this group occupy positions that are relatively well regarded and highly paid (e.g., lawyers, lower-level politicians, and physicians). ■ Owning class: Often referred to as the top 1% (White, Gebeloff, Fessenden, & Carter, 2012), this group includes individuals with enough wealth and property that they do not need to work (although they may choose to do so). These people own and control the resources by which the members of other classes make their livings and have significant social, political, and cultural power in addition to their economic power. This typology makes clear the economic component of social class—whether that means earnings, income, property, employment, or inherited wealth (Gilbert, 2008). In addition, prestige, or individuals’ perceived cultural capital (Bourdieu, 1984), can modify the interpersonal experience of social class membership. For example, the monetary earnings of poets, adjunct professors, and painters may often place them in the lowest social class brackets, but their presumed cultural knowledge, intellect, and aesthetic sensibilities may allow them to mix with members of higher social class groups (Smith, 2010; Weininger, 2005). Finally, there is a sociopolitical dimension in which behaviors, attitudes, associations (e.g., the people an individual knows, the prestigiousness of the schools attended), and socialization all interact with power held by members of other social classes; in turn, this interplay shapes public policy, influences social structures, and institutionalizes accessibility for members of some classes and not others (Gilbert, 2008). Like most attempts to impose theoretical frameworks on social reality, this typology contains gray areas and overlap, yet it provides a starting place for understanding a hierarchy that relegates some members of society to positions of relative power and privilege and leaves others without the resources to meet their basic needs. The process by which this differential class-related privileging occurs and is perpetuated—via sociopolitical structures, stereotypes, stigma, and discrimination—is termed classism (Lott, 2002; Lott & Bullock, 2007). Poverty as a Disempowered Social Class Position Poverty, while highly (and importantly) associated with a lack of economic resources, goes well beyond just money trouble. Nolan and Whelan (2010) have observed that individuals who live in poverty also experience nonmonetary forms of deprivation, including inadequacies with living spaces (noisy and often crime-ridden neighborhoods, environmental pollution, housing deterioration, lack of running water, heat, or air-conditioning), nutrition (inability to afford healthy or fresh food), and interpersonal support (feeling excluded from activities, customs, and middle-class living patterns). The inequality of poverty is also self-perpetuating, in that the poor continue to get poorer. Specifically, the obstacles faced by people living in poverty tend to restrict those individuals’ access to the resources that could possibly promote class mobility (i.e., good school districts, well-paying jobs in the neighborhood; Wilkinson & Pickett, 2006). Poverty can also be further deepened through lack of access to adequate medical and dental care. For example, if an undocumented construction worker receives an injury on the job, he will not have health insurance to pay for treating the injury and the injury will prevent him from working, which, in turn, prevents him from being able to afford medical treatment. Or, if a person living in poverty is unable to afford dental care and loses her front teeth, it is likely that she will experience employment discrimination that may block her from finding a position that could provide dental insurance to fix her teeth (Shipler, 2004). This self-perpetuating cycle can extend to the job interview process. Even when job applicants living in poverty are well qualified for open positions, they may be unable to afford “proper” clothing for job interviews. As Smith (2010) pointedly comments in discussing a client who was overlooked for a bank teller position because he was dressed too “casually” during an interview, “If [the bank] gave this talented young person a chance to earn a living, he might have more choices in what he wore to work” (p. 71). Stereotypical images of poverty correspond to the jobless or so-called chronic poor, although increasing numbers of people living in poverty are employed (Tait, 2005)—and estimates suggest that roughly a quarter of individuals living in homeless shelters in the United States have jobs (National Coalition for the Homeless, 2009). However, due to rising housing prices and the cost of living in most cities, the people who would best be categorized as “working poor” are still unable to secure housing and meet the basic needs of their family members (Smith, 2010). Housing costs push lowincome families outside the bounds of cities, increasing commute times to and from work (and decreasing time that could be spent sleeping, visiting with loved ones, and maintaining the home). Thus, even finding the means to travel to and from work becomes a challenge and an additional stressor for many people living in poverty. Decades of research provide evidence that living in poverty is closely linked with poor physical health outcomes, including, but not limited to, diabetes, obesity, respiratory and cardiovascular diseases, ulcers, rheumatoid disorders, some cancers, and mortality (for a review, see Sapolsky, 2005). Poverty is also considered to be “both a determinant and a consequence of poor mental health” (Murali & Oyebode, 2004, p. 217), in that psychiatric disorders—such as mood disorders, psychoses, anxiety disorders, and drug and alcohol dependence—all occur at higher rates among people living in the most disadvantaged social classes. The inverse relationship between poor physical and mental health and social class has been termed the SES gradient, and, notably, it persists even when health care access, health care utilization, and exposure to risk and protective factors are controlled for (Marmot & Wilkinson, 2005). This is a crucial point for understanding the full spectrum of oppression that accompanies life in poverty, in that even when these tangible, material aspects of deprivation are removed from the equation, poor people still get sicker and die earlier than the rest of us. What else about poverty, then, undermines people’s physical and emotional well-being? Researchers posit that the SES gradient has roots in psychosocial factors—that people living in poverty are harmed by ongoing encounters with interpersonal discrimination, bleak social realities, and chronically stressful life situations that are not experienced by members of the more privileged classes (Marmot et al., 1998). Moreover, the psychosocial stressors of living in poverty are exacerbated by the cognitive and behavioral distancing from poor people enacted by people in privileged social classes (Lott, 2002). Indeed, “the surest way to feel poor is to be endlessly made aware of the haves when you are a have-not” (Sapolsky, 2005, p. 98). Distancing From the Poor One of the psychosocial stressors associated with poverty comes in the form of social distancing from the poor. This distancing is perpetuated via intentional and unintentional “separation, exclusion, devaluation, discounting, and designation as ‘other,’ and that response can be identified in both institutional and interpersonal contexts” (Lott, 2002, p. 100). In institutional contexts, it is manifested by government agencies, schools, businesses, housing authorities, and health care facilities that create procedures and policies that favor the members of privileged classes and act as barriers that impede access to services by the poor. For example, landlords are often inclined to reject housing applications from potential tenants who receive government subsidies (Bernstein, 2001). Similarly, interpersonal distancing takes place in social situations in which people living in poverty are demeaned, discounted, or ignored in interactions because of their social class status; for example, low-income individuals may be eyed suspiciously by cashiers when they enter retail shops (Bullock, 1995). Both institutional distancing and interpersonal distancing are thought to be aspects of the deeper manifestation of classism posited by Bernice Lott (2002), who addresses cognitive distancing and behavioral distancing in her theorizing. These are implicit negative attitudes (and the actions that stem from them) directed toward people living in poverty, who are often tacitly assumed to be immoral, lazy, corrupt, expendable, deficient, stupid, unmotivated, angry, dirty, and deserving of their misfortune. As a result of these beliefs, individuals from more privileged classes engage in behavioral distancing, or tactics that reduce their contact with individuals from impoverished classes. Many well-intentioned people are not consciously aware that they are engaging in such behaviors, which might include crossing the street to avoid a homeless person or averting eye contact when asked for spare change—yet these actions create mental and physical space between the lived experiences of the more privileged and the realities of poverty. Mental Health Professionals and Poverty Research suggests that many mental health professionals struggle to connect therapeutically with lowincome clients (Leeder, 1996)—when they encounter them at all. Some of this trouble connecting may be linked to unaware cognitive distancing by providers, which has, in turn, been linked to the endorsement of negative beliefs about people living in poverty: that they may be lazy, apathetic, passive, unwilling to change, or secretly addicted to drugs or alcohol, and are not likely to be “good” therapy clients (Lorion, 1973, 1974). It has similarly been linked to therapists’ own class strivings and their coinciding (and unconscious) fear of the poor (Javier & Herron, 2002). As a result of these attitudes, mental health professionals themselves can become unintentional colluders in maintaining classism (Lott, 2002). This may be one of the reasons why counseling and therapeutic approaches to working with the poor remain understudied and underdeveloped (Smith, 2005). Other reasons may be that training curricula for counselors—even multicultural training—often fail to address counseling work with clients who live in poverty (Smith, 2010). Counseling in the Context of Poverty Given the origins of psychotherapeutic practice within middle-class/owning-class culture and the class-related attitudes that its practitioners can unintentionally bring to their work, it is not surprising to learn that poor people have not always felt well served by conventional counseling treatment. Chalifoux (1996) was one of the earliest researchers to provide a platform for these clients’ voices through her qualitative research, in which she interviewed poor and working-class clients about their therapeutic experiences. Her participants described clinicians who seemed to mean well but were nevertheless unaware of their assumptions and blind spots regarding social class: You don’t care if you eat dirt, but you’ll take a lot of crap to make sure that your kids get what they need. My therapist couldn’t understand that.... In her life, there has always been enough for everybody and that’s a big difference. (p. 30) In the preliminary phases of a similar study conducted more recently, one of Appio’s (2012) participants characterized her counseling session as “rigid” and “tense” in keeping with the atmosphere that the counselor’s demeanor and office conveyed to him: “The way they dressed, jewelry, their mannerisms were, everything was so... how can I say? It was just, everything was talking, and it’s like they didn’t fit for the people they were treating” (p. 8). Another participant commented on the seeming impossibility of raising such concerns with his or her counselor, feeling that discussing social differences and similarities with the therapist might be experienced as “an attack between classes” (p. 9). While some counselors are unaware of the messages they are conveying to their poor clients, others have encountered their blind spots and challenges via practice experience in the settings that serve poor clients. Smith, Li, Dykema, Hamlet, and Shellman (2013) interviewed a group of such clinicians, learning in the process that they felt that their training had not prepared them to encounter the impact of poverty in the lives of their clients or to address these realities within their interventions: You see examples of, sort of, what people go through, and how challenging it is to really just sort of navigate their day-to-day lives. You know, just maintaining their, their mental health and emotional stability on top of maybe not having enough money to, you know, to access all the resources that would help them maintain their emotional stability. It’s sort of, you know, kind of a double-edged sword to have to deal with both. (p. 142) If conventional counseling practice does not always enable practitioners to connect their interventions to the realities of life in poverty, what treatment innovations hold promise for increasing the relevance of mental health practice in poor communities? Smith (2010) has conceptualized such innovations as constituting a continuum of interventions that range in their degree of similarity to conventional counseling modalities. Those with the most similarity are termed transformed psychotherapeutic practices, while the two categories with increasingly less similarity are cocreated interventions and community praxis. Transformed psychotherapeutic practices are represented by clear, substantive modifications of traditional practice in keeping with social justice tenets. As a feminist orientation that is based on mutuality and power sharing within the counseling dyad, relational-cultural therapy is a well-established example of such a modification (e.g., Jordan, 2000). Cocreated interventions are new forms of counseling that are created in collaboration with clients or community members; these have included group counseling modalities based on poetry and spokenword performance (Smith, Chambers, & Bratini, 2009) and peer-led psychoeducational groups created to address depression in the context of urban poverty (Goodman et al., 2007). Finally, within community praxis, counselors engage with community members in practices/actions that explicitly connect individual and community well-being to the larger sociocultural context. Participatory action research (PAR) represents a vehicle by which community praxis can be practiced. In PAR, counseling professionals do not conduct studies on community members; rather, they conduct studies with community members on issues of local interest and urgency. This is a process in which all participants contribute, learn, and grow as they address the sociocultural conditions that undermine the community’s emotional well-being in the first place (Smith & Romero, 2010). Published accounts of class-aware counseling practices that fall along this continuum are scarce, but they include a recent description of an innovative intervention by Ali and Lees (2013). Developed in collaboration with the urban community-based organizations with which the researchers partnered, anti-oppression advocacy (AOA) addresses two issues in concert: therapeutic change and economic justice. In AOA, counselors weave awareness of poverty throughout the counseling context; they support clients’ social justice actions and also act as advocates themselves. Ali and Lees report an example of AOA that centered on the use of photovoice, an image-based technique for storytelling and meaning making that was created by Wang and Burris (1997) for use by PAR teams. The use of photovoice as a counseling intervention has been described by Smith, Bratini, and Appio (2012), who implemented such an intervention among teenagers in a poor community. Ali and Lees, however, created their PhotoCLUB for adult members, and they described both individual and group benefits to the participants. The process began with members taking pictures of their community and each member showing three photos to the group. Members were to choose photos that represented how they saw themselves and their futures and then describe them as such. The group then helped to brainstorm strategies for attaining the individual and collective well-being that was reflected there. In response to this strategizing, one member sent her pictures of abandoned buildings to a local coalition for the homeless, which used them to lobby for the conversion of several buildings into subsidized and transitional housing. Subsequently, a city government lawyer was invited to one of the group’s meetings and ultimately asked the group for permission to use the photos in following up on the unsafe conditions they depicted. Training Issues In Smith et al.’s (2013) study of clinicians working in the context of poverty, participants shared the challenges and rewards that they had encountered and ultimately emphasized that counselors in training should receive focused preparation to develop their personal and multicultural awareness with regard to poverty. Given that such training is rarely a part of counseling graduate curricula, how can graduate programs identify what some of the essential elements of such training might be? How can they address the preparation of trainees to provide innovative interventions such as those described above? Stabb and Reimers (2013) frame training for effective counseling in the context of poverty within a competency-based training model developed by the Education Directorate of the American Psychological Association (APA) and the Council of Chairs of Training Council (CCTC). Six clusters of benchmark competencies are represented within this model: professionalism, relationships, science, application, education, and systems. Under the heading of professionalism, Stabb and Reimers address the issue of how counselors can most appropriately present themselves and their work, given considerations of social class and poverty. Elements of professional presentation include attention to the class-related messages conveyed by expensive material possessions (such as jewelry or office decor) (Sweet, 2011) and the use of classist language such as “trashy” or “low-rent.” Professionalism also includes the professional’s responsibilities to acquire awareness regarding poverty and its causes and to selfmonitor for classist assumptions within teaching, supervision, and training. Relationship competencies include the facilitation of—and teaching students to engage in—critical dialogues around class issues and counseling practice, as well as helping class-privileged trainees build empathy with poor clients (and peers). Science competencies cluster around acquisition of an adequate knowledge base regarding class and poverty issues, and knowledge of research methods that are appropriate for use in the context of poverty. In particular, Stabb and Reimers note that fundamental flaws in such a knowledge base are reflected by a failure to study the strengths of poor and working-class people and/or by a tendency to study their challenges primarily as individual deficits without consideration of the impact of structural inequalities (Lott & Bullock, 2007). Stabb and Reimers (2013) address counseling practice more directly in elaborating the competencies that correspond to the applications benchmark, those related to assessment, intervention, and consultation. For example, they advise trainers to encourage contextualized conceptualizations of clients’ lives that include historical, political, social, economic, and religious or spiritual factors (Mattar, 2011). In addressing educational competencies, Stabb and Reimers discuss the effective provision and evaluation of instruction and skill development with regard to social class and poverty. Suggestions garnered from the literature include the provision of experiential opportunities through which trainees have the opportunity to engage with poor communities (Chu et al., 2012; Lewis, 2010) and incorporation of the materials provided by the APA Task Force on Resources for the Inclusion of Social Class in Psychology Curricula in its 2008 report, a compendium of class-related experiential exercises, course syllabi, and fiction along with a bibliography of relevant scholarship. Finally, the systems benchmark refers to interprofessional knowledge and collaboration, the management of organizations and programs, and organizational effectiveness and leadership. This domain also encompasses advocacy competencies, through which counselors acquire the skills to intervene in social, political, economic, or cultural processes in order to facilitate systemic change. Advocacy competencies are conceptualized as including the recruitment of economically diverse faculty and students and the provision of practicum sites that serve poor communities. Stabb and Reimers (2013) also call for the examination of values throughout academia. For example, they wonder whether advocacy work might be appropriately listed as direct service hours on internship applications—or, if not, perhaps a new category could be created. Advocacy competencies, they argue, are, in fact a vital accompaniment to the other benchmarks: Opportunities for advocacy in the face of poverty and classism abound. For example, Mattar (2011) calls for changes throughout the discipline of psychology, including curriculum, journal decisions, and in leadership. At the political level, advocacy competencies speak to the importance of supporting legislative initiatives to decrease mental health disparities (Belle & Dodson, 2006), attend to welfare and under-employment concerns (Smith, 2010) and numerous other inequities. At whatever level, from personal-micro to structural-macro, advocacy competencies are important to implement for competent poverty training. (p. 179) Critical Incident Counseling at the Intersection of Social Class, Race, and Rural Living Jeanette, a 54-year-old married African American woman, presented at a community mental health center in rural Georgia with symptoms of depression (weight gain, irritability, social isolation, crying spells). Jeanette’s husband is an independent contractor, but construction jobs have been few and far between with the economic downturn, and Jeanette herself is currently unemployed. Jeanette has one adult daughter with whom she describes a “distant” relationship because her daughter identifies as a lesbian and lives in Atlanta with her girlfriend. Jeanette states that she garners the majority of her social support through her women’s group at church, though she notes feeling “guarded” around friends who “don’t know too much” about her past. As a child, Jeanette experienced severe physical and psychological abuse from her mother and sexual abuse from her older brother. Despite having been raised in the 1960s, Jeanette grew up in a childhood home that had no indoor plumbing or heat, and she states that she was too embarrassed to make friends for fear they would find out about her poverty. She dropped out of high school in the 10th grade in order to get a full-time job as a line cook that enabled her to move away from her abusers and support herself. Jeanette entered therapy at the prompting of her husband, who claims that she “overeats away her pain” rather than facing her past trauma. Jeanette has a history of severe drug abuse, but she indicates that due to Narcotics Anonymous, raising her daughter, and her Baptist faith, she has been able to remain substance-free for 17 years and has instead shifted her coping method to food. Since her daughter moved away and came out as lesbian, Jeanette reports feeling that she has lost her identity as a mother and homemaker. Jeanette completed her GED after her daughter was born and has since enrolled in a few classes at the community college, but she has little desire to earn her associate degree. To pass the time, she is currently seeking employment, but because of her past involvement with narcotics, she has a criminal record and has been unsuccessful in securing even a minimumwage position. Jeanette indicates that she would like to work on her anger toward her family of origin, her feelings of helplessness, and her lack of a sense of purpose. In sessions, she explores the context of her traumatic experiences. Growing up in the rural and racially segregated South, she felt as though she could not report her abuse or rely on law enforcement for support or intervention. Moreover, as a Black woman, she describes feeling pressure not to bring negative attention to her family and community by reporting these assaults. Through therapy she begins to process how these early traumatic experiences may have contributed to her feelings of hopelessness and disempowerment, which eventually led to substance abuse and overeating. Jeanette feels “trapped” and discouraged by her inability to find employment and notes that her present disempowerment is triggering her to relive past trauma. At the end of her fourth session, Jeanette expresses the desire to set concrete goals for reestablishing her sense of personal mastery while allowing for a more healthy release of anger toward her mother and brother. Jeanette also notes that she would like to work on her relationship with her daughter but feels “stuck” because of her spiritual beliefs that same-gender romantic relationships are immoral. She fears that if her friends in the Baptist women’s group find out that her daughter is a lesbian, she and her husband will be marginalized by their community, and they might also lose the sporadic economic support they receive from religious leaders and food banks run by faith-based organizations. Discussion Questions 1. Jeanette’s presenting concerns emerge at the nexus of several poverty- and racism-related factors. How would you describe the influence of these systemic forms of oppression in her life and in her presenting concerns? 2. Poverty is often described as a damaging system that perpetuates itself (e.g., “the poor get poorer”). How might this have been the case for Jeanette? 3. A primary element within Jeanette’s history is the childhood abuse that appears to have triggered a pattern of withdrawal, depression, and avoidance of emotions via substance abuse. How has the impact of the trauma been exacerbated by the poverty that Jeanette’s family faces? 4. To supplement her husband’s sporadic wages, Jeanette and her husband receive support from their church—though this faith-based support feels tenuous, as Jeanette worries that it may be revoked if word of her daughter’s sexual orientation reaches members of the conservative church leadership. How do oppression-related issues intersect in this element of Jeannette’s story? How do they contribute to Jeanette’s lack of connection to others? 5. If you were a professional employed as Jeanette’s counselor, you might or might not share a number of social identities with your client with regard to race, gender, sexual orientation, and so forth. You would not, however, be likely to share her identity as a person currently living in poverty. What are your thoughts about how the correspondence of these identities (or the lack thereof) between you and your client would affect the treatment? How would you incorporate your understanding of these issues within your work with Jeanette? 6. How might this case and resultant therapeutic interventions proceed differently if Jeanette were an upper-middle-class woman who lives in the Northeast? References Albelda, R., Badgett, M. V. L., Schneebaum, A., & Gates, G. J. (2009). Poverty in the lesbian, gay, and bisexual community. Los Angeles: Williams Institute, UCLA School of Law. Retrieved from http://williamsinstitute.law.ucla.edu/wp-content/uploads/Albelda-Badgett-Schneebaum-Gates-LGBPoverty-Report-March-2009.pdf Ali, A., & Lees, K. E. (2013). The therapist as advocate: Anti-oppression advocacy in psychological practice. Journal of Clinical Psychology, 69, 162–171. American Psychological Association Task Force on Resources for the Inclusion of Social Class in Psychology Curricula. (2008). Report of the Task Force on Resources for the Inclusion of Social Class in Psychology Curricula. Washington, DC: American Psychological Association. American Psychological Association Task Force on Socioeconomic Status. (2008). Report of the APA Task Force on Socioeconomic Status. Washington, DC: American Psychological Association. Appio, L. (2012). Class-related experiences of poor and working-class clients in therapy with classprivileged therapists. Unpublished manuscript, Teachers College, Columbia University, New York. Belle, D., & Dodson, L. (2006). Poor women and girls in a wealthy nation. In J. Worell & C. Goodheart (Eds.), Handbook of girls’ and women’s psychological health: Gender and well-being across the lifespan (pp. 122–128). New York: Oxford University Press. Bernstein, S. (2001). The compromise of liberal environmentalism. New York: Columbia University Press. Bourdieu, P. (1984). Distinction: A social critique of the judgement of taste. Cambridge, MA: Harvard University Press. Browning, C. R., & Cagney, K. A. (2003). Moving beyond poverty: Neighborhood structure, social processes, and health. Journal of Health and Social Behavior, 44, 552–571. doi:10.2307/1519799 Bullock, H. E. (1995). Class acts: Middle-class responses to the poor. In B. Lott & D. Maluso (Eds.), The social psychology of interpersonal discrimination (pp. 118–159). New York: Guilford Press. Chalifoux, B. (1996). Speaking up: White, working class women in therapy. In M. Hill & E. D. Rothblum (Eds.), Classism and feminist therapy (pp. 25–34). New York: Haworth Press. Chu, J. P., Emmon, L., Wong, J., Goldblum, P., Reiser, R., Barrera, A. Z., & Byrd-Olmstead, J. (2012). Public psychology: A competency model for professional psychologists in community mental health. Professional Psychology: Research and Practice, 43, 39–49. doi:10.1017/a0026319 Gilbert, N. (2008). Researching social life (3rd ed.). Thousand Oaks, CA: Sage. Goodman, L. A., Litwin, A., Bohlig, A., Weintraub, S. R., Green, A., Walker, J., White, L., & Ryan, N. (2007). Applying feminist theory to community practice: A multilevel empowerment intervention for low-income women with depression. In E. Aldarondo (Ed.), Advancing social justice through clinical practice (pp. 265–290). Mahwah, NJ: Lawrence Erlbaum. Hill, M., & Rothblum, E. D. (Eds.). (1996). Classism and feminist therapy: Counting costs. New York: Haworth Press. Javier, R. A., & Herron, W. G. (2002). Psychoanalysis and the disenfranchised: Countertransference issues. Psychoanalytic Psychology, 19, 149–166. Jordan, J. V. (2000). The role of mutual empathy in relational/cultural therapy. Journal of Clinical Psychology, 56, 1005–1016. Leeder, E. (1996). Speaking rich people’s words: Implication of a feminist class analysis of psychotherapy. Women & Therapy, 18, 45–57. doi:10.1300/J015v18n03_06 Legal Momentum. (2010). Latest poverty data highlight critical need to strengthen social safety net. Retrieved from http://www.legalmomentum.org/news-room/press-releases/latest-poverty-data-1.html Leondar-Wright, B. (2005). Class matters. Gabriola Island, BC: New Society. Lewis, B. (2010). Social justice in practicum training: Competencies and developmental implications. Training and Education in Professional Psychology, 4, 145–152. doi:10.1037/a0017383. Lorion, R. P. (1973). Socioeconomic status and traditional treatment approaches reconsidered. Psychological Bulletin, 79, 263–270. Lorion, R. P. (1974). Patient and therapist variables in the treatment of low-income patients. Psychological Bulletin, 81, 344–354. Lott, B. (2002). Cognitive and behavioral distancing from the poor. American Psychologist, 57, 100–110. doi:10.1037//0003-066X.57.2.100 Lott, B., & Bullock, H. E. (2007). Psychology and economic injustice. Washington, DC: American Psychological Association. Lui, M., Leondar-Wright, B., Brewer, R., & Adamson, R. (2006). The color of wealth. Boston: New Press. Lustig, D. C., & Strauser, D. R. (2007). Causal relationships between poverty and disability. Rehabilitation Counseling Bulletin, 50, 194–202. Marable, M. (2000). How capitalism underdeveloped Black America. Chicago: South End Press. Marmot, M. G., Fuhrer, R., Ettner, S. L., Marks, N. F., Bumpass, L. L., & Ryff, C. D. (1998). Contribution of psychosocial factors to socioeconomic differences in health. Milbank Quarterly, 76, 403–448. doi:10.1111/1468-0009.00097 Marmot, M. G., & Wilkinson, R. G. (2005). Social determinants of health. Oxford: Oxford University Press. Mattar, S. (2011). Educating and training the next generations of traumatologists: Development of cultural competencies. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 258–265. doi:10.1037/a0024477 Murali, V., & Oyebode, F. (2004). Poverty, social inequality, and mental health. Advances in Psychiatric Treatment, 10, 216–224. doi:10.1192/apt.10.3.216 National Coalition for the Homeless. (2009). Who is homeless? (NCH Fact Sheet). Washington, DC: Author. Retrieved from http://www.nationalhomeless.org/factsheets/Whois.pdf Nolan, B., & Whelan, C. T. (2010). Using non-monetary deprivation indicators to analyze poverty and social exclusion: Lessons from Europe? Journal of Policy Analysis and Management, 29, 305–325. doi:10.1002/pam.20493 Oakes, J. M., & Rossi, P. H. (2003). The measurement of SES in health research: Current practice and steps toward a new approach. Social Science & Medicine, 56, 769–784. doi:10.1016/S02779536(02)00073-4 Redman, L. F. (2010). Outing the invisible poor: Why economic justice and access to healthcare is an LGBT issue. Georgetown Journal on Law & Policy, 123, 451–460. Sapolsky, R. (2005). Sick of poverty: New studies suggest that the stress of being poor has a staggeringly harmful influence on health. Scientific American, 293, 92–99. doi:10.1038/scientific american1205-92 Shipler, D. (2004). The working poor: Invisible in America. New York: Alfred A. Knopf. Smith, L. (2005). Psychotherapy, classism, and the poor: Conspicuous by their absence. American Psychologist, 60, 687–696. doi:10.1037/0003-066X.60.7.687 Smith, L. (2010). Psychology, poverty, and the end of social exclusion: Putting our practice to work. New York: Teachers College Press. Smith, L., Bratini, L., & Appio, L. (2012). “Everybody’s teaching and everybody’s learning”: Photovoice and youth counseling. Journal of Counseling & Development, 90, 3–12. Smith, L., Chambers, D. A., & Bratini, L. (2009). When oppression is the pathogen: The participatory development of socially just mental health practice. American Journal of Orthopsychiatry, 79, 159–168. Smith, L., Li, V., Dykema, S., Hamlet, D., & Shellman, A. (2013). “Honoring somebody that society doesn’t honor”: Therapists working in the context of poverty. Journal of Clinical Psychology, 69, 138–151. Smith, L., & Romero, L. (2010). Psychological interventions in the context of poverty: Participatory action research as practice. American Journal of Orthopsychiatry, 80, 12–25. Stabb, S. D., & Reimers, F. A. (2013). Competent poverty training. Journal of Clinical Psychology, 69(2), 172–181. Stapleton, D. C., O’Day, B. L., Livermore, G. A., & Imparato, A. J. (2006). Dismantling the poverty trap: Disability policy for the twenty-first century. Milbank Quarterly, 84, 701–732. Sweet, E. (2011). Symbolic capital, consumption, and health inequality. American Journal of Public Health, 101, 260–264. doi:10.2105/AJPH.2010.193896 Tait, V. (2005). Poor workers’ unions. Chicago: South End Press. U.S. Census Bureau. (2010). Poverty: Overview/highlights. Retrieved from http://www.census.gov/hhes/www/poverty/about/overview/index.html Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24, 369–387. Weininger, E. B. (2005). Foundations of Pierre Bourdieu’s class analysis. In E. O. Wright (Ed.), Approaches to class analysis (pp. 82–118). New York: Cambridge University Press. White, J., Gebeloff, R., Fessenden, F., & Carter, S. (2012, January 15). The top 1 percent: What jobs do they have? New York Times. Retrieved from http://www.nytimes.com/packages/html/newsgraphics/2012/0115-one-percentoccupations/index.html Wilkinson, R. G., & Pickett, K. E. (2006). Income inequality and health: A review and explanation of the evidence. Social Science & Medicine, 62, 1768–1784. doi:10.1016/j.socscimed.2005.08.036 Zweig, M. (2000). The working class majority: America’s best kept secret. Ithaca, NY: Cornell University Press. 18 The Ecology of Acculturation Implications for Counseling Across Cultures Jaimee Stuart Colleen Ward Primary Objective ■ To provide a conceptual framework for understanding the acculturation experience and how it influences counseling Secondary Objective ■ To help students understand the various research perspectives in the psychology of acculturation and adaptation People have always shifted from place to place, drawn by the opportunities that are present in particular locations, and this population movement has historically been one of the driving forces in changing demographics. The recent global increase in the mobility of cultural travelers brought about by relaxation of immigration laws, policy reforms regarding refugee resettlement, and access to global information, media, and transport networks has contributed to this trend. As a result, 214 million people (3.1% of the world’s population) currently reside outside their countries of birth, a figure that grew by an estimated 64 million over the past 10 years (International Organization for Migration, 2010). The long-term outcome of migration is the formation of culturally diverse populations in which different cultural groups reside together under shared social and political frameworks (Berry, 1997). In situations of sustained intercultural contact, individuals and groups are faced with the issue of how to adjust to cultural values, behaviors, and systems of beliefs that are different from their own. The period of adjustment following intercultural contact is known as acculturation and is defined as the process of mutual and reciprocal change that takes place as a result of intercultural contact between two or more cultural groups and their individual members within a society (Berry, 1997; Redfield, Linton, & Herskovits, 1936). Although some groups of people, and in fact some societies, face the challenges of acculturation more than others, it is undeniable that acculturation is a phenomenon that influences the lives of all people. Therefore, the changes arising from intercultural contact are not confined to people who relocate across cultures (e.g., sojourners, immigrants, refugees). Acculturation affects indigenous peoples who have been subject to involuntary colonization and established ethnocultural communities in multicultural societies, as well as majority groups in societies that are culturally diverse (Berry & Sam, 1997). In this chapter we will consider issues confronted by acculturating people and the implications of these issues for counseling professionals. Conceptualizations of Acculturation The term acculturation has been used to refer to both changes at the group level and changes in the psychology of the individual (Berry, 1997). At the group level, changes may occur in the social structure of the group or in the group’s economic and value base. At the individual level, changes take place in identity, values, and behavior (Sam, 2006). Acculturation itself is a neutral process, which effectively means that the changes arising from intercultural contact may be positive or negative depending on how the process is experienced by the individual or group. Contact with other cultures may result in an individual developing a range of cultural skills, better relationships with members of other ethnocultural groups, and a stronger sense of “world-mindedness.” On the other hand, intercultural contact can result in “culture shock,” intergroup anxiety, and identity conflict (Ward, Bochner, & Furnham, 2001). Historically, acculturation has been conceptualized on a bipolar continuum in which adherence to one’s culture of origin (ethnic culture) and adherence to the culture of the receiving society (host national culture) are mutually exclusive (Gordon, 1964, cited in Ryder, Alden, & Paulhus, 2000). Thus, as one adopts elements of the host national culture, adherence to one’s ethnic culture decreases and vice versa (LaFromboise, Coleman, & Gerton, 1993). In contemporary research, this conceptualization has been replaced with bidimensional models of acculturation in which maintenance of one’s culture of origin occurs concurrently with adoption of and participation in the host national culture (Berry, 1980). The difference between these approaches is that unidimensional models are based on the notion that cultural adaptation to the mainstream goes hand in hand with a loss of attachment to one’s own ethnic and cultural ties (culture shedding), whereas bidimensional models do not make this assumption. In fact, recent research has established that the relationship between cultural orientations is contingent on the context, meaning that in some situations ethnic and host national cultural orientations are negatively related, in others they are positively related, and in still others the two orientations are unrelated (Phinney, Berry, Vedder, & Liebkind, 2006; Ward & Kus, 2012). The most widely utilized bidimensional model of acculturation was developed by Berry (1980, 1997, 2005). This model posits that there are two major choices individuals make: whether to have contact with others outside their group, and whether to maintain traditional culture. These choices position individuals in one of four acculturation categories. When individuals place little value on maintaining their cultural heritage and choose to interact with and take on parts of the majority culture, they are seen to adopt a strategy of assimilation. In contrast, individuals who place a high value on retaining their ethnic culture while avoiding interaction with other cultures endorse a separation strategy. Individuals who retain their ethnic culture as well as interact with and adopt elements of the majority culture are seen to be engaged in integration. Lastly, when individuals neither maintain their ethnic culture nor participate in or adopt elements of the wider society, marginalization occurs. Although not without their critics (e.g., Rudmin, 2003), Berry and colleagues have produced persuasive evidence that integration is consistently the most favored acculturation response across sojourners, immigrants, refugees, and native peoples. Not only is integration preferred by acculturating groups, but also those who pursue an integration strategy are widely found to achieve better outcomes than those who acculturate in other ways (Sam, 2006). Integration is related to better psychological adaptation, more favorable intergroup attitudes, and less acculturative stress (Berry, 1997; A.-M. D. Nguyen & Benet-Martínez, 2013; Sam, 2000; Sam & Berry, 1995; Virta, Sam, & Westin, 2004). Beyond the four acculturation strategies, acculturating groups can be distinguished on three dimensions: mobility, permanence, and voluntariness (Berry, 2005). People who have made crosscultural relocations, such as refugees, asylum seekers, immigrants, and sojourners, are distinguished from members of sedentary groups, such as native peoples and established ethnocultural communities. Cross-cultural travelers who resettle temporarily, such as sojourners, differ from those, like immigrants and refugees, whose moves are more permanent (Van Oudenhoven & Ward, 2013). Finally, those who voluntarily engage in intercultural contact (e.g., immigrants, sojourners, and ethnocultural groups) are distinguished from those who are forced into involuntary interactions (e.g., refugees, asylum seekers, and indigenous peoples). Marked differences are evident across these three dimensions: Persons in groups that are involuntarily subjected to culture contact and change tend to suffer more mental health problems than voluntary migrants (Berry, Kim, Minde, & Mok, 1987). Identity issues, changing sense of self, and shifting values appear to be less troublesome issues for short-term, compared to long-term, migrants (Ward & Kennedy, 1993). Groups who relocate across cultures are likely to experience more acute stress than sedentary populations, although both are likely to confront chronic stressors (Zheng & Berry, 1991). By recognizing individual-level acculturation strategies and group-level characteristics relating to acculturation, we can understand how change occurs for individuals experiencing acculturation, but it is also important to consider what changes for individuals and groups as a result of negotiating new cultural environments (Sam, Vedder, Ward, & Horenczyk, 2006). The psychological and behavioral changes that take place in an individual or group in response to environmental demands are referred to as adaptation outcomes (Berry, 1997). It must be noted that changes following acculturation may or may not be positive, and therefore may enhance or diminish individuals’ capacity to “fit” into their environments. Berry (1997) suggests that in the short term, changes tend to be negative and often disruptive, whereas in the long term some positive adaptation usually occurs. The adaptiveness of long-term acculturative change can be gauged in two conceptually related but empirically distinct domains: psychological and sociocultural (Sam et al., 2006; Searle & Ward, 1990; Ward, 2001). Psychological adaptation consists of a person’s psychoemotional or affective responses to acculturation, such as sense of well-being, absence of depression, and life satisfaction within a new cultural situation. Sociocultural adaptation outcomes, by contrast, involve behavioral responses to acculturation, or the person’s skills for navigating and engaging successfully in novel cross-cultural encounters (Ward & Kennedy, 1993). The constructs of psychological and sociocultural adaptation are not only situated in two distinct theoretical domains, but they are also largely predicted by different variables and exhibit different patterns of change over time (Ward, 2001). While in the preceding section we have dealt broadly with the theories of acculturation, our major objective in this chapter is to offer a conceptual framework for understanding the acculturation experience as applied to the context of counseling and related therapeutic interventions. In the rest of the chapter, therefore, we will describe the ecology of acculturation as linked to contextual-, relational-, and individual-level factors. We will also offer guiding questions for counselors to target the appropriate ecological level when working with acculturating clients. The Ecology of Acculturation: Implications for Counseling The majority of acculturation research has focused on the process of change that occurs at the individual level, particularly centering on how acculturative strategies are developed through choices concerning culture maintenance and participation in the wider society. Focusing on the individual assumes that acculturative changes occur in ways that are mainly dependent on intrapersonal processes, which does not take into account the complex relationships that may exist among individuals and groups undergoing acculturation. Traditionally, applying acculturation theory to counseling practice has been particularly difficult because of inconsistencies in definitions and lack of understanding of the contextual, multilevel nature of intercultural contact (Kohatsu, Concepcion, & Perez, 2010). In order to assess acculturation adequately, especially within a counseling setting, mental health professionals need to consider various interdependent issues. Below, we outline three levels of acculturation that counselors can use to understand the various issues they may confront: the contextual level, the relational level, and the individual level. The theoretical underpinnings of these three levels of acculturation are informed by Bronfenbrenner’s (1994) ecological theory of development. Ecological theory is based on the concept that life-course development takes place across a variety of contexts in which the individual is in constant interaction with other individuals and groups. Behavior occurs within a set of overlapping ecological systems (e.g., the family, peer group, workplace, community, and broad social setting) that all operate together, creating a comprehensive set of influences on the individual. The contextual level of acculturation concerns where and under what conditions acculturation is taking place: the physical, geographical, or ideological setting (i.e., the influence of societal values and institutions; see Bronfenbrenner, 1994). The relational level concerns who is involved in the acculturation process and places emphasis on the interpersonal aspects of acculturation (i.e., the influence of family members, friends, school peers, workplace colleagues, and members of the neighborhood). The individual level concerns what characteristics of the individual affect the management of cultural transitions and how these characteristics interact with influences from the broader ecological environment. Figure 18.1 illustrates the proposed ecological model of acculturation. It must be noted that settings characterized by specific types of interpersonal relationships cross over the levels of acculturation, as they represent both contextual and relational aspects of acculturation. Figure 18.1 The Ecological Model of Acculturation The following subsections offer descriptions of the distinct elements of acculturation at each level, and counselors can use the model itself as a way to elicit information about interactions among the domains of acculturation. Tables 18.1, 18.2, and 18.3 provide summaries of relevant questions at the respective levels for counselors to consider when they are interacting with clients who present with acculturation-based issues. These questions may form the basis for therapeutic interventions, and counselors may use the tables as checklists to consult when interacting with clients undergoing acculturation. The Contextual Level Contextual factors are those that make up the broad social setting in which acculturation processes are embedded. These factors set the scene, define the “operating parameters,” and guide acculturative changes (for a review of contexts of acculturation, see Berry, 2006). Contextual factors can increase or diminish the likelihood that acculturating individuals will adapt well, acquire the necessary skills to negotiate multiple cultural demands and expectations, and enjoy well-being. The Multicultural Context Some of the most important and broad-based contextual factors relate to cultural diversity and the multicultural nature of the wider society: the extent to which the country, region, or neighborhood is culturally diverse in terms of population demographics; how cultural diversity is managed in terms of policies and practices; and how culturally diverse groups perceive and relate to each other (Berry & Sam, in press). Cultural diversity per se affords both risks and benefits. Under the right circumstances, enhanced creativity and innovation are more likely to arise in culturally diverse settings (Legrain, 2007). On the other hand, diverse environments can generate intergroup hostility and precipitate negative psychological and social consequences, including decrements in subjective well-being (Vedder, van de Vijver, & Liebkind, 2006). These are important considerations in North America, as there is evidence to suggest that both Canada and the United States are highly diverse, generally more so than European Union countries (Berry et al., 2006). Overall, the management of cultural diversity in terms of the presence or absence of policies that support multiculturalism is more important than diversity per se. For example, immigrant youth who reside in countries with policies favoring diversity are more likely to endorse integration, experience better school adjustment, and display fewer behavioral problems than their counterparts in other countries (Vedder et al., 2006). This is not surprising, as policies supporting multiculturalism encourage the maintenance of traditional ethnic cultures along with fair and equitable participation in the wider society. The United States lags behind Canada and many European countries, as well as Australia and New Zealand, in terms of multicultural policies (Multicultural Policy Index, 2010). While governments, institutions, and organizations can enact policies and prohibit blatant discrimination, they cannot regulate attitudes and perceptions, which form the basis of “everyday multiculturalism.” Is diversity ignored, rejected, tolerated, accepted, or celebrated? Are there generally positive or negative attitudes toward immigrants and ethnic minorities? Is subtle discrimination against visibly different individuals and groups common or rare? And how does this everyday multiculturalism—that is, how members of different cultural groups perceive and interact with each other—affect acculturation and adaptation? Many people hold the view that it is the responsibility of the immigrant, indigenous person, or ethnic minority member to “fit in” and adapt to the norms, values, and practices of the wider society. However, this view ignores wider contextual factors, in particular, how culturally “different” individuals are viewed and received by members of the wider society. Societal attitudes toward diversity and multiculturalism have marked influences on the acculturation experiences of individuals and groups, and negative sentiments are associated with psychological and social adaptation problems in minority youth (Ward & Stuart, 2012). National-level attitudes can constrain or increase acculturation options for ethnic minorities, particularly with regard to possibilities for maintaining heritage cultures. Such attitudes also interact with individual-level aspirations to affect acculturation outcomes. More specifically, if members of minority groups prefer to integrate—that is, maintain their heritage cultures and also participate in the wider society—but members of the majority group prefer assimilation, problematic consequences are likely, including strained intercultural relations, greater perceived discrimination, and higher levels of stress (Bourhis, Moïse, Perreault, & Senécal, 1997; Zagefka & Brown, 2002). In addition, when integration is preferred, perceived pressures to assimilate have negative impacts on immigrants’ life satisfaction (Ward, 2009). How members of a multicultural society perceive their environment—whether it is tolerant and accepting or rife with hostility and prejudice—is also important and has implications for psychological well-being and social functioning. Subjective multiculturalism has been shown to predict a range of positive outcomes in minority youth. It is associated with increased resilience, lower levels of stress, greater life satisfaction, fewer psychological symptoms, and fewer behavioral problems (Stuart, Ward, & Robinson, 2012). Similarly, within school contexts, perceived multiculturalism is linked to better academic performance and intentions to remain in school (Tan, 1999). Overall, a multicultural environment can diminish stress and enhance resilience in immigrants and other ethnic minorities. Public and Private Domains Acculturating individuals are called upon regularly to negotiate competing pressures between their traditional ethnic cultures and the mainstream society. However, the ways individuals manage these pressures tend to vary between public and private domains. In multicultural settings where cultural diversity is supported by policy and practices, the demands for cultural maintenance and participation are largely compatible. In assimilationist contexts individuals are generally required to adapt to and display behaviors in accordance with mainstream expectations. Within ethnic communities the norms, values, and behaviors associated with traditional culture are likely to prevail, as is the case in private settings, particularly within the family (Arends-Toth & van de Vijver, 2003). As different contexts demand different behavioral repertoires, what is adaptive in one setting may engender problems in another. Maintaining heritage culture may have a positive adaptive function in marriage and family domains, but adopting elements of the mainstream culture is likely to be more functional in public spheres such as school and work settings (Güngör, 2007). Fortunately, many immigrant and minority individuals are able to move between cultural contexts comfortably (Stuart & Ward, 2011). Others, however, have difficulty reconciling what they perceive to be incompatible demands and experience symptoms of distress (Ward, Stuart, & Kus, 2011). Family and peers play a significant role in encouraging or impeding the cultural frame switching associated with fluid movement between public and private domains; we discuss this role in the following section. The Relational Level At the most basic level acculturation involves exposure to others from different cultural groups, effectively meaning that acculturation cannot occur in social isolation. Acculturation takes place across a variety of social interaction contexts, including family, community, peer group, workplace, and educational settings. Similar to contextual factors, relational factors can increase or diminish the likelihood that acculturating individuals will adapt well. It is well established that the approach of any individual to acculturation is shaped by that person’s relationships before, during, and following cultural transition. Relational factors can provide the most important sources of support for acculturating individuals, but they can also foster interpersonal conflict and contribute to maladaptation. Social Support The direct positive effect of social support networks on the well-being of acculturating peoples is widely recognized (Jasinskaja-Lahti, 2006). Social support may come from a variety of sources (including family, friends, and acquaintances) and is found to be one of the most important resources in coping with acculturative stress. The presence of social support predicts both psychological adjustment and physical health and has a direct positive effect on sociocultural adaptation, whereas the absence of social support has been found to exacerbate the negative effects of perceived discrimination (Jasinskaja-Lahti, 2006; Noh & Kaspar, 2003; Ong & Ward, 2005). One of the biggest challenges faced by an acculturating person is a loss or lack of social support. Research with international students has found that moving to a different country means previously established support systems become inaccessible, making individuals feel less confident, increasingly anxious, and confused (Hayes & Lin, 1994). The combined effects of acculturative stressors (the experience of relocation, challenges of sociocultural adaptation, and dealing with a potentially prejudicial host environment) coupled with a lack of resources to manage the transition to the host society may render individuals susceptible to maladjustment (Berry, 2005; Poyrazli & Kavanaugh, 2004). For individuals undergoing acculturation, the establishment of interpersonal support networks can be challenging, and the ethnic composition of these networks may not be optimal for the difficulties they face (Finch & Vega, 2003). Co-national networks, such as the family and the ethnic community, have been found to provide social support that acts to enhance psychological adaptation (Finch & Vega, 2003; Martínez García, García Ramírez, & Maya Jariego, 2002; Noh & Kaspar, 2003). However, research indicates that when individuals have access only to co-nationals in their support networks, this can increase feelings of alienation, isolation, and discrimination (Ward & Kennedy, 1993). With regard to support networks that include host nationals, it is well recognized that contact with host nationals facilitates culture-specific learning, which is integral for cross-cultural adaptation (Wilson, Ward, & Fischer, 2013). Having host national friends and more frequent social contact with members of the wider society is associated with increased well-being and better general adaptation in sojourners and immigrants (Berry et al., 1987). Such networks are also an important factor in reducing cultural stress and encouraging the academic achievement of international students (Hayes & Lin, 1994; Poyrazli & Kavanaugh, 2004). However, the presence of host nationals in the support networks of immigrants and sojourners is often limited, especially if the society of settlement is not receptive to cultural diversity. Overall, research has shown that acculturating individuals are capable of drawing on sources of social support from both co-nationals and host nationals, but these sources offer differential benefits and drawbacks. Specifically, it has been found that host national support networks often provide more instrumental support, whereas ethnic social networks are responsible for more emotional assistance (Bochner, McLeod, & Lin, 1977; Johnson, Kristof-Brown, van Vianen, de Pater, & Klein, 2003). For acculturating individuals, relying primarily on co-national support may be easier in the short term but may lead to more long-term difficulties with regard to culture learning and sociocultural adaptation. Alternatively, social support from members of the host culture may be initially more difficult to access but may have advantages in terms of facilitating long-term adaptation in the new culture. The Family To understand an individual’s acculturation, it is important to consider the complex mutual and reciprocal relationships that person shares with intimate others (Georgas, Berry, van de Vijver, Kağitçibaşi, & Poortinga, 2006). The family plays a particularly important role in acculturation, fostering well-being, bolstering resilience, maintaining cultural values, and providing a context in which individuals can share and solve acculturative issues (Oppedal, 2006; Phinney & Ong, 2007). However, the acculturating family is confronted with many difficulties that challenge its functioning and the patterns of interaction among its individual members. These challenges include pressure on traditional roles (both gender roles and familial parent–child roles) and status changes associated with adapting to the new culture (Chung, 2001; Phinney, Kim-Jo, Osorio, & Vilhjalmsdottir, 2005), as well as issues of intergenerational conflict and threats to cultural transmission (Weaver & Kim, 2008). Consequently, acculturation, particularly when characterized by large differences in language, values, beliefs, and traditions between the culture of the family and the culture of the wider society, often requires fundamental changes in the functioning of the family unit. For acculturating individuals, the family is usually embedded in a culture that is different from the culture of the wider society, which effectively means that things may be valued within the wider society that are not valued in the family, and vice versa (Arends-Toth & van de Vijver, 2006). NonEuropean immigrant families in Western societies often hold collectivistic orientations and, as such, emphasize interdependence, obedience, and conformity. These values mean that all family members tend to feel a sense of duty to assist one another and take into account the needs and wishes of the family when making decisions (Fuligni, Tseng, & Lam, 1999). It has been found that family obligations are associated with both positive and negative outcomes for acculturating youth (Stuart et al., 2012). Specifically, strong obligations to assist the family have been associated with greater adaptation, interdependence, and resilience; however, when family obligations are very high, mismatched between family members, or viewed by the young person as unmanageable, they may be related to greater stress and poorer adaptation (Fuligni, 1998; Fuligni, Yip, & Tseng, 2002). (For more information on families in specific ethnic groups, see Chapter 21 in this volume.) Another important point to note is that experiences of acculturation are different for each member of the family; individuals differ in their personal adjustment to the new culture and their exposure to different sociocultural settings (such as work and school). A number of studies have found that this can lead to the endorsement of different acculturation strategies within the family (Kwak, 2003; Rothbaum, Pott, Azuma, Miyake, & Weisz, 2000). Farver, Narang, and Bhadha (2002) found that when family members share a preference for integration, there is less family conflict and adolescents have stronger ethnic identities and better adaptation than in families where parents and adolescents differ in their acculturation styles. However, it is a common theme within the acculturation literature that parents tend to endorse cultural maintenance more than do their children, whereas children value more contact and participation with the new culture (Costigan & Dokis, 2006; Fuligni et al., 1999). Often parents and children disagree on acculturation strategies because parents cannot rely on the new society to assist in the transmission of cultural values to their children (Kwak, 2003), leading to a greater adherence to traditional cultural values (Chung, 2001). In contrast, immigrant adolescents, as part of the process of maturation, tend to accept new cultural values and practices more easily than do their parents (Kwak, 2003; Rothbaum et al., 2000), a phenomenon Portes (1997) labels “dissonant acculturation.” The resultant inconsistency across family members can prove problematic for cultural maintenance and exacerbate experiences of conflict (Phinney, Ong, & Madden, 2000). It is well established that discrepancies between parents and their children concerning acculturation often elevate levels of conflict within the family and threaten the well-being and capacity for adjustment of family members (Kwak, 2003; Phinney et al., 2000, 2005). While families may face a variety of challenges in the acculturation process, it has also been found that family relationships can alleviate the stressful aspects of cultural contact and change. Family relationships can be strengthened as a result of acculturation, and they may provide a buffer to the negative impacts of stress by offering a platform to encourage the collective development of acculturative problems, promoting resilience and greater flexibility in coping with cultural transition (Arends-Toth & van de Vijver, 2006; Kağitçibaşi, 2007; Lin, 2008). In our own recent research, we have found that the impact of the family on the acculturating individual may in fact be a double-edged sword: The family can both promote positive outcomes and increase the negative impacts of the acculturation process (Stuart & Ward, 2011; Stuart, Ward, Jose, & Narayanan, 2010; Stuart et al., 2012). Specifically, elements of family interaction (particularly cohesion) can have a range of positive effects on adjustment outcomes (Stuart et al., 2012). However, family factors that are more closely aligned to the transmission of cultural values such as obligations and intergenerational conflict resulting from acculturation can have negative effects on adjustment (Stuart & Ward, 2011). In general, migrating families bring a range of strengths to the acculturation process, specifically in regard to the supportive function of the family unit. However, the acculturation process creates a variety of novel and sometimes problematic situations for the family unit (Ward, Fox, Wilson, Stuart, & Kus, 2010). Counselors should bear in mind how acculturation outcomes are influenced not only by the experiences of the individual but also by the experiences of all members of the family. The Individual Level Individual-level factors are the characteristics of the person undergoing acculturation. Whereas the contextual domain defines the operating parameters of acculturation and the relational domain illustrates the interpersonal parameters, the individual domain focuses on the specific experiences and personal attributes that guide each individual’s approach to acculturation. Below we briefly discuss three aspects of the individual domain: personal background, personality, and identity. Although a range of other individual-level factors are relevant for counselors to explore with crosscultural clients (e.g., physical and mental health status, trauma, employment status, education level, previous cultural experience), these are outside the scope of this chapter. Personal Background The age, gender, and generation of migration of the acculturating individual are factors well known to affect acculturation outcomes, although findings are mixed with respect to the influences of these factors on adjustment. With respect to gender there are conflicting research findings. Some studies indicate that adjustment outcomes do not differ for men and women (Neto, 1995; Nwadiora & McAdoo, 1996), whereas others have found that females tend to have a greater risk of psychological symptoms and poorer sociocultural outcomes than males (Berry et al., 1987; Poyrazli & Kavanaugh, 2004; Zlobina, Basabe, Paez, & Furnham, 2006) and that men and boys are more likely than women and girls to have behavioral and delinquency problems (Bui & Thongniramol, 2005; Sam et al., 2006). These trends are affected by assessments of psychological and sociocultural adaptation and reflect established gender differences in psychopathology (Sam et al., 2006; Ward et al., 2001). For example, research with immigrant youth has found that boys are more likely to report antisocial behaviors and engage in risky behaviors, while girls are more likely to display depressive symptoms and experience greater difficulty negotiating different cultural values. Differences in sociocultural adjustment between men and women may also be a consequence of changes in the traditional roles and status of women as part of the acculturation process. It is often the case that immigrant and refugee women have fewer opportunities than their male counterparts to learn about the culture of the wider society due to expectations that women are responsible for maintaining the home (Ataca & Berry, 2002). Also, because immigrant girls are often understood to be the gatekeepers of their heritage cultures’ traditions and values, they tend to be subjected to higher expectations for cultural maintenance, time spent with family, and engagement in traditional female household tasks (Dasgupta, 1998). This can potentially result in conflicting role expectations and lead to greater acculturative stress as young women attempt to develop autonomy while at the same time maintaining their family obligations (Dinh & Nguyen, 2006; Yeh, 2003). With respect to age differences, Beiser et al. (1988) have suggested that adolescence and old age are high-risk periods. In the first instance, the stress of migration may be intertwined with the stress of adolescent development; in the latter, it may be that older people have fewer psychological resources for coping with change. Although both adolescence and old age are seen as life stages during which acculturation may lead to maladjustment, young people may face more complex issues of adjustment than their adult counterparts (Oppedal, 2006; Sam et al., 2006; Smetana, Campione-Barr, & Metzger, 2006) because the physical, cognitive, and socioemotional changes that adolescents undergo as they transition into adulthood influence the manner in which they manage cultural change (Oppedal, 2006; Sam & Oppedal, 2003). Adolescence can, therefore, be seen as a period in which the issues raised by immigration, specifically those concerning identity, are particularly salient (Sam et al., 2006). Another important point to note is that acculturative outcomes for immigrants may differ across generations (Zlobina et al., 2006). Studies have found that first-generation immigrants experience greater stress than later-generation individuals, with each succeeding generation experiencing less stress (Mena, Padilla, & Maldonado, 1987). In contrast to these findings, it has been found that recently arrived immigrants experience less discrimination and have better adjustment outcomes than those who have resided in the host country for a longer time (Jasinskaja-Lahti & Liebkind, 2001). The phenomenon in which first-generation immigrants perform as well as, if not better than, host nationals on some measures has been labeled the immigrant paradox (H. H. Nguyen, 2006; Sam, Vedder, & Liebkind, 2008). Recent research has found that children from immigrant families generally adapt very well, and that first-generation immigrant youth exhibit better health and less involvement in negative behaviors than host national youth (Fuligni, 1998). Furthermore, results from the International Comparative Study of Ethno-cultural Youth indicate that second-generation immigrants and those in subsequent generations become proficient at understanding the social environment, but their psychological well-being is not necessarily on par with that of first-generation immigrants or host nationals (Sam et al., 2006). The influences of education, occupational status, and income are also important, and higher socioeconomic status has been found to buffer acculturative stress. In contrast, cultural distance (the degree to which one’s ethnic culture is dissimilar to the culture of the wider society) has a debilitating effect on the psychological well-being of acculturating persons (Ward et al., 2001). Related to cultural distance, host national language proficiency has important implications for individuals undergoing acculturation, and in many cases limited language proficiency constrains individuals’ choices among acculturation strategies (Poyrazli & Kavanaugh, 2004). Personality Personality traits and individual differences can function as resources or deficits in managing the stress of cross-cultural transition and intercultural interactions. For the most part, personality factors that contribute to positive adaptive outcomes during acculturation mirror those that are adaptive in stress and coping processes. There is strong evidence that an internal locus of control is associated with greater life satisfaction, more positive well-being, and lower levels of depression in immigrants, expatriates, and international students (Martínez García et al., 2002; Neto, 1995; Ong & Ward, 2005). Hardiness, personal and social self-efficacy, decisiveness, social initiative, flexibility, cultural empathy, and a sense of coherence also foster resilience and positive psychological outcomes (Ataca & Berry, 2002; Jibeen & Khalid, 2010; Leong, 2007; Van Oudenhoven, Mol, & Van der Zee, 2003; Van Oudenhoven & Van der Zee, 2002), while extroversion, agreeableness, conscientiousness, and openness are linked to better social adaptation (Wilson et al., 2013). In contrast, neuroticism predicts higher levels of acculturative stress (Mangold, Veraza, Kinkler, & Kinney, 2007) and sociocultural adaptation problems (Wilson et al., 2013), lower levels of life satisfaction, and more depressive symptoms (Ward, Leong, & Low, 2004; Zhang, Mandl, & Wang, 2010). While personality factors can bolster or diminish resilience and the capacity to cope with acculturative pressures, they can also interact with contextual factors to influence adaptive outcomes. For example, emotional stability, flexibility, and open-mindedness are related to positive affective outcomes under high-stress conditions but not under low-stress conditions (Van der Zee, Van Oudenhoven, & De Grijs, 2004). There is also some support for the cultural fit proposition—that is, the idea that the adaptiveness of some personality factors is determined by the sociocultural context. For example, it is possible that one can be “too extroverted” in a more introverted cultural context and that highly extroverted individuals can experience greater symptoms of psychological distress under these conditions (Ward & Chang, 1997). Identity The challenges faced by sojourners, immigrants, refugees, indigenous peoples, and members of other ethnocultural groups heighten the salience of issues pertaining to identity. As such, the development and maintenance of both ethnic and national identities are central to the experience of acculturating individuals. Ethnic identity is a complex construct that involves recognition and categorization of the self as a member of an ethnic group as well as a sense of group belonging and commitment (Ward, 2001). It is widely recognized that a strong ethnic identity leads to positive adaptation outcomes and can play a crucial role in increasing resilience (Phinney, 1990; Phinney, Horenczyk, Liebkind, & Vedder, 2001). Compared to ethnic identity, far less attention has been paid to conceptualizing and assessing identification with the wider society or national identity. Phinney and colleagues (2001) have argued that national identity also involves feelings of belonging and positive attitudes toward the larger society, although there is evidence that ethnic minorities are less likely than members of the majority group to access national identities successfully and legitimately (Devos & Heng, 2009). Ethnic and national identities can be related (both positively and negatively) or unrelated depending on individual and contextual factors (Phinney, 1990; Phinney et al., 2006). These two identities affect adaptation both jointly and independently, and research has shown that an integrated identity (the combination of a strong ethnic and a strong national identity) is related to a range of positive psychological outcomes (Sam & Virta, 2001; Stuart & Ward, 2011). Phinney (1990) suggests that ethnic identity is likely to be strong when a significant desire to retain identification exists along with the encouragement and acceptance of integration. Also, when groups feel accepted by the wider society, their national identity is likely to strengthen (Phinney, 1990). Effectively, multicultural contexts foster strong ethnic identities while also cultivating positive evaluation of and belonging to the wider society (LaFromboise et al., 1993; Phinney et al., 2001). For individuals who are members of marginalized, socially disenfranchised, and devalued groups, identity issues are very complicated. Retaining heritage culture implies acceptance of a negative social identity. Some members of such groups respond by rejecting or denying their ethnocultural heritages. In other instances, revitalization of ethnic consciousness and pride offers a means by which identity can be negotiated. Many individuals and groups are successful in achieving this, as evidenced, for example, by the link between ethnic identity and self-esteem found in African Americans, Asian Americans, and Latino/a Americans (Phinney, 1992). However, those who are not successful in managing their identities may be at risk of identity conflict, an inner struggle that is perceived to demand that an individual choose between two or more different identities that prescribe incompatible behaviors or commitments (Baumeister, 1986). Within an acculturation framework, the inability of an individual to resolve contradictory components of his or her cultural identity (termed ethnocultural identity conflict) is negatively related to adaptation (Lin, 2008; Ward et al., 2011). Research on the predictors of ethnocultural identity conflict has found that strong national and ethnic identities are both associated with decrements in experiences of such conflict (Stuart & Ward, 2011). There is also evidence that perceived value discrepancies between parents and children lead to greater ethnocultural identity conflict in immigrant youth, whereas family cohesiveness, congruence, and a secure attachment style mitigate feelings of conflict (Lin, 2008; Stuart & Ward, 2011). However, one of the most powerful predictors of ethnocultural identity conflict is perceived discrimination (Leong & Ward, 2000; Lin, 2008). Acculturation and the Counselor So far in this chapter we have focused on the ecology of acculturation. We have drawn together common themes and aspects of the acculturation experience, provided a framework that counselors can use to understand and interpret acculturation-related problems and challenges, and suggested questions that counselors might consider in formulating therapeutic plans. But working effectively with culturally diverse clients demands more than an understanding of the psychology and ecology of acculturation. More broadly, counselors’ multicultural competencies, based on culturally appropriate knowledge, awareness, and skills, affect therapeutic outcomes. These competencies include knowledge and awareness of key issues: that entry into the counseling system is affected by cultural conceptions of mental health; that culture-sensitive empathy and rapport are important in establishing a working alliance; that culture-specific modes of counseling work better with clients from some cultural groups; and that aspects of cultural background and the acculturation experience can influence receptiveness to counseling (Sue & Sundberg, 1996). However, awareness and knowledge alone are not sufficient. Counselors also need multicultural skills to achieve positive outcomes in counseling across cultures. Tatar (1998) has identified four intercultural counseling strategies with varying degrees of effectiveness. Although these approaches were originally developed for use with immigrant students, they can be extended to work with other acculturating persons. The first and most widely used strategy, “counselor as culturally encapsulated assimilator,” is the least reflective of multicultural effectiveness. In this approach, counselors are trapped in the culturally dominant way of thinking that advocates rapid assimilation “in the students’ best interests.” Tatar comments that the assimilative approach supports a cultural deficiency model, building on the premise that the dominant culture is also the superior one. The second approach Tatar identifies, “counselor as self-facilitator,” emphasizes the individuality of each student, rather than seeing an immigrant as a member of a labeled group. Tatar describes this method as involving the counselor as an active influence, working with the individual and with relevant others in recognition and acceptance of the client as undergoing a developmental transition in a multicultural society. In the third approach, labeled “counselor as specialist,” the counselor uses his or her personal and professional expertise to devise innovative strategies for client needs. Although this often achieves positive outcomes, a challenge for counselors working with allied professionals is to avoid ethnic stereotyping of certain client groups. Finally, there is the “counselor as translator” approach, in which the counselor serves as a bridge between two cultures, not only assisting the migrant client to operate effectively in the new environment but also educating local persons about other cultures and what can be learned from them. The last of these strategies most clearly reflects an ecological approach, as it involves interventions targeted at individual, relational, and contextual levels. While the application of the ecological model of acculturation may be relatively new to some counseling professionals, it should resonate with the more familiar systems theory employed in counseling and social work practice. Systems theory has been used to understand and interpret clients’ experiences in context and from a holistic and integrative perspective. It recognizes that individual traits and characteristics unfold within social systems and that these systems are situated in a larger environmental and sociopolitical context (Kaplan, 1995; Patton & McMahon, 2006). One of the most significant outcomes of systems theory, as with Tatar’s (1998) counselor translators, is the tendency to target interventions at levels of the system beyond the individual. We suggest that therapeutic effectiveness is enhanced by these multilevel interventions. Not only are they more holistic and ecologically valid, but they are also more meaningful to many immigrant and minority group members. For example, the high value placed on affiliation, interdependence, and family ties by Asian and Latino/a Americans suggests that the relational-level aspects of the acculturation experience assume greater importance (Fuligni et al., 1999). Relatedness is a core value in collectivist cultures and plays a key role in shaping interpersonal and intergroup behaviors (Triandis, 1989). Moreover, collectivist ideals often conflict with the individualist values enshrined in the United States and Canada, including the implicit values held by “mainstream” counselors. Ultimately, understanding this “big picture” is required for therapeutic success as contextual factors interact with individual and relational factors to constrain or enhance clients’ psychological and social well-being. Employing therapeutic interventions across levels can be difficult and in some instances beyond the range of a counselor’s capacity and expertise. Addressing the issue and outcomes of discrimination is a case in point. Surveys have found that 20% of Muslim Americans consider prejudice and discrimination against Muslims to be major problems (Pew Research Center, 2011). Three-quarters of Mexican immigrants and 57% of other immigrants in the United States say there is at least “some” discrimination against immigrants (Bittle, Rochkind, Ott, & Gasbarra, 2009). In Canada, 36% of visible minorities report that they have experienced discrimination on the basis of race or culture in the past 5 years (Reitz & Banerjee, 2007). We know that perceived discrimination is related to a variety of negative outcomes, including increased stress, lowered self- and group esteem, impaired health, antisocial behaviors such as drug use and delinquency, identity conflict, and poorer work adjustment and job satisfaction (Ward et al., 2001). Counseling efforts can be channeled to provide support to acculturating people, to increase their resilience, and to assist them in dealing with the stress of discrimination, but ecological interventions are also required. Further, strategies are needed to improve intercultural relations in schools, neighborhoods, and workplaces, and programs should be developed to counter negative societal attitudes toward visible minorities. Conclusion In this chapter we have identified generic themes and issues for acculturating persons and provided an ecological framework for interpreting and understanding their experiences. We have also recommended multilevel interventions for working with indigenous peoples, sojourners, immigrants, refugees, and ethnocultural groups. We challenge counselors to consider cross-cultural contact and change from a broad perspective and to acknowledge the sociopolitical, community, institutional, and relational influences on both client well-being and the wider outcomes of the counseling process. Fostering the notion that immigrants and refugees are active coping agents in a continuous process of life improvement, Ehrensaft and Tousignant (2006) note: Resilience does not develop in a social or cultural vacuum. The immigrant is part of a family, which is in turn part of a community, which also interacts with a host society. All of these levels contribute to the success or failure of the process of resilience. (p. 481) Mental health professionals should bear this in mind when counseling across cultures. Critical Incident Imagine that you are a school counselor in an urban center. A concerned teacher at your school has referred a 17-year-old female student to you because her behavior has become withdrawn and her grades have been consistently dropping over the past few months. The referring teacher, who leads the school orchestra, had noticed that the student, a secondgeneration immigrant from a Middle Eastern background, did not attend orchestra practice for 3 consecutive weeks and asked the other students if anyone knew the reason for her absence. In private, one of her friends disclosed that the young woman has been having family problems because her parents found out that some of her classmates were dating boys from another school and that as a group they had all been spending time together. Although the girl herself is not in a relationship, after finding out that she was unsupervised in the company of young men, her parents have stopped allowing her to go to extracurricular activities and outings with her friends. They also now drop her off at school and pick her up every day, and they will not let her answer phone calls from her friends. This situation is obviously negatively affecting the student’s well-being as well as her school performance. Discussion Questions 1. How might you facilitate an initial counseling session with this young woman? 2. How does this young woman’s situation illustrate tensions in the acculturation process? 3. In the contextual domain, what elements of the broader social setting and the specific school setting do you think are influencing the situation? 4. In the relational domain, how would you identify who should be part of the counseling process? Should friends, family members, or others be involved? Who should make the decisions regarding whom to include or exclude, and how will these choices affect the sessions? 5. In the individual domain, what identities, personality attributes, and personal characteristics are pertinent to the situation? 6. How does this situation illustrate the interactions among domains within the ecology of acculturation? 7. How would you design an intervention for this young woman that takes into account the influences from all ecological domains? References Arends-Toth, J., & van de Vijver, F. J. R. (2003). Multiculturalism and acculturation: Views of Dutch and Turkish-Dutch. European Journal of Social Psychology, 33(2), 249–266. doi:10.1002/ejsp.143 Arends-Toth, J., & van de Vijver, F. J. R. (2006). Assessment of psychological acculturation. In D. L. Sam & J. W. Berry (Eds.), The Cambridge handbook of acculturation psychology (pp. 142–162). Cambridge: Cambridge University Press. Ataca, B., & Berry, J. W. (2002). Psychological, sociocultural, and marital adaptation of Turkish immigrant couples in Canada. International Journal of Psychology, 37(1), 13–26. doi:10.1080/0020759014300013 Baumeister, R. F. (1986). Identity: Cultural change and the struggle for self. New York: Oxford University Press. Beiser, M., Barwick, C., Berry, J. W., da Costa, G., Fantino, A., Ganesan, S.,... Vela, E. (1988). Mental health issues affecting immigrants and refugees. Ottawa: Health and Welfare Canada. Berry, J. W. (1980). Acculturation as varieties of adaptation. In A. Padilla (Ed.), Acculturation: Theory, models, and some new findings (pp. 9–25). Boulder, CO: Westview Press. Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology, 46(1), 5–34. doi:10.1080/026999497378467 Berry, J. W. (2005). Acculturation: Living successfully in two cultures. International Journal of Intercultural Relations, 29(6), 697–712. doi:10.1016/j.ijintrel.2005.07.013 Berry, J. W. (2006). Contexts of acculturation. In D. L. Sam & J. W. Berry (Eds.), The Cambridge handbook of acculturation psychology (pp. 27–42). Cambridge: Cambridge University Press. doi:10.1017/CBO9780511489891.006 Berry, J. W., Kim, U., Minde, T., & Mok, D. (1987). Comparative studies of acculturative stress. International Migration Review, 21, 491–511. Berry, J. W., & Sam, D. L. (1997). Acculturation and adaptation. In J. W. Berry, M. H. Segall, & Ç. Kağitçibaşi (Eds.), Handbook of cross-cultural psychology: Vol. 3. Social behavior and applications (pp. 291–326). Boston: Allyn & Bacon. Berry, J. W., & Sam, D. L. (in press.). Multicultural societies. In V. Benet-Martínez & Y.-Y. Hong (Eds.), Handbook of multicultural identity: Basic and applied perspectives. New York: Oxford University Press. Berry, J. W., Westin, C., Virta, E., Vedder, P., Rooney, R., & Sang, D. (2006). Design of the study: Selecting societies of settlement and immigration groups. In J. W. Berry, J. S. Phinney, D. L. Sam, & P. Vedder (Eds.), Immigrant youth in cultural transition: Acculturation, identity, and adaptation across national contexts (pp. 15–46). Mahwah, NJ: Lawrence Erlbaum. Bittle, S., Rochkind, J., Ott, A., & Gasbarra, P. (2009). A place to call home: What immigrants say now about life in America. New York: Public Agenda. Bochner, S., McLeod, B. M., & Lin, A. (1977). Friendship patterns of overseas students: A functional model. International Journal of Psychology, 12(4), 277–294. doi:10.1080/00207597708247396 Bourhis, R. Y., Moïse, L. C., Perreault, S., & Senécal, S. (1997). Towards an interactive acculturation model: A social psychological approach. International Journal of Psychology, 32, 369–386. Bronfenbrenner, U. (1994). Ecological models of human development. In M. Gauvain & M. Cole (Eds.), Readings on the development of children (2nd ed., pp. 37–43). Oxford: Elsevier. Bui, H. N., & Thongniramol, O. (2005). Immigration and self-reported delinquency: The interplay of immigration generations, gender, race, and ethnicity. Journal of Crime and Justice, 28(2), 71–99. doi:10.1080/0735648X.2005.9721639 Chung, R. H. (2001). Gender, ethnicity, and acculturation in intergenerational conflict of Asian American college students. Cultural Diversity & Ethnic Minority Psychology, 7(4), 376–386. Costigan, C. L., & Dokis, D. P. (2006). Similarities and differences in acculturation among mothers, fathers, and children in immigrant Chinese families. Journal of Cross-Cultural Psychology, 37(6), 723–741. doi:10.1177/0022022106292080 Dasgupta, D. S. (1998). Gender roles and cultural continuity in the Asian Indian immigrant community in the U.S. Sex Roles, 38(11/12), 953–974. Devos, T., & Heng, L. (2009). Whites are granted the American identity more swiftly than Asians. Social Psychology, 40(4), 192–201. Dinh, K. T., & Nguyen, H. H. (2006). The effects of acculturative variables on Asian American parent–child relationships. Journal of Social and Personal Relationships, 23(3), 407–426. doi:10.1177/0265407506064207 Ehrensaft, E., & Tousignant, M. (2006). Immigration and resilience. In D. L. Sam & J. W. Berry (Eds.), The Cambridge handbook of acculturation psychology (pp. 469–483). Cambridge: Cambridge University Press. Farver, J. M., Narang, S. K., & Bhadha, B. R. (2002). East meets West: Ethnic identity, acculturation, and conflict in Asian Indian families. Journal of Family Psychology, 16(3), 338–350. Finch, B. K., & Vega, W. A. (2003). Acculturation stress, social support, and self-rated health among Latinos in California. Journal of Immigrant Health, 5(3), 109–117. Fuligni, A. J. (1998). Authority, autonomy, and parent–adolescent conflict and cohesion: A study of adolescents from Mexican, Chinese, Filipino, and European backgrounds. Developmental Psychology, 34(4), 782–792. Fuligni, A. J., Tseng, V., & Lam, M. (1999). Attitudes toward family obligation among American adolescents with Asian, Latin American and European backgrounds. Child Development, 70, 1030–1044. Fuligni, A. J., Yip, T., & Tseng, V. (2002). The impact of family obligation on the daily activities and psychological well-being of Chinese American adolescents. Child Development, 73(1), 302–314. Georgas, J., Berry, J. W., van de Vijver, F. J., Kağitçibaşi, Ç., & Poortinga, Y. H. (Eds.). (2006). Families across cultures: A 30-nation psychological study. Cambridge: Cambridge University Press. Gordon, M. M. (1964). Assimilation in American life. New York: Oxford University Press. Güngör, D. (2007). The interplay between values, acculturation and adaptation: A study on Turkish/Belgian adolescents. International Journal of Psychology, 42(6), 380–392. doi:10.1080/00207590600878657 Hayes, R., & Lin, H. (1994). Coming to America: Developing social support systems for international students. Journal of Multicultural Counseling and Development, 22(1), 7–16. doi:10.1002/j.21611912.1994.tb00238.x International Organization for Migration. (2010). World migration report 2010. The future of migration: Building capacities for change. Geneva: Author. Retrieved from http://www.publications.iom.int Jasinskaja-Lahti, I. (2006). Perceived discrimination, social support networks, and psychological well-being among three immigrant groups. Journal of Cross-Cultural Psychology, 37(3), 293–311. doi:10.1177/0022022106286925 Jasinskaja-Lahti, I., & Liebkind, K. (2001). Perceived discrimination and psychological adjustment among Russian-speaking immigrant adolescents in Finland. International Journal of Psychology, 36(3), 174–185. doi:10.1080/00207590042000074 Jibeen, T., & Khalid, R. (2010). Predictors of psychological well-being of Pakistani immigrants in Toronto, Canada. International Journal of Intercultural Relations, 34(5), 452–464. doi:10.1016/j.ijintrel.2010.04.010 Johnson, E. C., Kristof-Brown, A. L., van Vianen, A. E. M., de Pater, I. E., & Klein, M. R. (2003). Expatriate social ties: Personality antecedents and consequences for adjustment. International Journal of Selection and Assessment, 11(4), 277–288. doi:10.1111/j.0965-075X.2003.00251.x Kağitçibaşi, Ç. (2007). Family, self, and human development across cultures: Theory and applications (2nd ed.). Mahwah, NJ: Lawrence Erlbaum. Kaplan, D. M. (Ed.). (1995). Systems theory across the counseling spectrum. New York: New York Counseling Association. Kohatsu, E. L., Concepcion, W. R., & Perez, P. (2010). Incorporating levels of acculturation into counseling practice. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (3rd ed., pp. 343–356). Thousand Oaks, CA: Sage. Kwak, K. (2003). Adolescents and their parents: A review of intergenerational family relations for immigrant and non-immigrant families. Human Development, 46(2–3), 115–136. doi:10.1159/000068581 LaFromboise, T., Coleman, H. L. K., & Gerton, J. (1993). Psychological impact of biculturalism: Evidence and theory. Psychological Bulletin, 114(3), 395–412. Legrain, P. (2007). Immigrants: Your country needs them. Princeton, NJ: Princeton University Press. Leong, C.-H. (2007). Predictive validity of the Multicultural Personality Questionnaire: A longitudinal study on the socio-psychological adaptation of Asian undergraduates who took part in a study-abroad program. International Journal of Intercultural Relations, 31(5), 545–559. doi:10.1016/j.ijintrel.2007.01.004 Leong, C.-H., & Ward, C. (2000). Identity conflict in sojourners. International Journal of Intercultural Relations, 24, 763–776. Lin, E.-Y. (2008). Family and social influences on identity conflict in overseas Chinese. International Journal of Intercultural Relations, 32(2), 130–141. doi:10.1016/j.ijintrel.2007.09.005 Mangold, D. L., Veraza, R., Kinkler, L., & Kinney, N. A. (2007). Neuroticism predicts acculturative stress in Mexican American college students. Hispanic Journal of Behavioral Sciences, 29(3), 366–383. doi:10.1177/0739986307302167 Martínez García, M. F., García Ramírez, M., & Maya Jariego, I. (2002). Social support and locus of control as predictors of psychological well-being in Moroccan and Peruvian immigrant women in Spain. International Journal of Intercultural Relations, 26, 287–310. Mena, F. J., Padilla, A. M., & Maldonado, M. (1987). Acculturative stress and specific coping strategies among immigrant and later generation college students. Hispanic Journal of Behavioral Sciences, 9(2), 207–225. doi:10.1177/07399863870092006 Multicultural Policy Index. (2010). Multiculturalism policies in contemporary democracies. Retrieved from http://www.queensu.ca/mcp Neto, F. (1995). Predictors of satisfaction with life among second generation migrants. Social Indicators Research, 35, 93–116. Nguyen, A.-M. D., & Benet-Martínez, V. (2013). Biculturalism and adjustment: A meta-analysis. Journal of Cross-Cultural Psychology, 44(1), 122–159. doi:10.1177/0022022111435097 Nguyen, H. H. (2006). Acculturation in the United States. In D. L. Sam & J. W. Berry (Eds.), The Cambridge handbook of acculturation psychology (pp. 311–330). Cambridge: Cambridge University Press. Noh, S., & Kaspar, V. (2003). Perceived discrimination and depression: Moderating effects of coping, acculturation, and ethnic support. American Journal of Public Health, 93(2), 232–238. Nwadiora, E., & McAdoo, H. (1996). Acculturative stress among Amerasian refugees: Gender and racial differences. Adolescence, 31, 477–488. Ong, A. J., & Ward, C. (2005). The construction and validation of a social support measure for sojourners: The Index of Sojourner Social Support (ISSS) Scale. Journal of Cross-Cultural Psychology, 36(6), 637–661. doi:10.1177/0022022105280508 Oppedal, B. (2006). Development and acculturation. In D. L. Sam & J. W. Berry (Eds.), The Cambridge handbook of acculturation psychology (pp. 97–111). Cambridge: Cambridge University Press. Patton, W., & McMahon, M. (2006). The systems theory framework of career development and counseling: Connecting theory and practice. International Journal for the Advancement of Counselling, 28(2), 153–166. Pew Research Center. (2011). Muslim Americans: No signs of growth in alienation or support for extremism. Washington, DC: Author. Phinney, J. S. (1990). Ethnic identity in adolescents and adults: Review of research. Psychological Bulletin, 108(3), 499–514. Phinney, J. S. (1992). The Multigroup Ethnic Identity Measure: A new scale for use with diverse groups. Journal of Adolescent Research, 7(2), 156–176. doi:10.1177/074355489272003 Phinney, J. S., Berry, J. W., Vedder, P., & Liebkind, K. (2006). The acculturation experience: Attitudes, identities and behaviors of immigrant youth. In J. W. Berry, J. S. Phinney, D. L. Sam, & P. Vedder (Eds.), Immigrant youth in cultural transition: Acculturation, identity, and adaptation across national contexts (pp. 71–116). Mahwah, NJ: Lawrence Erlbaum. Phinney, J. S., Horenczyk, G., Liebkind, K., & Vedder, P. (2001). Ethnic identity, immigration, and well-being: An interactional perspective. Journal of Social Issues, 57(3), 493–510. doi:10.1111/0022-4537.00225 Phinney, J. S., Kim-Jo, T., Osorio, S., & Vilhjalmsdottir, P. (2005). Autonomy and relatedness in adolescent–parent disagreements: Ethnic and developmental factors. Journal of Adolescent Research, 20, 8–39. Phinney, J. S., & Ong, A. D. (2007). Conceptualization and measurement of ethnic identity: Current status and future directions. Journal of Counseling Psychology, 54(3), 271–281. doi:10.1037/00220167.54.3.271 Phinney, J. S., Ong, A. D., & Madden, T. (2000). Cultural values and intergenerational value discrepancies in immigrant and non-immigrant families. Child Development, 71(2), 528–539. Portes, A. (1997). Immigration theory for a new century: Some problems and opportunities. International Migration Review, 3(4), 799–825. Poyrazli, S., & Kavanaugh, P. (2004). Social support and demographic correlates of acculturative stress in international students. Journal of College Counseling, 7, 73–82. doi:10.1002/j.21611882.2004.tb00261.x Redfield, R., Linton, R., & Herskovits, M. J. (1936). Memorandum for the study of acculturation. American Anthropologist, 38(1), 149–152. Reitz, J. G., & Banerjee, R. (2007). Racial inequality, social cohesion, and policy issues in Canada. In K. Banting, T. J. Courchene, & F. L. Seidle (Eds.), Belonging? Diversity, recognition, and shared citizenship in Canada (pp. 489–545). Montreal: Institute for Research on Public Policy. Rothbaum, F., Pott, M., Azuma, H., Miyake, K., & Weisz, J. (2000). The development of close relationships in Japan and the United States: Paths of symbiotic harmony and generative tension. Child Development, 71(5), 1121–1142. Rudmin, F. W. (2003). Critical history of the acculturation psychology of assimilation, separation, integration, and marginalization. Review of General Psychology, 7(1), 3–37. doi:10.1037/10892680.7.1.3 Ryder, A. G., Alden, L. E., & Paulhus, D. L. (2000). Is acculturation unidimensional or bidimensional? A head-to-head comparison in the prediction of personality, self-identity, and adjustment. Journal of Personality and Social Psychology, 79(1), 49–65. doi:10.1037//00223514.79.1.49 Sam, D. L. (2000). Psychological adaptation of adolescents with immigrant backgrounds. Journal of Social Psychology, 140(1), 5–25. doi:10.1080/00224540009600442 Sam, D. L. (2006). Acculturation: Conceptual background and core components. In D. L. Sam & J. W. Berry (Eds.), The Cambridge handbook of acculturation psychology (pp. 11–26). Cambridge: Cambridge University Press. Sam, D. L., & Berry, J. W. (1995). Acculturative stress among young immigrants in Norway. Scandinavian Journal of Psychology, 36(1), 10–24. Sam, D. L., & Oppedal, B. (2003). Acculturation as a developmental pathway. Online Readings in Psychology and Culture, 8(1). Retrieved from http://scholarworks.gvsu.edu/orpc/vol8/iss1/6 Sam, D. L., Vedder, P., & Liebkind, K. (2008). Immigration, acculturation and the paradox of adaptation in Europe. European Journal of Developmental Psychology, 5(2), 138–158. doi:10.1080/17405620701563348 Sam, D. L., Vedder, P., Ward, C., & Horenczyk, G. (2006). Psychological and sociocultural adaptation of immigrant youth. In J. W. Berry, J. S. Phinney, D. L. Sam, & P. Vedder (Eds.), Immigrant youth in cultural transition: Acculturation, identity, and adaptation across national contexts (pp. 117–142). Mahwah, NJ: Lawrence Erlbaum. Sam, D. L., & Virta, E. (2001). Social group identity and its effect on the self-esteem of adolescents with immigrant background in Norway and Sweden. In R. G. Craven & H. W. Mars (Eds.), Selfconcept theory, research and practice: Advances for the new millennium (pp. 366–378). Sydney: Self Research Center, University of Western Sydney. Searle, W., & Ward, C. (1990). The prediction of psychological and sociocultural adjustment during cross-cultural transitions. International Journal of Intercultural Relations, 14(4), 449–464. doi:10.1016/0147-1767(90)90030-z Smetana, J., Campione-Barr, N., & Metzger, A. (2006). Adolescent development in interpersonal and societal contexts. Annual Review of Psychology, 57, 255–284. Stuart, J., & Ward, C. (2011). Predictors of ethno-cultural identity conflict among South Asian immigrant youth in New Zealand. Applied Developmental Science, 15(3), 117–128. doi:10.1080/10888691.2011.587717 Stuart, J., Ward, C., Jose, P. E., & Narayanan, P. (2010). Working with and for communities: A collaborative study of harmony and conflict in well-functioning, acculturating families. International Journal of Intercultural Relations, 34(2), 114–126. doi:10.1016/j.ijintrel.2009.11.004 Stuart, J., Ward, C., & Robinson, L. (2012). The double-edged sword: Family influences on Muslim immigrant young adults in N.Z. and the U.K. Paper presented at the 21st International Congress of the International Association for Cross-Cultural Psychology, Stellenbosch, South Africa. Sue, D., & Sundberg, N. D. (1996). Research and research hypotheses about effectiveness in intercultural counseling. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (4th ed., pp. 323–352). Thousand Oaks, CA: Sage. Tan, G. (1999). Perceptions of multiculturalism and intent to stay in school among Mexican American students. Journal of Research & Development in Education, 31(1), 1–14. Tatar, M. (1998). Counselling immigrants: School contexts and emerging strategies. British Journal of Guidance and Counselling, 26(3), 337–352. doi:10.1080/03069889808253847 Triandis, H. C. (1989). The self and social behavior in differing cultural contexts. Psychological Review, 96(3), 506–520. Van der Zee, K. I., Van Oudenhoven, J. P., & De Grijs, E. (2004). Personality, threat, and cognitive and emotional reactions to stressful intercultural situations. Journal of Personality, 72(5), 1069–1096. doi:10.1111/j.0022-3506.2004.00290.x Van Oudenhoven, J. P., Mol, S., & Van der Zee, K. I. (2003). Study of the adjustment of Western expatriates in Taiwan ROC with the Multicultural Personality Questionnaire. Asian Journal of Social Psychology, 6, 159–170. doi:10.1111/1467-839X.t01-1-00018 Van Oudenhoven, J. P., & Van der Zee, K. I. (2002). Predicting multicultural effectiveness of international students: The Multicultural Personality Questionnaire. International Journal of Intercultural Relations, 26(6), 679–694. doi:10.1016/S0147-1767(02)00041-X Van Oudenhoven, J. P., & Ward, C. (2013). Fading majority cultures: The implications of transnationalism and demographic changes for immigrant acculturation. Journal of Community & Applied Social Psychology, 23, 81–97. doi:10.1002/casp Vedder, P., van de Vijver, F. J. R., & Liebkind, K. (2006). Predicting immigrant youths’ adaptation across countries and ethnocultural groups. In J. W. Berry, J. S. Phinney, D. L. Sam, & P. Vedder (Eds.), Immigrant youth in cultural transition: Acculturation, identity, and adaptation across national contexts (pp. 143–166). Mahwah, NJ: Lawrence Erlbaum. Virta, E., Sam, D. L., & Westin, C. (2004). Adolescents with Turkish background in Norway and Sweden: A comparative study of their psychological adaptation. Scandinavian Journal of Psychology, 45, 15–25. doi:10.1111/j.1467-9450.2004.00374.x Ward, C. (2001). The A, B, Cs of acculturation. In D. Matsumoto (Ed.), The handbook of culture and psychology (pp. 411–445). Oxford: Oxford University Press. Ward, C. (2009). Acculturation and social cohesion: Emerging issues for Asian immigrants in New Zealand. In C.-H. Leong & J. W. Berry (Eds.), Intercultural relations in Asia: Migration and work effectiveness (pp. 3–24). Singapore: World Scientific. Ward, C., Bochner, S., & Furnham, A. (2001). The psychology of culture shock. London: Routledge. Ward, C., & Chang, W. C. (1997). “Cultural fit”: A new perspective on personality and sojourner adjustment. International Journal of Intercultural Relations, 21(4), 525–533. Ward, C., Fox, S., Wilson, J. K., Stuart, J., & Kus, L. (2010). Contextual influences on acculturation processes: The roles of family, community and society. Psychological Studies, 55(1), 26–34. doi:10.1007/s12646-010-0003-8 Ward, C., & Kennedy, A. (1993). Psychological and sociocultural adjustment during cross-cultural transitions: A comparison of secondary students overseas and at home. International Journal of Psychology, 28, 129–147. Ward, C., & Kus, L. (2012). Back to and beyond Berry’s basics: The conceptualization, operationalization and classification of acculturation. International Journal of Intercultural Relations, 36(4), 472–485. doi:10.1016/j.ijintrel.2012.02.002 Ward, C., Leong, C.-H., & Low, M. (2004). Personality and sojourner adjustment: An exploration of the Big Five and the cultural fit proposition. Journal of Cross-Cultural Psychology, 35(2), 137–151. doi:10.1177/0022022103260719 Ward, C., & Stuart, J. (2012). Societal-level predictors of immigrant adaptation: A 13-country study. Paper presented at the annual meeting of the Society for the Psychological Study of Social Issues, Charlotte, NC. Ward, C., Stuart, J., & Kus, L. (2011). The construction and validation of a measure of ethno-cultural identity conflict. Journal of Personality Assessment, 93(5), 462–473. doi:10.1080/00223891.2011.558872 Weaver, S. R., & Kim, S. Y. (2008). A person-centered approach to studying the linkages among parent–child differences in cultural orientation, supportive parenting, and adolescent depressive symptoms in Chinese American families. Journal of Youth and Adolescence, 37(1), 36–49. doi:10.1007/s10964-007-9221-3 Wilson, J. K., Ward, C., & Fischer, R. (2013). Beyond culture learning theory: What can personality tell us about cultural competence? Journal of Cross-Cultural Psychology, 44, 900–927. Yeh, C. J. (2003). Age, acculturation, cultural adjustment, and mental health symptoms of Chinese, Korean, and Japanese immigrant youths. Cultural Diversity & Ethnic Minority Psychology, 9(1), 34–48. doi:10.1037/1099-9809.9.1.34 Zagefka, H., & Brown, R. (2002). The relationship between acculturation strategies, relative fit and intergroup relations: Immigrant–majority relations in Germany. European Journal of Social Psychology, 32(2), 171–188. doi:10.1002/ejsp.73 Zhang, J., Mandl, H., & Wang, E. (2010). Personality, acculturation, and psychosocial adjustment of Chinese international students in Germany. Psychological Reports, 107(2), 511–525. doi:10.2466/07.09.11.17.PR0.107.5.511-525 Zheng, X., & Berry, J. W. (1991). Adaptation of Chinese sojourners in Canada. International Journal of Psychology, 26(4), 451–470. doi:10.1080/00207599108247134 Zlobina, A., Basabe, N., Paez, D., & Furnham, A. (2006). Sociocultural adjustment of immigrants: Universal and group-specific predictors. International Journal of Intercultural Relations, 30(2), 195–211. doi:10.1016/j.ijintrel.2005.07.005 Part V Professional Counseling in a Selection of Culture-Mediated Human Conditions and Circumstances In this final section of the volume, both the formats and the themes of cross-cultural counseling are extended beyond the prototypical encounter between one counselor and one counselee, both of whom endeavor to reduce the counselee’s distress and/or to improve his or her functioning. New objectives and concerns are incorporated into counseling, and procedures for counseling families and groups are explored in a multicultural context. In Chapter 19, Daisy R. Singla and Frances E. Aboud broaden the domain of culturally relevant counseling to include health issues and biomedical disorders. Steering clear of simplifications and avoiding stereotypes, they trace four pathways: physical stress, problems in the social environment both within the family and outside it, suboptimal behavior patterns in maintaining health and dealing with illness, and reduced or inadequate access to health services. All of these factors are negatively affected by low socioeconomic status, which often interacts with ethnocultural background, yet this interaction does not operate uniformly across ethnic groups or biomedical diagnostic categories. Moreover, demographic factors such as gender, age, marital status, and family composition often constitute important mediators in affecting vulnerability as well as compliance with or responsiveness to interventions. To cite but two examples of this complexity: Increased rates of hypertension have been found among African Americans at all levels of socioeconomic status, and Arab Americans living in ethnic enclaves have reported experiencing more ethnic discrimination than those who reside in ethnically diverse neighborhoods yet are less stressed by discriminatory practices. Negative health consequences associated with ethnicity have been detected prenatally; have assumed even greater importance in infancy, childhood, and adolescence; and have been observed throughout the life span. In regard to counseling interventions, Singla and Aboud emphasize the importance of counselors’ cultural competence, which they define as the aggregate of practices that promote treatment effectiveness in a multicultural clientele. Prominent among such skills is the ability to establish trust. Counselors can accomplish this objective by demonstrating flexibility and sensitivity in interventions, self-awareness, adaptability, and immersion in core cultural issues. The authors urge reliance on evidence-based techniques whenever they are available. Cognitive-behavioral therapy is widely applicable and lends itself easily to culturally appropriate modifications in many domains of treatment. In particular, self-monitoring has been effective with a great many conditions in diverse patient populations. Singla and Aboud recommend motivational interviewing as a highly useful procedure in both assessment and intervention, and they provide real-world examples of its use with health-related issues. Grounded in the client-centered ethos, motivational interviewing is nonetheless goal oriented. It helps identify and foster a client’s latent resources in promoting health, preventing illness, and counteracting illness at all stages of its progression. In general, readers of Chapter 19 will find in it a coherent and solid body of empirically based and practically applicable information on the relevance of racially and ethnically tailored approaches to promoting physical health and combating biomedical illness. In Chapter 20, James Allen, Jordan Lewis, and Michelle Johnson-Jennings introduce the promotion of well-being and emotional health as a major goal of counseling across cultures. Their chapter is organized around an extensive case study of a professional counselor who is trying to accept and integrate the disparate strands of his self and identity, which prominently include his ethnicity as experienced at different stages of his life. This process is guided and facilitated in a triadic relationship involving the client, his culturally oriented professional counselor, and a traditional healer or elder who acquired her sensitivity and skill not through academic training but from her father, who practiced and transmitted his age-old practices and outlook within the family setting. This account is notable for communicating the subtlety of cultural interaction in the course of counseling and for not shying away from exposing misunderstandings and misinterpretations. Recognizing and correcting these becomes an integral part of the counseling experience and contributes to its genuineness and spontaneity. On the academic level, the authors conclude that personal well-being is promoted by the integration of the personal value system with the manifold strands of the individual’s identity. They refer to the unique intertwining of these threads as intersectionality. Psychologists’ understanding of happiness and fulfillment has been greatly enriched by Diener’s theory of subjective well-being, which, however, is based on individualistic assumptions that prevail within the North American mainstream culture. Mastery is another, possibly culturally limiting, premise that may not be fully applicable to persons of different cultural heritages. Allen et al. articulate the contrast between separateness and connectedness as points of emphasis in various cultures. It is realistic to assume that persons everywhere strive for autonomy, competence, and relatedness. However, recent cross-cultural research has shown that while autonomy is highly valued in some cultures, other cultures prize relatedness more highly. In relation to counseling, Allen et al. assert that there are no culture-free measures or conceptualizations of well-being and that all counseling is culturally embedded. They therefore advocate an interpretive approach focused on values clarification at the points of intersection of the diverse facets of the self and identity. Both goals and methods of treatments should be chosen on the basis of cultural considerations, in collaboration between counselor and counselee whenever possible. Implicit philosophical conceptualizations of “the good life” are practically relevant in the planning and implementation of counseling with culturally distinctive groups of persons, but counselors should keep in mind that these groups are composed of individuals with unique life histories and constellations of values. These themes are further extended in Chapter 21 by Guillermo Bernal, Jennifer Morales-Cruz, and Keishalee Gómez-Arroyo as the focus is shifted from the person to the family as the modality of intervention. Birth family, as these authors assert, is a human universal; human beings are just not biologically equipped to survive unless they are nurtured and sheltered during a lengthy period of helplessness and dependence that extends from infancy through much of childhood. However, the structures of human families vary, and within the contemporary American culture there exist a great many variants in family composition, values, relationships, roles, and many other features. Both structurally and functionally, families in a multicultural society differ across ethnocultural and socioeconomic lines, and often the two strands of influence intertwine. It follows, then, that both the challenges that individuals face and the ways in which they cope with those challenges are rooted and reverberate within families. Family counseling is inescapably a major avenue of intervention, and it is imperative that counselors make it fit the ethnocultural realities of their clients’ family lives. As Bernal et al. point out, this approach has somewhat lagged behind others, especially in the development of conceptual models of culturally fitting and sensitive counseling. Historically, the family has lost much of its traditional economic function as an autonomous unit of production, while its expressive and affective aspects have become paramount. The modern family has also shrunk to become more nuclear and less extended. Current trends point to increases in egalitarianism and decreases in authoritarianism, but, as Bernal et al. emphasize, these tendencies are less pronounced in the ethnically distinct components of the American population. At the same time, the stability of such families is threatened not only by clashes between different sets of values but also by socioeconomic stress; social disadvantage; the historic, and often still real, burden of discrimination and oppression; and, more generally, rapid and abrupt sociocultural change. Bernal et al. provide a detailed and specific account of the values, practices, and challenges frequently encountered by families in the four major American ethnocultural groupings. The characteristics of these four groups differ in a great many particulars, but the thread that runs through all of them is an emphasis on the interdependence of individuals within the family and the sharp line that separates the often extended and ramified family from outsiders. The authors note the importance of the use of flexible and innovative approaches in conducting family counseling within multicultural milieus, and, like Singla and Aboud in Chapter 19, they emphasize the importance of cultural competence. Cultural competence encompasses both skills and attitudes. One of its attitudinal components, emphasized by Bernal et al., is humility. Not to be confused with self-abasement, humility in competent multicultural counseling involves openness to different modes of family experience and readiness to learn about them while suspending judgment. Humility holds in check any tendencies counselors may have to privilege their own cultural experiences and curbs their inclinations to dismiss ethnic families’ coping mechanisms as inadequate, dysfunctional, or pathological. In this connection, a specific facet worth mentioning is found in the critical incident presented at the end of the chapter. It pertains to the perpetuation across three generations of separations and losses, with grandmothers temporarily assuming the role of principal caregiver, with no support from fathers or other males, and enabling mothers to reunite with their children and thereby at least partially overcome adversity. In Chapter 22, Mary A. Fukuyama and Ana Puig introduce a topic that for too long has been neglected, shunned, or avoided by both theoreticians and practitioners in psychology—that of religion and spirituality. Dismissed by some of the major contributors to psychodynamic, behavioral, and cognitive psychology as artifactual or epiphenomenal, spiritual and religious concerns have long been relegated to the fringes of counseling and psychotherapy as the disguised expressions of more basic, biological needs. Yet, as Fukuyama and Puig point out, spiritual and religious concerns are real and often central in the lives of a great many counselees. Spirituality may be a part of the solution or a part of the problem, and frequently it is both. Moreover, spiritual themes are ingrained in cultural worldviews and are closely associated with disease, healing, and health in many cultures. The authors urge counselors to acquire both spiritual and multicultural competence, the foundations of which rest on self-awareness, knowledge of otherness, skill acquisition, and assessment of barriers. On a more specific level, Fukuyama and Puig introduce a brief assessment procedure consisting of the following four open-ended and general questions: What gives your life meaning? How important is your faith in your experience of adversity or illness and in your seeking help for it? How can a religious or spiritual community be helpful to you? How can spiritual issues be integrated in your life? In reference to actual counseling practices, the authors introduce a multitude of approaches that have been applied, although as yet not much evidence has accumulated on their demonstrated effectiveness. In general, the combination of creative and expressive therapies with innovative specific features appears to be particularly conducive to spiritual exploration. Fukuyama and Puig provide specific information on the spiritual needs and concerns frequently encountered among clients from the major American ethnocultural groups and on ways of responding to these needs and concerns through culturally sensitive counseling practice. It would appear that spirituality is an especially salient concern in these segments of the American population, perhaps even to a greater extent than in dominant, mainstream U.S. culture. Fukuyama and Puig pay special attention to the cultivation of mindfulness, an ancient practice that originated within the Buddhist religious and spiritual tradition and is now being focused on contemporary, yet ageless, concerns. On a general level, the authors emphasize that counseling cannot claim to be holistic, comprehensive, or culturally fitting unless it adequately addresses spirituality, a major aspect of human experience and existence. Like Chapter 20, Chapter 23, by Lisa Rey Thomas and Dennis M. Donovan, is centered on a detailed case study. Its subject is an American Indian woman who is struggling to put her life together after a brutal removal from her family and community, followed by the imposition of an alien language and culture. At the point of first contact with her counselor, she presents as a recovering alcoholic with specific aspirations and goals, but she is exhausted and discouraged and unsure of ever converting her dreams into reality. The authors follow her through the assessment and treatment procedures and thereby provide a specific account of current culturally sensitive practices of dealing with clients who experience alcohol and/or substance treatment problems. In line with the general theme of Part V, this chapter places special emphasis on the attainment and maintenance of health, over and above the clinical goals of reducing distress and counteracting disability. Thomas and Donovan advocate an elaborate multimethod collaborative assessment procedure. The client is regarded not just as an informant but as an expert on her life experience. Standardized assessment instruments are utilized, provided they have been normed and adapted for the ethnocultural group in question. The assessment is focused on the client’s developmental history, which is both provided by the client and supplemented by collateral sources of information. The client’s acculturative status is also investigated through interview procedures and validated and appropriate scales and instruments, if available. Information is gathered on the relevant sociocultural factors, and strengths as well as symptoms and problems are systematically explored. Thomas and Donovan note that it is important to pace, rather than rush through, the assessment process so as to allow time for trust to develop and to usher in the treatment phase. The authors guide the reader through all stages of the counseling process, from precontemplation to the attainment and maintenance of sustained change. This progression is not smooth, linear, or predictable in all cases. Failures do occur, and then treatment is resumed from an earlier stage. The authors are impressed with the effectiveness of motivational enhancement therapy, which shares many features with motivational interviewing, prominently featured in Chapter 19. They have found that American Indian clients favor a direct, pragmatic, fairly rapidly paced approach that is oriented toward the attainment of concrete goals. These clients have little tolerance for counselors’ passivity in letting counseling drift, and, although they welcome the inclusion of indigenous elders and incorporation of cultural rituals and ceremonies, they react negatively when professional counselors withdraw and turn over the entire treatment to indigenous healers. In Chapter 24, Mary B. McRae introduces the group relations model for exploring and changing group dynamics in multicultural groups. To this end, she presents the basic concepts of the psychoanalytic and systems theories on which the model is based. The participants in groups using the model learn experientially through the interplay between the “here and now” within the group and the “then and there” in the external world. In the process, defenses are shed and cultural hostilities and rivalries rise to the surface. These are then experienced, explored, and worked through, and feelings are both expressed and checked against their perception by other participants. Private fantasy comes to the fore, giving rise to clashes with social reality as well as with possible reconciliation with it. Understanding and acceptance of participants’ identities is promoted in the culturally diverse microenvironment of the group. In the course of the group experience, participants may experience being “pulled into” their respective ethnocultural stereotypes as well as being helped to free themselves of such stereotypes. McRae provides copious examples of the subtlety and complexity of this experience, and of its benefits at the individual and intergroup levels. For the chapter’s critical incident, however, she has chosen a case that at the end of the group session remains unresolved. She then invites the reader to suggest possible solutions for the issues that the client is experiencing, proceeding from the concepts and observations presented in the chapter. 19 Health Psychology and Cultural Competence Daisy R. Singla Frances E. Aboud Primary Objective ■ To identify associations among physical, mental, and social health and evaluate how health providers can counsel behavior change using culturally competent techniques and programs Secondary Objectives ■ To understand how and why socioeconomic status and ethnicity are related to illness and inadequate health behaviors ■ To outline the current concept of cultural competence in clinical practice and its application to cardiovascular disease, diabetes, and other chronic illnesses ■ To specify how evidence-based techniques and programs are applied to change health behaviors among ethnic minority groups The World Health Organization (WHO) has defined the health of individuals in terms of physical, mental, and social well-being, and not simply the absence of disease. This definition has at least two components that are of great significance to counselors. One is that health is seen as a continuum ranging from illness to well-being, with growth toward the positive end of the spectrum being as important as recovery from the disease end. Most people are somewhere in between the extremes and striving toward well-being. The second component is the explicit recognition of the importance of mental health and social health and their potential impact on physical health, and vice versa. The notion of health as a continuum is central to the philosophy of counselors who accept their clients’ current positions on the continuum and the clients’ desire to move forward. The research reviewed here therefore includes the perspectives of people who are more healthy as well as those of people who are less healthy. Counseling skills are as beneficial to a health care provider giving bad news of a cancer diagnosis as they are to a genetics counselor discussing the future probabilities of a client’s contracting a disease or a school counselor coordinating the efforts of a troubled child, parent, and teacher. Health promotion and education are important in counseling for cancer screening as well as in counseling for exercise and diet. It is now generally accepted that patient education and counseling on health-promoting and health-compromising behaviors are both clinically effective and cost-effective (Fielding, 1999). The interconnections among physical, mental, and social health are a matter for empirical examination. Consequently, the major themes running throughout this chapter concern how and why the three components of well-being connect and how counseling for cardiovascular diseases, diabetes, and other chronic illnesses addresses all three. The simple answer, of course, is that the three components are all parts of the same person. However, we know of people whose physical illnesses have not harmed the quality of their mental or social lives. For example, as a group, men with prostate cancer have a higher quality of life, according to their own reports of physical, social, and psychological functioning, than might be expected of individuals who have cancer (Clark, Rieker, Propert, & Talcott, 1999). Yet few people recognize the pervasiveness of the impact of pain (Skevington, 1998) or depression (Bonicatto, Dew, Zaratiegui, Lorenzo, & Pecina, 2001) on all domains of a person’s life. It is important to keep these discrepancies in mind while reviewing the evidence for generally strong connections among physical, mental, and social health. The significance for counselors is in being able to identify the nature of a problem as physical, mental, social, environmental, or more than one of these and selecting the best route to address the problem. Therefore, even if the problem is physical deterioration (e.g., as a result of overuse of alcohol), there are social and psychological implications for family and job functioning. Thus, addressing all components of well-being in the counseling encounter should prove efficacious. Physical Health and Social Markers Health centers and survey groups in the United States and elsewhere regularly collect data on a number of indicators of health and illness. By examining physical health in relation to socioeconomic status (SES), ethnicity, gender, and age, researchers have identified lower-SES groups, minority ethnic groups, and the young as being in special need of proactive services. The evidence is, of course, much more complex than this simple conclusion and depends on the type of health problem being addressed. Our overview below covers not only mortality but also specific types of illnesses, such as hypertension, diabetes, cancer, and obesity, for which ethnic disparities exist. Disparities also exist at birth in that minority children are more likely to be born preterm and underweight. In health studies in the United States, individuals are usually categorized into the following racial/ethnic groups: White (non-Hispanic), Black (African American), Hispanic, Native American, and Asian American (Williams & Collins, 1995). These categories are used with simplicity in mind, for the collection and analysis of health statistics; all of these groupings are heterogeneous in terms of their actual backgrounds, and they are social constructions unique to the United States (Bradby, 2012). Yet the disparities among ethnic groups in physical health are known to be large. Krieger, Williams, and Moss (1997) point out that ethnic minority groups also tend to have lower income and occupation levels and fewer economic assets to be used in emergencies than do Whites with the same education levels. While studies attempt to isolate the effects of ethnicity by statistically controlling for SES, careful readers should be aware that for many minorities ethnicity has a powerful effect on socioeconomic constraints and opportunities. If ethnicity by itself accounts for little of the variation in health after SES is controlled for, this is most likely because ethnicity and SES are closely connected, so both together are relevant. As might be expected, the impact of SES and ethnicity on health is due less to biological vulnerability than to social inequality. Mortality The “social gradient” in mortality is now a robust finding that is generally acknowledged by North American and European health professionals. It refers to the fact that both SES and ethnicity, separately or together, are strongly related to an individual’s chances of dying prematurely (for reviews, see Adler et al., 1994; Krieger et al., 1997; Lillie-Blanton & Laveist, 1996; Macintyre, 1997; Williams & Collins, 1995). The gradient appears to characterize a series of steps: with every increment in income, occupation, and education, a person’s chances of not dying prematurely are increased. This means that over a 10-year period, men and women between 25 and 64 years of age with only 8 years of schooling are more likely to die than are their counterparts with college educations. Several points could be made about the gradient (see the reviews cited above). One is that the gradient may by steeper for men than for women. Another is that the steps tend to be steeper at the lower-SES end than at the upper end, implying that small increments in income and education for those at the lower end are associated with larger differences in survival than are such increments at the upper end. Third, over the past 40 years, premature mortality has generally declined, but less so for people at the lower end of the SES scale. Not everyone has benefited equally from recent medical advances. There is a similar mortality gradient for ethnic differences (Kaufman, Long, Liao, Cooper, & McGee, 1998; Lillie-Blanton, Parsons, Gayle, & Dievler, 1996; Williams & Collins, 1995). African Americans, in particular, have a higher premature death rate than members of other groups, largely due to four causes: cardiovascular disease (heart attack and stroke), diabetes, cancer, and infant mortality. Higher rates of cardiovascular disease in African Americans are often attributed to hypertension due to the stresses of racism, higher rates of diabetes to diet, and cancer deaths to delayed treatment and inadequate screening (Gilliland, Hunt, & Key, 1998). In regard to infant mortality, compared to White infants, twice as many Black infants die as a result of being either low birth weight or premature due to maternal stress during pregnancy (Rosenthal & Lobel, 2011). In 2005, the number of infants who died per 1,000 live births in the United States was 5.6 for Whites and Hispanics, 4.9 for Asians, and 13.6 for African Americans. Yet medical advances are such that underweight and premature infants need not die or even be significantly delayed beyond the early years. Childhood mortality shows the same ethnic discrepancy: Compared with White children, mortality rates are twice as high for Black children between 1 and 4 years old, and only slightly lower for those between 5 and 14 years old (Singh, 2010). Hispanic and Asian (and Pacific Islander) children have mortality rates similar to or lower than those of White children, though there is national variation within these groups. The leading cause of death in children, accounting for some 40% of deaths, is unintentional injuries resulting from car accidents and violence. Physical and Mental Illness The association between SES and disparities across ethnic groups in illness and disability has also been well-documented for physical (e.g., Adler et al., 1994; Krieger et al., 1997; Lillie-Blanton et al., 1996; Ren, Amick, & Williams, 1999; Williams & Collins, 1995) and psychological illness (e.g., Kessler, Mickelson, & Williams, 1999). The latest evidence comes from a study in which disparities were found to persist between White and Black Americans over 20 years (Farmer & Ferraro, 2005). Serious chronic illnesses such as heart disease, hypertension, diabetes, cancer, and stroke were found to be 25% higher among Black citizens, whose activity limitations were also higher. Further, these estimates are conservative, because Black Americans are less likely than Whites to seek medical attention and receive diagnoses. People with less education and income were also found to be more likely to have serious illnesses. Research findings regarding mental illness are much the same: Both lifetime and 12-month combinations of depression, anxiety, and substance abuse are more likely to be present in those ages 18 to 54 years with lower education (Kessler, Foster, Saunders, & Stang, 1995; WHO International Consortium in Psychiatric Epidemiology, 2000). For example, a World Health Organization study found that 17% of Americans reported high levels of anxiety in the past 12 months, 10.7% reported depression, and 11.5% had substance abuse problems; 12% had more than one of these problems. Compared to those with college education, those who did not complete high school were almost four times as likely to have a combination of these mental illnesses (WHO International Consortium in Psychiatric Epidemiology, 2000). Conduct disorder and substance abuse have been found to be the two problems most likely to lead to early school dropout, especially among men (Kessler et al., 1995). Regardless of whether one looks at education, income, or employment, at each step down in the SES ladder there are more people with mental health problems. Ethnic inequalities in physical health are also very wide (see Lillie-Blanton et al., 1996). Black Americans experience more chronic illness and more restrictions in daily activities due to ill health than do White Americans (Ferraro, Farmer, & Wybraniec, 1997). Special attention has often been paid to cardiovascular disease, such as hypertension (high blood pressure). Black men and women are more likely to have hypertension than White men and women at each level of SES. We will see shortly how the experience of racial discrimination in daily life may contribute to this problem. Diabetes is also much more common among Black and Asian adults than among Whites, leading to more rapid decline in kidney function (e.g., Kropet al., 1999), and cancer outcomes are significantly worse for minority ethnic groups than for others (Jemal et al., 2008). Mental illness indicators are usually taken from self-reports of symptoms experienced in the past month or year, symptoms indicative of depression, anxiety, and perhaps substance abuse. In large national samples, Black adults have not been found to experience more depression or anxiety than White adults (e.g., Kessler et al., 1995, 1999; Ren et al., 1999). This is also the case for substance abuse, where even in the peak years of young adulthood, Black men and women are less likely than their White counterparts to abuse alcohol (Wallace & Muroff, 2002). However, when present in young minority men, alcohol abuse tends to have a greater impact on school, family, and job functioning, leading to school dropout and unemployment. In summary, there appear to be social inequalities in mortality and physical illness whereby those with lower education, income, and occupation are more likely to die prematurely and more likely to suffer from certain diseases, such as heart disease and diabetes, than those at a slightly higher SES, all the way up the SES scale. In comparison with Whites, African Americans and Native Americans have higher rates of infant and child mortality, more chronic illness, and worse outcomes for certain diseases, including hypertension, diabetes, and cancer. While mental illness also appears to be more common among those with lower SES, it does not appear to be more common among particular ethnic and racial minority groups. Pathways From SES–Ethnicity to Health To shed light on the social inequalities in health described above, we will review the major pathways studied. Many analysts have attempted to explain ethnic differences in terms of SES because minorities are disproportionately represented in lower-SES groups. This simply means that the pathways from minority ethnic status to poor health (e.g., through unhealthy work environments or difficulties accessing health care) are similar to the pathways from low income and low education to health. However, ethnicity may play a unique part in explaining why at each SES level, Black Americans show higher levels of illness and death than White Americans. Researchers have long been studying the pathways from social status to health (Macintyre, 1997). They fall into several categories: (a) the physical environment (e.g., crowding, toxicity); (b) the social environment (e.g., single-parent families, lack of control over job demands, poor neighborhoods); (c) health behaviors (e.g., smoking, drinking, diet, exercise); and (d) access to and use of medical information, treatments, and preventive services. All of these pathways are important reasons for the poor health of minority Americans. Below, we follow the pathways from three common sources of ill health, namely, pregnancy and birth outcomes, education, and timely access to care, including counseling care. The developmental course of poor and minority children indicates that early levels of poor health set a trajectory that culminates in poor adult health. Sources of early health problems that affect minority children include prematurity, low birth weight, asthma, and injuries. These childhood insults lead to more chronic health problems at 50 years of age and to Black/White disparities in disabilities at 50 years (Haas & Rohlfsen, 2010). So it is important to deal with early childhood health problems before they impede educational and other sources of opportunity. Prematurity and low birth weight are twice as high in Black children as in White children, yet both are preventable (Giscombe & Lobel, 2005; Lobel et al., 2008; Messer et al., 2008; Nepomnyaschy, 2010; Reagan & Salsberry, 2005; Rosenthal & Lobel, 2011). Furthermore, the childhood consequences of prematurity and low birth weight, namely, respiratory illness and delayed development, are preventable with proper care, as are the adult consequences, cardiovascular disease, hypertension, and diabetes. However, it is more effective to prevent these problems by addressing prematurity and low birth weight. What are the reasons for poor birth outcomes among Black Americans? SES differences do not explain birth outcome disparities. For example, maternal education might be expected to improve birth outcomes, but it does not for Blacks. Likewise, higher income and prenatal care do not improve birth outcomes for Blacks as they do for other Americans (Giscombe & Lobel, 2005). However, Black women experience more stress during pregnancy than do women in other groups; such stress arises from a number of sources, including insecure neighborhoods, low social support, discrimination by health professionals, and anxiety about job and financial security. An empirical study isolated pregnancy-specific stress from general stress and found that only the former was associated with poor birth outcomes (Lobel et al., 2008). Pregnancy-related stress also indirectly affected birth outcomes because it led to more smoking, caffeine consumption, and unhealthy eating, which in turn reduced birth weight. The strongest source of prenatal stress among Black women was associated with racial discrimination, such as being treated as if they were less competent, more dishonest, and more irresponsible than other pregnant women (Rosenthal & Lobel, 2011). Marci Lobel and her colleagues have proposed pathways through which prenatal stress and specifically stress associated with racial discrimination can negatively affect birth outcomes. The physiological pathways include the release of cortisol, higher blood pressure, and compromised immunity, all of which link discrimination with poor birth outcomes. Counseling pregnant women regarding stress, infection, and smoking during pregnancy is one avenue to explore to improve outcomes, along with facilitating medical services for them during pregnancy and delivery. Children’s and adolescents’ health behaviors may constrain their educational careers, and thereby their adult occupations and income (Evans, 2004). A comprehensive review of SES differences in mortality, chronic illness, symptoms of acute illness, injuries, and self-rated health found large differences among children under 10 years; these differences narrowed during the adolescent years, only to reappear in young adulthood (Goodman, 1999). P. West (1997) suggests that a leveling effect takes place when adolescents move away from a solely parental and neighborhood influence to the diverse influences of a large high school, along with peer and behavioral choices made by the adolescents themselves (e.g., to hang around with those who smoke and drink). Findings from a large study in Finland support this hypothesis. Karvonen, Rimpela, and Rimpela (1999) found that regardless of parental occupation, adolescents’ own educational status at 16 and 18 years (e.g., drop out or remain in school, and achievement) showed a stronger association with smoking, alcohol abuse, lack of physical exercise, and high-fat diet. In fact, among adolescents whose family origins were lower SES, those who remained in school and had high achievement showed better health behaviors. So, adolescents have the opportunity to diverge from their parents’ SES by making choices as to who their peer reference groups will be, how achievement oriented they will be, and how much drinking, smoking, and sexual activity they will engage in. These same choices are available to minority American youth. Medical care might also be poorer for low-SES and minority families. One of the reasons education translates into health and long life is that it improves individuals’ ability to seek and make good use of current health care information and services. Independent of education is health literacy, or the ability to understand health care materials, explanations, and medication instructions (Baker, Parker, Williams, Clark, & Nurss, 1997). For example, a common test of functional health literacy examines a patient’s understanding of written instructions by eliminating every seventh word of the instructions and asking the patient to select each missing word from a list. In one study, patients who took such a test were asked to read passages from a Medicaid application and a medication instruction sheet (Schillinger, Bindman, Wang, Stewart, & Piette, 2004). Those who scored in the inadequate range would be expected to often misread simple materials, such as instructions on prescription bottles, appointment slips, and nutrition labels. In the study’s sample from a low-SES multiethnic hospital clinic, 38% of diabetic patients were found to have inadequate health literacy. Without adequate health literacy, a patient is dependent on a health care provider to translate information into concrete and practical formats. However, the study participants reported that their providers did not meet these needs. Patients with inadequate literacy tended to be less satisfied with the clarity of their providers’ instructions; they reported that the providers spoke too fast and used too much medical jargon. They also tended to feel that their physicians did not tell them how or why certain care procedures were being done. Although overall patients were happy with the care they received, it was clear that many were confused about their conditions and hospital procedures. Such confusion would certainly have an impact on their health outcomes. Although African Americans say they are less likely to experience discrimination in medical settings than in other situations (Ren et al., 1999), they are unsatisfied with the time and explanations received from professionals. Researchers who have audio-recorded consultations between providers and patients and compared the communications of minority and White patients with their physicians have found that there appear to be a number of differences (Johnson, Roter, Powe, & Cooper, 2004). For example, physicians are more likely to dominate the conversation with minority Americans and to provide less patient-centered, collaborative care by asking about their symptoms and preferences. Black American patients and their physicians express fewer positive emotions such as optimism. The consequences of these kinds of exchanges are that, compared with White patients, minority patients feel less involved and responsible for their treatment and less positive about visits to the doctor. For their part, professionals often generalize about minority patients, viewing them as less likely to comply with medical advice, less likely to receive social support for complying, and more likely to engage in substance abuse than White patients, despite evidence to the contrary from the particular patients (van Ryn & Burke, 2000). Regardless of patients’ races, doctors are less likely to provide patient-centered care (i.e., are less likely to encourage patient participation in the treatment process) if they perceive the patients to be more contentious, less satisfied, and less likely to adhere to advice (Street, Gordon, & Haidet, 2007). Race concordance between patient and professional does not appear to improve the communication process. For these and other reasons, minority persons tend to delay seeking professional help for symptoms that might indicate serious physical diseases such as cancer, hypertension, and diabetes (Haas & Rohlfsen, 2010). Although the health care system may be the least racially or ethnically discriminatory of all public domains, the prevalence and impact of racial/ethnic discrimination in other walks of life can affect health. Within the category of social-environmental conditions that lead from SES and ethnicity to illness is racial discrimination. As mentioned above, being a target of racism and discrimination is stressful (Williams, Neighbors, & Jackson, 2003). Reasonable reactions to unfair treatment and prejudice include frustration, anger, and depression, but these emotions may be detrimental to physical and mental health. For example, frustration and anger can lead to heightened blood pressure and subsequently hypertension, an illness more prevalent among African Americans than among members of other groups (e.g., Gump, Matthews, & Raikkonen, 1999). And while we have found no evidence in the literature that minorities have more mental illness than Whites (Schwartz & Ilan, 2010), feelings of powerlessness, sadness, hopelessness, and shame can become a basis for depressed affect. Research using scales that measure discrimination and racism reveals how stressful and pervasive discriminatory and racist attitudes and actions are. In addition to structural forms of discrimination, such as access to neighborhoods, jobs, and schools, such scales measure frequency of interpersonal exposure using items describing different types of incidents (e.g., “Racial jokes or harassment are directed to me at work”; “I am often ignored or not taken seriously by my boss”), emotional responses (e.g., angry, frustrated, sad, ashamed), and coping reactions (e.g., “I work harder to prove them wrong”; “I deal with it by ignoring it”). Large surveys often include one or two questions about exposure, such as “Have you ever experienced unfair treatment, been prevented from doing something, or been made to feel inferior because of race at school, getting a job, at work, getting medical care, in a public setting... ?” (Kessler et al., 1999; Ren et al., 1999). Data from large national surveys reveal that 60% to 90% of Black Americans and 10% to 20% of White Americans have experienced discrimination due to their race at some point in their lives (Ren et al., 1999). While Black Americans in general do not have worse psychological distress or depression than White Americans, those who have had frequent exposure to racial and SES discrimination have been found to have higher levels of psychological distress, anxiety, and depression (Jackson et al., 1996; Kessler et al., 1999; Ren et al., 1999). The “racism as stressor” hypothesis is a promising new pathway to be explored. Research results so far have been somewhat surprising, in that while Black Americans appear to have more exposure to discrimination, they may be less vulnerable to emotional consequences—because parents teach their youngsters how to cope—but more vulnerable to cardiovascular problems (Harrell, Hall, & Taliaferro, 2003). Unexpectedly high levels of perceived discrimination have been reported by better-educated Black Americans. Also, the day-to-day variety of racism may be more detrimental to mental health than the lifetime variety (Kessler et al., 1999). Fewer measures of discrimination exist for use with children and adolescents, but even at these ages individuals are able to provide valid reports on their experiences of being unfairly treated on account of ethnicity, race, language, or religion. A recent review of research relating discrimination and health outcomes found that the physical health and mental health of children and adolescents are also associated with racial discrimination (Priest et al., 2013). Discrimination has a greater impact on adolescents than on children, perhaps because of the accumulation of stress or because bullying and exclusion can become more sophisticated and therefore more distressing as children become teenagers. In addition, rural adolescents are more affected by discrimination than are their urban counterparts. Rural youth may have fewer ingroup supports to help them cope with racial discrimination. Family and peer supports, academic success, and strong ethnic/racial identity help to buffer the effects of discrimination on health. Arab Muslim immigrants are one ethnic minority group about which relatively little is known in regard to discrimination and health. Technically Asian, Arab immigrants have historically been categorized as White (Caucasian) in the United States (Abdulrahim, James, Yamout, & Baker, 2012). They experience more or less discrimination depending on skin color and whether they live in an ethnic enclave, such as the one in Detroit, Michigan. Arab Americans who live in ethnic enclaves experience more discrimination but appear to be less distressed about the experience than those who live outside enclaves (Abdulrahim et al., 2012). An effective protective factor is strong identification with being Arab and Muslim, which individuals can enact more fully while living in enclaves. As Aroian et al. (2009) note, mothers and adolescents in this group experience cultural cross fire while living in the United States: mothers because they are responsible for maintaining family and religious obligations while helping their children negotiate American peer relations and school demands, and adolescents because they are expected to be obedient to parents and to conform to religious rules while trying to assimilate. Given these challenges, the adolescents in Aroian et al.’s study sample experienced more internalizing but fewer externalizing problems compared to normative samples. Mothers appeared to be less distressed than expected, despite low levels of education and often unemployed husbands who were disabled and traumatized by wars in Iraq, Lebanon, or Yemen. Ethnic enclaves may provide a number of protective structures, such as religious places, recreation facilities, and healthy food outlets that benefit newly arriving immigrants. Living in ethnic enclaves may benefit not only mental health but also physical health. For example, Chinese Americans and Hispanics who live in enclaves, compared with members of these groups who do not, have been found to have greater access to health food outlets and to eat healthier food, but they also have less access to facilities for physical activity (Osypuk, Diez Roux, Hadley, & Kandula, 2009). In the next section, we move from group-level evidence to the individual person who seeks health care. In many ways, ethnic minority patients are excluded from participating in and taking responsibility for their medical care. Cultural Competence in the Consultation Context Recently, there have been many efforts to address minority health care cultural competence among professionals. The most widely used definition of cultural competence is “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enable that system, agency, or other professionals to work effectively in cross-cultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989, p. 13). Another common definition is “the ability to provide care to patients with diverse values, beliefs and behaviors including tailoring delivery to meet patients’ social, cultural and linguistic needs” (Betancourt, Green, & Carrillo, 2002, p. v). Similar alternative constructs have also been introduced, such as cultural safety (Papps & Ramsden, 1996), cultural attainment (Falicov, 2009), and culturally sensitive, appropriate, and informed practice (Mier, Ory, & Medina, 2010). While multiple definitions and terms related to cultural competence are used, most emphasize the process underlying an attempt to make health care services more accessible, acceptable, and effective for people from diverse racial and ethnic communities. Cultural competence goes well beyond providing specialized translators who, unlike nonspecialized workers or family members, do not omit critical information about symptoms, leading to misdiagnosis (e.g., Elderkin-Thompson, Cohen Silver, & Waitzkin, 2001). Cultural competence is critical for enabling professionals to gain patients’ full participation in identifying and managing their health problems. When patients are limited in health literacy and professionals are limited in cultural competence, competent care may be compromised. Table 19.1 summarizes a major framework of cultural competence in clinical care developed by Teal and Street (2009). While acknowledging Betancourt, Green, Carrillo, and Park’s (2005) inclusion of organizational, structural, and clinical levels of cultural competence, here we focus on clinical competence among practitioners in clinical and counseling settings. Teal and Street’s (2009) framework highlights four aspects of counselor cultural competence: a broad repertoire of communication skills, an empathetic awareness of the patient’s situation and the counselor’s own reactions, adaptability to each different patient, and knowledge of potential cultural issues. For example, counselors’ repertoires of communication skills need to include skills that facilitate the participation of clients who might be reluctant to describe their symptoms or express their treatment preferences because of cultural constraints (Mead & Bower, 2002). Whatever counselors need to adapt and respond to each patient’s individuality adds an extra layer of knowledge, attitudes, and skills relating to patient culture. As Kleinman and Benson (2006) point out, it is better for a counselor to ask about a client’s ethnic identity and its salience in the client’s life than to make assumptions and risk generalizing from stereotypes. The acquisition of cultural competence is not simple, and counselors cannot achieve it by following a cookbook approach. Becoming culturally competent requires time, patience, and a commitment to meet the needs of each client as a unique individual. All individuals have multiple personal and social identities, but culturally competent professionals are knowledgeable and sensitive enough to interpret signals from their clients that reflect cultural styles. Training in cultural competence must therefore focus on common interpersonal skills, including sensitivity and openness to various cultural identities, rather than on the content of cultures in order to facilitate a strong therapeutic alliance between patient and counselor. Counselors can learn these skills through instruction and experience. Teal and Street (2009) provide examples of skills related to building relationships to enhance trust (a common issue between ethnic minority patients and their counselors), and to managing patient problems. For example, they point out that while eye contact and touching might be considered intrusive in many cultures, listening actively and focusing on the patient are generally positively interpreted. Expressing nonjudgmental concern, addressing symptoms mentioned by the patient, and checking for understanding are verbal responses that are universally acceptable to most patients. Asking open-ended questions and asking if the patient feels comfortable talking about a topic are relatively safe approaches if the counselor is unsure of cultural concerns. These are useful steps a counselor can take until he or she is sufficiently familiar with the patient and the patient is sufficiently trusting. Many of these communication skills are relevant to cognitive-behavioral techniques and motivational interviewing, which are frequently used to promote self-management of chronic illnesses, to be discussed next. Evidence-Based Culturally Competent Techniques and Programs Disparities among ethnic groups in rates of chronic illnesses such as cardiovascular disease and diabetes are related to behaviors such as diet, physical inactivity, and substance abuse. For example, data from the Multiethnic Cohort Study show that, among five ethnic groups, Black Americans have the highest energy density in their diets (Howarth, Murphy, Wilkens, Hankin, & Kolonel, 2006). Chronic illnesses are worsened by inattention to preventive screening and treatment adherence (McDonald, Garg, & Haynes, 2002). In order to improve health practices, counseling professionals have developed evidence-based practices, such as cognitive-behavioral techniques, motivational interviewing, and family social support, that are culturally tailored for specific groups and individuals. Below we present examples of some of these evidence-based techniques that have been shown to improve health in racial and ethnic minority populations. Cognitive-Behavioral Techniques Cognitive-behavioral techniques have been successful in improving medication adherence as well as physical activity and healthy diet among people with cardiovascular disease and diabetes. These strategies focus on modifying how individuals think about themselves, their behaviors, and their surrounding circumstances, as well as on how they can adjust these three components to achieve a healthier lifestyle. Effective cognitive-behavioral techniques include goal setting, self-efficacy enhancement, incentives, modeling, homework, and problem solving. Goal setting, for example, can be established collaboratively between patient and provider to facilitate patient-centered communication (Staten et al., 2004). The creation of goals to target specific behaviors should follow the SMART acronym—that is, goals should be specific, measurable, action oriented, realistic, and time limited. Further, goals that focus on patients’ behaviors (e.g., increasing intake of whole grains, fruits, and vegetables) rather than on physiological targets (e.g., improving low-density lipoprotein cholesterol) are preferable because they empower patients to take actions that are under their direct control and observation. In addition, self-monitoring, whereby patients develop awareness of their daily habits, can include both simple strategies such as handwritten diaries and technology-based approaches such as online electronic logs. Self-monitoring can be used alongside the well-known strategy of homework, in which program implementers track individuals’ progress in order to facilitate realistic feedback and reinforcement for the individuals. Problem solving has also been found to be effective in targeting lifestyle behaviors (e.g., Eakin et al., 2007; Yanek, Becker, Moy, Gittelsohn, & Koffman, 2001). In particular, problem solving promotes individuals’ ability to identify barriers to successful behavior change and resolve issues in order to achieve goals and maintain success. Problem solving has been shown to facilitate greater and longerterm weight loss by reducing relapse (Perri et al., 2001). In addition, both self-efficacy, defined as an individual’s confidence in his or her ability to make a desired change, and modeling are common cognitive-behavioral techniques that have been used to increase physical activity and improve diets among Blacks and Latinos in church settings (for a complete review, see Bopp, Peterson, & Webb, 2012). For example, trained church staff have been shown to influence self-efficacy by tailoring their programs to use scripture readings and Bible verses to supplement health interventions. Similarly, modeling can be effective, as church staff and members demonstrate healthy, positive behaviors through cooking classes or group grocery shopping. Multiple studies have shown these techniques to be successful in targeting a wide range of chronic illnesses among diverse ethnic groups. They include studies of self-management of diabetes among low-income Spanish-speaking patients (Rosal et al., 2005) and improvement in blood pressure control among Black Americans (Pickering, 2003). As mentioned above, self-monitoring involves individuals’ development of an awareness of their daily lifestyle habits, and thus an awareness of where their actual behavior conflicts with intended behavior. Rosal and colleagues’ (2005) pilot study on self-management of diabetes included an individual session for each participant followed by 10 weekly group sessions led by a nurse and a community volunteer. Self-completed logs helped participants to monitor their attainment of the goals of improving diet, increasing physical activity through walking, and regulating daily blood glucose level. This strategy was successful partly because participants discussed the facilitators and barriers to their adoption of new behaviors and then used problem solving to overcome identified barriers. The WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) program, funded by the Centers for Disease Control and Prevention (CDC), provides cognitive-behavioral prevention strategies to improve cardiovascular health as well as breast cancer screening among low-income, middle-aged women from multiethnic groups. Specific behavioral strategies vary by site and have included collaborative goal setting with community facilitators and completing homework through the use of self-monitoring. In addition, social support has been provided in group and community-based formats (Will, Farris, Sanders, Stockmyer, & Finkelstein, 2004). The program encourages variation in services depending on the cultural and regional nature of the clientele. Research has shown that WISEWOMAN interventions have produced significant increases in participants’ activity levels (Staten et al., 2004; Stoddard, Palombo, Troped, Sorensen, & Will, 2004). Motivational Interviewing Motivational interviewing is another individual-level counseling strategy that enhances positive change in health behaviors and adherence to treatment recommendations. Originally used for addiction treatments, motivational interviewing is a client-centered counseling style that entails openended questions, reflective listening, affirmations, and summarizations of what a client has said. Reflective listening, arguably the most crucial skill in this approach, requires that the counselor listen to the client and reflect what he or she says in an empathetic way. This, as well as agenda setting (i.e., inviting the client to select a target behavior that he or she is almost ready to tackle), facilitates a good rapport between practitioner and client. The purpose of motivational interviewing is to collaborate with the client to elicit discrepancies that point to the client’s ambivalence to change and help the client resolve that ambivalence (Rollnick & Miller, 1995). Rather than attempting to persuade, the counselor elicits the client’s subjective pros and cons for change and thereby draws attention to discrepancies between the person’s current health behaviors and his or her life goals. By attending to the client’s values and goals, this style of interviewing highlights the individual’s role and responsibility in making healthy choices and participating in his or her care. It challenges the individual to take ownership of his or her goals and arouses an internal motivation to change. By effectively using the three key communication skills of asking, listening, and informing, a practitioner can conduct a consultation with a patient efficiently and productively. Further, motivational interviewing has been shown to be successful in supporting smoking cessation, dietary change, weight loss, and reduction of substance abuse among various ethnic groups (e.g., Gil, Wagner, & Tubman, 2004; Lee et al., 2011; D. S. West, DiLillo, Bursac, Gore, & Greene, 2007). Motivational interviewing has been shown to be particularly effective when coupled with behavioral counseling and case management. For example, Lee and colleagues (2011) developed a brief motivational interview that was culturally adapted for immigrant Latinos with drinking problems. The interview emphasized the role of immigration, shifting family dynamics, and family support, and the researchers found that participants were highly engaged and satisfied with their treatment. Furthermore, nearly all participants reported that understanding their culture was important to understanding their drinking behaviors. Box 19.1 highlights a critical incident in which motivational interviewing techniques were used. Box 19.1 Critical Incident Using Motivational Interviewing Techniques A Latina patient who experienced a heart attack several weeks ago is being seen for follow-up. She is ambivalent about quitting smoking. Community-Based Programs In recent years, culturally competent programs have been delivered at the community level to overcome neighborhood-wide sources of ill health. These have included programs aimed at improving the environment, making neighborhoods more conducive to physical activity, and promoting the availability of healthy foods. In such programs, communities are involved in setting the goals and strategies. Community members are also involved in providing social support to one another and in program development and implementation (Fisher, Burnet, Huang, Chin, & Cagney, 2007). We describe two examples of successful community-based programs below. The CDC’s Racial and Ethnic Approaches to Community Health (REACH) initiative aimed to eliminate racial and ethnic disparities regarding diabetes. This initiative entailed a culturally tailored lifestyle intervention that was delivered by trained community residents. Community residents acted as family health advocates and used motivational interviewing in community meetings as well as home visits (for details, see Two Feathers et al., 2005). At the first meeting, the family health advocates provided information about diabetes and methods to reduce individuals’ stress. Subsequent meetings focused on encouraging community members to increase their physical activity, increase their consumption of fruits and vegetables, and decrease their intake of fatty foods and sugar. At the final meeting, advocates and other community members discussed the maintenance of behavioral changes, with social support as a key strategy. Study results showed that, in comparison with nonparticipants in the same health care system, Black REACH participants achieved greater improvements in their control of blood sugar levels (Spencer et al., 2011) as well as significant improvements in self-reported knowledge about diabetes self-management and physical activity. In a program called Supporting Healthy Activity and Eating Right Everyday (SHARE), Blacks received social support from family members and friends in a lifestyle modification program for managing diabetes and cardiovascular illness. Over 2 years, Kumanyika and colleagues (2009) evaluated weight loss in one cohort of patients who participated on their own and another cohort who participated with family and friends. Ninety-minute group sessions were held weekly for 6 months, biweekly for 6 months, and then monthly. Sessions included cognitive-behavioral techniques such as monitoring (weight and activity checks), skill building and homework, physical activity exercises, and counseling to enhance participants’ social support from others. Participants were advised on ways to elicit social support from and work with their partners, who could attend personal counseling sessions and field workshops. Relevant educational materials were mailed to participants’ partners. Individuals in control groups were not partnered with their support networks to complete such activities. The participants who had the most successful weight loss were partnered with family members and friends who were also successful in their weight loss. Although not measured in these studies, depression, which often accompanies physical health problems, may be reduced through similar interventions that use physical activity and social support. Studies examining exercise as a treatment for clinical depression have reported that significant changes in physical activity are associated with significant reductions in depressive symptoms (e.g., Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005; Van Voorhees, Walters, Prochaska, & Quinn, 2007). This may be an additional benefit that could be measured in future health promotion programs. Conclusions A review of the evidence strongly suggests that race and ethnicity, along with SES, are associated with disparities in infant mortality rates, rates of premature death, and rates of physical illness, such that certain minority groups, in comparison with Whites, are subject to much poorer outcomes. While there does not seem to be more psychological illness among ethnic minorities, the social and occupational consequences of physical and mental problems are more severe for minorities. The medical encounter is fraught with difficulties for both the patient and the professional. Counseling and education provided by professionals must engage patients through patient-centered and culturally competent practices. For counselors using cognitive-behavioral techniques and motivational interviewing, culturally competent communication skills, both verbal and nonverbal, are vitally important. A review of specific programs using these techniques points to the importance of tailoring lifestyle programs to the cultural needs of minority patients and communities. Discussion Questions 1. What are the benefits and the problems of the WHO’s definition of health as including physical, mental, and social well-being, and not simply the absence of disease? 2. Can you provide some examples of people whose physical health is compromised or unaffected by mental health problems, and vice versa? 3. Describe the relation between socioeconomic status and mortality. 4. Describe the relation between ethnicity and mortality. 5. Are physical and mental health similarly related to socioeconomic and ethnic status? What is the one exception to this pattern? 6. How is the health of children and adolescents affected if the parents are in lower-SES or ethnic minority groups? 7. Why is adolescence a pivotal period for health behavior? 8. Why are high education level and health literacy so closely associated with maintaining good health? 9. Name four pathways that explain how social status may influence an individual’s health. Give an example for each. 10. How might you try to prevent poor health by changing characteristics of each pathway to make it more health promoting? 11. Is there any evidence for or against the idea that being a target of racism is stressful, resulting in poor health? 12. What is culturally competent care? How does it improve a person’s health? 13. Why have cognitive-behavioral techniques and motivational interviewing become important strategies for effecting changes in health behaviors? 14. How have lifestyle behaviors such as diet and exercise been targeted for change among minority communities? 15. Could changes in lifestyle behaviors such as diet, exercise, and alcohol consumption improve mental health? Why? References Abdulrahim, S., James, S. A., Yamout, R., & Baker, W. (2012). Discrimination and psychological distress: Does Whiteness matter for Arab Americans? Social Science & Medicine, 75, 2116–2123. Adler, N. E., Boyce, T., Chesney, M., Cohen, S., Kaher, R. L., & Syme, S. L. (1994). Socioeconomic status and health: The challenge of the gradient. American Psychologist, 49, 15–24. Aroian, K., Hough, E. S., Templin, T. N., Kulwicki, A., Ramaswamy, V., & Katz, A. (2009). A model of mother–child adjustment in Arab Muslim immigrants to the US. Social Science & Medicine, 69, 1377–1386. Baker, D. W., Parker, R. M., Williams, M. V., Clark, W. S., & Nurss, J. (1997). The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health, 87, 1027–1030. Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. New York: Commonwealth Fund. Betancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2005). Cultural competence and health care disparities: Key perspectives and trends. Health Affairs, 24(2), 499–505. Bonicatto, S. C., Dew, M. A., Zaratiegui, R., Lorenzo, L., & Pecina, P. (2001). Adult outpatients with depression: Worse quality of life than in other chronic medical diseases in Argentina. Social Science & Medicine, 52, 911–919. Bopp, M., Peterson, J. A., & Webb, B. L. (2012). A comprehensive review of faith-based physical activity interventions. American Journal of Lifestyle Medicine, 6(6), 460–478. Bradby, H. (2012). Race, ethnicity and health: The costs and benefits of conceptualising racism and ethnicity. Social Science & Medicine, 75, 955–958. Clark, J. A., Rieker, P., Propert, K. J., & Talcott, J. A. (1999). Changes in quality of life following treatment for early prostate cancer. Urology, 53, 161–168. Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center. Dunn, A. L., Trivedi, M. H., Kampert, J. B., Clark, C. G., & Chambliss, H. O. (2005). Exercise treatment for depression: Efficacy and dose response. American Journal of Preventive Medicine, 28(1), 1–8. Eakin, E. G., Bull, S. S., Riley, K. M., Reeves, M. M., McLaughlin, P., & Gutierrez, S. (2007). Resources for health: A primary care–based diet and physical activity intervention targeting urban Latinos with multiple chronic conditions. Health Psychology, 26, 392–400. Elderkin-Thompson, V., Cohen Silver, R., & Waitzkin, H. (2001). When nurses double as interpreters: A study of Spanish-speaking patients in a US primary care setting. Social Science & Medicine, 52, 1343–1358. Evans, G. W. (2004). The environment of childhood poverty. American Psychologist, 59, 77–92. Falicov, C. J. (2009). On the wisdom and challenges of culturally-attuned treatments for Latinos. Family Processes, 48, 292–309. Farmer, M. M., & Ferraro, K. F. (2005). Are racial disparities in health conditional on socioeconomic status? Social Science & Medicine, 60, 191–204. Ferraro, K. F., Farmer, M. M., & Wybraniec, J. A. (1997). Health trajectories: Long-term dynamics among Black and White adults. Journal of Health and Social Behavior, 38, 38–54. Fielding, J. E. (1999). Public health in the twentieth century: Advances and challenges. Annual Review of Public Health, 20, xiii–xxx. Fisher, T. L., Burnet, D. L., Huang, E. S., Chin, M. H., & Cagney, K. A. (2007). Cultural leverage: Interventions using culture to narrow racial disparities in health care. Medical Care Research and Review, 64, 243–282. Gil, A. G., Wagner, E. F., & Tubman, J. G. (2004). Culturally sensitive substance abuse intervention for Hispanic and African American adolescents: Empirical examples from the Alcohol Treatment Targeting Adolescents in Need (ATTAIN) Project. Addiction, 99(Suppl. 2), 140–150. Gilliland, F. D., Hunt, W. C., & Key, C. R. (1998). Trends in the survival of American Indian, Hispanic, and non-Hispanic White cancer patients in New Mexico and Arizona, 1969–1994. Cancer, 82, 1769–1783. Giscombe, C. L., & Lobel, M. (2005). Explaining disproportionately high rates of adverse birth outcomes among African Americans: The impact of stress, racism, and related factors in pregnancy. Psychological Bulletin, 131, 662–683. Goodman, E. (1999). The role of socioeconomic status gradients in explaining differences in US adolescents’ health. American Journal of Public Health, 89, 1522–1528. Gump, B. B., Matthews, K. A., & Raikkonen, K. (1999). Modeling relationships among socioeconomic status, hostility, cardiovascular reactivity, and left ventricular mass in African American and White children. Health Psychology, 18, 140–150. Haas, S., & Rohlfsen, L. (2010). Life course determinants of racial and ethnic disparities in functional health trajectories. Social Science & Medicine, 70, 240–250. Harrell, J. P., Hall, S., & Taliaferro, J. (2003). Physiological responses to racism and discrimination: An assessment of the evidence. American Journal of Public Health, 93, 243–248. Howarth, N. C., Murphy, S. P., Wilkens, L. R., Hankin, J. H., & Kolonel, L. N. (2006). Dietary energy density is associated with overweight status among 5 ethnic groups in the Multiethnic Cohort Study. Journal of Nutrition, 136, 2243–2248. Jackson, J. S., Brown, T. N., Williams, D. R., Torres, M., Sellers, S. L., & Brown, K. (1996). Racism and the physical and mental health status of African Americans: A thirteen year national panel study. Ethnicity & Disease, 6, 132–147. Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., Murray, T., & Thun, M. J. (2008). Cancer statistics, 2008. CA: A Cancer Journal for Clinicians, 58, 71–96. Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L.A. (2004). Patient race/ethnicity and quality of patient–physician communication during medical visits. American Journal of Public Health, 94, 2084–2090. Karvonen, S., Rimpela, A. H., & Rimpela, M. K. (1999). Social mobility and healthy related behaviors in young people. Journal of Epidemiology & Community Health, 53, 211–217. Kaufman, J. S., Long, A. E., Liao, Y., Cooper, R. S., & McGee, D. L. (1998). The relation between income and mortality in U.S. blacks and whites. Epidemiology, 9, 147–155. Kessler, R. C., Foster, C. L., Saunders, W. B., & Stang, P. E. (1995). Social consequences of psychiatric disorders, I: Educational attainment. American Journal of Psychiatry, 152, 1026–1032. Kessler, R. C., Mickelson, K. D., & Williams, D. R. (1999). The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. Journal of Health and Social Behavior, 40, 208–230. Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of the cultural competency and how to fix it. PLos Medicine, 3(10), e294. Krieger, N., Williams, D. R., & Moss, N. E. (1997). Measuring social class in US public health research: Concepts, methodologies, and guidelines. Annual Review of Public Health, 18, 341–378. Krop, J. S., Coresh, J., Chambless, L. E., Shahar, E., Watson, R. L., Szklo, M., & Brancati, F. L. (1999). A community-based study of explanatory factors for the excess risk for early renal function decline in Blacks vs. Whites with diabetes: The Atherosclerosis Risk in Communities Study. Archives of Internal Medicine, 159, 1777–1783. Kumanyika, S. K., Wadden, T. A., Shults, J., Fassbender, J. E., Brown, S. D., Bowman, M. A., et al. (2009). Trials of family and friend support for weight loss in African American adults. Archives of Internal Medicine, 169(19), 1795–1804. Lee, C. S., López, S. R., Hernández, L., Colby, S. M., Caetano, R., Borrelli, B., & Rohsenow, D. (2011). A cultural adaptation of motivational interviewing to address heavy drinking among Hispanics. Cultural Diversity & Ethnic Minority Psychology, 17(3), 317–324. Lillie-Blanton, M., & Laveist, T. (1996). Race/ethnicity, the social environment, and health. Social Science & Medicine, 43, 83–91. Lillie-Blanton, M., Parsons, P. E., Gayle, H., & Dievler, A. (1996). Racial differences in health: Not just black and white, but shades of gray. Annual Review of Public Health, 17, 411–448. Lobel, M., Cannella, D. L., Graham, J. E., DeVincent, C., Schneider, J., & Meyer, B. A. (2008). Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health Psychology, 27, 604–615. Macintyre, S. (1997). The Black Report and beyond: What are the issues? Social Science & Medicine, 44, 723–745. McDonald, H. P., Garg, A. X., & Haynes, R. B. (2002). Interventions to enhance patient adherence to medication prescriptions. Journal of the American Medical Association, 288, 2868–2879. Mead, N., & Bower, P. (2002). Patient-centred consultations and outcomes in primary care: A review of the literature. Patient Education and Counseling, 48, 51–61. Messer, L. C., Vinikoor, L. C., Laraia, B. A., Kaufman, J. S., Eyster, J., Holzman, C., et al. (2008). Socioeconomic domains and associations with preterm birth. Social Science & Medicine, 67, 1247–1257. Mier, N., Ory, M., & Medina, A. (2010). Anatomy of culturally sensitive interventions promoting nutrition and exercise in Hispanics: A critical examination of existing literature. Health Promotion Practice, 11, 541–554. Nepomnyaschy, L. (2010). Race disparities in low birth weight in the U.S. South and the rest of the nation. Social Science & Medicine, 70, 684–691. Osypuk, T. L., Diez Roux, A. V., Hadley, C., & Kandula, N. R. (2009). Are immigrant enclaves healthy places to live? The multi-ethnic study of atherosclerosis. Social Science & Medicine, 69, 110–120. Papps, E., & Ramsden, I. (1996). Cultural safety in nursing: The New Zealand experience. International Journal of Quality in Health Care, 8(5), 491–497. Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., Renjilian, D. A., & Viegener, B. (2001). Relapse prevention training and problem-solving therapy in the long-term management of obesity. Journal of Consulting and Clinical Psychology, 69(4), 722–726. Pickering, T. G. (2003). Lifestyle modification and blood pressure control. Journal of the American Medical Association, 289, 2131–2132. Priest, N., Paradies, Y., Trenerry, B., Truong, M., Karlsen, S., & Kelly, Y. (2013). A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people. Social Science & Medicine, 95, 115–127. Reagan, P. B., & Salsberry, P. J. (2005). Race and ethnic differences in determinants of preterm birth in the USA: Broadening the social context. Social Science & Medicine, 60, 2217–2228. Ren, X. S., Amick, B. C., & Williams, D. R. (1999). Racial/ethnic disparities in health: The interplay between discrimination and socioeconomic status. Ethnicity & Disease, 9, 151–165. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325–334. Rosal, M. C., Olendzki, B., Reed, G. W., Ockene, I., Gumieniak, O., & Scavron, J. (2005). Diabetes self-management among low-income Spanish-speaking patients: A pilot study. Annals of Behavioral Medicine, 29(3), 225–235. Rosenthal, L., & Lobel, M. (2011). Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women. Social Science & Medicine, 72, 977–983. Schillinger, D., Bindman, A., Wang, F., Stewart, A., & Piette, J. (2004). Functional health literacy and the quality of physician–patient communication among diabetes patients. Patient Education and Counseling, 52, 315–323. Schwartz, S. B., & Ilan, H. M. (2010). Mental health disparities research: The impact of within and between group analyses on tests of social stress hypotheses. Social Science & Medicine, 70, 1111–1118. Singh, G. K. (2010). Child mortality in the USA, 1935–2007. Washington, DC: U.S. Department of Health and Human Services. Skevington, S. M. (1998). Investigating the relationship between pain and discomfort and quality of life, using the WHOQOL. Pain, 76, 395–406. Spencer, M. S., Rosland, A. M., Kieffer, E. C., Sinco, B. R., Valerio, M., Palmisano, G., et al. (2011). Effectiveness of a community health worker intervention among African American and Latino adults with type 2 diabetes: A randomized control trial. American Journal of Public Health, 101(12), 2253–2260. Staten, L. K., Gregory-Mercado, K. Y., Ranger-Moore, J., Will, J. C., Giuliano, A. R., Ford, E. S., et al. (2004). Provider counseling, health education, and community health workers: The Arizona WISEWOMAN project. Journal of Women’s Health, 13, 547–556. Stoddard, A. M., Palombo, R., Troped, P. J., Sorensen, G., & Will, J. C. (2004). Cardiovascular disease risk reduction: The Massachusetts WISEWOMAN project. Journal of Women’s Health, 13(5), 539–546. Street, R. L., Gordon, H., & Haidet, P. (2007). Physicians’ communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Social Science & Medicine, 65, 586–598. Teal, C. R., & Street, R. L. (2009). Critical elements of culturally competent communication in the medical encounter: A review and model. Social Science & Medicine, 68, 533–543. Two Feathers, J., Kieffer, E. C., Palmisano, G., Anderson, M., Sinco, B., Janz, N., et al. (2005). Racial and Ethnic Approaches to Community Health (REACH) Detroit partnership: Improving diabetes-related outcomes among African American and Latino adults. American Journal of Public Health, 95(9), 1552–1560. van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social Science & Medicine, 50, 813–828. Van Voorhees, B. W., Walters, A. E., Prochaska, M., & Quinn, M. T. (2007). Reducing health disparities in depressive disorders outcomes between non-Hispanic Whites and ethnic minorities: A call for pragmatic strategies over the life course. Medical Care Research and Review, 64(Suppl. 5), S157–S194. Wallace, J. M., & Muroff, J. R. (2002). Preventing substance abuse among African American children and youth: Race differences in risk factor exposure and vulnerability. Journal of Primary Prevention, 22, 235–261. West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type II diabetes. Diabetes Care, 30(5), 1081–1087. West, P. (1997). Health inequalities in the early years: Is there equalisation in youth? Social Science & Medicine, 44, 833–858. Will, J. C., Farris, R. P., Sanders, C. G., Stockmyer, C. K., & Finkelstein, E. A. (2004). Health promotion interventions for disadvantaged women: Overview of the WISEWOMAN projects. Journal of Women’s Health, 13(5), 484–502. Williams, D. R., & Collins, C. (1995). U.S. socioeconomic and racial differences in health: Patterns and explanations. Annual Review of Sociology, 21, 349–386. Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2003). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 93, 200–206. World Health Organization International Consortium in Psychiatric Epidemiology. (2000). Crossnational comparisons of the prevalences and correlates of mental disorders. Bulletin of the World Health Organization, 78, 413–425. Yanek, L. R., Becker, D. M., Moy, T. F., Gittelsohn, J., & Koffman, D. M. (2001). Project Joy: Faithbased cardiovascular health promotion for African American women. Public Health Reports, 116(Suppl. 1), 68–81. 20 Well-Being and Health James Allen Jordan Lewis Michelle Johnson-Jennings Primary Objective ■ To identify and describe key definitional issues in well-being for cross-cultural counselors Secondary Objectives ■ To describe ways in which cultural identity can play a pivotal role in well-being for many multicultural clients ■ To demonstrate the importance of intersectionality in identity statuses in multicultural wellbeing Silent, with a wary but distant gaze, John sat upright, grimacing and grinding his teeth. John, a 24year-old Alaska Native man who is gay, came to see me, an American Indian counselor who is heterosexual, for help in quitting drinking. We saw each other weekly during his outpatient program, then monthly. Now, almost a year later, he had called in agitation, wanting to be seen as soon as possible. We sat looking at each other without speaking. Through our work, I had become aware of the awful tensions hidden beneath John’s impassive stare; extreme dysphoria competed with an unendurable, deeply dreaded sense he might explode in rage at any moment. I sensed that John had identified his current state as one of his triggers. In years past, this would have precipitated days of nonstop drinking when John’s world would fall apart. Though this state was all too familiar, John’s current reaction was new. John was now determined he was not going back to drinking—this was out of the question. Instead, John had renewed attendance at daily Alcoholics Anonymous meetings and made this counseling appointment. I now found myself asking: “How do you want to respond to this person at work? He said you were overly sensitive about a joke he made about Native people drinking on First Avenue. How would you like to respond?” Silence. I realized I had overstepped. I had put John on the spot, before he was ready to speak. Perhaps this was due to my initial strong reaction to the event, an urge to help John, and feeling drawn to take action. Caught up in my personal process, I had not allowed John time to think carefully and compose his thoughts in the way the elders he so deeply respected had taught. Long silence ensued, as it was not yet the appropriate time to speak. Then, after several minutes, I realized that I had also not allowed John to provide context and understanding surrounding the profound impact of this microaggression. John spoke—quietly, breathlessly, almost imperceptibly: “Last week . . . he . . . mocked . . . gays . . . I walked out . . . got sick.” We sat in silence for several more long minutes. This time I knew better. I did not ask questions. Then, all at once, John visibly relaxed. The tension appeared to lift, and he did something new in our year of work together. He told a story. One section of the story included this: When I was first really getting to know Connie, she talked about when she was a young mom, raising nine kids in a one-room cabin on her own, in this village that she had not grown up in. Her husband had left her in his village. She said she took a lot of abuse. People would talk about her, right in front of her, as if she wasn’t there, as if she was invisible. People, and especially the White settlers, would say negative things about her, and about Native people like her. Connie told me a story about her father that guided her through this. She said: “I never let it bother me. That’s only one person like that. My dad drilled that into us when we were growing up, he said, ‘Our cultures, we’re just different from each other and different languages.’ He drilled this into my head before I left, ‘If you are treated badly, be silent about that and don’t fight back at it, because it’s going to make you just like them. Instead, treat them how you would like to be treated.’ I mean he trained us to live life well.” Connie was an elder with whom I had encouraged John to connect early in his struggles to stop drinking. Sharing Connie’s story marked John’s move into the realm of counseling for well-being and health. Counseling shifted from problem to future focus. Instead of coping with present urges to drink following this microaggression, John moved beyond it to define for himself what it meant to be “trained” in a life lived well. His search for the tools to build psychological well-being would involve negotiating multiple identity statuses in his relationships with others. While John was an Alaska Native person, he was also a gay person. The work required him to explore how each identity status—man, gay, and Alaska Native—carried its own and sometimes distinct set of cultural assumptions and values. At times, these identity statuses could be in conflict, with each other as well as with certain dominant cultural values. John’s quest involved more than defining a meaningful life without alcohol; it required reexamination, understanding, and, at times, reconciliation across these multiple identities. Situating Psychological Well-Being and Health Counseling Within Culture This chapter focuses on the ways in which psychological well-being and health counseling are inextricably linked to culture. While some people seek counseling specifically to enhance psychological well-being, most come seeking assistance in resolution of a problem. For many counselors, well-being counseling is associated only with the privileged and affluent, as in life coaching or executive coaching. The nature of much counseling work, in dealing with people facing very significant life problems, can further encourage counselors to fixate on problems and equate symptom remission with completion of their work. Further, the time-limited nature of many contemporary counseling relationships can drive counselors to lose sight of psychological well-being and health as crucial elements in defining long-term recovery, whether from alcohol, depression, or any number of other serious life problems. However, following significant and positive progress on the presenting problem, the counseling relationship frequently turns attention to the future in the termination process. At this juncture, therapeutic work moves beyond symptom relief, problem resolution, or prevention of relapse. Instead, during termination, the focus shifts to building on the gains made during counseling (Hill, 2005), and a focus on psychological well-being and health has the opportunity to be a near-universal element in a counselor’s termination work. Well-being is one of the most sought-after outcomes from counseling. The determinants of psychological well-being and health are rooted in the assumptions, beliefs, and values of culture. Hence, understanding the client’s culture becomes central to well-being counseling; stated differently, well-being counseling requires a “culture-centered” approach (Pedersen, 2003). Well-being and health counseling poignantly demonstrates how all counseling is cultural. Our goal in this chapter is to provide an understanding of ways in which cultural assumptions, beliefs, and values guide a person’s understanding, construction, and experience of well-being. Our objectives are (1) to describe key concepts that define how cultures vary in the ways they construct well-being, (2) to examine how development of cultural identity can play a central role in the formation of well-being, (3) to describe how well-being is often tied to the resolution of multiple, intersecting identities for contemporary multicultural individuals, and (4) to offer recommendations for integrating cultural elements into psychological health and well-being counseling. We close the chapter with some general conclusions about multicultural well-being counseling. In a seminal work in cultural psychology, Lewis-Fernandez and Kleinman (1994) identified three critical culture-bound assumptions limiting understandings in psychopathology: (1) an individualist or egocentric view of the self, (2) mind–body dualism, and (3) a view of culture as additive instead of central to defining psychological state. Our topic is well-being, not psychopathology. We emphasize that psychological well-being and health are qualitatively different from absence of psychopathology. Still, we believe these observations have relevance in that they identify parallel limitations in current understandings of psychological well-being and health with regard to multicultural populations. These assumptions constrain current psychological conceptions of well-being and health as well as current counseling approaches to foster them. In this chapter we develop a culture-centered approach to well-being and health counseling. Our approach is built on three critical assertions that call into question universalist assumptions regarding what constitutes well-being: ■ A life lived well is defined through values, and values are culturally embedded; culturecentered well-being counseling involves values clarification within the cultural frame of the person. ■ Being is defined through understandings of the self, and nature of the self is culturally defined; development of a coherent sense of cultural identity is an important goal for multicultural wellbeing counseling. ■ Multicultural individuals in contemporary societies typically occupy multiple identities; multicultural psychological well-being and health often involve negotiation of how different identities intersect. Because interest in psychological well-being and health has developed into a global literature of immense sociocultural complexity, we focus in this chapter on well-being and health counseling from the perspective of multicultural groups in the United States. Culture-Centered Well-Being and Health Counseling Though some elements of John’s story are unique to his personal and cultural background, others are common to many well-being counseling relationships. One common element is how the person arrives at the point where well-being becomes important. As in the cases of many who have struggled to overcome substance abuse, completion of John’s healing experience required him to define a meaningful life without alcohol. As we will see, as with many multicultural individuals, this included development of deeper connection as a cultural being. John was no longer interested in drinking, but he was unsure of how to proceed in living. Beyond learning to cope with problems without alcohol, John found himself searching for a sense of meaning and purpose in life. For John, this involved new appreciations of his cultural identity that he developed through actively seeking cultural experiences that fostered his sense of group membership. This included ways of joining more fully with the social network of his Native community and giving back to the community in return for what was given to him. A Cultural Framework for Well-Being and Health Counseling In well-being and health counseling, the symbolic meaning system of culture assumes singular importance. Accordingly, the working definition of culture for this chapter draws from Geertz (1973), who described culture as a “historically transmitted pattern of meanings embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which . . . [people] . . . communicate, perpetuate, and develop their knowledge about and their attitudes toward life” (p. 89). This definition emphasizes a shared meaning system crucial to culture-centered well-being counseling. It emphasizes exploration of ways culture forms understanding and directs action in construction of well-being. The Cultural Construction of Psychological Well-Being and Health A core foundation of multicultural counseling emphasizes examination of cultural values and assumptions underlying definitions and concepts (Pope-Davis, Coleman, Liu, & Toporek, 2003; Sue & Sue, 2008). Culture-centered well-being counseling inevitably involves questions about the different ways well and being are defined across cultures. It seeks to understand the values and assumptions with which individuals wish to identify. What describes a life lived “well” is defined through a shared vision, or cultural norms on what constitutes the good life. Stated somewhat differently, the nature of psychological well-being is largely defined through values, which are themselves culturally embedded. In a similar way, the nature of “being” is defined through cultural understandings regarding nature of the self and relation of self to other, sometimes referred to as self-construal (Markus & Kitayama, 2010). A significant body of research in cultural psychology documents enormous cultural variation in values and selfconstrual and the ways they are culturally shaped (Allen, Rivkin, & Lopez, 2014). One implication for multicultural counseling is that a person’s views about living well and the nature of being may be quite different from those of the dominant culture. A second implication is that when a client and counselor differ in cultural backgrounds, their values and beliefs about self may also differ. As we shall see in John’s story, this can be the case even when both come from the same broad ethnocultural group. In a provocative and influential review, Henrich, Heine, and Norenzayan (2010) describe numerous broad, universalistic statements in the psychological literature that were established through research limited to samples drawn from Western, educated, industrialized, rich, and democratic (WEIRD) societies. Yet people from WEIRD cultural backgrounds contrast markedly with the majority of people in the world, a fact that has important implications for well-being counseling. In contrast to most global cultures, WEIRD cultures possess a distinct and unusual set of values and way of thinking about the self as independent of others. Among WEIRD societies, the mainstream, dominant American cultural frame occupies an extreme pole regarding independence of the self. Even further out on this pole are U.S. undergraduates, who constitute the dominant samples in psychological research. This leads to a situation in which most current psychological knowledge uses samples constituting “an outlier in an outlier population” (Henrich et al., 2010, p. 78). The implications of this situation are as profound and far-reaching for well-being and health counseling as they are for any area of contemporary psychology. Mainstream psychological conceptions on the nature of well-being and health, and the events and behaviors that promote wellbeing and health, are based largely in a minority viewpoint among the world’s cultures. These conceptions may be in conflict with the explanatory models of many cultural groups. Multicultural well-being and health counseling requires considerably more than attention to cultural differences and multicultural awareness, knowledge, and skills sets. Effective well-being counseling must be culture-centered because it is precisely the culture-specific elements of the self that are central to well-being formation. Culturally defined values and conceptions of the self are at the heart of personal understandings of well-being. Psychological Well-Being and Health Are Defined Through Values: Values Are Culturally Defined Because any definition of the virtuous life is guided by values, all definitions of well-being are rooted in the systems of cultural assumptions that guide values formation. The events and behaviors believed to lead to the virtuous life are also guided by these values. In this way, how a person defines virtue and identifies the virtuous acts leading to a life lived well inevitably are culturally determined: “Understandings of psychological well-being necessarily rely upon moral visions that are culturally embedded and frequently culturally specific” (Christopher, 1999, p. 149). Western mainstream psychology describes people as universally valuing such things as being analytical when reasoning, having a wide range of options available when making choices, maintaining a highly positive self-image, and possessing a view of their own capabilities as above average. Yet emerging research finds that people from non-WEIRD societies may instead value being holistic in their reasoning, being less concerned with the importance of choice, and placing less importance on viewing themselves as above average (Jones, 2010). Well-being counseling with multicultural individuals in the United States requires the identification, open exploration, and reflexive acceptance of these alternative values distinctions and their underlying cultural assumptions. For many multicultural individuals, well-being counseling involves values clarification. This includes highlighting and bringing into awareness ways in which a person’s cultural values may at times differ from those of the mainstream or dominant culture. While any two cultural systems may share numerous values, other elements may prove unique. Even in the case of shared cultural values, elements within the same value structure may be weighted differently, or even interpreted differently across cultures. In the case of a person who inhabits more than one cultural identity status, culturecentered well-being and health counseling can reconcile opposing systems, exploring cultural assumptions leading to values conflict. The cultural assumptions underlying the counselor’s own values warrant careful personal exploration. This is not to say that the cultural embeddedness of the counselor is a shortcoming. Rather, cultural embeddedness is inevitable; it is a dialogue across cultures between counselor and client that will lead to health. What is potentially harmful is for a counselor to act ethnocentrically, as if values are not culturally embedded. Psychological Well-Being and Health Are Understood Through Beliefs About the Self: Culture Shapes Understandings of the Self The nature of the self encompasses a second cultural assumption defining well-being. Above, we discussed a robust finding from the cultural psychology research on how people from non-WEIRD cultural backgrounds tend to understand self as connected to others, while people from WEIRD cultures tend to view themselves as more separate (Heine, 2008). In the well-being literature, this cultural difference in self-construal is often described through the twin distinction of individualism/independence and collectivism/interdependence (Ryff, 1995). People from cultures aligned with an individualism/independence orientation conceive of themselves primarily as autonomous. This means they perceive themselves as possessing discrete abilities, attitudes, and personality traits. In contrast, people aligned with more of a collectivism/interdependence orientation conceive of themselves as intertwined with others in webs of social networks. They view themselves as possessing obligations toward others within these networks based on role expectations. This latter view is so culturally distinct that it emerges as “a rather peculiar idea within the context of the world’s cultures” (Geertz, 1975, p. 48). One important attribute of the interdependent model is that possibilities exist for well-being to constitute a shared experience with others. This means psychological well-being and health can extend beyond the realm of individual experience. This possibility requires counselor awareness that well-being for many people can be created only through interactions with others; this understanding adopts the perspective of intersubjectivity. Cultural Worldview and Well-Being To expand our understanding, we next briefly critique two prominent theories of well-being. We will examine implicit cultural assumptions in the theories of subjective well-being and self-determination theory/psychological well-being. Our goal is to expand appreciation of what we miss by limiting understanding of well-being exclusively to current perspectives. Through this exploration, we seek foundations for a more culture-centered approach to counseling. Well-Being as Life Satisfaction and Positive Affect: Subjective Well-Being For an example of how implicit cultural assumptions shape understandings of well-being, we need look no further than the most prominent theory of well-being, centered on subjective well-being (Diener, 2012). Subjective well-being is “a person’s evaluative reactions to his or her life—either in terms of life satisfaction (cognitive evaluations) or affect (ongoing emotional reactions)” (Diener & Diener, 1995, p. 653). The theory has generated an enormous body of research, firmly establishing well-being as a measureable outcome for psychological intervention (Diener, 2012; Morrison, Tay, & Diener, 2011). However, to evaluate well-being subjectively is to base it on a person’s own set of standards. Basing cognitive evaluations on one’s own standards, rather than on the standards of one’s ethnocultural group, invokes a particular system of cultural assumptions that, as described above, are associated with WEIRD societies and value personal independence over the strivings of the collective. In contrast, collectivism assumes mutually binding obligations to groups. Though this individualist/collectivist distinction runs the risk of oversimplifying issues of great complexity and is not without its numerous critics (Oyserman, Coon, & Kemmelmeier, 2002), a significant body of research spanning numerous cultural groups has identified collectivist beliefs, values, and selfrepresentations as offering one possible alternative to individualism (Owe et al., 2013). In a foundational article on subjective well-being, Diener (1984) posited that well-being (1) resides within the individual and within individual experience, (2) can be defined by measures that tap a specific set of constructs within positive psychology, and (3) encompasses a global assessment of all aspects of a person’s life. The first two assertions represent cascading arrays of cultural assumptions. The first proposes that well-being is subjectively evaluated and experienced solely on the level of the individual. This forecloses the possibility that well-being can be relationally experienced. The second assertion goes on to define positive psychology measures of well-being distinguished by value orientations around this individual locus of experience. In summary, subjective well-being uses an individualist self-construal and value orientation to define (1) the content of the cognitive evaluations and (2) the types of emotional experience in well-being. First, the content of the cognitive evaluations in subjective well-being include degree to which the person experiences self-esteem, self-determination, self-regulation of behavior, individuation, competence, and mastery. Taking mastery as an example from this list of cognitive evaluations, one is struck by how mastery is defined in one restricted way through autonomy. Mastery is defined as personal sense of control arrived at through personal achievement and effort in solving problems, coping with stressful situations, and overcoming life difficulties (Pearlin, Menaghan, Lieberman, & Mullan, 1981). This definition emphasizes personal agency and the pursuit of self-chosen goals. In numerous non-Western cultural frameworks, mastery is not identified as a component of well-being. For example, well-being may be defined through the skill by which individuals better align themselves with their existing realities (Weisz, Rothbaum, & Blackburn, 1984) rather than through mastery. Even within cultural settings where mastery is valued, it may be achieved in quite different ways. In communal mastery, people solve life problems by joining with other important figures within their social networks (Fok, Allen, Henry, Mohatt, & People Awakening Team, 2012). Joining with others, rather than autonomous behavior, is identified as an action defining well-being. Similar culture-specific assumptions underlie the values interpretation that elevates another example from this list of cognitive evaluations, high self-esteem, defined as favorable personal evaluations of the self (Schimmack & Diener, 2003). Yet, even though values elevating self-esteem are rooted in individualism, the behavior associated with public acts indicative of self-esteem remains to a significant degree relationally defined, even in individualist cultures (Guisinger & Blatt, 1994). Behaviors associated with self-esteem become acts with meaning when they are defined through the responses of others in the social environment (Bruner, 1990). These responses are guided by culturally normative scripts for behavior that are part of the process of meaning making provided by culture (Kitayama & Park, 2007). Normative scripts in personal independence models call for the person to act through behavior indicative of the internal attribute of high self-esteem. Others respond by providing approval and validation of the actor’s display of self-esteem. This self–other interchange is the cultural script that imbues the act with meaning, here defining self-esteem as an internal attribute of an independent self. In many non-Western cultures, including many East Asian cultures, an alternative cultural script is at play that values humility. The person instead is viewed as possessing, and often appropriately acknowledging, shortcomings and as being in need of support (Kitayama & Markus, 2000). Here the script calls for the other to express sympathy and interpersonal giving in response to acts that display need for support. This response from the other imbues these acts with different meaning, validating the actor as a person worthy of support. This script helps to form a community of interdependent selves, where humility regarding shortcomings and acceptance and giving of support create wellbeing. A different pathway to well-being emerges, based in different understandings of self and the meaning of action or behavior. Second, types of emotional states in which positive affect predominate are valued in subjective wellbeing. However, there are also important differences in how cultures value the subjective experience of positive affect and happiness. In many East Asian cultures, this emotion can have different meaning and provide different experience. Here, individuals may instead value a range of affective experience, acknowledging life more realistically and striving for balance between positive and negative affect (Kitayama, Markus, & Kurokawa, 2000). Overemphasis on maximizing positive affect as a well-being goal is viewed from this values perspective as undue self-aggrandizement, or drawing excessive attention to oneself inappropriately; it can also be viewed as naive in its lack of awareness of balance. Here balance refers to understanding how overreliance at one extreme end of affect, always happy, can have consequences, leading to inevitable swings to an equally extreme negative affective state. From this values perspective, happiness results from mutual validation, suggesting that the experience of well-being constitutes an intersubjective state shared between two or more people. Viewed from this interdependent perspective, well-being arises only when enjoined by others. Here the question arises, whose well-being is affected? In the individualist model, the focus on the interchange is clearly limited to the actor as individual, and the interchange is about individual well-being. In the interdependent model, the arena becomes broadened beyond the individual to others who are affected by the interaction. Our intent is not to critique cultural assumptions associated with individualism as flawed or maladaptive; multicultural perspectives instead embrace a reasoned cultural relativism. Applied to well-being, such relativism acknowledges that there can be multiple pathways to well-being and multiple understandings of what constitutes being psychologically healthy and well. Definitions of well-being based in individualism are just one option among many. Shortcomings emerge only when subjective well-being is represented as a universal theory (e.g., Diener, Tay, & Oishi, 2013; Morrison et al., 2011) rather than one of several possible cultural alternatives. This has important implications for counselors as they work to co-construct definitions of living life well with culturally distinct persons. Counselors need to remain attentive to their clients’ values, self-construal, and cultural scripts. Well-Being Through Realizing One’s Potential: Self-Determination Theory and Psychological Well-Being Subjective well-being, in its focus on life satisfaction and positive affect, adopts a hedonic perspective (Seligman, 2011), meaning it is focused on maximizing pleasure and minimizing pain (negative affect). In contrast, two of the major alternatives to subjective well-being in Western psychology, self-determination theory and psychological well-being, adopt a eudaimonic outlook. From the eudaimonic perspective, well-being involves more than simply pleasure and positive feelings. Instead, well-being is constructed through efforts to fulfill one’s full potential as an individual (Deci & Ryan, 2008; Ryan & Deci, 2001). Self-determination theory seeks to understand well-being as a universal striving for the realization of human potential (Ryan & Deci, 2011). It posits autonomy, competence, and relatedness as three universal psychological needs that, when fulfilled, create psychological well-being (Ryan & Deci, 2001, 2011). According to self-determination theory, the needs for autonomy, competence, and relatedness create intrinsic goals for the person, leading the person to actualization of his or her potential. The theory emphasizes intrinsic goals that provide for a deeper sense of well-being than extrinsic goals such as wealth, attractiveness, and social standing. Psychological well-being theory also broadens notions of well-being, emphasizing several dimensions of positive psychological functioning that do not appear in subjective well-being theory (Ryff, 1995). Working from the human development literature, Ryff (2008) describes well-being through a six-factor structure of needs assumed as universal among people. These are the needs for self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth. An important contribution of research spawned by the theory of psychological wellbeing has been to highlight ways in which the nature of well-being changes across the life span. The salience of each of these six factors shifts developmentally—for example, one study found that the needs for purpose in life and personal growth declined with age, while the needs for environmental mastery and autonomy increased (Ryff, 1995). You have probably noted by this point that both these theories, much like subjective well-being, place emphasis on autonomy. Autonomy values individuation, independence, self-determination, and the self-regulation of behavior. While these attributes are common to the people who have typically been studied in Western psychology, as we discussed earlier, ways of understanding the self differ across cultures. One variation is a cultural self-construal in which autonomy is not emphasized. Further, even within cultures that value autonomy as an important attribute of the self, autonomy itself can have different meanings (Christopher, 1999)—for example, autonomy can be valued as a striving for independence or as fulfillment of an important social role, such as a responsibility to one’s tribe. In other cultural frames where individuals attempt to align themselves with existing realities, pursuit of self-chosen goals through personal agency can be explicitly not valued by the culture (Weisz et al., 1984). Or in cultural settings where mastery is valued, it may instead be achieved communally, through joining with others to solve problems (Hobfoll, Schröder, Wells, & Malek, 2002). Many scholars working from the eudaimonic perspective display an awareness of these issues, and a number of their studies have found differences in the salience of well-being factors across cultures (Ryff, Keyes, & Hughes, 2004). Yet, while eudaimonic approaches propose alternatives to hedonic understandings of well-being, these approaches nonetheless propose a universalist model of psychological needs or dimensions of well-being. We have explored several lines of cultural research that question such universal models. A culture-centered approach to well-being counseling instead emphasizes how behavior and action are understood through relational interchanges governed by cultural scripts that vary across cultures. Different scripts lead to shifts in the meaning of behavior, even for behavior that outwardly appears as the same act. Nonequivalence of meaning emphasizes why exploration of local and personal meaning is at the heart of culture-centered well-being counseling. Sources of Values and Sense of Self: Racial and Ethnic Identity Ethnic identity is a person’s affiliation with the values and assumptions of an ethnic group and the resulting sense of group inclusion (Ong, Fuller-Rowell, & Phinney, 2011). In a recent meta-analysis, Smith and Silva (2010) explored the relation of ethnic identity to well-being among North American people of color. Their findings indicate that ethnic identity functions with greater salience during the developmental period of youth and within settings of significant cultural contact and/or change by directly affecting well-being variables and not by buffering against psychopathology. These findings suggest that negotiation of ethnic identity status can be a crucial element in the change processes of multicultural well-being counseling. Exploration of racial, ethnic, and cultural identities, including what these identities mean on a personal level and how they affect life experiences, are integral to personal constructions of well-being. How personal views become aligned with one or more cultural viewpoints depends on the person’s identification with an ethnic or racial group membership. Accordingly, culture-centered counseling involves facilitating the development of clients’ ethnic identities. This requires active engagement with clients’ cultural strengths, as well as with their ethnic, racial, and cultural identity distortions and confusions, given their centrality to well-being. Clarification of the rich and growing history of racial and ethnic identity is essential for well-being counselors, who are confronted with clients’ identities and both the problems and strengths these can create for the individuals. This is particularly relevant for persons with multiple identities. For John, the values of one ethnic, racial, cultural, or subculture group membership collided with those of another in which he shared membership. The Ecological Context of Well-Being Pedersen, Crethar, and Carlson (2008) emphasize the importance of contextual factors in culturecentered counseling, and especially ecological context, which refers to how the person fits into and is shaped by the broader social environment. Ecological perspectives are particularly important in understanding well-being (Brown & Kasser, 2005; Little, 2000); “key components of ecological context include class and socioeconomic status, religious community, ethnicity, quality of available education, quality of living environment, quality and availability of transportation to work and other various opportunities, and proximal availability of resources” (Pedersen et al., 2008, p. 67). People in U.S. society do not share equal access to these resources, and a disproportionate burden in the disparity falls upon people of color. This reminds counselors that well-being work includes a social justice dimension. For many multicultural individuals, the ecological context can exert profound limits on the impact of personal change on well-being in the absence of broader social change. In Search of a Life as It Is Meant to Be Lived: Three Sessions in Culture-Centered Well-Being Counseling Session 1. Resolving to Act as a Tradition Bearer: Living Life to Become an Elder in Training One reason John returned to Alaska was to reconnect with his culture. Yet over the years, John followed career ambitions, putting family and cultural connections on the back burner. When the move did not result in stronger connection, his drinking increased. He felt anxious much of the time and was episodically depressed, eventually hitting bottom. In addition to outpatient alcohol treatment, John saw a counselor. The counselor was also Native, an American Indian enrolled in a lower 48 tribe, but born in Alaska. Counseling initially dealt with craving for alcohol, coping with stressors, and triggers for drinking. The crisis described at the opening of this chapter precipitated three final sessions. The termination of counseling evolved into well-being counseling as John sought to define a meaningful life without drinking. Early in counseling, John’s counselor referred him to Connie, a respected Alaska Native elder. Connie joined an early session and talked about her own experiences stopping drinking; John’s counselor then suggested that John help Connie with some of the daily activities of life in the city, which were now sometimes a challenge for her. In between running errands for Connie, taking her to appointments, and doing minor home repairs for her, John would sit and talk with her. Sometimes, when the time was right, Connie would naturally shift into a different world and tell a story. Some of the stories were about her life, and others were from her father or her elders. The stories led John to a deeper understanding of the values underlying beliefs associated with his culture. One impact on John was a deeper appreciation of and renewed commitment to summer subsistence fishing. During this session, after telling the story that opened our chapter, John reflected with his counselor on how he had come to deeply respect his elder mentor. This led to a discussion of what it would mean to live a life to someday be considered an elder in training. By “elder in training,” John was referring to those middle-aged adults he knew who were not yet recognized as elders but were communally recognized as living in service to their tribe and community in preparation for possible selection to the role of elder. In John’s culture, as in many Native cultures, to become an elder is something different from becoming elderly. Elder is a social role of leadership created only through recognition by one’s community. John ended this session by stating that he saw in Connie a role model for well-being, and he wished to live a life that might prepare him to be like her someday. His counselor saw an opportunity and encouraged John to invite Connie to the next session. Session 2. Conjoint Session With an Elder John had actually known who Connie was for years before he entered counseling; they had always exchanged polite greetings when they came upon each other in the chance meetings of everyday community life. John believed he had always shown her respect, but he now admitted he had never known or understood her true substance. In fact, if he had been honest with himself then, he might have admitted he considered himself smarter. He shared with his counselor that this embarrassed him now. True, Connie never had formal schooling, and she spoke in “village” English, a dialect based in local vocabulary and her Native language’s syntax and sociolinguistics. Now John, who had prided himself on how he instead spoke English with a college vocabulary, felt embarrassed. John knew Connie as a woman who had worked much of her life doing housecleaning to support her children after she moved to the city. He had heard somewhere that Connie was the granddaughter of a famous leader and revered healer. John had only now come to appreciate the full meaning of this background through listening to her stories. His past attitudes were now a source of discomfort, as he now viewed them as condescending. Toward the end of their session together, John admitted to Connie with shame how he used to look at her. Connie surprised John by telling him she knew this at the time, but she also knew he would grow beyond this someday and would become an important leader and help his people. This seemed to open John up to deeper levels of candor and relationship, and he next found himself confiding in Connie about his sexual orientation. As he told her, it seemed a big relief, a weight off his shoulders, as if he had been hiding something from her, and perhaps himself. Connie again surprised John, telling him she knew this about him, and she repeated her belief that he would become an important leader and help his people. John became emotionally overwhelmed and, hiding a tear in his eye, ended by saying that he wanted to live his life from this day forward in a right way, so he could grow more like her. Session 3. Reconciling Intersectionality In their last session, John talked with his counselor about how as he progressed through his education he experienced an inner struggle with identity and where he belonged in the world. On the outside and on paper, John had achieved his career goals and had high ambitions. Yet he was struggling with selfidentity and his sexuality, trying to accept who he was as a Native gay man. It was during this time in his late 20s that his battle with alcohol became more difficult. He noted that he now was much more comfortable in his identity as a professional while also feeling he could be a gay Alaska Native male, and all these threads could be in service to his tribal people. Though he knew that at times it might be hard, as not everyone at home might accept him for who he was, he felt immeasurably strengthened through the support of Connie. He ended therapy clear about what living life well meant for him—in close relationship to the land of his people, where he vowed to return to subsistence fish each summer, deeply engaged in the cultural practices and traditions of his tribal people, and connected with his family and members of his tribal community. Through these practices, he could live a life following the example of Connie, so that someday he might possibly be able to fill the role of elder. He closed therapy by telling his counselor he did this not for himself but for his people and their future. Cultural Factors in Well-Being Counseling We have emphasized a culture-centered approach to well-being counseling because often what is culture specific is central to individual well-being. Well-being counselors must also remain mindful of the broad variability within racial and ethnic groups and the ways ethnic and racial categories can intersect with other identity statuses that include, but are not limited to, gender, socioeconomic status, religion, sexual orientation, and disability. The concept of intersectionality allows us to consider both the meanings and the consequences of these multiple categories of social group membership (Cole, 2009). Some of these complexities of intersectionality in psychological well-being and health are illustrated in John’s story. In our remaining discussion, we identify features within understandings of well-being from the perspectives of selected ethnocultural groups in the United States. In so doing, we acknowledge two shortcomings. First, these descriptions are not intended as exhaustive. Instead, they are illustrative of the types of culture-specific elements among many, but not necessarily all, individuals within each group. Second, such descriptions always risk stereotype, and we are mindful that presenting groups in this way often constitutes an ethnic gloss (Trimble & Dickson, 2005). Tremendous variability exists within each ethnocultural group, so much so that none of the material below will apply to all members of any such group. Instead of assuming these stances are true of any particular individual, a counselor can approach a person from a different cultural background using these ideas as possible starting points for understandings of well-being. The counselor can incorporate structural elements of the approach we have presented with John, seeking to discover if any of the elements discussed below are also relevant in this particular person’s own search for well-being. In this spirit, we briefly present selected concepts from the well-being literature on Asian American, African American, Hispanic, and American Indian and Alaska Native people. Asian American Compared with members of the dominant U.S. cultural groups, people from Asian cultural backgrounds often respond differently to measures of two key elements within subjective well-being: satisfaction with life and positive affective experience. Cultural factors provide an explanation for these findings. Kitayama and Markus’s (2000) review of a significant body of research documents how many people from East Asian cultural backgrounds occupy contrasting value poles from the tenets of subjective well-being theory in the areas of self-evaluation and affectivity. These values are formed through distinct culturally shaped elements of self-concept, relationality, cognitive style, and attributions (Kitayama & Park, 2007). One set of East Asian cultural values has important implications for the expression of satisfaction with life. These values emphasize self-criticism instead of the self-enhancement common to the independence models implicit in subjective wellbeing theory. As described earlier, another set of values prioritizes balance between positive and negative affective experience, regarding an expectation for constant positive affect as unrealistic and unhealthy in that it overlooks the importance of balance to all human experience. By adopting a culture-centered perspective, counselors from non-Asian cultural backgrounds can avoid misattributing the meaning of these value stances as indicative of dissatisfaction and unhappiness with life. Instead, these stances and their aligned behaviors may represent adaptive, culture-specific pathways to well-being. African American For many African Americans, well-being is inextricably linked to supportive social networks and strong spiritual orientation (Jackson & Sears, 1992; Utsey et al., 2007). Among African American adults, 89% self-identify as religious and 78% attend religious services regularly, and existing research links religiosity and spirituality to African American well-being (Mattis & GraymanSimpson, 2013). This research shows that spirituality facilitates African American well-being by mediating the relation between culture-specific coping strategies and well-being (Utsey et al., 2007) and by interacting with adherence to African American culture (Jang, Borenstein, Chiriboga, Phillips, & Mortimer, 2006). Well-being outcomes among African Americans have also been associated with strong social support formed through the construction of affiliative networks, seeking guidance from elders, and ritual (Elliott Brown, Parker-Dominguez, & Sorey, 2000; Utsey, Adams, & Bolden, 2000). Finally, more advanced stages of racial identity development have emerged as predictive of well-being among African American youth (Seaton, Scottham, & Sellers, 2006). While perceived discrimination has been linked to diminished well-being (Seaton, Caldwell, Sellers, & Jackson, 2010), advanced racial identity statuses are protective against negative effects of discrimination, racism, and microaggressions (Elmore, Mandara, & Gray, 2012). Well-being counselors working with African American people should be aware of the important strengths related to the culturespecific elements of social support, spirituality, and racial identity formation. Hispanic Familismo is the strong identification and attachment many Hispanic (or Latino/Latina) people experience with their nuclear and extended families, often involving elevation of family over individual needs (Smith-Morris, Morales-Campos, Castañeda Alvarez, & Turner, 2012). As a value system, it emphasizes obligations of material and emotional support to family members. In return, the individual receives family help and support to solve problems. Through this process, the family becomes central for decision making and behavior (Sabogal, Marin, Otero-Sabogal, Marin, & PerezStable, 1987). For many individuals of Hispanic origin, these values guide well-being formation. In return for identification with familismo, the individual gains social support, close proximity to aid in times of need, and identity formation. Familismo combines with religion and spirituality to create well-being (Koss-Chioino, 2013). In addition, Hispanic ethnic identity is associated with well-being, and research has documented its protective effects in providing a buffer from perceived discrimination and acculturative stress (Iturbide, Raffaelli, & Carlo, 2009). Important to well-being counseling, these findings suggest that those Latinos who perceive more ethnic discrimination tend to identify more with their ethnic group, and those with greater ethnic identification exhibit greater wellbeing; political activism is an important component of the expression of ethnic identity for Latinos (Cronin, Levin, Branscombe, van Laar, & Tropp, 2012). Finally, among the most valuable assets of Latino families are their social support networks. However, homophily and absence of weak ties characterize these social networks. Homophily is an inclination to associate and bond with people who are like oneself (McPherson, Smith-Lovin, & Cook, 2001). Weak ties are links to individuals outside daily social circles. Homophily and absence of weak ties in Latino networks, and especially immigrant networks, may affect potential for well-being (Ayón & Bou Ghosn Naddy, 2013). Wellbeing counseling can contribute by introducing strategies to broaden linkages to additional weak ties among social networks and to build on cultural strengths such as respect, cooperative behavior, and familismo (Chapman & Perreira, 2005). American Indians and Alaska Native American Indians and Alaska Natives represent an extraordinarily diverse ethnocultural grouping of 566 federally recognized tribes. While generalization across such a broad array of cultures is exceedingly difficult, connectedness describes one core value common to many individuals with tribal affiliation. Connectedness is concerned with how the welfare of the individual is interrelated within the extended family, the community, and the surrounding natural world (Mohatt, Fok, Burket, Henry, & Allen, 2011). More broadly, many Native people emphasize how a holistic connectedness with the larger spiritual universe underpins a healthy Native lifestyle. Trimble (2013) proposes connectedness as one of several common elements found among many Native people in their sense of well-being. He provides examples of concepts that appear repeatedly across several diverse tribal groups. These include mitakuye oyas’in (all of my relatives), a central concept to Lakota spirituality, referring to everything that is, has been, or ever will be created, and tiwahe eyecinka egloiyapi nahan oyate op unpi kte, the Lakota definition of healthiness, meaning “the family moving forward interdependently while embracing the values of generosity and interdependence.” Similarly, the Muscogee refer to a healthy individual as ho-nondawgii ahthlot tzeemonadzit heenlee hahdzii doeezh, or “this person is there, a person of good repute, around and available to help.” In Navajo or Dine, balance and beauty is hozho, and sa’ah naaghaii bi’eh hozho describes hozho through health, long life, happiness, wisdom, knowledge, harmony, the mundane, and the divine. In Tewa, ta e go mah ana thla mah can be translated as “this person is of good demeanor, kind and empathetic to the people and generous to those in need, including the animals.” And finally, among the Yup’ik, the concept appears in ellangneq, awareness of consequences; ellanaq, the process of becoming aware; and, finally, the spiritual source, Ellam-iinga, the eye of the awareness. Connectedness also links to sense of place, defined as the meanings and attachments many Native people hold to their traditional homelands (Semeken, 2005). Place as a lived and living presence is often central to identity, providing a source for well-being: wellness of the land becomes reflected in well-being of the people, and, reciprocally, the well-being of the people is reflected in the land (Bishop, Vicary, Mitchell, & Pearson, 2012). In the case of John, an important element of well-being counseling facilitated his sense of connectedness and of place. Conclusions: Values Clarification, Formation of Sense of Self, and Resolution of Intersectionality Tensions John is an Alaska Native man who considered himself to live in multiple worlds. To his family he was an Alaska Native professional doing work on behalf of his people. But John was also a gay man, and he struggled to accept this aspect of his life when it was not embraced by his immediate family. John also identified with his Alaska Native heritage. He spent considerable time learning more about his culture and its history. John sought a better sense of who he is and from where he and his family have come. Well-being counseling for John involved work at the intersection of these identities. The nature of intersectionality varies across ethnocultural groups and individuals within groups. However, we can draw some general conclusions about the nature of culture-centered well-being counseling. John’s story illustrates ways in which the development of well-being among many contemporary multicultural individuals involves navigation of intersectionality. John is male, Alaska Native, and gay, to name just three elements important to his own evolving sense of identity. Theories of well-being are at best different understandings of what makes up a good person and a life lived well. These understandings are moral visions in that they are based in values, frequently culturally embedded, and often culture specific. If we ignore this, we run the risk of interpreting the lives of non-Western people, ethnic minority people, women, LGBT people, people with disabilities, and others as less well. We also run the risk of closing ourselves off to the possibilities arising from culturally different values, visions of self, and understandings of well-being. This leads us to four conclusions about the nature of culture-centered well-being counseling: 1. There are no universal or “culture-free” measures or theories of well-being. 2. All counselors are culturally embedded, which is part of what makes them human and effective as counselors. At the same time, it requires them to recognize the limitations in their own understandings of well-being and to be insightful about their assumptions. 3. There is no single universal approach to well-being or to well-being counseling; instead, an interpretive approach can help to clarify values, sense of self, and identities and their intersectionality in order to strengthen well-being. 4. A critique of what is promoted as well-being by current psychological theory (e.g., autonomy, mastery, self-direction, positive emotion over balance) leads to a broader critique of the treatment goals and choices of intervention in other areas of counseling, something that can further invigorate the field of multicultural counseling. Critical Incident As John discussed feeling unaccepted as a child, tears fell from his eyes. My first instinct was to validate his emotions using my basic therapist tool of reflection. “John, I can see that this was a very painful time for you.” John nodded and seemed to relax. I could tell our working alliance around his identity was growing deeper. I could have stopped there, but given that John had shared a story with me, I felt the time was right to share a story with him. I shared how my uncle and cousin were “two-spirit” and faced a lot of outside discrimination. However, my family and local community truly valued them as the connection between male and female genders. Despite colonization, my indigenous culture maintained this respect. This gave them strength as they attempted to navigate the dominant culture. John turned to me with a confused expression. “Two-spirit?” he asked. “Oh, do you know what ‘two-spirit’ means?” I inquired. He did not, so I explained that “two-spirit” among many American Indian cultures refers to a person who is LGBT. John was silent. Though I was used to silence and saw it as valuable, I also knew culturally this could mean disapproval or disagreement. I was then surprised to see John’s eyes glaze over. Struggling to recover, I began by reflecting, “This ‘two-spirit’ term does not seem to resonate with you, does it?” He shook his head. More tears fell. “I’m not sure what you are talking about. My family is in Alaska and I’ve yet to even discuss my sexual identity with them. I’ve no idea how they would react. They attend the Catholic Church and are quite religious. But I’m pretty sure it wouldn’t be by valuing it!” My stomach flipped. I realized I had presumed that John grew up sharing my own cultural values. I had failed even to ask if his family was accepting of his sexual orientation. A feeling of shame crept over me. I had acted on an untested assumption that because we are both Native, we would share a similar understanding on this issue. Though I have been careful to explore the cultural backgrounds of my clients who are nonindigenous, I had just assumed my cultural schema fit for John. I sighed and said, “John, I just realized that I made a big mistake, and I am sorry. I presumed that you shared a cultural background similar to my own without determining first if this was the case.” John shifted uncomfortably in his seat and nodded slightly. All I could do was genuinely apologize: “You know, I really can’t stand it when others do that to me, and to do the same to you is not acceptable. I apologize and would like to start over, if we could.” John nodded. I knew it might take several sessions to repair our working relationship. “John,” I stated, “how about we begin our next session simply discussing what it was like for you to grow up as an Alaska Native who is gay?” I began to describe the cultural genogram (Gallardo-Cooper & Zapata, 2014) and asked if it would be okay to draw out his relationships for our next discussion. “Let’s start next time by discussing what you valued most about your home life, elders, culture.” John stated that he liked learning from Connie, and, after discussing her life, he wanted to take a look at his own. A wave of relief rolled over me; I had the feeling John would be back. I had learned a valuable lesson regarding ethnocultural transference (Comas-Díaz, 2014), and in particular, a specific variant—denial of ethnocultural difference. A critical incident of cultural misunderstanding emerged when I leaped to preconceptions about a client’s circumstances from my own subjective cultural frame, discounting his very different personal experience. This highlights the tremendous diversity across Native American cultures, and how our exchange involved elements of cross-cultural counseling across two indigenous cultures. The point generalizes to all therapy dyads in which counselor and client share membership in the same ethnic group, as such groupings often represent ethnic glosses (Trimble & Dickson, 2005) encompassing tremendous within-group diversity. Discussion Questions 1. Think back to before you read this chapter—at that point, what was your own personal understanding of well-being? 2. What are your own personal values as they relate to well-being? What are your understandings about the nature of the self as you see it at work for you? What are some of the implicit cultural assumptions you have been raised with, or have adopted, that guide these understandings? 3. Can you think of an example of intersectionality in your current life? If you can, do the identities involved fit together well for you, or has their intersection ever been a source of inner conflict? If the latter, how have you resolved the conflict, or how might you resolve it? 4. Visit with a friend from another cultural background or, alternatively, a relative from another age cohort in your family. Ask the other person if he or she has any thoughts about what constitutes a “life lived well.” (Most people have some thoughts about this topic). How are this person’s thoughts similar to your own? How are they different? 5. What are some ways in which counselors can ensure that they remain aware of implicit cultural biases? References Allen, J., Rivkin, I. D., & Lopez, E. D. S. (2014). Health and well-being. In F. T. L. Leong (Ed.), APA handbook of multicultural psychology: Vol. 1. Theory and research. Washington, DC: American Psychological Association. Ayón, C., & Bou Ghosn Naddy, M. (2013). Latino immigrant families’ social support networks: Strengths and limitations during a time of stringent immigration legislation and economic insecurity. Journal of Community Psychology, 41(3), 359–377. doi:10.1002/jcop.21542 Bishop, B. J., Vicary, D. A., Mitchell, J. R., & Pearson, G. (2012). Aboriginal concepts of place and country and their meaning in mental health. Australian Community Psychologist, 24(2), 26–42. Brown, K. W., & Kasser, T. (2005). Are psychological and ecological well-being compatible? The role of values, mindfulness, and lifestyle. Social Indicators Research, 74(2), 349–368. Bruner, J. S. (1990). Acts of meaning. Cambridge, MA: Harvard University Press. Chapman, M. V., & Perreira, K. M. (2005). The well-being of immigrant Latino youth: A framework to inform practice. Families in Society, 86(1), 104–111. Christopher, J. C. (1999). Situating psychological well-being: Exploring the cultural roots of its theory and research. Journal of Counseling & Development, 77(2), 141–152. Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64(3), 170–180. doi:10.1037/a0014564 Comas-Díaz, L. (2014). Multicultural psychotherapy. In F. T. L. Leong (Ed.), APA handbook of multicultural psychology: Vol. 2. Applications and training (pp. 419–441). Washington, DC: American Psychological Association. Cronin, T. J., Levin, L., Branscombe, N. R., van Laar, C., & Tropp, L. R. (2012). Ethnic identification in response to perceived discrimination protects well-being and promotes activism: A longitudinal study of Latino college students. Group Processes & Intergroup Relations, 15(3), 393–407. doi:10.1177/1368430211427171s Deci, E. L., & Ryan, R. M. (2008). Hedonia, eudaimonia, and well-being: An introduction. Journal of Happiness Studies, 9(1), 1–11. doi:10.1007/s10902-006-9018-1 Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95(3), 542–575. doi:10.1037/0033-2909.95.3.542 Diener, E. (2012). New findings and future directions for subjective well-being research. American Psychologist, 67(8), 590–597. doi:10.1037/A0029541 Diener, E., & Diener, M. (1995). Cross-cultural correlates of life satisfaction and self-esteem. Journal of Personality and Social Psychology, 68(4), 653–663. doi:10.1037/0022-3514.68.4.653 Diener, E., Tay, L., & Oishi, S. (2013). Rising income and the subjective well-being of nations. Journal of Personality and Social Psychology, 104(2), 267–276. doi:10.1037/A0030487 Elliott Brown, K. A., Parker-Dominguez, T., & Sorey, M. (2000). Life stress, social support, and well-being among college-educated African American women. Journal of Ethnic & Cultural Diversity in Social Work, 9(1/2), 55–73. Elmore, C. A., Mandara, J., & Gray, L. (2012). The effects of racial identity on African American youth well-being: A clarification of the research and meta-analysis. In J. M. Sullivan & A. M. Esmail (Eds.), African American identity: Racial and cultural dimensions of the Black experience (pp. 89–124). Lanham, MD: Lexington Books/Rowman & Littlefield. Fok, C. C., Allen, J., Henry, D., Mohatt, G. V., & People Awakening Team. (2012). Multicultural Mastery Scale for youth: Multidimensional assessment of culturally mediated coping strategies. Psychological Assessment, 24(2), 313–327. doi:10.1037/a0025505 Gallardo-Cooper, M., & Zapata, A. L. (2014). Multicultural family therapy. In F. T. L. Leong (Ed.), APA handbook of multicultural psychology: Vol. 2. Applications and training (pp. 499–525). Washington, DC: American Psychological Association. Geertz, C. (1973). Religion as a cultural system. In The interpretation of cultures: Selected essays (pp. 87–125). New York: Basic Books. Geertz, C. (1975). On the nature of anthropological understanding. American Scientist, 69, 4–53. Guisinger, S., & Blatt, S. J. (1994). Individuality and relatedness: Evolution of a fundamental dialectic. American Psychologist, 49(2), 104–111. doi:10.1037/0003-066x.49.2.104 Heine, S. J. (2008). Cultural psychology. New York: W. W. Norton. Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world? Behavioral and Brain Sciences, 33(2–3), 61–83. doi:10.1017/S0140525x0999152x Hill, C. E. (2005). Therapist techniques, client involvement, and the therapeutic relationship: Inextricably intertwined in the therapy process. Psychotherapy, 42, 431–442. Hobfoll, S. E., Schröder, K. E. E., Wells, M., & Malek, M. (2002). Communal versus individualistic construction of sense of mastery in facing life challenges. Journal of Social and Clinical Psychology, 21(4), 362–399. doi:10.1521/jscp.21.4.362.22596 Iturbide, M. I., Raffaelli, M., & Carlo, G. (2009). Protective effects of ethnic identity on Mexican American college students’ psychological well-being. Hispanic Journal of Behavioral Sciences, 31, 536–552. doi:10.1177/0739986309345992 Jackson, A. P., & Sears, S. J. (1992). Implications of an Afrocentric worldview in reducing stress for African American women. Journal of Counseling & Development, 71, 184–190. Jang, Y., Borenstein, A. R., Chiriboga, D. A., Phillips, K., & Mortimer, J. A. (2006). Religiosity, adherence to traditional culture, and psychological well-being among African American elders. Journal of Applied Gerontology, 25(5), 343–355. doi:10.1177/0733464806291934 Jones, D. (2010). A WEIRD view of human nature skews psychologists’ studies. Science, 328, 1627. Kitayama, S., & Markus, H. R. (2000). The pursuit of happiness and the realization of sympathy: Cultural patterns of self, social relations, and well-being. In E. Diener & E. M. Suh (Eds.), Culture and subjective well-being (pp. 113–161). Cambridge: MIT Press. Kitayama, S., Markus, H. R., & Kurokawa, M. (2000). Culture, emotion, and well-being: Good feelings in Japan and the United States. Cognition and Emotion, 14(1), 93–124. doi:10.1080/026999300379003 Kitayama, S., & Park, H. (2007). Cultural shaping of self, emotion, and well-being: How does it work? Social and Personality Psychology Compass, 1(1), 202–222. doi:10.1111/j.17519004.2007.00016.x Koss-Chioino, J. (2013). Religion and spirituality in Latino life in the United States. In K. I. Pargament (Ed.), APA handbook of psychology, religion, and spirituality: Vol. 1. Context, theory, and research (pp. 599–615). Washington, DC: American Psychological Association. Lewis-Fernandez, R., & Kleinman, A. (1994). Culture, personality and psychopathology. Journal of Abnormal Psychology, 103, 67–71. Little, B. R. (2000). Free traits and personal contexts: Expanding a social ecological model of wellbeing. In W. B. Walsh, K. H. Craik, & R. H. Price (Eds.), Person–environment psychology: New directions and perspectives (2nd ed., pp. 87–116). Mahwah, NJ: Lawrence Erlbaum. Markus, H. R., & Kitayama, S. (2010). Cultures and selves: A cycle of mutual constitution. Perspectives on Psychological Science, 5, 420–430. Mattis, J. S., & Grayman-Simpson, N. A. (2013). Faith and the sacred in African American life. In K. I. Pargament (Ed.), APA handbook of psychology, religion, and spirituality: Vol. 1. Context, theory, and research (pp. 547–564). Washington, DC: American Psychological Association. McPherson, M., Smith-Lovin, L., & Cook, J. M. (2001). Birds of a feather: Homophily in social networks. Annual Review of Sociology, 27, 415–444. Mohatt, N. V., Fok, C. C. T., Burket, R., Henry, D., & Allen, J. (2011). Assessment of awareness of connectedness as a culturally-based protective factor for Alaska Native youth. Cultural Diversity & Ethnic Minority Psychology, 17(4), 444–455. Morrison, M., Tay, L., & Diener, E. (2011). Subjective well-being and national satisfaction: Findings from a worldwide survey. Psychological Science, 22(2), 166–171. doi:10.1177/0956797610396224 Ong, A. D., Fuller-Rowell, T. E., & Phinney, J. S. (2011). Measurement of ethnic identity: Recurrent and emergent issues. Identity, 10(1), 39–49. Owe, E., Vignoles, V. L., Becker, M., Brown, R., Smith, P. B., Lee, S. W. S.,... Jalal, B. (2013). Contextualism as an important facet of individualism–collectivism: Personhood beliefs across 37 national groups. Journal of Cross-Cultural Psychology, 44(1), 24–45. doi:10.1177/0022022111430255 Oyserman, D., Coon, H. M., & Kemmelmeier, M. (2002). Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin, 128(1), 3–72. Pearlin, L. J., Menaghan, E. G., Lieberman, M. A., & Mullan, J. T. (1981). The stress process. Journal of Health and Social Behavior, 22, 337–356. Pedersen, P. B. (2003). Increasing the cultural awareness, knowledge, and skills of culture-centered counselors. In F. D. Harper & J. McFadden (Eds.), Culture and counseling: New approaches (pp. 31–46). Needham Heights, MA: Allyn & Bacon. Pedersen, P. B., Crethar, H. C., & Carlson, J. (2008). Inclusive cultural empathy: Making relationships central in counseling and psychotherapy. Washington, DC: American Psychological Association. Pope-Davis, D. B., Coleman, H. L. K., Liu, W. M., & Toporek, R. L. (Eds.). (2003). Handbook of multicultural competencies in counseling and psychology. Thousand Oaks, CA: Sage. Ryan, R. M., & Deci, E. L. (2001). On happiness and human potentials: A review of research on hedonic and eudaimonic well-being. Annual Review of Psychology, 52, 141–166. doi:10.1146/annurev.psych.52.1.141 Ryan, R. M., & Deci, E. L. (2011). A self-determination theory perspective on social, institutional, cultural, and economic supports for autonomy and their importance for well-being. In V. I. Chirkov, R. M. Ryan, & K. M. Sheldon (Eds.), Human autonomy in cross-cultural context: Perspectives on the psychology of agency, freedom, and well-being (pp. 45–64). New York: Springer Science + Business Media. Ryff, C. D. (1995). Psychological well-being in adult life. Current Directions in Psychological Science, 4(4), 99–104. doi:10.1111/1467-8721.ep10772395 Ryff, C. D. (2008). Challenges and opportunities at the interface of aging, personality, and well-being. In O. P. John, R. W. Robins, & L. A. Pervin (Eds.), Handbook of personality psychology: Theory and research (3rd ed., pp. 399–418). New York: Guilford Press. Ryff, C. D., Keyes, C. L. M., & Hughes, D. L. (2004). Psychological well-being in MIDUS: Profiles of ethnic/racial diversity and life-course uniformity. In O. G. Brim, C. D. Ryff, & R. C. Kessler (Eds.), How healthy are we? A national study of well-being at midlife (pp. 398–422). Chicago: University of Chicago Press. Sabogal, F., Marin, G., Otero-Sabogal, R., Marin, B. V., & Perez-Stable, E. J. (1987). Hispanic familism and acculturation: What changes and what doesn’t. Hispanic Journal of Behavioral Sciences, 9, 397–412. Schimmack, U., & Diener, E. (2003). Predictive validity of explicit and implicit self-esteem for subjective well-being. Journal of Research in Personality, 37, 100–106. doi:10.1016/S00926566(02)00532-9 Seaton, E. K., Caldwell, C. H., Sellers, R. M., & Jackson, J. S. (2010). An intersectional approach for understanding perceived discrimination and psychological well-being among African American and Caribbean Black youth. Developmental Psychology, 46(5), 1372–1379. doi:10.1037/a0019869 Seaton, E. K., Scottham, K. M., & Sellers, R. M. (2006). The status model of racial identity development in African American adolescents: Evidence of structure, trajectories, and well-being. Child Development, 77(5), 1416–1426. Seligman, M. E. P. (2011). Flourish: A visionary new understanding of happiness and well-being. New York: Free Press. Semeken, S. (2005). Sense of place and place-based introductory geoscience teaching for American Indian and Alaska Native undergraduates. Journal of Geoscience Education, 53, 149–157. Smith, T. B., & Silva, L. (2010). Ethnic identity and personal well-being of people of color: A metaanalysis. Journal of Counseling Psychology, 58, 42–60. doi:10.1037/a0021528 Smith-Morris, C., Morales-Campos, D., Castañeda Alvarez, E. A., & Turner, M. (2012). An anthropology of familismo: On narratives and description of Mexican/immigrants. Hispanic Journal of Behavioral Sciences, 35(1), 35–60. doi:10.1177/0739986312459508 Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5th ed.). Hoboken, NJ: John Wiley. Trimble, J. E. (2013). Well-being considerations among North American Indians: Scripts, relationships, and connections. Paper presented at the annual meeting of the American Psychological Association, Honolulu. Trimble, J. E., & Dickson, R. (2005). Ethnic gloss. In C. B. Fisher & R. M. Lerner (Eds.), Encyclopedia of applied developmental science (Vol. 1, pp. 412–415). Thousand Oaks, CA: Sage. Utsey, S. O., Adams, E. P., & Bolden, M. (2000). Development and validation of the Africultural Coping Systems Inventory. Journal of Black Psychology, 26, 194–215. Utsey, S. O., Bolden, M. A., Williams, O., III, Lee, A., Lanier, Y., & Newsome, C. (2007). Spiritual well-being as a mediator of the relation between culture-specific coping and quality of life in a community sample of African Americans. Journal of Cross-Cultural Psychology, 38(2), 123–136. doi:10.1177/0022022106297296 Weisz, J. R., Rothbaum, F. M., & Blackburn, T. C. (1984). Standing out and standing in: The psychology of control in America and Japan. American Psychologist, 39(9), 955–969. doi:10.1037/0003-066x.39.9.955 21 Family Counseling and Therapy With Diverse Ethnocultural Groups Guillermo Bernal Jennifer Morales-Cruz Keishalee Gómez-Arroyo Primary Objective ■ To familiarize counselors and therapists with the conceptual tools they need to understand diverse families in changing social, historical, and multicultural contexts Secondary Objectives ■ To provide an overview of the definitions of family, taking into account changing social, historical, economic, and cultural contexts ■ To review recent advances in the tools and resources for working with diverse ethnocultural families, multiculturalism, and the movement toward evidence-based practices Multiculturalism abounds, but theories and models for counseling work with families of diverse backgrounds have generally lagged behind the social, cultural, and linguistic realities of practice, research, and training. Consider the following statement from established family counseling scholars: “Family therapy has ignored [the] multicultural dimension of our society. We have proceeded to develop models without regard to their cultural limitations. We have failed to notice that families from many cultural groups never come to our therapy or find our techniques helpful” (McGoldrick & Hardy, 2008, p. 4). Calls to “re-vision,” revisit, or even revise theories of family counseling and psychotherapy are certainly needed. While the multicultural family counseling and therapy movement has advanced the field from one focused almost exclusively on the individual’s internal world to one that examines external environments, systems, and contexts, McGoldrick and Hardy (2008) call for a deeper revisioning of family theories and models, given the limitations of current theories and models for application to various ethnocultural groups (ECGs). The multicultural movement also has called for a recasting of the field of counseling and psychotherapy to include consideration of the role of culture and context in mental health treatments. Some have proposed cultural enhancement (S. Sue, Zane, Hall, & Lauren, 2009), others have encouraged adaptation of evidence-based treatments (Bernal & Domenech Rodríguez, 2012), and still others have urged the development of completely new treatments for particular ECGs (Gone, 2010). Both the family systems and the multicultural counseling and therapy movements have encouraged counselors to move beyond what was almost an exclusive vision of the person’s interior world and/or individual behaviors. While not negating the importance of subjectivity, a re-visioning privileges the individual within his or her social and cultural contexts, such as various family systems. A reframing or re-visioning of family counseling and therapy implies an appreciation of human systems embedded in larger structures and organized around categories such as family, ethnicity, gender, sexual orientation, and disability. In the family counseling and therapy field, a number of scholars have proposed a more integrative and inclusive view (Boyd-Franklin, 2003; Falicov, 1998; McGoldrick, Giordano, & García-Preto, 2005; Pinsof & Lebow, 2005; Szapocznik & Kurtines, 1993). However, a close examination of the contents of theories and research reveals that culture, ethnicity, and language have been historically absent (Bernal, Trimble, Burlew, & Leong, 2003; Pedersen, 1999; S. Sue et al., 2009; Wampold, 2001). The gap between theories and practice can be explained in part by changing socioeconomic and cultural contexts. Theories based on concepts assumed to operate as universal with a particular population may not apply to other groups. The gap between theories of family change and the implementation of these theories in the world of practice may be attributable to challenges in understanding the family—how it changes over time, how it is influenced by culture—and the challenge of viewing culture as dynamic rather than static. Revisioning family counseling theories and therapy necessitates an appreciation of how notions of the family have evolved over time. The challenge becomes how to inform mental health professionals’ understanding of the family and family process with an appreciation of the sociohistorical and cultural contexts. Below, we examine some basic definitions of the family and discuss how these definitions have changed over the years. What Is the Family? The family is a fundamental social unit of society (Parsons, 1949) that some have defined as a system of social interaction (Waller, 1938). While there are many definitions of the family, in Western societies the “nuclear family,” as traditionally defined, consists of a heterosexual couple with their children living in the same household. Single-parent families, blended families (couples and their children from other relationships), and unmarried persons living together are just a few possible other forms of families; also, family members may be heterosexual, homosexual, multicultural, and so on (Crawford, 1999). The term family has its origin in the Latin familia, meaning household, the root of which is famulus, meaning servant. The family may be defined as a group of persons who live in one house, including parents, children, and servants (or domestic slaves). Family is also defined as a group of persons consisting of parents and their children, whether or not they actually live together as a unit, based on affinity or blood relations. A somewhat broader view of the family is that it encompasses those descended or claiming to have descended from a common ancestor (lineage). Engels (1884/1972) defined the family as a social institution that is changing and certainly not eternal or fixed in time. In 1949, Murdock published an extraordinary volume on the social structure of the family in which he affirmed that the family is a basic group present within all human cultures, using his research through 250 cross-cultural studies to support his thesis. Murdock described the nuclear family as “a social group characterized by common residence, economic cooperation, and reproduction. It includes adults of both sexes, at least two of whom maintain a socially approved sexual relationship, and one or more children, own or adopted, of the sexually cohabiting adults” (p. 1). Based on his research, Murdock asserted that the nuclear family is a universal form of human grouping. Murdock’s view of the family had a major impact in the field, despite the critiques of many scholars. A challenge to the universalistic view of the nuclear family came from Ward Goodenough, one of Murdock’s students. Goodenough (1970/2009) noted that Murdock’s view was a reflection of middleclass families in developed Western societies such as the United States and Western Europe. Indeed, what may be considered as the nuclear family in other cultures and societies could be what Goodenough termed the “functional analogue” (p. 4) of nuclear families in Western countries. He defined the family unit as one made up primarily of a mother and her children, but also potentially including others who are defined as significant and who serve particular functions (p. 164). The family is more than a group of people sharing a physical and psychological space; the relationships among the members of this microculture are full of meaning, multilayered, and based on a shared sense of purpose. In such a system, individuals are tied by emotions and loyalties, and the intensity of relationships may change over time, but the relationships are presumed to be constant over the family members’ lifetimes. Today, families occur in a diversity of forms. They are constituted as natural social systems with their own properties. Each family and its members develop rules and roles to form an organized structure that engages in problem-solving activities that enable the system to function effectively (Goldenberg & Goldenberg, 2000). Changes in the Family Over Time The family and views of the family have evolved over the past century and a half. These changes are relevant to the notion of the family as a social institution as it is restructured across cultures and over time (Hill, 2012). One key notion is based on an evolutionary perspective: that families adapt in response to social, historical, and economic transformations to ensure the physical survival of their members. Families are often presented as primary institutions in sociology, because they have a critical and early role in the lives of their offspring. The rise of industrialization displaced thousands of agricultural workers, thereby creating familybased cottage systems of industry that drew on the labor of the entire family (Hill, 2012). By the middle of the 19th century, the industrial economy was struggling to meet the demands of the new markets being opened around the world, and factories were springing up in cities and towns; this economic transition took place over the course of more than a century and resulted in massive social, geographical, and family changes. With technological advances and the growth in mass production of staple goods, the need for small family farms was reduced. The onset of World War II further increased labor market participation by women, as many were drawn into the workforce to replace the men who went off to war. The increased industrial production that occurred in the United States during World War II revitalized the nation’s economy, making it the strongest economy in the world. With industrialization, new social institutions emerged (e.g., public schools, hospitals, social security programs) that assumed some of the tasks and functions once fulfilled by families, making people less dependent on the family. Some important functions seemed to be lost as societies modernized and marriage became optional rather than essential for survival. Parsons and Bales (1955) theorized that advanced societies underwent a process of structural differentiation resulting in the construction of nonkinship structures (e.g., churches, hospitals, schools) that provided specialized functions. Key functions once provided by family, such as caring for the sick, educating children, and producing food, were replaced by the new social institutions. Parsons was convinced that human character is constructed through socialization processes (Hill, 2012). Among the nonkinship structures that arose were organizations designed to provide support in the form of mental health care, psychotherapy, and other social services that also served as substitutes for former family functions. The peace and prosperity that characterized the 1950s led scholars to call the era “the golden age of the family.” The social protest movements of the 1960s and 1970s sparked a broader human liberation focused on civil rights, denouncing racial segregation and ethnic discrimination and promoting gender equality. Movements emerged that asserted the rights of the elderly, gays and lesbians, and the differently abled. Such movements transformed the field of family studies. Strides toward gender equality are currently reflected in the private arena of the home, where men and women today tend to share responsibility for housework and child care (Sullivan, 2006). Alternative definitions of marriage and family have arisen, transcending the traditional nuclear family. Such newer definitions include homosexual couples, who may or may not have children (Gittins, 1993). Indeed, advances in medicine such as in vitro fertilization have led to substitution of even the family function of reproduction itself. The notion of the family as nuclear was in part supported by changes in capitalism, technology, innovation, and acceptance of modern values. The expansion of capitalism to new markets across the world sparked a process of modernization, and the advent of new technologies created a global economy that was impossible to ignore, especially within the family system (Hill, 2012; Sullivan, 2006). Lash’s (1984) critique of the modern family goes a step further, arguing that the contemporary family is “the product of egalitarian ideology, consumer capitalism, and therapeutic interventions” (p. 186). According to Lash, even parenting and child rearing are now taken away from parents: “The ‘helping professions’ sided with the weaker members of the family against patriarchal authority. The school system, the child-care professions, and the entertainment industry have now taken over the custodial, disciplinary, and educative activities formerly carried out by the family” (p. 186). Another perspective is the contextual developmental model of family change (Kağitçibaşi, 1996), which encompasses socioeconomic processes (Bekman & Aksu-Koç, 2009). According to this model, interdependence, independence, and emotional interdependence are the three contextual patterns of family that explain variations in family functions in diverse socioeconomic status (SES) groups. These patterns are categorized in two dimensions: emotional and material. The first pattern, interdependence, is explained as the typical model of the extended family, consisting of all material and emotional interdependence in families located in rural/agrarian traditional societies. The second pattern, mainly independence, describes nuclear families such as those in middle-class cultures in industrialized Western countries. One of the most comprehensive cross-cultural studies of the family was conducted by Georgas, Berry, van de Vijver, Kağitçibaşi, and Poortinga (2006). These scholars examined similarities and differences among families in 27 countries based on hypotheses derived from Berry’s (1979) ecocultural theory and Kağitçibaşi’s (1999) model of family change. The study focused on social variables such as socioeconomic status, education, religion, and workforce engagement. Family variables included roles of the immediate and extended family members. The results of this landmark study have important implications for the field. First, SES accounted for differences in family and psychological variables. For example, hierarchical values explained the differences between more and less affluent countries, with lower-SES countries favoring greater hierarchical family values compared to higher-SES countries. Important differences were found for psychological factors such as emotional bonds, personality characteristics, and values. Similar SES patterns were found for personal and family values (e.g., respect, honor, reputation, harmony). The instrumental and expressive roles of families, however, were similar to those described by Parsons (1949): In lowSES countries parents shared the expressive role with their children, whereas in the more affluent countries mothers and fathers shared financial responsibilities. The findings from work by Georgas et al. (2006) and Kağitçibaşi (2007) suggest that family structure (nuclear or extended) is associated with social and economic contexts. Members of ethnocultural groups from more agricultural and lower-SES countries are more likely to conceive of the family as extended than as nuclear. Also, family values (authoritarian versus egalitarian or shared power) are salient factors that distinguish families from more and less affluent countries. Is Love All We Need . . . in Families? The transformations experienced by the family over the past 150 years or so have been unparalleled. Before industrialization, the family was involved in a host of activities and functions that united members in shared tasks and functions, such as the protection and socialization of members, reproduction, education of the children, and care of the sick and aged, as well as economic activities providing food, shelter, and financial support. The family was also a means for the satisfaction of the affective and emotional needs of its members. With industrialization and now globalization, nearly all of the tasks and functions once provided by the family are now offered by other social institutions. The family has transformed from a taskoriented organization, whose members were bound and connected by many ties derived from engaging together in a wide range of activities and functions, to a social organization almost exclusively bound by expressive and affective ties—that is, ties of love. If affection and love are the only basis for family relationships, then the threat of losing love unhinges group cohesiveness. If no other bonds, ties, or connections exist to sustain the family system, it is unlikely that the family can stay together. For example, if the career plans of one member of a couple interfere with those of his or her spouse, can the marital unit stay together simply based on unconditional love? If unconditional love is indeed one of the only remaining bonds that keeps family members united, is it a coincidence that family therapy arose in the 1950s, soon after large numbers of women left the workforce and returned to the home to make jobs available for World War II veterans, and when the “nuclear family” was being idealized? Multiculturalism and Families We began this chapter by acknowledging that while the multicultural world is a reality, many of the mental health profession’s theories, methods, and research continue to lag behind the changes that are taking place daily. Multiculturalism is now considered the fourth force in psychology (Pedersen, 1990), and it became a force as professionals in different venues realized that their theories, research, and practice methods did not seem relevant or even applicable to the changing demographic landscape. Prominent scholars in the field suggest that contemporary psychotherapy and counseling practices have harmed the members of ethnocultural groups by “invalidating their life experiences, by defining their cultural values or differences as deviant and pathological, by denying them culturally appropriate care, and by imposing the values of a dominant culture upon them” (D. W Sue & Sue, 2008, p. 34). Not only has the universality of theories, practices, and treatments been questioned, but also the basic ethical principle of doing no harm is at stake. A number of terms have emerged, such as cultural sensitivity, cultural competence, and cultural adaptation, that reframe the therapeutic encounter to include the experience of race, culture, language, ethnicity, gender, and context. Below, we consider the meanings of some key terms and subsequently offer a brief commentary on some of the advances in the culturally informed evidence-based movement as applied to ethnocultural families. Cultural Sensitivity, Competence, and Humility Cultural sensitivity has emerged as a fundamental prerequisite for counseling with ECGs (D. W. Sue, Arredondo, & McDavis, 1992; Trimble, 2003). Recognition of the need for mental health professionals to consider race, culture, language, and context in counseling has evolved over the years. Today, some professional organizations have policy statements concerning diversity, such as the American Psychological Association’s (2003) guidelines on multicultural education, training, research, practice, and organizational change. One of the early terms employed in relation to counseling with multicultural clients is cultural sensitivity. In part, sensitivity is the counselor’s capacity to respond psychologically to changes in his or her interpersonal or social relationships (Trimble, 2003, p. 16). People in all cultures hold exclusive, unique, and distinctive values, customs, traditions, languages, beliefs, and consequent behaviors. At a minimum, the counselor’s acknowledgment and appreciation of the uniqueness of the client’s cultural group’s contributions are important aspects of culturally sensitive counseling (D. W. Sue et al., 1992; Trimble, 2003). Cultural sensitivity in therapy consists of understanding the client’s cultural values, beliefs, and language preferences, which may include providing or facilitating services outside the therapy (Gargi, 2009; D. W. Sue et al., 1992). Cultural sensitivity in therapy involves counselors’ engagement in processes of self-reflection and self-exploration in working with multicultural families. Counselors need to examine their own cultural and ethnic heritages as well as possible sources within themselves of intolerance to other cultures, discrimination, attitudes, feelings, beliefs, values, affective styles, and personal behaviors that could affect their ability to work with these families. Counselors’ responsibility as clinicians entails learning more about their own cultural and ethnic backgrounds as well as those of their clients. For counselors, assuming a position of cultural humility is a strategy that reduces the risk of stereotyping and encourages appreciation of the nuances of cultures other than their own (Tervalon & Murray-García, 1998). Learning about clients’ backgrounds and their family experiences in the acculturation process (see Chapter 18 in this volume) might well include learning about the legacies of oppression, slavery, genocide, and conquest. Knowledge about ECGs’ preferences in terms of foods, languages, dress styles, and ceremonial and religious celebrations may help counselors to understand how family members give meaning to their experiences and thus help in the engagement and maintenance of families in counseling. Notions of cultural competence and cultural sensitivity have evolved over the years, in part as a result of the development of multiculturalism as a field (Bernal & Domenech Rodríguez, 2012). The concept of cultural competence added both process and skill components to the earlier notion of knowledge and awareness (S. Sue, 1998). Other approaches in counseling work with ECGs include the development of culturally sensitive treatments that are designed for particular groups (Hall, 2001) and cultural adaptations of evidence-based treatments that infuse already established treatments with culture, language, and context (Bernal & Domenech Rodríguez, 2012). Multiculturalism has come of age with the publication of journals, handbooks, and journal special issues. Most recently, the American Psychological Association (APA) published a two-volume handbook on multicultural psychology (Leong, 2014), and the Journal of Cross-Cultural Psychology published a special issue on cultural competence (Chiu, Lonner, Matsumoto, & Ward, 2013). Salient Features of Prototypical Ethnocultural Families in the United States It would be folly for us to attempt to list all possible types of the social entities we call families that have elements of culture or ethnicity at their cores. Instead, we offer below brief overviews of families in four traditional ethnic group structures that are quintessentially North American: American Indian/Alaska Native, African American, Asian American, and Latino. We recommend that counselors also consult the chapters in Part II of this text, which contain valuable information about all of these groups, as well as information on persons from Muslim and Arab backgrounds (the focus of Chapter 9). We further recommend that counselors consult reviews of the literature on the effectiveness of evidence-based treatments (EBTs) with ECGs (Hall, 2001; Miranda et al., 2005; S. Sue, Zane, & Young, 1994), as well as national registries, and consider selecting treatments with established evidence for the ECGs of interest. If no EBTs are available for particular ECGs, Domenech Rodríguez and Bernal (2012) offer evaluation guidelines on the need for cultural adaptation and both general and specific guidelines for conducting cultural adaptations of EBTs. American Indian/Alaska Native Families In the 2010 U.S. census, 5.2 million persons (1.7% of the U.S. population) identified as American Indian/Alaska Native, either alone or in combination with one or more other races. The population of American Indians and Alaska Natives is projected to increase to 8.6 million, or 2% of the total U.S. population, by 2050 (Norris, Vines, & Hoeffel, 2012). More than 565 American Indian and Alaska Native tribes are recognized by the federal government (Bureau of Indian Affairs, 2009), and American Indian families are by no means a homogeneous community; important language, regional, cultural, and tribal differences exist among members of this group. In counseling Native American and Alaska Native families, it is critical for mental health professionals to assume a position of cultural humility while developing ways in which they can be helpful to families in need. The rub here is the degree to which being “helpful” may be another way of imposing assimilation via “counseling” or “treatments” based in dominant Western mainstream worldviews and values. The approach to counseling Native Americans needs to be grounded in a basic knowledge of the legacy that may be affecting these families. Basic knowledge of Native Americans’ histories, cultures, languages, values, lifeways, pathways, and changing contexts is fundamental. This knowledge must be fluid; if it is static, the counselor runs the risk of stereotyping. As S. Sue (1998) suggests, dynamic sizing and scientific-mindedness can serve as checks on static knowledge that may not apply to particular families. Assuming a position of humility—in which counselors let individual families teach them about their cultures and values and how they understand their legacy—complements the dynamic sizing approach. There is a growing literature on counseling with American Indians and Alaska Natives. As suggested above, the literature emphasizes that it is fundamental for counselors to understand the specific social and historical contexts of families, as each may have particular customs and values, worldviews, and family processes (Gray & Rose, 2012; Jackson & Hodge, 2010; Schinke, Tepavac, & Cole, 2000). For example, in the 19th century, the U.S. government employed the ideology of Manifest Destiny (i.e., the God-given right of territorial expansion) to support a policy of genocide against American Indians. Millions of indigenous people died and entire communities, tribes, and families were decimated (Sutton & Broken Nose, 1996). The policy of relocating American Indians to reservations in the late 1880s created a forced migration of tribes. Forced assimilation meant that American Indians were removed from their lands and required to dress in Western clothing and abandon their customs, languages, religions, and philosophies; the result was the disruption of Native culture (Gray, 2012; Stone, 2008). Such policies continued until as recently as the 1950s and the 1960s, when American Indian families and homes were relocated to urban sites. These experiences have led to profound historical trauma. Forced assimilation was an attempt to destroy Native cultures and their roots (Sutton & Broken Nose, 1996; Tafoya & Del Vecchio, 1996). Knowledge of this historical legacy may be an important resource for counselors working with American Indian and Alaska Native families, given that this legacy is likely to have a major impact on family structure. The concept of the so-called nuclear family does not seem to make much sense in a context where the community is privileged over the individual. Nevertheless, according to the U.S. Census Bureau, there were 557,185 American Indian and Alaska Native families in 2010; of these, 57% were married-couple families, including with children (Norris et al., 2012). The family is a central unit to American Indians, but family values vary depending on tribal and regional differences. American Indian families have been described as valuing spirituality, humility, respect, generosity, honesty, honor, gratefulness, forgiveness, helping, and courage (Limb & Hodge, 2009; Red Horse, 1981). American Indians have been described as speaking softly, but speech is usually a secondary expression to such behavior as avoiding direct eye contact (an expression of respect) and silence with careful listening, which is highly appreciated. Many Native Americans prefer indirect forms of communication, such as the use of metaphors, and view time as cyclical rather than lineal and discrete (Herring, 1990; Sutton & Broken Nose, 1996). The typical extended American Indian family differs substantially from the Western norm. For example, the grandfather and father are key figures, with responsibilities to their grandsons, sons, and nephews as caregivers in providing discipline. The role of parent is not limited by biological lineage, as “parenting” responsibilities are shared among various family members. In some American Indian cultures the term in-law does not exist, as inclusion in the family system is privileged (Sutton & Broken Nose, 1996). In counseling American Indian families, focusing on the strengths of the family and the culturally sanctioned value of collaboration can go a long way toward helping to address problems or conflicts (Sutton & Broken Nose, 1996). American Indians who enter counseling often do so for many of the same reasons as members of other groups. These include dealing with issues of discrimination, mental health problems (e.g., depression), marital problems (e.g., stress associated with intermarriage), family problems (e.g., behavior of children, communication patterns), and substance abuse (Gray & Rose, 2012). As some have suggested, family counseling and therapy strategies may need to be culturally adapted for work in American Indian communities (Gray, 2012). Counselors might consider developing new counseling strategies and treatments that are attuned to the cultures, languages, and contexts of American Indians (Gone, 2008). Therapists need to examine their own personal values in relation to their clients’ worldviews, including in regard to religion, spirituality, rituals and ceremonies, and traditions (Herring, 1990; Limb & Hodge, 2009; Stone, 2008). A wealth of information, both historical and contemporary, is available that can enhance the competence of counselors working with this diverse population (American Psychological Association, 2003; Miranda et al., 2005; Red Horse, 1981). African American Families Persons identifying as African American alone (38.9 million, 13% of the U.S. population) or in combination with one or more other racial or ethnic groups (another 3.1 million, or 1% of the population) represent 42 million people, or 14% of the U.S. population. In the U.S. Census Bureau’s categories, “Black or African American” refers to persons who identify with any Black racial groups of African origin. More specifically, this group consists of those who self-identify as African American, sub-Saharan African, Kenyan, Nigerian, or Afro-Caribbean, such as Haitian or Jamaican (Rastogi, Johnson, Hoeffel, & Drewery, 2011). This is a group characterized by diversity in terms of geography, age, skin color, religious affiliation, socioeconomic status, national origin, and more (Moore-Hines & Boyd-Franklin, 1996). Counselors need to understand the social and historical contexts of the lives of their African American clients (Bernal et al., 2003). Africans originally reached the United States for a variety of reasons, but most came by force as slaves. As a result of slavery, families were uprooted from their homelands, tribal lives, native languages, religions, and customs (Moore-Hines & Boyd-Franklin, 1996). From about the 15th century to 19th century, in the New World the enslavement of African peoples emerged and developed. This period was characterized by harsh punishments, torture, executions, and sexual abuses as means to retain control over forced labor. Approximately 15 million Africans were enslaved in the United States before slavery was abolished (Black, 1996). The institution of slavery brutally deformed the kinship and extended family structure of Africans in the United States. A host of prohibitions were instituted, including intermarriage of African Americans with persons of other races. Changes in partners became a strategy to avoid punishments and sanctions. Gatherings for traditional celebrations or religious rites were not allowed. African Americans maintained family ties despite such prohibitions, in part because of the value they placed on blood and orientation to the group. The belief that distance does not take away the bonds of blood remained strong. The extended family managed to survive slavery and remained an indelible value (Black, 1996). An example of the inclusiveness of the African American view of family is the use of the terms brother and sister directed toward nonblood “relations” as if they were family. Today, there are 9.4 million African American households, and 44% of African Americans report being married (Rastogi et al., 2011). African American families are diverse and tend to embrace an extended kinship system. The extended family is linked not only by biology but also by emotional ties, which are equally important. For counselors, determining whether family members are present or absent is an important first step in understanding the nature of the African American family. In counseling and therapy situations, issues of racial differences between family and counselor, if they exist, should be acknowledged and discussed. As with American Indian and Alaska Native families, assuming a position of cultural humility can go a long way toward helping counselors understand African American families’ experiences of discrimination, immigration, and spirituality. An acknowledgment of differences early in therapy signals to the family that the counselor is open to discussing difficult issues and facilitates the engagement of the family in treatment. Building trust is an essential part of any counseling experience. Given the discrimination that many African American families have experienced, distrust in counseling itself may be an issue, particularly with men, because of counseling’s association with the mainstream establishment. In these instances, it is often helpful for counselors to explore signs of distrust and use creative and flexible interventions (such as contacting hesitant male family members directly by phone or other means). African American women are often described in the literature as being somewhat more religious than their male counterparts. They frequently assume a position of strength and self-sacrifice, and they are usually the ones who initiate family therapy (Moore-Hines & Boyd-Franklin, 1996). Counselors need to understand the harmful impacts of the legacy of slavery on African American communities (Bernal et al., 2003), but they also need to recognize that, despite the negative consequences of racism, oppression, and discrimination, African Americans have a rich heritage of strength and survival. The cultural values of spirituality and the importance of the welfare of the family and the larger group serve as resources enabling African Americans to resist oppression. Even today the church is an important part of community life and serves many important functions in the everyday lives of African American families (Moore-Hines & Boyd-Franklin, 1996). Asian American Families According to the 2010 census, 17.3 million persons (5.6% of the U.S. population) identify as Asian American. Individuals who self-identify as Asian American or part Asian American constitute the second most quickly growing ethnocultural group, right after Latinos or Hispanics (Grieco & Trevelyan, 2010). The term Asian American encompasses a population of great diversity and includes persons whose heritages link them with any of the original peoples of the Far East, Southeast Asia, and the Indian subcontinent (Hoeffel, Rastogi, Kim, & Shahid, 2012). The numbers of Asian American families have grown markedly (Passel, 2011). In 2010, more than 4.5 million families identified as Asian American alone (Hoeffel et al., 2012); of these, 60% were husband-and-wife households, 3.6% were unmarried couples, and 9.5% were female heads of households. Asian American families, while sharing a number of cultural values, are widely diverse in terms of language, migration history, religion, educational level, occupation, income, degree of acculturation, and political interest. The primary Asian groups in the United States are Chinese, Japanese, Koreans, Filipinos, East Indians, and Southeast Asians. Most of the mental health research on Asian Americans conducted thus far has focused on Chinese Americans, Japanese Americans, and Southeast Asian refugees (E. Lee, 1996a, 1996b). A review of the outcome literature on evidence-based treatments found that few studies included Asian Americans (Miranda et al., 2005). Hwang (2012) has proposed integrating top-down and bottom-up approaches in adapting EBTs for Asian American studies. He advocates using cultural adaptations that integrate the pertinent cultural backgrounds of individual clients to improve outcomes, such as addressing issues of immigration, acculturative stress, language limitations, and disconnections from friends and family members. In addition, it is helpful for counselors to maintain a balance between dynamic sizing and knowledge of the legacies and cultural contexts of the members of this highly diverse group. For example, among Chinese Americans, migration histories are varied. Many of the Chinese who came to the United States to help build the transcontinental railroad in the mid-1800s worked under near slave-like conditions. During World War II, Japanese Americans were relocated to internment camps. After the Vietnam War ended in 1975, a large number of educated Vietnamese entered the United States as refugees. Different Asian American legacies are characterized by difficult migrations, discrimination, loss, separation, and other traumas. However, individuals and families attach different meanings to these experiences (E. Lee, 1996a). In counseling Asian American families, it is important that mental health professionals understand the roles such legacies might have. Knowledge of cultural values is another central aspect of counselors’ being able to engage and work effectively with Asian families. In general, Asian cultural values are distinct from Western values. Six cultural value dimensions have been identified as having an important role in counseling with Asian American families: collectivism, conformity to norms, emotional self-control, family recognition through achievement, filial piety, and humility (Kim, Yang, Atkinson, Wolfe, & Hong, 2001). Two aspects of Confucianism are also part of Asian American family values: harmony and well-being (Toyokawa & Toyokawa, 2013). In addition, religion and spirituality play important roles in Asian American families. Koreans and Chinese share an East Asian Confucian heritage with an emphasis on a hierarchical and patriarchal family structure. Thus children are expected to fulfill obligations of filial piety (Oak & Martin, 2000) and to refrain from confronting or disagreeing with parents (Chung, 1992). A common challenge faced by immigrant Asian American families is intergenerational conflict, which arises as the younger generation acculturates to the new context more rapidly than their parents; such conflict may lead to anxiety and depression (Farver, Narang, & Bhadha, 2002). Portes (1997) suggests that the phenomenon of “acculturation dissonance” usually occurs when the children assimilate faster than their parents, adopting the language and values of the new culture while showing less interest in the values of the traditional culture. Addressing the phenomenon of acculturation, value conflicts, and the intergenerational struggle within the family as a normal process of immigrant families is a useful strategy for counselors to employ in helping both sides adapt to the new realities. According to R. M. Lee, Choe, Kim, and Ngo (2000), adolescents with high levels of acculturation perceive their parents as having lower levels, and conflicts are more frequently reported in families where both generations have high levels of acculturation. (See Chapter 18 of this volume for more information on acculturation processes.) As Juang, Baolin, and Park (2013) observe, “Immigrants may be even more traditional than their nonimmigrant counterparts in the heritage countries, and in some ways immigrants may continue to operate on a frozen and mummified notion of their heritage culture” (p. 4). Practitioners need also to assess core differences in the cultural values underlying behaviors. Helping the family discuss values discrepancies in the face of conflicting cultural norms can increase both parents’ and children’s understanding of their respective positions (Juang et al., 2013). D. W. Sue (1994) notes that Asian Americans who hold traditional cultural values consider it shameful and embarrassing for any stranger to have information about the problems of the family. With these families, counselors need to pay close attention to the issues of “face” and shame, so that they are allowed into the family system and can engage family members in a counseling process acceptable to all. The use of traditional Western approaches that privilege independence, support self-disclosure, and foster the expression of feelings may be ill-advised in these instances. Hwang (2012) notes that “acculturative family distancing” (p. 194) can result when communications are focused on cultural conflicts between parents and youth. It may be helpful for counselors to describe intergenerational differences in respectful ways and label the resulting conflicts as acculturative distance. Therapeutic benefits are most likely to result for Asian American families when counselors incorporate diverse strategies that make use of Asian American cultural values and family processes. Latino Families Latinos constitute the largest ethnocultural group in the United States (50.5 million), representing 16% of the total population. The Latino population has grown 43% faster than the overall population. These data, however, underestimate the actual number of Latinos, as undocumented individuals are not counted in the U.S. census. Latinos are a diverse group, with Mexican Americans numbering 20.6 million (54% of the total Latino population), Puerto Ricans 4.6 million (9%), and Cuban Americans 1.8 million (4%) (Ennis, Ríos-Vargas, & Albert, 2011). Other important subgroups of Latinos have roots in the Caribbean as well as in Central and South America. There is a great deal of diversity among Latinos in the United States in terms of identity, migration, history, traditions, and use of the Spanish language; this diversity reflects, in part, certain sociohistorical contexts (Bernal, Sáez-Santiago, & Galloza-Carrero, 2009; Calderón, 1992; Padilla, 1995). Latinos have migrated to the United States for diverse reasons, and there are many different histories of migration among this population. Mexican migration has long been stimulated by the demand for cheap labor in the United States, and also by high rates of unemployment in Mexico. Many Cuban migrants have been motivated by political reasons, particularly those in the initial waves, who have been characterized as being of high to middle socioeconomic status. Later waves of Cubans from lower SES levels were motivated by the expectation of a better economic situation. Many Latinos who have migrated from Argentina, Chile, Nicaragua, and San Salvador came to the United States as political refugees. In contrast, the Puerto Rican migration during the 1940s and 1950s was stimulated by local policies aimed at reducing overpopulation in Puerto Rico (Bernal & Enchauteguide-Jesús, 1994; Bernal & Flores-Ortiz, 1982; García-Preto, 1996). In the broader context, Latinos in the United States share a legacy of colonization, oppression, and conquest with roots in the ideology of Manifest Destiny. Understanding the historical context of Latino families’ migration can help counselors to appreciate the potential links to social and psychological processes associated with discrimination, lack of mental health care, and the cycle of poverty (Bernal & Enchautegui-de-Jesús, 1994; Bernal et al., 2009; Comas-Díaz, 2014). For example, Mexican Americans and Puerto Ricans share a legacy of subordination and defeat. In 1845, the United States extended its territory and occupied Mexican lands under the doctrine of Manifest Destiny. In the Mexican–American War, Mexico lost 48% of its national territory to the United States. After the Spanish–American War in 1898, the United States invaded Puerto Rico, and in 1917 Puerto Ricans became U.S. citizens by an act of Congress. There are important differences between groups that have been conquered or occupied and those that have immigrated (Bernal & Enchautegui-de-Jesús, 1994; Bernal et al., 2003; Comas-Díaz, 2012). While there are important differences among Latinos, there are also many areas of similarities across subgroups. Spanish is the common language, except among Brazilians, who speak Portuguese. Many Latinos share common life experiences such as immigration, and too many face the challenges of poverty, discrimination, poor housing, and single-parent families. Latinos share a number of values, including that of personalismo—an orientation toward personal relationships and spirituality that includes a strong sense of family, both nuclear and extended. The notion of familismo—or valuing loyalty to the family over individual interests—is central. With familismo, there is a strong sense of obligation, responsibility, and dedication to the family. The nuclear and extended family guarantees protection and mutual caretaking. The family is generally an extended system that transcends blood ties and marriage. For example, families include comprades (godparents) and hijos de crianza (adopted children, not necessarily legally adopted). Compadrazco (godparenthood) is a system with reciprocal obligations of economic help, co-parenting, and support. The concept of hijos de crianza includes the transferring of children in times of crisis from the nuclear family to other members of the extended family, for help with parenting and child rearing. Extended family members assume responsibility as if the children were their own (Bernal, Cumba-Avilés, & Sáez-Santiago, 2006; Bernal et al., 2009; Massey, 1993). It is important for counselors to understand the differences and similarities among Latino families. What are family members’ stories and experiences of migration if they are recent immigrants? What are their language preferences? With immigrant families, the younger generations often prefer to speak in English while the parents tend to be more comfortable in Spanish. One key assessment issue involves exploring the family and extended family resources available to the family members. Where are potential sources of support? Is the family relatively isolated? Depending on the geographic area, there may or may not be Latino communities nearby that can be sources of support and offer a sense of community. With Latino families, as with the other families described above, counselors should assume a position of cultural humility and let the families teach them about their stories, histories, and cultures. Such an approach can go a long way toward supporting engagement in family counseling and therapy (Falicov, 1998; García-Preto, 1996). Summary and Conclusions In this chapter we have emphasized how historical, social, and cultural processes can serve as resources for counselors who seek to understand how best to approach counseling work with diverse families in a changing multicultural context. We have provided an overview of basic definitions of the family, taking into consideration their evolution over time as well as recent cross-cultural research suggesting that family structure is associated with social and economic contexts. We have reviewed recent advances in multiculturalism research and have described a number of conceptual tools and methods (e.g., cultural sensitivity, cultural competence, cultural humility, and cultural adaptation) and a variety of EBTs that are available to mental health professionals working with diverse ethnocultural families. The consensus in multicultural psychology is that, at a minimum, counselors need to consider client preferences, values, beliefs, and worldviews for therapy to be optimally beneficial. There is also growing evidence that culturally adapted treatments are effective; as more cultural adaptations are made to EBTs, the better the outcomes. Further, a variety of approaches to counseling with diverse ethnocultural families incorporate the clients’ cultures, languages, values, beliefs, and worldviews. While cultural competence is an ideal that aims to integrate cultural knowledge, skills, and awareness, counselors should keep in mind that approaching the family from a position of cultural humility is likely to ensure engagement in counseling and to yield positive results. Critical Incident A family therapy research program focusing on drug abuse in a large metropolitan city on the West Coast included 41 families, 16 of which were Latino. The clients were affected by a variety of psychological disorders, and all had histories of drug abuse. The Latino families in the program came from a wide range of Latin American countries. The research program entailed 10 sessions of family intergenerational therapy that was manual based and conducted in a bilingual format. The Latino participants were all second-generation immigrants (i.e., the children of immigrants to the United States). During the course of the therapy, a number of issues came up, as illustrated by the material presented here. Most of the Latino families were struggling with challenges related to immigration, family roles, and separation from the nuclear and extended family, in addition to the challenges of drug abuse. Nearly all of the Latino families were facing issues that often emerge in family counseling and therapy with linguistically and culturally different clients. As an example, we present the case of the Martinez family. Identifying details of this family have been altered to protect anonymity. The Martinez family consisted of Victor, the 33-year-old “identified patient,” and the family members with whom Victor lived: his 57-year-old mother and his 36-year-old sister, both divorced; a 10-yearold nephew; and a great aunt, 84 years old. Victor’s extended family included an older brother (age 40) and the brother’s wife and children. Victor had a history of heroin abuse since adolescence. At the moment of entering the family therapy treatment, he was in a methadone maintenance program, yet he admitted to continued casual use of heroin. He was disconnected or cut off from his father. Victor’s older sister, Patricia, was the breadwinner of the family; Victor did not finish high school and could not hold a job for more than a few weeks. Victor’s mother received Social Security benefits and helped support Victor, which included giving him money for his drug use. She was worried about the shame that would come to her family if Victor were arrested for a crime and convicted, so she preferred to give him money to prevent his committing a crime. Later it became clear that the vergüenza, or shame, would be particularly bad for the older brother, who was a law enforcement officer. When Victor was 5 years old, he and his mother lived with his grandmother and Patricia in Nicaragua; his mother then migrated to California alone before gradually bringing her children to join her, beginning with her daughter. It took 9 years for Victor to be reunited with the rest of his family. An examination of the family genogram showed a three-generation pattern of losses and separations, with women in charge of the family but without much help from their male partners, who were involved in alcohol abuse. Victor’s mother left Nicaragua to improve the family’s economic situation and left the children behind under the care of the grandmother. The women were seemingly overinvolved and enmeshed with their children. Gradually, the mother began to bring the children to the United States, first her daughter and later the grandmother and Victor. One of the key elements in family counseling is engaging the family. The research context in this case provided a great deal of flexibility with regard to making reminder calls to the family about appointments or even holding sessions in the home if necessary. The sessions with the Martinez family were conducted in both English and Spanish. The older members of the family were addressed in Spanish, and the younger ones spoke English. Language can be a powerful tool for engaging the less acculturated members of a family. Deciding which family members to invite is also important. From an intergenerational perspective, the ideal approach is to invite anyone who is available and can help. These invitations are not left up to the identified patient or any other family member. In the case of the Martinez family, the counselor obtained the necessary contact information and called the potential participants, inviting them to one session. With Latino families, the value of familismo often means that family members will show interest in being part of at least a first session. Soon thereafter, the use of the genogram helped to broaden the family members’ views of their situation. An early task assigned in therapy was for all family members to engage in the joint project of diagramming their family tree as far back as possible. The diagram was later discussed in a session with all members present. Discussion This case illustrates many of the complexities involved in counseling families. A first concern was how to handle the integration of a serious substance abuse condition within the psychological, family, and social contexts. Our approach was based on a family therapy strategy that incorporates culture and context. We used the contextual family therapy (CFT) model, which aims to include all available individuals in its preventive strategies (Boszormenyi-Nagy & Ulrich, 1981) for the benefit of current and future generations. We culturally adapted the approach as suggested by Bernal and Domenech Rodríguez (2012). CFT views drug abuse as predominantly rooted in social and community processes that affect the entire family. Second, we needed to culturally adapt and contextualize notions about high levels of interpersonal involvement among family members, often viewed as “enmeshment” and considered pathological and indicative of overly flexible boundaries. When mothers become single parents, left to take care of their families on their own, how is it possible for them not to be “overly” involved with their children? Here we see that Victor’s mother assumed both instrumental and affective roles. And given the cultural context of familismo (valuing the unity of the family), we needed to culturally adapt and contextualize the pathological concepts of enmeshment, fusion, and undifferentiated ego mass. A third consideration is the immigrant experience, which includes the intergenerational conflicts that evolve from the pressures on the younger generation to assimilate, adapt, and/or acculturate. With migration comes the loss of social capital and disconnection from the family of origin and the network of relationships at home. In this case, a number of relational issues arose. Victor’s mother migrated alone to the United States from Nicaragua with hopes of improving the economic situation and quality of life of the family; that by itself is a courageous endeavor for anyone and in particular for a woman from a context of limited resources and education. She left her children to be raised by her mother when Victor was 5 years old. The therapy supported Victor and his mother in talking about the losses they had experienced and ways for the mother to give to her son directly that did not entail paying for his drug use, perhaps as a way to make up for having left him. At the same time, Victor’s contribution was recognized as a sacrifice—that is, through his addiction he seemingly remained dependent on the family as a way to give to his mother. The effort here was to build trust in family relationships. Could the contributions of each member of the family be recognized, and could a plan be devised based on an understanding of the legacy of abandonment, limited resources, and loss? Once mother and son exonerated each other, the focus of the therapy turned to identifying resources and problem solving for all family members. Finally, the genogram was a resource for exploring the family’s history and changing contexts. From the genogram it was clear that the family had a three-generation pattern of women leaving children with their mothers, serious challenges with men suffering from alcoholism and subsequently abandoning the family, and overinvolvement of women with their children. A broader contextual view emerged in which all were understood to be victims of a legacy of poverty, war, and exploitation. The question became what they could do about it now, and the promise of therapy was that they could learn how to transcend the generational legacy to prevent the younger generation from further victimization. Discussion Questions 1. What definition of “family” would you use in this case? How would you describe the structure of the Martinez family and the impact of social, historical, and cultural processes on the family’s basic functions (e.g., instrumental, expressive, child rearing)? 2. Did the therapy conducted with the Martinez family follow the APA guidelines on multicultural education, training, research, practice, and organizational change for psychologists? If so, in what ways? 3. Cultural adaptations of evidence-based treatments are resources for working with diverse ECGs. If you identify an EBT that has not been tested with ECGs, what are basic issues you should consider in culturally adapting the EBT for a particular family? 4. What conceptual resources or tools could help you approach a family that is different from your own racial, ethnic, and cultural background, given the changing social, historical, and multicultural contexts? 5. Was the Martinez family helped through this intervention? What other culturally sensitive approach might have been suitable for this family, and what would you have done differently? References American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58(5), 377–402. Bekman, S., & Aksu-Koç, A. (Eds.). (2009). Perspectives on human development, family and culture. Cambridge: Cambridge University Press. Bernal, G., Cumba-Avilés, E., & Sáez-Santiago, E. (2006). Cultural and relational processes in depressed Latino adolescents. In S. R. H. Beach, M. Z. Wamboldt, N. J. Kaslow, R. E. Heyman, M. B. First, L. G. Underwood, & D. Reiss (Eds.), Relational processes and DSM-V: Neuroscience, assessment, prevention, and treatment (pp. 211–224). Washington, DC: American Psychiatric Association. Bernal, G., & Domenech Rodríguez, M. M. (2012). Cultural adaptation in context: Psychotherapy as a historical account of adaptations. In G. Bernal & M. M. Domenech Rodríguez (Eds.), Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: American Psychological Association. Bernal, G., & Enchautegui-de-Jesús, N. (1994). Latinos and Latinas in community psychology: A review of the literature. American Journal of Community Psychology, 22(4), 531–557. Bernal, G., & Flores-Ortiz, Y. (1982). Latino families in therapy: Engagement and evaluation. Journal of Marital and Family Therapy, 8, 357–365. doi:10.1111/j.1752-0606.1982.tb01458.x Bernal, G., Sáez-Santiago, E., & Galloza-Carrero, A. (2009). Evidence-based approaches to working with Latino youth and families. In F. A. Villarruel, G. Carlo, J. M. Grau, M. Azmitia, N. J. Cabrera, & T. J. Chahin (Eds.), Handbook of U.S. Latino psychology: Developmental and community-based perspectives (pp. 309–328). Thousand Oaks, CA: Sage. Bernal, G., Trimble, J. E., Burlew, A. K., & Leong, F. T. L. (2003). Introduction: The psychological study of racial and ethnic minority psychology. In G. Bernal, J. E. Trimble, A. K. Burlew, & F. T. L. Leong (Eds.), Handbook of racial and ethnic minority psychology (pp. 1–12): Thousand Oaks, CA: Sage. Berry, J. W. (1979). A cultural ecology of social behavior. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 12). New York: Academic Press. Black, L. (1996). Families of African origin: An overview. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed.). New York: Guilford Press. Boszormenyi-Nagy, I., & Ulrich, D. N. (1981). Contextual family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. Boyd-Franklin, N. (2003). Black families in therapy: Understanding the African American experience (2nd ed.). New York: Guilford Press. Bureau of Indian Affairs. (2009). 2009 national aviation plan. Boise, ID: Author. Calderón, J. (1992). “Hispanic” and “Latino”: The viability of categories for panethnic unity. Latin American Perspectives, 19(4), 37–44. Chiu, C. Y., Lonner, W. J., Matsumoto, D., & Ward, C. (Eds.). (2013). Cross-cultural competence [Special issue]. Journal of Cross-Cultural Psychology, 44(6). Chung, D. K. (1992). A comparison with mainstream American culture. In S. M. Furuto, R. Biswas, D. K. Chung, K. Murase, & F. Ross-Sheriff (Eds.), Social work practice with Asian Americans (pp. 27–31). Newbury Park, CA: Sage. Comas-Díaz, L. (2012). Multicultural care: A clinician’s guide to cultural competence. Washington, DC: American Psychological Association. Comas-Díaz, L. (2014). Multicultural psychotherapy. In F. T. L. Leong (Ed.), APA handbook of multicultural psychology: Vol. 2. Applications and training (pp. 419–441). Washington, DC: American Psychological Association. Crawford, J. M. (1999). Co-parent adoptions by same-sex couples: From loophole to law. Families in Society, 80(3), 271–278. Domenech Rodríguez, M. M., & Bernal, G. (2012). Bridging the gap between research and practice in a multicultural world. In G. Bernal & M. M. Domenech Rodríguez (Eds.), Cultural adaptations: Tools for evidence-based practice with diverse populations (pp. 265–288). Washington, DC: American Psychological Association. Engels, F. (1972). The origin of the family, private property, and the state (E. B. Leacock, Ed.). New York: International, 1972. (Original work published 1884) Ennis, S. R., Ríos-Vargas, M., & Albert, N. G. (2011, May). The Hispanic population: 2010 (Census Brief No. C2010BR-04). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-04.pdf Falicov, C. J. (1998). Latino families in therapy: A guide to multicultural practice. New York: Guilford Press. Farver, J. A. M., Narang, S. K., & Bhadha, B. R. (2002). East meets West: Ethnic identity, acculturation, and conflict in Asian Indian families. Journal of Family Psychology, 16(3), 338–350. García-Preto, N. (1996). Latino families: An overview. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed.). New York: Guilford Press. Gargi, R. (2009). Evidence practice and its implications for culturally sensitive treatment. Journal of Multicultural Counseling and Development, 37(2), 66–82. Georgas, J., Berry, J. W., van de Vijver, F. J. R., Kağitçibaşi, C., & Poortinga, Y. H. (2006). Families across cultures: A 30-nation psychological study. New York: Cambridge University Press. Gittins, D. (1993). The family in question: Changing households and familiar ideologies. Basingstoke, England: Macmillan. Goldenberg, I., & Goldenberg, H. (2000). Family therapy: An overview (5th ed.). Pacific Grove, CA: Brooks/Cole. Gone, J. P. (2008). “So I can be like a Whiteman”: The cultural psychology of space and place in American Indian mental health. Culture & Psychology, 14(3), 369–399. Gone, J. P. (2010). Psychotherapy and traditional healing for American Indians: Exploring the prospects for therapeutic integration. The Counseling Psychologist, 38(2), 166–235. doi:10.1177/0011000008330831 Goodenough, W. H. (2009). Description and comparison in cultural anthropology. Cambridge: Cambridge University Press. (Original work published 1970) Gray, J. S. (2012). Cultural adaptation for American Indian clients. In G. Bernal & M. M. Domenech Rodríguez (Eds.), Cultural adaptations: Tools for evidence-based practice with diverse populations (pp. 201–221). Washington, DC: American Psychological Association. Gray, J. S., & Rose, W. J. (2012). Cultural adaptation for therapy with American Indians and Alaska Natives. Journal of Multicultural Counseling and Development, 40(2), 82–92. Grieco, E. M., & Trevelyan, E. N. (2010, October). Place of birth of the foreign-born population: 2009 (American Community Survey Brief No. ACSBR/09-15). Washington, DC: U.S. Census Bureau. Hall, G. C. N. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69(3), 502–510. Herring, R. D. (1990). Understanding Native American values: Process and content concerns for counselors. Counseling and Values, 34(2), 134–137. Hill, S. A. (2012). Families: A social class perspective. Thousand Oaks, CA: Pine Forge. Hoeffel, E. M., Rastogi, S., Kim, M. O., & Shahid, H. (2012, March). The Asian population: 2010 (Census Brief No. C2010BR-11). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf Hwang, W.-C. (2012). Integrating top-down and bottom-up approaches to culturally adapting psychotherapy: Application to Chinese Americans. In G. Bernal & M. M. Domenech Rodríguez (Eds.), Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: American Psychological Association. Jackson, K. F., & Hodge, D. R. (2010). Native American youth and culturally sensitive interventions: A systematic review. Research on Social Work Practice, 20(3), 260–270. Juang, L. P., Baolin, D., & Park, I. J. K. (2013). Deconstructing the myth of the “tiger mother.” Asian American Journal of Psychology, 4(1), 1–6. Kağitçibaşi, Ç. (1996). Family and human development across cultures. Mahwah, NJ: Lawrence Erlbaum. Kağitçibaşi, Ç. (1999). The model of family change: A rejoinder. International Journal of Psychology, 34(1), 15–17. doi:10.1080/002075999400069 Kağitçibaşi, Ç. (2007). Family, self, and human development across cultures: Theories and applications (2nd ed.). Mahwah, NJ: Lawrence Erlbaum. Kim, B. S. K., Yang, P. H., Atkinson, D. R., Wolfe, M. M., & Hong, S. (2001). Cultural value similarities and differences among Asian American ethnic groups. Cultural Diversity & Ethnic Minority Psychology, 7(4), 341–361. Lash, C. (1984). The minimal self: Psychic survival in troubled times. New York: W. W. Norton. Lee, E. (1996a). Asian families: An overview. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed.). New York: Guilford Press. Lee, E. (1996b). Chinese families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed.). New York: Guilford Press. Lee, R. M., Choe, J., Kim, G., & Ngo, V. (2000). Construction of the Asian American Family Conflicts Scale. Journal of Counseling Psychology, 47(2), 211–222. Leong, F. T. L. (Ed.). (2014). APA handbook of multicultural psychology (Vols. 1–2). Washington, DC: American Psychological Association. Limb, G. E., & Hodge, D. R. (2009). Utilizing spiritual ecograms with Native American families and children to promote cultural competence in family therapy. Journal of Marital and Family Therapy, 37(1), 81–94. Massey, D. S. (1993). Latinos, poverty, and the underclass: A new agenda for research. Hispanic Journal of Behavioral Sciences, 15(4), 449–475. McGoldrick, M., Giordano, J., & García-Preto, N. E. (Eds.). (2005). Ethnicity and family therapy (3rd ed.). New York: Guilford Press. McGoldrick, M., & Hardy, K. V. (2008). Introduction: Re-visioning family therapy from a multicultural perspective. In M. McGoldrick & K. V. Hardy (Eds.), Re-visioning family therapy: Race, culture, and gender in clinical practice (2nd ed., pp. 3–24). New York: Guilford Press. Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W.-C., & LaFromboise, T. (2005). State of the science on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology, 1, 113–142. Moore-Hines, P., & Boyd-Franklin, N. (1996). African American families. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed.). New York: Guilford Press. Murdock, G. P. (1949). Social structure. New York: Macmillan. Norris, T., Vines, P. L., & Hoeffel, E. M. (2012, January). The American Indian and Alaska Native population: 2010 (Census Brief No. C2010BR-10). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-10.pdf Oak, S., & Martin, V. (2000). American/Korean contrasts: Patterns and expectations in the U.S. and Korea. Elizabeth, NJ: Hollym International. Padilla, A. M. (Ed.). (1995). Hispanic psychology: Critical issues in theory and research. Thousand Oaks, CA: Sage. Parsons, T. (1949). The social structure of the family. In R. N. Anshen (Ed.), The family: Its function and destiny (pp. 173–201). Oxford: Harper. Parsons, T., & Bales, R. F. (1955). Family, socialization and interaction process. Glencoe, IL: Free Press. Passel, J. S. (2011). Demography of immigrant youth: Past, present, and future. Future of Children, 21(1), 19–41. Pedersen, P. (1990). The constructs of complexity and balance in multicultural counseling theory and practice. Journal of Counseling & Development, 68(5), 550–554. Pedersen, P. (1999). Multiculturalism as a fourth force. Philadelphia: Brunner/Mazel. Pinsof, W. M., & Lebow, J. L. (Eds.). (2005). Family psychology: The art of the science. New York: Oxford University Press. Portes, A. (1997). Immigration theory for a new century: Some problems and opportunities. International Migration Review, 3(4), 799–825. Rastogi, S., Johnson, T. D., Hoeffel, E. M., & Drewery, M. P., Jr. (2011, September). The Black population: 2010 (Census Brief No. C2010BR-06). Washington, DC: U.S. Census Bureau. http://www.census.gov/prod/cen2010/briefs/c2010br-06.pdf Red Horse, J. (1981). American Indian families: Research perspectives. In F. Hoffman (Ed.), The American Indian family: Strengths and stresses. Isleta, NM: American Indian Social Research and Development Associates. Schinke, S. P., Tepavac, L., & Cole, K. C. (2000). Preventing substance use among Native American youth: Three-year results. Addictive Behaviors, 25(3), 387–397. Stone, J. B. (2008). Recognizing the issues of historical trauma and intergenerational post-colonial stress with a healing framework of tribal and cultural values, beliefs, and strengths. Paper presented at the the 21st Annual Conference of American Indian Psychologists and Psychology Graduate Students, Logan, UT. Sue, D. W. (1994). Asian American mental health and help-seeking behavior: Comment Solberg et al. (1994), Tata and Leong (1994), and Lin (1994). Journal of Counseling Psychology, 41(3), 292–295. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70(4), 477–486. Sue, D. W., & Sue, S. (2008). Counseling the culturally different: Theory and practice (5th ed.). Hoboken, NJ: John Wiley. Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440–448. Sue, S., Zane, N., Hall, G. C. N., & Lauren, K. B. (2009). The case for cultural competency in psychotherapeutic interventions. Annual Review of Psychology, 60, 525–548. Sue, S., Zane, N., & Young, K. (1994). Research on psychotherapy with culturally diverse populations. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 783–817). Oxford: John Wiley. Sullivan, O. (2006). Changing gender relations, changing families: Tracing the pace of change over time. Lanham, MD: Rowman & Littlefield. Sutton, C. T., & Broken Nose, M. A. (1996). American Indian families: An overview. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 31–54). New York: Guilford Press. Szapocznik, J., & Kurtines, W. M. (1993). Family psychology and cultural diversity: Opportunities for theory, research, and application. American Psychologist, 48(4), 400–407. doi:10.1037/0003066X.48.4.400 Tafoya, N., & Del Vecchio, A. (1996). Back to the future: An examination of the Native American holocaust experience. In M. McGoldrick, J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 45–54). New York: Guilford Press. Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care to the Poor and Underserved, 9(2), 117–125. Toyokawa, N., & Toyokawa, T. (2013). The construct invariance of family values in Asian and Hispanic immigrant adolescents: An exploratory study. Asian American Journal of Psychology, 4(2), 116–125. doi:10.1037/a0029170 Trimble, J. E. (2003). Cultural sensitivity and cultural competence. In M. J. Prinstein & M. D. Patterson (Eds.), The portable mentor: Expert guide to a successful career in psychology (pp. 13–32). New York: Kluwer Academic/Plenum. Waller, W. (1938). The family: A dynamic interpretation. New York: Cordon. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum. 22 Religion, Spirituality, and Culture-Oriented Counseling Mary A. Fukuyama Ana Puig Primary Objective ■ To provide an overview of how spirituality and religion are relevant to cross-cultural counseling Secondary Objectives ■ To clarify the meanings of spirituality and religion as they relate to mental health, illness, and healing ■ To examine universal and culture-specific approaches to understanding spirituality and religion in cultural worldviews ■ To address the competencies for integrating spiritual and religious issues into cross-cultural counseling An integral part of any 21st century spirituality is what I call “deep ecumenism” or others call “interfaith” and “inter-spirituality.” Spirit works and has worked through all cultures and all religions—Vatican II supported this reality—and today humans cannot afford tribalism and hiding in their denominational boxes throwing stones or, what’s worse, missiles at one another. We have to dig up our deepest wisdom from all our wisdom traditions, and most of that wisdom we share in common. —Matthew Fox (quoted in Shapiro, 2012, p. 29) Spiritual and religious beliefs are embedded in culture and contain the myriad cultural differences that all cultures offer, but at the same time commonalities are shared across faiths, as noted in the above quote. The overall purpose of this chapter is to highlight both commonalities and differences in spirituality and religion that are relevant to cross-cultural counseling. We will focus on how mental health professionals can integrate spirituality into cross-cultural counseling by taking a multicultural approach. The chapter has the following main goals: to provide an overview of the importance of spirituality and religion to multicultural counseling and psychotherapy, to examine how spirituality and religion are expressed through different cultural worldviews, and to offer recommendations for counselors who wish to integrate spirituality and religion into cross-cultural counseling. We use the terms multicultural and cross-cultural interchangeably throughout the chapter to refer to cultural differences and similarities based on membership in broadly and inclusively defined identity groups, such as race/ethnicity, gender, sexual orientation, age, national origin, physical ability, religion, and class. In addition, we sometimes use the terms spirituality and religion interchangeably; we define these terms in more detail in the overview section below. The contents of this chapter are built on several assumptions: ■ Spiritual and religious beliefs and practices are common to humanity and are connected to health, sickness, and healing in most cultures of the world (Koenig, 1997, 2005; Moodley & West, 2005). ■ There is growing interest in spirituality in American society at large and within the profession of psychology, counseling, and other mental health professions in particular, evident in increased conference programming and publications (Morgan, 2007; Pargament, 2013). ■ Although it is not possible for counselors to be experts on all religious or spiritual beliefs, it is possible for them to have a basic understanding of how religion and spirituality affect people’s lives and how they relate to counseling issues and the counseling process (Aten & Leach, 2009). ■ Spirituality has a “natural home” within multiculturalism, and counselors who aspire to be multiculturally sensitive should become familiar with diverse spiritual and religious languages, beliefs, and practices. Understanding these aspects of cultural diversity has the potential to aid counselors in becoming more effective and sensitive in many cross-cultural encounters (Fukuyama & Sevig, 1999). ■ All people have multiple identities, including the possibility of spiritual and religious affiliations. Some identities may be more or less salient in counseling, illustrating the importance of cultural context, thus it is important for counselors to consider the “intersection” of multiple identities (Fukuyama, Puig, Wolf, & Baggs, 2014). Before proceeding with this topic, however, we offer this caveat: It is important to understand why one would not want to talk about religion and spirituality in a professional context. Bringing up the subject of religion and spirituality in the workplace may trigger an automatic avoidance response. Speaking personally, I (Fukuyama) typically ask students and workshop participants at the beginning for their thoughts by sharing the following: My mother told me, “Don’t talk about politics or religion in mixed company!” The context was that I was a child of a Protestant minister in rural communities in the Midwest, and, by today’s standards, my father was a progressive thinker and social justice advocate. So when I approach the topic of spirituality and religion with mental health professionals in conference workshops, I am aware that the potential for offending members of the audience is very real indeed. So what is it about this topic that gives one pause before engaging it in a public venue (or in the classroom)? I ask audience members for their input, and here are some typical responses: I fear judgment. I don’t want to offend. It’s personal. It’s private. I don’t talk about my spiritual beliefs at work (at school). It’s not safe to be honest about my beliefs. There’s no place for religion or spirituality in science. My professors would judge me. My classmates would think less of me. I don’t know how to talk about this with clients. I am ignorant. Psychology and counseling is a specialty, and I should let clergy be the specialists to talk about such matters. It’s better to keep the sacred separate from the secular and church separate from state. I don’t want to be pressured to believe in a particular way (fear of proselytizing). People might judge me because I am an atheist or agnostic. It is for these many reasons that it is important for counselors to establish a sense of safety in pursuing this topic further. I find it helpful to invoke multicultural guidelines such as respecting differences, withholding judgment, and practicing active listening. So why do we want to talk about spirituality and religion in counselor training in the 21st century? First, let’s consider its relevance. In surveys, 86% of Americans report that they believe in God, and 55% indicate that religion is very important in their lives (Gallup, 2007). Even though mental health professionals tend to be less religious than clients, religion and spirituality matter to many clients. The United States remains a religiously diverse nation, with growth in numbers of nondenominational Christian churches that are related to social status, geography, and sociopolitical attitudes (Newport, 2012). Second, spirituality and religion are particularly relevant in cross-cultural counseling because they are embedded in culture and cultural worldviews. This holistic approach to life is in contrast to the secular culture in the United States, which is compartmentalized through professional specialties, separateness, and emphasis on individualism (Myers, 2000). Third, spirituality and religion are associated with disease, healing, and health (Koenig, King, & Carson, 2012; Levin, 2001; Miller & Thoresen, 2003) and may be considered part of the problem and/or part of the solution. The remainder of this chapter is divided into three main sections. In the first, we provide a brief overview of the various movements within psychology and counseling that have shaped a contemporary view of spirituality and religion and present accompanying definitions. In the second section, we address the inclusion of spirituality within cultural worldviews from both universal and culture-specific perspectives, with a focus on ethnicity and gender. In the third section, we consider the implications of integrating spirituality into cross-cultural counseling. Overview In the information age of the 21st century, spiritual knowledge from all perspectives is easily available and no longer reserved for religious experts. Spirituality is a concept that is ever present in human life and yet, paradoxically, remains difficult to put into words in the traditional sense of a singular definition. Some of the dimensions that have been identified in the literature range from esoteric mysticism to matters of everyday living. In fact, many definitions of spirituality include both vertical and horizontal dimensions. The vertical connects people with transcendence or something “beyond self,” also called the transpersonal. Spirituality is seen as an innate need to connect to something larger, something that may be felt as divine, sacred, and out of the ordinary. Such experiences are commonly met through religion, but they may also be found through philosophy, science, and art—that is, through the seeking of an ideal, a truth, or beauty. Hill and colleagues (2000) have suggested that spirituality includes thoughts, feelings, experiences, and behaviors that arise from a search for the sacred, for those things that are holy, “set apart,” transcendent, and of ultimate value to a person. The horizontal dimension includes a connection to self as well as to others and nature. Both dimensions are reflected in the following definition of spirituality, which emphasizes relatedness or connection: Spirituality is a commitment to choose, as the primary context for understanding and acting, one’s relatedness with all that is. Within this commitment, one attempts to stay focused on relationships between oneself and other people, the physical environment, one’s heritage and traditions, one’s body, one’s ancestors, saints, Higher Power, or God. It places relationships at the center of awareness, whether they be interpersonal relationships with the world or other people, or interpersonal relationships with God or other nonmaterial beings. (Griffith & Griffith, 2002, pp. 15–16) Spirituality includes certain values, including meaning and purpose in life, a sense of mission and goals, helping others, and striving toward making the world better (Elkins, Hedstrom, Hughes, Leaf, & Saunders, 1988). Kelly (1995) emphasizes that boundaries are important in any definition or discussion of religion and spirituality. He suggests that spirituality and religion are, at a minimum, grounded in a reality that is clearly outside the boundaries of the empirical, perceived, and material world. Achieving spirituality is more often a process than an end point, but some would speak of striving for “spiritual intelligence,” that being defined by inner wisdom, compassion, equanimity, and inner peace. Just as the mental health profession is open to this exploration, there are those who are interested in how spiritual values may be applied in the workplace (Wigglesworth, 2012). Religion has been defined as “the means and methods (e.g., rituals or prescribed behaviors) of the search [for the sacred] that receive validation and support from within an identifiable group of people” (Hill et al., 2000, p. 66). Albanese (cited in Kelly, 1995) has described religion as having an “extraordinary” dimension that is centered on “otherness,” “transcendence,” and moving beyond everyday culture and a second dimension of “ordinary” that is centered on everyday life, culture, and norms. Although some people consider themselves to be spiritual without being religious, by definition, religion encompasses spirituality because spirituality is its most central function (Pargament, 1999). Religion by nature has concerned itself with the “big questions” or “ultimate concerns” of life. Core considerations for religious teachings include such existential questions as “Who am I?” “Where did I come from?” “Where am I going?” and “Why?” (Shapiro, 2013). From a historical perspective, psychology in general, and counseling in particular, has had an uneasy and at times conflicted relationship with spirituality and religion (May, 1982). Although one of the fathers of modern psychology, William James, studied the religious experience, other psychotherapists have spoken against religion. As psychology embraced the scientific method as its foundation, religious and spiritual beliefs were marginalized or considered to be delusions or symptoms of mental illness. Sigmund Freud was one of the early critics, believing that religion was a neurosis, and B. F. Skinner and Albert Ellis found little use for religion, preferring deterministic and rational approaches (Plante, 2009). Conversely, Carl Jung acknowledged the importance of spirituality as a component of wholeness and necessary for healing from alcohol addiction. Subsequently, 12-step programs for addiction recovery have supported this view (Hopson, 1996). The humanistic and transpersonal psychology movements in the 1960s and 1970s counterbalanced the psychoanalytic and behavioral movements and focused on values and phenomena that may now be included under the umbrella term spirituality. Notable humanistic psychologists of this era included Gordon Allport, Viktor Frankl, Erich Fromm, Abraham Maslow, Rollo May, and Carl Rogers. However, most humanists focused on individual values such as “freedom, responsibility, anxiety in the face of death and crises of meaning that occur in life” rather than on a supreme being (Frame, 2003, p. 13). Thus, there have been subsequent negative reactions from religious conservatives against “secular humanists.” Now with the arrival of multiculturalism and postmodern constructivism, multiple perspectives are invited to define reality. Recent developments in positive psychology and social justice movements have incorporated religious and spiritual values. Despite the increasing recognition of religion and spirituality and their impact on clients’ lives, psychologists remain skeptical and are reluctant to introduce these topics in therapy (Pargament, 2007; Richards & Bergin, 2000). Puig and Adams (2007) surmise that mental health practitioners might be reluctant to broach these topics partly because they are unaware of the positive and negative impacts of religion and spirituality on health. Frame (2003) suggests that mental health professionals might avoid religious/spiritual themes because of their own personal histories of unresolved religious questioning or even wounding. There continues to be expanding interest in spiritual and religious themes in multiple fields of psychological research and practice (Aten, McMinn, & Worthington, 2011; Pargament, 2007, 2013; Plante, 2009; Richards & Bergin, 1997; Scotton, Chinen, & Battista, 1996; Shafranske, 1996). Some of the applications can be found in areas such as addiction recovery, wellness promotion, holistic health, and transpersonal growth and development, and some have been incorporated into multicultural counseling and training (Cashwell & Young, 2011; Cornish, Schreier, Nadkarni, Metzger, & Rodolfa, 2010; Fukuyama & Sevig, 1999; Richards & Bergin, 2000). An example of the exponential growth of interest in this topic is reflected in the American Psychological Association’s recent publication of the two-volume APA Handbook of Psychology, Religion, and Spirituality (Pargament, 2013). With more than 130 contributors and 75 chapters, this work covers a wide range of themes relating spirituality and religion to psychological theory and research, measurement, methodology, and various social contexts. The authors discuss why and how people are religious and spiritual, describe characteristics of specific populations (by age, ethnicity, major religions, Eastern and Western perspectives), and elucidate applications such as in counseling theories, in clinical issues, and in specific settings, including prisons, the workplace, education, veterans’ health care, and health care training. The dominant culture in the United States, meaning the culture of the group in power, has a religious base also. Because people originating from Europe, particularly Britain, have held power since the founding of this country, Anglo-European Christian values permeate the dominant culture of the United States. Lynch and Hanson (2004) suggest that the values contained within this dominant culture include individualism, privacy, belief in human equality, informal interaction, future orientation, progress, change, achievement and competitiveness, strong work ethic, and assertiveness, among others. Maxims such as “Cleanliness is next to Godliness” and “Idle hands are the devil’s workshop” reflect religious roots. “Majority-minority” statuses and various degrees of power and privilege for religious groups are factors that influence intergroup relations and political dynamics. These dominant culture values may be reinforced through religious beliefs propagated by mainstream churches or challenged by alternative paradigms or culturally different ethnic groups. We discuss some of these contrasts in the next section along with culture-specific approaches to religion and spirituality. However, religious groups are not homogeneous; there is much within-group diversity, even among adherents of established world religious traditions. It is important to note that there are differences in levels of orthodoxy—that is, religious practices and values differ along a continuum: on the right are fundamentalist, literal, authoritarian values; in the middle are conservative, traditional, or moderate values; and on the left are progressive, liberal (flexible, reformed, relativist) values. On the far extremes of this continuum one can find fanatics and radicals who behave outside convention but receive most of the (negative) news headlines. The mass media tend to present a skewed picture, thus promoting negative stereotypes that fuel prejudice against and misunderstanding of mainstream religious groups (Plante, 2009). In addition, people have diverse beliefs about God. Judaism, Christianity, and Islam are the three major monotheistic religions and have a shared history; other world religions may have more than one godhead (Hinduism) or none at all (Buddhism). Many of the world’s religions include mystery practices (e.g., mysticism in Christianity, Sufism in Islam, and Kabbalah in Judaism) that embrace the concept of unity within diversity (Fox, 2000). Religious expressions also vary in whether practices are public (exoteric) or private (esoteric). Individual participation in religious activities varies along lines of practicing for extrinsic (other-oriented) or intrinsic (inner-oriented) reasons (Plante, 2009). Included in these definitions of religious differences, we define atheism as a belief that God does not exist in reality and agnosticism as “not knowing” whether or not God exists, but keeping an open mind. Given that religious diversity is the norm, in the next section we describe universal and culturespecific approaches to understanding the complexity of religion and spirituality as it is embedded in culture. Spirituality and Cultural Worldviews God is unity, but God always works in variety. —Ralph Waldo Emerson In cross-cultural psychological research and scholarship, the etic (cultural universal) and emic (culture-specific) perspectives offer insights into the human condition and the diverse ways in which people survive in the world. Both approaches are helpful for understanding cross-cultural healing and helping (Fukuyama, 1990; Locke, 1990). An investigation of world religions illuminates common themes (Beversluis, 2000). Below, we examine universal perspectives drawn from the 15th- to 16thcentury Perennial Philosophy brought into modern times by Aldous Huxley (1945) and elaborated further by professor emeritus of world religions Huston Smith. We then explore culture-specific examples, examining worldviews influenced by race/ethnicity and gender. It is our hope that counselors will become familiar with diverse spiritual and religious languages, beliefs, and practices in order to understand the role of spirituality and religion in healing. Universal Perspectives Aldous Huxley sought the wisdom offered about the nature of God by all religions (Shapiro, 2011) called the Perennial Philosophy. Huston Smith (cited in Cortright, 1997) described a conceptual framework for understanding the universal qualities of spirituality and the commonalities that exist across all religions. This framework provides common ground for understanding a variety of multicultural expressions found in both organized religion and diverse spiritual paths. The concept of God taken from world religions’ perspectives is that God is personal and impersonal and that Eastern and Western religions include both perspectives (see Smith, 1991). What differentiates them is a matter of emphasis. From a Western perspective, God is a Personal Divine, as found in monotheism in the three major Middle Eastern religions, Judaism, Christianity, and Islam. The personal God is known by many names and is contextualized in culture. For example, in the Hebrew tradition G-d has a Covenant with a chosen people. Even though G-d is so unfathomable the Name cannot be spoken, G-d is also as intimate as the love between newlyweds. From a Christian perspective, God’s love is manifested in the life of Jesus, who calls people into loving one another responsibly and provides a source of salvation to humanity. The Islamic tradition shares its origins with the Hebrew and Christian traditions. Muslims believe that the Prophet Muhammad was the last messenger of God, but they also recognize Abraham, Moses, and Jesus as important historical figures. Central Islamic beliefs include the unity of God and all things, the recognition of Muhammad as the Prophet, the innate goodness of human beings, the importance of a community of faith, and the need to live a devout and righteous life to achieve peace and harmony (Altareb, 1996). In contrast, in the Eastern traditions, God is known as the Impersonal Divine and is nondual in nature. Nonduality refers to the unity or completeness of reality despite differences or polarities. A spiritual goal is to merge the individual into the Impersonal Divine, and this is accomplished through spiritual practices such as meditation, yoga, and service. As the individual becomes aware of normal human conditioning and develops an observer self, a connection with his or her nondual nature or unity becomes possible. In the Hindu worldview, the impersonal God gives rise to the personal God, and both are present everywhere. In this way, Hinduism values both the personal and the impersonal equally, and God is depicted with several faces as well as seen as a unified force. Another way of expressing this concept is to say that God is both immanent (personal and present) and transcendent (impersonal and beyond human understanding). For many people, it is easier to develop a devotional relationship with an anthropomorphic God because it is difficult to relate to an abstract impersonal being (Shumsky, 1996). After conducting grounded theory research concerning the multiple manifestations of spirituality and religion, we developed an emergent theory of multicultural spirituality (Puig & Fukuyama, 2008). We found that across the racial/ethnic and cultural groups represented in our study sample, there were salient, shared themes that included notions of God, relationship and connection, subjective inner experience, external actions or behaviors, way of life (e.g., morals, culture), and religion. Moving from these broad and overarching themes to more specific ones, in the remainder of this section we describe the worldviews and spiritualities of selected cultural groups to expand readers’ awareness of different ways of conceptualizing spirituality and its role in mental health. We have selected these specific worldviews to be illustrative, but they are certainly not inclusive of all possible worldviews. By presenting a variety of perspectives, we hope to encourage readers to seek further knowledge of various cultural spiritual and religious worldviews. Culture-Specific Perspectives African Americans. Taking an Afrocentric approach to counseling, Parham, Ajamu, and White (2011) have suggested that for African Americans spirituality may be based in traditional African worldviews. Concepts such as consubstantiation (the belief that all things are interconnected) and the belief that a spiritual life force permeates everything, including humans, provide a basis for meaning making in counseling. Mental health professionals working with African American clients should explore how their clients approach life struggles (Parham & Parham, 2002), and counselors may need to shift their therapeutic focus from the individual to include groups and families (Mattis & Jagers, 2001). For example, a collective identity, with values of cooperation and group survival, may be more salient than with individualism (Parham & Parham, 2002). Boyd-Franklin (2003) emphasizes the importance of Black churches in providing support networks for African American extended families. Black churches provide not only social support in the face of institutionalized racism but also therapeutic responses through worship, prayer, catharsis, and validation of life experiences (Frame & Williams, 1996). Liberation themes are reflected in gospel and rap music, and in church involvement in social movements, such as for civil rights (Morris & Robinson, 1996). Asian Americans. Asian Americans participate in diverse faith systems, and their religious/spiritual experiences may be an amalgam of Eastern and Western beliefs and values. Religion and spirituality are central to the lives of many Asian Americans (Ano, Mathew, & Fukuyama, 2009). According to T. Carnes and Yang (2004), about two-thirds of Asian Americans report that religion plays a very important role in their lives; these authors also observe that the largest pan–Asian American movement is religious, Asian Americans more readily identify with a religion than with a political party, the largest Asian American college and university student organizations are religious, and many Asians come to the United States seeking religious freedom. Asian American immigrants face challenges of coping with multiple cultural adjustments. For those who deal with prejudice, racism, and discrimination, religion may provide a sense of refuge. The ethnic church may provide social support and mediate pressures to assimilate. T. Carnes and Yang (2004) note that some Asian Christians, particularly Koreans, actually immigrate to the United States as a means of seeking validation for their religious identity. Asian Americans may attribute mental and physical illness to spiritual causes. The concepts of spirit possession and soul loss are related to illnesses in traditional Asian cultures (Das, 1987). Such patients may be treated with exorcism, magic, or shamanic rituals to retrieve lost parts of self (Fadiman, 1997; Moodley & West, 2005). One widely practiced religion that is unfamiliar to many Westerners is Sikhism, which originated in India and is considered to be the world’s fifth-largest organized religion. Approximately 300,000 Sikhs are currently living in the United States (“Sikhism in America,” 2012). Sikhs believe in a genderless, formless, immortal, loving, and omnipotent God and embrace the concept of unity and equality of humanity. They are encouraged to meditate on God’s name, work honestly, and share their wealth with others. Because of their outward physical symbols of religious identity (men wear turbans because they do not cut their hair), Sikhs in the United States have often been targeted for discriminatory practices and hate crimes. Some examples include the vandalizing of Sikh temples, physical assaults, and threats of job loss for Sikh men if they do not remove their turbans (Chilana, 2005). Indigenous peoples and other adherents of Earth-based spirituality. Earth-based spirituality may be found in various spiritual, religious, and political movements. American Indian traditions (King & Trimble, 2013), paganism and Wicca (Starhawk, 1999), deep ecology, ecofeminism, and the study of religion and nature (Taylor, 2008) all share a common focus on the Earth, environmental concerns, and living in balance with natural forces. The history of cultural genocide against American Indians has included direct attacks on their lands, spiritual practices, beliefs, and customs. Healing practices may include the use of herbs, plants, songs, ceremonies, charms, and prayers guided by a medicine man/woman. However, American Indians may be cautious about sharing their practices because of the tendency within the popular culture to exoticize American Indian spirituality and to appropriate spiritual practices (such as the sweat lodge) for profit (LaDue, 1994; Trimble & Thurman, 2002). In addition, paganism (the name of which comes from the Latin term meaning “country dweller”) has been persecuted historically by institutionalized religion, for example, through witch hunts. Latino/as. Religion and spirituality have traditionally been integral parts of Latino/a cultures. Catholicism is the predominant religion among Latin Americans, although Latino/as participate in many of the world religions. Recent missionary efforts carried out in Latin America by Pentecostals, Jehovah’s Witnesses, mainline denominations, and various other evangelical religious groups have introduced a variety of Protestant traditions (Falicov, 1999). It is common to find a mixture of religious traditions among Latino/as, including Christianity, Afrocentric practices (e.g., Santeria), and indigenous folk beliefs (e.g., espiritismo). Spiritual beliefs may be intertwined with physical symptoms, psychological problems, and healing, and illness may be perceived to have supernatural causes, such as malevolent spirits, bad luck, or witchcraft. Latino/a clients may benefit from consulting psychics and mediums, but they are not likely to talk to their counselors about participating in rituals that involve communing with spirits (Zea, Mason, & Murguía, 2000). At the same time, Latinas who are perceived to have psychic abilities may gain social status and influence within their communities (Espin, 1990). These diverse examples from Latino/a cultures reflect various beliefs about religion, spirituality, psychological issues, the causes of illness, and the necessary treatments, both physical and spiritual. For counselors, the process of understanding Latino/a spiritual and religious beliefs may include seeking knowledge about the concepts of spirit possession and spirit guides, as well as rituals for healing. Mental health professionals may need to collaborate with indigenous spiritual and religious leaders to learn more about these cultural traditions (see Moodley & West, 2005). Gender Perspectives Several scholars have considered the potential impacts of gender on spiritual development. Below we highlight the work of some who have contributed toward increased understanding of how gender affects both women’s and men’s spirituality. Women’s spirituality. Most women’s spiritual development takes place within patriarchal cultural and religious systems (Anderson & Hopkins, 1991). Western women as an oppressed group have few current institutional or cultural images that reflect feminine spirituality or religious figures. Therefore, they are faced with acceptance of current patriarchal religious systems, trying to connect with the relatively few female figures (e.g., the Virgin Mary) or developing their own paths. Carol Christ (1997) argues that the current lack of feminine cultural/spiritual role models is not historically the norm, nor is it true for all religions. Goddess worship and goddess figures were integral parts of spiritual practice for many cultures in early history, and they continue to be so in some cultures today. For example, Shakti is a powerful goddess in the Hindu religion who is related to death and rebirth—the cycle of life. Goddess worship is one way in which both women and men may find connection to or expression of the divine feminine, or woman-centered spirituality. Traditional and nontraditional religious women’s circles, Wicca, paganism, and neopaganism have all been part of the women’s spirituality movement (R. D. Carnes & Craig, 1998). The predominant Western metaphor for spiritual development is that of the journey (Culliford, 2011), but Anderson and Hopkins (1991) argue that this concept is based on male hero myths and the idea that an individual needs to leave home to fully mature. Joseph Campbell described how in almost every culture the hero myth involves a man severing old bonds and moving “his spiritual center of gravity” from family to some unknown territory (cited in Anderson & Hopkins, 1991, p. 46). Parks (2000) has written extensively on the spiritual development of men and women. She has taken into account groundbreaking work such as Carol Gilligan’s In a Different Voice (1993), which expanded the concept of moral development to include the primacy of connection for women. Parks describes the experience of developing faith as involving both journeying and abiding. Her description of the young adult’s process of “venturing and dwelling” (p. 52) echoes the words of other authors on the subject of women’s spiritual development. For example, Anderson and Hopkins (1991) state that the concept of leaving home to develop spiritually may often be much more literal for men than for women. Women’s transformations may happen while they remain connected to home. Finally, gender may interact with other factors such as race or ethnicity to create unique developmental paths for women. For example, Watts (2003) suggests that spirituality offers African American college women a way to (1) cope with racism and prejudice, (2) resist the negative cultural images of being Black and female, and (3) develop an integrated identity. The poet Ntozake Shange speaks to the double burden of being a woman and Black in a society defined by white men. In defiance of this, she proclaims, “I found god in myself... & I loved her fiercely” (quoted in Christ, 1995, p. 97). Rodriguez (2004) has proposed a new paradigm for “mestiza spirituality,” stating that “Latino/a culture, religion, and spirituality are so integrated that to try to define spirituality separated from culture creates a false dichotomy and does a disservice to the Latina community” (p. 319). Because they live in the cultural borderlands of multiple identities, Latinas must confront oppositional or exclusive (“either/or”) thinking and shift their identities depending on the cultural context and type of oppression they encounter (sexism, racism, heterosexism, and so on). The process of being bicultural necessitates that one be able to hold multiple worldviews simultaneously and, in doing so, creatively build bridges that emerge with new paradigms, often resulting in inclusive or “both/and” perspectives. The bicultural Latina thus has to deal with conflicting languages and values, see beyond dichotomies, and transform oppression through developing compassion. Rodriguez proposes that Latinas (drawing from their Catholic and indigenous roots) simultaneously engage in traditional religious rituals and community and social justice initiatives. This is an example of a situation in which being in the intersection of multiple identities is empowering spiritually. The work of all the authors just discussed illustrates how the spiritual development of women may be influenced by myriad factors that differentiate that process from men’s spiritual development. Men’s spirituality. Recent “men’s movements” have highlighted alternative views of spirituality for men in the United States, such as the movement based in the work of Robert Bly and his exploration of expressions of masculinity and spiritualities (Bly, 1990; Hillman, 1996). Based in Jungian archetypes, the mythopoetic movement has encouraged men to go more deeply into the meaning of father–son relationships in defining what it means to be a man. Bly (1990) introduced the use of sacred space and rituals, similar to indigenous rituals for initiation into manhood, to aid men in getting in touch with their authentic selves and healing psychological wounds. The importance of connection and mentorship between men has also been described by Rohr (2005), who has developed a program of rites of passage based in Christian mysticism. Fox (2008) has addressed the “sacred masculine” by proposing 10 archetypes that can help men to reconnect with their spirituality. He suggests that men have boxed up their spiritual yearnings just as they have been conditioned to restrain emotions or think they must hide feelings such as love, wonder, or sorrow. Observing that veterans of war who suffer from posttraumatic stress disorder have great difficulty expressing the pain they have experienced, that they feel compelled to hide their suffering, Fox notes, “A lot of self-preservation seems to require silence” (p. ix). In response, he provides metaphors and exercises designed to empower men (and women) to connect to their spiritual cores through nature, myths, rituals, sexuality, and role models. Other men’s movements have been inspired by conservative religious leaders. Louis Farrakhan, leader of the Nation of Islam, called on hundreds of thousands of African American men to gather in Washington, D.C., in October 1995 for the Million Man March to affirm their commitments to family and community (CNN, 1995). A conservative evangelical Christian men’s movement called Promise Keepers was in the news in the 1990s. Largely appealing to White males, this movement endorsed traditional gender roles and strict interpretation of the Bible. The group held mass rallies as a means of inspiring men to lead moral lives (Robinson, 2012). Such movements speak to the need for men to mentor one another and to go beyond the limitations of traditional masculine gender roles. The intersection of ethnicity, culture, gender, and religion offers complex interactions. Counselors who aspire to be cross-culturally sensitive to spiritual beliefs and practices should expose themselves to diverse belief systems and then decide to what extent they can effectively relate to particular beliefs. In this section we have offered a modest sampling of spiritualities found in diverse cultural worldviews. We address the issue of spiritual competencies in the next section. Implications of Integrating Spirituality Into Cross-Cultural Counseling Frame (2003) lists the following as important steps for counselors seeking to attain competency in working with spiritual issues: (1) self-awareness, (2) knowledge of otherness in learning about differences, (3) skill acquisition, (4) assessment of barriers, and (5) willingness to learn. The Association for Spiritual, Ethical, and Religious Values in Counseling (2009) has enumerated spiritual competencies for counselors. According to the association’s guidelines, a counselor needs to be able to articulate religious and spiritual beliefs, practices, and development over the life span. To this end, the counselor should be knowledgeable about culture and worldview; counselor selfawareness; human and spiritual development; communication; and the assessment, diagnosis, and treatment of spiritual and religious concerns in counseling. In addition to examining spiritual competencies (Cashwell & Young, 2011; Fukuyama, Siahpoush, & Sevig, 2005), professional mental health workers are encouraged to adopt and operationalize multicultural competencies (American Psychological Association, 2003; Arredondo et al., 1996). These areas of competency development are compatible and complementary, and it has been suggested that training programs incorporate both simultaneously. Following a multicultural learning model of engaging awareness, knowledge, skills, passion, and action cross-culturally (Fukuyama & Sevig, 1999), counselors can develop multicultural and spiritual competencies. Ironically, multiculturalism continues to be challenged by fundamentalist movements that embrace ideological purity and group loyalty (Atran, 2012). Various assessment and intervention strategies in therapy utilize spirituality to guide and inform counseling practice across cultures. The multicultural literature provides a framework of crosscultural counseling that utilizes an intentional focus on understanding the client’s spiritual background and identity (Shimabukuro, Daniels, & D’Andrea, 1999). Therefore, in a clinical assessment, it is important for the counselor to assess the clinical issue of focus as well as the client’s spiritual beliefs and practices that might be influencing the issue. A simple clinical assessment tool that health care providers can use to explore clients’ spiritual beliefs is known as FICA (Fitchett, 2002). The first question is about faith or beliefs: What gives your life meaning? The second question addresses the importance of the client’s faith, or the influence of faith on the illness (or psychological difficulty) and/or the role of faith in recovery or healing. The third question relates to community: How can a religious/spiritual community be helpful to you? The final question focuses on how the client would like the health care provider to address these spiritual/religious issues in his or her care. Since it is not always easy to articulate spiritual beliefs in words, the counselor may sometimes find it useful to ask the client to paint or draw an image of what God or spirituality means to him or her (Horovitz, 2002). Such an image can be helpful for diagnostic purposes and can also lead to a deeper examination of how spirituality is or is not playing a role. This exploration phase also helps the client feel fully understood and suggests directions for possible interventions. Certain counseling issues include spirituality as a visible component, while other issues are related to spirituality only indirectly. For example, most clients regard death and dying as having a spiritual or religious component. Issues such as the meaning of life, the meaning of death, what happens after death, and terminal illness involve very direct connections with religious and spiritual domains. Other counseling issues may include spirituality depending on the person’s development or particular history. For example, a career counseling client may be questioning, “What is the meaning of my life?” or “What is my calling in life?” (Duffy & Dik, 2012). Religion acts as social “glue” that solidifies ingroup identity and more clearly defines “the other”; thus, it can fuel political and social dissent. Religious groups may act in altruistic ways toward their own members but generate highly negative rhetoric and possibly violent acts against other groups (Atran, 2012). Since the terrorist attacks on New York City and Washington, D.C., on September 11, 2001, and subsequent U.S. military operations in Iraq and Afghanistan, there has been a noticeable backlash against Muslims in the Western world (Esposito & Kalin, 2011), which feeds social prejudice known as Islamophobia (Love, 2009). Unfortunately, this prejudice has motivated hate crimes against Muslims and Sikhs in the United States. Another area of rapid social change in the United States is that surrounding LGBT rights and recognition of same-sex marriage. Religious groups are divided on the issue of gay marriage, but progressive movements within various denominations recognize the sanctity of same-sex couples’ commitment. The public debate on this issue has raised awareness that LGBT persons have spiritual and religious yearnings that warrant attention from mainstream religious groups (Gray & Thumma, 2005), and such concerns may also be addressed in counseling (Davidson, 2000). Such sociopolitical forces are likely to affect clients who identify as members of religious and/or sexual minority groups. Religious and spiritual beliefs and practices may be expressed in both functional and dysfunctional ways, and the counselor should work with the client to determine in what ways spirituality is part of the solution and/or part of the problem (Fukuyama & Sevig, 1999). Problematic manifestations of religion may take several forms, such as contributing to rigidity and restriction of human growth or bolstering a sense of superiority over others (Griffith, 2010). In some instances, people may have religious wounds or use spirituality to bypass necessary psychological growth (Battista, 1996; Cashwell, Myers, & Shurts, 2004). After the assessment, decisions about interventions can be made. When deciding with a client how best to intervene, the counselor may find a classification from Faiver, O’Brien, and Ingersoll (2000) helpful. These authors outline five categories of spiritual interventions: (1) in session versus out of session, (2) religious versus spiritual, (3) denominational versus ecumenical, (4) transcendent versus nontranscendent, and (5) affective, behavioral, cognitive, and interpersonal. Within each of these five categories, Faiver et al. list a number of specific interventions. Plante (2009) elaborates additional concrete spiritual interventions, including bibliotherapy, meditation, prayer, service and social justice, forgiveness, practicing gratitude, learning from spiritual models, clarifying meaning and purpose, and consulting with clergy. Other examples of spiritual counseling interventions include taking a spiritual history by using a spiritual genogram (Dunn & Dawes, 1999; Frame, 2000), using nontraditional techniques for creativity in emotional expression (Frame, Williams, & Green, 1999; Puig, Lee, Goodwin, & Sherrard, 2006), and utilizing visualization or focusing techniques (Hinterkopf, 1997). The spiritual genogram is a particularly useful way to help clients explore the intersections of spirituality, religion, race/ethnicity, and culture as they relate to family-of-origin issues. The tool may also be used in training or supervision to encourage counselors to explore their own heritages and the potential impacts of their spiritual beliefs on their work with clients (Frame, 2000). The integration of creative and expressive therapies, in particular, has been increasingly popular in the psychotherapy literature (e.g., Gladding, 2011), especially as it relates to spiritual explorations (Rogers, 1993, 2011). For example, Puig et al. (2006) conducted research that explored the efficacy of multimodal art therapies on breast cancer patients and found the intervention enhanced the participants’ psychological wellbeing. The creative interventions included poetry, drawing, painting, spiritual exploration, and guided imagery. The degree to which counselors elect to incorporate spiritual techniques depends on such factors as the counselors’ spiritual beliefs, their theoretical orientation and style, the employment setting, and the counselors’ training and supervision. The integration of spiritual and religious competencies in counseling is more art than science, although several modalities are being researched, including the application of mindfulness meditation (Plante, 2009), a relatively independent approach that has recently gained wide attention in psychology. Mindfulness meditation is based on Eastern meditation practices and encourages the individual to pay attention in the present in a nonjudgmental manner. Mindfulness has found its way into the fields of psychiatry, counseling, and medicine (Germer, Siegel, & Fulton, 2005; Kabat-Zinn, 1990). Numerous psychotherapy approaches have included some form of mindfulness meditation (Hayes, Strosahl, & Wilson, 1999; Kabat-Zinn, 2003; Linehan, 1993; Roemer & Orsillo, 2009). Mindfulness-based approaches have been used in the treatment of anxiety disorders, depression, and trauma, as well as in pain management, and they have received empirical support in these applications. Recently they have been applied to medical education (Ritz et al., 2010) and K–12 education, through teacher and student involvement in meditation practice (“Teaching Teachers Mindfulness,” 2009). Plante (2009) has identified several examples of best practices in spirituality and psychotherapy integration, including 12-step programs for addiction recovery, biosocial approaches for health, and manualized religiously and spiritually integrated psychotherapy protocols. Some of these treatments are based in Christianity, and others are more adaptable to a nonreligious clientele. Another new development in science is the investigation of brain imaging for meditators. In a field of study known as neurotheology, scientists are examining the role of the brain in the “experience of God” (Ritz, 2012, p. 153). With the development of sophisticated imaging technology, studies of the brain have shown that meditation builds gray matter and increases functioning in the areas of the brain used for cognitive and emotional processing (Hölzel et al., 2011). Recent trends show modern science joining forces with ancient meditation traditions for the betterment of the human condition (Hanson, 2009). As we have mentioned, it is important for counselors working with multicultural clients to be able to recognize and address multiple social identities (Fukuyama et al., 2014). With respect to assessing the relevance of spirituality and religion to a client’s presenting issue, sometimes a simple question is all that is necessary; for example, “How do you handle your many social identities as they relate to religion and/or spirituality?” The professional guidelines for multicultural competencies encourage practitioners to collaborate with indigenous healers and religious or spiritual resources and to refer clients to these resources when appropriate. Counselors need to know their comfort zones and their limits with respect to religious and spiritual processes. It is appropriate and desirable for counselors to develop boundaries concerning this work, especially given the personal and powerful nature of spiritual experiences. Although this may seem antithetical to learning and growing as a practitioner, it is not. Counselors often grow along with the clients with whom they are working; however, what is always central is the client’s need for help. This is why the guidelines for competencies in spiritual issues instruct counselors to know themselves and understand when to refer clients to religious/spiritual practitioners. If a counselor starts to feel that he or she is learning but is not providing the help that the client is seeking, then it is time for the counselor to consult and/or refer. It is helpful for counselors to become familiar with religious leaders (e.g., ministers, priests, shamans, imams) for referral or consultation purposes in advance of referring clients. Such familiarity can help counselors to avoid the possibility of retraumatizing clients if they have had negative religious experiences in the past. Ethically speaking, it is important for practitioners to stay within their areas of competence, to avoid dual role relationships in religious communities, and to avoid bias and prejudice in working with religious clients (Plante, 2009). APA Division 36 guidelines recommend that counselors obtain informed consent before embarking on religious/spiritual interventions, use only valid clinical interventions, work within the client’s worldview related to presenting problems, be aware of contraindications such as active psychosis, and “promote more adaptive forms of the client’s own faith rather than to undermine that faith” (Hathaway, 2011, p. 74). Conclusion Our goal in this chapter has been to introduce the reader to theory and practice related to incorporating spirituality and religion into counseling across cultures. We have included several examples of cultural groups and accompanying worldviews in discussions of health, illness, and healing processes related both in general and specifically to counseling. We invite the reader to find other cultural expressions of mental health and mental illness, with the goal of contributing to a framework of incorporating spirituality into counseling across cultures. We reflect here on a number of current and future developments in this specific part of multicultural counseling. As we have noted, in recent years there has been a growing awareness—indeed, more than awareness, a blossoming—of work on spirituality. In fact, some scholars have suggested that spirituality is becoming a fifth force in counseling (Stanard, Sandhu, & Painter, 2000). As the field continues to grow in knowledge that lends itself directly to spiritual issues, a number of considerations will need to be addressed. Both quantitative and qualitative research efforts are needed to explicate the complexities of religion, spirituality, and the transpersonal in multicultural counseling. Traditional quantitative studies are more likely to be devoted to measuring correlates of religion and health (Koenig, 2005) or to take the form of studies in psychology of religion or social psychology. A 2002 review of the quantitative measures used to measure transpersonal and spiritual constructs found that few studies crossvalidated the various instruments currently available in the literature (Friedman & MacDonald, 2002). Given the complexity of spirituality, the researchers recommended that research studies should incorporate multidimensional measures of constructs. It is recommended that students and professionals alike engage in training, coursework, supervision, and/or continuing education workshops on this topic. Training in this area requires a balance of personal exploration, experiential learning, didactic understanding, and skill building (Savage & Armstrong, 2010; Sevig & Etzkorn, 2001). In consideration of developing “inclusive cultural empathy,” it is important that students engage in spiritual and religious diversity activities to broaden their understanding of “the other.” Although counselors typically seek strategies and advice about interventions, we suggest that personal awareness is a prerequisite of doing this work. As we have mentioned, many counselors and psychologists have transference issues that may be triggered by engagement with religious, spiritual, and transpersonal phenomena. Finally, we would like to end this chapter by suggesting an expansion of the landscape of spirituality in cross-cultural counseling. This could include some nontraditional approaches within the traditional boundaries of counseling, such as incorporating creative activities, working collaboratively with pastoral counselors, and helping clients to integrate day-to-day religious or spiritual practices in conjunction with traditional psychological counseling (Plante, 2009). We recommend that counseling’s path to the integration of mind, body, and spirit be holistic and inclusive of diversity at many levels. Critical Incident A recent shooting incident at a Sikh temple in the Midwest highlights racist hate crimes against Muslims and Sikhs in the United States fueled by Islamophobia. A Sikh undergraduate student comes into the counseling center seeking help. The student complains of sleeplessness, anxiety, and grief resulting from this tragedy. His academic performance has suffered and he is concerned about failing classes. He no longer feels safe and wonders about his visibility on campus. Consider the following areas to explore in your counseling session with this student: 1. How severe are his symptoms (e.g., sleep pattern, anxiety, grief)? 2. Has he witnessed or experienced prejudice and/or discrimination previously and how did he handle it (i.e., protective factors)? 3. Does he have a history of previous trauma? 4. What kind of support does he have from his Sikh community? 5. Can he identify his allies on campus? 6. What other questions might you want to ask him? Comment: One response to the shooting incident from a campus Sikh group was to sponsor a “wear a turban day,” during which all students were encouraged to wear turbans and interact with Sikh students to learn more about Sikhism. Would you join in such an activity? If so, how do you imagine your friends and family would react? How can you be an ally for members of religious minority groups? Discussion Questions 1. What were your initial reactions as you began to read this chapter? Do you have further points to add to the list of reasons to avoid talking about spirituality and religion in the classroom? 2. Are there any particular biases for or against this topic in your academic training program? Identify and discuss ways in which this topic can be made “safe” for exploration and discussion. 3. Recall a time or place or experience that for you felt “spiritual.” Describe it in detail using your five senses and note the feelings that are associated with it. 4. What is your personal story regarding your experiences with organized religion? What metaphor might represent your spiritual/religious story? For example, was it like a road winding through peaks and valleys, or was it like a container ship on a stormy sea? 5. Who are some spiritual or religious role models (living or not) from whom you gain inspiration and insight? Describe the relevance of their wisdom to your life. 6. How has your racial/ethnic and family background influenced your spiritual/religious development? 7. Visit a religious/spiritual worship service (e.g., at a church, synagogue, or mosque) or meditation group (or the like) that is unfamiliar to your life experience. Discuss what you learned and what it was like to take part in a “religious diversity activity.” 8. Do you have any experience with “religious wounding”? If so, can you journal about it and/or share your experiences with a trusted friend/counselor? 9. Do you have any experience with a “spiritual bypass”—that is, using a spiritual excuse to avoid necessary psychological work? If so, can you journal about it and/or share your experiences with a trusted friend/counselor? 10. Review the various types of spiritual interventions and identify those that would be a comfortable fit for you (or not). Discuss your choices. 11. What do you see as your strengths in engaging in spiritual/religious issues in counseling? 12. For which clinical issues might you need further training and supervision before engaging in spiritual/religious interventions? References Altareb, B. Y. (1996). Islamic spirituality in America: A middle path to unity. Counseling and Values, 41, 29–38. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402. Anderson, S. R., & Hopkins, P. (1991). The feminine face of God: The unfolding of the sacred in women. New York: Bantam Books. Ano, G., Mathew, E., & Fukuyama, M. (2009). Religion and spirituality. In A. Alvarez & N. Tiwari (Eds.), Asian American psychology: Current perspectives. Mahwah, NJ: Lawrence Erlbaum. Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalization of the multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24(1), 42–78. Association for Spiritual, Ethical, and Religious Values in Counseling. (2009). Competencies for addressing spiritual and religious issues in counseling. Retrieved from http://www.aservic.org/resources/spiritual-competencies Aten, J. D., & Leach, M. M. (Eds.). (2009). Spirituality and the therapeutic process: A comprehensive resource from intake to termination. Washington, DC: American Psychological Association. Aten, J. D., McMinn, M. R., & Worthington, E. L., Jr. (Eds.). (2011). Spiritually oriented interventions for counseling and psychotherapy. Washington, DC: American Psychological Association. Atran, S. (2012, August 6). God and the ivory tower. Foreign Policy. Retrieved from http://www.foreignpolicy.com/articles/2012/08/06/god_and_the_ivory_tower?page=full Battista, J. R. (1996). Offensive spirituality and spiritual defenses. In B. W. Scotton, A. B. Chinen, & J. R. Battista (Eds.), Textbook of transpersonal psychiatry and psychology (pp. 250–260). New York: Basic Books. Beversluis, J. (Ed.). (2000). Sourcebook of the world’s religions: An interfaith guide to religion and spirituality. Novato, CA: New World Library. Bly, R. (1990). Iron John: A book about men. Reading, MA: Addison-Wesley. Boyd-Franklin, N. (2003). Black families in therapy: Understanding the African American experience (2nd ed.). New York: Guilford Press. Carnes, R. D., & Craig, S. (1998). Sacred circles: A guide to creating your own women’s spirituality group. San Francisco: HarperCollins. Carnes, T., & Yang, F. (2004). Asian American religions: The making and remaking of borders and boundaries. New York: New York University Press. Cashwell, C. S., Myers, J. E., & Shurts, W. M. (2004). Using the developmental counseling and therapy model to work with a client in spiritual bypass: Some preliminary considerations. Journal of Counseling & Development, 82, 403–409. Cashwell, C. S., & Young, J. S. (Eds.). (2011). Integrating spirituality and religion into counseling: A guide to competent practice (2nd ed.). Alexandria, VA: American Counseling Association. Chilana, R. S. (2005). Sikhism: Building a basic collection of Sikh religion and culture. Reference and User Services Quarterly, 45, 11–21. Christ, C. (1995). Diving deep and surfacing: Women writers on spiritual quest (3rd ed.). Boston: Beacon Press. Christ, C. (1997). Rebirth of the Goddess: Finding meaning in feminist spirituality. New York: Routledge. CNN. (1995, October 16). The Million Man March. Retrieved from http://wwwcgi.cnn.com/US/9510/megamarch/march.html Cornish, J. A. E., Schreier, B. A., Nadkarni, L. I., Metzger, L. H., & Rodolfa, E. R. (Eds.). (2010). Handbook of multicultural counseling competencies. Hoboken, NJ: John Wiley. Cortright, B. (1997). Psychotherapy and spirit: Theory and practice in transpersonal psychotherapy. Albany: State University of New York Press. Culliford, L. (2011). The psychology of spirituality: An introduction. Philadelphia: Jessica Kingsley. Das, A. K. (1987). Indigenous models of therapy in traditional Asian societies. Journal of Multicultural Counseling and Development, 15, 25–37. Davidson, M. G. (2000). Religion and spirituality. In R. M. Perez, K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 409–433). Washington, DC: American Psychological Association. doi:10.1037/10339-017 Duffy, R. D., & Dik, B. J. (2012). Research on work as a calling. Journal of Career Assessment, 20(3), 239–241. Dunn, A. B., & Dawes, S. J. (1999). Spirituality-focused genograms: Keys to uncovering spiritual resources in African American families. Journal of Multicultural Counseling and Development, 27, 240–254. Elkins, D. N., Hedstrom, L. J., Hughes, L. L., Leaf, J. A., & Saunders, C. (1988). Toward a humanistic-phenomenological spirituality: Definition, description, and measurement. Journal of Humanistic Psychology, 28, 5–18. Espin, O. M. (1990). Third woman: The sexuality of Latinas. Journal of Sex Research, 27(1), 143–145. Esposito, J. L., & Kalin, I. (2011). Islamophobia: The challenge of pluralism in the 21st century. New York: Oxford University Press. Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus & Giroux. Faiver, C. M., O’Brien, E. M., & Ingersoll, R. E. (2000). Religion, guilt, and mental health. Journal of Counseling & Development, 78, 155–161. Falicov, C. J. (1999). Religion and spiritual folk traditions in immigrant families: Therapeutic resources with Latinos. In F. Walsh (Ed.), Spiritual resources in family therapy (pp. 104–120). New York: Guilford Press. Fitchett, G. (2002). Assessing spiritual needs: A guide for caregivers. Lima, OH: Academic Renewal Press. Fox, M. (2000). One river, many wells: Wisdom springing from global faiths. New York: Jeremy P. Tarcher/Putnam. Fox, M. (2008). The hidden spirituality of men: Ten metaphors to awaken the sacred masculine. Novato, CA: New World Library. Frame, M. W. (2000). The spiritual genogram in family therapy. Journal of Marital and Family Therapy, 26(2), 211–216. Frame, M. W. (2003). Integrating religion and spirituality into counseling: A comprehensive approach. Pacific Grove, CA: Brooks/Cole. Frame, M. W., & Williams, C. B. (1996). Counseling African Americans: Integrating spirituality in therapy. Counseling and Values, 41(1), 16–28. Frame, M. W., Williams, C. B., & Green, E. L. (1999). Balm in Gilead: Spiritual dimensions in counseling African American women. Journal of Multicultural Counseling and Development, 27, 182–192. Friedman, H. L., & MacDonald, D. A. (2002). Approaches to transpersonal measurement and assessment. San Francisco: Transpersonal Institute. Fukuyama, M. A. (1990). Taking a universal approach to multicultural counseling. Counselor Education and Supervision, 30, 6–17. Fukuyama, M. A., Puig, A., Wolf, C. P., & Baggs, A. (2014). Exploring the intersections of religion and spirituality with race-ethnicity and gender in counseling. In M. L. Miville & A. D. Ferguson (Eds.), Handbook of race-ethnicity and gender in psychology (pp. 23–43). New York: Springer. Fukuyama, M. A., & Sevig, T. D. (1999). Integrating spirituality into multicultural counseling. Thousand Oaks, CA: Sage. Fukuyama, M. A., Siahpoush, F., & Sevig, T. D. (2005). Religion and spirituality in a cultural context. In C. S. Cashwell & J. S. Young (Eds.), Integrating spirituality and religion into counseling: A guide to competent practice (pp. 123–142). Alexandria, VA: American Counseling Association. Gallup. (2007). Religion. Retrieved from http://www.gallup.com/poll/1690/religion.aspx#1 Germer, C. K., Siegel, R. D., & Fulton, P. R. (Eds.). (2005). Mindfulness and psychotherapy. New York: Guilford Press. Gilligan, C. (1993). In a different voice: Psychological theory and women’s development. Cambridge, MA: Harvard University Press. Gladding, S. (2011). The creative arts in counseling (4th ed.). Alexandria, VA: American Counseling Association. Gray, E. R., & Thumma, S. (2005). Gay religion. Walnut Creek, CA: AltaMira Press. Griffith, J. L. (2010). Religion that heals, religion that harms: A guide for clinical practice. New York: Guilford Press. Griffith, J. L., & Griffith, M. E. (2002). Encountering the sacred in psychotherapy: How to talk with people about their spiritual lives. New York: Guilford Press. Hanson, R. (with Mendius, R.). (2009). Buddha’s brain: The practical neuroscience of happiness, love and wisdom. Oakland, CA: New Harbinger. Hathaway, W. L. (2011). Ethical guidelines for using spiritually oriented interventions. In J. D. Aten, M. R. McMinn, & E. L. Worthington, Jr. (Eds.), Spiritually oriented interventions for counseling and psychotherapy. Washington, DC: American Psychological Association. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experimental approach to behavior change (2nd ed.). New York: Guilford Press. Hill, P. C., Pargament, K. I., Hood, R. W., McCullough, M. E., Swyers, J. P., Larson, D. B., et al. (2000). Conceptualizing religion and spirituality: Points of commonality, points of departure. Journal for the Theory of Social Behavior, 30(1), 50–77. Hillman, J. (1996). The soul’s code: In search of character and calling. New York: Random House. Hinterkopf, E. (1997). Integrating spirituality in counseling: A manual for using the experiential focusing method. Alexandria, VA: American Counseling Association. Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging Section, 191(1), 36–43. doi:10.1016/j.pscychresns.2010.08.006 Hopson, R. E. (1996). The 12-step program. In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 533–558). Washington, DC: American Psychological Association. Horovitz, E. G. (2002). Spiritual art therapy: An alternate path (2nd ed.). Springfield, IL: Charles C Thomas. Huxley, A. (1945). The perennial philosophy. New York: Harper & Brothers. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Delta. Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144–156. Kelly, E. W., Jr. (1995). Spirituality and religion in counseling and psychotherapy: Diversity in theory and practice. Alexandria, VA: American Counseling Association. King, J., & Trimble, J. E. (2013). The spiritual and sacred among North American Indians and Alaska Natives: Mystery, wholeness, and connectedness in a relational world. In K. I. Pargament (Ed.), APA handbook of psychology, religion, and spirituality: Vol. 1. Context, theory, and research. Washington, DC: American Psychological Association. Koenig, H. G. (1997). Is religion good for your health? The effects of religion on physical and mental health. New York: Hawthorn Pastoral Press. Koenig, H. G. (2005). Faith and mental health: Religious resources for healing. West Conshohocken, PA: Templeton Foundation Press. Koenig, H. G., King, D. E., & Carson, V. B. (Eds.). (2012). Handbook of religion and health (2nd ed.). New York: Oxford University Press. LaDue, R. A. (1994). Coyote returns: Twenty sweats does not an Indian expert make. Women & Therapy, 15(1), 93–111. Levin, J. (2001). God, faith, and health: Exploring the spirituality–healing connection. New York: John Wiley. Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press. Locke, D. (1990). A not so provincial view of multicultural counseling. Counselor Education and Supervision, 30, 18–25. Love, E. (2009). Confronting Islamophobia in the United States: Framing civil rights activism among Middle Eastern Americans. Patterns of Prejudice, 43(3), 401–425. doi:10.1080/00313220903109367 Lynch, E. W., & Hanson, M. J. (Eds.). (2004). Developing cross-cultural competence: A guide for working with children and their families (3rd ed.). Baltimore: Paul H. Brookes. Mattis, J. S., & Jagers, R. J. (2001). A relational framework for the study of religiosity and spirituality in the lives of African Americans. Journal of Community Psychology, 29(5), 519–539. doi:10.1002/jcop.1034 May, G. (1982). Will and spirit: A contemplative psychology. New York: Harper & Row. Miller, W. R., & Thoresen, C. E. (2003). Spirituality, religion, and health: An emerging research field. American Psychologist, 58(1), 24–35. Moodley, R., & West, W. (Eds.). (2005). Integrating traditional healing practices into counseling and psychotherapy. Thousand Oaks, CA: Sage. Morgan, O. (Ed.). (2007). Counseling and spirituality: Views from the profession. Boston: Lahaska Press. Morris, J. R., & Robinson, D. T. (1996). Community and Christianity in the Black church. Counseling and Values, 41(1), 59–69. Myers, D. G. (2000). The American paradox: Spiritual hunger in an age of plenty. New Haven, CT: Yale University Press. Newport, F. (2012). God is alive and well: The future of religion in America. Omaha, NE: Gallup Books. Pargament, K. I. (1999). The psychology of religion and spirituality? Yes and no. International Journal for the Psychology of Religion, 9(1), 3–16. Pargament, K. I. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. New York: Guilford Press. Pargament, K. I. (Ed.). (2013). APA handbook of psychology, religion, and spirituality (2 vols.). Washington, DC: American Psychological Association. Parham, T. A., Ajamu, A., & White, J. L. (2011). Psychology of Blacks: Centering our perspectives in the African consciousness (4th ed.). Upper Saddle River, NJ: Prentice Hall. Parham, T. A., & Parham, W. D. (2002). Understanding African American mental health: The necessity of new conceptual paradigms. In T. A. Parham (Ed.), Counseling persons of African descent: Raising the bar of practitioner competence (pp. 25–37). Thousand Oaks, CA: Sage. Parks, S. D. (2000). Big questions, worthy dreams: Mentoring young adults in their search for meaning, purpose, and faith. San Francisco: Jossey-Bass. Plante, T. G. (2009). Spiritual practices in psychotherapy: Thirteen tools for enhancing psychological health. Washington, DC: American Psychological Association. Puig, A., & Adams, C. (2007). Introducing spirituality into multicultural counseling. In W. M. Parker & M. A. Fukuyama (Eds.), Consciousness-raising: A primer for multicultural counseling (3rd ed., pp. 181–203). Springfield, IL: Charles C Thomas. Puig, A., & Fukuyama, M. A. (2008). A qualitative investigation of multicultural expression of spirituality: Preliminary findings, Counseling et Spiritualité/and Spirituality, 27(2), 11–37. Puig, A., Lee, S. M., Goodwin, L., & Sherrard, P. A. D. (2006). The efficacy of creative arts therapies to enhance emotional expression, spirituality, and psychological well-being in early stage breast cancer patients. International Journal of the Arts in Psychotherapy, 33(3), 218–228. Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psychotherapy. Washington, DC: American Psychological Association. Richards, P. S., & Bergin, A. E. (Eds.). (2000). Handbook of psychotherapy and religious diversity. Washington, DC: American Psychological Association. Ritz, L. (2012). Neurotheology: The brain and the science of meditation. In R. Singh (Ed.), Meditation as medication for the soul (pp. 152–171). Lisle, IL: Radiance. Ritz, L., Cooper, L. A., Murphy, M., Puig, A., Tannen, C., & Vidaurreta, B. (2010, November). Mindfulness in medicine. Paper presented at the annual meeting of the American Association of Medical Colleges, Washington, DC. Robinson, B. A. (2012, April 2). Promise Keepers (PK), pro and con. Ontario Consultants on Religious Tolerance. Retrieved from http://www.religioustolerance.org/chr_pk.htm Rodriguez, J. (2004). Mestiza spirituality: Community, ritual, and justice. Theological Studies, 65(2), 317–339. Roemer, L., & Orsillo, S. M. (2009). Mindfulness and acceptance-based behavioral therapies in practice. New York: Guilford Press. Rogers, N. (1993). The creative connection: Expressive arts as healing. Palo Alto, CA: Science & Behavior Books. Rogers, N. (2011). The creative connection for groups: Person-centered and expressive arts for healing and social change. Palo Alto, CA: Science & Behavior Books. Rohr, R. (2005). From wild man to wise man: Reflections on male spirituality. Cincinnati: St. Anthony Messenger Press. Savage, J., & Armstrong, S. (2010). Developing competency in spiritual and religious aspects of counseling. In J. A. E. Cornish, B. A. Schreier, L. I. Nadkarni, L. H. Metzger, & E. R. Rodolfa (Eds.), Handbook of multicultural counseling competencies (pp. 379–413). Hoboken, NJ: John Wiley. Scotton, B. W., Chinen, A. B., & Battista, J. R. (1996). Textbook of transpersonal psychiatry and psychology. New York: Basic Books. Sevig, T. D., & Etzkorn, J. (2001). Transformative training: A year-long multicultural counseling seminar for graduate students. Journal of Multicultural Counseling and Development, 29, 57–72. Shafranske, E. P. (Ed.). (1996). Religion and the clinical practice of psychology. Washington, DC: American Psychological Association. Shapiro, R. (2011). Rabbi Rami guide to God: Roadside assistance for the spiritual traveler. Traverse City, MI: Spirituality & Health Books. Shapiro, R. (2012, November/December). Former priest Matthew Fox on 21st century spirituality. Spirituality and Health: The Soul–Body Connection, pp. 28–29. Shapiro, R. (2013, January/February). Roadside assistance for the spiritual traveler. Spirituality and Health: The Soul–Body Connection, p. 18. Shimabukuro, K. P., Daniels, J., & D’Andrea, M. (1999). Addressing spiritual issues from a cultural perspective: The case of the grieving Filipino boy. Journal of Multicultural Counseling and Development, 27, 221–239. Shumsky, S. G. (1996). Divine revelation. New York: Simon & Schuster. Sikhism in America: A guide to the targeted religion. (2012, August 6). The Week. Retrieved from http://theweek.com/article/index/231562/sikhism-in-america-a-guide-to-the-targeted-religion Smith, H. (1991). The world’s religions. San Francisco: HarperSanFrancisco. Stanard, R. P., Sandhu, D. S., & Painter, L. C. (2000). Assessment of spirituality in counseling. Journal of Counseling & Development, 78, 204–210. Starhawk. (1999). The spiral dance: A rebirth of the ancient religion of the great Goddess. San Francisco: HarperSanFrancisco. Taylor, B. (Ed.). (2008). The encyclopedia of religion and nature (Vol. 1). New York: Continuum Books. Teaching teachers mindfulness to foster education, improve well-being. (2009, April 10). Penn State News. Retrieved from http://news.psu.edu/story/177561/2009/04/10/teaching-teachers-mindfulnessfoster-education-improve-well-being Trimble, J. E., & Thurman, P. (2002). Ethnocultural considerations and strategies for providing counseling services for Native American Indians. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th ed., pp. 53–91). Thousand Oaks, CA: Sage. Watts, S. K. (2003). Come to the river: Using spirituality to cope, resist and develop identity. New Directions for Student Services, 104, 29–40. Wigglesworth, C. (2012). Talking about spirit at work. Houston: Conscious Pursuits. Retrieved from http://healingdeliverance.net/free_pdf_ebooks/wigglesworth/wigglesworth_TalkingAboutSpiritualWor Zea, M. C., Mason, M. A., & Murguía, A. (2000). Psychotherapy with members of Latino/Latina religions and spiritual traditions. In P. S. Richards & A. E. Bergin (Eds.), Handbook of psychotherapy and religious diversity (pp. 397–419). Washington, DC: American Psychological Association. doi:10.1037/10347-016 23 Drug and Alcohol Abuse and Health Promotion in CrossCultural Counseling Lisa Rey Thomas Dennis M. Donovan Primary Objective ■ To identify and describe essential definitional issues in cross-cultural counseling with substance-abusing and recovering clients Secondary Objectives ■ To identify and describe key components of a strengths-based cultural model for assessment and case conceptualization ■ To identify and describe essential factors for culturally appropriate treatment and aftercare planning “My group facilitator, Shelly, suggested I make an appointment with you.” Calliyah looked up briefly from her hands and then back down again. “I don’t really know why I’m here. I don’t know if therapy will help at all. I’ve been clean and sober for 4 months. I just got a job. But I need a house. I need clothes and food. I need my children back. I don’t know how therapy is going to help that.” I asked her if she wanted to tell me how she was feeling. No words came. She continued to look at her hands. Finally, without looking at me, Calliyah replied, “Tired. I’m so tired.” More silence and one-word answers to questions encouraged me to ask more questions and to be patient in waiting for responses. The client in the story above is Calliyah Miller, a 39-year-old Pacific Northwest American Indian female who is a single mother of three and a grandmother of two. She was born and raised on a small reservation and has lived there her entire life, as have most of her family members. She started using alcohol when she attended the local high school. For the past 10 years she struggled with abusing both alcohol and prescription pain medications. She has been raising her 16-year-old daughter as well as her grandchildren, who are 3 and 5 years old. One year ago, the tribe’s Indian Child Welfare (ICW) authorities removed her daughter and grandchildren due to neglect resulting from her substance abuse. Devastated, Calliyah began outpatient treatment last year and has been clean and sober for 4 months. Part of her treatment and recovery plan includes attending a group therapy program developed by the tribe’s Wellness Center. Calliyah gave permission for her group facilitator to share her notes, which help a bit: Calliyah’s family has lived on the reservation for three generations. She was raised by her grandmother, Julia. Julia was forcibly taken from her home on the reservation as a young child and moved to a boarding school, where she lived until she was 15. When Julia returned to the reservation, she no longer spoke her tribe’s language or engaged in traditional practices or healing. Julia never spoke about her time at the boarding school, but other children who attended the school reported neglect and abuse at the hands of the school staff. Julia began using alcohol and, with only the boarding school model of “parenting,” struggled to parent her own children. When Calliyah was born, Julia quit drinking in order to raise her. Calliyah’s siblings went to live with other family members, and all but one, who passed away last year, still live on the reservation. Until Calliyah began outpatient treatment for her substance abuse, none of the family utilized behavioral health services; in fact, Calliyah and her family are extremely apprehensive about seeking services. Calliyah states that she is committed to her sobriety and to getting her child and grandchildren back but is unsure how to do that. She trusts her group and her group facilitator, which is the only reason she has agreed to explore individual therapy to support her sobriety and recovery. Recently, she has begun to explore her own culture and cultural traditions and practices. This case defines a set of challenges for the counselor who will treat Calliyah and help her navigate the potentially challenging course of her recovery. These issues are in some ways universal, in that they surface in most cross-cultural alcohol and drug counseling cases. They can include highly prevalent psychological disorders such as depression and posttraumatic stress disorder co-occurring with substance abuse, complex medical problems, the need for a culturally appropriate assessment of the substance abuse problem and recovery plan, the challenges of establishing and maintaining a cross-cultural therapeutic relationship with a substance-abusing person and/or person in recovery, the challenges of working with clients in small and close-knit communities, and the need to develop individualized, culturally grounded, strengths-based, and culture-specific strategies for effective interventions. Drug and alcohol abuse, and its associated negative consequences and comorbidities, presents critical issues for cross-cultural counseling. A client may present with substance abuse as the primary concern, or, as in Calliyah’s case, substance abuse and recovery may be only a part of many issues the client faces (e.g., difficulty meeting basic needs, marital and other family problems, daily living problems, health problems). The client may not view his or her substance abuse as important at all, relative to other presenting and immediate issues. Approaches to treating substance abuse are well documented and include a variety of different “evidence-based” approaches (for reviews, see Donovan & Marlatt, 2005; Longabaugh et al., 2005; Marlatt & Donovan, 2005; McGovern & Carroll, 2003: P. M. Miller, 2009; Waldron & Turner, 2008). However, empirical support for the usefulness, appropriateness, and effectiveness of current evidence-based practices for diverse populations remains minimal. One recent review identified 43 different interventions possessing at least some evidence of being effective for treating substance abuse. Out of these 43 interventions, 4 had been tested with African Americans and 2 with Hispanics/Latinos/Latinas; none had been tested with Asian Americans/Pacific Islanders, American Indians/Alaska Natives, or gay/lesbian/bisexual/transgendered populations (University of Washington Alcohol and Drug Abuse Institute, 2013). Given this current status, it is critical that strategies developed in cross-cultural counseling for mental health concerns inform counselors’ approaches in working with ethnically and culturally diverse clients with substance abuse problems and in recovery (Blume, Resor, & Kantin, 2009). As there are a number of counseling and therapeutic strategies for the treatment of substance abuse from which counselors can draw, but few possessing any empirical support with diverse populations, there is increasing need for rigorous adaptation or cultural tailoring of existing interventions (see Bernal & Domenech Rodríguez, 2012). This emerging and critical area has to date focused primarily on adapting interventions for prevention of youth substance abuse (Thomas, Donovan, Sigo, Austin, & Marlatt, 2009; Whitbeck, 2006), grounding treatment approaches in local culture (Gone, 2011; Gone & Calf Looking, 2011), and emphasizing the need for future research (Unger, 2012). Given the current lack of comprehensive culturally grounded and empirically supported approaches, we will present a methodology for adapting methods that appear to us as promising in their potential to fit within a cultural model for treatment. We begin by addressing definitional issues in culture and how culture shapes the counselor’s work with a client. We then discuss a cultural model for assessment and case conceptualization, followed by a presentation of cultural factors in treatment and aftercare planning. We conclude the chapter with a discussion of some of the cultural considerations important in substance abuse counseling with people from four ethnic, racial, and cultural groups: African Americans, Latino/as, Asian Americans, and American Indians/Alaska Natives. Cultural Frames for Alcohol and Drug Abuse Counseling: A Point of Departure For the purposes of this chapter, our working definition of culture comes from Geertz (1973): The concept of culture I espouse . . . is essentially a semiotic one. Believing, with Max Weber, that man is an animal suspended in webs of significance he himself has spun, I take culture to be those webs. . . . It is public because meaning . . . systems of meaning are necessarily the collective property of a group. (pp. 4–5) This definition stresses that culture is a shared meaning system, one that regulates the web of behavior. In this chapter we focus on four aspects of culture that are critical to the counseling process: linguistics, sociolinguistics, values, and symbolic meaning. Each of these aspects has a specific role in the counseling relationship, as well as in helping counselors and clients to understand important cultural factors in drug and alcohol abuse and the recovery from abuse. In addition to these four aspects, the unique sociopolitical, historic, and current contexts of each client are critical. Linguistics Recognition of linguistic differences is critical to the counselor’s ability to understand the person he or she is working with in the counseling relationship. The client may be unable to explain his or her experience to a counselor who speaks a different language or dialect, or to do so adequately and with trust that the counselor will understand. The counselor will have great difficulty in understanding the client unless he or she is able to do so through the client’s first language. In order to understand the client’s experience, which is essential for developing a therapeutic alliance, the counselor may need to work with an interpreter, who will become, inevitably, a co-counselor. This is particularly the case in refugee counseling. As complex as language differences are, many of the differences among English-language dialectics can also present a challenge. How will Calliyah talk to the counselor? Is there a reservation dialect? If so, the counselor must be aware of it and know the words Calliyah chooses to express emotions in that dialect. What did Calliyah mean by “tired . . . so tired”? Within her dialect, tired may refer not only to physical exhaustion but also to the experience of being overwhelmed or even depressed. This is a working hypothesis that the counselor will need to explore further, given the high rates of cooccurrence of substance use disorders and depression (Beals et al., 2005; Rieckmann et al., 2012). What is clear is that the counselor must gain access to an understanding of the client’s meanings, as embedded in the client’s language and dialect, in order to conceptualize the client’s issues and strengths and form a treatment and recovery plan. To the extent that the client has the perception of the therapist being attentive to and appreciative of cultural issues as described in his or her dialect, the therapeutic alliance is strengthened, which enhances the likelihood of treatment success (Owen, Tao, Leach, & Rodolfa, 2011). Sociolinguistics Sociolinguistics encompasses the social language of nonverbal behavior (e.g., body language, eye gaze, nodding) as well as the verbal sequencing of speech (e.g., pace, pause time). For example, some African Americans may speak in a rapid and nuanced way that forms a sense of interactional rhythm, while many American Indians/Alaska Natives (AI/ANs) might speak at a slower pace and take longer pauses in establishing an interactional rhythm. The interactional rhythm between client and counselor is critical for a sense of comfort and for the client’s development of trust that he or she will be understood (Erickson, 1975). Nonverbal expressions can also serve as a source of data that allows the counselor to make assessments about the client and how counseling is progressing. Calliyah’s group facilitator wondered why she seemed so engaged and animated during group but had a more monotonic verbal presentation and avoided eye contact during the one-on-one intake session. Calliyah’s counselor concluded that this sociolinguistic aspect of the interaction might be a sign of depression. However, an alternative explanation is that Calliyah’s alternation of averted gaze with direct gaze signified the working out of a culturally based interactional rhythm that would become the heart of a comfortable, trusting relationship. Values Values are significant and fundamental aspects of culture. For example, many AI/AN groups are collectivist in nature (Herring, 1999; Triandis, 1988; Trimble, 1987). Calliyah presents a number of values-focused issues for the counselor to address and to integrate into therapy using a strengthsbased perspective. For example, Calliyah is a caretaker for her family and, prior to ICW involvement, was the sole caretaker for two of her grandchildren. How might the counselor see this? Is this codependence as defined from a Western perspective, or is this an expression of culturally defined role responsibilities that Calliyah takes on as a member of her extended family? Without a cultural assessment and understanding of values, the counselor cannot accurately assess Calliyah’s life situation in order to begin to work effectively with her, as well as her family network, in counseling. If this caretaker role is a culturally sanctioned role and responsibility, the counselor will want to nurture and support it, build on the strengths that it lends to Calliyah’s life, and avoid labeling and pathologizing it according to a Western model of case conceptualization. Other values issues also emerge in Calliyah’s case. She stated that she was “tired... so tired” but also shared that she needed to “keep going.” The counselor will need to work with Calliyah to determine if her cultural value of supporting her family network is overwhelming her and she could benefit from some life skills building, or if she is interpreting her depressive symptoms as fatigue, knowing that her ancestors taught her to “go on” no matter what. Calliyah also shared that her family was not supportive of her seeking services outside the family, and in fact preferred that she not do so. American Indians/Alaska Natives’ history with institutional care is one in which great harm has been done to children, families, and the community. The counselor will need to take care to understand any reluctance toward treatment and therapy that Calliyah might exhibit. Symbolic Meaning Culture relates to the symbolic order, the deep cultural meanings and explanatory models (Kleinman, 1988) for illness and health held by the client. Calliyah presents an emergent and somewhat conflicted example of the symbolic. Like many American Indians who were taken from their tribal communities and placed in boarding schools, Calliyah’s grandmother was forced to stop speaking her Native language and practicing culturally valued ceremonies, traditions, and activities; this was an attempt on the part of the government and certain religious missionaries to “tame the Natives” and assimilate them into Western ways. As a result of her grandmother’s experiences and the horrific impact that practicing traditional culture had on her grandmother and their community post–European contact, Calliyah has been taught by her grandmother to dismiss the traditional values, practices, and teachings of her tribe. However, Calliyah is beginning to explore her culture and teachings and may be ready to begin to understand her experiences and issues through this symbolic lens. Importantly, the symbolic may also provide culturally grounded healing and health promotion. For example, Calliyah may begin to hear the whispering of the teachings of her ancestors. A careful history of Calliyah’s background and cultural orientation, what the voices are saying, when they began, and how they began, can help the counselor properly identify if these voices are potential culturally based symbols related to spirituality or if they may be symptoms of an undiagnosed mental health issue. Sociopolitical Context Finally, it is critical that the counselor be aware of the unique and diverse sociopolitical context of the client, both current and historic. For example, a counselor may have a general understanding of AI/AN culture and history, but there are more than 565 federally recognized tribes in the United States, and while there may be some overall shared cultural values (e.g., reverence for elders and children), each tribe is unique culturally and has been affected differently by colonization and current political climates. Clients from diverse ethnocultural backgrounds may differ immensely with regard to political status, geographic location, language, refugee and immigrant status, enculturation, acculturation, assimilation, biculturality, and so on. Situating the client and his or her community in their current and historical sociopolitical context is critical. For example, Calliyah’s tribe is semirural and had most of its land and culture (practices, language) taken away during the 1800s; only recently has the tribe’s traditional culture reemerged. We have now provided a case example, a brief description of our understanding of culture, and a sense of how this cultural framework may inform our understanding of this case. For a counselor to utilize this framework in counseling, he or she must next have a methodology that situates the client within his or her culture. Clearly, Calliyah is a complex person possessing many aspects of her indigenous culture along with a number of influences from Euro-American culture. Creating a collaborative, strengths-based counseling plan for her will require an equally sophisticated assessment approach that links culture to an understanding of Calliyah’s present and emergent problems, builds on her culturally grounded values and teachings for good health, and informs treatment and recovery planning (Allen, Donohue, Sutton, Haderlie, & Lapota, 2009; Asnaani & Hofmann, 2012; Blume, Morera, & García de la Cruz, 2005; Donovan, 2003, 2005, 2013). Multicultural Substance Abuse Assessment Substance abuse assessment is most effective when practiced using models that systematically bring cultural knowledge into the assessment process (Asnaani & Hofmann, 2012). This can be achieved through the use of a culturally congruent, collaborative, and strengths-based approach that includes the input of a collateral information source. Drug and alcohol abuse assessment should explore the client’s history of substance use/abuse and its consequences, as well as the client’s acculturation status, levels of identity, motivation for change, and personal assets, all of which include important cultural elements (Trimble, 1987). Multicultural substance abuse assessment identifies cultural factors that are important to a positive counseling outcome. Each of the five aspects of culture essential to cultural competency in multicultural substance abuse counseling—linguistics, sociolinguistics, values, symbolic meaning, and sociopolitical context—is also critical in the assessment interviewing process. Knowledge of how interpersonal interactions are sociolinguistically patterned within the cultural group of the person being assessed, the meaning of nonverbal cues within the culture, and nuances of local dialect and linguistic conventions are all examples of culturally competent interviewing skills in assessment that are crucial to the establishment of trust, which is the first step in obtaining a detailed history and understanding of the client. In addition, the counselor should approach this work with cultural humility. Cultural humility, which is different from cultural competence, has been defined as “a process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners” (Tervalon & Murray-García, 1998, p. 118). A Collaborative Approach A strengths-based, culturally informed collaborative approach to assessment can be particularly helpful in multicultural substance abuse assessment. In the case of cross-cultural assessment, the assessor’s cultural background is often different from that of the client. The power differential between minority clients and majority or high-status counselors replicates the historical and institutional context of racism and oppression experienced by many clients and their ethnic groups. This alone can produce distrust between counselor and client. One goal of a collaborative assessment approach is empowerment of the individual through the assessment process. Providing an opportunity for the client to achieve a sense of control and self-direction in the assessment process can serve as an antidote to the sense of disempowerment that such contexts have created in the past, and instead enhance client self-efficacy and commitment to the treatment and recovery process. Collaborative assessment also allows the client to share local expertise and knowledge about issues as well as solutions that the counselor may not have access to. In collaborative assessment, the client is invited to frame his or her own assessment questions regarding use and misuse of drugs and alcohol, to describe his or her history of past attempts to reduce or abstain from substances, and to provide input and reflection on the interpretation of the meaning of assessment results and the use of these results. This also allows the person to include information on issues in addition to substance abuse–related goals, such as difficulty in meeting basic needs. Alongside the assessor, the client develops a description and interpretation of the assessment findings. The client may even assist in modifying an initial assessment finding to improve its accuracy and usefulness. Clear procedures are laid out in advance for dealing respectfully with instances in which client and counselor disagree on the meaning of a behavior or the consequences of substance use. Cultural Assessment of Use and Consequences Multicultural substance abuse assessment entails a comprehensive exploration of the client’s history and consequences of use, motivation for change, acculturation status, and personal assets. The importance of a thorough psychosocial history in substance abuse assessment cannot be overemphasized. It is crucially important for counselors to develop the ability to explore with clients their social histories, important life events (especially traumatic experiences), and histories of mental health problems, within an atmosphere of trust. For many multicultural clients, gaining an understanding of historical events that have affected their entire cultural group is also critical to their understanding of their current challenges. Genograms may be useful in assisting clients in identifying important family relationships as well as patterns of substance abuse within kinship networks (Witko, 2006). From a strengths-based perspective, genograms may also highlight patterns of wellness, sobriety, and health in kinship networks. In addition, more specialized elements of history taking are needed related to the person’s lifelong use of substances. This should include an assessment of initiation into and patterns of early use, as well as past and present quantity and frequency of use. For a client in recovery, a history of past attempts to reduce or abstain from substances is important, along with information on the challenges and successes associated with prior attempts. It is important for counselors to be aware of cultural factors in quantity and frequency of use. For example, within some cultures, such as some American Indian and Alaska Native groups, drinking style is often characterized by binge use (May & Gossage, 2001) followed by long periods of abstention. Alcohol and drug use assessment instruments can be helpful for assessing the severity of a substance abuse problem. Two measures of hazardous or harmful drinking patterns and consequences that have been used or adapted for use with multicultural groups are the Drinker Inventory of Consequences (DrInC; W. R. Miller, Tonigan, & Longabaugh, 1995) and the Alcohol Use Disorders Identification Test (AUDIT; Conigrave, Hall, & Saunders, 1995). The AUDIT was developed by the World Health Organization (WHO), has been used globally, and examines quantity, frequency, alcohol-related problems, and signs of alcohol dependence. The DrInC is a widely used measure of adverse drinking consequences developed for Project MATCH, a multisite alcohol treatment matching study that included Hispanic and African American samples. The DrInC, as a measure of consequences, avoids confounding drinking style with more severe, long-term alcohol dependence; it is available in both long and short forms, as are versions designed to assess drug use consequences. The WHO has also developed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), which assesses the frequency of use, negative consequences, and dependence symptoms of alcohol, tobacco, illicit drugs, and pain medications (Humeniuk et al., 2008). Acculturation Status Assessment An important component in multicultural substance abuse assessment, as in all multicultural assessment, is the assessment of acculturation status and racial, ethnic, or cultural self-identification (Dana, 2005; Trimble, 1996, 2003). If possible, this should be done early in the assessment process to ensure that the counselor can be as respectful and culturally appropriate as possible. In the acculturation assessment, the focus is at the individual level of analysis. Berry, Poortinga, Breugelmans, Chasiotis, and Sam (2011) provide one useful way of understanding cultural contact status in terms of integration or biculturalism, assimilation, separation, or marginalization. From the perspective of a person from the nondominant group, assimilation occurs when the individual no longer wishes, or is able, to maintain his or her cultural identity but rather adopts that of the majority culture; separation occurs when the individual maintains his or her cultural identity; integration, or biculturalism, occurs when the individual maintains his or her original culture and seeks also to participate in the more dominant cultural network; and marginalization occurs when the person has little interest in cultural maintenance or participation in the dominant culture. Assessment of Calliyah’s acculturation status can help the counselor to understand Calliyah’s strengths, identify assets that can be mobilized in counseling as well as in Calliyah’s own community, and establish an appropriate balance between culturally specific approaches and more conventional treatment choices. Counselors should keep two important cautions in mind when thinking about acculturation. First, though there has been a significant effort in the research to understand cultural identification as a protective factor in relation to substance abuse, with some promising findings (e.g., Gone, 2011; Gone & Calf Looking, 2011; Torres Stone, Whitbeck, Chen, Johnson, & Olson, 2006), no direct relationship has emerged; rather, the relationship appears to be complex (Oetting, Donnermeyer, Trimble, & Beauvais, 1998; Trimble & Mahoney, 2002; Whitbeck, Hoyt, McMorris, Chen, & Stubben, 2001). Second, although an understanding of cultural identity can be enormously beneficial for clients in long-term recovery from substance abuse problems, for clients who are very early in the recovery process, engaging in counseling that directly explores identity issues may be premature. As mentioned earlier, the assessment of acculturation and identity is critical and should be done as early as possible, but only when the client is ready to increase the success of the process of learning and using critical skills necessary to cope with the immediate feelings of craving and the triggers for relapse into substance abuse. Collateral Assessment Although a client has taken the important step of seeking treatment and support for recovery, denial and minimization can be part of the problem in substance abuse. Therefore, collateral assessment, if possible, can be useful. A collateral is someone who can provide an additional perspective on the issues that the client is facing as well as the strengths and resources available to support recovery. The collateral can be a significant other, a relative, or a concerned friend; for Calliyah, it is her auntie. Aunties play a very important role for many AI/AN people and communities. An auntie is usually someone who has known the person for most, if not all, of the individual’s life. In most AI/AN communities, aunties have the role and responsibility of helping to raise their nieces and nephews (not necessarily biologically related). Providing the client has given permission to work with a collateral, he or she serves as an additional source of information, providing a cross-check on the veracity of the assessment information provided by the client; he or she may also share information on important historic events as well as local knowledge and healing practices that the client might benefit from. In the case of Calliyah, her auntie was a rich source of cultural knowledge regarding Calliyah’s identity, cultural factors in her substance use, and, in particular, some of the culturally based strengths that could motivate Calliyah to change. The auntie offered this new information about Calliyah: Calliyah rarely leaves the reservation area except to shop or take her family members on errands. Her mother was killed in an alcohol-related auto accident, which is why her grandmother raised her. There is a new group on the reservation that is focused on intergenerational and historical trauma; the community is just recently willing to begin to discuss and reflect on the impact that the boarding schools had on their families and their tribe. Calliyah was a good student but experienced a lot of racism and prejudice at the local school. She wants to try college but is reluctant given her past experience; however, she aspires to an undergraduate and then graduate degree to better serve her own tribe. The Wellness Clinic now offers traditional healing as well as conventional therapy. Though Calliyah does not speak her tribal language, she is taking a class in the language and understands a little; she has tried speaking it with a couple of elders and young people. She has begun volunteering at tribal events and is learning some of the old stories from the elders. Before she started using drugs and alcohol heavily, she was a devoted mother and grandmother, and she is determined to get her children back. This is what finally motivated her to seek individual therapy in her recovery efforts. On the basis of these observations, the acculturative status concept of integration informs the counselor’s cultural understanding of Calliyah’s strengths and status. Strengths-Based Assessment Following an examination of acculturation and self-identification status, a culturally informed strengths-based substance abuse assessment focuses on the identification of strengths and assets that a treatment approach might access, including individual, family, community, and cultural strengths. Across cultures, assessment in three general areas can guide the counselor in identifying these assets: behavioral control and prosocial commitment, mood stability, and psychocultural factors. Behavioral undercontrol (Sher & Trull, 1994), which includes impulsivity, sensation seeking, and, at the extreme, antisocial characteristics, can increase risk for substance abuse. Though Calliyah has experienced recent periods of severe distress as she has struggled to secure basic resources for herself and her children while working on her recovery and sobriety, she has refrained from acting impulsively (as she reported she did in the past). Instead, she has participated regularly in her therapeutic group, is working with ICW to fulfill the requirements for having her children returned, has applied for and obtained a job with the tribe, and has sought individual treatment to support her recovery. This suggests that one of Calliyah’s strengths is her ability to control her behavior. This assessment was confirmed by her auntie (collateral). A second behavioral pattern to assess in multicultural substance abuse assessment is mood stability. Degree of uncomfortable anxiety and depression, often termed negative affectivity, increases risk of using substances for relief from discomfort (Conger, 1956; Sher, 1987). Calliyah appears to endure a significant degree of psychological pain, as reflected in her reporting of being extremely tired; in addition, she may have feelings of disappointment, failure, and shame regarding the loss of her children. This highlights the important consideration of co-occurring disorders in substance abuse assessment. Like many other individuals with alcohol and drug disorders, Calliyah may have a cooccurring mental health disorder; in this case possibly depression. Many American Indians and Alaska Natives have been found to have high rates of depression and posttraumatic stress disorder, often based on intergenerational historical trauma such as that experienced by Calliyah’s grandmother and transmitted to her, as well as current contributors to stress and anxiety that are comorbid with substance use (Beals et al., 2005; Rieckmann et al., 2012). Thus, the likelihood is high that a counselor will encounter a substance abuse client who also has some form of psychological disorder. It is important that the counselor screen for potential signs and symptoms of such disorders as part of the assessment process, and that the counselor review and interpret these signs and symptoms within the individual client’s cultural context. However, this may require a more thorough and focused psychiatric diagnostic assessment to determine whether the individual meets the diagnostic criteria for one or more disorders as specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). If present, these disorders need to be taken into account and incorporated into an integrated treatment plan to ensure a coordinated treatment for comorbid disorders, both to reduce symptom severity and to minimize the risk of relapse to alcohol or drugs. Using the DSM-5, the counselor can develop a cultural formulation and link the substance abuse and any mental health issues to a cultural explanatory model specific to the individual’s cultural group that can inform treatment and recovery (see “Cultural Formulation,” 2009). An assessment of psychocultural factors is potentially the most important area for multicultural substance abuse treatment and recovery planning. These factors include such things as community and cultural norms for health; community and cultural norms for substance use; peer influences; role models of sobriety, recovery, and abstention; and the types of prosocial cultural role expectations, obligations, and practices that are incompatible with drug and alcohol abuse. Calliyah’s collateral informant, her auntie, shared the following additional information on psychocultural factors: Most of Calliyah’s friends used to abuse alcohol and other drugs. However, over the past few years many of them have reduced or quit altogether in order to fulfill their roles and obligations in the community, to participate in traditional activities and practices, and for other reasons. In addition, the younger people in the tribe are standing up and asking their families and their community to become drug- and alcohol-free. The tribe also has more financial stability, and college scholarships are available to members who commit to working hard to maintain a certain grade point average and to working for the tribe over the summer breaks. Calliyah has a strong and large family network. She has begun spending time with the elders and knows that substance abuse is in conflict with their teachings. Calliyah has a strong desire to serve her reservation community now and in the future as an elder herself. She also wants to model good health and sobriety for her own children, grandchildren, nieces, nephews, and the community. A clear strength coming out of Calliyah’s cultural background is her commitment to her tribal cultural values of extended family and kin as well as of serving her community. Her strong desires to bring her family back together, to learn about her culture, and to continue her education motivate Calliyah to continue to gain control over her life. These are examples of the types of strengths-based psychocultural factors that can facilitate recovery from substance abuse, maintain sobriety, and promote good health. Motivation to Change An additional area to consider in substance abuse assessment is the person’s current level of motivation for change. At the beginning of her outpatient treatment last year, Calliyah completed the DrInC with her counselor as part of one of their first interviews. Calliyah had reported that she had been aware of a problem with her drinking and drug use for some time but had been unsure about her ability to change anything about it. Calliyah said that she and her treatment counselor reviewed the long list of life consequences from alcohol in Calliyah’s life. This had proved to be a key moment in the assessment, and in the entire counseling and intervention process. As Calliyah looked at her answers and her score on the DrInC, she said she cringed when told she experienced a level of consequences from drinking at an intensity similar to people admitted to inpatient treatment. Calliyah said she was surprised when the counselor, rather than making her feel this was something shameful, instead invited Calliyah to work with the counselor to try to make sense of this in terms of what it meant in Calliyah’s life. She said she told her counselor, “I am ready. I am ready to become the person that I was meant to be. My children and grandchildren and their grandchildren deserve that. I deserve that. I am ready.” As Calliyah shared her story, she and the counselor carefully identified the challenges she had overcome and the success she was experiencing in her sobriety at 4 months and assessed her readiness, motivation, and commitment to continued recovery. Assessment was carefully paced, and trust was built slowly along the way; it was made clear to Calliyah that she was the expert about herself and her recovery. Instead of leaving Calliyah feeling ashamed about the disarray of her life, the assessment process proved therapeutic in supporting her continued recovery. From Assessment to Counseling In terms of allowing Calliyah to move along in her readiness to continue her change away from her addictive behaviors, we can understand this readiness as a cycle, from Stage 1, precontemplation (not yet considering change), to contemplation (an awareness of the problem and ambivalence), to determination to change, then action to change, and finally to maintenance of sustained change, with occasional relapse, involving a return to Stage 1 (DiClemente & Prochaska, 1998). The counselor, during Calliyah’s intake for outpatient treatment, assessed Calliyah as moving into Stage 3, determination. Today, we can see her moving from action to maintenance. This model of change is very helpful in engaging those entering into the treatment process and facilitating change across time (Connors, DiClemente, Velasquez, & Donovan, 2013). Calliyah’s counselor proposed a complementary therapeutic approach for recovery. This included work with her counselor to enhance her motivation to continue to abstain from the use of alcohol and substances, using a culturally adapted motivational enhancement therapy (MET) approach (W. R. Miller, Zweben, DiClemente, & Rychtarik, 1992). As part of their review of the assessment, the counselor also discussed with Calliyah a referral to a respected local traditional healer, who would work with Calliyah to prepare her for her continued recovery and to support her health from a holistic perspective (emotional, physical, mental, spiritual, and cultural). Additionally, the counselor encouraged Calliyah to continue attending Alcoholics Anonymous and Narcotics Anonymous group meetings in her reservation community. They also discussed traditional cultural activities that Calliyah might want to participate in and planned to get her connected with a caseworker to begin to address her need for housing and other basic resources. Finally, Calliyah agreed to continue to attend her group, continue her counseling, and see a psychiatrist for a more thorough diagnostic assessment for depression or other psychiatric disorders. Each of these elements is part of a multimodal system of care that mixes indigenous and Western treatments, patterned according to the client’s cultural background and the recently completed assessment. Next, we briefly describe key elements in this mix. Motivational Enhancement Therapy The counselor chose the MET approach because of its cross-cultural use, its congruence with the assessment approach taken, including the use of the DrInC, its flexibility for cultural adaptation, and its fit with the work of Marlatt and Donovan (2005) on mindfulness training as part of relapse prevention later in the counseling process. MET is based on the principles of motivational interviewing (W. R. Miller & Rollnick, 1991), which is consistent with AI/AN cultural perspectives and values, with its person-centered emphasis on listening, reflecting, respect, and personal empowerment (Venner, Feldstein, & Tafoya, 2007). MET has been found to be more effective than either 12-step facilitation or cognitive behavioral therapies with alcohol-dependent American Indians (Villanueva, Tonigan, & Miller, 2007), and the effect sizes for motivational interviewing interventions have been shown to be larger in ethnic minority populations than in the dominant population (Hettema, Steele, & Miller, 2005). Our experience with indigenous groups points to a number of factors critical in the selection of counseling approaches with culturally diverse individuals. No one set of factors applies to all groups, but in our clinical and research experience with American Indians and Alaska Natives, we have found that certain qualities are important. First, AI/AN clients often desire a practical, problemsolving approach (LaFromboise, Trimble, & Mohatt, 1990). Second, they expect to make rapid progress and experience relief analogous to their experience with healing ceremonies (Mohatt, 1988). Third, depending on their acculturation status, they prefer to combine and integrate Western and indigenous approaches (LaFromboise et al., 1990). Fourth, they prefer an approach that enhances efficacy, particularly in the form of communal mastery (Hobfoll, Jackson, Hobfoll, Pierce, & Young, 2002). Fifth, although clients want their clinicians to be open to working with healers and other healing modalities, they expect that the counselors will commit to work on this material with them in counseling, rather than simply refer them to other people for this work (Mohatt, 1988). This last factor is consistent with face-to-face, kinship-based cultural values that emphasize personal and consistent relationships. The following are recommendations for a brief counseling approach that comes out of these considerations, recognizing that no two clients are alike, new information may arise in the process, and changes in a client’s life circumstances will always require flexibility in any approach. Session 1: Feedback For Calliyah, the foundation of empathy was achieved during the initial assessment process. As the treatment system places her with new counselors, each counselor will need to achieve this same relationship. Our recommendation is that one person complete the assessment and continue as the counselor to preserve continuity and established trust. If the client seeks additional therapy, as Calliyah did, then transparency, respect, and continuity of care among clinicians, across agencies or programs, and in collaboration with the client are critical, with the client determining when, and with whom, her information is shared. An important issue with respect to trust and information sharing in Calliyah’s case is whether her involvement in treatment has been mandated as part of the requirements for her to get her children and grandchildren back from the ICW authorities. If she has been mandated to treatment, this may have an impact on her motivation. On one hand, individuals mandated to treatment often feel resentful and may be less likely to engage fully in the therapeutic process. On the other hand, as it appears with Calliyah, knowing that engagement in therapy may facilitate a desired outcome, such as the return of children to the home, may serve as a powerful incentive that helps move a person forward and motivates positive behavior change. The client also needs to be made aware of the parameters of the information the counselor may be required to share to the mandating authority. Discussing such an issue openly is a crucial initial step, because it affects the building of trust in such circumstances, which is essential for effective intervention. The nonjudgmental approach of motivational interviewing has been used to address such issues with mandated clients (Lincour, Kuettel, & Bombardier, 2002; Mullins, Suarez, Ondersma, & Page, 2004). In Calliyah’s case this discussion reveals that she has not been mandated to therapy; rather, she sees therapy as a positive step that, if taken and successful, will increase her likelihood of regaining her parental rights. One focus during the assessment feedback session is ensuring that the sociolinguistics, environment of the sessions, and feedback information provided are consistent with the client’s views and explanatory models about his or her substance abuse problem and reflect the client’s sense of self. This serves to enhance the client’s sense of efficacy. At each point in this session, Calliyah guides the process, receives feedback from the clinician, and decides on the next step. At the end of the feedback session, the final summary worked out by the clinician and Calliyah leads the clinician to choose a set of treatment and recovery support modalities that include counseling, Alcoholics Anonymous (AA), use of a traditional healer, work with a case manager, and possible work with a psychiatrist for a more thorough diagnostic assessment, a medication regime if indicated, and continual monitoring of Calliyah’s depression in the course of ongoing therapy (which could also be addressed within the context of a motivational interviewing approach) (Hails et al., 2012; Westra, Aviram, & Doell, 2011). Therefore, the first session of MET recapitulates this assessment summary and provides additional feedback to enhance Calliyah’s sense of determination, to solidify her current stage of change, and to encourage her to move into the next phase of change, maintenance. The counselor lets Calliyah direct much of this process, allowing her to further educate the counselor about who Calliyah is and what she learned during the assessment process. In closing this session, the counselor finalizes the specific set of modalities that Calliyah has chosen (AA, psychiatrist, and so on). The counselor also might ask at the end of the session if Calliyah would like to choose some symbolic item that represents the work of the assessment and her commitment to maintenance, such as an oral recording, a stone, a piece of sage, a photograph, or a written contract. This will then allow the counselor to move seamlessly into the second session, devoted to values clarification. It is critical at this and every stage of Calliyah’s process for the counselor to consider how to integrate his or her work into the traditional ceremonies that Calliyah might be attending by utilizing an integrative strategy. For example, Calliyah plans to attend a healing ceremony on the reservation to request help in her progress and healing. The counselor can encourage Calliyah to present the feedback plan within the ceremony and to request assistance in developing a plan based on this assessment. The counselor can also suggest that Calliyah bring the symbolic item from counseling to the ceremony, in order to present it with a verbal prayer if appropriate. Session 2: Values Clarification In the second session the counselor and Calliyah begin to create a plan based on Calliyah’s values, with the goals of strengthening her motivation to move toward maintenance and fostering and maintaining those motivational strategies inherent in her cultural life. For Calliyah, many of these assets emerge from her commitment to her family, her cultural role as a caretaker, and her desire to serve her community as a strong role model. In addition, she has a goal to continue her education. The session should provide her with opportunities to reflect on how she feels when she is able to care for her family, how her decisions influence her relationships and roles within her family, and how her decisions affect her family and tribal community. The counselor can invite Calliyah to consider how she will begin to experience, as she continues to recover successfully, having her children returned and her family moving toward a life that is safe and protected, as well as herself becoming helpful to the next generation. The focus on these positive aspects of Calliyah’s recovery process also is meant to deal with her depression, which has been monitored across time. She has seen a psychiatrist as part of the coordinated treatment process, and in that therapist’s opinion her depression is mild to moderate and does not warrant treatment with medications. Calliyah’s depressive affect is related to her current life situation and the negative feelings she has held toward herself for past failings regarding family and children. In the context of the therapy, with its focus on the positive changes she is making in her life, in conjunction with some very basic cognitive restructuring regarding her sense of disappointment, failure, and shame over the loss of her children, the treatment of her substance use disorder and the co-occurring depression is integrated. If left unaddressed, her negative feelings represent a potential “trigger” or a high risk for relapse, but her feelings are being addressed in the context of family values, and the depression and relapse risk have been reduced. Further, the positive appraisal of her evolving recovery serves to reinforce her motivation to change. Mindfulness exercises that allow Calliyah to feel within her body and her thoughts this sensation of helpfulness and how service to the next generation can replace it may be taught in this session. She may choose to make these experiences concrete by writing statements on a card such as “When I sit with my grandson and share stories of our past, he wants me to continue. I can’t do this unless I am well and sober. Accomplishing this makes me feel like I am doing what a grandmother is supposed to do in our culture.” Another motivational resource that represents a culture-based asset is Calliyah’s increasing involvement with the elders. Her ability to serve them and learn from them is a point of pride and humility, another important cultural value. She may also write on a card a statement about her ability to embrace this value in action: “When I am involved with the elders I help them and future generations. I receive guidance, teaching, and help from them that makes me realize how important it is for me to be healthy. I can heal and help others.” Finally, Calliyah is beginning to attend traditional activities and ceremonies. This is a good time for the counselor to review with her what she is learning and what she is being advised to do (e.g., have other ceremonies for healing, review her thoughts regarding her goals toward healing). For example, she might be thinking of promising to complete a ceremony to help her family. Exploring the meanings she is making out of her immersion in ceremonial life can help Calliyah choose ways to become further involved with these cultural practices that can help sustain her sobriety and good health. At the end of this session, the counselor should review with Calliyah how she feels about each value that she has articulated. Is it consistent with her desires? Will it support her toward the changes that she wants, to live a “clean” life committed to her family and community? Again, at the end of this session, the counselor should encourage her to summarize her ideas regarding her most important values for maintaining sobriety and to present them in the next ceremony she attends, during which she can again ask for help in achieving them. Sessions 3 and 4: Recapitulation and a Plan for Change The first two sessions provide a base for spending the next two sessions recapitulating the work that Calliyah and her counselor have done and crafting this work into a long-term plan for maintaining sobriety, with specific goals toward holistic health. We suggest a minimum of four sessions for Calliyah, as many AI/AN ceremonies are in multiples of four (e.g., Sun Dance, Four Winds, Four Season, Vision Quest, and healing ceremony for a serious illness). It is important for counselors working with ethnically and culturally diverse clients to orient formal therapy plans so that they correspond with elements of the clients’ cultural frameworks. At this stage, the counselor should discuss with Calliyah the possibility of having a special traditional ceremony at the end of their sessions in which the counselor and Calliyah jointly present the change plan and ask for assistance from all of those involved in the plan (e.g., the family, the AA group, professionals, healers, and Calliyah). The counselor’s attendance would recapitulate the integrative nature of the process that is at the foundation of this cross-cultural work. Finally, the counselor should schedule a follow-up session with Calliyah for a later date. This will serve as more than simply a “booster” session. Within the AI/AN cultural context, the follow-up session has meaning in that it communicates to Calliyah the sense that this is a relationship that she can count on, and that the counselor is willing to continue to assist. Counselors working with clients from other cultures should approach the idea of such a follow-up by analyzing whether their clients would prefer a level of autonomy that is less interdependent. Treatment Framework Synopsis Because our focus here is on counseling, we have not described in detail each of the other treatment modalities chosen by Calliyah (AA, psychiatric consultation, and so on) and the cultural considerations related to them. The counselor needs to address each of these during the counseling process, consistently reviewing with Calliyah important elements outside counseling, such as how she is doing in AA, or with the psychiatrist, or in her role with the elders and her family. In Calliyah’s substance use counseling, the counselor is actively working with a mixture of traditional and Western approaches that constitute a system of care for Calliyah. Therefore, we would recommend that the counselor consider facilitating a meeting among Calliyah, the traditional healer, the psychiatrist (if needed), Calliyah’s AA sponsor, family members such as her auntie and adult children, and the counselor to discuss ways to collaborate and integrate the elements of Calliyah’s treatment (Herring, 1999; Trimble & Thurman, 2002). Such communication would allow the key members of the treatment team to receive direction from Calliyah and her family, identify areas that might present problems with integration, and discuss openly the cultural framework of the therapeutic process. Cultural Factors in Substance Abuse Counseling We have emphasized assessing and understanding the within-group variability in substance use patterns and assets useful to recovery among ethnocultural groups. Thus far, we have used a case study with an American Indian woman to elaborate key concepts. In the remaining discussion, we describe selected strengths common to many members of other selected ethnocultural groups that provide examples of the types of assets that can be mobilized in recovery. Though we focus here on groups in the United States, elements of the discussion are relevant to immigrant groups globally and provide a model for beginning to think of assets within specific cultural contexts. In addition, we acknowledge that in providing these examples we risk stereotyping members of cultural groups, particularly when presenting groupings that often constitute an ethnic gloss (Trimble, 1995). Tremendous variability exists within ethnocultural groups, and none of these examples applies to all members of a group. However, any approach to substance abuse treatment with a client whose culture is different from the counselor’s can utilize many of the conceptual structures that we present. First, we recommend that counselors use the cultural formulation interviews in the DSM-5 to guide case conceptualization, diagnosis, and treatment planning. Second, careful attention to initial matching of counselor and client ethnicity can be important, as it was in our example because of Calliyah’s family and tribal history. Such matching may or may not be critical to counselors’ work with other ethnocultural clients, but that possibility deserves careful consideration. Third, counselors should attend carefully to linguistics, sociolinguistics, values, symbolic meaning, and sociopolitical context (both current and historical) for all ethnocultural clients. Fourth, strengths-based assessments of acculturation, significant family relationships, and motivation to change are appropriate for use with clients from most ethnocultural groups. Fifth, blending culturally relevant traditional healing practices with more conventional treatment approaches may be beneficial for all ethnocultural clients. Below, we briefly describe specific cultural assets associated with four ethnocultural groups: African Americans, Latino/as, Asian Americans, and American Indians/Alaska Natives. African Americans Substance abuse remains a serious problem for many African Americans. However, surveys suggest that drug use prevalence rates are decreasing for younger African Americans (Johnson, O’Malley, & Bachman, 1996). At the symbolic level, spirituality has played an important historical role for African Americans as they endured slavery and racism in the United States. This role for spirituality, along with the important role of the church, continues to this day. Afrocentric identity, or Nigrescence (White & Parham, 1990), emphasizes collectivism, a focus on concern for the welfare of the whole group and for relationships within the community. Values associated with spirituality, family, religion, community, and collectivist concern all provide important assets that can potentially be mobilized in an African American person’s recovery from substance abuse (Antai-Otong, 2002). Latino/as The general term Latino/a refers to members of many disparate groups that vary enormously in their substance use patterns. For example, heroin has been the main drug of abuse for several generations among certain families in East Los Angeles who identify with the pachuco or cholo lifestyle (Moore, 1990), as well as the most frequent illicit drug of abuse for people of Mexican descent, according to a study of substance abuse treatment admissions (Rouse, 1995). Similar to American Indians/Alaska Natives, Latino/a clients vary widely in acculturation. Some may be steeped in a culture of healing that utilizes various types of traditional healing systems such as the curandero. Careful assessment of culture-specific explanatory models for substance abuse must take into account such systems. Potential assets for Latino/a clients in substance abuse counseling include the values of respeto, deference to elders and others of higher social ranking; personalismo, attention to the wishes of others; and confianza, the development of strong interpersonal relationships based on trust. Asian Americans Although Asian Americans constitute perhaps the most diverse ethnocultural group in the United States, data on patterns of drug and alcohol use for this group are limited. Further, the studies that have been conducted have often combined disparate Asian subgroups possessing quite different languages, religions, and histories (Yu & Whitted, 1997). In contrast to the “model minority” stereotype, research suggests that recent Japanese immigrants, along with Chinese Americans who are at higher levels of assimilation to the host culture, exhibit high levels of alcohol use, while the less assimilated members of many Asian American subgroups are heavy cigarette smokers (Myers, Kagawa-Singer, Kumanyika, Lex, & Markides, 1995). It is difficult to generalize about a pan-Asian values set, but many Asian Americans are influenced by values emphasizing the importance of family as the central social unit and the avoidance of behavior that brings shame to the family; a social hierarchy of respect to elders and those of higher social rank; and personal and emotional restraint. Recognition of these values as assets, and adaptation of conventional substance abuse counseling approaches to accommodate them as strengths, can facilitate the substance abuse recovery process for many Asian Americans. Explanatory models that reflect the symbolic understanding of disease and the use of traditional healers are important, particularly for many of the more recent Asian immigrant groups, such as the Hmong (Fadiman, 1997). American Indians/Alaska Natives In the case study discussion, we illustrated an integrated, complementary approach to assessment and counseling structured by indigenous culture-specific treatments that utilize traditional healers, ceremonial life, collaborative assessment, and a cultural adaptation of MET. Additional culturespecific treatments include cultural or spirit camp immersion experiences that accentuate traditional values and spirituality. Other modern forms of treatment have been culturally adapted for American Indians and Alaska Natives. A good example is the talking circle, a form of group counseling that was derived from the ways in which healing ceremonies are structured. Mindfulness training and meditation have been adapted for use with AI/AN adolescents to resonate with the cultural-spiritual systems of their particular indigenous groups. Each of these treatments focuses on providing the client with a linguistic and sociolinguistic context that is comfortable, that is structured by indigenous values, and that resonates with the explanatory models that symbolically make sense within the culture. Summary: Cultural Factors in Multicultural Substance Abuse Counseling Table 23.1 provides an overview of the principles of multicultural substance abuse counseling that guided our work in the case presented and organized our discussion in this chapter. The principles emphasize the importance of consideration of the high rates of comorbidity of substance abuse with other disorders in substance abuse counseling. They also emphasize the importance of the social context, including attention to the acculturation status of the individual; appreciation of cultural norms, not only in terms of risk but also as providing protection from substance abuse and serving as assets that can support recovery; and attention to cultural understandings of spirituality and its role in the recovery process. Most important, the substance abuse counseling process should be structured to fit the individual client’s cultural understandings, providing a culturally based system of care. By way of summary, we conclude with four recommendations for structuring multicultural substance abuse counseling driven by the guiding principles described in Table 23.1. 1. Establishing a relationship of trust is essential for effective multicultural substance abuse counseling; such a relationship is best initiated by assessment, intake, and counseling processes that are collaborative and strengths based in nature. This also requires cultural competence and cultural humility on the part of the person completing the assessment and doing counseling. A professional of the same ethnicity as the client can often establish trust most effectively, provided the professional has the requisite cultural humility and competency. When it is not possible to match counselor and client ethnicity, the counselor must possess cultural competency with the client’s ethnocultural group. 2. Training and supervision of the counselor should include continuing development of an understanding of cultural factors at the linguistic and sociolinguistic levels, as well as an understanding of how values, explanatory models, and symbolic systems can structure each part of the process of understanding and helping the client. Training and supervision should also include ongoing reflection of cultural humility. 3. Complementary therapeutic approaches that utilize existing local knowledge, practices, and resources from within the community can be crucial elements for effective treatment. These resources include traditional healers and ceremonies; elders as role models, mentors, and potential natural helpers; and significant others in the extended family system. All of these cultural assets can influence clients to initiate change or to maintain gains and avoid relapse. 4. Substance abuse often is comorbid with various psychiatric disorders, including depression, anxiety, and posttraumatic stress disorder. The presence of such comorbid disorders has major repercussions for the client’s extended family and for community systems within the culture. It requires an integrated approach to treatment that does not separate services by agencies or by healing approaches (i.e., Western versus traditional). In multicultural substance abuse, the counselor must understand the counseling process as it fits within a system of care of complementary therapeutics that includes community resources and professionals. Counseling cannot be separate; rather, it must be actively linked with traditional healing practices, other resources, and other professionals in the system of care. Further, the system of care in multicultural substance abuse treatment should be client and family directed. In summary, cultural factors structure the patterns and the meaning of substance use and abuse, the client’s expectations for the substance abuse counseling process, and several important factors within the course of recovery. Throughout this chapter, we have emphasized an approach that highlights the strengths and assets within various cultural traditions that can be mobilized in the recovery from substance abuse. A deeper understanding of the role of culture in the substance abuse counseling process can allow counselors to form relationships that empower their clients to initiate, maintain, and solidify change. Discussion Questions 1. Calliyah, your counseling client, invites you to the graduation ceremony for the group she just completed and wants to honor you publicly. What should you do? What may be some of the consequences of your attending or not attending the graduation ceremony? 2. Because you have worked as a counselor with a number of American Indian/Alaska Native clients from two Pacific Northwest tribes, a colleague asks you to consult on a case with a Native client from a tribe in the Southwest. Do you feel qualified to do so? In what ways might there be similarities and differences between the clients from the Pacific Northwest and those from the Southwest? 3. Calliyah’s Aunt Carrie, who is also a respected elder, needs a place to stay for a few months. Carrie’s daughter struggles with substance use and misuse and often turns to her mother for support. As Calliyah’s counselor, how would you support her as she decides what to do? What are some of the possible unique cultural tensions in this situation? 4. Think of clients you have worked with whose backgrounds are different from your own. What are the similarities and differences? Are the steps outlined in this chapter appropriate for all clients? Why or why not? References Allen, D. N., Donohue, B., Sutton, G., Haderlie, M., & Lapota, H. (2009). Application of a standardized assessment methodology within the context of an evidence-based treatment for substance abuse and its associated problems. Behavior Modification, 33(5), 618–654. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Antai-Otong, D. (2002). Culturally sensitive treatment of African Americans with substance-related disorders. Journal of Psychosocial Nursing and Mental Health Services, 40(7), 14–21. Asnaani, A., & Hofmann, S. G. (2012). Collaboration in multicultural therapy: Establishing a strong therapeutic alliance across cultural lines. Journal of Clinical Psychology, 68(2), 187–197. Beals, J., Manson, S. M., Whitesell, N. R., Spicer, P., Novins, D. K., & Mitchell, C. M. (2005). Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations. Archives of General Psychiatry, 62(1), 99–108. Bernal, G., & Domenech Rodríguez, M. M. (Eds.). (2012). Cultural adaptations: Tools for evidencebased practice with diverse populations. Washington, DC: American Psychological Association. Berry, J. W., Poortinga, Y. H., Breugelmans, S. M., Chasiotis, A., & Sam, D. L. (2011). Cross-cultural psychology: Research and applications (3rd ed.). Cambridge: Cambridge University Press. Blume, A. W., Morera, O. F., & García de la Cruz, B. (2005). Assessment of addictive behaviors in ethnic-minority cultures. In D. M. Donovan & G. A. Marlatt (Eds.), Assessment of addictive behaviors (2nd ed., pp. 49–70). New York: Guilford Press. Blume, A. W., Resor, M. R., & Kantin, A. V. (2009). Addiction treatment disparities: Ethnic and sexual minority populations. In P. M. Miller (Ed.), Evidence-based addiction treatment (pp. 313–325). Burlington, MA: Academic Press. Conger, J. J. (1956). Reinforcement theory and the dynamics of alcoholism. Quarterly Journal of Studies on Alcohol, 17, 296–305. Conigrave, K. M., Hall, W. D., & Saunders, J. B. (1995). AUDIT questionnaire: Choosing a cut-off score. Addiction, 90, 1349–1356. Connors, G. J., DiClemente, C. C., Velasquez, M. M., & Donovan, D. M. (2013). Substance abuse treatment and the stages of change: Selecting and planning interventions. New York: Guilford Press. Cultural formulation [Special issue]. (2009). Transcultural Psychiatry, 46(3). Dana, R. H. (2005). Multicultural assessment: Principles, applications, and examples. Hillsdale, NJ: Lawrence Erlbaum. DiClemente, C. C., & Prochaska, J. O. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors (2nd ed., pp. 3–24). New York: Plenum Press. Donovan, D. M. (2003). Assessments to aid in the treatment planning process. In J. P. Allen & V. B. Wilson (Eds.), Assessing alcohol problems: A guide for clinicians and researchers (2nd ed., pp. 125–188). Bethesda, MD: U.S. Department of Health and Human Services. Donovan, D. M. (2005). Assessment of addictive behaviors for relapse prevention. In D. M. Donovan & G. A. Marlatt (Eds.), Assessment of addictive behaviors (2nd ed.). New York: Guilford Press. Donovan, D. M. (2013). Evidence-based assessment: Strategies and measures in addictive behaviors. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook (2nd ed., pp. 311–351). New York: Oxford University Press. Donovan, D. M., & Marlatt, G. A. (Eds.). (2005). Assessment of addictive behaviors (2nd ed.). New York: Guilford Press. Erickson, F. (1975). Gatekeeping and the melting pot: Interaction in counseling encounters. Harvard Educational Review, 45(1), 44–69. Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus & Giroux. Geertz, C. (1973). The interpretation of cultures. New York: Basic Books. Gone, J. P. (2011). The red road to wellness: Cultural reclamation in a Native First Nations community treatment center. American Journal of Community Psychology, 47, 187–202. Gone, J. P., & Calf Looking, P. E. (2011). American Indian culture as substance abuse treatment: Pursuing evidence for a local intervention. Journal of Psychoactive Drugs, 43(4), 291–296. Hails, K., Brill, C. D., Chang, T., Yeung, A., Fava, M., & Trinh, N. H. (2012). Cross-cultural aspects of depression management in primary care. Current Psychiatry Reports, 14(4), 336–344. Herring, R. (1999). Helping Native American Indian and Alaska Native male youth. In A. M. Horne & M. S. Kiselica (Eds.), Handbook of counseling boys and adolescent males: A practitioner’s guide (pp. 117–136). Thousand Oaks, CA: Sage. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91–111. Hobfoll, S. E., Jackson, A., Hobfoll, I., Pierce, C. A., & Young, S. (2002). The impact of communalmastery versus self-mastery on emotional outcomes during stressful conditions: A prospective study of Native American women. American Journal of Community Psychology, 30, 853–871. Humeniuk, R., Ali, R., Babor, T. F., Farrell, M., Formigoni, M. L., Jittiwutikarn, J.,... Simon, S. (2008). Validation of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Addiction, 103(6), 1039–1047. Johnson, L. D., O’Malley, P. M., & Bachman, J. C. (1996). National survey results on drug use from the Monitoring the Future Study, 1975–1994: Vol. 2. College students and young adults. Rockville, MD: National Institute on Drug Abuse. Kleinman, A. (1988). Rethinking psychiatry: From cultural category to personal experience. New York: Free Press. LaFromboise, T., Trimble, J. E., & Mohatt, G. V. (1990). Counseling intervention and American Indian tradition: An integrative approach. The Counseling Psychologist, 18, 628–654. Lincour, P., Kuettel, T. J., & Bombardier, C. H. (2002). Motivational interviewing in a group setting with mandated clients: A pilot study. Addictive Behaviors, 27(3), 381–391. Longabaugh, R., Donovan, D. M., Karno, M. P., McCrady, B. S., Morgenstern, J., & Tonigan, S. (2005). Active ingredients: How and why evidence-based alcohol behavioral treatment interventions work. Alcohol: Clinical & Experimental Research, 29, 235–247. Marlatt, G. A., & Donovan, D. M. (Eds.). (2005). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (2nd ed.). New York: Guilford Press. May, P. A., & Gossage, P. (2001). New data on the epidemiology of adult drinking and substance use among American Indians of the northern states: Male and female data on prevalence, patterns, and consequences. American Indian and Alaska Native Mental Health Research, 10(2), 1–26. McGovern, M. P., & Carroll, K. M. (2003). Evidence-based practices for substance use disorders. Psychiatric Clinics of North America, 26(4), 991–1010. Miller, P. M. (Ed.). (2009). Evidence-based addiction treatment. Burlington, MA: Academic Press. Miller, W. R., & Rollnick, S. (Eds.). (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press. Miller, W. R., Tonigan, J. S., & Longabaugh, R. (1995). The Drinker Inventory of Consequences (DrInC): An instrument for assessing adverse consequences of alcohol abuse (Vol. 4; NIH Publication No. 95-3911). Rockville, MD: U.S. Department of Health and Human Services. Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational enhancement therapy manual: A clinical tool for therapists treating individuals with alcohol abuse and dependence (Vol. 2). Rockville, MD: U.S. Department of Health and Human Services. Mohatt, G. V. (1988). Psychological method and spiritual power in cross-cultural psychotherapy. Journal of Contemplative Psychotherapy, 5, 85–115. Moore, J. (1990). Mexican American women addicts: The influence of family background. In R. Glick & J. Moore (Eds.), Drugs in Hispanic communities (pp. 127–153). New Brunswick, NJ: Rutgers University Press. Mullins, S. M., Suarez, M., Ondersma, S. J., & Page, M. C. (2004). The impact of motivational interviewing on substance abuse treatment retention: A randomized control trial of women involved with child welfare. Journal of Substance Abuse Treatment, 27(1), 51–58. Myers, H. F., Kagawa-Singer, M., Kumanyika, S. K., Lex, B. W., & Markides, K. S. (1995). Behavioral risk factors related to chronic diseases in ethnic minorities. Health Psychology, 14, 613–621. Oetting, E. R., Donnermeyer, J. F., Trimble, J. E., & Beauvais, F. (1998). Primary socialization theory: Culture, ethnicity, and cultural identification. The links between culture and substance use: IV. Substance Use & Misuse, 33, 2075–2107. Owen, J. J., Tao, K., Leach, M. M., & Rodolfa, E. (2011). Clients’ perceptions of their psychotherapists’ multicultural orientation. Psychotherapy, 48(3), 274–282. Rieckmann, T., McCarty, D., Kovas, A., Spicer, P., Bray, J., Gilbert, S., & Mercer, J. (2012). American Indians with substance use disorders: Treatment needs and comorbid conditions. American Journal of Drug and Alcohol Abuse, 38(5), 498–504. Rouse, B. A. (1995). Substance abuse and mental health statistics sourcebook (DHHS Publication No. SMA 95-3064). Washington, DC: U.S. Department of Health and Human Services. Sher, K. (1987). Stress response dampening. In H. T. Blane & K. E. Leonard (Eds.), Psychological theories of drinking and alcoholism. New York: Guilford Press. Sher, K., & Trull, T. (1994). Personality and disinhibitory psychology: Alcoholism and antisocial personality disorder. Journal of Abnormal Psychology, 103, 91–102. Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. Thomas, L. R., Donovan, D. M., Sigo, R., Austin, L., & Marlatt, G. A. (2009). The community pulling together: A tribal community–university partnership project to reduce substance abuse and promote good health in a reservation tribal community. Journal of Ethnicity in Substance Abuse, 8(3), 283–300. Torres Stone, R. A., Whitbeck, L. A., Chen, X., Johnson, K., & Olson, D. M. (2006). Traditional practices, traditional spirituality, and alcohol cessation among American Indians. Journal of Studies on Alcohol, 67, 236–244. Triandis, H. C. (1988). The self and social behavior in differing cultural contexts. Psychological Review, 98(3), 506–521. Trimble, J. E. (1987). Self-understanding and perceived alienation among American Indians. Journal of Community Psychology, 15, 316–333. Trimble, J. E. (1995). Toward an understanding of ethnicity and ethnic identity, and their relationship with drug use research. In G. Botvin, S. Schinke, & M. A. Orlandi (Eds.), Drug abuse prevention with multiethnic youth (pp. 3–27). Thousand Oaks, CA: Sage. Trimble, J. E. (1996). Acculturation, ethnic identification, and the evaluation process. In A. Bayer, F. Brisbane, & A. Ramirez (Eds.), Advanced methodological issues in culturally competent evaluation for substance abuse prevention (pp. 13–61). Rockville, MD: U.S. Department of Health and Human Services. Trimble, J. E. (2003). Introduction: Social change and acculturation. In K. Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 3–13). Washington, DC: American Psychological Association. Trimble, J. E., & Mahoney, E. (2002). Gender and ethnic differences in adolescent self-esteem: A Rasch measurement model analysis. In P. D. Mail, S. Heurtin-Roberts, S. E. Martin, & J. Howard (Eds.), Alcohol use among American Indians and Alaska Natives: Multiple perspectives on a complex problem (Research Monograph No. 37, pp. 211–240). Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Trimble, J. E., & Thurman, P. (2002). Ethnocultural considerations and strategies for providing counseling services for Native American Indians. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (5th ed., pp. 53–91). Thousand Oaks, CA: Sage. Unger, J. B. (2012). The most critical unresolved issues associated with race, ethnicity, culture, and substance use. Substance Use & Misuse, 47(4), 390–395. University of Washington Alcohol and Drug Abuse Institute. (2006). Evidence-based practices for treating substance use disorders: Matrix of interventions. Retrieved from http://adai.washington.edu/ebp/matrix.pdf Venner, K. L., Feldstein, S. W., & Tafoya, N. (2007). Helping clients feel welcome: Principles of adapting treatment cross-culturally. Alcoholism Treatment Quarterly, 25(4), 11–30. Villanueva, M., Tonigan, J. S., & Miller, W. R. (2007). Response of Native American clients to three treatment methods for alcohol dependence. Journal of Ethnicity and Substance Abuse, 6(2), 41–48. Waldron, H. B., & Turner, C. W. (2008). Evidence-based psychosocial treatments for adolescent substance abuse. Journal of Clinical Child and Adolescent Psychology, 37(1), 238–261. Westra, H. A., Aviram, A., & Doell, F. K. (2011). Extending motivational interviewing to the treatment of major mental health problems: Current directions and evidence. Canadian Journal of Psychiatry, 56(11), 643–650. Whitbeck, L. B. (2006). Some guiding assumptions and a theoretical model for developing culturally specific preventions with Native American people. Journal of Community Psychology, 34(2), 183–192. Whitbeck, L. B., Hoyt, D. R., McMorris, B. J., Chen, X., & Stubben, J. D. (2001). Perceived discrimination and early substance abuse among American Indian children. Journal of Health and Social Behavior, 42, 405–424. White, J. L., & Parham, T. A. (1990). The psychology of Blacks: An African-American perspective. Englewood Cliffs, NJ: Prentice Hall. Witko, T. M. (2006). A framework for working with American Indian parents. In T. M. Witko (Ed.), Mental health care for urban Indians (pp. 155–171). Washington, DC: American Psychological Association. Yu, E. S., & Whitted, J. (1997). Task Group I: Epidemiology of minority health. Journal of Gender, Culture, & Health, 2, 101–112. Authors’ Note: Preparation of this chapter was supported by a grant from the National Institutes of Health/National Institute on Minority Health and Health Disparities (5R24MD001764) (Dennis M. Donovan, principal investigator, and Lisa Rey Thomas, coinvestigator). Portions of this chapter are preserved, with minor revisions, from “Drug and Alcohol Abuse in Cross-Cultural Counseling” in the previous edition of Counseling Across Cultures to honor the late Dr. Gerald V. Mohatt. 24 Group Dynamics in a Multicultural World Mary B. McRae Primary Objective ■ To provide a conceptual framework for understanding racial and cultural dynamics in group and organizational life Secondary Objectives ■ To present an experiential model of working with multicultural groups ■ To describe racial and cultural dynamics that occur in intergroup, group, and group-as-awhole relations Groups are microcosms of the societies in which they are formed and offer opportunities for people to work within and across the multiple differences that exist among individuals. Aside from personality differences, there are many differences that are related to attitudes, beliefs, stereotypes, and hidden assumptions about others who belong to certain racial, ethnic, and cultural groups, as well as those who differ from us in sexual orientation, social class, religion, age, and disability. The tensions between these differences can linger just below the surface, not talked about, continuously reenacted interpersonally and in groups. In this chapter I will introduce an experiential model for the study of group dynamics, with a focus on issues of authority and leadership in groups and organizational life. In a society where there are strongly knit identity groups, each having a stance on values, beliefs, ideology, religion, class, and sexual orientation, the question of who has the authority to make decisions and who will lead the process creates tension. In this model, a combination of systems and psychoanalytic theories is used as a lens for analyzing and making meaning of interpersonal, group, intergroup, and group-as-a-whole relations as they occur in the “here and now” of the moment and later in the more reflective space of the “then and there” of the experience. When a multicultural lens is added to this model it allows us to explore the dynamic interactions that occur between participants from varying social and cultural identity groups, an increasingly important ability in the current age of globalization. These interactions can be experienced and observed in the ways in which group participants engage in working to task, managing boundaries, and working with those in various roles of authority. The Group Relations Model The group relations model is part of the Tavistock tradition of experiential learning. A group relations conference is an intensive temporary experiential educational institution designed for the study of authority and leadership. It enables participants to examine and question the kinds of roles taken (leader or follower), who takes them, how authority is taken up, and how others authorize or deauthorize those in authority roles. Roles, boundaries, and authority are examined on three levels— interpersonal, group, and organizational—all in the context of the socioeconomic and political environment. Such a conference provides a place for learning about feelings, thoughts, expectations, impressions, fears, and assumptions. The experiential learning process involves sharing of similar and conflicting narratives, space for reflection and meaning making, and openness to learning what is immediately visible and known and what is not. The group relations conferences were developed at the Tavistock Institute in London during the 1950s and were brought to the United States in the 1960s. Miller and Rice (1975) developed the conceptual framework for the group relations model, and Rice (1975) developed the conference design. This model of learning has spread to many institutions around the world, including across the United States. Theoretical Framework The theoretical framework for the group relations model is based on psychoanalytic and systems theories. This framework holds together the importance of emotions, relationships, and the contexts in which interactions occur. Psychoanalytic Theory From a psychoanalytic perspective, the concepts of splitting, projection, and projective identification are helpful for understanding the dynamic processes that occur interpersonally, in groups, and in intergroup relations. These are defense mechanisms, unconscious processes that can distort reality and impede optimal functioning (Klein, 1946). Individuals use defense mechanisms to ward off and to manage the anxiety related to the desires and fears about belonging and rejection held by those in the group. According to Bion (1961), individuals are afraid of being engulfed by or excluded from the group. At the same time, defense mechanisms are social tools of survival; they help us to cope with the anxiety that surfaces when we are confronted with emotional and physical challenges to our daily well-being. Splitting, projection, and projective identification are social defense mechanisms used in groups to protect members from feelings of inadequacy and vulnerability (Cheng, Chae, & Gunn, 1998). In multicultural groups where there are issues of power, control, leadership, and authority, social defenses allow members to view one group as different and/or better than the other, and perhaps more or less deserving of certain privileges. When anxious, most people tend to see things as “either/or”—the dichotomy simplifies the situation, making it more manageable. Splitting refers to ambivalent and conflicting emotions that create opposite feelings within the self, such as good/bad, powerful/powerless, smart/dumb, and happy/sad. Splitting involves ridding oneself of the anxiety stimulated by the emotions of shame, guilt, or other negative feelings about self (McRae & Short, 2010). Creating the polarities of good and bad helps to identify or characterize group members in positive and negative ways. When intergroup conflict arises in groups, it is often related to cultural, racial, ethnic, social class, gender, religion, or sexual identity differences, where one group is identified as the negative “other.” In some groups splitting can occur along occupational lines of status, power, and control of resources. Splitting within groups may be related to internalized messages that individual members have received about their own group as well as other groups, and the historical relationships that exist between groups (Alderfer, 1997). The internalized messages may be related to race, ethnicity, gender, religion, sexual orientation, age, or social class with regard to good and bad, or worthy and unworthy of certain privileges and resources. When the opposing feelings are too difficult to contain, they are split off and projected onto others, who may be targeted because of certain characteristics attributed to their being “other,” objects deserving of those unwanted, undesirable, and potentially frightening emotions. The targeted others may be chosen because of proximity and relationships. In groups, they may be targeted based on stereotypes, attitudes, hidden assumptions, beliefs, and perceptions about race, ethnicity, gender roles, social class, religion, sexual orientation, and disability. Projection involves the process of projecting those parts of self that are too difficult to hold, those unacceptable and undesirable impulses, onto the “other” (Kernberg, 1976). In groups projections often are related to what individuals might represent in the minds of others. For example, an Asian man who has displayed leadership skills may be perceived stereotypically as not the best candidate to lead the group in an activity, this perception having little to do with his actual role in the group and more with what he might represent to others in the group. The Asian man may represent for other group members the passive and vulnerable parts of themselves, aspects of self that they find unacceptable. Projective identification is an interactive process in which group members who are targets of the projections identify with them and act “as if” they are true. “Projective identification occurs when the group deposits these ambivalently held emotions onto a member or members of the group. These emotions are experienced by all group members but are aspects of themselves that they refuse to acknowledge” (Cheng et al., 1998, p. 376). Many members of disenfranchised groups have internalized negative messages, attitudes, and perceptions about their identity groups and can be drawn into enacting certain behaviors in mixed racial and cultural groups. Projective identification is an unconscious defense mechanism that involves projection of undesirable aspects of self onto others who in some way identify with these projections. In groups members of subgroups that are disenfranchised or stigmatized may become the recipients of negative attributes and can be pulled into a dynamic of enactment. In the example of the Asian man above, he may indeed find himself being silenced and not taking up a leadership role as he has in other group situations. The targeted person of the projections often has a valence or tendency to take up certain roles in groups. The Asian man may have a valence for stepping back when not asked to lead or acknowledged for his leadership skills. This valence may have grown out of his upbringing and his family’s cultural value of humility. A Black woman in a group may become the target and container for group anger, holding to the stereotype of the angry Black woman and perhaps her own assertive tendency for her voice to be heard and recognized. The Asian man and the Black woman have a valence to take on and identify with the projections bestowed on them by others in the group. Systems and Context A key area of learning in the group relations model is that of experiential learning about the systemic structures in which group members function. The experiential learning theory model purports that there are “two dialectically related modes of grasping experience—apprehension (concrete experience) and comprehension (abstract conceptualization)—and two dialectically related modes of transforming experience—intension (reflective observation) and extension (active experimentation)” (Kolb, Baker, & Jensen, 2002, p. 52). The goal of the group relations conference is to create a receptive space where participants learn through their experience of conversing and engaging with each other in various group and intergroup events. A system consists of several levels of functioning. If we consider an institution as a whole, its various subsystems, the interactions of those subsystems, the interpersonal interactions in and across subsystems, and then this institution and other institutions in the contexts of city, state, country, and world, the complexity of the group as part of a larger system becomes clear. Systems exist in social, political, and economic contexts that affect attitudes, beliefs, perceptions, and values (Lewin, 1951). A group can be examined in terms of its overall structure as well as its various levels of functioning. The group consists of its members and leader(s). The members belong to certain social identity groups that often represent the various identity groups in the community and thus some of the attitudes and beliefs ascribed to those groups. Overall structure of the group. The concept of BART (boundaries, authority, role, and task), which is drawn from systems theory, is used to create a structure for the survival of the group (Green & Molenkamp, 2005). Boundaries are the psychological and physical spaces of the group, such as time, task, and territory (Hayden & Molenkamp, 2004). Boundaries can be permeable or impermeable, setting the rules for inclusion and exclusion. Boundaries determine the meeting time, the territory or location, and the task that the group will work on. Boundaries also are psychological in that they create a sense of belonging to or being excluded from the group. Authority is the right to do work in the service of the task, and it comes from three sources. Authority can be obtained from someone with more authority and power in the structural hierarchy. It can also come from those below or on the same level, such as subordinates and colleagues. Then there is personal authority, or the individual’s capacity to take up his or her own authority (Obholzer, 1994). Role refers to the individual functions that members take up in the group. The task is the work that the group is supposed to be doing. Kahn and Kram (1994) note that classic social psychology studies have indicated the power of roles and norms in shaping the experiences and behaviors of group members in their relations to authority. They suggest that certain internal models (dependence, interdependence, and counterdependence) shape how individuals authorize and deauthorize themselves and others in roles of authority. Wells (1990) addresses the complexity of groups by identifying multiple levels of group functioning: (1) intrapersonal processes (the internal life of the individual group member, which includes personality characteristics, levels of self-awareness, and object representation), (2) interpersonal processes (the relations and dynamics between individuals in the context of the group), (3) group-asa-whole processes (the group’s behavior as a social system, an entity), (4) intergroup processes (the relations and dynamics between and among groups in an overall system), and (5) interorganizational processes (the relationships among organizations, environmental conditions in which the organizations exist, and the impacts of the environment on them). Wells’s work offers a perspective from which to examine group and organizational processes and diagnose psychosocial activities and behavior. At the intrapersonal level, a group member’s behavior is related to the member’s racial/cultural identity and sense of affiliation, as well as the impact these factors have on the member. As Cross and Cross (2008) have indicated, a person’s sense of affiliation to a racial or ethnic identity group may vary and have different meanings for the individual. When a group forms, each member enters with multiple racial/cultural and subgroup affiliations (race, ethnicity, gender, age, religion, social class, and sexual orientation, as well as social and occupational affiliations), with some being more salient than others, given the context. Interpersonally, group members may view each other as racial/cultural beings with similarities, or they may face challenges related to internalized/externalized identities, perceptions, and projections of power, authority, and privilege (McRae, 1994). At the group level, members are part of interdependent subsystems, and their actions or behaviors are on behalf of the group or certain members of the group. According to Wells (1990), each person is “a vehicle through which the group expresses its life” (p. 54). McRae, Kwong, and Short (2007) provide an example of this, describing a large group session in which the majority of the members were White women and the topic of discussion was racial differences. When a Black woman attempted to take up a leadership role by leading the discussion, she was perceived by the group as angry. She became the vehicle through which the group could express its anger at the leaders of the group for not being more giving and nurturing. When Black women identify with the “angry Black woman” stereotype, they contain the anger of White women as well as other women of color and make it more difficult for others to see and identify with their vulnerability. When these dynamics occur in groups, they are immediately available for exploration and meaning making, allowing White women and other women of color to own and speak to their anger, and Black women to own and speak to their feelings of vulnerability. The final level, interorganizational processes, involves the relatedness of various institutions in a community, a state, a nation, and the world. These institutions may have collaborative or conflicting relationships. Interorganizational relations are influenced by power and control of resources as well as by political and social privileges. Institutional affiliations affect the ways in which members interact and work toward accomplishing a task with members of other institutions. Wells’s (1990) work addresses the complexity of group life as it involves multiple levels of functioning, each affected by context, relatedness, and possible influence on the others. Groups establish cultural norms that guide group interactions and behavior. When members come from diverse backgrounds, the question of who sets the group norms, what those norms are and why, and whose cultural values are dominant are underlying issues often difficult to discuss. In the case of group therapy, the therapist sets the preliminary guidelines for group participation, but members determine the group’s cultural norms, which are usually based on therapeutic factors of universality, hope, imparting information, altruism, improving socializing skills, and imitative behavior (Yalom & Leszcz, 2005) as well as shared and different assumptions, beliefs, and feelings related to creating positive and negative environments. Experiential Learning The experiential component of the group relations model is essential. The model’s method of working has been described as one that deals with “knowledge of acquaintance,” or learning through interpersonal, group, and intergroup behavior. In the traditional model, experiential learning takes place during an intense residential or nonresidential group relations conference—a temporary educational institution, a laboratory—that includes a number of events designed to provide opportunities for learning through interpersonal, group, intergroup, and institutional experience. This temporary institution is formed with a hierarchy of roles, such as director, associate director, administrator, consultants, and members: The Group Relations conference provides a highly visible but minimal structure. The time schedule, the staff roles, the theoretical perspective about group-as-a-whole, and the arrangement of the chairs constitute its basics. Beyond that, the structure is provided by the members and their projections. (Hayden & Molenkamp, 2004, p. 155) Providing space for the freedom of discovery permits conference participants to explore their perceptions and projections of the structure. In group relations conferences members and staff learn about boundaries, authority, roles, and task as issues, and dynamics related to each concept occur in the here and now of the moment. Issues of power, privilege, leadership, and followership surface during the various conference events, such as the intergroup, institutional, community, and world events. The intergroup event involves members forming their own small groups and studying the relationships as they occur between and among groups (Hayden & Molenkamp, 2004). In the institutional event, members are also free to form their own groups: the directorate of the conference does its work publicly, working with the consultant staff to make meaning of their understanding and experiences that are taking place in the institution as a whole. The world event is a combination of the intergroup and the institutional events, designed to explore the relatedness of the multiple social identity differences represented by members and staff to the roles given and taken of leadership and followership and the authority and authorization of these roles in the temporary institution created (McRae, Green, & Irvine, 2009). Greater emphasis is placed on how differences of representation among the members change the nature of authority relations. The group relations conference method is constructed to reduce conventional social defenses that constrain interpersonal and intergroup hostilities and rivalries, thus permitting examination of the forces at work by lowering the barriers for expressing both friendly and hostile feelings while providing opportunities for continuous checking in on one’s own feelings and comparing with those of others in a given situation (Rice, 1975). The entire institution is studied, including how it is managed and the competence of the staff in carrying out their task; all parts of the temporary institution contribute to the learning. In adapting this model to train counselors, psychologists, and other mental health professionals, I include a significant amount of time in experiential groups. The group dynamics course consists of three components: lecture and discussion of theoretical concepts, experiential groups, and review and application of learning. Ideally, a weekend group relations conference is a part of the group dynamics course. The group course always engages students as participant/members of small groups so that they can experience the dynamics that occur in groups and learn to identify and diagnose group behavior. The group experience provides an opportunity for students to learn through the “knowledge of acquaintance” as described above. They are then able to reflect on their experience, applying theoretical concepts to give meaning to behaviors. The method values both emotion and intellect, providing space for direct and honest feedback, allowing those who wish to take the risk of giving voice to experience. Interpersonal and group learning is a process of internalizing and incorporating “felt experience into the inner world of fantasy and reason” (Rice, 1975, p. 72). Racial and Cultural Group Dynamics Group dynamics are related to the stages of groups’ development (Tuckman, 1965). When a group is forming, members are more inclined to polite engagement, as they are getting to know each other; as time passes, conflicts emerge, resolutions are made, group norms are established, and the search for productive work on the group’s task takes place. The dynamic interactions that occur interpersonally and for the group determine how the group moves through the various stages of development. Bion (1961) has described the group as an entity that functions on two levels: as a “work group” and as a “basic assumption group.” The work group works diligently toward accomplishing its tasks and objectives, usually in a predetermined structure (Rioch, 1975). The work group is functional; members contribute in various clearly defined roles to achieve a task in a given period of time. However, groups do not always behave in a sensible manner; as Rioch (1975) observes, “Man seems to be a herd animal who is often in trouble with his herd” (p. 23). The basic assumption mode of functioning is a defense mechanism that helps members to cope with anxiety that they experience in the group. Each of the basic assumptions represents a way in which group members experience some tensions in belonging to the group. They desire to be a part of the “herd,” but anxiety around feelings of dependency, inclusion/exclusion, affection, and control can make it difficult to remain a member. Bion (1961) identifies three basic assumptions in groups: basic assumption dependency, basic assumption fight/flight, and basic assumption pairing. In basic assumption dependency, the group functions “as if” it is totally dependent on the leader, powerless, and lacking in intellectual capacity. In basic assumption fight/flight, group members avoid talking about or dealing with issues that may seem obvious to an observer, or they engage in conflict with each other or the leader, another way to avoid the task at hand. In basic assumption pairing, two members are put forth by the group as its leaders who will produce a “messiah,” or something that will save the group. To these assumptions, Turquet (1985) has added the basic assumption “one-ness” to address the rise of cults and gangs in which members merge to form a single identity, and Lawrence, Bain, and Gould (1996) have identified basic assumption “me-ness” to address the narcissistic and ego-centered individuals who find it almost impossible to work as a part of a group or team. In mixed racial and cultural groups members may be particularly dependent on the leader to address issues of difference. If the leader is a person of color, members may want to know that individual’s stance—that is, is the leader biased toward one group, or is there a sense of social justice in the group? Members from similar cultural backgrounds may feel free to fight with members from similar or different backgrounds. Two members from different identity or ideological groups may pair after a conflict to demonstrate symbolically the potential for members to work across differences. Intergroup Dynamics Racial and cultural dynamics in groups are related to some basic intergroup differences that are contextual in society. According to embedded intergroup relations theory, five characteristics can be observed in groups: group boundaries, power differences, affective patterns, cognitive formations and distortions, and leadership behavior (Alderfer, 1997). In multicultural groups members have an opportunity to experience the interplay of the management of boundaries; working with power differences; various cultural modes of emotional expression; the testing of assumptions, beliefs, and myths held about individuals who are different from them; and working with perceptions of leadership fit as a role for members and the group leader. A multicultural group functions as a “group as a whole” that consists of multiple subgroupings with varying cultures, beliefs, and behaviors. I use the term culture broadly here as defined by Goldberger and Veroff (1995), who include the traditional definitions of shared history, geographic region, language, rituals, values, rules, and laws but also add that in a pluralistic society, groups of individuals with shared characteristics (such as race, gender, social class, ethnicity, sexual orientation, disability, and age) may call themselves “cultures,” and be regarded as such by others, despite their membership in the larger culture and dissimilarities of history, language, rules, beliefs, and cultural practices. This broader definition of culture makes for a more complex understanding of multiple identities and the ways in which they intersect. It becomes more difficult to identify just one aspect of any individual or group; each is like a Janus figure, with many different faces. Therefore, the cultural, economic, political, and social contexts in which interactions occur become the background and sometimes the foundation for our efforts to communicate with and understand one another. Power differences encompass differences in access to resources and assumptions concerning who has control and who does not. Reed and Noumair (2000) describe how power differences affect intergroup relations: There may be significant intergroup conflict related to which groups are most deserving of corrective advantage. Identity groups and individuals may minimize their own advantage or emphasize their disadvantage within the context of such discussions. We refer to this as the relationship between context and currency: What chips are worth the most in what context, and how is public identity selected and displayed to others on this basis? (pp. 62–63) In my experience in working with multicultural groups, the issue of context and currency is usually prevalent. It is a competitive process to give precedence of oppression to one group, with little room for recognition of multiple kinds of oppressive experiences. Conflicts and disconnections occur in groups when the emotions related to power, authority, and leadership bump up against one another or collide without group members’ recognition or cognitive understanding of what is happening. Many experience the “disconnect” as it occurs but are unable to label or acknowledge it in a manner that makes sense. When the subtle meanings ascribed to comments and behaviors—whether intended or not—are negative, the consequence can be withdrawal or conflict (Tsui, 1997). These interactions could be described as racial, ethnic, and cultural microaggressions. Sue et al. (2007) define racial microaggressions as brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color [or cultural groups]. Perpetrators of microaggressions are often unaware that they engage in such communications when they interact with racial/ethnic [or cultural] minorities. (p. 271) Racial and cultural microaggressions are often the results of individuals’ perceptions, hidden assumptions, stereotypes, and attitudes about the social roles expected for members of different racial, ethnic, and cultural groups. In multicultural groups the roles taken by members and the leader may not fit what some members have seen and experienced in the past. For some members who have had little exposure to multicultural environments, a form of cognitive dissonance may occur. Making sense and meaning of an experience sometimes requires exposure to additional voices, knowledge, alternative considerations, and opinions. When group members are in an environment that provides opportunities for more freedom of expression of both positive and negative thoughts and feelings, risks are taken, anxiety rises, and learning occurs. Groups can be safe spaces for members to be curious, ask questions, and challenge, confront, and test interpretations about dynamic processes as they occur from a spectrum of levels: interpersonal, group, intergroup, group as a whole. Strategies for Working With Racial and Cultural Dynamics The A. K. Rice Institute for the Study of Social Systems (2003), the national organization responsible for bringing the group relations model to the United States in the 1960s, deems a number of competencies important for leaders working with groups and organizations. Those that are most relevant to working with multicultural groups are as follows: ■ The capacity to maintain task and role boundaries in the face of positive or negative responses from others ■ The courage to speak what is felt to be unspeakable in the particular work context as long as it relates to the task of the group at hand ■ The ability to reflect on and express one’s internal experience rather than acting on it ■ An understanding of how elements of one’s own identity and history affect one’s work as well as call forth particular fantasies and projections from others in the context of groups ■ The ability to recognize that individuals “carry” or express some aspect of the experience of the group as a whole—for example, scapegoating and rescuing ■ An understanding that the exercise of leadership and representation affects, and is affected by, group and intergroup dynamics ■ An understanding of how group and organizational dynamics are reflections of the larger sociopolitical context Each of these competencies requires a certain level of awareness and curiosity about self and others in a sociopolitical context: a capacity to do internal work, an ability to focus on task and maintain boundaries, an ability to hold the group in mind as an entity with its own characteristics, and the courage to speak the unspeakable. Thus, group leaders who work with multicultural groups must be willing to state observations that may sound politically incorrect—otherwise, the unspoken topic will become the elephant in the room, something that everybody sees but pretends is not there. Below, I provide some examples from small groups at weekend conferences. These vignettes are taken from transcripts of my research and have been edited to demonstrate some of the racial and cultural dynamics that occur in groups. Here-and-Now Experience of Differences In this small group, the members talked about differences outside the group, with no mention of their current experience in their group that was racially and culturally diverse. The group consultant asked, “How could this discussion be brought to your experience here, now, in this group?” An African American man spoke of his fears of being attacked in other group situations, so he came prepared to do battle in the current group: Being an African American, I’m generally accustomed to being attacked and having others consider my thoughts as being out of line. As I sit here my heart is racing because I have to be ready to fend off whatever is going to come at me next. I’m ready to do battle. I was talking about this with a friend this morning. It sucks to always be this tough warrior and it’s exhausting. I wish I could show people that I can be weak. I wish I could show people that I have a heart. I’m afraid I’ll be destroyed. Because being a Black male, I feel as though I’ve spent my entire life experience carrying negative projections. So to a certain extent, I have to be rugged in order not to collapse. But that’s not all of who I am. Another African American man, who was older, stated that for himself he was more concerned about aging and how others in the group might see him as fragile. His warrior days were over, and now he felt more vulnerable. While the older man was dealing with the loss of virility, the younger one was speaking of his need to be constantly on guard when engaged in predominantly White groups. His defense, his struggle for survival against the negative perceptions, acted to reinforce perceptions of him as the “cautious, angry, hostile Black male other.” A White male member spoke about his experience of being gay: I dressed with a sort of unusual attention this morning. I was like, “How am I going to be a militant faggot?” I put on seven different things only to put on the thing that I was originally going to put on. I think there is a silent homosexual subgroup in here and nobody is talking about it. The initial intervention allowed three different subgroups to emerge, based in race, age, and sexual orientation. When salient identities are acknowledged, they become available for discussion. The gay member learned that he was not the only gay person in the group and that he could talk openly about his experience. The two African Americans were able to share experiences of how they are perceived as Black men and received feedback about other members’ perceptions. The leader then intervened, saying, “I wonder what you have to suffer to get in here? It feels like competition to prove who has the biggest wound.” The group members unconsciously identified currency as competition, related to outsider status of race, age, and sexual orientation. While the young African American man seemed to have currency in his role of victimization due to negative stereotypes and projections about Black men in society, the older man claimed the currency of the vulnerability of aging, and the gay man claimed the currency of discrimination against homosexuality. The group spent time on each issue and explored some of the members’ assumptions. While risky and at times tense, the discussion provided an openness that allowed members to explore differences and competition, and to recognize that these issues could not be resolved during the group’s time together. So there was some agreeing to disagree as a way of managing the tension. It is often the case that White group members are cautious about broaching the subject of race; doing so can bring up feelings of guilt and shame that make the group feel stuck and threaten group survival. The issue of representation by race, sexual orientation, age, and gender in relationship to authority, power, and leadership is another aspect of this group’s experience. The members of groups are cognizant of whether those in roles of leadership represent their particular social identity groups. The leader of this group was a White man who had been hired by a gay African American man to work with the group. When group members see their own social identities represented by those with authority, it seems to give them personal authority to take up roles of leadership or give them stronger voices in the group. The members were able to connect with the multiple identities of the gay African American male in charge, given their own fantasies, personal needs, and desires. The group leader in this instance spoke the unspeakable about currency and competition in the group. He encouraged members to speak to internal feelings, which decreases the potential risk of acting on them. He also demonstrated an understanding that each of these members represented certain aspects of the group in terms of intergroup dynamics. Sometimes women in groups have a valence for working to keep the group feeling safe or for taking up stereotypical gender roles. In a small experiential group of students in a class, a Muslim woman and a Jewish woman who had experienced some tensions between them began to talk about their cultural differences. Another woman in the group quickly intervened and was joined by other women discussing other differences that existed in the group, taking the focus away from the work the Jewish and Muslim women were about to embark on. The consultant to the group asked, “I wonder if the Jewish/Muslim differences are too hot for exploration in this group. What are some of the fears of what might happen if the conversation between these two members continued?” At the time, Israeli– Palestinian conflict was on the front pages of the daily newspapers. Brazaitis (2004) notes that White women take on the role of being fragile or emotionally sensitive in groups. They are the ones who cry. White women’s historical legacy is that of delicateness and fragility. I have yet to be a participant in a Group Relations conference as a staff or member when a White woman did not burst into tears, silently weep, or leave the room wiping her eyes in the middle of a group session. (p. 105) Representation I have also found that there is power in numbers. Often when we create groups at group relations conferences, we distribute the people of color to provide some diversity in all groups, with the hope that this will enhance the experience of all members. At one conference I had a large number of members who needed to be divided into seven small groups. I decided to group members by race, ethnicity, and sexual orientation, using information they had provided on their registration applications. In one group there was a predominance of Latino members with a Latino consultant. The Latino members monopolized the first 20 minutes of the session, sharing stories about having their names changed because their original names were too difficult for either priests or educators to pronounce: Alberto: There was a time that I was Albert. And now I’m Alberto. I was originally Alberto, then Albert. When I went away to college, I became Alberto again. It felt good to go back home as Alberto. Fernando: I have a story. I was brought up Catholic. And when I was being baptized, my mother was asked to state my name and she says Fernando. The Catholic priest, who happened to be White, went into a conference, and said that’s not his name. That’s not a real name. So my baptism certificate says Frederick. Even though that’s not my name. Fernando: These stories are about painful experiences. What’s sort of hidden is the reality of what it feels like when I change from one side, then to become someone else. Alberto: So, to be part of that group, we change our name, instead of being Alberto, we become Albert. After listening to the Latinos in this discussion for some time, the group leader, who was Latino, commented: “What is the message the Latinos are sending to other members in this group and why is there no space for other voices? Perhaps the Latinos in this group now have the power to change the course of things?” The group leader recognized that individuals carry and express some aspects of the group as a whole. He was also aware that his ethnic identity may have helped the Latino members feel empowered to speak to their experiences, letting others know what they have done to belong. The issues of power differences, boundaries, affective expression, cognitive formations, and leadership are all at play in these examples. The basic assumption groups are also visible. In the first group, the members initially took flight to discuss issues of differences outside the group; when the group leader brought their attention to this, the members began to focus on the here and now of their experience in the group. In the second example, the group used Alberto and Fernando as a basic assumption pair to give birth to the Latino voice and experience in the group. The number of Latinos and the presence of a Latino leader were instrumental in allowing them this opportunity. One of the Latino members commented after the group that he had rarely been in a work or educational situation where Latinos were the dominant group. He felt a sense of empowerment and freedom to speak his mind that he had not experienced before. The young African American man entered a group in which most of the members were White. His perception of his role in the group was one of less power and authority; he must stand strong, hold his own. How much of his position was based on the reality of this group and how much was a consequence of his living in an environment where he is constantly perceived as a threat? In the predominantly Latino group, the power to control the topic was taken up and later owned as most memorable by one of the members. There is power in numbers, and experiencing this can be empowering for the members of any disenfranchised group who are most often in the minority. Conclusion In this chapter I have provided an overview of the group relations model of working with groups and how this model has been adapted to train counselors, psychologists, and other mental health professionals to work with different types of groups. This experiential model based on psychoanalytic and systems theories provides unique opportunities for students to learn through experience. While this form of learning is intense and at times difficult, it has proven to be immensely valuable to most students who have participated. This approach to group work promotes an understanding of the dynamic interplay of different perspectives of authority and leadership in interpersonal, group, and intergroup relations while at the same time exploring conscious and unconscious processes that affect interactions within and across social identity differences. Critical Incident Alice is a 25-year-old second-generation Chinese woman who has been educated in the United States. Her parents moved here long before she was born; in fact, they met and were married in a northeastern state. Alice is the older of two children and has attended top schools. She is highly intelligent and competitive, and she held a number of leadership roles in high school and college. Alice attended a weekend group relations conference and was assigned to a small group in which she was the only Asian. At first this was not an issue, since she had become used to this pattern in the schools she had attended. The group was to meet for four 1-hour sessions over the weekend. Other small groups were occurring simultaneously, and Alice was engaged in a number of other events during the weekend. During the second session Alice told the group that she had been a member in other groups that talked about racial and cultural differences. She noted that she was often the leader in these groups and was able to demonstrate her leadership ability, stating that she was good at delegating and getting people to follow her command. She told the members that when she is in a culturally mixed group where she is the minority, she gets frustrated. She found herself falling into the stereotypical Asian female role of being quiet and submissive. She could not identify anything that anyone had done to her. She was perplexed about how she had fallen into that role. Discussion Questions 1. What are some of the racial and cultural dynamics that Alice may be experiencing in the group? 2. Why do you think Alice has been pulled into this particular role? 3. What competencies would the leader need to help the group explore this issue? 4. Can you think of other situations that might occur in counseling and psychotherapy groups where members from different backgrounds might take up stereotypical roles related to their race, ethnicity, gender, sexual orientation, social class, or age? References A. K. Rice Institute for the Study of Social Systems. (2003). Group relations consultant competencies. Retrieved from http://www.akriceinstitute.org Alderfer, C. P. (1997). Embedded intergroup relations and racial identity development theory. In C. E. Thompson & R. T. Carter (Eds.), Racial identity theory: Applications to individual, group, and organizational interventions (pp. 237–263). Mahwah, NJ: Lawrence Erlbaum. Bion, W. R. (1961). Experiences in groups. New York: Brunner-Routledge. Brazaitis, S. J. (2004). White women—protectors of the status quo; positioned to disrupt it. In S. Cytrynbaum & D. Noumair (Eds.), Group dynamics, organizational irrationality, and social complexity: Group relations reader 3 (pp. 99–116). Jupiter, FL: A. K. Rice Institute. Cheng, W. D., Chae, M., & Gunn, R. W. (1998). Splitting and projective identification in multicultural group counseling. Journal for Specialists in Group Work, 23(4), 372–387. Cross, W. E., Jr., & Cross, T. B. (2008). The big picture: Theorizing self-concept structure and construal. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (6th ed., pp. 73–88). Thousand Oaks, CA: Sage. Goldberger, N. R., & Veroff, J. B. (1995). The culture and psychology reader. New York: New York University Press. Green, Z. G., & Molenkamp, R. J. (2005). The BART system of group and organizational analysis: Boundaries, authority, role and task. Retrieved from http://www.it.uu.se/edu/course/homepage/projektDV/ht09/BART_Green_Molenkamp.pdf Hayden, C., & Molenkamp, R. J. (2004). The Tavistock primer II. In S. Cytrynbaum & D. Noumair (Eds.), Group dynamics, organizational irrationality, and social complexity: Group relations reader 3 (pp. 135–156). Jupiter, FL: A. K. Rice Institute. Kahn, W. A., & Kram, K. E. (1994). Authority at work: Internal models and their organizational consequences. Academy of Management Review, 19(1), 17–50. Kernberg, O. F. (1976). Object relations theory and clinical psychoanalysis. New York: Aronson. Klein, M. (1946). Notes on some schizoid mechanisms. International Journal of Psycho-analysis, 27, 99–110. Kolb, D. A., Baker, A. C., & Jensen, P. J. (2002). Conversation as experiential learning. In A. C. Baker, P. J. Jensen, & D. A. Kolb (Eds.), Conversational learning: An experiential approach to knowledge creation (pp. 51–66). Westport, CT: Quorum Books. Lawrence, W. G., Bain, A., & Gould, L. (1996). The fifth basic assumption. Free Associations, 6(37), 28–55. Lewin, K. (1951). Field theory in social science. New York: Harper & Row. McRae, M. B. (1994). Interracial group dynamics: A new perspective. Journal for Specialists in Group Work, 19, 168–174. McRae, M. B., Green, Z., & Irvine, B. (2009). The world event: A new design for study of intergroup behavior in group relations conferences. Organisational and Social Dynamics, 9(1), 43–65. McRae, M. B., Kwong, A., & Short, E. L. (2007). Racial dialogue among women: A group relations theory analysis. Organisational and Social Dynamics, 7(2), 211–234. McRae, M. B., & Short, E. L. (2010). Racial and cultural dynamics in group and organizational life: Crossing boundaries. Thousand Oaks, CA: Sage. Miller, E. J., & Rice, A. K. (1975). Selections from Systems of organization. In A. D. Colman & W. H. Bexton (Eds.), Group relations reader 1 (pp. 21–33). Washington, DC: A. K. Rice Institute. Obholzer, A. (1994). Authority, power and leadership: Contributions from group relations training. In A. Obholzer & V. Z. Roberts (Eds.), The unconscious at work: Individual and organizational stress in the human services (pp. 39–47). London: Routledge. Reed, G., & Noumair, D. (2000). The tiller of authority in a sea of diversity. In E. B. Klein, F. Gablenick, & P. Herr (Eds.), Dynamic consultation in a changing workplace (pp. 51–79). Madison, CT: Psychosocial Press. Rice, A. K. (1975). Selections from Learning for leadership. In A. D. Colman & W. H. Bexton (Eds.), Group relations reader 1 (pp. 71–158). Washington, DC: A. K. Rice Institute. Rioch, M. J. (1975). The work of Wilfred Bion on groups. In A. D. Colman & W. H. Bexton (Eds.), Group relations reader 1 (pp. 21–33). Washington, DC: A. K. Rice Institute. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286. Tsui, P. (1997). The dynamics of cultural and power relations in group therapy. In E. Lee (Ed.), Working with Asian Americans: A guide for clinicians (pp. 354–363). New York: Guilford Press. Tuckman, B. W. (1965). Developmental sequence in small groups. Psychological Bulletin, 63(6), 384–399. Turquet, P. M. (1985). Leadership: The individual and the group. In A. D. Colman & M. H. Geller (Eds.), Group relations reader 2 (pp. 71–87). Jupiter, FL: A. K. Rice Institute. Wells, L. (1990). The group as a whole: A systematic socioanalytic perspective on interpersonal and group relations. In J. Gillette & M. McCollom (Eds.), Groups in context: A new perspective on group dynamics (pp. 49–85). New York: Addison-Wesley. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books. Index Acculturation acculturative stress, 84–85, 130, 390 adaptation outcomes, 385–386 American Indians and Alaskan Natives, 103 Asian Americans, 128–129, 467–468 assimilation, 103, 330, 384 bidimensional models of, 384–385 contextual level of, 386–389, 387 (figure), 389 (table) counseling strategies, 396–398 definition of, 84, 383–384 ecological model of, 386–396, 387 (figure), 397 family, role of, 391–393 individual level of, 386, 387 (figure), 393–396, 396 (table) integration, 103, 330, 385 Latino/as, 174–175 marginalization, 103, 385 measure in substance abuse assessment, 506 relational level, 386, 387 (figure), 390–393, 392 (table) separation, 103, 384 social support/networks, 390–391 treatment outcomes and, 85–86 well-being and, 85 See also Marginalization Adams, C., 481 Additive approach to oppression, 218 ADDRESSING assessment framework, 61 Adolescents. See Children and adolescents Adrian, G., 146, 147 African Americans achievement gaps, student, 249–250, 251–252 African consciousness, 147–148 challenges in cross-cultural counseling, 146–147 collectivism of, 155–156 colonialism, adaptations to, 150–151 counseling approaches, 144, 152, 154–156, 465–466 demographical information, 144–145, 465 family, 155, 465–466 gender discrimination, 216–218 historical background, 145–146, 465 identity development, 147–151 integration, effects of, xiv mental health issues, 151–154 physical health, 415–416, 417–418 racial discrimination, 82, 145–146, 149–150, 154, 216–218 racio-ethnic culture, xv, 83–84 Shamanism, 21–22 spiritual/religious influences, 148–149, 483–484 substance abuse, 515 traumatic experiences, 149–150 well-being, counseling strategies for, 448 Ægisdóttir, S., 56 Airhihenbuwa, C. O., 22 Ajamu, A., 483 A. K. Rice Institute for the Study of Social Systems, 531 Alabi, D., 153 Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), 506 Alcoholism. See Substance abuse Alcohol Use Disorders Identification Test (AUDIT), 505–506 Ali, A., 375 American Counseling Association, xiv, 238 American Indians and Alaska Natives acculturation, 103, 108 communication styles, 107, 502 counseling approaches, 109–112, 445–446, 463–465 counseling considerations, 113–114 counselor multicultural competence, 78, 102, 103, 105–107, 463–465 family, 110–111, 463–465 gender roles, 111, 221–222 healing practices, 21–22, 102, 106, 112–113 Shamanism, 21–22 sociopolitical history of, 103–105, 464, 503–504 spirituality/religion, 484–485 tribal rituals, 104–105, 112–113 well-being, counseling strategies for, 445–446, 449 worldviews and values, 108–109, 502–503 American Personnel and Guidance Association, xiv American Psychiatric Association, 63, 276 American Psychological Association (APA), 35, 218, 231, 238, 239, 248, 462, 463 American School Counselor Association (ASCA), 253 Anderson, S. R., 486 Anti-oppression advocacy, 375 Aosved, A. C., 214 APA Handbook of Psychology, Religion, and Spirituality (Pargament), 481 APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation, 284 Appio, L., 374, 375 Arabs and Muslims acculturation, 188–189, 194–195 collectivist culture of, 199 counselor and client matching, 193–194 counselor competencies, 194–195 culturanalysis approach, 197–198 discrimination and health effects, 420–421 family systems, 189, 191, 196 indirect therapies, 198–199 Islamophobia, 488–489 language/communication styles of, 194, 198–199 mental health assessment, 192–193, 194–195 political history, 187–188 psychosocial development, 190–191 psychotherapy process with, 195–196 PTSD and, 193 religion, 185–188, 196 sexuality, 187 Shari’aa laws, 187 transference and countertransference, 196–197 Aroian, K., 420 Arora, A. K., 175 Arredondo, P., 78 Arthur, N., 28, 32 Asian Americans acculturation, 128–129, 467–468 attitudes toward mental health services, 129–130 as collectivist culture, 20–22, 23 communication styles, 125–126 counseling considerations, 135–136, 467–468 cross-cultural competencies of counselor, 131–134, 467 cultural congruence model of counseling, 136–137 demographical information, 466–467 family, 123–124, 126–128, 466–468 gays/lesbians, 222 gender roles, 124, 127, 221–222 mental health issues, 130–131 personality characteristics, 122–124 racialization and racism, 132–133 racial match and treatment outcomes, 134–135, 137n1 research trends on, 121–122 shame/loss of face, 124–125 spiritual/religious support, 131, 484 substance abuse, 515 traditional healing methods, 132 well-being, counseling strategies for, 447 worldviews, 122–124, 442 Assessments/appraisals bias, 59 equivalence, 56–58 general considerations, 52 of human values, 67–68 isomorphism, 53 knowledge-based, 64–68 mixed methods and models, 61–63, 62 (figure) multicultural assessment-intervention process (MAIP), 61–62, 62 (figure) multicultural assessment procedure (MAP), 62–63 NEO Personality Inventory—Revised, 56, 66 neuropsychological, 63–64 preliminary assessments, 54 qualitative approach to, 59–60 quantitative approach to, 55–58 of spiritual beliefs, 488 Assimilation. See Acculturation Association for Spiritual, Ethical, and Religious Values in Counseling, 487 Atkinson, D. R., 176 Austin, R., 79 Autonomy, 443–444 Ayurvedic therapy, 20 Bailey, J. M., 215 Bain, A., 529 Bales, R. F., 460 Baolin, D., 468 Beggs, B., 64 Behavior, cultural expectations of, 23–25, 23 (table), 33–34 Bennett, R., 111 Bennett, S., 107 Benson, P., 422 Bernak, F., 329, 337 Bernal, G., 126, 337, 463 Berry, J. W., 19, 384, 385, 461 Betancourt, J. R., 421 Bhadha, B. R., 391 Bias (in assessment), 56 BigFoot-Sipes, D., 107 Bion, W. R., 524, 529 Black Bear, T., 111 Bly, Robert, 487 Boesch, Ernest, 52 Bohart, A. C., 37 Bonilla, K., 337 Bonilla-Silva, E., 147 Bordin, E. S., 36 Borodowsky, L., 37 Boyd-Franklin, N., 484 Bratini, L., 375 Brave Heart, M. Y. H., 104 Bresler, D., 199 Brislin, R., 34, 58 Bronfenbrenner, U., 168, 386 Brown, K., 261 Brown, S. P., 78 Buddhist therapy, 21 Bullying, 250–251 Burke, L. A., 153 Burris, M. A., 375 Calf Looking, P. E., 105 California Brief Multicultural Competence Scale (CBMCS), 61 Canada indigenous peoples, treatment of, 104–105 regional cultural variations, 57 Career counseling of international students, 310–313 Carlson, J., 37, 328, 444 Carnes, T., 484 Carr, S. C., 60 Carrillo, J. E., 421 Casas, J. M., 170 Castillo, R. J., 61 Centers for Disease Control and Prevention, 348 Chalifoux, B., 374 Chang, D., 136 Changing the Odds (Pelavin & Kane), 261 Charles, C., 337 Ch’i, 21 Children and adolescents acculturation levels, effect of, 84–85, 392, 394 Arabs, 190–191 Asian Americans, 128, 131 bullying, 250–251 educational achievement gaps, 249–250, 261–262 gender and sexuality, 219–220, 221 mental health disparities among minorities, 248–249 student-adult relationships, impact of, 260–261 Chinese culture familistic collectivism, 15, 23 interpersonal relatedness, 135 social orientation, 15–17 therapies of, 21, 23 See also Asian Americans Cho, Y., 134 Choe, J., 468 Christian, A., 38 Chung, R. C.-Y., 337 Chung, R. H., 127 Civil rights movement, xiv, 217 Clairmont, J., 106 Classism, 218–220 Classism and Feminist Therapy (Hill & Rothblum), 370 Client outcomes. See Outcomes, client Clinical Versus Statistical Prediction (Meehl), 55 Coates, T., 282 Cocreated interventions, 375 Cognitive-Behavioral Intervention for Trauma in Schools, 248–249 Cognitive-behavioral therapy (CBT) cultural adaptations to, 89 evidence-based treatments and, 38–39, 423–424 with Native clients, 110 Cohen, D., 57 Colby, S. M., 425 Cole, M., 60 Collectivism in African American culture, 155–156 Arabs and Muslims and, 199 in Asian American culture, 20–22 human values, 68, 439–440 non-Western therapies and, 20–22 vs. individualism, 41–42 well-being and, 439–444 Collins, S., 32 Colmant, S., 113 Color-blindness, 147 The Color of Wealth (Lui, Leondar-Wright, Brewer, & Adamson), 370 Comas-Díaz, L., 169, 172 Communication styles. See Language/communication Competence, counselor, 64–65, 77–81 See also Multicultural competencies; specific ethnic/racial subject headings Complementarity, 44 Conceptual (Construct) equivalence, 56–57 Confucianism, 23, 467 Conner, A., 67 Construct bias, 59 Consultation approach, school counseling, 257–259 Conversion therapy, 284 Conwell, Y., 153 Cook, D. A., 105, 146 Council for the Accreditation of Counseling and Related Educational Programs, 248 Counseling, purposes of, 31–32, 238 Countertransference, 196–197 Cox, R. S., 352 Crethar, H. C., 37, 328, 444 Cross, T. B., 527 Cross, W. E., Jr., 527 Cross-cultural counseling with African Americans, 146–147 alignment and adaptation to clients, 88–90 with American indigenous peoples, 105–107 with Asian Americans, 131–134 gender and sexual orientation implications, 222–223, 279–286 of immigrants, 335–339 of international students, 301–303, 313–318 with Latino/as, 170, 171 (figure), 172–174 school counseling approaches, 255–262 See also Multicultural competencies; Multicultural perspectives in counseling Cultural adaptations, 88–90 Cultural awareness, 19–20, 26–27, 32, 77–79, 105–107 Cultural competence. See Multicultural competencies Cultural dimensions, Hofstede’s, 41–43, 67 Cultural empathy, 301 Cultural encapsulation, 146 Cultural intelligence, 56 Culturally Informed Functional Assessment (CIFA), 38–39 Cultural psychology, 437–440 Cultural recovery programs, 105 Cultural sensitivity, 462–463 Culturanalysis, 197–198 Culture, components of, 33–34, 438, 501, 530 Culture-infused counseling, 32 Culture-oriented perspectives in counseling evidence-based treatments, effects on, 35 goals and outcomes, 2–3 influences on psychotherapy, 26–27 well-being and health counseling, 438–440 Culture shock, 306–308, 315 Culture teachers, 1, 17, 18 (table) Daibo, I., 15 Dana, R. H., 57, 61 Darlington, J. D., 353 Das, A. K., 153 Dasen, P. R., 19 das Nair, R., 275 Davenport, D. S., 238 Davies, D., 258 Day-Vines, N. L., 133, 257 DeBruyn, L., 104 Defense mechanisms, 524, 529 Der-Karabetian, A., 57 Development theories, 168–169, 190 Diagnostic and Statistical Manual of Mental Disorders (APA), 193, 276, 508 Diamond, L. M., 274 Diener, E., 441 Disaster mental health care barriers/challenges for, 359–361 characteristics of services, 355–356 crisis teams, 363–365 goals of, 354–355 Inter-Agency Standing Committee guidelines, 361–362 postdisaster interventions, 356–359 predisaster community connections, 356 psychological first aid, 359 See also Disaster victims Disaster victims community reactions, 352, 360–361 cultural context of effects, 353–354, 360–361 individual reactions, 350–351 phases of disasters, 349–350 types of disasters, 348 Discrimination employment, 216 female athletes, 217 gender inequality, 211–214 in health care system, 418–420 against immigrants, 237, 332–334 transphobia, 214–216 See also Racism Diverse populations identities, intersectionality of, 283–285 and inclusive cultural empathy, 13–14 and mental health disparities, 248 support and management of, 387–389 Dixon, D. N., 131 Domenech Rodríguez, M. M., 126, 463 Donovan, D. M., 510 Draguns, J. G., 337 DREAM Act, 333 Drinker Inventory of Consequences (DrInC) measure, 505–506 Drug use. See Substance abuse Duarte-Velez, Y., 337 Duncan, C. F., 258 Duran, B., 104 Duran, E., 104, 112 Dykema, S., 374, 376 Eastern psychology vs. Western psychology, 15–17, 22 Ecological culture, xiv, 444–445 Ecological model of acculturation, 386–396, 387 (figure), 397 See also Acculturation Ecology of human development theory, 168–169 Economic status. See Poverty; Social class Education achievement gaps, 249–250, 251–252 college access disparities, 250, 261–262 drop-out disparities, 250 English language learners, 252 immigrants and, 332 peer victimization in school, 250–251 See also School counselors Ehntholt, K. A., 338 Ehrensaft, E., 398 Elliott, R., 37 Ellis, Albert, 480 Embedded intergroup relations theory, 530–531 Emerson, Ralph Waldo, 482 Emotional intelligence, 56 Empathy, 13–14, 18–19, 36–37 See also Inclusive cultural empathy (ICE) Empathy, cultural, 2, 7–8 See also Inclusive cultural empathy (ICE) Empirically supported treatments, 316–317 Empowerment-based counseling, 256–257 Engels, F., 458 English language learners (ELL), 252 Enigmatic other, concept of, 52–53 Environment and person, theory of, 167–169 Epidemiological Catchment Area (ECA) studies, 152 Equivalence, types of, 56–58 Erikson, E. H., 190 Espin, O. M., 274 Ethical considerations codes of ethics, knowledge of, 239–240 conversion therapy, 284 counselor multicultural competence, 77 race discrimination issues, 146–147 for school counselors, 253–255, 255 (table) Ethical Principals of Psychologists and Code of Conduct (APA), 147 Ethical Standards for School Counselors (ASCA), 253 Ethnic identity. See Identity Ethnocentrism, 14–15 Etics, 123 Eubanks, R., 146, 147 Evidence-based treatments (EBTs) cognitive-behavioral techniques, 38–39, 423–424 community-based programs, 427–428 and cultural adaptations, 35, 126 effectiveness of, 35, 39–40 motivational interviewing, 424–425, 425–427 (box) skills identification model (SIM), 39 Fadiman, Anne, 53 Faiver, C. M., 489 Family acculturation and, 391–393 adaptations of, 459–460 African American, 155, 465–466 American Indian and Alaska Native, 110–111, 463–465 Arab and Muslim, 189, 191, 196 Asian American, 15, 123–124, 466–468 developmental model of change, 460–461 functions of, 461–462 immigrants and, 331–332, 338 Latino/a, 468–470 multicultural counseling strategies, 462–470 types/structures of, 458–459 Family Almost Perfect Scale (FAPS), 127–128 Farrakhan, Louis, 487 Farver, J. M., 391 Fausto-Sterling, A., 274 Federal Emergency Management Agency (FEMA), 355 Feisthamel, K. P., 152, 154 Feller, R. W., 251 Feminist activism, 220 Feminist multicultural psychology, 218 Feminist Theory (hooks), 229 Fernando, S., 152 Fetzer, J. S., 237 Finch, C., 148 Firehammer, J., 104 Fisek, G. O., 191 Ford, D. Y., 260 Foreign students. See International students Fothergill, A. E., 353 Fox, Matthew, 477, 487 Frame, M. W., 481, 487 Freud, Sigmund, 7, 190, 480 Full-score comparability, 58 Gallardo, M. E., 39 Gamoran, A., 261 Gamst, G. C., 57 Garrett, J. T., 111, 112 Garrett, M. T., 107, 111, 112 Gay, Lesbian & Straight Education Network, 251 Gays/lesbians. See Gender and sexuality; Homosexuality Geertz, Clifford, 17, 438, 501 Gender and sexuality in American indigenous cultures, 111 in Arab and Muslim cultures, 187 in Asian American cultures, 124 child development and, 219–220, 221 class/economic status, effects of, 218–220 counseling implications, 222–223, 279–287 employment discrimination, 218–219 femininity/masculinity, 213–214, 278–279, 282 feminist theories on multiple discrimination, 218 gender expectations, 213, 278–279 gender privilege, 214–216 heteronormativity and heterosexism, 220–222, 273–274, 277–279 racism and gender discrimination, 216–218 self-identification, 275 sexism and male privilege, 211–214, 219, 278 sexual identity, 274–276 social class and, 370 spirituality/religion and, 485–487 terminology of gender-related concepts, 209–211, 278, 289n1 transphobia, 214–216 See also Homosexuality; Sexism; Sexual identity; Transgender Genograms, 505 The Geography of Thought (Nisbett), 126 Georgas, J., 461 Gerstein, L. H., 56 Gibbs, J. T., 257, 258 Gilligan, Carol, 486 Glassgold, J. M., 287 Globalization and cultural adjustments, 34 Goldberger, N. R., 530 Gone, J. P., 105, 107, 113 Gong, Y., 56 Gonzalez, J., 104, 110, 111, 112 Gonzalez-Santin, E., 111 Goodenough, Ward, 459 Goodwin, L., 489 Gould, L., 529 Graham, S., 251 Grandbois, D., 106 Grant, S. K., 176 Grantham, T. C., 260 Green, A. R., 421 Greenberg, L. S., 37 Greene, B., 284, 285, 286 Griner, D., 38 Grothaus, T., 133, 257 Group relations model experiential learning, 528–529 psychoanalytic theory, 524–525 systems and context, 526–527 See also Organizational and group dynamics “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” (APA), 231, 238 Guterman, D. K., 126 Guttman, M., 112 Hage, S. M., 177 Hall, G. C. N., 35 Hall, J. M., 126, 234 Hambleton, R. K., 58 Hamlet, D., 374, 376 Hannigan, E. C., 261 Hanson, M. J., 481 Hardin, E. E., 123 Hardinge, G. B., 252 Hardy, K. V., 457 Hartmann, W. E., 105 Hawley, E., 256 Hayes, S. A., 110 Healing practices, traditional, 14 African Americans, 148–149 American Indians, 21–22, 102, 106, 112–113 Asian American, 132 immigrant considerations of, 327–328 Health care system. See Mental health services, cultural adaptation of; Physical health Heilbron, C., 112 Heine, S. J., 439 Helms, J. E., 61, 105, 146 Henrich, J., 439 Heppner, P. P., 56 Hernández, L., 425 Herring, R. D., 111, 113 Heteronormativity and heterosexism counselor’s awareness of, 279–282 definitions of, 220–221 as dominant social norm, 273–274, 277–279 Hicks, C., 274 Hill, C. L., 62 Hill, Marcia, 370 Hill, P. C., 479 Hipolito-Delgado, C. P., 256 Ho, David, 23 Hodge, D. R., 112 Hofstede, Geert, 34, 41, 43, 56, 67 Hofstede, G. J., 34, 41 Holcomb-McCoy, C., 254 Homophobia, 280, 282 Homosexuality coming out process, 285–286 counseling considerations, 222–223, 285–287 femininity and masculinity, concepts of, 213–214, 278–279 and heterosexism, 220–221, 273–274, 277–283 historical context of, 276–277 peer victimization, 250–251 social class and, 370 spirituality/religion and, 284–285 stigma and, 279 transgender inclusion in community, 221–222 See also Heteronormativity and heterosexism Hood, R. W., 479 hooks, bell, 229 Hopkins, P., 486 Hough, E. S., 420 Howard, G. S., 17 Huxley, Aldous, 482 Hwang, K.-K., 15, 23 Hwang, W.-C., 467, 468 Identity acculturation and, 395–396 ethnocultural identity conflict, 396 foreclosed/diffused, 190 gender, 210–211 intersectionality of, 283–285 perceived racism, 81–82 and psychological well-being, 83–84, 444 psychosocial development of, 190 racial and ethnic development, 83–84, 147–151, 188–189 sexual, 274–276 Identity Continuums, 210 Idle No More movement, 105 Immigrant paradox, 236–237, 394 Immigrants acculturation, 330 adaptation factors, 329–330 counseling approaches, 335–339 cultural belief systems, 327–328 demographics, 324 employment issues, 331 family considerations, 331–332, 334–335, 338 forced migration/refugees, 323–324, 325–326 hate crimes against, 333 language barriers, 330–331 marginalization of, 234–238 myths about, 324–325 premigration trauma, 326–327 racism and xenophobia barriers, 237, 332–334 utilization of mental health services, 328–329 See also Acculturation Imparato, A. J., 370 In a Different Voice (Gilligan), 486 Inclusive cultural empathy (ICE) features of, 18 importance of, 2 and multicultural counseling, 19–20 as therapeutic influence, 37 Indigenous resources of healing, 14 relational counseling and, 23 therapeutic alternatives, 15–17 Individualism in American counseling, 42 collectivismvs., 41–42 human values, 68 well-being and, 439–444 in Western society, 16–17 Ingersoll, R. E., 489 Institute of Medicine, 359 Intelligence tests, 56 Interactionist perspective of oppression, 218 Inter-Agency Standing Committee, 361 Intercultural counseling, effectiveness of, 4–5 Internal dialogues (self-talk), 25–26 International Comparative Study of Ethno-cultural Youth, 394 International students academic issues, 308–310 career issues, 310–313 counseling considerations, 313–318 culture shock, 306–308, 315, 390 deciding factors for, 305 enrollment trends, 303 learning experiences, 305–306 mental health issues, 315 reentry process, 313 International Test Commission, 59 Islam. See Arabs and Muslims Islamophobia, 488–489 Item bias, 59 James, William, 40, 480 Japanese therapies, 21 See also Asian Americans Jaycox, L. H., 236 Jiménez-Chafey, M. I., 126 Johnson, C., 110 Johnson, D., 110 Journal of Cross-Cultural Psychology, 12 Juang, L. P., 468 Judd, T., 64 Jung, Carl, 480 Kağitçibaşi,Ç., 191, 461 Kaffenberger, C., 260 Kahneman, D., 64 Kalibatseva, Z., 136 Kalyanpur, M., 259 Kane, M. B., 261 Karvonen, S., 418 Kataoka, S. H., 236 Katz, A., 420 Keith, K. D., 43 Kelly, E. W., Jr., 480 Kerka, S., 251 Kessler, R. C., 149 Kim, G., 468 Kim, H., 127 Kinsey, Alfred, 274 Kitayama, S., 41, 67 Kleinman, Arthur, 33, 53, 422, 437 Kluckhohn, C., 43 Knowledge, shared, 34 Knowledge-based assessment cross-cultural competence, 64–65, 77–79 of human values, 67–68 patterns and categories, 65–67 Koenig, H. G., 196 Kohut, Heinz, 37 Koltko-Rivera, M. E., 59 Kopp, R. R., 198 Korean Americans. See Asian Americans Kulwicki, A., 420 Kumanyika, S. K., 428 Kurtines, W. M., 175 Kwan, K.-L., 56 Kwan, Michelle, 334 Kwong, A., 527 LaDue, R., 113 LaFromboise, T. D., 110, 112 Language/communication American Indians and Alaska Natives, 107 Arabs and Muslims, 194, 198–199 Asian Americans, 125–126 assessments, cross-cultural, 58 challenges for immigrants, 330–331 international students, proficiency of, 309 in medical/clinical settings, 421–423, 422 (table) metaphor therapy, 198–199 nonverbal communication, 502 in substance abuse counseling, 502 Lash, C., 460 Last Real Indians, 105 Latino/as acculturation, 174–175 achievement gaps, student, 249–250, 251–252 counseling approaches, 176–178, 469–470 counselor competence, 172–174 cross-cultural counseling of, 170, 171 (figure), 172–174 cultural diversity of, 165–166, 468–469 demographical information, 164, 468 economic status, 167 educational factors, 166–167 ethnic identity and well-being, 84 family, 468–470 perceived racism, 82 racism and discrimination of, 174 religion/spirituality, 485 strengths and resilience of, 175–176 substance abuse, 515 and theory of person and environment, 167–171 well-being, counseling strategies for, 448–449 Laungani, P., 31 Lawrence, W. G., 529 Lawson, K., 153 Lee, C. C., 256 Lee, C. S., 425 Lee, H. B., 126 Lee, R. M., 468 Lee, S.-H., 43, 136 Lee, S. M., 489 Lees, K. E., 375 Leong, F. T. L., 43, 44, 121, 123, 135, 136 Leu, J., 127 Leung, S.-M. A., 56, 58, 59 Lewin, Kurt, 168 Lewis, E., 112 Lewis, T. K., 215 Lewis-Fernandez, R., 437 Li, L. C., 62 Li, V., 374, 376 Liang, C. T. H., 57 Limb, G. E., 112 Linguistic equivalence, 58 Lipps, Theodor, 7 Little, S. G., 126 Liu, J. H., 16 Liu, S. H., 16 Livermore, G. A., 370 Lloyd, A. W., 215 Lobel, Marci, 418 Loewen, J. W., 145 Long, P. J., 214 Lonner, W. J., 56 López, S. R., 425 Lott, Bernice, 373 Luria, A. R., 25 Lustig, D. C., 370 Lykes, M. B., 216 Lynch, E. W., 481 Maestas, E. G., 353 Maestas, M., 56 Male privilege, 211–214, 219 Malone, J., 111 Mandlis, L., 210, 215 Mangelson-Stander, E., 111 Mankowski, E. S., 213 Marginalization counseling considerations, 234, 238–240 definition of, 103, 230–231 dimensions of, 232–233 of female athletes, 217–218 health outcomes, effects on, 233–234 male privilege, 211–214 perspectives of, 231–232 of undocumented immigrants, 234–238 Markus, H. R., 41, 67 Marlatt, G. A., 510 Marsella, A. J., 34, 58, 60 Martin, K. A., 221 Martín-Baró, I., 287 Matheson, L., 113 Maton, K. I., 213 Matsumoto, D., 59 McCabe, K., 38 McCarthy, E., 146, 147 McCullough, M. E., 479 McCurtis, H. L., 153 McDevitt-Murphy, M. E., 153 McDonald, J. D., 110, 112 McGoldrick, M., 457 McIntosh, Peggy, 83, 146, 211 McLeod, J. D., 213 McRae, M. B., 527 McWhirter, E., 256 McWhirter, J., 110 Measurement unit equivalence, 58 Meehl, P. E., 55 Meleis, A. I., 234 Mental health. See Well-being, client Mental health services, cultural adaptation of cultural competence in, 421–423, 422 (table) discrimination in, 419–420 effectiveness of, 37–38 levels of, 38 Mental illness, ethnic and social factors, 415–421 See also Well-being, client Merta, R., 113 Meta-analytic research methods, 76–77, 80 Metaphor therapy, 198–199 Method bias, 59 Meyer, O., 134 Mickelson, K. D., 149 Microaggressions, 15, 81–82, 279, 334, 530–531 Miller, D. T., 17 Miller, E. J., 524 Million Man March, 487 Milner, R. H., 261 Milton, M., 274 Mindfulness meditation, 490 Minnesota Multiphasic Personality Inventory (MMPI), 56 Minorities, underrepresentation of, 15 Miserandino, M., 40 Mixed-method assessments, 61–63, 62 (figure) Mixed race/ethnicity, 98 Mizock, L., 215 Mohatt, G. V., 110 Moodley, R., 14, 28 Morita therapy, 21, 89 Morris, E. F., 61 Morrison, E. G., 215 Morrissette, P., 105 Motivational enhancement therapy, 510–514 Motivational interviewing, 424–425, 425–427 (box), 511 Muhammed, C. G., 262 Multicultural assessment-intervention process (MAIP), 61–62, 62 (figure) Multicultural assessment procedure (MAP), 62–63 Multicultural competencies in clinical care communication, 421–423, 422 (table) components of, 77–81 in family counseling, 462–470 of school counselors, 252–253, 267–272 spiritual competencies, development of, 487–488 See also specific ethnic/racial subject headings Multicultural perspectives in counseling empirically supported treatments, 316–317 in family counseling, 462–470 goals and outcomes of, 2–3, 76–77 inclusive cultural empathy and, 19–20 influences on psychotherapy, 26–27, 462 interpersonal behavior expectations, 23–25, 23 (table) meta-analytic research on, 76–77 Multiphase model of psychotherapy (MMP), 335–339 Multiracial background, identity choices of, 98 Murdock, G. P., 459 Murray, H. A., 43 Naikan therapy, 21, 89 Napoli, M., 111 Narang, S. K., 391 National Biodefense Science Board, 359 National Center for Children in Poverty, 236 National Comorbidity Survey (NCS), 152 National culture, definition of, xiv–xv Native American cultures. See American Indians and Alaska Natives Natural disasters. See Disaster mental health care; Disaster victims Neimeyer, R. A., 153 Nell, V., 64 NEO Personality Inventory—Revised, 56, 66 Nestor-Baker, N., 251 Neuropsychological assessment, 63–64 Neville, H. A., 146 Ngo, V., 468 Nisbett, R. E., 126 No Child Left Behind, 249 Nolan, B., 372 Non-Western perspectives in health care, 21–22 on self, 66–67, 441–442 values and well-being, 442–443 Norcross, J. C., 35, 40 Norenzayan, A., 439 Norsworthy, K. L., 56 Noumair, D., 530 Obama, Barack, 279 Obasi, E. M., 153 O’Brien, E. M., 489 O’Day, B. L., 370 Officer, L M., 275 Olendzki, B., 424 Olfson, M., 153 Organizational and group dynamics cultural competencies for leaders, 531–534 group relations model, 524–529 intergroup, 530–531 racial and cultural, 529–530 Osipow, S. H., 123 Outcomes, client acculturation and, 84–86 counseling methods and, 76 racial and ethnic matching with counselor, 86–88, 133–134, 137n1 Owens, T. J., 213 Paniagua, F. A., 63 Pargament, K. I., 196, 479 Parham, T. A., 39, 483 Park, E. R., 421 Park, I. J. K., 468 Parks, S. D., 486 Parsons, T., 460, 461 Participatory action research (PAR), 375 Pedersen, P. B., 15, 28, 37, 173, 306, 328, 444 Peer victimization, 250–251 Pelavin, S. H., 261 Peng, C., 124 Perez, L. M., 196 Perry, K.-M. E., 352 Personality traits acculturation and, 394–395 Arabs and Muslims, 191–192 Asian Americans, 122–124 five-factor model of, 66 Person and environment theory, 167–169 Person-in-Culture Interview, 192 Petermann, F., 40 Pew Hispanic Center, 164, 165, 167, 252 Pew Research Center, 97 Pfeiffer, Wolfgang, 36 Physical health cultural competence in consultation, 421–423, 422 (table) ethnic and social factors, 415–421 mental illness and, 415–417 mortality, social gradient of, 415 social markers and, 414–415 Pichette, E. F., 107 Pinderhughes, E., 146 Pipes, R. B., 238 Plante, T. G., 489, 490 Political countertransference, 333, 334 Ponterotto, J. G., 61, 79 Poortinga, Y. H., 19, 59, 461 Portes, A., 392, 467 Post-traumatic slave syndrome, 149, 337 Poverty classification of, 371, 372–373 counseling considerations, 374–376 counselor training issues, 376–377 cycle of, 372 health outcomes, effect on, 373 as margin, 230–231 physical and mental health, effects on, 417–421 social distancing, 373–374 See also Social class Prejudices, overcoming, 37 Professional development of multicultural competence, 79–81 Projection, 525 Projective identification, 525 Promise Keepers, 487 Pryzwansky, W. B., 258 Pseudoetics, 123 Psychoanalytic theory, 524–525 Psychological first aid, 359 Puig, A., 481, 489 Purcell, I. P., 60 Qualitative methods of assessment, 59–60 Quantitative methods of assessment, 55–56 bias, 59 equivalence, types of, 56–58 Racial and Ethnic Approaches to Community Health (REACH) initiative, 427–428 Racial microaggressions, 15, 81–82, 530–531 Racio-ethnic culture, xv Racism African Americans and, 81–82, 146–150 Asian Americans and, 130, 132–133 color-blindness, 147 effects on well-being, 81–83, 149–150, 154 and gender discrimination, 216–218 Latino/as and, 174 microaggressions, 15, 81–82, 279, 334, 530–531 perceived, 82 scientific, 14–15 white privilege, 146 See also Discrimination Ramaswamy, V., 420 Rao, S. S., 259 Rape myth, 214 Reed, G. W., 424, 530 Refugees. See Immigrants Regional culture, xv Reimers, F. A., 376, 377 Relational counseling, 23 Relationships. See Therapy relationships Religion. See Spiritual/religious influences Renfrey, G., 110 Rice, A. K., 524 Ridley, C. R., 37, 62 Rimpela, A. H., 418 Rimpela, M. K., 418 Rioch, M. J., 529 Roberts, J., 153 Robinson, T. L., 212 Rodriguez, J., 486 Rogers, Carl R., 81 Rohr, R., 487 Rokutani, L. J., 252 Romano, J. L., 177 Root, Maria P. P., 98 Rosal, M. C., 424 Rothblum, Esther, 370 Rothenberg, P. S., 239 Rust, P. C., 275 Ryan, C., 110 Ryff, C. D., 443 Salzman, M., 105, 114 Santee, R. G., 15 Scalar equivalence, 58 Schmidt, C. D., 252 School counselors accreditation standards, 248 consultation approach, 257–259 data utilization by, 259–260 empowerment-based counseling, 256–257 impact on school culture, 260–261 multicultural competencies of, 252–253, 267–272 social-justice framework for, 253–255, 255 (table) strengths-based counseling, 257 See also Education School culture, 260–261 Schwartz, R. C., 152, 154 Schwartz, Shalom, 68 Scientific racism, 14–15 Scott, N. E., 37 Scott-Dixon, K., 214 Segall, M. H., 19 Self, concepts of assessments/appraisals of, 66–67 interdependent and independent, 41, 67 non-Western perspectives, 20 twenty statements test (TST), 66 well-being and, 440 Self-determination theory, 443–444 Self-esteem, 441–442 Self-interest, 17 Self-talk, interpretation of, 25–26 Sennott, S., 210 Serano, J., 282 Sexism benevolent sexism, 220 concept definition, 211–212, 278 consequences of, 213–214 social constructs of, 212, 278–279 in the workplace, 219 See also Heteronormativity and heterosexism Sexual identity categorization of, 274–276, 289n1, 289n3 historical context of, 276–277 religion/spirituality and, 284–285 See also Gender and sexuality; Homosexuality Sexuality. See Gender and sexuality Sexual orientation, 276 Sexual stigma, 279 Shamanism, 21–22 Shame in Asian American culture, 124–125 Shared knowledge, 34 Shellman, A., 374, 376 Sheridan, S. M., 258 Sherrard, P. A. D., 489 Shin, R. Q., 275 Short, E. L., 527 Shults, J., 428 Silva, L., 444 Simms, W., 112 Simning, A., 153 Skinner, B. F., 480 Smith, Huston, 482 Smith, L., 372, 374, 375, 376 Smith, L. C., 275 Smith, P. A., 338 Smith, P. B., 65 Smith, T. B., 38, 210, 444 Social axioms, 60, 65 Social class definitions of class structure, 369–372 gender and, 370 physical health and, 414–415 poverty, cycle of, 372–373 race and, 370 sexual orientation and, 370 See also Poverty Social justice counseling, 253–255, 255 (table) Socioeconomic status (SES). See Poverty; Social class Spanierman, L. B., 146 Spates, K., 153 The Spirit Catches You and You Fall Down (Fadiman), 53–54 Spiritual/religious influences on African Americans, 148–149, 483–484 on American Indians and Alaska Natives, 112–113, 484–485 on Arabs/Muslims, 185–188 on Asian Americans, 131, 484 counseling approaches/interventions, 488–491 counselor competencies, 487–488 dimensions/definitions of, 479–480 FICA assessment of clients’ beliefs, 488 gender perspectives, 485–487 intersectionality of identities, 283–285 on Latino/as, 485 mindfulness-based approaches in treatment, 490 and psychology movements, 480–481 sexual identity and, 283–285 universal perspectives, 482–483 See also Healing practices, traditional Spitzer, Robert, 284 Splitting, 524–525 Stabb, S. D., 376, 377 Stanford Achievement Test (SAT), 250 Stapleton, D. C., 370 Stein, B. D., 236 Stereotypes, 80–81 Stevens, P. E., 234 Stevenson, M. R., 287 Strauser, D. R., 370 Street, R. L., 421, 422 Strengths-based counseling, 257, 507–509 Strickland, B. R., 279 Structural equivalence, 57–58 Substance abuse African Americans, 515 American indigenous cultures, 111–112, 499–513, 516 Asian Americans, 515 collateral assessment, 507 communications in therapeutic relationships, 502 cultural considerations in counseling, 514–517, 516 (table) effectiveness of treatment options, 500–501 Latino/as, 515 motivational enhancement therapy, 510–514 motivation to change, 509 multicultural assessments, 504–506 sociopolitical contexts, considerations of, 503–504 spirituality and psychotherapy integration for treatment of, 490 stages of acceptance of treatment, 509–510 strengths-based assessment, 507–509 values-focused issues, 502–503 Sue, David, 4, 26, 128, 468 Sue, Stanley, 27, 128, 464 Sufism, 21 Sundberg, Norman, 4 Supporting Healthy Activity and Eating Right Everyday (SHARE), 428 Suro, R., 237 Systems and context in group relations, 526–527 Szapocznik, J., 175 Takeuchi, D., 127 Talking about a significant object (TASO) technique, 192 Tanaka-Matsumi, J., 38 Tart, C. T., 27 Tatar, M., 397 Tavistock Institute, 524 Teal, C. R., 421, 422 Templin, T. N., 420 Theory of person and environment, 167–169 Theory of the ecology of human development, 168–169 Therapeutic alliance, 35–36, 78 Therapy relationships complementarity, utilization of, 44 cultural barriers, 36 inclusive cultural empathy and, 18–19, 36–37 prejudices, overcoming, 37 race and ethnic identity, dialogues about, 82–84 racial and ethnic matching, 86–88 therapeutic alliance, 35–36 trust in, 75–76, 103 Thomas, S., 275 Thompson, C. E., 146, 176 Thornton, R., 109 Timimi, S. B., 190 Timm, J., 337 Tjosvold, D., 124 Toporek, R., 78 Tousignant, M., 398 Training programs for multicultural competence, 79–81 Transference, 36, 196–197 Transformed psychotherapeutic practices, 375 Transgender definition of, 210–211 inclusion in LGB community, 221–222 transphobia, 214–216 Transphobia, 214–216 Traumatic experiences African Americans, 149–150 American Indians, 103–105 community reactions to, 352 individual reactions to, 350–351 of minority children, 248–249 premigration trauma, 326–327 Triad training model (TTM), 25–26 Triandis, Harry, 42 Trimble, J. E., 39, 105, 110, 113 Trust, 75–76, 103 Turner, S. M., 258 Turquet, P. M., 529 Udipi, S., 37 Ulane v. Eastern, 215 United Nations Environment Programme, 325 United States demographical information, 97–98 regional cultural patterns, 57 Universal culture, xiv, 43–44 U.S. Census Bureau, 97, 98, 164, 167 U.S. Department of Education, 250 U.S. Department of Homeland Security, 235 U.S. Department of Labor, 236 Utsey, S. O., 146, 147 Values, culturally defined, 67–68, 439–440, 502–503 Values Survey, 68 Vandello, J. A., 57 van de Vijver, F. J. R., 38, 56, 58, 59, 461 Vasquez, M. J. T., 170 Veroff, J. B., 530 Vischer, Robert, 7 Vygotsky, L. S., 25 Wadden, T. A., 428 Walker, R. L., 153 Walton, E., 127 Wampold, B. E., 35, 40 Wang, C., 375 Wang, K. T., 127 Watson, J. C., 37 Weaver, Jim “Ironlegs,” 101 Weiss, J. T., 221 Weissman, M. M., 153 Well-being, client acculturation levels, 85 African Americans, counseling approaches for, 448 American Indians and Alaska Natives, counseling approaches for, 445–446, 449 Asian Americans, counseling approaches for, 447 culture-centered health counseling, 438–449 ecological context, 444–445 intersectionality and, 449–450 Latino/as, counseling approaches for, 448–449 racial and ethnic identity and, 81–86, 444 and self, nature of, 440 self-determination theory, 443–444 self-esteem and, 441–442 subjective, 440–443 universalist assumptions, 437–438, 450 and values, culturally defined, 439–440 Wells, L., 526, 527 West, P., 418 West, W., 14, 28 Western perspectives on self, 66–67 vs. Eastern perspectives, 15–17, 22 Whelan, C. T., 372 White, J. L., 483 White privilege, 83, 146, 239 Whiting, G. W., 260 Wijngaarden, E., 153 Williams, D. R., 149 Williams, J. L., 153 WISEWOMAN interventions, 424 Women. See Gender and sexuality Women’s National Basketball Association, 217–218 Wood, S., 257 Wood, S. M., 133 Woodard, Colin, 57 Woodis, W., 112 World Health Organization, 338, 413, 506 Worldviews, 59–60 American Indians and Alaska Natives, 108–109 Asian Americans, 122–124 well-being and, 440–444 Worthington, R. L., 146 Wu, K. A., 175 Xenophobia, 332–333 Yang, F., 484 Yang, K.-S., 15, 16 Yeh, C. J., 39, 175 Yellow Horse-Davis, S., 104 Yin/yang, 21 Yip, A. K. T., 285 Yoga, 21 Young, A., 260 Yule, W., 338 Yurkovich, E. E., 106 Zane, N., 134 Zeldow, P. B., 39 Zen Buddhism, 21 Zenisky, A. L., 58 Zhang, N., 131 Zulu, 148–149 About the Editors Paul B. Pedersen is Visiting Professor in the Department of Psychology at the University of Hawaii and Professor Emeritus from Syracuse University. He has taught at the University of Minnesota, Syracuse University, University of Alabama at Birmingham, and, for 6 years, at universities in Taiwan, Malaysia, and Indonesia. He was also on the Summer School Faculty at Harvard University, 1984–1988, and the University of Pittsburgh–Semester at Sea voyage around the world, spring 1992. His international experience includes numerous consulting positions in Asia, Australia, Africa, South America, and Europe and a Senior Fulbright award for teaching at National Taiwan University, 1999–2000. He has authored, coauthored, or edited 40 books, 99 articles, and 72 chapters on aspects of multicultural counseling and international communication. He is a Fellow in Divisions 9, 17, 45, and 52 of the American Psychological Association. For more information and a complete curriculum vitae, contact http://soeweb.syr.edu/chs/Pedersen. Walter J. Lonner is a charter member, Past President, and Honorary Fellow of the International Association for Cross-Cultural Psychology (IACCP). As either author or editor, he has been involved with about 40 books that have been central to the field. For 25 years he was coeditor (with John Berry) of the SAGE book series Cross-Cultural Research and Methodology. He is Founding and Special Issues Editor of the flagship Journal of Cross-Cultural Psychology (inaugurated in 1970) and Founding Editor of IACCP’s Online Readings in Psychology and Culture (founded in 2001). He has had sabbatical leaves in Germany (as a Fulbright scholar), Mexico, and New Zealand (twice) and has participated in conferences in more than 30 countries and traveled in many others. He is the 1993 recipient of the Paul and Ruth Olscamp Outstanding Research Award, given annually by Western Washington University, where in 1969 he cofounded the Center for Cross-Cultural Research and where he is currently Professor Emeritus of Psychology. Honoring his many contributions to the field, in 2004 IACCP inaugurated the biennial Distinguished Invited Lecturer Series in his name. In 2014 he received the Outstanding International Psychologist award from Division 52 (International Psychology) of the American Psychological Association. He is the 2015 recipient of the APA award, “Distinguished Contributions to the International Advancement of Psychology.” Juris G. Draguns was born in Riga, Latvia. He completed his primary education in his native country, graduated from high school in Germany, and obtained his undergraduate and graduate degrees in the United States. He holds a PhD in clinical psychology from the University of Rochester. For 30 years he was on the faculty of the Pennsylvania State University, where he is now Professor Emeritus of Psychology. His areas of interest encompass cross-cultural research on personality, psychopathology, psychotherapy, and counseling as well as on interaction among ethnic and cultural groups. He has taught and lectured, in six languages, in Australia, Estonia, Germany, Latvia, Mexico, Sweden, Switzerland, and Taiwan, and has held a visiting appointment at the East-West Center in Honolulu, Hawaii. He has made presentations at conferences in 24 countries. He was awarded an honorary doctoral degree by the University of Latvia, served as President of the Society for Cross-Cultural Research, and received the American Psychological Association’s Award for Contributions to the International Advancement of Psychology. The Penn State College of Liberal Arts bestowed upon him the Emeritus Distinction Award, and the New York Academy of Sciences chose him as invited speaker for its annual Psychology Address, on empathy and culture. Joseph E. Trimble, PhD, is Distinguished University Professor and Professor of Psychology at Western Washington University; he is also a President’s Professor at the Center for Alaska Native Health Research at the University of Alaska Fairbanks. Throughout his long career, he has focused his efforts on promoting psychological and sociocultural mental health research with indigenous populations, especially American Indians and Alaska Natives. He is the editor or author of 19 books and more than 140 journal articles and chapters and the recipient of 20 fellowships, awards, and other honors. Among these are the Excellence in Teaching Award and the Paul J. Olscamp Outstanding Faculty Research Award at Western Washington University; the Distinguished Psychologist Award from the Washington State Psychological Association; the Peace and Social Justice Award from the APA’s Division on Peace Psychology; the Distinguished Elder Award from the National Multicultural Conference and Summit; the Henry Tomes Award for Distinguished Contributions to the Advancement of Ethnic Minority Psychology from the Council of National Psychological Associations for the Advancement of Ethnic Minority Interests and APA’s Society for the Psychological Study of Ethnic Minority Issues; and the International Lifetime Achievement Award for Multicultural and Diversity Counseling from the Ontario Institute for Studies in Education, University of Toronto. In 2013 he received the national Elizabeth Hurlock Beckman Award, which is given by the Elizabeth Hurlock Beckman Award Trust in Atlanta, Georgia, to current or former academic faculty members who have inspired their former students to “create an organization which has demonstrably conferred a benefit on the community at large.” Also in 2013 he received the Frances J. Bonner, MD, Award from Massachusetts General Hospital. This annual award recognizes an individual who has overcome adversity and has made significant contributions to the field of mental health and/or the care of ethnic minority communities. María R. Scharrón-del Río is Associate Professor and Program Coordinator of the School Counseling Program in the Department of School Psychology, Counseling, and Leadership at Brooklyn College City University of New York. She received her PhD in clinical psychology from the University of Puerto Rico and completed her clinical internship at Harvard Medical School in Boston. After moving to New York City, she worked as a child psychologist at the Washington Heights Family Health Center, a primary care clinic that serves a predominantly Latino/a immigrant community. She has been an active leader in GLARE (GLBTQ Advocacy in Research and Education) since she joined the Brooklyn College faculty in 2006. She is committed to the development of multicultural competencies in counselors, psychologists, and educators using experiential and affective educational approaches. Her research, scholarship, and advocacy focus on ethnic and cultural minority psychology and education, including multicultural competencies, LGBTQ issues, gender variance, mental health disparities, spirituality, resilience, and well-being. About the Contributors Frances E. Aboud is Professor of Psychology at McGill University in Montreal. She has been conducting research on ethnic identity and prejudice for the past 35 years. In addition to her publications in social psychology and child development journals, she is the author of Children and Prejudice (1988). She has also taught courses and studied issues in health psychology, particularly as they apply to problems of developing countries. After her experience in Ethiopia as a member of the McGillEthiopia Community Health Project, she published Health Psychology in Global Perspective (1998). More recently, as a scientist associated with the Centre for Health and Population Research (ICDDR, B) in Bangladesh, she has given courses and conducted research on early childhood education and feeding in rural Bangladesh. She is currently serving as a consultant to international organizations evaluating early childhood health and development programs in Southeast Asia and East Africa. James Allen, PhD, is Professor and Head of the Department of Biobehavioral Health and Population Sciences, University of Minnesota Medical School, Duluth Campus. His research focuses on American Indian and Alaska Native health, rural community health and health services, and culture and health. Part of this research includes construct elaboration of well-being, and wellbeing and health counseling and promotion strategies. He is also interested in community-based participatory research and its role in the development of tribal and community-directed intervention. His current research tests health, community resilience, and well-being interventions as prevention efforts to address a broad array of problem areas among youth, including suicide, substance abuse, metabolic syndrome, and vascular risk. Kelechi C. Anyanwu is a doctoral student in counseling psychology at Howard University. Her research interests include academic success, religious coping, cumulative stress, and historically Black colleges and universities. She received a BA in psychology with a minor in mass communications from Winston-Salem State University and an MA in counseling psychology from Bowie State University. She has served two terms as president of the Howard University Graduate Student Council, and currently she is the coordinator of the Graduate Student Assembly, an organization that represents all graduate and professional students at Howard University. She is an active member of the American Psychological Association and the American Psychological Association of Graduate Students and a lifetime member of Psi Chi, the international honor society in psychology. She is also a student representative for the Student Affiliates of Seventeen as well as an active member of Delta Sigma Theta sorority. Nancy Arthur is Professor and Associate Dean Research, Educational Studies in Counseling Psychology, Werklund School of Education, University of Calgary. Her research and teaching interests include professional education for multicultural counseling and social justice, international transitions, and career development. She has provided training and consultation on counseling and counselor education in Canada as well as in many other countries. She is the author of Counseling International Students: Clients From Around the World. She has authored and presented nationally and internationally on the counseling model she developed in collaboration with Sandra Collins and described in Culture-Infused Counselling, which received a Best Book Award from the Canadian Counselling and Psychotherapy Association. Her work as coeditor, with Paul Pedersen, of Case Incidents in Counseling for International Transitions involved collaboration with more than 60 authors from 12 countries, highlighting the diversity of theoretical and applied approaches to counseling. Fred Bemak is Professor in the College of Education and Human Development and Director of the Diversity Research and Action Center at George Mason University. He received his master’s and doctoral degrees from the University of Massachusetts, Amherst, and he has held administrative and faculty appointments at Johns Hopkins University and Ohio State University and faculty appointments at the Federal University of Rio Grande do Sul (Brazil), Universidad Iberoamericana (Mexico), and University of Queensland (Australia). He directed the University of Massachusetts Upward Bound program, the Massachusetts Department of Mental Health’s Region I Adolescent Treatment Program, and a National Institute of Mental Health–funded training consortium. He has done extensive consultation and training and has presented throughout the United States and in 55 other countries. His work has focused on cross-cultural counseling, refugee and immigrant mental health, counseling at-risk youth, and postdisaster counseling. He was a Fulbright scholar in Brazil, Turkey, and Scotland; World Rehabilitation Fund International Exchange of Experts Fellow in India; Research Visiting Scholar in Taiwan; Kellogg International Fellow; and American Psychological Association Visiting Psychologist. He has published more than 90 book chapters and professional journal articles and has coauthored five books. In addition, he is the founder of Counselors Without Borders and the recipient of numerous national and regional awards for his human rights and social justice work. He is a Fellow in APA Divisions 17 and 52. Guillermo Bernal, PhD, is Professor of Psychology at the University of Puerto Rico and Director of the Institute for Psychological Research. His work has focused on research, training, and the development of mental health services for ethnocultural groups. His current research is in efficacy trials on culturally adapted treatments. He was an early contributor to the dialogue on cultural adaptations of evidence-based treatments. Since 1992, his team has generated evidence on the efficacy of culturally adapted cognitive-behavioral therapy and interpersonal therapy, carried out translations and development of instruments, and published on factors associated with vulnerability to depression. His cultural adaptation framework has served as a guide for many in the field of psychotherapy research. He is a Fellow in APA Divisions 12, 27, and 45. His most recent books are Cultural Adaptations: Tools for Evidence-Based Practice With Diverse Populations, with Melanie M. Domenech Rodríguez, and Estudios de Casos Clínicos (Clinical Case Studies: Contributions to Psychology in Puerto Rico), with Alfonso Martínez-Taboas. Beth Boyd, PhD, is an enrolled member of the Seneca Nation of Indians. She teaches in the clinical psychology doctoral program at the University of South Dakota, where she is Director of the Psychological Services Center and a member of the Disaster Mental Health Institute (DMHI). She has responded to numerous disasters nationally and internationally, working with the American Red Cross, Substance Abuse and Mental Health Services Administration, the Indian Health Service, and the DMHI. She is Past President of the American Psychological Association’s Society for the Psychological Study of Culture, Ethnicity, and Race, and of the Society of Clinical Psychology’s Section on the Clinical Psychology of Ethnic Minorities. She has served on the Board for the Advancement of Psychology in the Public Interest and on the Presidential Task Force on PTSD and Trauma in Children and Adolescents, and she is Chair of the Commission on Ethnic Minority Recruitment, Retention and Training in Psychology II Task Force. Melanie E. Brewster, PhD, Assistant Professor of Psychology and Education at Columbia University. She earned her doctoral degree from the University of Florida. Her research focuses on marginalized groups and examines how experiences of discrimination and stigma may influence the mental health of members of such groups. She also examines potential resilience factors, such as bicultural selfefficacy and cognitive flexibility, that may promote the mental health of minority individuals. Most of her research has centered on the experiences of members of sexual minority groups; specifically, she has focused on people who occupy the “margins of marginalized populations” (i.e., bisexual individuals, queer people of color, and transgender persons). Her first book, Atheists in America, was recently published. A. Pati Cabrera, PhD, received her doctorate from the Counseling, Clinical, and School Psychology Department at the University of California, Santa Barbara. She was awarded a university-wide dissertation fellowship at UCSB to support the completion of her dissertation, which focused on the characteristics of natural mentoring relationships among high-risk Latino/a youth. She has published in the areas of Latino/a mental health, Latino/a resilience, and prevention program development and evaluation. She completed her predoctoral clinical psychology internship at the Albany Psychology Internship Consortium in the Department of Psychiatry at Albany Medical College. She began her postdoctoral psychology fellowship in September 2014 at the Infant, Child, and Adolescent Psychiatry Department at University of California, San Francisco/San Francisco General Hospital. J. Manuel Casas, PhD, received his doctorate from Stanford University in counseling psychology. He is Professor Emeritus in the Counseling, Clinical, and School Psychology Department at the University of California, Santa Barbara. He has published extensively in the area of minority mental health and serves on numerous editorial boards. He is coauthor of the Handbook of Racial/Ethnic Minority Counseling Research and one of the editors of the three editions of the Handbook of Multicultural Counseling. His research in this area gives special attention to the resilience factors that can help Latino/a families avoid or overcome mental health problems. He is a Fellow in APA Divisions 17 and 45. He has received many honors and awards, including the California Association of School Psychologists Research Award, the Distinguished Contributions to Latino Psychologists Award, the National Multicultural Conference and Summit’s Distinguished Elders Award, and the 2010 Elder Recognition Award for Distinguished Contributions to Counseling Psychology. Rita Chi-Ying Chung is Professor in the College of Education and Human Development at George Mason University. She received her PhD in psychology from Victoria University in Wellington, New Zealand. She has held positions at the World Bank, Johns Hopkins University, Ohio State University, and the University of California, Los Angeles, where she was a project director for the National Research Center on Asian American Mental Health. She has done extensive work related to Asian mental health, immigrant and refugee mental health, and child trafficking. She has more than 90 professional publications and has consulted, provided training, and given presentations throughout the world, including in Africa, Asia, the Caribbean, Europe, the Pacific Rim, and Latin America, on cross-cultural mental health. She was invited to present on her work on child trafficking at the United Nations in New York. She has been the recipient of numerous human rights and social justice awards for her work, including the American Counseling Association (ACA) Kitty Cole Human Rights Award and the ACA Gilbert and Kathleen Wren Humanitarian Award. She was recently awarded the Commonwealth of Virginia State Council of Higher Education Outstanding Faculty Award and the Commonwealth of Virginia General Assembly Commendation Award for her social justice and human rights work. She is a Fellow in APA Divisions 45 and 52. Melanie M. Domenech Rodríguez, PhD, is Professor of Psychology at Utah State University. Her scholarship has focused broadly on research, teaching, practice, and training with diverse populations. In her clinical research she has contributed evidence of the importance of engaging cultural adaptations of evidencebased interventions. She recently coedited a book on the topic, Cultural Adaptations: Tools for Evidence-Based Practice With Diverse Populations (2012). She has specific expertise in Parent Management Training–Oregon (PMT-O), a model program that has been adapted for use across ethnic and cultural groups internationally. She has also made substantive contributions to teaching, research, and training in professional ethics. She received her doctoral degree from Colorado State University (1999) and was a postdoctoral fellow with the Family Research Consortium–III. She is a Fellow of the American Psychological Association. Dennis M. Donovan, PhD, a clinical psychologist, is Director of the Alcohol and Drug Abuse Institute and Professor in the Department of Psychiatry and Behavioral Sciences, University of Washington. He has more than 30 years of experience as a direct service provider, clinical trainer and supervisor, treatment program administrator, and clinical researcher in the substance abuse field. He has been involved in a number of community-based studies investigating substance abuse and mental health issues in urban and reservation American Indian and Alaska Native (AIAN) populations, including National Institute on Alcohol Abuse and Alcoholism–funded research focusing on alcohol abuse in urban AIAN adolescents and women and on statewide treatment among AIAN individuals. As the Principal Investigator on the current community-based participatory research project Healing of the Canoe, funded by the National Institute on Minority Health and Health Disparities, he is working with two tribal communities to culturally adapt, implement, and evaluate an evidence-based intervention for substance abuse prevention among Native youth, incorporating the communities’ culture, traditions, and values into the program. Melissa Donovick, PhD, is Assistant Professor in the Counseling Psychology and Human Services Department at the University of Oregon. She received her doctoral degree in combined clinical, counseling, and school psychology from Utah State University. She completed her clinical internship at the University of Southern California, Children’s Hospital Los Angeles, and postdoctoral research at the University of Southern California focused on Latino/a mental health and cultural competence. Her research and scholarship are focused on the cultural contexts of family processes among Latino/a immigrant families. In her current projects, she is evaluating culturally relevant parenting interventions to prevent child emotional and behavioral problems and examining Latino/a child mental health and educational outcomes to improve family well-being. Her clinical interests include multicultural child and family therapy and bilingual psychological assessment. She is committed to reducing mental health disparities among ethnic and cultural minority children and families and enhancing multicultural therapy training and development. Eliza A. Dragowski, PhD, is Assistant Professor at the Graduate School Psychologist Program in Brooklyn College, City University of New York. She is interested in issues of social justice in education. Her research and pedagogy are aimed at exploring and implementing socioemotional supports for students who are marginalized by structural inequalities. Marwan Dwairy, DSc, who is Palestinian, is Professor of Psychology at Oranim Academic College in Israel. He is a licensed expert and supervisor in three areas: educational, medical, and developmental psychology. In addition, he is a licensed clinical psychologist. He has served as a professor at several universities: the graduate program at Nova Southeastern University in Florida; Haifa University, Israel; and Technion, Israel. He has conducted many cross-cultural research projects on identity, individuation, parenting, and mental health in Western and Eastern countries. He is an editorial board member and reviewer for many journals, and he has published several books, book chapters, and articles on cross-cultural psychology and mental health among Arabs in which he has presented his models and theories concerning culturally sensitive psychology. His most recent book is Counseling and Psychotherapy With Arabs and Muslims: A Culturally Sensitive Approach. Fatimah El-Jamil, PhD, is Assistant Professor and Director of the Graduate Clinical Program in the Department of Psychology at the American University of Beirut in Lebanon. She is a New York–licensed clinical psychologist with a private practice in Beirut. She received her doctoral degree in clinical psychology from St. John’s University, New York, in 2003. Both her writing and her clinical work have focused on ways of adapting current psychotherapy models for use within Arab populations and addressing the challenges of psychological practice in non-Western countries. She is also exploring culturally relevant ways of handling such challenges during the psychotherapy process. Michi Fu, PhD, is Associate Professor of the Clinical PhD Program of the California School of Professional Psychology at Alliant International University, where she teaches courses related to diversity and mental health, advocacy in community psychology, and cultural immersion. She is also the Statewide Prevention Projects Director for Pacific Clinics, where she manages mental health programs related to stigma and discrimination reduction. Her current research interests include Asian American psychology, gender, sexuality, positive psychology, and cross-cultural issues. Her private practice is focused on providing culturally sensitive mental health services to Mandarin- and Taiwanese-speaking clients. She also serves as a consultant and provides workshops to the community to help spread awareness regarding mental health issues. She maintains a blog (http://asianamericanpsych.blogspot.com) and is the resident contributing psychologist to the Asian American blog Thick Dumpling Skin (http://www.thickdumplingskin.com). She enjoys mentoring students and young professionals and has coauthored multiple publications and presentations. Mary A. Fukuyama received her PhD in counseling psychology from Washington State University and has worked at the University of Florida Counseling and Wellness Center for the past 32 years as a counseling psychologist, supervisor, and trainer. She is a member of the University of Florida’s Center for Spirituality and Health, where she teaches a graduate seminar on spiritual issues in multicultural counseling. She has coauthored numerous publications and conference presentations on multicultural counseling and spiritual themes in counseling. She is coauthor, with Todd D. Sevig, of Integrating Spirituality Into Multicultural Counseling (1999) and, with Woodrow M. Parker, Consciousness-Raising: A Primer for Multicultural Counseling (3rd edition, 2007). She is a Fellow in Division 17 (Counseling Psychology) of the American Psychological Association. Keishalee Gómez-Arroyo, BA, is a doctoral student in the clinical psychology program at the University of Puerto Rico, Río Piedras Campus, and a Research Assistant at the Institute for Psychological Research. She has trained in cognitive-behavioral therapy, hypnosis, and family, couples, and group therapy. Her work has focused on health psychology research, and she served as coordinator of the Breast Cancer Research Project for the Management of Secondary Effects of Chemotherapy. She has also worked as a group therapist in a study treating adolescents with type 1 diabetes and depression. She is a member of the Family and Couples Therapy Association of the Puerto Rico Psychological Association and is part of its Health Psychology interest group. Currently, she is completing her clinical internship at the University of Puerto Rico Medical School’s Department of Psychiatry. She has coauthored several articles, most recently a paper on the conceptual, methodological, and ethical issues of cognitive-behavioral therapy plus hypnosis as an adjunctive therapy for breast cancer patients, published in Revista Salud y Sociedad. Ileana Gonzalez, PhD, is Assistant Professor of Counseling and Development at Johns Hopkins University. She received her doctorate in counselor education from the University of Maryland, College Park. Prior to her doctoral work, she was a school counselor for Broward County Public Schools in Florida, working with underserved immigrant populations. She is currently the coordinator for the School Counseling Fellows Program, an urban-based, social justice–focused training program. Her research interests include urban school counselor preparation, school counselor social justice belief systems, and cultural competence in counseling. John Gonzalez is a member of the White Earth Anishinaabe Nation and Associate Professor of Psychology at Bemidji State University. He received his doctorate in clinical psychology from the University of North Dakota through the support of the Indians into Psychology Doctoral Education (INPSYDE) Program. His professional interests include multicultural psychology, cultural psychology, and community psychology. All of these areas come together to provide a holistic view of people and their environments. His research interests are in the areas of mental and behavioral health for indigenous people and ethnic minorities, with an emphasis on understanding ethnic and cultural identity factors. Related to this, he has engaged in communitybased participatory research methods, which involve developing and building relationships with communities to work collaboratively to address the issues the communities view as important. He has published and presented in the areas of multicultural and cultural psychology, with an emphasis on indigenous populations. Derek Griner, PhD, is a licensed psychologist and assistant clinical faculty member at Brigham Young University. He currently holds a joint appointment in which he teaches graduate students in BYU’s counseling psychology doctoral program and provides direct clinical services to students at BYU’s Counseling and Psychological Services. He has worked in several university settings in various capacities. He is committed to furthering knowledge surrounding diversity, has conducted research in this domain, and in 2007 received APA’s Division 17 Outstanding Contribution to Scholarship on Race & Ethnicity Award and the Jeffrey S. Tanaka Memorial Dissertation Award in Psychology. Cheryl Holcomb-McCoy, PhD, is Vice Provost of Faculty Affairs and Professor of Counseling and Human Development at Johns Hopkins University. Previously, she held appointments as Vice Dean of Academic Affairs at JHU’s School of Education and Associate Professor of Counselor Education at the University of Maryland, College Park. She received her doctoral degree in counseling and educational development from the University of North Carolina at Greensboro, and an MEd in school counseling and a BS in early childhood education both from the University of Virginia. Her areas of research specialization include the measurement of multicultural self-efficacy in school counseling and the examination of school counselors’ influence on low-income students’ college and career readiness. She is the author of the best-selling book School Counseling to Close the Achievement Gap: A Social Justice Framework for Success and is Associate Editor of the Journal of Counseling & Development. In 2014 she was selected to speak at the White House summit titled “College Opportunity Agenda: Strengthening School Counseling and College Advising,” which was held at the Harvard Graduate School of Education. Michelle Johnson-Jennings, PhD, an enrolled tribal member of the Choctaw Nation, is an integrated primary care psychologist and Assistant Professor at the University of Minnesota College of Pharmacy. She is also the founding Codirector of the Research for Indigenous Community Health (RICH) center, a joint project of the university’s School of Medicine and the College of Pharmacy that promotes interdisciplinary research in indigenous health equity. She received her PhD in counseling psychology from the University of Wisconsin–Madison, her master’s degree in human development and psychology from Harvard University, and her BS from the University of Oklahoma. Her therapeutic expertise lies in working with members of indigenous communities and cross-cultural psychology. Her research involves her expertise as an integrated primary care psychologist and focuses on patients’ cultural health beliefs, American Indian health, provider unconscious bias, and chronic pain and prescription medication misuse. Zornitsa Kalibatseva, MA, is a doctoral student in the clinical psychology program at Michigan State University. She works under the mentorship of Professor Frederick Leong at the Consortium for Multicultural Psychology Research. She received her dual BA in psychology and area studies in Spanish from Kenyon College and her MA in clinical psychology from Michigan State University. Her research and clinical interests focus on cross-cultural psychopathology and cross-cultural psychotherapy. She is interested in examining how culturally relevant factors may influence the prevalence, experience, expression, diagnosis, and treatment of psychological disorders. In particular, she has concentrated on investigating the symptom presentation and assessment of depression among Asians and Asian Americans. Additionally, she is interested in the adaptation of existing psychotherapies for culturally diverse individuals. D. John Lee, PhD, is a staff psychologist and Coordinator of the Multi-Ethnic Counseling Center Alliance (MECCA) at the Michigan State University Counseling Center. He specializes in working with Asian American and mixed-race students as they negotiate living in a multicultural but racialized American society. He received his BA in psychology from the University of British Columbia, his MSc in counseling psychology from Western Washington University, and his PhD in cognitive psychology from Kansas State University, where he was an American Psychological Association Minority Fellow. He completed his postdoctoral clinical training at the Michigan and Hudson Valley (New York) Psychodrama Institute and is certified as an action methods facilitator. Frederick T. L. Leong, PhD, is Professor of Psychology and Psychiatry at Michigan State University. He is also Director of the Consortium for Multicultural Psychology Research within the department. Previously, he held faculty positions at Southern Illinois University, the Ohio State University, and the University of Tennessee. He obtained his PhD from the University of Maryland with a double specialty in counseling and industrial/organi-zational psychology. He has authored or coauthored more than 150 articles in various psychology journals and 100 book chapters, and he has also edited or coedited 15 books. He is Editor in Chief of the Encyclopedia of Counseling and APA Handbook of Multicultural Psychology. His honors include the 1998 Distinguished Contributions Award from the Asian American Psychological Association, the 1999 John Holland Award from the APA Division of Counseling Psychology, the APA Award for Distinguished Contributions to the International Advancement of Psychology, and the 2009 Stanley Sue Award for Distinguished Contributions to Diversity in Clinical Psychology. Jordan Lewis, PhD, is Assistant Professor at the University of Washington School of Social Work and the Indigenous Wellness Research Institute. He is Aleut, from the Native village of Naknek. He received his doctoral degree in cross-cultural community psychology from the University of Alaska Fairbanks, where he conducted research with Alaska Native elders to establish an Alaska Native model of successful aging. As a cross-cultural community psychologist and social worker, he has focused on exploring the role of culture in the aging process—specifically, how culture affects individuals’ ability to age successfully despite sociocultural challenges. As a researcher interested in the mental health and well-being of indigenous elders, he has attempted to shed light on these issues and bring much-needed awareness directly from the perspectives of those with firsthand experience. As a social worker, community psychologist, and gerontologist, he uses a holistic or ecological systems approach to health, incorporating the family, community, and environment in explorations of health behaviors and health disparities among American Indian and Alaska Native populations. Casilda R. Maxwell is a doctoral student in the counseling psychology program at Howard University. Her research interests include trauma recovery, posttraumatic growth, and religious coping. She received her bachelor of science degree in psychology from Morgan State University and her master’s degree in counseling psychology from Howard University. She is an active member of the American Psychological Association, the American Psychological Association of Graduate Students, and APA Trauma Division (Division 56), and she is a lifetime member of Psi Chi, the international honor society in psychology. Her passion to work in the area of trauma in the field of psychology led her to work with the DC Rape Crisis Center and then to train at the Washington, D.C., Veteran Affairs Medical Center. Currently, she is conducting research on posttraumatic growth among African American men who experience trauma in the military. Mary B. McRae, EdD, is Associate Professor in the Department of Applied Psychology, Steinhardt School of Culture, Education and Human Development, at New York University, where she teaches courses in group dynamics and cross-cultural counseling. She received her doctoral degree in counseling psychology from Teachers College, Columbia University. Her scholarship involves a psychoanalytic and systemic study of authority and leadership in groups and organizations, with a focus on issues of difference such as race, ethnicity, gender, social class, and culture. She is the founder of and has directed New York University’s annual experiential group relations conferences, considered to be the most innovative adaptation of the Tavistock model in working with issues of diversity by the A. K. Rice Institute for the Study of Social Systems, where she is a fellow. She has codirected the internationally renowned Leicester Conference and has been a consultant at other conferences and institutions in the United States, Britain, the Netherlands, Switzerland, and Peru. Jennifer Morales-Cruz has a bachelor’s degree in social work and is a doctoral candidate in the clinical psychology program at the University of Puerto Rico. She is affiliated with the Institute for Psychological Research. She has extensive practicum experiences in family therapy, cognitive-behavioral therapy (CBT), and suicide prevention. She has worked on several research projects, including a campus-wide suicide prevention program at the University of Puerto Rico. She has served as a therapist for a study exploring the efficacy of a culturally adapted CBT with adolescents who have type 1 diabetes and major depression. She is a member of the Puerto Rican Family and Couples Therapy Association and a member of APA Division 12, Section 6, Clinical Psychology of Ethnic Minorities. She is coauthor of a paper on the conceptual, methodological, and ethical issues related to the use of hypnosis as an adjunct to CBT to treat the side effects of chemotherapy for women with breast cancer. She is currently completing her clinical internship at the Roberto Clemente Family Guidance Center in New York City. Joe Nee, MA, is a doctoral student in clinical psychology at the California School of Professional Psychology at Alliant International University, Los Angeles. He is a Research Assistant working under the guidance of Dr. Michi Fu. He is trained in cognitive-behavioral therapy, motivational interviewing, seeking safety, and individual and group therapy. His clinical and research interests have been focused on multicultural and community psychology. Specifically, he is interested in ethnic and minority psychology, as well as in working with underserved populations. He is committed to synthesizing academics, clinical research, and clinical work to make meaningful contributions to the field. He is a student affiliate of the American Psychological Association (Divisions 45 and 52), the Asian American Psychological Association, the Western Psychological Association, the California Psychological Association, the Los Angeles County Psychological Association, and the San Gabriel Valley Psychological Association. Mark Pope, EdD, is Professor and Chair of the Department of Counseling and Family Therapy at the University of Missouri–Saint Louis. He has served as president of the American Counseling Association (2003–2004), the National Career Development Association (1998–1999), the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (1976–1978), and the Society for the Psychological Study of Lesbian, Gay, Bisexual, and Transgender Issues (Division 44 of the American Psychological Association) (2011–2012), and he was founder and first chair of the Professional Counseling Fund (2004–2006). He is the author of numerous books (10+), book chapters (35+), and professional journal articles (40+), as well as more than 100 international, national, regional, state, and local presentations, including keynote addresses in China, Australia, Canada, and the United States. He has served as a consultant in Malaysia, Singapore, Hong Kong, and throughout the United States with companies such as Apple, Hewlett-Packard, and AT&T, and with agencies such as the U.S. Internal Revenue Service. Ana Puig, PhD, NCC, LMHC, serves as Associate Scholar and Research Director in the Office of Educational Research, College of Education at the University of Florida, and as affiliate faculty of counselor education in the School of Human Development and Organizational Studies in Education. She is a licensed mental health counselor and qualified supervisor in the state of Florida and a National Certified Counselor. She holds a spirituality and health certificate from the Center for Spirituality and Health at the University of Florida. Most recently, her research interests have focused on the integration of spiritual and religious competencies in counselor training and supervision, creativity and play across the life span, and adolescent palliative care program evaluation. Yin-Chen Shen, PsyD, is a psychologist at North Kern State Prison in Delano, California, where he provides access to and delivery of mental health services for inmates incarcerated in California state prisons. He is also a psychologist at BHC Alhambra Hospital in Rosemead, California, where he provides clinical care for pediatric, adolescent, adult, and geriatric clients and oversees all aspects of individual treatment plans in an acute inpatient psychiatric setting. He has a strong interest in gender and multicultural issues and is devoted to helping individuals find a greater sense of self-esteem, self-worth, and empowerment. He has published in the Journal of Motor Behavior, and for his doctoral research he placed emphasis on clinical considerations for the assessment of attention-deficit/hyperactivity disorder in adult transgender students. His latest publication is a coauthored chapter in the APA Handbook of Multicultural Psychology: Volume 2. Applications and Training (2013). Daisy R. Singla is a PhD candidate at the Department of Psychology at McGill University in Montreal. As a clinician, she has a vested interest in ethnic minority health and the promotion of culturally competent and evidence-based techniques for disadvantaged groups. As a researcher, she studies maternal health and its impact on young children as well as the integration of mental health services in current health systems. By developing and evaluating culturally appropriate strategies, she advocates building capacity for local, long-term, sustainable solutions in lowresource settings. Her clinical and research experiences range from community-based clinics and hospitals in North America to rural and semiurban settings in Uganda, South Africa, Ethiopia, Bangladesh, and India. Laura Smith, PhD, is Associate Professor in the Department of Counseling and Clinical Psychology at Teachers College, Columbia University. She received her doctoral degree in counseling psychology from Virginia Commonwealth University. Previously, she worked in a variety of applied settings in New York City. She was the founding Director of the Rosemary Furman Counseling Center at Barnard College and the Director of Psychological Services at the West Farms Center, where she provided services, training, and programming within a multifaceted community-based organization in the Bronx. Her research interests include social class and poverty, the influence of classism on psychological theory and practice, the development of socially just practice models for psychologists at the community level, and participatory action research in schools and communities. Timothy B. Smith, PhD, is Professor and Chair of the Department of Counseling Psychology and Special Education at Brigham Young University in Provo, Utah. His scholarship focuses on spirituality, quality relationships, and multicultural psychology. Alberto Soto is a doctoral student in the counseling psychology program at Brigham Young University in Provo, Utah. Kee J. E. Straits, PhD, is an American Psychological Association Minority Fellow (she is Quechua, born in Peru). She received her doctoral degree in professional psychology from Utah State University. She has focused her career on reducing mental health disparities among Native American, immigrant Latino, and other underserved communities. She is the sole owner and manager of Tinkuy Life Community (TLC) Transformations, LLC, through which she provides direct clinical services, training, consultation, and research/evaluation. She is also a Research Assistant Professor in the Department of Psychology and an Associate Fellow of the Robert Wood Johnson Center for Health Policy at the University of New Mexico. Her work addresses social inequities at the individual, family, community, and systemic levels that have impacts on the mental health of culturally disenfranchised youth. Her current endeavors also focus on the development of ethical research guidelines for collaborating with Native communities; substance abuse prevention through a strength-based, decolonizing model of community change; and the mentoring of ethnic minority students in health fields who intend to return to their communities to serve. Jaimee Stuart received her PhD and MSc in cross-cultural psychology from Victoria University of Wellington and went on to hold a research position at the University of Auckland in the Centre for Longitudinal Research. She is now working as a Fellow of the Centre for Applied Crosscultural Research and the Roy McKenzie Centre for the Study of Families at Victoria University of Wellington. She also works as a trainer in the area of intercultural awareness. She is the author of a variety of journal articles and research reports spanning many facets of social, developmental, and cultural psychology. Her research focuses on positive youth development, with particular emphasis on methodologies for assessing change over time. In 2012 she was awarded a 3-year grant to study the longitudinal impacts of bullying and victimization on youth in New Zealand. Lisa Rey Thomas, PhD, is a member of the Tlingit Tribes, and her family is from southeast Alaska. Her doctoral degree is in clinical psychology. With more than 25 years of experience working with indigenous communities, she is currently a Research Scientist at the Alcohol and Drug Abuse Institute and Codirector of Indigenous Protocols and Research Ethics at the Indigenous Wellness Research Institute Center of Excellence, both at the University of Washington. She is Coinvestigator and Project Director of the community-based participatory research project Healing of the Canoe: The Community Pulling Together and the Strong People Pulling Together, funded by the National Institute on Minority Health and Health Disparities. She has also been principal investigator on a number of other National Institutes of Health–funded projects in collaboration with American Indian and Alaska Native communities. She has served on numerous committees and task groups and is currently an Associate Reviewer for CES4Health. Ivory Achebe Toldson, PhD, was recently appointed by President Obama as the Deputy Director of the White House Initiative on Historically Black Colleges and Universities. Previously, he was an Associate Professor at Howard University, Senior Research Analyst for the Congressional Black Caucus Foundation, and Editor in Chief of the Journal of Negro Education. He is a regular education contributor for TheRoot.com and has been featured on C-SPAN2 Books, NPR, the BBC, and POTUS on XM Satellite Radio. His research has been featured on Essence.com, BET.com, and theGrio.com, and in Ebony magazine. He is the author of the Breaking Barriers series, which analyzes academic success indicators from national surveys that together give voice to more than 10,000 Black male pupils from schools across the United States; coeditor of Black Male Teachers: Diversifying the Nation’s Teacher Workforce; and author of the novel Black Sheep. Melba J. T. Vasquez, PhD, is Past President of the American Psychological Association, the first Latina and woman of color of 120 presidencies of APA to serve in that role. Her theme for the 2011 APA convention was social justice, and several of her presidential initiatives (immigration, reducing prejudice and discrimination, educational disparities) were relevant to that theme. Previously, she served a term on the APA Board of Directors. She is a former president of the Texas Psychological Association and of Divisions 35 (Society of Psychology of Women) and 17 (Society of Counseling Psychology) of the APA. She is a cofounder of APA Division 45, Society for the Psychological Study of Ethnic Minority Issues, and of the National Multicultural Conference and Summit. She is a Fellow in 10 divisions of the APA and holds the Diplomate of the American Board of Professional Psychology. She is in full-time private practice in Austin, Texas. Clemmont E. Vontress, PhD, Professor Emeritus of Counseling at George Washington University, was born in Alvaton, Kentucky, in 1929. He graduated from high school in 1948 and received the BA degree in French and English from Kentucky State University in 1952. After college, he spent two years in Europe, where he encountered Jean-Paul Sartre and Simone de Beauvoir, both of whom would later influence his view of existence as a licensed psychologist. When he returned from Europe, he entered Indiana University in Bloomington, where he received the MS and the PhD in counseling. He then served as Professor of Counseling at George Washington University. He has published more than 100 chapters, books, and articles in national and international journals. He also has studied and published on the problems of immigrants in France and the use of ethnopsychiatry, the therapeutic intervention developed by Tobie Nathan and his colleagues at the University of Paris, to help them. Colleen Ward, PhD, is Professor of Psychology and founding Director of the Centre for Applied Cross-Cultural Research, Victoria University of Wellington. She received her doctoral degree in social psychology from Durham University in England and held an Organization of American States postdoctoral fellowship at the University of the West Indies, Trinidad. Since then she has held academic appointments at the Science University of Malaysia, National University of Singapore, University of Canterbury (New Zealand), and Victoria University of Wellington. Her areas of research expertise include identity, acculturation, adaptation, and intercultural relations, topics summarized in her coauthored book The Psychology of Culture Shock and featured in the more than 150 journal articles and book chapters she has published. She has served as Secretary General of the International Association for Cross-Cultural Psychology and as President of the International Academy of Intercultural Research and the Asian Association of Social Psychology. She is currently editor of the International Journal of Intercultural Relations.