Therapy

Introduction

There is increasing motivation among psychologists to understand culture and ethnicity factors in order to provide appropriate psychological services. This increased motivation for improving quality of psychological services to ethnic and culturally diverse populationsis attributable, in part, to the growing political and social presence of diverse cultural groups, both within APA and in the larger society. New sets of values, beliefs, and cultural expectations have been introduced into educational, political, business, and healthcare systems by the physical presence of these groups. The issues of language and culture do impact on the provision of appropriate psychological services.

Psychological service providers need a sociocultural framework to consider diversity of values, interactional styles, and cultural expectations in a systematic fashion. They need knowledge and skills for multicultural assessment and intervention, including abilities to:

1. recognize cultural diversity;

2. understand the role that culture and ethnicity/race play in the sociopsychological and economic development of ethnic and culturally diverse populations;

3. understand that socioeconomic and political factors significantly impact the psychosocial, political and economic development of ethnic and culturally diverse groups;

4. help clients to understand/maintain/resolve their own sociocultural identification; and understand the interaction of culture, gender, and sexual orientation on behavior and needs.

Likewise, there is a need to develop a conceptual framework that would enable psychologists to organize, access, and accurately assess the value and utility of existing and future research involving ethnic and culturally diverse populations.

Research has addressed issues regarding responsiveness of psychological services to the needs of ethnic minority populations. The focus of mental health research issues has included:

1. The impact of ethnic/racial similarity in the counseling process (Acosta & Sheenan, 1976; Atkinson, 1983; Parham & Helms, 1981);

2. Minority utilization of mental health services (Cheung & Snowden, 1990; Everett, Proctor, & Cartmell, 1983; Rosado, 1986; Snowden & Cheung, 1990);

3. Relative effectiveness of directed versus nondirected styles of therapy (Acosta, Yamamomoto, & Evans, 1982: Dauphinais, Dauphinais, & Rowe, 1981; Lorion, 1974);

4. The role of cultural values in treatment (Juarez, 1985; Padilla & Ruiz, 1973; Padilla, Ruiz, & Alvarez, 1975; Sue & Sue, 1987);

5. Appropriate counseling and therapy models (Comas-Diaz & Griffith, 1988; McGoldrick, Pearce, & Giordino, 1982; Nishio & Blimes, 1987);

6. Competency in skills for working with specific ethnic populations (Malgady, Rogler, & Constantino, 1987; Root, 1985; Zuniga, 1988).

The APA's Board of Ethnic Minority Affairs (BEMA) established a Task Force on the Delivery of Services to Ethnic Minority Populations in 1988 in response to the increased awareness about psychological service needs associated with ethnic and cultural diversity. The populations of concern include, but are not limited to the following groups: American Indians/Alaska Natives, Asian Americans, and Hispanics/Latinos. For example,the populations also include recently arrived refugee and immigrant groups and established U.S. subcultures such as Amish, Hasidic Jewish, and rural Appalachian people.

The Task Force established as its first priority development of the Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations. The guidelines that follow are intended to enlighten all areas of service delivery, not simply clinical or counseling endeavors. The clients referred to may be clients, organizations, government and/or community agencies.

Guidelines

Preamble: The Guidelines represent general principles that are intended to be aspirational in nature and are designed to provide suggestions to psychologists in working with ethnic, linguistic, and culturally diverse populations.

1. Psychologists educate their clients to the processes of psychological intervention, such as goals and expectations; the scope and, where appropriate, legal limits of confidentiality; and the psychologists' orientations.
   
   a. Whenever possible, psychologists provide information in writing along with oral explanations.
   b. Whenever possible, the written information is provided in the language understandable to the client.

2. Psychologists are cognizant of relevant research and practice issues as related to the population being served.
   
   a. Psychologists acknowledge that ethnicity and culture impacts on behavior and take those factors into account when working with various ethnic/racial groups.
   
   b. Psychologists seek out educational and training experiences to enhance their understanding to address the needs of these populations more appropriately and effectively. These experiences include cultural, social, psychological, political, economic, and historical material specific to the particular ethnic group being served.
   
   c. Psychologists recognize the limits of their competencies and expertise. Psychologists who do not possess knowledge and training about an ethnic group seek consultation with, and/or make referrals to, appropriate experts as necessary.
   
   d. Psychologists consider the validity of a given instrument or procedure and interpret resulting data, keeping in mind the cultural and linguistic characteristics of the person being assessed. Psychologists are aware of the test's reference population and possible limitations of such instruments with other populations.

3. Psychologists recognize ethnicity and culture as significant parameters in understanding psychological processes.
   
   a. Psychologists, regardless of ethnic/racial background, are aware of how their own cultural background/experiences, attitudes, values, and biases influence psychological processes. They make efforts to correct any prejudices and biases.
   Illustrative Statement: Psychologists might routinely ask themselves, 'Is it appropriate for me to view this client or organization any differently than I would if they were from my own ethnic or cultural group?'
   
   b. Psychologists' practice incorporates an understanding of the client's ethnic and cultural background. This includes the client's familiarity and comfort with the majority culture as well as ways in which the client's culture may add to or improve various aspects of the majority culture and/or of society at large.
   Illustrative Statement: The kinds of mainstream social activities in which families participate may offer information about the level and quality of acculturation to American society. It is important to distinguish acculturation from length of stay in the United States, and not to assume that these issues are relevant only for new immigrants and refugees.
   
   c. Psychologists help clients increase their awareness of their own cultural values and norms, and they facilitate discovery of ways clients can apply this awareness to their own lives and to society at large.
   Illustrative Statement: Psychologists may be able to help parents distinguish between generational conflict and culture gaps when problems arise between them and their children. In the process, psychologists could help both parents and children to appreciate their own distinguishing cultural values.
   
   d. Psychologists seek to help a client determine whether a 'problem' stems from racism or bias in others so that the client does not inappropriately personalize problems.
   Illustrative Statement: The concept of 'healthy paranoia,' whereby ethnic minorities may develop defensive behaviors in response to discrimination, illustrates this principle.
   
   e. Psychologists consider not only differential diagnostic issues but also cultural beliefs and values of the clients and his/her community in providing intervention.
   Illustrative Statement: There is a disorder among the traditional Navajo called 'Moth Madness.' Symptoms include seizure-like behaviors. The disorder is believed by the Navajo to be the supernatural result of incestuous thoughts or behaviors. Both differential diagnosis and intervention should take into consideration the traditional values of Moth Madness.

4. Psychologists respect the roles of family members and community structures, hierarchies, values, and beliefs within the client's culture.
   
   a. Psychologists identify resources in the family and the larger community.
   
   b. Clarification of the role of the psychologist and the expectations of the client precede intervention. Psychologists seek to ensure that both the psychologist and client have a clear understanding of what services and roles are reasonable.
   Illustrative Statement: It is not uncommon for an entire American Indian family to come into the clinic to provide support to the person in distress. Many of the healing practices found in American Indian communities are centered in the family and the whole community.

5. Psychologists respect clients' religious and/or spiritual beliefs and values, including attributions and taboos, since they affect world view, psychosocial functioning, and expressions of distress.
   
   a. Part of working in minority communities is to become familiar with indigenous beliefs and practices and to respect them.
   Illustrative Statement: Traditional healers (e.g., shamans, curanderos, espiritistas) have an important place in minority communities.
   
   b. Effective psychological intervention may be aided by consultation with and/or inclusion of religious/spiritual leaders/practitioners relevant to the client's cultural and belief systems.

6. Psychologists interact in the language requested by the client and, if this is not feasible, make an appropriate referral.
   
   a. Problems may arise when the linguistic skills of the psychologist do not match the language of the client. In such a case, psychologists refer the client to a mental health professional who is competent to interact in the language of the client. If this is not possible, psychologists offer the client a translator with cultural knowledge and an appropriate professional background. When no translator is available, then a trained paraprofessional from the client's culture is used as a translator/culture broker.
   
   b. If translation is necessary, psychologists do not retain the services of translators/paraprofessionals that may have a dual role with the client to avoid jeopardizing the validity of evaluation or the effectiveness of intervention.
   
   c. Psychologists interpret and relate test data in terms understandable and relevant to the needs of those assessed.

7. Psychologists consider the impact of adverse social, environmental, and political factors in assessing problems and designing interventions.
   
   a. Types of intervention strategies to be used match to the client's level of need (e.g., Maslow's hierarchy of needs).
   Illustrative Statement: Low income may be associated with such stressors as malnutrition, substandard housing, and poor medical care; and rural residency may mean inaccessibility of services. Clients may resist treatment at government agencies because of previous experience (e.g., refugees' status may be associated with violent treatments by government officials and agencies).
   
   b. Psychologists work within the cultural setting to improve the welfare of all persons concerned, if there is a conflict between cultural values and human rights.

8. Psychologists attend to as well as work to eliminate biases, prejudices, and discriminatory practices.
   
   a. Psychologists acknowledge relevant discriminatory practices at the social and community level that may be affecting the psychological welfare of the population being served.
   Illustrated Statement: Depression may be associated with frustrated attempts to climb the corporate ladder in an organization that is dominated by a top echelon of White males.
   
   b. Psychologists are cognizant of sociopolitical contexts in conducting evaluations and providing interventions; they develop sensitivity to issues of oppression, sexism, elitism, and racism.
   Illustrative Statement: An upsurge in the public expression of rancor or even violence between two ethnic or cultural groups may increase anxiety baselines in any member of these groups. This baseline of anxiety would interact with prevailing symptomatology. At the organizational level, the community conflict may interfere with open communication among staff.

9. Psychologists working with culturally diverse populations should document culturally and sociopolitically relevant factors in the records.
   
   a. number of generations in the country
   b. number of years in the country
   c. fluency in English
   d. extent of family support (or disintegration of family)
   e. community resources
   f. level of education
   g. change in social status as a result of coming to this country (for immigrant or refugee)
   h. intimate relationship with people of different backgrounds
   i. level of stress related to acculturation

References

Acosta, F. X., & Sheehan, J. G. (1976). Preference towards Mexican American andAnglo American psychotherapists. Journal of Consulting and Clinical Psychology, 44(2), 272-279.

Acosta, F., Yamamoto, J., & Evans, L (1982). Effective psychotherapy for low income and minority patients. New York: Plenum Press.

Atkinson, D. R. (1983). Ethnic similarity in counseling psychology: A review of research. The Counseling Psychologists, 11, 79-92.

Cheung, F. K., & Snowden, L. R. (1990). Community mental health and ethnic minority populations. Community Mental Health Journal, 26, 277-291.

Comas-Diaz, L., & Griffith, E. H. (1988). Clinical guidelines in cross-cultural mentalhealth. John Wiley.

Dauphinais, P., Dauphinais, L., & Rowe, W. (1981). Effects of race and communication style on Indian perceptions of counselor effectiveness. Counselor Education and Supervision, 20, 37-46.

Everett, F., Proctor, N., & Cartmell, B. (1983). Providing psychological services to American Indian children and families. Professional Psychology: Research and Practice, 14(5), 588-603.

Juarez, R. (1985). Core issues in psychotherapy with the Hispanic child. Psychotherapy, 22(25), 441-448.

Lorion, R. P. (1974). Patient and therapist variables in the treatment of low income patients. Psychological Bulletin, 81, 344-354.

Malgady, R. G., Rogler, L. H., & Constantino, G. (1987). Ethnocultural and linguistic bias in mental health evaluation of Hispanics. American Psychologist, 42(3), 228-234.

McGoldrick, M., Pearce, J. K., & Giordano, J. (1982). Ethnicity and family therapy. New York: Guilford Press.

Nishio, K., & Bilmes, M. (1987). Psychotherapy with Southeast Asian American clients. Professional Psychology: Research and Practice, 18(4), 342-346.

Padilla, A. M., & Ruiz, R. A. (1973). Latino mental health: A review of literature (DHEW publication No. HSM 73-9143). Washington, DC: U.S. Government Printing Office.

Padilla, A. M., Ruiz., R. A., & Alvarez, R. (1975). Community mental health for the Spanish-speaking/surnamed population. American Psychologist, 30, 892-905.

Parham, T. A., & Helms, J. E. (1981). The influence of Black students racial identity attitudes on preferences for counselor's race. Journal of Counseling Psychology, 28, 250-257.

Root, Maria P. P. (1985). Guidelines for facilitating therapy with Asian American clients. Psychotherapy, 22(2s), 349-356.

Rosado, J. W. (1986). Toward an interfacing of Hispanic cultural variables with school psychology service delivery systems. Professional Psychology: Research and Practice, 17(3), 191-199.

Snowden, L. R., & Cheung, F. K. (1990). Use of inpatient mental health services by members of ethnic minority groups. American Psychologist, 45, 347-355.

Sue, D., & Sue, S. (1987). Cultural factors in the clinical assessment of Asian American. Journal of Consulting and Clinical Psychology, 55(4), 479-487.

Zuniga, M. E. (1988). Assessment issues with Chicanas: practical implications. Psychotherapy, 25(2), 288-293.

Task Force on the Delivery of Services to Ethnic Minority Populations:

• Charles Joseph Pine, PhD, Chair

• Jose Cervantes, PhD

• Freda Cheung, PhD

• Christine C. Iijima Hall, PhD

• Jean Holroyd, PhD

• Robin LaDue, PhD

• LaVome Robinson, PhD

• Maria P. P. Root, PhD

These guidelines were approved by the Council of Representatives in August of 1990 during the 98th Annual Convention in Boston, Massachusetts.

Date created: 1990

You can find the above information on the APA website: https://www.apa.org/pi/oema/resources/policy/provider-guidelines

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