INTERVENTION: Subdomain 3 -- Cultural Competency in Treatment in Diversity Issues COPY

Question 1

What are some dimensions of cultural difference to consider in therapy?

(1–3 of 5)

Answer 1

(Sue et al., 2022)

1. People-Nature dimension
   ——Western idea of mastery and control over nature may differ from other cultures
   ——Some cultures value harmony and acceptance of the environment
   ——Things like direct confrontation may run counter to cultures focused on harmony
2. Time dimension
   ——U.S. majority culture is future oriented. The U.S. majority culture treats time compulsively and as a commodity
   ——Other cultures may have past or present focus (or a combination)
   ————Some Latin-American people have a combination past-present focus
   ————Some Indigenous groups have a here-and-now present focus
3. Relational dimension
   ——Western idea of individualism
   ————Protestant work ethic and achievement-oriented
   ————The individual is the unit, responsible for their own actions
   ————Autonomy and independence are highly valued
   ——Collectivism
   ————Collectivism is common among many groups with strong links to each other and to people from the past
   ————Connections to others may be the priority and pushing individualism could cause harm to the client

Question 2

What are some dimensions of cultural difference to consider in therapy?

(4 + 5)

Answer 2

(Sue et al., 2022)

4. Activity dimension
   —— a) White U.S. culture is action-oriented, prioritizing pragmatism
   ————We expect clients to master and control their lives
   —— b) Some cultures value being over doing
   ————Some Indigenous and Latin-America people value being strongly
5. Nature of People dimension
   —— a) Middle class Western U.S. culture tends to view people as neutral and products of environment
   —— b) Other cultures may value the inherent goodness of people
   ————Example: some Indigenous groups emphasize inherent goodness of people
   —— c) Some cultures may view people as containing both good and bad (e.g,. some Latin-American people hold this view)

Question 3

What is cultural competence?

Answer 3

(Huey et al., 2014)

• Cultural competence requires the awareness of cultural differences and the application of this knowledge to diverse clients.

Cultural competence refers to the ability of a therapist or mental health professional to:

1. Understand and appreciate thecultural background of their clients
2. Recognize how cultural factors influence the client’s presenting problems, beliefs about mental health, and attitudes toward treatment
3. Adapt their therapeutic approach and interventions to be culturally appropriate and effective
4. Develop skills to work effectively with clients from diverse cultural backgrounds

Question 4

What are the models of culturally competent treatment?

Answer 4

(Huey et al., 2014)

Skills-based model:

• Therapist aware of own worldview
• Attempts to understand client’s worldview
• Develops culturally appropriate interventions

Adaptation model:

• Modifications to make interventions congruent with client’s belief system
• Surface level changes: changing superficial characteristics
• Deeper level: targeting cultural values and traditions
• Eight dimensions of adaptation –> language, person (ethnic match of therapist), metaphors, content (application of cultural knowledge), concepts, goals, methods, and context

Process-oriented model:

• Dynamic mechanisms underlying therapist-client interaction
• Considers how cultural meaning contributes to specific behavior and treatment contexts
• Best model for capturing nuances of culture

Question 5

Is therapy effective across diverse clients?

Answer 5

(Huey et al., 2014)

• Recent research suggests therapy is effective for diverse clients
• The research suggests that therapies focused on clients from marginalized groups are effective across a range of presenting problems
• Minority-focused treatments help reduce symptoms and increase engagement in treatment

Question 6

Do treatment effects differ by ethnic group?

Answer 6

(Huey et al., 2014)

Treatment effectiveness does not differ substantially by ethnicity

• 60-70% of RCTs or meta-analyses found no significant moderator effects
• Results support “ethnic invariance”
• Treatment results are mixed –> they may favor White clients in some cases and minority clients in other cases

(Smith et al., 2011)

• Asian Americans benefitted > African Americans, Latinos, and Native Americans
• Minority-focused therapies were effective for a range of issues
• Effect sizes .29—.76 (small to large effects)

Question 7

Does culturally tailoring treatment work?

Answer 7

(Huey et al., 2014)

• Cultural tailoring is recommended but research shows only small effect on enhancing treatment
• There needs to be more research
• Effort should be put into creating forms of culturally competent treatment that are actually effective and accessible to clinicians to implement
• Recommends using EBT (evidence-based treatment)
  ——Some already have multicultural elements to include
• Possible that tailoring is best for older, less acculturated individuals and that directly addressing cultural differences is helpful.
• Congruence on treatment goals and using metaphors/symbols that match client worldview strengthens treatment efficacy
• Incorporating client beliefs about symptoms, etiology, consequences, and treatment improves outcomes.

Question 8

What is the Hays ADDRESSING model?
(+ 3-legged stool consideration)

Answer 8

(Hays, 2004)

• Hays’s ADDRESSING Model considers the multiple dimensions of identity

ADDRESSING

1. Age and generational influences
2. Disability (developmental)
3. Disability (acquired)
4. Religion and spiritual orientation
5. Ethnicity
6. Socioeconomic status
7. Sexual orientation
8. Indigenous heritage
9. National origin
10. Gender

Where is culture represented in the three-legged stool metaphor of EBP?

• The three-legged stool model represents the three core aspects of evidence-based practice
• The leg of client characteristics and values is where cultural considerations fall

Question 9

When learning about cultural competence, what should you keep in mind?

Answer 9

(Berman & Shopland, 2005)

• Learn about cultural group differences, but remember not all clients will have the same experiences
• Remember to let the client define their identity and experience

Question 10

What are some factors to consider about your client?

Answer 10

(Berman & Shopland, 2005)

• Age and generational differences
  ——-Problems related to aging
• Piagetian stages of development
• Gender roles (leadership, appearance, sexuality)

Question 11

What are some aspects of treatment that cultural factors influence?

Answer 11

(Gopalkrishnan, 2018)

1. What gets defined as a problem

• The nature of what is considered a problem is based on cultural ideas
• Bias can lead to clinicians overlooking problems, stereotyping clients, and mishandling interactions
• Particularly concerning overdiagnosis of certain mental health disorders in certain groups (i.e. over diagnosing schizophrenia in African American clients)
• Cultures may differ in what they define as a stressor and what is considered a normal part of life

2. How the problem is understood
3. What solutions are acceptable

Question 12

What are the essential components of diverse cultures to consider for therapy?

Answer 12

(Gopalkrishnan, 2018)

1. Emotional Expression
2. Shame
3. Power distance
4. Collectivism
5. Spirituality and religion:

• People may understand mental health in the context of religion/spiritual practice
• They may seek help from within their religion (like temples, etc.)

Question 13

What does cultural meaning around health and illness influence?

Answer 13

(Gopalkrishnan, 2018)

1. Willingness to seek help
2. How symptoms are coped with
3. How much support the client will have from family and community
4. Where the client will seek help
5. The pathways they take to seek help
6. How well treatment will go
7. When they will go to treatment

• People who are marginalized seek help later and under conditions of more distress than members of the dominant culture

Question 14

What are some differences to consider between Western cultures and Nonwestern cultures?

Answer 14

(Gopalkrishnan, 2018)

• Western cultures: individual internal experiences and individual pathology
• Other cultures may have a community and familial-based process

Other cultures may have different ideas around the connection/separation of mind and body

• Western reductionistic idea that mind and body are separate
• Research suggests there is a connection and working with both body and mind is more effective

Therapy focused on talking about problems may not be as effective for all cultures

• May need to do therapies based on movement and expression
• Online therapies may be effective

Question 15

What are some special considerations for colonized cultures?

Answer 15

(Gopalkrishnan, 2018)

Historical trauma: the complex, inter-generational trauma often experienced by First Nations People

• Often experienced as a collective phenomenon
• The trauma is cumulative

Mental health professionals may be seen as part of the problem (historically and systematically)

• African American and Latin-American people also show higher rates of distrust toward clinicians based on historic oppression and current discrimination/prejudice

Question 16

What is intersectionality?

Answer 16

(PettyJohn et al. 2020)

Intersectionality: “an individual’s exposure to multiple, simultaneous, and interactive effects of different types of social organization and their experiences related to prejudice and power or societal oppression”

• Intersectionality accounts for various pieces of an individual’s identity
• These identities come together (intersect) to form one’s social location, determining the power and privilege held by an individual

Question 17

How does intersectionality affect the therapeutic alliance?

Answer 17

(PettyJohn et al. 2020)

• Dynamics of power and oppression are expressed at the relational level in therapy
• As a highly educated, trained professional, therapists hold power
• A therapist with multiple marginalized identities working with a client with privileged identities may be in a reverse position, holding less power than the client
• Addressing power dynamics may be essential to the therapeutic alliance
• Trust is formed early, therapists need to be aware of the initial impression they give clients, including topics they choose to address or not address
• Clients may not feel fully seen or understood until dimensions of power are worked through
• Therapists unaware of client’s multiple identities are more likely to express microaggressions
• Therapists who do not address notable differences in privilege may unintentionally come across as more authoritarian

Question 18

How can a therapist handle differences of power/privilege?

Answer 18

(PettyJohn et al. 2020)

Therapists should work collaboratively with client on goals and interventions

• Remember worldview is going to affect how interventions are perceived
• Ask for feedback from the client
• Ask the client about what has been helpful

Question 19

How can a therapist approach conversations around intersectionality?

Answer 19

(PettyJohn et al. 2020)

• Developing an in-depth demographics form which will help the therapist to review literature on identities in which they are less familiar and check biases or stereotypes
• Conceptualize how client identities may interact with the presenting problem and how intersectionality between the clients and therapist may influence treatment
• Remember conversations about intersectionality between therapist and client may become relevant at any point throughout treatment
• For some, this may be important to address explicitly upfront—if client appears quiet, resistant, or anxious when discussing their identity
• May come up later when revisiting past experiences or other external events occur
• Think critically about whether or not the client wishes to discuss identity issues or if they feel uncomfortable initiating the conversation themselves
• Not necessary or helpful for ALL therapist/client relationships but the decision to not have these conversations should not come from ignorance
• When discussing, position “From my experience as a white, American woman raised in the US, I may not always understand your experiences and I invite you to correct me when I get things wrong.”
• Gauge clients’ reactions to the disclosure, then decide whether to follow up with questions that help to conceptualize how the client’s intersectionality may influence the presenting problems, and what the client views as valuable tasks and goals to pursue in therapy.
• Maintain a position of curiosity and cultural humility because we can never truly know another person and their experiences and lives
• With self-disclosure there are risks and self-disclosure should be viewed as an intervention to be used strategically and not a way to ease our own anxieties. The disclosures must be clinically relevant

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• Demographics form
• Conceptualize client’s
• Can become relevant whenever
• Attempt explicit discussions
• Don’t avoid convo out of ignorance
• Don’t engage in self-dislocure to ease own anxiety
• Maintain curiosity and humility

Question 20

How does minority stress affect mental health and treatment?

Answer 20

(Meyer, 2003)

• Minority stress –> Stress coming from discrimination and stigma that is unique, chronic, and socially based
• The minority stress model examines the ways minority stress affect the well-being of marginalized people
• Mental health may be at risk when social constructs of normality are incongruent with the lived experience of marginalized individuals
• Self-concepts are important to mental health, and stressors that attack self-concept are likely to lead to mental health problems
• Victimization based on identity has worse mental health outcomes than other forms of victimization
• Research suggests that stigma (a form of minority stress) leads to feeling alienated, a lack of self-acceptance, and lack of community integration. Leads to negative mental health outcomes

Question 21

What are some factors to consider when working with transgender or gender-nonconforming clients?

Answer 21

(Leland & Stockland, 2019)

• Psychologists are in a position of being able to provide support and affirming services to TGNC clients, who face barriers to health care, housing, and employment.
• High rates of suicide and emotional distress exist among TGNC population.
• Disproportionately high experiences of discrimination and harassment in the workplace, including being forced to use a bathroom that did not align with their gender identity or being forced to present as the wrong gender to keep their job.
• High rates of verbal, physical, and sexual abuse
• Experiences of homelessness at a rate three times higher than the general population
• TGNC affirming practices should be in place generally within the office, not just when you assume a client falls in this category.
• TGNC is an umbrella term covering various gender identities and behaviors.
• Creation of a 28 item self-assessment tool for clinicians to use to determine how supportive and affirming their practices are. Can help to choose specific areas of growth and plan specific goals. Also helps to review current strengths.
• Therapy should not be used to force clients to align with gender expectations

Question 22

What is cultural humility?

Answer 22

(Sue et al., 2022)

Cultural humility: Open attitude stance toward diverse people and groups

Cultural humility is an ongoing process of self-reflection and learning about different cultures, involving:

• Recognizing one’s own cultural biases
• Being open to other cultural perspectives
• Acknowledging the limits of one’s cultural knowledge
• Showing respect for cultural differences

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• It is a way of being not something one does
• This stance is considered important to many clients
• Correlates with likelihood of continuing therapy
• Strongly relates to the strength of therapeutic alliance
• Relates to perceived benefits in therapy

Question 23

What can the minority stress model teach us about working with LGBTQIA+ clients?

Answer 23

(Meyer, 2003)

Consider the presence of minority stress specific to this community

1. Concealment: Not being “out”
2. Expectation of rejection
3. Internalized stigma

• LGBTQIA-affirming therapies aim to help the individual do reappraisal of identity using the group membership rather than comparison to the dominant group

Question 24

What does it mean to be a social justice-focused therapist?

Answer 24

(Sue et al. 2022)

It means changing assumptions about therapy

• The focus of the problem may reside in the social system rather than the individual
• If a behavior violates a social norm that does not necessarily mean it is disordered or unhealthy
• Social norms, prevailing beliefs, and institutional policies that maintain the status quo may need to be challenged and changed
• Remediation is important, but prevention is more effective long-term
• Organizational change requires macrosystem approach that may go beyond the traditional therapy role

It means considering that intervention can affect the four different focuses:

• Individual: the traditional focus on the personal
• Professional: Modifying professional codes of practice
• Organizational: addressing monoculture institutions
• Societal: Addressing social policies

Learn to develop a balance perspective between the person and the system

Question 25

SUBDOMAIN 3: CITATIONS

Answer 25

SUBDOMAIN 3: CITATIONS

Question 26

Sue et al., 2022

Answer 26

(Sue et al., 2022)

• What are some dimensions of cultural difference to consider in therapy?
• What does it mean to be a social justice-focused therapist?
• What is cultural humility?

Question 27

(Huey et al., 2014)

Answer 27

(Huey et al., 2014)

• What is cultural competence?
• What are the models of culturally competent treatment?
• Is therapy effective across diverse clients?
• Do treatment effects differ by ethnic group?
• Does culturally tailoring treatment work?

Question 28

(Hayes, 2004)

Answer 28

(Hayes, 2004)

• What is the Hays ADDRESSING model? (+ 3-legged stool consideration)

Question 29

Berman & Shopland, 2005

Answer 29

Berman & Shopland, 2005

• When learning about cultural competence, what should you keep in mind?
• What are some factors to consider about your client?

Question 30

Gopalkrishnan, 2018

Answer 30

Gopalkrishnan, 2018

• What are some aspects of treatment that cultural factors influence?
• What are the essential components of diverse cultures to consider for therapy?
• What does cultural meaning around health and illness influence?
• What are some differences to consider between Western cultures and Nonwestern cultures?
• What are some special considerations for colonized cultures?

Question 31

PettyJohn et al., 2020

Answer 31

PettyJohn et al., 2020

• What is intersectionality?
• How does intersectionality affect the therapeutic alliance?
• How can a therapist handle differences of power/privilege?
• How can a therapist approach conversations around intersectionality?

Question 32

Meyer, 2003

Answer 32

Meyer, 2003

• How does minority stress affect mental health and treatment?
• What can the minority stress model teach us about working with LGBTQIA+ clients?

Question 33

Leland & Stockland, 2019

Answer 33

Leland & Stockland, 2019

• What are some factors to consider when working with transgender or gender-nonconforming clients?