Multicultural counseling competencies: guidelines in working with children and adolescents.
Andrew was an 11-year-old Asian American. Because over the past year he was growing disruptive and uncooperative, his parents enrolled him in a 2-week, therapy-focused day camp during the summer. His parents felt the experience was positive for him, and suggested he continue individual therapy. Some of his reported "problems" included fighting with his mother in the morning when getting ready for school, not stopping his playing of video games when it was time for dinner, and some lying and stealing. He also wet his bed several times a week, but would try to hide the sheets in the wash. During the initial interview for counseling, background information gathered provided some clues to Andrew's "disruptive" behaviors. Andrew is ethnically Chinese, but was adopted by his parents when he was 2 years old from a woman in the United States. He is the youngest of four adopted children, all of whom are women, the oldest in the family being 23 years old. Andrew's behaviors became chaotic when his father disclosed to his family that he had terminal lung cancer with only about a year to live. During camp, Andrew's behavior moderated, and during his individual sessions he was cooperative, lucid, and warm. However, as his father's illness worsened and he had to be hospitalized, Andrew's behavior became erratic. At one point, Andrew was hospitalized for 2-weeks in a behavior-intensive child evaluation ward. Afterwards, Andrew described the experience as "ok." When his father died, he came into counseling but was inattentive and withdrawn. Attempts to speak with him typically resulted in his glancing to the floor. The only interaction that was possible for several weeks after the death was to play HORSE with a Neff basketball during the therapy hour. Individual therapy progressed well for 2-years until the counselor was transferred. When the transfer was brought up in counseling with Andrew, he became withdrawn again, but was willing to talk about his sadness and his hope to continue an email relationship with the therapist.
The first author was his therapist at the time and this was his first experience working with children. His previous training in a master's and a doctoral program included a course on child counseling, several courses in multicultural counseling, and active participation on multicultural research.
The case of Andrew is used to illustrate the various layers of culture with which counselors are sometimes faced when working with children and adolescents. Counselors are sometimes trained to be multiculturally competent (e.g., knowledge, awareness, and skills; Sue, Arredondo, & McDavis, 1992), but in therapy, it is important to understand how to focus on culture and how to use it to the clinician and client's benefit (Sherraden & Segal, 1996). That is, being multiculturally competent does not always imply introducing and using culture in therapy, but to have the knowledge, awareness, and skills to know when and how culture can be best used. It is also important to consider multiculturalism as encompassing of all forms of culture such as gender, race, sexual orientation, age, and so on (Stone, 1997), rather than just race and ethnicity as a way to consider the array of cultural issues clients bring to therapy. Because cases like Andrew's represent a complex mixture of cultural issues and clinical symptoms, counselors may be faced with a score of questions such as: How are cultural issues relevant? What are the cultural assumptions of the client and counselor? How much should culture play into the evaluation and treatment of this case? What skills and information are needed to deal with this case from a culturally competent perspective? What are the treatment options and what are the cultural assumptions of each? And finally, which treatment best incorporates strengths of relevant cultures?
In order to address these questions and provide counselors with an approach that could work with this case and similar cases, this article focuses on five steps to guide counseling decision-making when working with culturally diverse child clients (see Table). These are: (1) evaluate which cultural aspects are relevant, (2) determine the level of skills and information necessary for competent treatment and possible referral, (3) determine how much, when, and how to incorporate cultural issues, (4) examine the potential list of treatments and understand the cultural assumptions of each, and (5) implement the treatment using the cultural strengths. This article will address each of these steps and offer some suggestions for clinicians.
Five Steps to Guide Decision-Making when Working with Diverse Children
1. Evaluate which, if any, cultural aspects are relevant.
2. Determine the level of skills and information necessary for competent treatment and possible referral.
3. Determine how much, when, and how to incorporate cultural issues.
4. Examine potential treatments and understand the cultural assumptions of each.
5. Implement the treatment using cultural strengths.
EVALUATE WHICH CULTURAL ASPECTS ARE RELEVANT
Although there are a number of different cultural issues present in this case study, the authors have chosen to focus on a few salient dimensions for illustration. But before beginning, it is important that counselors be aware of their own biases and worldviews. Sue, Ivey, & Pederson (1996) consider this self-awareness prior to engaging in any therapy a "self-audit." Awareness of one's own lenses, experiences (educational, occupational, familial, and cultural), will allow the clinician to understand how the client's behaviors and attitudes sometimes conflict. This self-awareness is the foundation for multicultural therapy (Sue et al., 1996).
To begin working with Andrew, counselors may want to broadly assess Andrew's understanding and integration of diversity and multiculturalism in his life. This is necessary since some clients, culturally or developmentally, may still be unable to abstractly understand the concepts of culture and race and to place themselves in these constructs. Children may also understand culture differently depending upon the context (i.e., school or at home; Coleman, Casali, & Wampold, 2001), and may have different ways of behaving in different contexts (e.g., bi-culturalism; LaFromboise, Coleman, & Gerton, 1993; Yeh & Hwang, 2000). Counselors who can assess these dimensions will have a better foundation from which to work with clients and to engage in multiculturally related discussions in therapy.
Another consideration is to assess his ethnic identity (i.e., being Chinese American). With Andrew, his most obvious culture (i.e., physical features) is his Chinese heritage and the related cultural considerations such as emotional restraint, impulse control, and deference to authorities (Lung & Sue, 1997). But in this case, because Andrew was adopted, some of these cultural assumptions are challenged. It is not clear in this case if these "typical" Chinese cultural attributes were socialized while living in a Caucasian family. Consequently, it may not be feasible to approach Andrew as a typical Chinese-American child. Andrew's issues may be common among racial minority children adopted by White families. Interpersonally, as an adopted ethnically Chinese child he must function within the contexts of both heritages: Chinese and Asian American. Intrapsychically, however, he would be less ethnically identified than other Chinese-American children reared in Chinese-American homes. Additionally, one should assess how well the parents have socialized Andrew to understand his race and ethnicity within a dominant White culture. These are important considerations for the clinician, especially when making the initial diagnosis and treatment plan, since Andrew may filter his behaviors through several cultural lenses that may distort his real thoughts and feelings (Canino & Spurlock, 2000).
Another salient cultural dimension is that of being a boy. The literature seems to suggest that boys in general are at a greater risk than girls for some behavioral and developmental challenges (Johnson-Powell, 1997; Malmquist, 1985). Some of these potential problems may be associated with the emotional retardation that occurs with some boys through socialization, that rewards boys for aggression and silence (i.e., masculinity), and punishes them for weakness and emotional expression (i.e., femininity; Pollack, 1998a, 1998b; Pollack &
Levant, 1998). Added to this is Andrew's anticipation of his father's death, which for many boys and men may characterize a developing father-hunger that may develop into a father wound later in life (Mooney, 1998). His situation may lead to feelings of depression and hypermasculine behaviors to compensate for the expected loss and to cope with feelings he may not fully understand.
This may be one possible important cultural consideration since there is research to suggest that male adolescents experiencing depression may engage in aggressive behaviors (Kann, & Hanna, 2000; Knox, King, Hanna, Logan, & Ghaziuddin, 2000). The positive aspect of understanding this masculine socialization is that the counselor can use "typical" boyhood experiences to connect and as aspects of conversation that could eventually lead to client information and insight about the client. For instance, the first author, knowing that Andrew enjoyed competition in sports and games, readily used board games, Neff games, and outside activities to join with the client in therapy, which eventually allowed Andrew an opportunity to discuss his feelings and thoughts without the perception of being in therapy or treatment. Hence, the counselor needed to be aware of how multiple cultural socializations interacted and worked to facilitate and sometimes impede counseling.
Finally, as an 11 year old, Andrew exists within a culture of burgeoning adolescence and developmental issues, and the clinician needs to be aware of these pressures and expectations (Kaczmarek & Wagner, 1994; Wagner, 1996). Johnson-Powell (1997) offers several considerations for clinicians. First, Andrew will be moving toward peer group identification. Second, Andrew will be developing the capacity to have emotionally close friendships. Third, he will have more fluidity with language and, for instance, be able to joke. Fourth, he will experience events and situations more intensely and personally and may start to show more "moodiness" than before. Finally, Andrew may show more oscillations in his academics. That is, he may progress and regress without much warning or ability to identify precipitating factors. Hence, along with the cultural dimensions, clinicians need to consider the developmental issues Andrew faced, and how adolescent culture can contribute to Andrew's challenges. Along with the cultural information gathered, clinicians should be aware of other potential sources of information that can help in treatment.
DETERMINE THE LEVEL OF SKILLS AND INFORMATION NECESSARY FOR COMPETENT TREATMENT AND POSSIBLE REFERRAL
Potentially, there are multiple areas of information that counselors can gather. In fact, clinicians could spend much of their therapy time collecting a detailed client history without ever venturing toward intervention. Thus, when does the clinician know that enough information is gathered? And, what are the first steps in working with a client like Andrew?
The preparation to work with Andrew comes long before he walks through the therapist's door. Therapists should be aware and knowledgeable of various cultural groups with whom they are likely to work. Clinicians must comprehend the various norms and expectations that cultural groups inhabit and how these may differ from the clinician's own worldview of how people should act and think. This first step is crucial, not only intellectually and emotionally, but also ethically as we consider our competency in working with certain clinical populations (Johnson-Powell, 1997).
Certainly, clinicians could be overwhelmed with the multitude of groups one would have to learn about to be considered competent. One strategy to develop competence is to understand the population the clinician will likely work with within his or her neighborhood and community. In other words, while the U.S. in general is a diverse place, this diversity is geographically stratified (U.S. Census Bureau, 2001). This means that African, Asian, Latino, and American Indians are located in specific regions of the United States. Using the census profiles, clinicians can develop a picture of their community and the types of clients they may likely encounter. Thus, it is possible for clinicians to concentrate on a few racial minority groups that are prevalent in their environment as well as other forms of diversity (e.g., boys and masculinity, social class, ability). This is not to say that clinicians should not be aware and knowledgeable of all forms of diversity, but to say instead that clinicians can strategize their own learning process as they become more multiculturally competent. Once the information is gathered clinicians can compare what they have learned about the client with the prototypical client profiles developed through census and other demographic information.
The next step is to seek out ways to enhance therapy through concerted work with other health care providers. For instance, counselors could team with other help providers within the child or adolescent's life such as school psychologists and school counselors who can provide invaluable support and insight into the child or adolescent's peer, school, and socialization experiences. Such partnerships can better provide culturally relevant treatment by having at the onset congruent goals and assumptions (Barnett et al., 1995; Donovan & Spence, 2000). This is especially useful if the counselor is expanding his or her area of expertise and seeking some collegial support and consultation.
Once this information is gathered, the counselor should decide if the child or adolescent's presenting issue is within his or her area of expertise and competency, or if the therapist has adequate supervision and an ability to consult with experts in working with this case. Depending upon the place the therapist is practicing (e.g., rural or urban), sometimes these decisions are made more difficult. For example, in a rural setting a therapist may be the only one available to help Andrew, and so a referral to another therapist may be difficult or impossible. In these cases the therapist is responsible for gathering additional information, working with the client in session to understand relevant cultural issues, and seeking additional supervision as necessary. This supervision may need to occur via telephone if distance prohibits face-to-face contact.
DETERMINE HOW MUCH, WHEN, AND HOW TO INCORPORATE CULTURAL ISSUES
Essentially, in this stage, the therapist needs to understand when culture is in the foreground or in the background when working with a case like Andrew. But first, in order to understand the salience of culture within a child's life, it is important to gather the appropriate information relevant to the case. Johnson-Powell (1997) offers several suggestions for clinicians when working with diverse children. She suggests that in the interview, the clinician (a) enter the world of the client, (b) shape the content and context of the interview, (c) make the client comfortable, (d) decrease social distance, (e) increase the perception of sameness, and (f) elicit as much information as possible at each contact depending upon the level of comfort (p. 351). The argument for the last suggestion is not to treat the child or adolescent as an adult, but to pay attention to the working relationship, and operate within those opportunities. The risk would be to make the child "not like" the therapy situation and see it as punitive rather than helpful.
Second, the counselor needs additional information to guide decision making about if, how, and how much to include cultural issues in treatment. For example, the counselor must determine to what extent:
* Do the client's beliefs and values reflect his or her given culture?
* Do these beliefs and values influence susceptibility to treatment?
* Does the client see culture as important?
* Are the client's beliefs and behaviors influenced by culture?
* Do cultural issues factor into treatment acceptability and treatment goals?
Answers to these questions will help the counselor to make judgments regarding inclusion of culture and cultural issues in the treatment. As in the case with Andrew, culture may, in fact, be less important to the client than is perceived by the counselor. In this case, it is important not to dwell on cultural issues. Doing so would reflect a misjudgment of the counselor and likely result in early termination or ineffective treatment.
Because each case differs, there is no golden rule for when to include or exclude culture. Counselors can approach the therapy situation with a healthy willingness to make mistakes and to discuss these missteps with the client if possible and with colleagues and supervisors. In this case with Andrew, the first author made several mistakes at various times throughout therapy. Some of these were: to discuss his Chinese-American heritage when Andrew did not initiate the discussion; to talk about male socialization when Andrew was unable to comprehend the abstractness of masculine culture, and to explain his emotional reticence as potentially threatening to his masculinity, to name a few. In each incident, the author focused on cultural issues even though Andrew wanted to talk about other things such as sports or television. While clients can use obtuse topics to avoid talking about themselves, the challenge in the session to be focused on Andrew sometimes became a struggle because the counselor wanted to focus on cultural explanations for Andrew. Thus, it is important for the counselor to use information from the client to guide decision making regarding incorporating cultural issues in the treatment process.
EXAMINE THE POTENTIAL LIST OF TREATMENTS AND UNDERSTAND THE CULTURAL ASSUMPTIONS OF EACH
One potential source for treatment planning is manualized therapies, or empirically validated treatments (EVT). However, what initially seemed to be a formalized treatment method has been critiqued with comments indicating it was not culturally relevant (Clay, Mordhorst, & Lehn, in press; Jensen, Hoagwood, & Petti, 1996). In a review of empirically validated treatments within pediatric psychology, Clay et al.'s (in press) study revealed that, of the 71 studies used to support current empirically validated treatments, only 27% of the studies reported any race/ethnicity data, only 18% reported any socioeconomic data, and only 6% discussed culture as a potentially moderating variable. Consequently, the current EVT available for adolescents and children have some limitations and use of these treatments must be done cautiously. It is important for counselors to identify potentially beneficial treatments such as EVTs, and then to evaluate the cultural assumptions of each to determine which is most appropriate for the client based on his or her unique situation. For example, treatments that use social networks (i.e., family therapy or group therapy) may be more appropriate for people from cultures that value social networks. Conversely, individual therapy that focuses on acquiring skills to meet individual needs may not be appropriate for clients from collectivist cultures since these may sometimes conflict with the values of the group and family.
IMPLEMENT THE TREATMENT USING THE CULTURAL STRENGTHS
As noted earlier, one of the salient cultures for Andrew was not his race or ethnicity, but being a boy. Being able to discuss with Andrew his behaviors and attitudes as an 11-year-old boy was important. For instance, knowing the field positions for a soccer team in order to have a conversation with him was salient; knowing about Pokemon was essential; understanding the normalcy of his ambivalent feelings about "girls" was helpful; and seeing his occasional use of derogatory language (e.g., "fag") as a point of learning for Andrew rather than punishment was critical. For the counselor to develop cultural competency, to build rapport, and to establish a relationship with Andrew meant watching MTV, viewing professional wrestling, and enjoying afternoon cartoons. By learning Andrew's culture, we were able to bond so that we could work on his occasional behavioral problems and emotional challenges. As a positive side effect, Andrew looked forward to his therapy sessions and started to arrive early to get the full hour. It is also worth noting that since Andrew's Chinese heritage was not a salient factor for him, issues regarding his Chinese heritage were ultimately not included in his treatment.
Other aspects of Andrew's treatment revolved around three foci. First, Andrew was involved in group therapy among other boys in his age group. The group therapy met once a week for 90 minutes and focused on his ability to work in small groups, to transition from activity to activity, to take responsibility, and to carry on a long-term group project (e.g., such as building a model city). The second aspect of his therapy was individual counseling. Both the group and individual therapy were focused on psychosocial development and behavior modification, understanding and expressing his feelings, understanding his relationship with his parents, death and mourning, and his impact upon other people. Finally, the third feature of his therapy was to work with the family doctor who prescribed medication for his bed-wetting. In combination with some behavioral therapy, Andrew was able to decrease the frequency of his bed-wetting episodes.
Andrew's case represents a situation wherein the most obvious cultural issues were not the most relevant. Instead, the dimension of "boyhood" represents a salient gender culture that may be overlooked if counselors take a limited approach to multiculturalism. Moreover, with a case such as Andrew, counselors may approach therapy with different lenses and agendas, and may not view or value Andrew's culture in a similar way. In this case, because the therapist was transferred and Andrew continued treatment, it was imperative that future clinicians be informed as to how culture fit into Andrew's treatment plan. Hence, when conferring with colleagues, counselors should be aware to include salient cultural information along with the standard case history such as cultural reference group(s), language, involvement with culture of origin and host culture, cultural elements of the counselor-client relationship, and how culture was used and integrated into therapy (Johnson-Powell, 1997). Cultural highlights can be communicated either by the case-notes, or in a referral summary.
SUMMARY AND CONCLUSIONS
This case example represents a complex array of cultural and clinical issues that counselors typically encounter in therapy. Rarely will counselors work with clients who present with only one salient identity or culture, so it is imperative that therapists understand the various cultures within which clients may live. Because cultural and clinical issues interact, clinicians may sometimes feel overwhelmed. However, multicultural competencies were not meant to constrain but rather to facilitate therapist work with diverse people.
In order to work with the multiple cultural and clinical concerns such as Andrew's, we have provided a way to integrate culture into treatment. We encourage counselors to be aware of the boundaries of their own biases and worldviews before working with diverse clients.
Consider the various ways culture impacts Andrew. In this case, recognition that masculinity seemed to be most prominent feature of therapy allowed the therapist to work with Andrew in a manner that was congruent with his current worldview, which was not related to his Chinese heritage as one might predict initially. Yet this therapy approach also came from several therapy mistakes and failures, and the authors encourage counselors to work closely with qualified supervisors and colleagues when working with new competencies. The five steps described here can help guide the counselor in providing multiculturally competent counseling services to a diverse child clientele.
Barnett, D. W., Collins, R., Coulter, C., Curtis, M. J., Ehrhardt, K., Glaser, A., Reyes, C., Stollar, S., & Winston, M. (1995). Ethnic validity and school psychology: Concepts and practices associated with cross-cultural professional competence. Journal of School Psychology, 33, 219-234.
Canino, I. A., & Spurlock, J. (2000). Culturally diverse children and adolescents: Assessment, diagnosis, and treatment (2nd ed.). New York: Guilford.
Clay, D. L., Mordhorst, M. J., & Lehn, L. (in press). Empirically supported treatments in pediatric psychology: Where is the diversity? Journal of Pediatric Psychology.
Coleman, H. L. K., Casali, S. B., & Wampold, B. E. (2001). Adolescent strategies for coping with cultural diversity. Journal of Counseling and Development, 79, 356-364.
Donovan, C. L., & Spence, S. H. (2000). Prevention of childhood anxiety disorders. Clinical Psychology Review, 20, 509-531.
Jensen, P. S., Hoagwood, K., & Petti, T. (1996). Outcomes of mental health care for children and adolescents: II. Literature review and application of a comprehensive model. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1064-1077.
Johnson-Powell, G. (1997). The culturologic interview: Cultural, social, and linguistic issues in the assessment and treatment of children. In G. Johnson-Powell & J. Yamamoto (Eds.), Transcultural child development: Psychological assessment and treatment (pp. 349-364). New York: John Wiley.
Kann, R. T, & Hanna, F. J. (2000). Disruptive behavior disorders in children and adolescents: How do girls differ from boys? Journal of Counseling and Development, 78, 267-274.
Kaczmarek, P. G., & Wagner, W. G. (1994). Future training requirements for counseling psychologists: Competence with children. The Counseling Psychologist, 22, 426-443.
Knox, M., King, C., Hanna, G. L., Logan, D., & Ghaziuddin, N. (2000). Aggressive behavior in clinically depressed adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 611-618.
LaFromboise, T., Coleman, H. L. K., & Gerton, J. (1993). Psychological impact of biculturalism: Evidence and theory. Psychological Bulletin, 114, 395-412.
Lung, A. Y., & Sue, S. (1997). Chinese American children. In G. Johnson-Powell & J. Yamamoto (Eds.), Transcultural child development: Psychological assessment and treatment (pp. 208-236). New York: John Wiley.
Malmquist, C. P. (1985). Handbook of adolescence: Psychopathology, antisocial development, psychotherapy. New York: Jason Aronson.
Mooney, T. F. (1998). Cognitive behavior therapy for men. In W. S. Pollack & R. F. Levant (Eds.), New psychotherapy for men (pp. 57-82). New York: John Wiley.
Pollack, W. S. (1998a). The trauma of Oedipus: Toward a new psychoanalytic psychotherapy for men. In W. S. Pollack & R. F. Levant (Eds.), New psychotherapy for men (pp. 13-34). New York: John Wiley.
Pollack, W. S. (1998b). Mourning, melancholia, and masculinity: Recognizing and treating depression in men. In W. S. Pollack & R. F. Levant (Eds.), New psychotherapy for men (pp. 147-166). New York: John Wiley.
Pollack, W. S., & Levant, R. E (1998). Introduction: Treating men in the 21st century. In W. S. Pollack & R. E Levant (Eds.), New psychotherapy for men (pp. 1-12). New York: John Wiley.
Sherraden, M. S., & Segal, U. A. (1996). Multicultural issues in child welfare. Children and Youth Services Review, 18, 497-504.
Spence, S. H. (1997). Structure of anxiety symptoms in children: A confirmatory factor-analytic study. Journal of Abnormal Psychology, 106, 280-297.
Stone, G. L. (1997). Multiculturalism as a context for supervision. In D. B. Pope-Davis, & H. L. K. Coleman (Eds.), Multicultural counseling competencies: Assessment, education and training, and supervision (pp. 263-289). Thousand Oaks, CA: Sage.
Sue, D. W., Arredondo, E, & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling and Development, 70, 477-486.
Sue, D. W., Ivey, A. E., & Pedersen, E B. (1996). A theory of multicultural counseling and therapy. Pacific Grove, CA: Brooks/Cole.
U.S. Census Bureau. (2001). Population profile of the United States: America at the close of the 20th century (Department of Commerce, Economics and Statistical Division Publication No. P23-205). Washington, DC: U.S. Government Printing Office.
Wagner, W. G. (1996). Optimal development in adolescents: What is it and how can it be encouraged? The Counseling Psychologist, 24, 360-399.
Yeh, C. J., & Hwang, M. Y. (2000). Interdependence in ethnic identity and self: Implications for theory and practice. Journal of Counseling and Development, 78, 420-429.
William M. Liu, Ph.D., is an assistant professor and Daniel Clay, Ph.D., is an associate professor. Both are faculty members in the counseling psychology program at the University of Iowa, Division of Psychological and Quantitative Foundations, Iowa City. Email WilliamLiu@uiowa.edu and Daniel-Clay@uiowa.edu.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Counseling Adolescents|
|Author:||Clay, Daniel L.|
|Publication:||Journal of Mental Health Counseling|
|Date:||Apr 1, 2002|
|Previous Article:||Passing notes: the use of therapeutic letter writing in counseling adolescents.|
|Next Article:||The JMHC news: changes and stability. (Editorials).|