Cultural and Contextual Variables in Clinical Practice

1. Cultural and Contextual Variables in Clinical Practice Glenn M. Callaghan, Ph.D. San José State University [PSYC 160]

2. Review of the Homework • Trull: p. 76-77 • Sue: Psychotherapeutic Services for Ethnic Minorities (article) • Davidson: Conceptual and Ethical Issues for GLB (article) • Kupers & Ross: Gender bias (”Issue 2” – chapter) • Questions? • Comments? • How does this fit in?

3. Culture and Context • Psychotherapy with Racial/Ethnic Minorities, Disabilities, and those with Disenfranchised Status • The importance of contextual variables and the sensitivity to diversity • Abilities and disabilities • Gender, minority and disenfranchised status

4. What is Culture? • What is the culture of … • the US? • California? • Northern California? • San Jose? • San Jose State University? • students in the Department of Psychology at SJSU?

5. Current Status of Treatment with Diversity • Last two decades - more interest in this area • Argument is made that “interest” or “intention” hasn’t made a difference in terms of competencies • Equivocal data on whether there are differential outcomes for different minority groups (Sue, Zane, & Young, 1994) • Social class appears not to be a variable that predicts outcome (Garfield, 1994) • Big question on matching therapist to patient on variables

6. Things to Consider about Ethnic/racial Minority Issues • Making assumptions about individuals based on group membership • Are there important cultural influences that we might miss because of our own cultural values? • Are there other groups that also should be addressed (e.g., obese people, older adults, people from rural communities)? • Where do we draw the line? • Who is not disenfranchised? • Is the assumption of differences a discriminatory or racist practice in itself?

7. Definitions • Race: “A biological classification system determined by physical characteristics (e.g., skin pigmentation, head form, nasal index, color distribution and texture of body hair) that are of genetic origin, the combination of which helps to distinguish one human subgroup from other subgroups” (Krogman, 1945)

8. Definitions • Ethnicity: “a group classification of individuals who share a unique social and cultural heritage (e.g., language, religion, customs) that is passed on from generation to generation” (Rose, 1964). • Within any race, there can be many ethnicities (Caucasian) and within any ethnicities, there can be many races (American)

9. Definitions • Culture: “the configuration of learned behavior whose components and elements are shared and transmitted by the members of a particular society” (Linton, 1945)

10. Definitions • Minority: “a group of people who, because of physical or cultural characteristics, are singled out from others in society in which they live for differential and unequal treatment, and who therefore regard themselves as objects of collective discrimination…Minority status carried with it the exclusion from full participation in the life of society” (Wirth, 1945)

11. Definitions • Majority: “In the United States, the group that holds the balance of economic and political power. Also, the group whose cultural value system is deemed by its members to be the model value system, the one to be emulated.” (Bongar & Beutler, 1995)

12. Definitions • Acculturation: “a process of attitudinal and behavioral change undergone, willingly or unwillingly, by individuals who reside in multicultural societies or who come in contact with a new culture due to colonization, invasion, or other political changes” (Marin, 1992)

13. Limitations of Theories • Factors that limit applicability of theories to racial/ethnic minority groups • Belief that problems are mostly intrapsychic • As opposed to just social • Ignoring social, political, and economic conditions and addressing “the problem” • The fact that our science historically is a science of educated white males • both research subjects and the researchers

14. Limitations of Theories • Factors that limit applicability of theories to racial/ethnic minority groups • That the goal has historically been to get people to adjust to white values and norms • That we start from the assumption that counseling is the solution for everybody • That we evaluate, treat and experience people with our own biases and stereotypes

15. Racial/Ethnic Group “Profiles” • Native Americans/American Indians • Diverse and heterogeneous group • 511 distinct federally-recognized native entities • 365 state-recognized native tribes • 200 different languages • About 1.9 million in 1990 (probably low estimate) • Increasingly urbanized - only about 24% live on reservations

16. Racial/Ethnic Group “Profiles” • Native Americans/American Indians • Serious mistreatment ever since whites got here • High levels of unemployment, malnutrition, inadequate health care, shortened life expectancy, high levels of substance abuse and suicide • Very little research on what works • Much more likely to use natural helpers and spiritual guidance than mental health services

17. Racial/Ethnic Group “Profiles” • African Americans • U.S.’s second largest racial/ethnic minority at about 12.3% • Tremendous diversity within the group, but discrimination reported throughout • Racial identity potentially very important to therapy

18. Racial/Ethnic Group “Profiles” • Hispanics/Latinos • Fastest-growing racial/ethnic group in the U.S. • Currently 12.5% of the pop (9% growth from 1990) • annual growth rate is 6.1% (probably underestimates) • Diversity within group both inter-cultural (Mexican versus Puerto Rican) and generational (first-generation versus third generation) • Within U.S., they tend to be younger, less educated, poorer, and more likely to live in an inner-city neighborhood • Often a language barrier that may make living here even more difficult

19. Racial/Ethnic Group “Profiles” • Asian-Americans/Pacific Islanders • 3.6% of US pop in 2000 • Umbrella term used to describe Japanese, Chinese, Filipinos, Koreans, Guamians, Malays, Samoans, and Southeast Asians • Third-largest racial/ethnic minority group • Very diverse group • Portrayed as “model minorities” in terms of educational and economic success

20. Racial/Ethnic Group “Profiles” • White • 79.1% of US pop in 2000 • Umbrella term used to varied backgrounds and cultural histories • Very diverse group • New census category • 2.4% respondents are multiracial • 2 or more races • What will this mean/allow us to do with these “profiles”?

21. Developing “Profiles” • Advantages • Sensitivity to issues • Cultural Sensitivity - ability to recognize issues and how different cultures bring different sets of issues to therapy • Potentially can be competent • Cultural Competence - ability to know these issues for one or more groups and be fluid in provision of services to that group • Help develop guidelines

22. Developing “Profiles” • Problems • Beware the new stereotypes, new racism • New heuristic, new prejudice • Proxy variables (stand ins) • Tend to be non-manipulable • Tend to be vague, not behaviorally specific

23. Developing “Profiles” • Problems • Examples • “Racial identity” • Acculturation • Religiosity • Geography (urban or rural) • Socio economic status (SES) • How could one manipulate these to bring about change?

24. Gender Bias • Kupers & Ross articles • Biases in diagnosing genders • Arguments for and against the DSM being biased • Not biased • should see differences, these are traits, genders are different • Biased • look at who is diagnosed more often

25. Critical Thinking Moment • How many for and against? • Does it matter? • How does history of development of DSM play in? • What could the worries be?

26. Gender Bias • Counting the Base Rates • Men • ASPD 5.8% males vs. 1.2% females • Also OCPD, soc phob, Nar PD, Intermittent Explosive, Paraphilias • Women • Maj Dep, HistrionicPD, BPD, Eating, Dependent PD, PMDD • What do these have in common? • What about Penis Envy as a trait? • What about PMS as a disorder • Late Luteal Phase Dysphoric Disorder  now Premenstrual Dysphoric Disorder

27. Critical Thinking Moment • How about for men? • Homophobia disorder • Sexual conquistador disorder • Emotionally avoidant disorder • Dependency phobia • Workaholism • Lack of parental involvement disorder • Anti-collaborative disorder, anti-collectivist disorder • Mid-life wife-drop disorder

28. Broad Considerations • Need to ask • What do we want to know? • What will most help the client? • Who is making these summaries and providing this information? • Will I be participating in a new prejudice?

29. Broad Considerations • Do not be satisfied with census categories • Do not buy into cultural sensitivity or cultural competency blindly • Try to appreciate the the complexities of the individual and the situation he or she comes from • Try to look at individual histories

30. Getting Back to the Question • The “Paul question”: "What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?" (Paul, 1969, p. 44) • The “Follette re-phrase”: “What principles, requiring what resources, applied in what context, produce the most meaningful change for a particular person?” (Follette, 2002)

31. Rethinking Context • Individual histories • How does this person experience their context? • What is it like to be this person with thisbackground having this problem? • How will I affect the interaction and ability to bring about change with my backgroundand my way of viewing the world?