Chapter 11
Multicultural Issues
Juan R. Riker and Anna M. Kokotovic
Introduction
Cultural considerations are receiving increasing attention in the field of mental health, as our pluralistic
society demands that providers of mental health services be culturally sensitive as well as competent.
Therapists working with traumatized children and families must be especially attuned to cultural issues.
Cultural definitions of family and what constitute appropriate family dynamics and roles can vary widely.
Furthermore, there may be a great deal of within-group cultural variation even within a single family system,
and intergenerational issues that may need to be recognized and sensitively addressed by the therapist
(Gushue and Sciarra, 1995). Gushue and Sciarra state that the family and multicultural perspectives in
counseling and psychotherapy share the premise that no adequate understanding of a particular individual
may be attained apart from an understanding of a larger context family or culture, respectively that
shapes that person (p. 586). Thus, therapists who regularly work with children and families are in a good
position to and indeed must evaluate and address cultural issues in counseling. Furthermore, child
welfare codes in most states mandate that child protective systems incorporate cultural information when
interventions are made with families to protect children. For example, California Welfare & Institutional
Code, 1996, section 16509 states that cultural and religious childrearing practices and beliefs which differ
from general community standards shall not in themselves create a need for child welfare services unless the
practices present a specific danger to the physical or emotional safety of the child (p. 150). On a national
level, the federal Indian Child Welfare Act (ICWA) dictates that tribal authorities must be involved in
decisions to remove an Indian child from a home, and that an Indian child must be placed in an Indian
home whenever possible. For a detailed discussion of cultural and legal issues, see Levesque (2000).
This chapter is intended to provide an overview of fundamental multicultural counseling issues and how they
pertain to working with families and child trauma victims. The discussion is limited to issues that transcend
specific cultural groups. For a detailed discussion of universal or transcultural approaches to multicultural
counseling, see Fukuyama (1990). In addition to competence in dealing with consumers of mental health, it
is also imperative for providers of mental health services to attend to their own cultural contexts. The first
sections deal with therapist self-awareness and client within-group variability (acculturation and racial
identity). The chapter concludes with issues pertaining to assessment, intervention and ethics. It should
be noted that culture-specific knowledge while not the focus here is important and necessary. In
counseling situations in which the mental health professional is unfamiliar with the clients (or familys)
cultural background, we recommend professional development in the form of reading, inservice training,
and consultation with other mental health professionals and indigenous healers. For detailed discussions on
referral to and consultation with traditional healers, see Lee and Armstrong (1995) and Atkinson, Thompson
and Grant (1993).
Therapist Self-Awareness
When working in a multicultural context, it is imperative to be aware of ones own frame of reference and
worldview. The term worldview is defined by Lonner and Ibrahim (1996) as how an individual sees the
world from a moral, social, ethical, and philosophical perspective. It is the source of a persons values,
beliefs, and assumptions (p. 295). Embedded in this definition is the fact that the helping professions have
their own unique biases and ways of viewing the world and other people. Furthermore, most professional
training in counseling and psychotherapy is extremely culture-bound, in that many of the assumptions that
underlie our training are distinctly Western (Fukuyama, 1990; Pedersen, 1987). The values that therapists
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bring to the counseling setting may be incongruent with those of many of the clients and families that they
serve. Pedersen (1987) has discussed some of the cultural biases of counseling: an assumption of the
universality of normality; an emphasis on individualism and independence; an expectation of openness
and psychological mindedness; and an expectation of client self-disclosure. Awareness of ones own
worldview and specific biases becomes particularly important during the assessment phase of working with
child trauma victims and their families, since behavior that is seen as deviant or abnormal may in fact be
culturally appropriate. The therapist must be attuned to the danger of re-traumatizing clients and families
by inappropriately pathologizing them. For example, avoiding eye contact, lowering the head and disclosing
very little may be a sign of respect in some cultures, but a Western-trained therapist might interpret this as
depression, avoidance or resistance.
Within-Group Differences
The subject of within-group variability has received much attention from mental health professionals.
Within-group variability results from the existence of subgroups within a larger population. For example,
the Hispanic-American population consists of individuals of Mexican, Puerto Rican, and Cuban descent,
among others. Similarly, the Asian-American population consists of people from many different and distinct
groups. Clearly, there is a great deal of variation within the major cultural groups. However, tremendous
variation also exists within each subgroup. Sevig, Highlen, and Adams (2000) recently noted the importance
of avoiding stereotyping by attending to within-group differences. For example, while some Asian
individuals may tend to avoid direct eye contact out of deference and respect, others may not. In this
section, acculturation and racial identity are considered as they relate to families and child trauma victims.
Acculturation
The term acculturation has been used to refer to the process of adaptation that a population experiences
as it comes into contact with another culture. Ethnic families and individuals in the U.S. vary greatly with
regard to acculturation level, depending on factors such as geographic location, socioeconomic status and
overall exposure to U.S. mainstream culture. For a thorough discussion of acculturation, see Casas &
Vasquez (1996). Culturally aware therapists are informed of immigration and related acculturation issues
for individual clients as well as families. For example, the needs of a client who left Mexico for economic
reasons and is well acculturated differ greatly from those of a family that fled violence in Guatemala or
Honduras and has had little contact with the dominant culture.
Acculturation level can vary significantly between generations and within a single family. For example,
parents may maintain close ties to their roots while their children are exposed to the mainstream culture
through school attendance and general exposure to outside influences (Gushue and Sciarra, 1995).
Therapists working with these families need to be skilled at recognizing and negotiating such intrafamilial
differences, since there may exist significant frustration and lack of understanding between generations.
When working with a family, therapists may find themselves having difficulty connecting with less
acculturated parents. Atkinson et al. (1993) suggested that level of acculturation should, at least in part,
dictate what role therapists take with clients and what types of interventions they employ. For example,
the roles of adviser, advocate, consultant or facilitator of indigenous support and healing systems may be
appropriate and helpful to clients and families with limited exposure to the mainstream culture. However,
these approaches may be ineffective or even offensive to a more acculturated family.
Two additional points regarding acculturation are worth noting. First, level of acculturation can play a role
in an individuals or familys decision to enter or leave therapy, and in the level of trust placed in the helping
professional. Less acculturated clients may be less familiar with and more distrustful of professional
mental health services. It is important for the helping professional to recognize the validity of this distrust,
as there is consensus that our mental health system has generally failed to provide culturally responsive
treatment (for example, lack of bilingual therapists and access to low-cost treatment; see Leong, Wagner, &
Tata, 1995; Levesque, 2000). The culturally responsive therapist recognizes that an initial and possibly
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extended period of trust building may be necessary before any significant therapeutic work can take place.
Second, old assimilation models of acculturation, which assumed that movement toward or identification
with one culture necessitated movement away from the other, have given way to recognition of the reality
that many individuals are bicultural and able to independently identify with more than one culture (Casas &
Pytluk, 1995). When working with children and families, it is important to note that family members often
adopt different roles outside of the home than inside (for example, speaking English at school or work and
identifying more with Anglo culture, while speaking ones native language and being more traditional at
home). It is important to accurately assess variations in behavior and not automatically pathologize or label
them as erratic.
Racial Identity Status
Another marker of within-group variability is racial identity status, which is based on the premise that people
of color are at various stages of dealing with internalized racism. Identity development models generally
assume that individuals range from non-awareness or non-identification with ones racial or ethnic group
(identification with the dominant culture) to full awareness and appreciation of self as well as others (Helms,
1995; Parham, 1989). The middle stages consist of the accumulation of information, increasing awareness of
ones oppressed status, and the denigration of the dominant culture. As with acculturation, members of the
same culture or family can vary greatly in terms of their identity status. Gushue and Sciarra (1995) suggest
that the creation of a cultural map, in which the racial identity status of each family member (as well as the
therapist) is noted, can assist in determining the types of interventions to employ with a family. These
authors emphasize the importance of attending to racial identity issues, as they bear directly on individuals
valuing of self and heritage.
Automatic assignment to a therapist of the same race or ethnicity with no attention to the racial identity
status of the therapist or the client can result in premature termination or poor outcome. Depending on
racial identity status, a client may prefer to work with a therapist from the same background, while another
may want a therapist from the mainstream culture. In one agency, a Mexican-American client was
automatically assigned to a Mexican-American therapist, while no attention was given to her level of racial
identity. Consequently, she dropped out of therapy three times. When assigned to a culturally sensitive
Anglo therapist, she was able to work on issues related to years of physical and emotional abuse as a child.
If therapists are not aware of their own level of racial identity, they may project their own worldview onto the
client and consequently be ineffective or damaging. For example, a therapist in a child abuse agency who
rejected the dominant culture and associated only with her own cultural group did not work effectively with
a parent from the same culture who identified with the dominant culture. When assigned to a culturally
sensitive therapist from the mainstream culture, the client was able to resolve her parenting issues.
Assessment, Intervention and Ethical Issues
Consideration of within-group differences (acculturation and racial identity status) is an important
component of the assessment process, in that ones relationship to a culture directly affects the way in
which problems and symptoms are perceived and reported (Suzuki & Kugler, 1995). For example, a
parent in an earlier stage of racial identity development might tend to minimize the degree to which his or
her child is subjected to racism at school. The family therapist who is able to accurately assess this dynamic
may be able to work with the parent in a more effective and compassionate way. There are clearly significant
differences between cultural groups as well and as discussed above it is important to have at least
some knowledge of the group with which one is working. For this reason, the task force recommends
professional development and consultation with appropriate professionals and culturally prescribed healers.
Furthermore, an ethical duty to refer emerges if a therapist lacks the knowledge or ability to appropriately
assess and treat an individual or family.
Culturally sensitive mental health professionals are aware that they bring their own biases and set of values
(both personal and professional) into the counseling arena. Kleinman (1988) mentions the category fallacy
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of projecting one cultures diagnostic categories onto individuals of another culture without ensuring that
those categories have validity in that culture. Trimble et al. (1996) discussed an example where a lack of
cultural awareness on the part of mental health professionals has often resulted in inappropriate diagnostic
practices. They describe a cultural time-out in which certain Sioux Indians regularly participate, where
symptoms similar to depression are typically manifested. This behavior is culturally appropriate and even
expected, but therapists outside that culture may see it as a problem due to the projection of their own
diagnostic classification system.
The category fallacy issue also applies to standardized psychological and intellectual testing. Clinicians must
be cautious when utilizing formalized assessment instruments, as many of these instruments were created
and normed by a white middle-class culture and may have little meaning or relevance for some individuals
(Suzuki & Kugler, 1995). Persons raised and educated in the United States are often afraid of taking tests.
This can be extremely intimidating, and even overwhelming, for persons from other cultures. Clients with
limited fluency in English or limited education may be unable to understand and complete even simple
paper and pencil assessments. Having assessments available in the relevant language does not solve all of
the problems. In one child abuse agency, some immigrant clients did not understand the concept of
responding to a statement using a three-point scale. Others respond in a random manner to cover their
lack of understanding of the task, or just to please the person administering the instrument. Thus, special
consideration must be given to explaining the purpose of any assessment, assisting in administration of
the assessment, and in interpreting the results in culturally sensitive manner.
The ethical guidelines that most mental health professionals adhere to were created in the context of the
majority culture and therefore are not always relevant or realistic for those who work in multicultural
settings. For example, multiple relationships are not avoidable, particularly in smaller communities in which
there is a lack of ethnic or bilingual mental health professionals (LaFromboise, Foster, & James, 1996).
Culturally sensitive therapists working to earn the trust of individuals or families may choose to participate
in functions outside of therapy. For example, a therapist might attend a graduation or award ceremony as a
way to show support and foster a trusting connection. Home visits are another example of the frequent
need for therapists to stretch themselves to meet the needs of a clientele with limited access to telephones
or transportation. When making home visits, it is important to be informed about the norms of a particular
culture. For example, there are often strict rules of hospitality, and the visitor can be interpreted as being
rude or insulting if norms are violated. In summary, role clarity and the maintenance of firm boundaries
are not always possible or even therapeutically indicated when working with a multicultural clientele.
For a thorough discussion of the limited value of multiple relationship prohibitions, see Ebert (1997).
Finally, many therapists are uncomfortable receiving gifts from clients. The culturally sensitive mental
health professional must differentiate between what is therapeutic and connecting, and what is adherence
to a set of professional dictates that may lack cultural relevance. For example, a grandmother who had
faithfully brought her three grandsons to therapy for over a year brought a gift to the director, who almost
rejected it in her desire to adhere to strict ethical guidelines. Fortunately, a culturally sensitive therapist
informed the director that it would be an insult to reject the gift.
Therapists working with child trauma victims frequently must make child abuse reports. Some families may
be distrustful of and unknowledgeable about professional mental health services; therefore, it is critical for
the therapist to take the time that is needed to ensure that clients understand the therapists mandate
regarding child abuse. As with any counseling situation, when working in a multicultural context it is
essential to begin with a clear and thorough informed consent process. Culturally sensitive therapists are
aware that they may encounter manifestations of culturally appropriate healing practices (Keitel, Kopala, &
Georgiades, 1995) and take the initiative to become informed before taking action that might alienate an
individual or family from necessary mental health services. For example, Asian cultures often employ
rubbing with warm objects for healing purposes. These practices may be effective when applied by
traditional healers who understand the entire procedure, which can be time-consuming and incorporate
other elements such as chants, songs, incense burning, and so on. This holistic approach is often lost with
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the more acculturated generations. In one county, a child was burned and the parents reported for physical
abuse. When such a report needs to be made, it is important for all investigating parties to be informed of
the cultural issues, and for the therapist to report in as clear and sensitive a manner as possible. In the case
of the burn injury, it was critical to understand that the intent had been healing, not physical punishment.
A culturally sensitive response must include education and support for both parents and the child.
Working with trauma is challenging, and the challenge becomes greater when working with culturally
different children and families. In order for mental health professionals to provide effective and appropriate
services, they must understand their own cultural contexts as well as those of the clients they serve. The
task force recommends that therapists seek self-knowledge and the recognition of their own biases and
assumptions regarding the nature of human behavior and change. While being a culturally sensitive
professional is personally and professionally demanding, there is much to gain from being open to the
rich and diverse cultural influences that continue to shape our communities.
References
Atkinson, D. R., Thompson, C. D., & Grant, S. K. (1993). A three-dimensional model for counseling racial/
ethnic minorities. The Counseling Psychologist, 21, 257277.
Casas, J. M., & Pytluk, S. D. (1995). Hispanic identity development: Implications for research and practice.
In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of Multicultural
Counseling (pp. 155180). Thousand Oaks, CA: Sage Publications.
Casas, J. M., & Vasquez, M. J. T. (1996). Counseling the Hispanic: A guiding framework for a diverse
population. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling Across
Cultures (4th ed.) (pp. 146176). Thousand Oaks, CA: Sage Publications.
Ebert, B. W. (1997). Dual-relationship prohibitions: A concept whose time never should have come.
Applied and Preventive Psychology, 6, 137156.
Fukuyama, M. A. (1990). Taking a universal approach to multicultural counseling. Counselor Education
and Supervision, 30, 617.
Gushue, G. V., & Sciarra, D. T. (1995). Culture and families: A multidimensional approach. In J. G.
Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of Multicultural Counseling
(pp. 586606). Thousand Oaks, CA: Sage
Helms, J. E. (1995). An update of Helms 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. 181198). Thousand Oaks, CA: Sage Publications.
Keitel, M. A., Kopala, M., & Georgiades, I. (1995). Multicultural health counseling. In J. G. Ponterotto, J.
M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of Multicultural Counseling (pp. 535548).
Thousand Oaks, CA: Sage Publications.
Kleinman, A. (1998). Rethinking Psychiatry. New York: The Free Press.
LaFromboise, T. D., Foster, S., & James, A. (1996). Ethics in multicultural counseling. In P. B. Pedersen, J.
G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling Across Cultures (4th ed. ) (pp. 4772).
Thousand Oaks, CA: Sage Publications.
Lee, C. C., & Armstrong, K. L. (1995). Indigenous models of mental health interventions: Lessons from
traditional healers. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook
of Multicultural Counseling (pp. 441456). Thousand Oaks, CA: Sage Publications.
Leong, F. T. Wagner, N. S., & Tata, S. P. (1995). Racial and ethnic variations in help-seeking attitudes.
In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of Multicultural
Counseling (pp. 415437). Thousand Oaks, CA: Sage Publications.
Multicultural Issues
11-5
Levesque, R. J. R. (2000). Cultural evidence, child maltreatment, and the law. Child Maltreatment, 5, 146
160.
Lonner, W. J., & Ibrahim, F. A. (1996). Appraisal and assessment in cross-cultural counseling. In P. B.
Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling Across Cultures (4th ed.)
(pp. 293322). Thousand Oaks, CA: Sage Publications.
Parham, T. A. (1989). Cycles of psychological nigresence. The Counseling Psychologist, 28, 187226
Pedersen, P. (1987). Ten frequent assumptions of cultural bias in counseling. Journal of Multicultural
Counseling and Development, 1623.
Sevig, T. D., Highlen, P. S., & Adams, E. A. (2000). Development and validation of the Self-Identity
Inventory (SII): A multicultural identity development instrument. Cultural Diversity and Ethnic Minority
Psychology, 6, 168182.
Suzuki, L. A., & Kugler, J. F. (1995). Intelligence and personality assessment: Multicultural Perspectives.
In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of Multicultural
Counseling (pp. 493515). Thousand Oaks, CA: Sage Publications.
Trimble, J. E., Fleming, C. M., Beauvais, F., & Jumper-Thurman, P. (1996). Essential cultural and social
strategies for counseling native American Indians. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, &
J. E. Trimble (Eds.), Counseling Across Culture (4th ed.) (pp. 177209). Thousand Oaks, CA: Sage
Publications.
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