Difficult Dialogues: A Cultural Humility Approach to Broaching Cultural Issues (AAMFT 2016)

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A presentation on developing the skills to address multicultural issues and improve cultural competence for therapists. Presented at AAMFT 2016.

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  • So you get images like climbing levels, checking boxes, and becoming “superior”
  • “And over here we have gay men, who are all going to the club and swapping partners.”
    “Beyond them, you’ll see the Irish families, all praying the rosary.”
  • Pretty much the opposite of the “cultural tourism” model of “multicultural competency” which encourages, in worst cases, a kind of “keyword mentality” – Asians are collectivist, concerned with family honor and somatisize a lot; African Americans practice kinship parenting and are suspicious of institutions due to racism; Latinos practice essentialist gender roles and something called “machismo & marianismo”, etc.
  • The “not-knowing” state that Harlene Anderson & Harold Goolishian (Collaborative therapy or CLS) talk about – also adopted by Tom Andersen, Lynn Hoffman, Michael White, David Epston, Insoo Kim Berg, Steve deShazer
  • Some folks say “I don’t want to read the file before I see the client the first time – I don’t want to form any pre-judgments.”
    A not-knowing stance, when well-cultivated, means you can read the file, and still be open and curious – how did these stories about the client – these diagnoses, these incidents, etc. – come to be? What else is there to the story? What can this client tell me about his or her situation that I can’t possibly know from the file?
    We form instant judgments & assumptions the moment we register race, gender, age, body size, grooming, clothing, posture, mannerisms, accent – the cultural competence model may steer us into making “adjustments” before we even know whether they’re needed or appropriate, while the cultural humility model says “stay open, learn more, ask good questions.” - from Joan Laird writing about “learning about how to learn about culture” (“Tell me about your culture” is not a “good question.”)
  • When we feel like the alliance is threatened, it’s natural to get anxious. But that can result in us driving a tank through the counseling process – smashing through the clients’ concerns to get them onto a topic where we feel more confident we can “help” – or clumsily informing the client of how sensitive and aware and informed and open we are.
    Cultural humility lets us stay present and say “wow, tell me more about that,” even when what the client is saying is “you don’t get this because ____.”
  • Maybe we should release a counseling textbook with this title.
  • As an MFT, I’m trying to balance this all the time. I have to be willing to ask.
    The failure mode of confidence is arrogance; the failure mode of humility is self-deprecation.
  • Remember our not-knowing stance as we look at building this skill!
  • Day-Vines and her colleagues initially explored broaching largely in terms of race, ethnicity, and culture, because race is such a powerful organizing principle in U.S. culture.
    However the concept of broaching applies equally powerfully to gender, sexual identity, gender identity, age, class, disability, and other contextual factors that are influenced by privilege & oppression.
    We also use the term “culture” or “context” to refer to the more over-arching concept that we might also call “background” or “identity.”
    Within the context of broaching, the therapist should aim to understand the client in a cultural context, and translate cultural knowledge into meaningful practice.
  • Norma Day-Vines
    Notice that Alan is the one being sat on.
    Day-Vines starts with Intra-Counseling, but we’ll start with Intra-Individual
  • The client’s internal experience of their own identities.
    This is often a very familiar, beloved elephant for clients – their lived experience goes back their whole life.
    This is the one most multiculturally-educated counselors feel comfortable with, at least with some practice. This is the relatively safe zone because it doesn’t implicate us directly, and although we can get tangled up in language or get an unexpected reaction, over time, we can settle into a style that is fairly smooth without too much anxiety.
  • Not all of these are equally easy, though – some are more awkward than others.
    Think, pair, share: Which of these would be harder for you to ask about?
    SES, disability, and body size are often hard in addition to race, because we’re not supposed to notice or talk about them.
  • How’s this statement? What would be better?
    I’d say: Good in general, but it still puts the client on the spot. What if the answer is “no”?
  • Don’t: Working with a Latino person – “So I’m guessing your family is Catholic?”
    Do: “How does your family identify in terms of race or culture?”
    Do: “Do you have a label you prefer to describe your sexuality?” or “What words do you use for your body size?”
    I had to train myself out of asking same-sex couples “are you married” when I was first working b/c some found it painful. Then I had to re-train myself to ask something like “is marriage an option you want to pursue?” Now I can just ask everyone if they’re married or co-habiting. And then ask “are you interested in marriage?”
    I work with a lot of people in CNM relationships – I make sure to ask things like “is there anyone else significant in the picture?” and “what are your agreements about monogamy or otherwise?”
  • As with intra-individual dimensions, this is something that more multiculturally-confident counselors may feel OK addressing… if they can spot the intersectional elephant.
  • See “pride/shame issues” per McGoldrick et al in “Ethnicity and Family Therapy.”
    The elephant may not look the way we expect, especially if we’ve been accustomed to the “cultural tourist” model of diversity that can lead to stereotyping.
    Sometimes, clients drop clues to these dynamics that we have to pick up on – e.g. “she just has issues with me.” Sometimes there is a strong taboo against sharing your group’s “business” with outsiders.
    Sometimes, they don’t necessarily identify the intra-group conflict themselves and we have to make an educated guess (meaning we have to be educated enough to develop informed hypotheses!)
  • How is this broaching statement?
  • How is this broaching statement?
  • Pathologizing – e.g. “I guess it must have been hard coming out as transgender in a Chinese family.”
  • This is a dimension that multiculturally-aware MFTs may want to help with, but they can devolve into problem-solving. Advice from “well-meaning” outsiders may not be very welcomed.
  • How’s this statement? What would you say?
  • How’s this statement? What would you say?
  • Imagine if the gay Latino male client from an earlier slide came to us and we explored his “black and white thinking” or his “persecution complex” that we see as being part of “a pattern of self-sabotage,” and prescribed him some thought-stopping exercises to do whenever he got angry, plus some yoga for self care?
  • This is the conversation most MFTs fear, and screw up out of anxiety, or just avoid all together.
  • This is from an article about addressing difference.
    What do you think about this example? Ask audience.
    Puts the client on the spot and asks them to take care of the counselor.
    My “let me know if I’m getting too white on you” conversation.
    Janie’s example – “difference matters.”
  • My “let me know if I’m getting too white on you” conversation.
    Janie’s example – “difference matters.”
  • “I know how that kind of comment might feel to me as a woman, but I’m wondering how it hit you.”
    “What was it like for you coming out to your family?” – even if you did it yourself
    I broach gender with heterosexual couples all the time.
  • Humility is not “you’re so brave!” Humility is “I am honored.”
  • How’s this? What would you say?
  • Demographic Shifts
    30% of US population comprised of minorities
    Minorities expected to constitute majority by 2050
    Population becoming more diverse, while counseling force remains homogeneous
    Cultural differences could lead to conflict, misunderstanding, mistrust during the counseling process
    Minority groups often have negative perceptions of counseling and mental health
    Ethical Responsibility
    Therapists have an ethical obligation to deliver culturally competent services
  • We also have evidence that LGBTQ clients are less satisfied with counseling and report negative experiences with counselors whom they perceive as either unsupportive or uncomfortable with the topic of sex or gender.
  • Coined by psychiatrist Chester M. Pierce to describe his experiences around race. Derald Wing Sue ID’ed 3 types of microaggressions: Microassaults (conscious actions or slurs), Microinsults (rudeness & insensitivity in ways that demean a person’s identity), and microinvalidations (negating people’s reality or feelings)The less obvious nature of the latter two “puts people of color in a psychological bind, he asserts: While the person may feel insulted, she is not sure exactly why, and the perpetrator doesn't acknowledge that anything has happened because he is not aware he has been offensive. ‘The person of color is caught in a Catch-22: If she confronts the perpetrator, the perpetrator will deny it,’ Sue says.”
    Name some micro-aggressions you’ve experienced recently.
    Has anyone caught themselves committing a micro-aggression against someone else? (tell my story about meeting Neil deGrasse Tyson in NY, during Ferguson part I)
  • Now imagine having straw after straw, when you already feel bad, from the person you’re seeking help from.
    When we commit microaggressions against clients, they silence themselves or terminate therapy.
    “For someone who came from such a hard background, you’re really showing tremendous promise.” - someone whose parents were lawyers
    A male therapist getting the afternoon “yawns” with a female client in his office.
    “I never would have guessed you were a lesbian.”
    “You need to take some time for you, really indulge yourself” – a client who was living on food stamps, caring for her father who had been unable to find work since the recession who was off his medication and having psychotic symptoms
  • Being on the lookout for microaggressions is a healthy adaptation to living in oppressive circumstances.
    Recent news story – a woman in Pittsburgh was shot in the head in January after rejecting a man’s advances. Another woman was shot in Brooklyn just last week after telling a man grinding on her at a street festival to get off.
    Steve’s story – driving in the South as a gay couple
  • But when clients feel like they can’t talk about microaggressions they experience, in therapy or in their lives, it is unhealthy.
    E.g. – a man offends a woman colleague, and she walks around feeling terrible, holding all the stress of it, while also feeling even worse because he’s acting like nothing happened (because to him, nothing did!)
    E.g. – Randy White, in interviewing Hardy at Psychotherapy.net, talks about meeting with a Black couple whose kid was kicked out for fighting, and CPS was called because the kid said his father was using physical discipline on him. And the father was really angry, but the mother was saying “shh, tone it down, you’re in a professional office.” White met with the father alone and validated his anger and sense of unfairness, let him give voice to those feelings, and reframed the father’s harsh punishment as trying to keep his son safe. And the father softened, and was more willing to participate in the sessions, and the family was able to talk (with a white therapist) about what Dad’s fears were for his son as a black man.
  • The counselor creates a certain emotional safety so that the client can talk freely about concerns and move from a level of superficiality towards greater depth of analysis of problem situations.
    After you broach, clients feel more comfortable articulating cultural dimensions of their problems, showing increased levels of introspective awareness
  • The effect of broaching: we make friends with the elephant.
    Clinicians often fear that talking directly about cultural differences (or similarities) will undermine their credibility, but research says it’s just the opposite.
  • When we can welcome in the elephants, clients feel more trusting. (Zhang & Burkard, 2008)
  • We miss clinical opportunities. We err in our case conceptualizations. We create inaccurate treatment plans. Clients silently tolerate our lack of understanding, feeling that it’s not safe to correct us.
    “I worked with my therapist for 3 years and never told her I was a lesbian.”
  • Clients drop out when we can’t broach these topics.
    It’s great when clients correct us, but if you can’t broach the topic of culture to begin with, how are you going to handle being called out for your lack of cultural sensitivity? It’s more common for therapists to start to struggle with the client over whether or not they “understand,” or to get wrapped up in shame and over-apologizing which doesn’t make the client feel secure.
  • Wait, what was that image from two slides ago?
    Clients self-censor!
  • Among many counselors who are uncomfortable with cultural factors and who lack cultural understanding, there may be a tendency to circumvent issues of race and representation.
    If these issues are salient for the client but inconsequential to the counselor, the counselor may neglect to attend to the prominent features in clients’ lives.
    We don’t take clients’ descriptions of their families at face value; why would we exclude culture and power from the things we look for “beneath the surface”?
  • “Who benefits?”
    Often, it’s us. KVH taught me: when I’m tempted to say “the client isn’t ready” or “the client can’t handle it,” check to see whom I’m really protecting. Often, it’s ME.
  • This is called “selective inattention.” It’s actually a real psychological phenomenon. (Gorilla in the basketball game video?)
    It’s the model taught to most white people by their families and the culture at large. It’s also an attitude that is strongly correlated with subconscious racial bias.
    If you’re a woman: are you ever NOT thinking about whether there are any men around when you’re walking to your car or waiting for the bus late at night? See: “Healthy paranoia.”
    Difference, and particularly difference related to power is almost ALWAYS salient.
  • A client may not come to counseling because they are Latina, but being Latina may impact the problem they bring in.
    For instance, a Latina business manager seeks counseling services for job related stress. During the context of counseling she may notice that clerical support personnel take care of her Caucasian colleagues insofar as booking appointments, scheduling travel arrangements, coordinating materials for meetings, etc. However, she has noticed that she does not receive the same consideration. The presenting problem is stress related, but racial factors may compound some of those stressful experiences.
    An effective counselor would examine the problem situation with the client and develop an action plan that would permit the manager to address this problem and explore possible options in a pro-social and pro-social manner. The generation of solutions may include an effort to ask the clerical staff to perform similar duties for her, document instances of perceived injustices, identify ways to enlist more support from her peers around her concerns, lobby for standardization of the job description for clerical support personnel, suggest cultural competence training, etc. Afterward the counselor and client may analyze the most appropriate resolution. But you can’t do that if you don’t talk about race!
  • it’s like the waitress asking if you want ketchup or mustard - if it’s not an issue, leave it alone. (Though they may want it again later!)
    But it’s an assessment of where they think the problem lies, and also how comfortable the client is with talking about identity and difference, in terms of how they react
     
  • You don’t have to agree philosophically with these ideas but you need to recognize that this is out there and may be helpful to the client. If you choose not to use these tools, are you really using best practices?
  • The therapists I worry most about.
  • These are counselors who know there’s a hard way, and they wish they could take the easy way.
  • And you’re STILL going to screw it up. You’re STILL going to step in it. And hopefully, clients will let you know!
  • Ask for a volunteer.
    Ask about his history of education post-HS
    Be shocked that he was in the military, then condescending. “Good for you! That must have been a real achievement! You must have had to be so brave! I just love the military, even though I’ve never been in it.”
    Then broach – I’m not an expert on military culture, since I haven’t served, but guessing that may not have been easy as a gay man.
  • Ask for another volunteer.
    Broach gender – based on client’s concern about fertility
    Do it badly – “what’s it like to talk to a male counselor? I totally get where you’re coming from, and I hope you feel like you’re safe with me.”
    Do it well – “I know from my female colleagues that can be a big issue for women As a man I don’t have to worry about that so much.”
  • Broach body size
    Anxiety about sex – “performance, whether my husband is attracted to me”
    “You must have gained weight since the military, I can see how that would make you feel bad about your body.”
    “There’s so much negative imagery and stigma if your body is larger. I don’t know if that’s something that bothers you personally but it’s something I know about from clients and from my own life.”
  • What feedback would you give a supervisee or student who said these things while practicing broaching?
    Bonus: Imagine you’re a Latino, male, full professor talking to the first student, who is working class, first in her family to go to college. How might you use broaching?
    Bonus: Imagine your student is African-American. How might you use broaching?
  • Free write: What word(s) do you use for each of these? “I am a…”
    Second: Choose 4 identities that you might broach with a client
    Consider what words you might use to fill out these statements.
  • Pair up. Try out some of these beginnings and endings.
    Just try saying your beginnings and endings to your partner – regardless of their identities
    If you have a lot of anxiety, try something relatively neutral – “As a tall guy, I may not understand what it’s like for you as a shorter person.” “Although we’re both blondes, we probably have a lot of differences that are important too.”
  • Questions on the next slide. Case study is on their handout.
  • Gather into groups of 3-5 and discuss – 10 minutes? Then report back
  • Both ways have costs
  • Difficult Dialogues: A Cultural Humility Approach to Broaching Cultural Issues (AAMFT 2016)

    1. 1. Difficult Dialogues: A Cultural Humility Approach to Broaching Cultural Issues Dr. Sheila Addison, LMFT drsaddison@gmail.com Presented at AAMFT 2016, Indianapolis IN
    2. 2. Learning Objectives Attendees will be able to: 1.Describe the difference between cultural competence and cultural humility as approaches to therapy. 2.Articulate professional and clinical rationales for broaching cultural issues with clients during therapy. 3.Generate examples of when and how to broach cultural issues during therapy sessions.
    3. 3. Cultural humility model  Developed for physician training (Tervalon & Murray-Garcia, 1998)  Social work (Ortega & Coulborn Faller, 2011; Schuldberg et al., 2012)  Counseling psychology; Hook et al., 2013)
    4. 4. Cultural humility model  Competetency implies:  Collecting knowledge  Mastering skills  Producing a particular outcome that can be evaluated
    5. 5. Cultural humility model  Danger: The “cultural zoo” or “tourist” model of diversity
    6. 6. Cultural humility model  Humility: “Having a sense that one’s own knowledge is limited as to what truly is another’s culture.” (Hook et al. 2013)  Other-oriented rather than self-focused  Respect for others  Lack of superiority  Entertaining hypotheses rather than drawing conclusions
    7. 7. Cultural humility model Life-long commitment to self-evaluation & critique  Staying open to new information  Wrestling with the tendency to view one’s own beliefs, values, and worldview as superior  Willingness to hear “you don’t get it”
    8. 8. Cultural humility model Not-knowing stance  Consistent with Narrative, SFBT, Collaborative Language Systems, feminist approaches Accept you will always be naïve about others’ cultures  “Embrace the failure”(Wilchins, 2004)
    9. 9. Cultural humility model  An “antidote to or brake on feelings of superiority, frustration, and alienation” that may occur when cultural differences arise in therapy  An ability to stay open and other-oriented when clients are talking about identity in ways that raise our anxiety
    10. 10. Not-knowing?  Not the same as being ignorant or lost
    11. 11. Cultural humility model  Manifests in an ability to express respect and take a one-down stance, even when difference threatens the therapeutic alliance
    12. 12. Cultural humility model
    13. 13. Cultural humility model
    14. 14. Broaching cultural issues Day-Vines et al., 2007  Broaching: Directly addressing issues of culture and identity  That translate into dynamics of privilege and oppression  Which influence the presenting issues, the client’s history, and the counseling relationship  Humility: Reminds us that we need to ASK, not ASSUME
    15. 15. Broaching cultural issues Day-Vines et al., 2007
    16. 16. Broaching cultural issues Day-Vines et al., 2007 Multidimensional Model of Broaching Behavior  Or, “How to see the Elephant”  4 Dimensions  Intra-Counseling  Intra-Individual  Intra-Group  Inter-Group
    17. 17. Intra-individual Dimensions The client’s internal experience of their identities  Race  Ethnicity  Culture  Gender  SES  Sexual Orientation  Religious Orientation  Disability  Geographic Location  Immigration Status  Linguistic Diversity  Body size
    18. 18. Intra-individual Dimensions The client’s internal experience of their identities  Race  Ethnicity  Culture  Gender  SES  Sexual Orientation  Religious Orientation  Disability  Geographic Location  Immigration Status  Linguistic Diversity  Body size Think, pair, share: Which of these dimensions would be harder for you to broach?
    19. 19. Broaching Attempt: "Often I ask my clients about their [cultural] background because it helps me have a better understanding of who they are. Is that something you'd feel comfortable talking about?" Cardemil & Battle (2003) •What works & doesn’t? What would be better? Intra-individual Dimensions
    20. 20. Better?: “Were you raised with any particular religious or spiritual identity? How does that influence you now?” Better?: “What’s your relationship like with your body size? How does that influence this situation, do you think?” •What works & doesn’t? What would be better? Intra-individual Dimensions
    21. 21.  Don’t ask questions laden with assumptions Do use open-ended, neutral questions Do use a curious, not-knowing approach (humility) Do learn enough to ask good questions (and keep learning) Intra-individual Dimensions
    22. 22. Intra-Group Dimensions Intra-Racial, -Ethnic, -Religious, etc.  Within-group issues between the client and people with whom they share culture  Family of origin  Community  In-group  Beliefs, values, identities,& behaviors that are at odds with values and viewpoints sanctioned by their cultural group
    23. 23. Intra-Group Dimensions  Examples:  LGBTQ people of color  Bi-racial/cultural people  2nd , 3rd , etc. generation immigrants – assimilation vs. cultural fidelity  People who transgress cultural pride/shame issues (McGoldrick et al.)
    24. 24. Intra-Group Dimensions  Broaching attempt: “What’s it been like for you to navigate being both Chinese- American and transgender? ” • What works & doesn’t? What would be better?
    25. 25. Intra-Group Dimensions  Broaching attempt: “Marisol, it almost sounds like it’s an issue for your college friends that you don’t speak Spanish, like they think you’re ‘not Latina enough.’ Is that your sense of what’s going on?” • What works & doesn’t? What would be better?
    26. 26. Intra-Group Dimensions  Don’t jump to assumptions that pathologize parts of a client’s identity  Do use open-ended questions and “hedging” to defer to the client’s expertise and invite correction (humility)  Do use a curious, not-knowing approach  Do know enough to ask good questions
    27. 27. Inter-Racial, -Cultural -Gender, etc. Client is managing cultural differences between themselves and people from at least one other cultural group They may be negotiating the sociopolitical dynamics of discrimination, oppression, and powerlessness Inter-Group Dimensions
    28. 28.  Broaching attempt: What has it been like for you as a gay Latino man to work in a primarily White organization that isn’t welcoming to sexual minorities? • What works & doesn’t? What would be better? Inter-Group Dimensions
    29. 29.  Broaching attempt: It strikes me that as a person from a working-class background, it might be hard for you to find allies in the world of academia. What’s your experience been? • What works & doesn’t? What would be better? Inter-Group Dimensions
    30. 30.  Danger: We can “gaslight” clients out of our own unresolved racial and cultural anxieties  “Maybe there’s another explanation”  We may try to to help clients “adjust” to oppressive conditions  Making themselves less visible, less outspoken about micro- aggressions & systemic oppression  We may try to teach them to “cope” rather than to explore advocacy for themselves and their communities Inter-Group Dimensions
    31. 31. The interpersonal processes that govern the therapist-client relationship.  Cultural differences and misunderstandings between the therapist and client have the potential to add to the potential for unhealthy power dynamic in therapy Intra-counseling Dimensions
    32. 32. Every clinical relationship contains some kind of cross-cultural dimension! (just like every couple does)  Race  Gender  Age  SES Intra-counseling Dimensions
    33. 33. We may not see how the difference impacts the relationship. But clients do. Intra-counseling Dimensions
    34. 34.  Broaching Attempt: "I know that this can sometimes be a difficult topic to discuss, but I was wondering how you feel about working with someone who is from a different racial/ethnic background? I ask because although it is certainly my goal to be as helpful to you as I possibly can, I also know that there may be times when I cannot fully appreciate your experiences. I want you to know that I am always open to talking about the topics whenever they are relevant." (Cardemil & Battle, 2003) Intra-counseling Dimensions
    35. 35.  Better?: “I want to acknowledge the reality that race and gender are here in the room with us, and let you know that those are things we can talk about, even if it’s complicated.”  What works & doesn’t? What would be better? Intra-counseling Dimensions
    36. 36.  Don’t try to develop a “script.”  Don’t ask the client to validate you (even if you screw up)  Do broach intra-counseling dimensions after you’ve begun developing a rapport with the client. Joining is critical.  Do practice! With colleagues, with yourself and a tape recorder, with your partner, with your pets…. Intra-counseling Dimensions
    37. 37.  Even if our backgrounds are nearly identical, that can be a topic that needs to be broached.  Silence can be an oppressive force saying to the client: they don’t have permission to be different from you. Intra-counseling Dimensions
    38. 38.  As clients take risks:  Go back to the intra-counseling dimension and check in  Acknowledge the risks they took  Offer appreciation from a place of humility Intra-Counseling (again?)
    39. 39.  Broaching attempt: I want to acknowledge that it can be complicated and even dangerous for a person of color to talk about their experiences around race [especially with a White person]. How has this conversation been for you today?  What works & doesn’t? What would be better? Intra-Counseling (again?)
    40. 40. Rationales  Demographic shifts in population  Homogeneity of mental health force  Negative perceptions from minorities  Ethical responsibility  Part of professional competency Why broach?
    41. 41.  30% of clients prematurely terminate.  But 50% of minority clients prematurely terminate.  What could explain this?  Cultural misunderstanding contributes to premature termination, particularly among clients from culturally and linguistically diverse backgrounds. (Pope-Davis et al, 2002) Why broach?
    42. 42. Damage of micro-aggressions Damage of silence about cultural factors Why do minorities prematurely terminate?
    43. 43.  Brief, commonplace, daily  Verbal, behavioral, or environmental slights, snubs, or insults  Whether intentional or unintentional  Which communicate hostile, derogatory, or negative messages  Toward people of marginalized identities Microaggressions per D.W. Sue
    44. 44. Microaggressions from therapists - Toward clients  “I don’t think of you as a black girl, I just think of you as a successful student.”  “It must be hard for you to thrive in that environment”  “So who in your family has ever been in a gang?”  “So, do you have a boyfriend?”  “LET ME KNOW IF I TALK TOO FAST FOR YOU”  “When did your family immigrate?”  “It must take you a while to get here on the bus”
    45. 45. Microaggressions from therapists - Toward colleagues  “Ohhh you work with parents??”  “You must see a lot of low-fee clients”  “You must have experience with body image stuff”  “I just assumed that you were into video games and computers”  “I didn’t realize that you worked with straight couples!”  “Oh, not one of THOSE cases again….”  “Maybe you could do some training on diversity for us!”
    46. 46. Microaggressions in therapy  Distrust  Confusion  Frustration  Anger  Exhaustion  Silence  RAGE  Then we diagnose them as “treatment resistant.”
    47. 47. “Healthy Paranoia"  “Black Rage: Two Black Psychiatrists Reveal the Full Dimensions of the Inner Conflicts and the Desperation of Black Life in the United States”(Cobbs & Grier, 1968)  As a minority, your inability to recognize threatening situations can be dangerous  You may be in danger if you don’t think about how people will potentially react to you  “Paranoia” = adaptive
    48. 48. Silence about culture  Silence about these experiences is a contributor to minority stress  Silencing the self protects those in the majority  Silence also leads to RAGE  “Part of the task of the subjugated is to give voice to one’s experiences” – Ken Hardy
    49. 49. Silence undermines therapeutic joining  When clients of color perceive that therapists lacked the capacity to broach racial, ethnic, and cultural concerns, clients opt to meet their needs outside of therapy within the safety and familiarity of friends and family members (Pope-Davis et al., 2002).
    50. 50. Result: Minority clients leave therapy early and fail to get as much benefit.  “A counselor’s refusal to both develop and exercise multicultural counseling competence represents a potential act of malfeasance toward clients.” (D. Sue & Sundberg, 1996). Microaggressions & silence
    51. 51.  Broaching enhances:  Therapist credibility  Client satisfaction  Depth of client disclosure  Clients’ willingness to return for follow-up sessions (D. Sue & Sundberg, 1996) Effects of broaching
    52. 52. Broaching combats silence Gives permission to the client to discuss the effects of outside cultural forces (speak their truth) Gives permission to the client to comment on their experience in the room
    53. 53. Broaching combats silence Acknowledging that culture may be an influence on the therapeutic relationship makes us more credible with clients, not less. (Zhang & Burkard, 2008).
    54. 54.  White therapists who addressed racial and cultural factors were regarded more favorably by minority clients than those who ignored racial and cultural factors  Talking about race (etc.) may be uncomfortable…  But not talking about it is WORSE. Effects of broaching
    55. 55.  May prevent the client from addressing pertinent clinical concerns  Imbalance in power silences clients  Client accommodates the therapist’s inability to broach  Client censors their own thoughts  Loss of trust in the therapist & the process Failure to broach
    56. 56.  Or, client educates therapist in ways that detract from the counseling process  Power struggle  Shame & apology from therapist  Client dissatisfaction  Premature termination Failure to broach
    57. 57. Discomfort with broaching  Shows up in the language we use:  “Projecting” your issues onto the client  “Forcing” your “agenda” into counseling  “Rushing” to talk about difference before the client is “ready “Wait for the client to bring it up”
    58. 58. Discomfort with broaching  “Projecting” or following an “agenda”?  Broaching behavior involves selective attention to cultural factors  Looking for cultural “clues” is part of our job!  Just like looking for family patterns, unwritten rules, etc.  Be humble enough to acknowledge we’ll miss things if we don’t ask
    59. 59. Discomfort with broaching  We need to make sure we don’t screen out clues about culture because it makes us more comfortable  “When presenting problems do have cultural connections, [we must] acknowledge [them] in a meaningful and substantive manner.”  “Clients may not always immediately give credit to the way cultural factors are in play, or speak up about their relevance, because they are taught not to from birth.” (Day-Vines) “Cui Bono?”
    60. 60. Discomfort with broaching  We’re taught to screen out and reject information about difference  “I don’t see color.”  “How do you know it was (sexism, etc.)?”  “We’re all the same under the skin.”  “Why are you making this an issue?”  “People shouldn’t shove their lifestyle in our faces.”
    61. 61.  “It’s really important to me to name race very early in the process…. I’ve written about the importance of the therapist being the broker of permission.”  “Permission to acknowledge and talk about race has to be given before it ever happens because the rules of race in our society is that we don’t talk about it.” Taking the initiative Dr. Kenneth V. Hardy, Drexel University, Ackerman Institute for the Family
    62. 62.  “I believe that permission granting maneuver requires some subtlety. I don’t agree with the strategy where white therapists ask clients of color, ‘How do you feel about being in therapy with me?’”  “I think there’s a greater likelihood to be a problem when it doesn’t come up than when it does come up.” Taking the initiative Dr. Kenneth V. Hardy, Drexel University, Ackerman Institute for the Family
    63. 63.  Issues of difference may not impact every presenting concern, but the therapist has an obligation to consider the extent to which culture does serve as a context for the client’s concerns.  The therapist’s broaching behavior serves as an assessment tool. Broaching as assessment
    64. 64. Broaching as assessment  “It’s my job, the way I see it, to put my views out there about it and not require an answer. It’s up to the client if they want to pick it up and go with it. But my putting it out there is not contingent on them picking it up and going with it. So it’s not like a chess game.” – Ken Hardy
    65. 65. Willingness to broach  Depends on:  Our clinical imagination and empathy  Our courage  Once you name it, you can’t pretend it doesn’t exist!  Our willingness to consider how the therapeutic relationship might suffer if these factors are NOT addressed – humility again
    66. 66. Therapist reasons for not broaching  “Good therapy is good therapy.”  “Blaming everything on race or gender is just the client avoiding taking responsibility for their actions.”  “I’m worried that the client won’t benefit from it.”  “If I say the wrong thing, I’m afraid I’ll lose the client, and it’s not worth the risk.”  “It just seems like projecting an agenda onto the client before they’re ready.”
    67. 67. Other counselor responses  “I feel really awkward when I do it.”  “Sometimes it’s hard for me to know what to say once the client begins to talk about cultural factors.”  “I was taught not to notice race.”  “I asked if the client was OK having me as a therapist and they said it was fine.”  “I brought it up!” (One time. Whew, checked off that box!)
    68. 68. Social justice-informed responses  “I try to make it safe for clients to talk about cultural factors in their lives.”  “I’d rather risk talking about difference and screwing up, than being complicit in silence.”  “I want my clients to have a place to talk about their experiences of unfairness and discrimination.”  “As an MFT, I want to do whatever it takes to eradicate all forms of oppression.”  “Disagreeing with discrimination isn’t enough. We have to change the system.”  “I’m willing to go to bat for a client who experienced discrimination at my agency.”
    69. 69. Broaching in practice
    70. 70. Broaching in practice  Client: 47-year-old White gay man, married, no children, history of service in the Navy for 4 years  Presenting with anxiety
    71. 71. Broaching in practice  Client: 43-year-old White woman, unmarried, no children  Problem: Presenting with concerns about whether she should decide to have children late in life
    72. 72. Broaching in practice  Same client as #1 – gay man, Navy vet, higher weight  Anxiety is specifically about his perception of his husband’s lack of sexual interest
    73. 73. Broaching in teaching & supervision  MFT trainee conducts a broaching interviewee with her best friend. The trainee is a White woman and the interviewee is a woman of color. In an effort to address Intra-Counseling Dimensions, the interviewee says:  “I’m a White woman and you’re a Hispanic girl.”  MFT trainee conducts a practice broaching interview with her fiancé’s co-worker, who is Korean-American. She makes an effort to open the session and states:  “Your English is really good, I can tell, so – when did your family come here?”
    74. 74. Practice  How do you identify your  Gender  Race  Ethnicity/culture  Age  SES/class  Education level  Dis/ability or health status  Religion/spirituality  Body shape/size  What words would you use with clients?  “As a ____”  “I’ve grown up in/as ______”  “As someone with a background in/from ______”  “My experience as _____”  “Coming from the perspective of ____”  “We both have ____ in common”
    75. 75. Practice  “As a ____”  “I’ve grown up in/as ______”  “As someone with a background in/from ______”  “My experience as _____”  “Coming from the perspective of ____”  “We both have ____ in common”  “… I don’t have the experience of ____”  “…I may not understand what it’s like for you as ____”  “…we probably have some differences in terms of _____”  “…there’s probably things I don’t get about ____”  “… I hope we can talk about our differences around ____.”  “… but we probably have a lot of differences that are important too.”
    76. 76. Guided practice  Gabe is a 16-year-old African-American male. He was referred to the school counselor by his mother due to what she feels is his inability to open up and truly express his thoughts and feelings; the school counselor refers the family to you.  In the past the family has interactions with the D.S.S. due to a report by a neighbor of suspected abuse.  During the intake Mother is very upfront with information and answers all questions asked. Gabe arrives to the first session with a flat affect and says very little during the session.  As sessions continue, the therapist fails to build rapport with Gabe and eventually finds that he is completely disengaged from the therapy and that he and his mother no longer wish for him to receive services.
    77. 77. Guided practice  What are the different dimensions of diversity in this case?  How do you believe these different contextual issues might affect Gabe’s reluctance to express his feelings, in general, and specifically in family therapy?  If you could do things over again, how might you broach cultural issues with Gabe and his mother?
    78. 78. Broaching’s role in treatment  Validates the client’s concerns  Empowers client  Affirms client’s competence  Accepts the feelings and meanings client attaches to problem situation  Identifies client strengths and resources  Frames discussion of the context of the client's concerns  Generates broaching statements & questions from observations for effective clinical dialogue  Engages in multicultural case conceptualization
    79. 79. There is no easy way! Don’t Acknowledge Difference  Oblivious; ignorant  Angry; resentful of having to be “PC”  Support status quo  -> Avoidance, denial Acknowledge Difference  Defensive  Guilty  Shameful  Hurt  -> Exhaustion, burn- out
    80. 80. Dr. Sheila Addison, LMFT drsaddison@gmail.com http://www.drsheilaaddison.com

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