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ACA 2016 - Difficult Dialogues: A Cultural Humility Approach to Broaching Cultural Issues


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A presentation at ACA 2016 in Montreal on broaching difference in counseling work

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ACA 2016 - Difficult Dialogues: A Cultural Humility Approach to Broaching Cultural Issues

  1. 1. Difficult Dialogues: A Cultural Humility Approach to Broaching Cultural Issues Steve Schoser, LPCC • Dr. Sheila Addison, LMFT • Presented at ACA 2016, Montreal, QC, Canada
  2. 2. Learning Objectives Attendees will be able to: 1.Describe the difference between cultural competence and cultural humility as approaches to counseling work 2.Articulate professional and clinical rationales for broaching cultural issues during counseling 3.Generate examples of how to broach cultural issues during counseling sessions
  3. 3. ACA Social Justice Advocacy Competencies:  Client empowerment  Client advocacy  Community collaboration  Systems advocacy  Public information  Social & political advocacy
  4. 4. 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)
  5. 5. Cultural humility model  Competetency implies:  Collecting knowledge  Mastering skills  Producing a particular outcome that can be evaluated
  6. 6. Cultural humility model  Danger: The “cultural zoo” or “tourist” model of diversity
  7. 7. 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
  8. 8. 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”
  9. 9. 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)
  10. 10. 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
  11. 11. Not-knowing?  Not the same as being ignorant or lost
  12. 12. Cultural humility model  Manifests in an ability to express respect and take a one-down stance, even when difference threatens the therapeutic alliance
  13. 13. Cultural humility model
  14. 14. Cultural humility model
  15. 15. 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
  16. 16. Broaching cultural issues Day-Vines et al., 2007
  17. 17. 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
  18. 18. The interpersonal processes that govern the counselor-client relationship.  Cultural differences and misunderstandings between the counselor and client have the potential to create an unhealthy power dynamic within the counseling dyad Intra-counseling Dimensions
  19. 19. Every counseling relationship contains some kind of cross-cultural dimension!  Race  Gender  Age  SES Intra-counseling Dimensions
  20. 20. We may not see how the difference impacts the relationship. But clients do. Intra-counseling Dimensions
  21. 21.  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
  22. 22.  Broaching Example: "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
  23. 23. 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
  24. 24. 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?
  25. 25. Sample Broaching Statement: "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) Intra-individual Dimensions
  26. 26. Intra-Group Dimensions Intra-Racial, -Ethnic, -Religious, etc.  Sociocultural or within group issues that may arise between the client and people with whom he or she shares a common heritage.  Beliefs, value orientations, and behaviors that are at odds with values and viewpoints sanctioned by their cultural group
  27. 27. Intra-Group Dimensions  Examples:  LGBTQ people of color  Bi-cultural socialization  Second, third, etc. generation immigrants – assimilation vs. cultural fidelity  Transgressing cultural pride/shame issues (McGoldrick et al.)
  28. 28. Intra-Group Dimensions  Sample Broaching Statement: Marisol, it almost sounds like you are feeling rejected by your friends as “not Latina enough,” since you don’t speak Spanish. Is that your sense of what is going on?
  29. 29. Inter-Racial, -Cultural, etc.  Client is managing cultural differences between her- or himself and people from at least one other cultural group  Includes efforts to help the client negotiate the sociopolitical dynamics of discrimination, oppression, and powerlessness (social justice advocacy competencies) Inter-Group Dimensions
  30. 30.  Sample Broaching Statement: What has it been like for you as a gay Latino man to work in an organization that is hostile to sexual minorities? Inter-Group Dimensions
  31. 31.  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
  32. 32.  As clients take the risk of talking about about intra-individual, intra-group, and inter-groupl experiences of privilege and oppression, it’s critical to go back to the intra-counseling dimension and check in Intra-Counseling (again?)
  33. 33.  Sample Broaching Statement: Today we’ve been talking about your sense that many of your coworkers are prejudiced. How has it been for you to share experiences of discrimination with a White therapist who hasn’t had those kinds of experiences? Intra-Counseling (again?)
  34. 34. 34  Rationales  Demographic shifts in population  Homogeneity of counseling force  Negative perceptions from minorities  Ethical responsibility  Counseling competencies Why broach?
  35. 35.  Research indicates that cultural misunderstanding contributes to premature termination among clients from culturally and linguistically diverse backgrounds.  30% of clients prematurely terminate. But 50% of minority clients prematurely terminate.  What could explain this? Why broach?
  36. 36. Damage of micro-aggressions Damage of silence about cultural factors Minorities prematurely terminate?
  37. 37.  Brief, commonplace, daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults toward people of marginalized identities Microaggressions
  38. 38. Microaggressions from counselors - 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”
  39. 39. Microaggressions from counselors - 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!”
  40. 40. Microaggressions in counseling  Distrust  Confusion  Frustration  Anger  Depression  RAGE  Then we diagnose them as “treatment resistant.”
  41. 41. Silence about culture  When clients of color perceive that counselors lacked the capacity to broach racial, ethnic, and cultural concerns, clients opt to meet their needs outside the counseling relationship within the safety and familiarity of friends and family members (Pope-Davis et al., 2002).
  42. 42. Silence about culture  “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  “Healthy paranoia”  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
  43. 43. Silence about culture  But silence about these experiences is a contributor to minority stress  Silencing the self protects those in the majority  Ssilence also leads to RAGE  “Part of the task of the subjugated is to give voice to one’s experiences” – Ken Hardy
  44. 44. 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
  45. 45. Effects of broaching Establishing rapport Establishing counselor credibility Acknowledging that difference may be an influence on the relationship
  46. 46. Effects of broaching Giving permission to the client to comment on their experience of difference in the room Giving permission to the client to discuss the effects of outside cultural forces
  47. 47.  Enhances  Counselor credibility  Client satisfaction  Depth of client disclosure  Clients’ willingness to return for follow-up sessions (D. Sue & Sundberg, 1996) Effects of broaching
  48. 48.  Clients want to feel understood  White counselors who addressed racial and cultural factors were deemed more credible than those who ignored racial and cultural factors (Zhang & Burkard, 2008). Effects of broaching
  49. 49.  Due to counseling power dynamics, avoiding the client’s cultural context may prevent the client from addressing pertinent counseling concerns  Loss of counselor credibility  Client accommodates the counselor’s inability to broach  Client censors their own thoughts Failure to broach
  50. 50.  Client educates counselor in ways that detract from the counseling process  Client dissatisfaction  Premature termination Failure to broach
  51. 51. 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”
  52. 52. Salience of culture  Broaching behavior involves selective attention to cultural factors that may impact the client’s sociopolitical experience  Yes, we see what we look for  But looking for cultural “clues” is part of our job!
  53. 53. Salience of culture  We have an obligation to make sure we don’t screen out clues about the salience of culture because it is comfortable for us to do so  “I do not believe that every issue is related to culture and identity, but recognize that when presenting problems do have cultural connections, the counselor has an obligation to acknowledge these factors in a meaningful and substantive manner. I also recognize that 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
  54. 54. Salience of culture  We’re taught to screen out information about difference  Being “colorblind”  Looking for explanations other than race  Laughing at sexist or racist “jokes”  Expecting people to “pass” as part of the majority culture (“keep it to themselves,” “not shove it in our faces,” etc.)  “We’re all the same under the skin”
  55. 55.  “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
  56. 56.  “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
  57. 57.  Issues of difference may not impact every presenting concern, but the counselor has an obligation to consider the extent to which culture does serve as a context for the client’s concerns.  The counselor’s broaching behavior serves as an assessment tool. Broaching as assessment
  58. 58. 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
  59. 59. Willingness to broach  Depends on:  Our clinical imagination and empathy!  Our willingness to directly address these dynamics, knowing they will then become visible in the therapy room  Our willingness to consider how the counseling relationship might suffer if these factors are NOT addressed overtly.
  60. 60. Counselor reasons for not broaching  “Good counseling is good counseling.”  “Blaming everything on race or gender is just the client's effort to avoid taking responsibility for his or her actions.”  “I am not sure that broaching is an effective counseling strategy.”  “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.”
  61. 61. 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!)
  62. 62. Social justice-informed counselor responses  “I generally bring up identity and oppression every so often throughout my counseling sessions with clients”  “I want to know what my minority clients have experienced in terms of racism and discrimination.”  “I try to make it safe for clients to talk about cultural factors in their lives.”  “As a counselor, I want to do whatever it takes, socially and politically, to eradicate all forms of oppression.”  “Disagreeing with discrimination isn’t enough. We have to change the system, even if it’s at our own expense sometimes.”  “I’m willing to go to bat for a client who experienced racism or sexism at my agency.”
  63. 63. Broaching in practice
  64. 64. 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
  65. 65. Broaching in practice  Client: 42-year-old White woman, unmarried, bisexual, no children  Problem: Presenting with concerns about having children late in life
  66. 66. Broaching in practice  Same client as #1  Anxiety is specifically about sexual performance
  67. 67. Broaching, or Micro-aggressions?  Counselor trainee conducts a broaching interviewee with her best friend. The trainee is Caucasian female and the interviewee is a person of color. In an effort to address Intra-Counseling Dimensions, the interviewee says:  “I’m a White woman and you’re a Hispanic girl.”  Counselor trainee conducts a 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?”
  68. 68. Practice  How do you identify your  Gender  Race  Ethnicity/geography  Age  SES/Class  Education level  Dis/ability or health status  Religion/spirituality  Body shape/size  Education level  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”
  69. 69. 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 probably can’t fullly understand what it’s like for you as ____”  “…we probably have a lot of differences in terms of _____”  “…there’s probably a lot of things I don’t get about ____”  “… we probably have a lot of differences in terms of ____ that are important too.”
  70. 70. Guided practice  Gabe is a 16-year-old African-American male. He was referred to the School Linked Services Program by his mother due to what she feels is his inability to open up and truly express his thoughts and feelings.  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.
  71. 71. 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 counseling?  If you could do things over again, how might you broach cultural issues with Gabe and his mother?
  72. 72. 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 sociopolitical basis of the client's concerns  Generates broaching statements & questions from observations for effective clinical dialogue  Engages in multicultural case conceptualization
  73. 73. 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
  74. 74. Steve Schoser, LPCC • Dr. Sheila Addison, LMFT •