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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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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 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