Beyond Sensitivity: Integrating Culture and Context in the Psychological Care of Veterans

Beyond
Sensitivity:
Integrating Culture
and Context in the
Psychological Care of
Veterans
Presented by
Shelly P. Harrell, Ph.D.
Veteran’s Administration Health Services
November 7, 2016

We are all
AT THE SAME TIME
Like ALL others
Like SOME others
Like NO others
(paraphrased from Kluckhohn & Murray, 1953)
Copyright 2016. Shelly P. Harrell, Ph.D. All Rights
Reserved
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ALL OTHERS Our Common Humanity
SOME OTHERS Our Groups
NO OTHERS Our Unique Individuality
Copyright 2016. Shelly P. Harrell, Ph.D. All Rights Reserved 3

Attention to “Some” Others
Group Level of Analysis
Where “differences” are illuminated
Where culture lives
Where power and privilege dynamics are
manifested
Some others includes:
Like MANY others Majority Group (or In-group)
Like FEW others Minority Group (or Out-group)
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The “Some Others” Dilemma
We would rather not think too much about our differences
Focusing on differences in the context of what is “better”
CAN lead to negative interactions and outcomes
Ignoring differences can communicate invalidation or
devaluing the experience of others
The paradox: Our differences are a simultaneously a reality
we cannot afford to ignore and a myth that we must
ignore.
The challenge is to hold similarity (“all others”) and
difference (“some others”) in our hearts and minds
simultaneously, while seeing the amazing uniqueness (“no
others) of each person
5Copyright 2016. Shelly P. Harrell, Ph.D. All Rights Reserved

It is the ultimate challenge to humanity to live in
the world with our differences and the greatest
failings of humanity has been our inability to do
this.
These macro-level failings in the form of genocide,
slavery, colonialism, and oppression live in our
historical and recent collective memory and are
triggered in our micro-level relationships.
On a micro-level, how we manage “difference” shows
up in our moment-to-moment interactions with
others
All human encounters include not only
opportunities for healing but the inevitable ways
that we participate in the triggering of the pain
and shame of our human history

All human encounter is an opportunity to participate in
healing the collective damage of how difference has
been managed in our human history and the damage
that it continues to do
Each encounter confronts us simultaneously with the
human challenge of difference, otherness, and threat
of disconnection and the human need for similarity
and affirmation, visibility, and connection
 It is about the ongoing and moment-to-moment dance of
connection and disconnection
What do we do with the “some others” challenge in
our interactions our clients, our students, our
colleagues?

“Some Others” in Psychological
Theory and Research
The psychological study of culture
and context is our discipline’s
attempt to understand and manage
the “some others” challenge
Copyright 2016. Shelly P. Harrell, Ph.D. All Rights Reserved

Overview of the Day
MORNING
Multicultural Competence and Foundations of Culturally-
Competent Practice: Understanding Culture and Context
Multiple Dimensions of Diversity: Military Culture and
Intersectionality
Racism, Implicit Bias and Race-Related Stress: Implications
for health and psychological treatment
AFTERNOON
Empirically-Supported Treatments and Evidence Based
Practice for Culturally Diverse Populations
Applications: Integration of Culture and Context within a
Culturally-Syntonic, Strengths-Based perspective

First sentence of APA
Multicultural Guidelines
“All individuals exist in social,
political, historical and economic
contexts and psychologists are
increasingly called upon to
understand the influence of these
contexts on individuals’ behavior.”

APA Multicultural Guidelines
Approved as policy by the APA Council of
Representatives in 2003
Addresses multicultural competence
Professional practice
Research
Education and Training
Organizational Change
Areas for Competence Development
Cultural Awareness
Cultural Knowledge
Cultural Skills

What is Multicultural Competence (MC)
for Psychologists?
The demonstrated ability to
consistently and carefully consider
the cultural dimensions of
Self, Other, and Context,
and to engage in ethical and culturally
responsive behavior that reflects these
considerations in all professional roles
(i.e., assessment, intervention, research,
teaching, consultation, supervision,
administration).
(S.P. Harrell, 1997/2016)

Self and Other as Cultural Beings
 Self and Other emphasized in APA Professional Competencies
 INDIVIDUAL AND CULTURAL DIVERSITY (ICD) COMPETENCY AREA:
Awareness, sensitivity and skills in working professionally with diverse
individuals, groups and communities who represent various cultural
and personal background and characteristics defined broadly and
consistent with APA policy.
 Independently monitors and applies knowledge , skills, and attitudes
regarding dimensions of diversity to professional work
o Knowledge of SELF as a cultural being in assessment, treatment,
and consultation
o Knowledge of OTHERS as cultural beings in assessment,
treatment, and consultation
o Knowledge of the role of culture in INTERACTIONS in
assessment, treatment, and consultation of diverse others

“Cultural competence is the ability to engage in actions
or create conditions that maximize the optimal
development of the client and client systems.”
(Whaley & Davis, 2006, p. 564)
Culturally competent care includes
 acknowledging the importance of culture
 intentionally incorporates culture
 assessment of cross-cultural relations,
 vigilance toward the dynamics that result from cultural
differences,
 expansion of cultural knowledge, and
 adaptation of interventions to meet culturally unique needs at all
levels of service
(Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003)

The Importance of Military Culture
Military Culture Self-Assessment
http://deploymentpsych.org/self-
awareness-exercise

Would you consider a psychologist
competent to work with veterans
who had not processed most or all
of these questions?

Status of Cultural Competence
Value of considering culture outpaces behavior
What we’ve done well
 Modified explicit attitudes
 Integration into professional norms
 Identified specific competencies
Where we still need to go
 Modify implicit attitudes (Smith, Constantine, Dunn, Dinehart, &
Montoya, 2006)
 Increase Knowledge of relevant conceptual and
empirical literature MC Psych 101
 Improve Skills: Cultural adaptation and Cultural
attunement

Multicultural Psychology 101
1. Terminology (Race, Ethnicity, and Culture)
2. The “Culture” of Psychology
3. Psychological Research and Cultural Diversity
4. Dynamics of Difference
5. Racial-Ethnic Socialization and Identity
6. The Sociopolitical and Sociohistorical Context
7. Immigration, Refugee, Colonization, Genocide, and Slavery Experiences
8. Acculturation, Assimilation, Biculturation, Alienation
9. Collectivism, Communalism, and the Interdependent Self
10. Worldview and Culture
11. Indigenous Psychologies
12. Intersectionality and Ecological Niche
13. Narrative “lived experience” of Culturally Diverse Groups
14. Stereotypes, Prejudice, Discrimination and Oppression
15. Stereotype Threat research
16. Racism-related Stress: episodic life events, chronic, microaggressions, vicarious, transgenerational
17. The Physical and Mental Health Effects of Racism
18. Internalized Racism and Colorism
19. White Privilege
20. Intergroup Relations and the Dynamics of Difference
21. Liberation Psychology and the role of Social Justice in Psychotherapeutic Interventions
22. Critical Consciousness
23. Multicultural Competence
24. EBPP and Cultural Diversity
25. Culture and Theoretical Orientation
26. Culturally-Adapted and Culturally-Centered Interventions
27. Language and Psychotherapy

Cultural Competence Skills
A set of problem-solving skills that includes
(a) the ability to recognize and understand the dynamic
interplay between the heritage and adaptation
dimensions of culture in shaping human behavior;
(b) the ability to use the knowledge acquired about an
individual’s heritage and adaptational challenges to
maximize the effectiveness of assessment, diagnosis, and
treatment;
(c) internalization (i.e., incorporation into one’s clinical
problem-solving repertoire) of this process of recognition,
acquisition, and use of cultural dynamics so that it can be
routinely applied to diverse groups.
(Whaley and Davis, 2006)

A CASE ANCHOR
Identify one or two cases you
have worked with or supervised
closely within the past 5 years
where issues of race, ethnicity,
gender, or sexual orientation were
present and challenging for a
member of a non-dominant
group on that dimension of
diversity

Understanding
Culture and Context
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Culture and Context in Psychological Practice
Harrell (2016)
THERAPIST CLIENT
Individual Cultural Expressions (identity, values, and
behaviors) across Multiple Dimensions of Diversity
Historical and Current Intergroup &
Sociopolitical Dynamics
Institutional & Environmental Contexts
Culture of Psychological Theory and Practice

On Colorblindness
“Before you can read me, you’ve got to learn how to see me.”
~En Vogue, “Free Your Mind”
Colorblindness….In the service of WHAT?
 Colorblindness is important for connecting to the basic humanity of
another person and when it is in the service forming a meaningful and
strong therapeutic alliance necessary for treatment engagement and
effectiveness
 Colorblindness is problematic in the context of understanding and seeing
the wholeness of another person’s experience so that treatment can be
tailored for maximum effectiveness
Being blind to any part of a person’s experience can create
invisibility; experience of not being seen as a person but as an
object of the clinician’s prejudgments, assumptions, biases and
projections
 “Love sees ALL color.”

Costs of Culture and Context Blindness
Colorblindness is fundamentally a problem of
“missing data” that compromises our understanding
and analysis of the whole picture of a person’s life
experience and clinical presentation; Puts us at risk for
inaccurate diagnosis and less optimal treatment
 Increased likelihood of treatment disengagement
 Incomplete assessment
 Inaccurate diagnosis
 Incomplete treatment plan
 Unrefined intervention techniques that fall flat
 “Resistance” / Treatment non-compliance
 Premature Termination

Why do we engage in culture
and context blind practices?
Treasured Values of Equality and Sameness
Cognitive Strategies (Miser, Meaning-
Making)
Unquestioned Acceptance of Dominant
Stereotypes
Default to Comfort Zone

Cognitive Miser Strategies
 Term was coined by Fiske and Taylor in 1984
 Refers to the general idea that individuals frequently rely on simple
and time efficient strategies when evaluating information and making
decisions
 We assign new information to existing categories that are easy to
process mentally; these categories arise from prior information,
including schemas, scripts and other knowledge structures, that has
been stored in memory such that the storage of new information
does not require much cognitive energy.
 Results in a tendency to not stray far from established beliefs when
considering new information
 We have the capacity to be aware when we are being cognitive
misers
 Important questions
 When and under what circumstances do we rely on cognitive miser strategies?
 What is the role of values, attitudes, and motivation?

Understanding “Privilege” as a Facilitator of
Blindness
Privilege is fundamentally about what we don’t
have to be concerned with because it doesn’t
directly effect our well-being
Examples of heterosexual privilege
Clinically, this leads to
What we miss or minimize
What is seen as normal vs. “pathology”
What we see as important or unimportant
Assumptions of meanings, needs, wishes
Cultural empathy failures
Emotional responses (pity, guilt, irritation, defensiveness,
boredom, disinterest)

Integrating Culture and Context
Human behavior is multiply determined and culture is one of
those determinants
All behavior occurs in a cultural context – we see,
experience, and interpret the world through a cultural lens
Culture provides a context for making meaning of the world
and understanding one’s place in it
The inclusion of culture in the analysis of human experience,
behavior, and transformation facilitates the identification of
constructs, methods, and strategies that may enhance the
effectiveness of applied work in diverse cultural contexts

Conceptualizing Culture
Culture is a set of complex, adaptive and
interconnected human systems that:
1) provide the superordinate context in which
human experience, functioning, and
transformation occur by providing organizing
structures for interpreting and living in the world;
2) are learned, expressed, and passed along through
a vast network of shared material, social, and
ideological structures including ideas, values,
beliefs, sensibilities, social roles, language,
communication patterns, physical artifacts,
rituals, and symbols

Culture is…
The multiple organizing systems of meaning and living in the
world that
consist of patterns of being, believing, bonding, belonging,
behaving, and becoming which provide the foundational
frames for developing worldviews, interpreting reality, and
acting in the world
ofor a group of people who share common ancestry, social
location, group identity, or defining experiential contexts;
but for whom, as individuals or intersectional subgroups,
elements of a particular cultural system may be
embraced, internalized, and expressed differentially.
emerge and transform through cumulative and adaptation-
oriented person-environment transactions over time
are maintained and transmitted through collective
memory, narrative, and socialization processes

Culture is…
The patterns, rhythms, and ways of:
Being (identity, self, and experiential processes)
Believing (values, meanings, and worldview)
Bonding (attachment and relational processes)
Belonging (community and group processes)
Behaving (actions, agency, daily living)
Becoming (transformation and healing)
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Culture is…
 Particularly relevant to the delivery of psychological services in
many of its expressions including:
 language and communication
 mental processing and learning styles
 emotional expression,
 interpersonal behaviors,
 family and social roles,
 values and normative behaviors
 individualism – collectivism - communalism
 independent – interdependent self construal
 role of spiritual forces and phenomena
 ideas of health and illness,
 health and healing practices,
 coping and help-seeking
 norms of privacy and disclosure
 institutional structures & organizational policies and practices,

Culture, Power, & Privilege
Some ways of being, believing, bonding,
belonging, behaving, and becoming are more
valued than others
We need to be aware of the internalization of
dominant cultural narratives of what is
acceptable, desirable, healthy, “normal”
Impact on members of non-dominant groups
Impact on members of dominant group

Culture is…
 …LIVED and not always easily articulated
by members of the culture-carrying
group
 “Tell me about your culture” may not always yield
complete or sufficient data.
 Cultural socialization is about transmitting “norms”
so it is not something that is distinct from daily life
 …Often only recognized in contrast;
which is why “minority” groups may be
more aware of salient cultural processes.

Culture is…
embedded in social and institutional
contexts,
internalized as patterns of meaning and
identity,
expressed through actions and relationships
in the context of power dynamics, and
interactive with co-existing and intersecting
cultural systems through multiple dimensions
of human diversity that reflect shared identity
and experience

Understanding Context
Context- the multiple and
encapsulating environmental,
interpersonal, societal, and historical
conditions and circumstances within
which we live, grow, and change
Contexts have “culture”

The Importance of Context
Central principle: Behavior cannot be
understood outside of the settings and
circumstances in which it occurs; EVERYTHING
we do and become takes place in multiple
layers of contexts
The idea of “people in context” is support
across multiple disciplines of psychology

Mind in Context
No clear boundaries indicate where
the mind stops and the cultural
ecology of the situation starts. Mind
and culture mutually constitute each
other. -Barrett, Mesquita, & Smith (2010, p. 9)

The Role of Context in Human Behavior
Behaviorism- Human behavior is shaped by the
reinforcements and contingencies of the environment
Developmental Psychology: Bronfenbrenner’s
Bioecological Theory of Human Development (aka
Ecological Systems Theory)
 Microsystems, Mesosystems, Exosystems, Macrosystems,
Chronosystems / Process-Person-Context-Time Model
Social Psychology: Kurt Lewin’s formula for understanding
human behavior (Field Theory) B=f(P,E): Behavior is a
function of person and environment interaction; Context
Minimization Error
Interpersonal Neurobiology:
 “Mental events and human behaviors can be thought of as states
that emerge from moment-to-moment interaction with the
environment, rather than proceeding in a context-free fashion from
preformed dispositions or causes. Inherently, a mind exists in
context.” (Barrett, Mesquita, and Smith, 2010)
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MORE…
Health Psychology: George Engel’s Biopsychosocial
Model of Health & Illness; Health and illness develop
out of the complex relationships between biological,
psychological, and social determinants
Functional Contextualism: A philosophy of science
that guides modern behaviorism’s insistence that
behavior must always be understood in relation to its
historical and current context, the focus of study
should be function rather than topography in order
to understand and influence behavior, and the
importance of contextual cues that determine the
process of relational responding

MORE…
Community Psychology: Multiple Levels of
Analysis Conceptual Framework
Individual, Microsystem, Organizational,
Community, Macrosystem
Multicultural Psychology: Centers the
consideration of culture and human diversity in
understanding individual and group behavior
Wade Nobles’ “Culturecology”; Celia Falicov’s
Multidimensional-Ecosystemic-Comparative
Approach (MECA)
Feminist Psychology: Centrality of the dynamics
of power and privilege, social location, and
relational ways of being to the psychology of
women
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MORE…
Constructivist/Narrative Psychology: Meanings of
experience and events emerge from socially constructed
narratives (stories) that are tied to our personal, social,
temporal, political, and cultural contexts. These
meanings influence identity and memory, as well as
shape our understanding and interactions with others
and in the world.
Existential Psychology: “The world…is the natural
setting of, and field for, all my thoughts and all my
explicit perceptions…Man is in the world and only in the
world does he know himself.” –Maurice Merleau-Ponty
Humanistic Psychology: Roger’s necessary and sufficient
conditions (“the soil”) for optimal development and
functioning

Importance of Ecological and
Contextual Variables
Context affects conditions of living and access to societal
resources
Context determines exposure to particular societal,
sociocultural, and community narratives that define self,
acceptable roles, as well as appropriate thoughts, feelings,
and behaviors
Context impacts options for support and coping
Context influences opportunities for affirmation and
validation of self and community
Unhealthy contexts can impede functioning and well-being,
compromise or confuse personal and collective identity, and
suppress or misdirect health-promoting behaviors.

Culture is carried by many different
collective entities and contexts that
reflect multiple dimensions of human
diversity
These dimensions of diversity can be
demographically-based (e.g., ethnicity,
religion) or experientially-based (e.g.,
occupation, defining life experience)
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How is Culture Carried and
Transmitted?

 Individuals are exposed to and internalize
multiple cultural influences which intersect
in particular ways and are woven into
 Identity
 Narratives
 Memory
 Behaviors
 Preferences
Reserved
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The Integrative and
Foundational Role of Culture

Reserved

 Primary Macrocultural Collective Entities
 Deeply embedded in the functioning of persons and contexts
 Transmitted within family and community socialization processes
 Cultural elements of privileged macrocultural entities are woven
into the dominant cultural narratives of society (e.g., generational
trends, heteronormativity, ideology of white supremacy)
 EXAMPLES: Nationality, Ethnicity, Religion
 Microcultural Collective Entities
 Function within particular sociocultural communities
 Exposure typically occurs after childhood and outside of the family
socialization context
 Immersion in these entities may be voluntary
 EXAMPLES: Military culture, Alcoholics Anonymous, Gay male
culture
Reserved
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Culture-Carrying Entities:
Where culture is learned and transmitted

The Sociocultural Context of Identity
Identity emerges at the nexus of society and the individual; it is
embedded in one’s historical, cultural, and social context (E. Erikson)
Who we say we are and how we experience ourselves is influenced
by who others say we are and the reflections of ourselves in the world
around us
Identity is dynamic and contexualized
 Family, culture, and the larger sociopolitical context contribute to the development
and meaning of specific dimensions of identity
 Various aspects of identity become more or less salient depending on life
experiences
 Context determines which aspects of our identities are important at any particular
time in our lives

Dominance, Power & Identity
Societal power and dominance influence the
significance and salience of cultural aspects
of identity
Dominant group identities are usually less
salient to group members than those
associated with groups that are stigmatized
or oppressed

Diversity Dimension and Blindspots
(where privilege lives)
Circle those dimensions of diversity where your
membership category is a relatively more
dominant group in larger society
 In more advantaged position in terms of social
indicators such as education, occupation,
 A desirable “in-group” in larger society
 Held in relatively higher esteem
 In the majority

Intersectionality
Intersectionality refers to the overlapping and
interactive dynamics of multiple dimensions of
diversity
The effects of one diversity dimension in our lives is,
in part, dependent on one’s status on additional
dimensions of diversity
Being a man, Being a Latino man, Being a gay Latino man
Culture is always expressed and lived intersectionally
Ecological niche
 the place where a one’s multiple contexts and cultural locations
converge
 Implications for social support and sense of community
 Also implications for identity conflicts

Core Characteristics of Military Culture
Hierarchical, Authoritarian, and Rule-based
Emphasis on interdependence and cooperation
Focus on duty and mission
Military Values and Virtues
Honor Courage Loyalty
Integrity Commitment Restraint
Obedience Perseverance Sacrifice
(Exum, Coll & Weiss, 2011)

The Warrior Ethos
Dedicated to defending a social order or way of life
Living by a moral code and higher calling
Selflessness, self-denial, self-sacrifice (group over individual)
Responsibility to and for others
Unwavering commitment to mission and unit
 Placing the mission above all else
 Never leaving an American behind
 Not accepting defeat and never quitting
Courage, bravery, valor
Fulfillment in fighting, competing, winning
Accepting dependence on others (the team)
Pride in meeting and maintaining ideals
Relationship with loss, suffering and death

Military Culture and Multiple
Dimensions of Diversity
Military culture includes a value on uniformity
and the primacy of military culture, minimizing
individual differences and other dimensions of
diversity
May present internal conflict for members where
other cultural dimensions are also strong aspects
of identity
Identity and/or role conflict as potential sources
of stress for veterans
Identity contingencies- the things you have to deal with
in a situation related to a particular social identity group

Total Military Force (active +
reserve) Demographics (2014)
Women comprise 16.5%
31.2% identify as a minority (Latino/Hispanic not
included as “minority”)
92.1% have a high school diploma; 7.0% have a
Bachelor’s degree or higher (83% of officers
have a Bachelor’s degree or higher)
California has the highest active duty population
of any state
Geographically, the South is overrepresented

Military Culture PLUS…
Complexity of a strong military identity co-
existing with other significant dimensions of
diversity
 Gender
 Race
 Sexual Orientation
 Religion
 Social Class
Compatible? Consistencies? Inconsistencies?

Societal patterns mirrored in
Military
 Example: African Americans
 African Americans are more likely to be Enlisted vs.
Officers than Caucasians
 Lower officer ranks
 Longer time before promotion
 More sexual harassment, mediated by lower rank
 Sexual harassment co-occurs with racial stressors
 Almost twice as many A.A. females as A.A. males
(Settles, Buchanan & Colar, 2012)

Gender and Sexual Violence
Active duty military approximately 86% male
20-30% females and 2-4% males experience
sexual assault during military service
Hypothesized relationship to “hypermasculine”
culture

Sexual Orientation
Historical Context: Don’t Ask Don’t Tell
 “Sexual orientation is considered to be a personal and private
matter, and homosexual orientation is not a bar to service entry or
continued service unless manifested by homosexual conduct”
(Secretary of Defense, 1993, p. 1)
 ”Homosexuality is incompatible with military service because it
interferes with the factors critical to combat effectiveness
including unit morale, unit cohesion and individual privacy”
(Secretary of Defense, 1993, p. 1)
 This was a policy which was more relaxed and less discriminatory
than the previous policies
 Repealed in 2011, now openly homosexual people can serve.
What implications might this have for LGBT veterans?

“Help explore complex relationships
with the cultures that contributed to
and sustain their identities, so that
they come to terms in their own
way with inconsistencies and
discontinuities in shared value
systems and practices”. (Litz et al in
“Adaptive Disclosure”)

A Meta-Theoretical Model for a Culture-
and Context- Conscious Psychology
A tool for making cultural and contextual
considerations fundamental to our work
vs. an afterthought or add-in

Centering Culture
Consideration of culture as an “add-
on” inevitably privileges the dominant
status quo and existing structures of
power and inequality that maintain
asymmetries in health and wellness
Collusion with the dynamics of
oppression in contemporary
psychological theory and practice
occurs primarily through omission
Reserved

Person-Environment-and-Culture-
Emergence (PEaCE) Theory
Person-Environment-and-Culture-Emergence
Theory is offered as a response to the challenge of
more fully incorporating the contextualized and
culturally-embedded nature of human experience in
theory, research, and practice.
Primary Goal of PEaCE Theory:
More comprehensively inform our understanding
and intervention related to health and wellness
outcomes
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Explicit Integration of Culture
Culture has some degree of influence on all
elements of the multiple systems involved in
human functioning:
-BIO: Genetic, physiological, neurological,
biochemical
-PSYCHO: Mental, emotional, behavioral,
identity, meaning-making processes
-RELATIONAL: Close interpersonal relationships
-SOCIO: Group and community social contexts
-ECOLOGICAL: Institutions, organizations,
environments, settings, macrosystem contexts
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65

A Culturally-Infused
Biopsychorelational-Socioecological Approach
PEaCE Theory focuses on the ongoing and complex transactions
within and between three interconnected complex systems:
BioPsychoRelational (person)
SocioEcological (environment)
multi-Cultural (culture)
 Informs an ever-increasing holistic understanding of the
interconnected elements of the complex and interacting systems
that impact human functioning and health outcomes
 Health outcomes are enhanced with a non-reductionistic approach
that is informed by a culture- and context- conscious psychology.
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Overview of the PEaCE Transactional
Wellness Theory
Individual and Collective Health and Wellness
Outcomes emerge from the dynamic and
ongoing transactions in the Person-
Environment-and-Culture-Emergence (PEaCE)
Transactional Field where multidimensional
Person Processes, multilevel Environmental
Processes, and the intersectional dynamics of
Cultural Process are continuously interacting to
produce subjective lived experience and human
agency that more proximally influence health.
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Reserved

Foundations of PEaCE Theory
PEaCE Theory extends the person-environment
interaction foundations of field theory (Lewin),
bioecological systems theory (Bronfenbrenner), and
the biopsychosocial framework (Engel) to explicitly
include culture.
 PEaCE theory is based on the proposition that all of
human experience occurs at the intersection of
persons, environments, and culture, and that culture is
infused into all subsystems of both persons and
environments.
A goal of developing the theory is to fully capture the
dynamic process of the individual as a living multi-
system that is interdependent with multiple cultural
and ecological systems.
Reserved

PEaCE Theory Basics
Persons, Environments, and Culture are
multidimensional/multilevel complex systems and
do not function independently of each other
 Persons cannot be separated from culture and context
 Person-in-Culture-in-Context (aka “Being-in-Culture-in-the-World)
Cultural processes are infused into the expressions
of persons and environments in the world
Health outcomes are emergent properties of the
ongoing and dynamic transactions within and
between persons, environments, and culture

That culture and psyche make up
and sustain one another dynamically
is so fundamental to understanding
human behavior and cognition.
(Mendoza-Denton and Espana 2010)

The Person
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The Two Cultural Infusion Processes
Psychocultural Processes
o Reflect the transactions between culture and the multiple and
interconnected biopsychorelational systems of the person
o The unique ways that cultural systems are internalized and expressed by
the individual person
o The intentional choices that individuals makes regarding adopting and
participating in particular cultural values, customs, behaviors, etc.
o The meaning of culture to the individual
Sociocultural Processes
o Reflect the transactions between culture and the multiple ecological
contexts within which we develop, live, and change
o The shared core elements of the cultural worldview, beliefs, customs,
etc.
o General and commonly expressed cultural characteristics: Material
culture, Social culture, Symbolic Culture, and Ideological Culture
o Manifestations of culture that emerge from a group’s cultural context
o The essential elements of a culture’s way of life passed down from
generation to generation
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The PEaCE Transactional Field
 It is in this dynamic “field” where lived experience is co-
created and human agency is activated through the
constant and ongoing transactions between the
interconnected Person, Environment, and Cultural
systems
 Transactional processes in the field determine the
emergence of individual, relational and collective health
and wellness outcomes. Outcomes are NEVER the
product of one system independent of the others
 Person-in-Culture-in-Context transactions can be
neutral, pathogenic, or wellness promoting with respect
to their contribution to the emergence of positive and
negative outcomes for persons, relationships, groups,
communities, and institutions.
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Person-in-Culture-in-Context
Transactions are Always Involved in
Experience and Behavior
Subjective Lived Experience (what we
experience) is co-created by interacting
individual, contextual, and cultural
processes
Human Agency (what we do) is an
emergent property of Person-in-Culture-
in-Context transactions
What we experience and what we do can
be wellness-promoting or pathogenic
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Person-Environment-and-Culture Fit
 Refers to the qualities of the interaction and degree of
compatibility of co-occuring elements of
 Biopsychorelational processes and characteristics of the
PERSON
 Salient aspects of CULTURE
 The historically-influenced and currently manifested demands
and resources of the social and physical ENVIRONMENT at
multiple ecological levels of contextualization
 It is reflected in the degree to which person-
environment-and-culture transactions “bring out the
best” in individuals, relationships, and settings. When
there is optimal Person-Environment-Culture Fit, the
functioning and well-being of persons, contexts, and
cultural communities are enhanced.
 The nature and quality of Person-Environment-Culture
Fit shifts as change occurs within persons and contexts.
79

Where can we impact
Person-Environment-Culture Fit?
Interpersonal interactions
Considering beliefs about health, illness, etc.
 Acculturation and Identifications
Experiences with systems, agencies, and providers
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Activity in the PEaCE Transactional Field:
Person-in-Culture-in-Context Transactions
Pathogenic Transactions
 Decrease the likelihood that the positive wellness outcomes of
resilience, wellbeing, thriving, and optimal functioning will
emerge
 Increase the likelihood that the negative wellness outcomes of
distress, dysfunction, disorder, and disease will emerge
Wellness-Promoting Transactions
 Increase the likelihood that the positive wellness outcomes of
resilience, wellbeing, thriving, and optimal functioning will
emerge
 Decrease the likelihood that the negative wellness outcomes of
distress, dysfunction, disorder, and disease will emerge
Neutral Transactions
 Everyday transactions that neither significantly increase nor
decrease the likelihood of positive or negative wellness
outcomes

Pathogenic and Wellness-Promoting
Transactions
Pathogenic Person-in-Culture-in-Context Transactions
 Traumatic Experiences
 Historical and Collective Trauma
 Collective Memory and Transgenerational processes
 Interpersonal, Cultural, and Institutional Oppression (racism,
sexism, heterosexism, classism, etc.)
Wellness-Promoting Person-in-Culture-in-Context
Transactions
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Implicit Bias, Racism, and
Racism-related Stress

Why is understanding “isms”
important?
Human behavior cannot be separated from the
context in which it develops and manifests
 Isms reflect our interaction with organizational and
macrosystemic contexts
Identity and “self” form at the intersection of
individual characteristics and experiences in the
social environment
 Isms can affect identity and sense of self
Stress exposure has been associated with the
development and exacerbation of negative physical
and psychological outcomes
 Isms influence content, frequency and intensity of stress
exposure

“Isms” and Context
➢Contexts reflect isms through
 Asymmetries in conditions of living and
access to societal resources
 Options for support and coping
 Opportunities for affirmation and validation
of self and community
 Exposure to particular societal, sociocultural,
and cultural resources that define self,
acceptable roles, as well as appropriate
thoughts, feelings, and behaviors
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A Few Terms
Stereotype = Group + Overgeneralization
(Thought/Label)
Prejudice = Stereotype + Judgment
(Attitude)
Discrimination = Prejudice + Differential Tx
(Behavior)
Oppression/”Isms” = Discrimination + Power
(Structural and Systemic)

“Isms”: Multiple Forms of
Oppression
Racism
Sexism
Heterosexism
Classism
Ageism
Ableism

Power Asymmetries: Race, and Gender
White Euro-American males are 33% of the population:
 80% of tenured positions in higher education.
 80% of Congress
o Other: 20% female; 92% Christian; 6% of Senate are racial/ethnic
minorities
 92% of Forbes 400 Executive CEO level positions
 90% of Public School Superintendents
 99.9% of Athletic Team Owners
 97.73% of U.S. Presidents

Isms and Health
➢Isms present challenges to achieving, sustaining, and
promoting health and wellness
➢Health is threatened by multiple oppressions (racism,
sexism, classism, heterosexism, etc.) and all forms of
group-based violence (structural, cultural,
interpersonal), each of which are intolerant of human
diversity and perpetuate social asymmetries
➢Groups along multiple dimensions of diversity who are
less dominant in society experience compromised
health on various indicators
 Race
 Gender
 SES
 Sexual Orientation

“Isms” and Trauma
 Various “isms” may
 place individuals at risk for trauma exposure,
 exacerbate the impact of trauma and increase the risk of impairment, and
 be a form of psychological trauma in itself (Ghosh Ippen, 2012; Ford, 2008).
 With respect to racism
 Ethnic minorities are more likely to live in dangerous ecological contexts;
 they are more likely to have histories of oppression and group trauma that
have lasting consequences, and
 they are more likely to have experienced immigration-related adversities and
race-related stressors.
 Thus, it is important to screen for exposure to a range of traumatic
events even when a client is referred for exposure to one specific
event and to consider the historical nature of the trauma exposure.

Some Effects of Exposure to “isms”
 Hypertension and Cardiovascular Reactivity
 Negative Health Behaviors (smoking, low routine health care)
 Depression and Anxiety; increase suicide risk
 Hostility
 Intrusive thoughts and rumination
 Difficulties concentrating and distractibility
 Avoidance
 Impaired performance and role functioning
 Apathy/Powerlessness
 Identity Confusion
 Internalized oppression
 Self-doubt
 Disruption of Interpersonal Relationships

Prejudice, Stereotypes, &
Discrimination
TONS of basic research from social psychology,
particularly social cognition, informs our
understanding of these category-based thoughts,
attitudes, and behaviors
Bottom line: We ALL engage in these category-
based processes and it is our responsibility as
health care providers to monitor and modify their
impact on our judgments, decisions, interactions,
and treatment implementation

Our Biases
“An important component of working with
any culture is to understand your own biases,
expectations, and beliefs about members of a
cultural community.”
from: http://deploymentpsych.org/self-awareness-exercise
Why do health disparities persist despite
strong stated values of equity among health
care providers?
IMPORTANT: Conscious attitudes toward
diversity may not reflect subtle, hard-to
control bias.

IMPLICIT BIAS
Part of the evolving and accumulating body of
research that is informing our understanding of
“unconscious” mental processes.
Connected to research on implicit memory, implicit
attitudes, and implicit cognition
Underlying assumption is that “actors do not always
have conscious, intentional control over the processes
of social perception, impression formation, and
judgment that motivate their actions” (Greenwald and
Krieger, 2006)
A process is implicit when a person cannot voluntarily
retrieve or identify a mental process and where there
is simultaneously evidence in behavior that process is
present (memory, etc.)

Implicit Mental Processes
Implicit mental processes can be understood as
“introspectively unidentified (or inaccurately
identified) traces of past experience” that mediate
 favorable or unfavorable feeling, thought, or action toward
social objects. (implicit attitude)
 attributions of qualities to a member of a social category
(implicit stereotype)
-Greenwald and Banaji (1995)
Implicit biases are based on implicit attitudes or
stereotypes and produce behavior that diverges from
a person’s avowed or endorsed beliefs or principles

Implicit Bias and the IAT
Discrepancy between explicit and implicit attitudes is
a concern for health care providers
Discrepancies are commonly found in attitudes
toward stigmatized groups by race, age, ethnicity,
disability, and sexual orientation
The Implicit Association Test (IAT) was developed to
assess these dissociations between implicit and
explicit
Website data suggests more than half participants
exhibited significant implicit bias
 Self selected sample so probably an underestimate
 Af-Am only group without a dominant pro-white bias

More on the IAT
Predictive validity of the IAT has been explored in
relationship to voting behavior, measures of warmth
and discomfort in interactions, and measure of brain
activity when viewing images of members of a racial
group.
Meta-analysis of 61 studies provided strong support
for the IAT in relationship with other more “objective”
measures vs. self-report of biases

Taking the IAT
Project Implicit where you can take
the IAT and get more info:
https://implicit.harvard.edu/
Fazio, R.H., & Olson, M. A. (2003). Implicit measures in social
cognition research: Their meaning and use. Annual Review of
Psychology, 54, 297-332.
Nosek, B.A., Greenwald, A.G., & Banaji, M.R. (2006). The IAT at
age 7: A methodological and conceptual review. In J.A. Bargh
(Ed.) Automatic Processes in Social Thinking and Behavior

Implicit Bias and Therapists
The presence of implicit bias and a strong belief in
personal competency when working with diverse
clients can occur together. (Boysen & Vogel, 2008)
Studies of implicit bias among mental health providers
have consistently documented significant levels of bias
(Abreu, 1999; Boysen & Vogel, 2008; Castillo et al.,
2007)

A Closer Look At Race
HANDOUTS from chapter
 Harrell, S.P. (2014). Compassionate confrontation and
empathic exploration: The integration of race-related
narratives into the supervision process. In C. Falender, E.
Shafranske, & C. Falicov (Eds.) Diversity and
multiculturalism in clinical supervision: Foundation and
Praxis—A guide to supervision practice. Washington
D.C.: American Psychological Association.
Race-related Multicultural Competencies
Signs that greater attention to race may be
needed

Racism as a form of Oppression (Harrell, 2000)
A system of dominance , power, and privilege based on
racial group designations rooted in the historical
oppression of a group defined or perceived by
dominant-group members as inferior, deviant, or
undesirable
Occurs in circumstances where members of the
dominant group create or accept societal privilege by
maintaining structures, ideology, values, and behaviors
that have the intent or effect of leaving nondominant
group members relatively excluded from power,
esteem, status, safety, and/or equal access to societal
resources.
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Racism-Related Stress (Harrell, 2000)
Particular type of Pathogenic Person-in-Culture-in-
Context Transaction
Six dimensions of racism-related stress (measured by
the RaLES; Harrell, 1997)
 Racism-related life events
 Vicarious racism experiences
 Daily racism microstressors (e.g., microaggressions)
 Chronic racism-related stress
 Collective racism experiences
 Transgenerational transmission of racism trauma
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Daily “ism-related” Microstressors
Insults, put-downs, rejections, and other
“microaggressions” encountered in one’s daily
interactions in the world
Create “invisibility” of personhood and experience
Objectifying and dehumanizing
Impact is cumulative
Difficult to “prove” (Did that just happen?)

Why a focus on Microaggressions?
Interpersonal nature of microaggressions
Potential for microaggressions to reflect implicit bias
Polarizing re: their role and significance (suggests
attention is needed to increase understanding)
 Racial, gender and sexual orientation microaggressions create
psychological dilemmas because they represent a clash of
racial, gender and sexual orientation realities. (Sue, 2014)
Impact psychological processes and emotional well-
being of members of targeted groups
Related to greater mistrust and vigilance
Because a fundamental task of our role is to understand
the experience of others

Microaggressions
“Brief and commonplace daily verbal, behavioral or
environmental indignities, whether intentional or
unintentional, that communicate hostile, derogatory, or
negative racial slights and insults”
Characterized by their invisible, unintentional and subtle
nature; usually outside the level of conscious awareness.
They are often unconsciously delivered in the form of
subtle snubs or dismissive looks, gestures and tones.
Send denigrating and devaluing messages; constant
reminders of second-class status in society
Symbolize past historic injustices and collective traumas
Particularly target people from historically oppressed and
marginalized groups
▪ (Sue et al., 2007)

Three Forms of Microaggressions
Microinvalidations
 Communications that exclude, negate, or nullify the thoughts
and feelings of a member of the category group
Microinsults
 Insensitivities, demeaning remarks, and subtle snubs that may be
out of the awareness of the person doing it (e.g., jokes,
questions, compliments)
Microassaults
 Explicit derogations characterized primarily by a verbal or
nonverbal expression that are mean-spirited and intentionally
meant to hurt or put down another person (e.g., name-calling,
rudeness) or “put them in their place”

Microaggression Themes
Color-Blindness
Objectification
Assumption of Inferiority / Myth of Meritocracy
Assumption of Criminal Status
Assumption of Universal Experience
Pathologizing Cultural Values/Behaviors
Environmental Microaggressions
Denial of Racism/Prejudices
Ascription of Intelligence/Capacity
Alien in Own Land / Don’t Belong
Second-Class Citizen / Not Valued / Less “human”
Exoticization / Sexualization

Effects of Microaggressions
“It gets so tiring, you know. It sucks you dry.”
Moment-to-Moment Experience
Requires ongoing management of physiological activation,
cognitive attentional processes (such as questioning
oneself), and emotional reaction to being demeaned
Acute Emotional/Physiological Reactions
frustration, anger, sadness, fear, belittled, stress response
Chronic Negative Emotional States
apathy, hopelessness, powerlessness, anxiety,
hypervigilance, depression, alienation, low self-esteem, self-
doubt
Behavior and Performance
Impaired task performance, reduced engagement and
initiative, avoidance of people and places

Environmental Impact
When microaggressions are unchallenged,
accepted as normal, minimized as “no big deal”,
and allowed to proliferate they not only impact
individual well-being but also impact the norms of
the environment
Saturate broader societal settings with cues that
signal the acceptability of devaluing particular
social group identities
Create a hostile, invalidating, or intimidating
environment related to race, immigration status,
language, gender, sexual orientation, etc.

Intent and Impact
Important to NOT equate intent with impact
Many microaggressions are not meant to be hurtful and may
be jokes or naïve curiosity
If we only focus on intention, we continue to center and
prioritize the perspective of the dominant group member
who commits the microaggression and invalidate the
experience of the targeted group members
 “Get over it”; “Didn’t mean anything by it”; “You’re making a big deal
out of nothing”; “You’re oversensitive”
Dominant group members have broad societal support for
validation of their opinions and feelings with respect to
gender, race, sexual orientation
We are socialized to believe people with social power.

Assumptions of Normality
Ideas of what is normal / good / “better”
 Heteronormativity
 White “Supremacy”
 Male Dominance
We are socialized to give more credibility to those
from high social power groups (e.g., whites, men,
higher SES)
How we deal with “exceptions”
How does this impact our evaluations of client
behavior?

Microaggressions and
Stereotypes
Microaggressions can be thought of as impulsive
behaviors and unprocessed decisions the
emerge from unchallenged or rigid stereotypes
about another group of people
Understanding the research on stereotypes, how
they function, and how to manage them to
lessen their destructive potential to be
manifested in microaggressions
Prejudice and motivation to change one’s
thinking and behavior are also important
considerations that can be informed by
understanding basic research on attitude change
and motivation

Stereotypes are “In The Air”
Stereotypes are simplistic ways of categorizing others
by grouping people into preconceived categories
 Easier stimulus processing but high risk for faulty decisions
 Strong impact on microbehaviors in interpersonal interactions
Stereotypes are “floating in the air like a cloud
gathering the nation’s history” (Steele, 2010)
 we know the major stereotypes about most groups and what
people could be thinking of us
 We can often “feel” when we stereotypes are strongly
activated

Stereotype Threat Research
 Stereotype threat refers to being at risk of confirming, as a self-
characteristic, a negative stereotype about one's social group (Steele &
Aronson, 1995).
 Functions like a self-fulfilling prophecy; worrying that behavior may
confirm stereotypes splits attention between the task at hand and
anxieties/fears, and increases likelihood of compromised performance
in ways that may “confirm” the very stereotypes at the root of our
anxieties
 Stereotype threat occurs when the relationship between the social
category (e.g., race, gender) and the negative performance expectation
is made salient in some way
 The research provides evidence that situational factors—more than
individual personality or other characteristics—can strengthen or
weaken the stereotype-threat effect
 Decreased performance in academic and non-academic domains,
increased use of self-defeating behaviors, disengagement, and altered
professional aspirations are just a few of the outcomes.

More on Stereotype Threat
OVER 300 studies done since the original Stanford University
studies that confirm the stereotype threat phenomena
 Race/Ethnicity
 Gender
 Sexual Orientation
 More
Implications for health and mental health care settings
 Assessment
 Treatment Engagement
Can be helped through reduction of stereotype threat
triggers in the environment and interpersonal interactions
(e.g., microaggressions)
 Steele, C.M. (2010). Whistling Vivaldi: How Stereotypes Effect Us and
What We Can Do. New York: Norton.
 http://reducingstereotypethreat.org
 http://perception.org/wp-content/uploads/2014/11/Transforming-Perception.pdf

Internalized Oppression
When a member of an oppressed group believes
and acts out the stereotypes created about their
group (internalized racism, homophobia, sexism,
etc.).
 Colorism is an example
Critical consideration when working with
historically oppressed and marginalized groups
Steele’s research on stereotype threat
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Mediators of Ism Experience, Strengths,
and Resilience
 ADVERSITY AND CHALLENGE CAN BUILD POSITIVE WELL-BEING
 supportive responses from the environment
 validation of one’s feelings and experiences
 the simultaneous presence affirming messages
 a safe community of connection and belonging
 a larger cognitive frame within which to understand the experiences
 creative expression
 opportunity to utilize experiences to help/support others
 collective or prosocial coping and social justice involvement
 development of strengths and resilience
 transformation of rage
 increase in faith, hope, spirituality
 Compassion and forgiveness for the perpetrator

Implicit Bias and Dynamics of
Difference
The existence of difference and all that it means
in social context is at the root of implicit bias
The 5 Ds of Difference provides a framework for
checking in with ourselves on implicit bias
Developed over 20 years ago to conceptualize
common “difference dynamics” (Harrell, 1995)

The 5 Ds of Difference (Harrell, 1995)
Ways we attempt to resolve the anxiety and dissonance
that difference creates
There are 5 basic strategies that people
use in difference encounters
Distancing
Denial
Defensiveness
Devaluing
Discovery

About the 5 Ds
We all manifest each of these dynamics in
a variety of everyday situations
The function of these strategies is
protective as they seek to reduce anxiety
We can’t eliminate discomfort with
difference (either our own or others), it is
a normal reaction
Self-awareness is the key

Denial
 Minimize the existence or significance of the difference
 Colorblindness, universality, invisibility
 Selective attention to similarities; need for conformity and sameness;
low tolerance for disagreement and conflict
Defensiveness
 Stance that "I" have no problem with differences
 Defensive declaration of strong values of equality and “proof” through
close relationships with the “different” group
 Threatens sense of self as not having “isms”
Distancing
 Create separation from the difference
 Physical, emotional (e.g., pity), cognitive (e.g., intellectualization)
Devaluing
 Difference is experienced as deviance, pathology, or “wrong”
 Maintain sense of superiority or being “right”
 Inflexibility and anger
Discovery
 Curiosity and active engagement with the difference
 Positive feelings about the different group
 Can be objectifying and boundaries may not be respected

So, What Should We Do?
Focus on continual personal and professional
development
 Differences can be experienced as challenges and
opportunities for learning and growth
Place high value on intergroup dialogue and
understanding
 Confronting and active processing our differences can be
experienced as empowering
 Conflict and disagreement are accepted as a part of dealing
with differences
Check ins with self and others
 Awareness of when you are triggered by difference or when
you may have participated in triggering others
 Awareness of your “go to” strategies
 Asking about the impact you may have had

Evidence-based Practice and
Empirically-Supported
Treatments with Culturally
Diverse Populations

Evidence-Based Practice
APA’s Definition of Evidence Based Practice
for Psychologists (EBPP)
An integration of…
The Best Available Research
Clinical Expertise
In the Context of:
• Patient Characteristics
• Patient Culture
• Patient Preferences

Challenges to Evidence-Based Practice
There are problems in the operationalization and
application of evidence-based practice
What evidence is considered acceptable?
RCTs only?
Lack of distinction between evidence-based practice and
empirically-supported treatments such that the evidence
is limited to the existence of ESTs for specific disorders
EBPP is broader than ESTs
Outcome variables; should disorder-specific symptom
reduction be the only outcome studied?
Efficacy studies establish ESTs but continuing need for
effectiveness studies
Internal and external validity issues

Benefits of the EST Approach
 (a) evidence-based treatments give guidance to better serve
patients or clients seeking care;
 (b) using the scientific approach to evaluate treatment is the
best way to advance knowledge in order to provide the best
mental health services in the future;
 (c) it is necessary to use limited mental health resources wisely;
 (d) there are treatments that work that most practitioners do
not use; and
 (e) there may be no better alternative than to use science as the
standard for practice.
Whaley & Davis, 2007

Are ESTs Appropriate for
Diverse Cultural Groups?
Treatments were not originally developed and tested
with various cultural and SES groups in mind.
RCT samples are quite homogeneous, largely white and
educated
Few ESTs have been systematically studied with
culturally diverse populations
WE DON’T ACTUALLY HAVE THE “EVIDENCE” to use
them with diverse populations
 One other consideration regarding intervention efficacy and
effectiveness involves the criterion of effectiveness, as defined
in reference to a specific population or group. This criterion is
that “A statement of efficacy should be of the form that,
‘Program or policy X is efficacious for producing Y outcomes
for Z population.’” (Flay et al. 2005, Castro et al, 2010).

In the Meantime…
Until we have a sufficient body of empirical literature
to inform the use of ESTs with culturally-diverse
populations:
 (a) allow basic research, especially studies on the target
population of color, to guide the development of an
intervention;
 (b) apply a standard intervention to the specific ethnic/racial
group without any cultural modifications to learn which
components are useful; and
 (c) systematically examine a particular intervention from a
cultural competence perspective and assess the potential
cultural match of the intervention’s components to the group
under study.
(Whaley & Davis, 2007)

Demand for ESTs
The growing demand for ESTs has emerged despite
clinicians’ concerns that it may be premature and
may impose unrealistic constraints on clinical
practice
The cultural adaptation of ESTs has emerged as an
intervention strategy and will likely grow in
prominence as a result of two trends
 (a) the growing demand for ESTs and
 (b) the growing diversification of the American population.
(Castro et al., 2010)

There has been some progress in the application
of evidence-based psychological practice with
culturally diverse, underserved, and marginalized
populations, but this work is certainly in its
infancy.
Attrition over the course of treatment, lack of
participation in treatment activities (or low level
participation) are challenges
Quality of life and well-being as potentially
relevant outcome variables

Challenges to Service Utilization
Lower rates of service utilization and higher rates of
attrition have been found among ethnic minorities
both for general mental health services
Ethnic minorities are more likely than Whites to
perceive bias and lack of cultural competence in health
care
Recent national and state-level studies revealed
continual problems with mental health services
utilization among African Americans, Asian Americans,
Latinos, and Native Americans
(Breaux & Ryujin, 1999; Whaley and Davis, 2006; Ghosh-Ippen, 2008)

When a client doesn’t respond
to treatment…
Non-compliant
Resistance
Not psychologically-minded
Not “ready” for treatment
Not willing to do the work
WE NEED TO RE-THINK THESE CONCLUSIONS IN
THE CONTEXT OF CULTURE AND DIVERSITY

Pre-Adaptation Issues
Increasing the acceptability of interventions may
help to increase treatment engagement
Before a treatment can work, there must be
engagement
Research is needed on drop outs from ESTs
In addition, more research needs to be conducted
on dropout rates AFTER initial engagement and just
before treatment starts.

Castro et al (2010) suggest that the impact
of culture may occur in the process of
therapy rather than the outcome.
High rates of treatment dropout among
ethnic minority patients so the outcome of
the treatment actually remains unknown.
Culture may be particularly important
during the process of therapeutic
engagement.

Culture & Psychological Practice
The inclusion of culture in the
analysis of human experience,
behavior, and transformation
facilitates the identification of
constructs, methods, and
strategies that may enhance the
effectiveness of applied work in
diverse cultural contexts
Reserved

Culturally adapted therapy approaches
may be more compatible with
ethnic/racial minority patients’ cultural
experiences compared with standard
therapeutic approaches and, therefore,
may be better at treating their
psychological problems (Kohn, Oden,
Munoz, Robinson, & Leavitt, 2002;
Whaley and Davis, 2007; Ghosh Ippen,
2012).

Effectiveness of Culturally-
Adapted Interventions
Promising evidence so far from three meta-
analyses
Griner and Smith (2006)

Three Cultural Infusion Strategies for
Psychological Practice
Culturally-Adapted - Start with presumably universal
constructs, strategies and methods and make cultural
adaptations to fit client values, preferences, and needs
Culturally-Centered - Start with theoretical frameworks
and empirical research from cultural psychology and
diversity science to inform conceptualization,
treatment planning, and service delivery; integrate
culturally-congruent contributions from multiple
traditions as appropriate
Culturally-Specific – Start with the specific culture and
design strategies that emerge from constructs relevant
to the target group
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139

DSM 5 Outline for a Cultural Formulation
Aim is to provide a framework for assessing cultural features
of mental health problems with which clients present
Involves the systematic assessment within five categories:
 Cultural Identity
 Cultural Conceptualizations of Distress (cultural idioms, cultural
ideas about causes, help-seeking and treatment)
 Psychosocial Stressors and Cultural Features of Vulnerability and
Resilience (status-based stressors, social support)
 Cultural Features of the Relationship between the Individual and
Clinician (communication, trust, rapport, alliance)
 Overall Cultural Assessment (implications for diagnosis and
treatment)
The Cultural Formulation Interview (CFI) was developed to
assist in this assessment

Systematic assessment for
diverse populations (Ghosh Ippen, 2012)
the larger sociocultural context,
diversity-informed assessment of trauma history,
racism and discrimination, and
 language issues
religion and spirituality, family relationships and
social support
views of mental health treatment, views on
assessment and research,
cross-cultural differences in symptom expression).

Considerations for cultural
adaptations
(a) Comprehension: understandable
content that is matched to the linguistic,
educational, and/or developmental needs
of the consumer group;
(b) Motivation: content that is interesting
and important to this group; and
(c) Relevance: content and materials that
are applicable to participants’ everyday
lives
(Castro et al. 2010)

Cultural Adaptation
Developing tailored interventions consists of
two dimensions (Castro et al):
surface structure adaptations –(micro)
deep structure adaptations. – (macro)
It is also important to attend to intergroup
and bias issues; interpersonal issues are
impacted more on some dimensions of
diversity where fundamental cultural ways of
being are strongly held

Acculturation As A Critical
Consideration
Acculturation is an important aspect of
intragroup variability
Acculturation may influence effectiveness of
ESTs and need for cultural adaptation
Understanding cultural history and exposure is
important even if client rejects culture of origin
or says that it is not important to them
Complexity of acculturation and cultural identity
 Dangers of internalized oppression

Cultural Identification and
Cultural Orientation
Cultural identification – the degree to which
one consciously identifies with the cultural
heritage and cultural expressions of one or
more cultural groups
Cultural orientation – individual preferences for
various cultural patterns, beliefs, and behaviors
Cultural identification and cultural orientation
are intentional processes that contribute to the
formation of self-identity and worldviews

What is Acculturation?
The process of change resulting from the interaction of
one’s culture of origin with another culture
Acculturation involves the process of adopting values
and behaviors of the new culture, forming relationships
with people in the new culture, and identification with
the new culture
Simultaneously, acculturation involves the process of
retaining values and behaviors of the culture of origin,
maintaining relationships within one’s culture of origin,
and continuing identity and identification with the
culture of origin

Acculturative Stress
The experience of stressors related to the
acculturation process
Examples:
Second-language acquisition
Intergenerational conflicts
Social role confusion

Linear Model of Acculturation
Levels of Acculturation
Culture A Culture B
1 2 3 4 5

Orthogonal Model

High
Culture A
Low
Culture A
High
Culture
B
Low
Culture
B

Two-factor model of acculturation
(John Berry)
Orientation to Host/Dominant Culture
LO HI
LO
HI
Marginalization
(deculturation,
alienation)
Assimilation
(loss of culture
of origin)
Separation
(self-segregation,
traditionalism)
Integration
(biculturalism,
pluralistic)

Types of acculturating groups
Immigrants – migratory and relatively voluntary
Refugees – migratory and relatively involuntary
Native people – indigenous, nonmigratory, and
involuntary
Previously Colonized or Enslaved- forced and
involuntary contact in the context of collective trauma
Ethnic groups – nonmigratory groups who have lived in
the society for multiple generations
Sojourners – temporary cultural contact with society

A Cultural Adaptation Checklist
Review for bias and then replace elements as
necessary
Review Materials for Cultural Congruence
Review Examples and Metaphors
Explore Meanings, Values, Religious Beliefs
Assess Client’s Language of origin
Complex issues of bilingual service delivery

Creative Brainstorming
Cultural adaptation possibilities in CBT
based interventions
Small discussion groups
Use your experience with actual clients as
clues for possible points of adaptation

Terminology for Incorporating Culture
Culturally-Sensitive
Culturally-Appropriate
Culturally-Relevant
Culturally-Intentional
Culturally-Adaptive
Culturally-Alert
Culturally-Responsive
Culturally-Congruent
Culturally-Competent
Culturally-Centered
Culturally-Infused
Cultural Humility
Cultural Attunement (Falicov)
Cultural Resonance (Trimble)
Culturally-Syntonic Practice (Harrell, 2008)
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154

Why Culturally “Syntonic”?
o Syn – with or together
o the Greek “suntonos”-- in harmony with – Collins English Dictionary
o Emotionally in harmony with one’s environment -Collins English
Dictionary
o Normally responsive and adaptive to the social or
interpersonal environment -Merriam Webster’s Medical Dictionary
o In emotional equilibrium and responsive to the
environment –YourDictionary.com
o Describes somebody who is normally attuned to the
environment; used to describe behavior that does not
conflict with somebody’s basic attitudes and beliefs –Microsoft
Encarta College Dictionary
o Characterized by a high degree of emotional
responsiveness to the environment; Of or relating to two
oscillating circuits having the same resonant frequency -American Heritage Dictionary
155

Culturally-Syntonic Practice (CSP)
In the context of psychologically-informed interventions,
culturally-syntonic practice involves:
Processes, activities, relationships, and experiential presence
that reflect attunement, harmony, and resonance
with relevant dimensions of collective cultural aspects
(sociocultural processes) and their individual expressions
(psychocultural processes),
such that engagement with, and the effectiveness of,
interventions is enhanced and optimized.
(Harrell, 2008/2011)

More on a Culturally-Syntonic Approach
Characterized by
 activities, interactions, and perspectives
that reflect consistency with and responsiveness to a
person’s or group’s
 relevant cultural contexts;
 internalized cultural meanings, beliefs, values; and
 manifested actions and behaviors
such that there is a “fit” or resonance between the
practice and the relevant person-environment
transactions

Culturally-Syntonic Practice
Cultural Assessment (self and other)
Cultural Attunement (attending to interpersonal
interactions)
Cultural Infusion Strategies
Culturally Adapted
Culturally Centered
Culturally Specific

Three Principles to Guide Culturally-Syntonic
Practice
Principle of Community Culture
 Descriptive Approach
 Informed Compassion
Principle of Community Context
 Critical Analytic Approach
 Contextual Understanding
Principle of Self-in-Community
 Reflective Approach
 Empowered Humility
(Harrell & Bond, 2006)

Informed Compassion
Balanced integration of head and heart
Seeking knowledge and awareness from a place
of openness, respect, and caring
Not distanced over-intellectualized position nor
emotion-driven overidentified position

Contextualized Understanding
Multiple levels of analysis
Individual, Microsystem, Organizational,
Identity Group, Macrosystem
Temporal context
Person and interactions among persons are a
function of variables at all levels of analysis
Decontextualized analysis risks
oversimplified and superficial understanding

Empowered Humility
Proactive engagement grounded in awareness
of our vulnerabilities and limitations
Acknowledgement of another’s right to self-
determination
Understanding that stronger connection and
greater empowerment emerges from healthy
humility that frees us to be open to see, hear,
and learn in unanticipated ways– gives us
confidence to walk in unfamiliar terrain and
meet the “other” where s/he stands

The Four Ways that Culture and Context
Impact Human Experience
Cultural Socialization and Identity
 Dimensions of Exposure
 Patterns of Being, Believing, Bonding, Belonging, Behaving, Becoming
 Sociocultural and Intersectional Identities
Macrocultural and Microcultural Belonging
 Composition of settings (e.g., minority/majority status)
 Opportunities for affirmation and validation
Dynamics of Difference
 In the client’s life
 In the practitioner’s life
Sociopolitical/Sociohistorical Considerations
 “Isms” / Collective/Historical trauma and memory
 Social location, power, and privilege
 Immigration/Refugee experience; Acculturation processes
Copyright 2016. Shelly P. Harrell, Ph.D. All Rights Reserve

Some Suggestions
 PEaCE as a guiding model
 Intentional development of mental habits.
 The good news is that research indicates that we can interrupt the
impact of implicit bias on behavior through effortful attention to
our thoughts and motivations
 Self-regulation of bias can also become automatic! May not be
eliminated entirely but can be overridden by incompatible implicit
egalitarian motives and goals.
 QUESTION ASSUMPTIONS – Am I making any assumptions about
this client and their care
 Promote opportunities for positive relations
 can inhibit the activation of implicit bias
 Cultural adaptation as a NORM of practice
 Commitment to reflective practice beyond individual level
phenomenon

Main Take-Aways
Cultural Competence is ultimately a way of THINKING
about culture and translating that into practice
Normalize consideration of culture and context; they
must be central in the clinical conversation
LEARN the theory and research of cultural and
multicultural psychology
Our work as psychologists should be informed not only
be RCTs but by basic science research
 Implicit bias and stereotype threat research are examples
Explore the role of implicit bias and non-conscious
enactment of privilege
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DISCUSSION QUESTIONS
What challenges have you encountered or
observed related to culture and diversity?
What thoughts, reflections, and ideas are
you left with at the end of this day?
What are topics and ideas for continued
discussion in your setting?

Encouragement
Towards an ongoing deepening of awareness
that others may experience the world, see the
world, and be treated by the world very
differently than we are
Requires continuous reminders for Openness
and Humility that can get lost in our busy
days
Use this awareness to motivate building
greater knowledge and skills to work more
effectively across multiple dimensions of
diversity with clients and colleagues
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