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