Tag Archives: Multiculturalism

Practical Application of Vygotsky


Vygotsky “believed that all human cognition takes place within a matrix of social history, and thus cognition must be considered within this context.”  (Bergen, 2008, p. 105)  This is of particular interest to me since I am a high school history teacher by training, so to put it bluntly, I couldn’t agree with Vygotsky more on this point.  The way in which individuals acquire both thought and language is firmly situated within the context of the culture within which they reside.  This means that when we endeavor to help an individual with who, at first glance, may appear to have a “learning disability…” we should take into account the cultural symbolism that the child will likely identify with.  We should make every effort to communicate in terms that the child will understand, and that others will also understand if the child were to imitate the words or actions.  As an example, if we are working with a child that resides in a predominately Spanish speaking neighborhood where Spanish is the language of choice, then we should utilize that language to facilitate learning (even if it is too soon to be verbal).

Furthermore, when constructing interventions that are intended to maximize learning potential for children, we should take Vygotsky’s “zone of proximal development” into consideration in effort to make learning “relevant” for the learner.  “The ZPD is the distance between what tasks children can do independently and their potential competence at those tasks, which can be achieved with adult or peer assistance.”  (Bergen, 2008, p. 107)  In more simple terms, learning is social… and we learn how to extend our thought and action by observing people around us in a social context.  In early childhood, this takes form in pretend play… which Vygotsky would assert is absolutely essential for later school success.  We should encourage and facilitate private speech to assist the child in internalizing action with thought, especially during difficult problem solving activities.  In short, during play therapy, have them “talk it out.”  This may be as simple as continually asking “tell me what you’re doing right now.”  (Bergen, 2008, p. 111)

 

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Reference

Bergen, D. (2008). Human development: Traditional and contemporary theories. Upper Saddle River, NJ: Pearson Prentice Hall.

 

ACA Ethical Statement – Multiculturalism


In my opinion, having an awareness of multiculturalism and diversity are a foremost in my mind as being important to our success at developing healthy working relationships with clients.  The word culture appears 8 times in the American Counseling Association (ACA) Code of Ethics.  Specifically, it suggests that “counselors recognize that culture affects the manner in which clients’ problems are defined.  Clients’ socioeconomic and cultural experiences are considered when diagnosing mental disorders.”  (ACA, 2005, p. 19)  Ivey, Ivey & Zalaquett (2010) broadly define multiculturalism and diversity to include “race/ethnicity, gender, sexual orientation, language, spiritual orientation, age, physical ability/disability, socioeconomic status, geographical location, and other factors.”  (Ivey, Ivey, & Zalaquett, 2010, p. 43)  Given this broad contextual definition of culture, and the mandate of the ACA, we can deduce that multiculturalism should be an integral part of every counseling interaction we undertake.

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Some would suggest that the only alternative is functioning as a culturally encapsulated counselor who defines reality according to one set of cultural assumptions, shows insensitivity to cultural variations, makes little effort to accommodate the behavior of others, and resists adaptation and rejects alternatives.  (Corey, Schneider-Corey, & Callanan, 2007, p. 117)  While it is suitable difficult to criticize multiculturalism in moderation, at its extremes I would suggest that multiculturalism can be detrimental.  Specifically, cultural relativism presents a dimension of diversity that, when examined closely, undermines the validity and the usefulness of some multicultural pursuits.  The influential American anthropologist Ruth Benedict, in her seminal work entitled Patterns of Culture (1934), described cultural relativism:

No man ever looks at the world with pristine eyes.  He sees it edited by a definite set of customs and institutions and ways of thinking.  Even in his philosophical probings he cannot go behind these stereotypes…  The life-history of the individual is first and foremost an accommodation to the patterns and standards traditionally handed down in his community.  From the moment of his birth the customs into which he is born shape his experience and behavior.  By the time he can talk, he is the little creature of his culture, and by the time he is grown and able to take part in its activities, its habits are his habits, its beliefs his beliefs, its impossibilities his impossibilities.  Every child that is born into his group will share them with him, and no child born into one on the opposite side of the globe can ever achieve the thousandth part.  (Benedict, 1934, p. 2-3)

To most, that makes sense, and I wager that most would agree with the above statement.  However, consider this.  “If all morality is relative, then what moral objection could one make to the Nazi holocaust, to the economic deprivation of a Latin American underclass, or to a militaristic nation’s unleashing nuclear devastation on others?  And what would be wrong with conducting painful experiments on young children, using them for case studies on the long-term psychological effects of mutilation?  In a world where no moral court of appeals exists, might makes right.  The only appeal can be to power.”  (Holmes, 1984, p. 17, 18)

Making cultures equally valuable makes them equally valueless.  The point, if there is one, is that we need to seek out and obtain a balance between multiculturalism and ethnocentrism.  If we go too far in either extreme, we do so at our own peril.

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References

American Counseling Association. (2005). ACA code of ethics. Retrieved from http://www.counseling.org/Files/FD.ashx?guid=ab7c1272-71c4-46cf-848c-f98489937dda

Benedict, R. (1934). Patterns of culture. Boston: Houghton Mifflin.

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th ed.). Belmont, CA: Brooks/Cole.

Holmes, A. F. (1984). Ethics. Downers Grove, IL: InterVarsity Press.

Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing & counseling (7th ed.). Belmont, CA: Brooks/Cole.

Ponton, R. F., & Duba, J. D. (2009, Winter). The ACA code of ethics: Articulating counseling’s professional covenant. Journal of Counseling and Development : JCD, 87(1), 117-121. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1618074141&sid=2&Fmt=2&clientId=4683&RQT=309&VName=PQD

Intentional Interviewing


Within the context of the therapeutic exchange, the word ‘intentional’ in ‘intentional interviewing’ seems to suggest that every motion (think micro-skills) a therapist makes should be motivated by a sense of purpose.  Beyond a results driven goal-oriented structure, Ivey, Ivey, and Zalaquett (2010) seem to be proponents of a ‘structured interview’ that remains flexible enough to account for ‘the unexpected,’ and semi-structured enough to account for the multicultural variation of clients.  Given a broad interpretation of culture that could literally represent any number of demographic variables including “age, gender, place of residence; status variables such as social, educational, and economic background; formal and informal affiliations; and the ethnographic variables of nationality, ethnicity, language, and religion;” it is literally impossible for two people to match on every variable.  (Corey, Schneider-Corey, & Callanan, 2007, p. 115)  As a result, I am inclined to suggest that every counseling session should invariably be built on a foundation that advances diversity and diminishes stereotypical generalizations.

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This structured interviewing process is founded on a 5 step process that includes building the relationship, identifying a story and strengths, goals, restory, and action.  The relationship is of paramount importance to the establishment and maintenance of a working alliance between the therapist and the client.  The foundation of the relationship building process is listening.  “It is consistently estimated that 30% of successful counseling and therapy outcome is due to relationship or common factors consisting of caring, empathy, acceptance, affirmation, and encouragement.”  (Ivey et al., 2010, p. 19)  None of the above common factors are possible without listening.  Personally, I think 30% is modest.

The story and strengths portion of the interview will be variably determined by the underlying system or theory that is being employed by the therapist.  This is an attempt to determine “where the client is at” as determined by the underlying theoretical premise(s) to which we subscribe.  The authors suggest we be sensitive to themes that would allow us to draw out, identify, and accentuate one or more strengths of the client.  This may be as mundane as acknowledging that the client has sufficient insight to recognize that they needed help, or it may manifest as highlighting adaptive coping mechanisms within the context of the stories told.

Once we have determined “where the client is at,” it is important that we allow the client to verbalize “where they would like to be.”  I have chosen my words carefully because the notion of client autonomy and self determination is paramount to the goal setting process.  Furthermore, this process of goal identification proves useful in focusing motions on the objective.  Ideally, the stories we attempt to cultivate should be relevant to the verbalized goal.  The alternative is a meandering experience without a focal point.

Restory is an element of the equation that I consider to be more of an art than a science.  Restory represents a process whereby we reinterpret and reframe events in an attempt to “help clients generate new ways to talk about themselves.”  (Ivey et al., 2010, p. 19)  I liken this portion of the interview to the ‘trial close’ in a sales presentation.  This is a critical element because there is a process of ‘trial and error’ on the part of the therapist whereby we attempt to find a ‘trigger’ in the client that will serve as a catalyst.  Just as no single type of close works on every customer, no single theoretical solution is going to work for every client.  As a result, Ivey and associates suggest we keep an open theoretical stance and remain flexible in our endeavor to find a personalized solution for the each individual client.

Action… action is ‘the test’ to attempt to see if our proposed solution is ‘close enough to the target’ to be effective.  I stress ‘close enough to the target’ because more often than not the colloquial maxim ‘there’s more than one way to skin a cat’ holds up.  If we are successful the client will generalize concepts explored in therapy to the ‘real world’ and subsequently make progress toward his or her stated goal.

There is one specific aspect about this process that I feel the authors have neglected… perhaps this aspect is addressed later in the text, or in another section, but where do ‘implications’ fit into the mix?  In my view, it is absolutely necessary for us to have the client identify the implications of both action and inaction, be they positive or negative.  Through this process, we leverage the relationship to position the action as a solution to the predicament.  In this process, I believe it is imperative that we ask the question ‘What if you choose to try XXXX?’ or ‘What if you choose to do nothing?’  Without a client realizing the implications of the choice, there’s no point in taking the action.  Just food for thought…

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References

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th ed.). Belmont, CA: Brooks/Cole.

Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing & counseling (7th ed.). Belmont, CA: Brooks/Cole.

Substance Abuse: Diagnosis, Comorbidity, and Psychopathology


Because substance abuse disorders (SUDs) are among the most common psychiatric conditions in the United States, approaching 9% prevalence of individuals aged 12 or older, I anticipate that it would be extremely difficult to function as a Licensed Mental Health Professional (LMHP) without being a Licensed Alcohol and Drug Counselor (LADC) as well.  (Blaney & Millon, 2009, p. 280)  Just out of curiosity, are most of the people in my cohort also going to pursue the LADC license?

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I was surprised to see a lack of diagnostic distinction for individuals at different developmental points in life.  Early onset (Type 2, or Type B) SUDs are typically associated with very different etiologies and outcomes, but the treatment options for the two types are similar.  Is there any speculation where there is a lack of a specific treatment options for these divergent types of SUDs?  As was suggested in the text, it seems self evident that engaging in preventative measures on behalf of people whom “are not yet symptomatic but evidence various characteristics of a known subtype” seems to be in order.  (Blaney & Millon, 2009, p. 282)

“The familial link for alcohol use disorders is widely established in the research literature.”  (Blaney & Millon, 2009, p. 282)  It remains unclear which familial association is most responsible for the increased risk, because both genetic and environmental factors play significant roles.  Exposure to parental SUDs, for example, exerts both a genetic and environmental predisposition that can reliably predict development of SUDs in the children.

I expected more discussion regarding multiculturalism when it came to alcohol and expectancies.   Differences in family structures (nuclear vs. extended) and media influences, in particular, have a great deal of impact on the development of expectations regarding the effects of alcohol and other substances.  The admission that expectancies are modifiable gives us some hope for cognitive-behavioral treatments.

I was suitably surprised that the gender gap is narrowing for both alcohol and illicit drugs over time.  (Blaney & Millon, 2009, p. 284)  “Telescoping” refers to the fact that women experience problems faster, meet criteria for abuse and dependence in a shorter time, and present for treatment earlier (at similar levels of consumption).  This would appear to suggest that women are more vulnerable to the physical and mental consequences of alcohol use and abuse.  Women experience more psychiatric comorbity when compared to men.  (Blaney & Millon, 2009, p. 285)

I disagree with the statement that “substance use does not directly lead to violence or criminal behavior.”  (Blaney & Millon, 2009, p. 285)  Here is just one example… http://www.youtube.com/watch?v=RbwSwvUaRqc I think this particular example is an excessive use of force, but the reality is this gentleman would have had no issues if he kept his hand out of the cookie jar.

Comorbidity is the rule not the exception when it comes to SUDs.  There are several factors that may contribute to this astonishing fact, among them the fact that “base rates of common psychiatric disorders naturally result in co-occurrence.”  (Blaney & Millon, 2009, p. 287)  Additional support may be found in the likelihood of seeking treatment (due to the comorbid disorder, exacerbation of sub-clinical symptoms, common genetic factors, and/or shared environmental risk factors.  Comorbid disorders, especially SUDs, complicate diagnosis and treatment.  Substance use and abuse can decrease medication adherence, cause side effects, and “potentiate some psychotropic medications increasing the potential for overdose.”  (Blaney & Millon, 2009, p. 287)  Mood disorders, anxiety disorders, eating disorders, ADHD, and ASPD (as well as schizophrenia and other psychoses) were all implicated as being “highly comorbid” with SUDs.

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Ooops! …on the potential for malpractice when serving diverse populations.


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If there is anything that keeps a therapist up at night, it’s the potential for a malpractice suit… misdiagnosis, diagnostic errors, and/or delayed diagnosis are at the forefront of our concerns.  “What if I get it wrong?”

Braun & Cox (2005) suggest some measures that can be implemented to reduce likelihood of getting into this legal or ethical dilemma.  Informed consent can help clients understand benefits, and allow the clinician to properly set expectations around the services that are covered… especially with regard to termination since additional sessions are likely to be expensive in some cases.  Furthermore, clients need to be aware that counselors can no longer ensure privacy of disclosure because managed care organizations (MCOs) may require sensitive information.  The release of this information may precipitate changes in treatment and outcome due to the fact that MCOs typically determine the type of treatment that should be employed and/or would be covered.  We would also need to familiarize ourselves with “brief therapy models” in order to be competent at providing services through MCOs.  (Braun & Cox, 2005, p. 426)  If we intend to work with this specific client population we need to be well versed in all of the above considerations before we even consider taking a client that intends to utilize them as a 3rd party payer.

Although I do not consider it to be a personal deficit, historically, there is a general mistrust and underutilization of the medical and mental health communities as it relates specifically to people of color.  Adequately addressing this climate of mistrust demands that we engage in an “honest and thorough self-examination of conscious and unconscious attitudes about race and the legacy of racism in the United States.”  (Suite, La Bril, Primm, & Harrison-Ross, 2007, p. 883)  Furthermore, Suite and associates (2007) suggest we “keep at arm’s length assumptions of cultural homogeneity and offer contextually based mental healthcare.”  They define contextually based mental healthcare as “extensive and critical interpretation of the historical, cultural, spiritual, political, social and philosophical underpinnings of racism in medicine and draw connections on how these factors impact the self-identities of communities and individuals therein.”  In my opinion, it is absolutely imperative that we attempt to understand how individual people of color perceive mental healthcare as an institution, as well as rebuild trust in the institution as a whole by delivering culturally sensitive options at every step of the therapeutic process.

References

Braun, S. A., & Cox, J. A. (2005, Fall). Managed mental health care: Intentional misdiagnosis of mental disorders. Journal of Counseling and Development : JCD, 83(4), 425-433. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=916199881&sid=10&Fmt=3&clientId=4683&RQT=309&VName=PQD

Suite, D. H., La Bril, R., Primm, A., & Harrison-Ross, P. (2007, Aug). Beyond misdiagnosis, misunderstanding and mistrust: Relevance of the historical perspective in the medical and mental health treatment of people of color. Journal of the National Medical Association, 99(8), 879-885. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1319356711&sid=10&Fmt=3&clientId=4683&RQT=309&VName=PQD

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Matching yourself with a therapist… important or irrelevant?


The word culture can be interpreted broadly.  It can include demographic variables such as age, gender, and place of residence; status variables such as social, educational, and economic background; formal and informal affiliations; and the ethnographic variables of nationality, ethnicity, language, and religion.  (Corey, Schneider-Corey, & Callanan, 2007, p. 115)  Given this broad based definition, it is literally impossible for us to consider every interaction as anything less than multi-cultural.  No single person is capable of sharing all the traits that contribute to our cultural identity, and as a result, any attempt to match ourselves with our clients (or clients to ourselves) is an exercise in futility.  It is impossible to match client and therapist in all areas of potential diversity, which means that all encounters with clients are diverse, at least to some degree.  (Corey et al., 2007, p. 141)  It’s a safe to assume that while you may share commonalities in one specific variable, like age for example, you likely do not share one or more demographic variables that contribute to the definition of culture.

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I would suggest we tread lightly when generalize about any single group in effort to “match” ourselves to our clients… or try to match ourselves to a potential therapist.  In doing so, we not only do injustice to our clients but we do injustice to ourselves and our own personal growth.  In my own personal journey to becoming a counselor, and indeed throughout my life, I am amazed and humbled by the differences among us.  Every time we meet someone, the potential is there to see the world through a new set of eyes.  I aspire to find as many opportunities as I can to walk in another man’s shoes, and to see through her eyes, so that I can understand more fully what it really means to be human.

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Reference

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th ed.). Belmont, CA: Brooks/Cole.