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Counseling Across Cultures

Seventh Edition

Counseling Across Cultures

Seventh Edition
Edited by
Paul B. Pedersen
Syracuse University (Emeritus); University of Hawaii (Visiting); Maastricht School of
Walter J. Lonner
Western Washington University (Emeritus)
Juris G. Draguns
Pennsylvania State University (Emeritus)
Joseph E. Trimble
Western Washington University
Mara R. Scharrn-del Ro
Brooklyn College City University of New York

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Introduction: Learning From Our Culture Teachers
1. 1. Toward Effectiveness Through Empathy
2. 2. Counseling Encounters in Multicultural Contexts: An Introduction
3. 3. Assessment of Persons in Cross-Cultural Counseling
4. 4. Multicultural Counseling Foundations: A Synthesis of Research Findings on Selected
1. 5. Counseling North American Indigenous Peoples
2. 6. Counseling Asian Americans: Client and Therapist Variables
3. 7. Counseling Persons of Black African Ancestry
4. 8. Counseling the Latino/a From Guiding Theory to Practice: Adelante!
5. 9. Counseling Arab and Muslim Clients
1. 10. Gender, Sexism, Heterosexism, and Privilege Across Cultures
2. 11. Counseling the Marginalized
3. 12. Counseling in Schools: Issues and Practice
4. 13. Reflective Clinical Practice With People of Marginalized Sexual Identities
1. 14. Counseling International Students in the Context of Cross-Cultural Transitions
2. 15. Counseling Immigrants and Refugees
3. 16. Counseling Survivors of Disaster
4. 17. Counseling in the Context of Poverty
5. 18. The Ecology of Acculturation: Implications for Counseling Across Cultures
1. 19. Health Psychology and Cultural Competence
2. 20. Well-Being and Health
3. 21. Family Counseling and Therapy With Diverse Ethnocultural Groups
4. 22. Religion, Spirituality, and Culture-Oriented Counseling
5. 23. Drug and Alcohol Abuse and Health Promotion in Cross-Cultural Counseling
6. 24. Group Dynamics in a Multicultural World
About the Editors
About the Contributors

Elder Wisdom
An elder Lakota was teaching his grandchildren about life. He said to them, A fight is going on
inside me... it is a terrible fight and it is between two wolves.
One wolf represents fear, anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment,
inferiority, lies, false pride, superiority, and ego.
The other stands for joy, peace, love, hope, sharing, serenity, humility, kindness, benevolence,
friendship, empathy, generosity, truth, compassion, and faith.
This same fight is going on inside you, and inside every other person, too.
The grandchildren thought about it for a minute, and then one child asked her grandfather,
Which wolf will win?
The Elder replied simply, The one you feed.
The Western conception of the person as a bounded, unique, more or less integrated motivational
and cognitive universe, a dynamic center of awareness, emotion, judgment, and action, organized
into a distinctive whole and set contrastivelyboth against other such wholes and against social
and natural backgroundis however incorrigible it may seem to us, a rather peculiar idea within
the context of the worlds cultures. (p. 34)
Geertz, C. (1973). The interpretation of cultures: Selected essays. New York: Basic Books.
The first peace, which is the most important, is that which comes within the souls of men when they
realize their relationship, their oneness, with the universe and all its Powers, and when they
realize that at the center of the universe dwells Wakan-Tanka, and that this center is everywhere,it
is within each of us. This is the real Peace, and the others are but reflections of this.
The second peace is that which is made between two individuals, and the third is that which is
made between two nations. But above all you should understand that there can never be peace
between nations until there is first known that true peace which... is within the souls of men. (p.
Black Elk, in Neihardt, J. G. (1961). Black Elk speaks: Being the life story of the holy man of the
Oglala Sioux. Lincoln: University of Nebraska Press.
Conscientization does not consist, therefore, of a simple change of mind about reality, of a change
in individual subjectivity that leaves intact the objective context; conscientization supposes a
change in people in the process of changing their relationship with the environment, and above all,
with others.

True knowledge is essentially bound with transformative social action and involves a change in
the relationship between human beings.
Martn-Bar, I., & Blanco Abarca, A. (1998). Psicologa de la liberacin. Madrid: Editorial Trotta.

Nearly every academic book ever published has acknowledged individuals who in some way played
important roles in the books development. In this book we depart from the usual custom and
acknowledge those who, on one hand, were important in organizing, editing, and producing the book,
as well as those who, on the other hand, played important roles in the lives of the five coeditors. The
former can be considered general acknowledgments that we all share. The latter are necessarily
different for each of us. Thus we have agreed to contribute individually.
In the general category we want to thank SAGE Publications for the confidence it has shown in us
throughout the years. The two key SAGE people with whom we have worked are Kassie Graves, who
has been part of this effort for many years, and her assistant, Carrie Baarnes. Although a relative
newcomer to SAGE, Carrie was a big help in the latter stages. We were flattered that Claudia
Hoffman, SAGEs director of U.S. book production, pointedly selected Counseling Across Cultures
as a book she wanted to usher through its final copyediting and production stages. In characteristic
good judgment, Claudia chose Judy Selhorst to be copy editor for the book. It is remarkable how
careful and efficient Judy was during the latter part of the process, when it is so important to be
complete and precise. Candace Harman and her crew in the graphics department did an excellent job
with the cover. Further north, on the campus of Western Washington University, is Genavee Brown. A
graduate student in the Department of Psychology and a most promising young scholar, Genavee was
the organizer in crucial stages. When the book is published, the first copy will go to Paul Pedersen
and the second will go to Genavee.
On the personal side, we offer the following highly individualized acknowledgments:
Paul B. Pedersen. I would like to acknowledge and to dedicate my role in the preparation of this
book to Anthony J. Tony Marsella, professor emeritus of the University of Hawaii. Tony was my
prime teacher at so many different levels. He was as comfortable in the village council of a Borneo
community as he was, for example, during a World Health Organization committee meeting many
years ago, or as he was in his lectures throughout his illustrious career. The classes he taught would
frequently end with standing ovations by his students. He originated the awareness, knowledge, and
skill model, which became the basis of the measures for competence within the field of multicultural
counseling. Many other examples of his influence come to mind. Most important, he has in recent
years become a first-class friend and co-traveler in lifes journey. In the metaphor of family, Tony has
fathered many children among his students, his colleagues, and his other brothers and sisters. For all
that you have given, Tony, I send you my thanks.
Walter J. Lonner. Above all else I want to thank my immediate family, consisting of many people,
both living and dead. Among the living are my everything-and-then-some wife, Marilyn, and our three
great children (Jay, Alyssa, and Andrea), each of whom has two daughters with terrific spouses. The
world had better watch out for those six little dynamos. By name and current age they are Sika (14)
and Brenna (11) Lonner, Sophia (11) and Alena (8) Naviaux, and Nina (7) and Sage (4) Howards. I
was blessed with great parents and two brothers: Terry, the youngest of us, who is a beacon of honor
and dependability and a jack-of-all-trades; and George, the oldest. We grew up in beautiful and

generous western Montana. George died October 8, 2012, about midway through the work on this
book. George was the familys Don Quixote, dreaming big things and imagining the impossible. It is
he, not I, who should have been a university professor, for he would have dazzled thousands of
students with his talent of mixing fact with fantasy. The encouragement and praise that Terry and
George and the rest of my family piled upon me, through thick and thin, has always kept me going. I
also want to acknowledge the multidimensional influence that an international network of scholars has
had on my 50-plus years of trying to understand the nature of cultures influence on everything we say,
think, and do. Part of this network consists of the many talented people, including the current slate of
coeditors, who have contributed to one or more of the seven editions of Counseling Across Cultures.
Juris G. Draguns. Throughout the seven editions of Counseling Across Cultures, I have enjoyed
marvelous support, encouragement, and understanding from my wife, Marie. We have shared 52
wonderful years, and Maries love and empathy have helped me overcome whatever obstacles have
stood in my way, sometimes tangible, more often subjective. As I thought about, wrote, and edited
Counseling Across Cultures, I would temporally disappear into the book, and Marie was always
there to welcome me when I reemerged from its pages. My two children, Julie and George, were
young when Counseling Across Cultures first appeared. They grew up as the book evolved through
its several transformations, and the two processes intertwined. What has remained constant is our
mutual love and my vicarious enjoyment of and pride over Julies and Georges families, careers, and
achievements. Thinking back on my early years, I gratefully remember my parents, especially my
mother, who instilled in me a curiosity and love of learning and protected me from the dangerous
world outside our home. It is thanks to her that I survived and was able to work toward the realization
of my version of the American Dream. And in the course of the ensuing multiple transitions I
benefited from a host of culture teachers who helped me become more empathetic and perhaps more
helpful across cultural barriers. They are too numerous to mention, but my sincerest thanks go to them
Joseph E. Trimble. I owe Paul Pedersen a special measure of personal gratitude and appreciation. In
August 1972 Paul met with me and my wife, Molly, at a lanai in Honolulu. Over a late-morning
breakfast he vividly described his new triad theory of counseling training to underscore his strong
growing interest in culture and psychological counseling. It was a memorable occasion for the three
of us. A few years later, Paul invited me to give a symposium paper on counseling American Indians
and later publish a chapter in the first edition of Counseling Across Cultures. Molly was extremely
helpful when I wrote that first chapter and continues to be insightful and helpful in almost all of my
writing activities. She has a keen eye for detail and a spirited mind for novel concepts and ideas.
Throughout the course of each of the Counseling Across Cultures editions our three lovely and
talented daughters, Genevieve, Lee Erin, and Casey Ann, have been with me when each edition
arrived home for their review and comment, and it has always been a proud moment for me when they
read their names in the acknowledgments and commented on it. Also, I am deeply grateful for all of
the people who have provided me with guidance, advice, and collaboration on the contents of the
various chapters put together for the seven editions. Thank you especially to Candace Fleming, Fred
Beauvais, Pamela Jumper Thurman, and John Gonzales.
Mara R. Scharrn-del Ro. I am very grateful for the love, guidance, and support of mi familia. My
mother, Rosarito, and my sister Marilia housed and fed me in Puerto Rico as I was finishing the final

editing process for this book. My sister Marichi also assisted me with her commentary during this
time, and my father, Rafael, accompanied me on a couple of hour-long mental health escapades to the
ocean. I am also grateful to my partner, Yvonne, for her love, support, and understanding, and for
providing a home for me in Germany during part of my sabbatical. Many thanks also to my chosen
family in New York CityCody, Mara, Barb, Wayne, Paul, and Flowho helped in too many ways
to count. I owe a special thanks to Joseph Trimble and Guillermo Bernal, who have been outstanding
mentors and friends since I was an undergraduate student in the Career Opportunities in Research
(NIMH-COR) program at the University of Puerto Rico. I also want to thank Eliza Ada Dragowski
for her exceptional work and support in the completion of this book. Finally, my thanks to the
wonderful group of people who provided additional guidance on the content of various chapters of
the book: Priscilla Dass-Brailsford, Stuart Chen-Hayes, Hollyce Giles, Vic Muoz, Delida Snchez,
and Avi Skolnik.
Paul B. Pedersen
Walter J. Lonner
Juris G. Draguns
Joseph E. Trimble
Mara R. Scharrn-del Ro

During a lifetime of more than four score and four years, I have seen culture change before my eyes
like a fast-moving kaleidoscope. Old ways of being are replaced rapidly by new ones. Each
generation upgrades its relationships with the various environments that affect its existence. As I
developed and acquired more information about my time-and-space world, I understood the
complexity of culture. In high school, I heard it discussed in connection with geography. My teachers
talked about how the natural environments in which people live necessarily influence their ways of
life. Their environments determine the kinds of homes they build to protect themselves from outside
elements. Since climates vary from one time zone to another, it is tenable to conclude that the
structures in which people live and work also differ from one part of the world to another.
In undergraduate school, I learned other things about culture. People in various groups often dress
differently from one another and may speak languages other than English. They often observe
religious practices different from the ones I knew. From the social science classes I took, I acquired a
general understanding of culture. After graduating from college, I spent two years in Europe. There I
saw up close what my professors had meant about people being different from one part of the world
to another. I kept journals on places I visited and people I met that confirmed the content of my
professors lectures. Notable among my experiences was the day I encountered Jean-Paul Sartre and
his companion Simone de Beauvoir in a small Parisian caf where they were reading some of their
works. When I entered graduate school at Indiana University, understanding culture was my passion. I
read as much as I could about it; I took as many sociology courses as I could work into my academic
program. I learned that there were more than a hundred definitions of culture and that cultural
theorists used a variety of concepts to highlight ideas that they deemed uniquely theirs. I learned that
culture is not only material but also immaterial. That is, there are objects in our environment that
determine the nature of our existence. There are also many things we cannot see. For example, we
have values and attitudes about everybody and everything. People interact with their surroundings.
The individuals behavior is influenced by that of others. Culture is learned. It is experienced and
internalized. This internalization is often referred to as personality. It is conscious and unconscious,
affective and cognitive, perceptible and imperceptible, and much more.
When I became a practicing psychologist and counselor educator, I felt the need to understand the
cultures of my clients, because I soon became aware that their problems were usually related to the
cultural contexts in which they grew up and resided. By the 1960s, the civil rights movement in the
United States was going full blast. Integration was becoming a reality for African Americans who had
previously lived in an apartheid-like society. They had always lived in segregated communities and
attended segregated schools. After the changes of the 1960s, African Americans began showing up in
formerly all-White classrooms and in the offices of school counselors. The American Personnel and
Guidance Association (now called the American Counseling Association, or ACA), officially
organized in 1952, soon found itself in the midst of the turmoil of a dramatically changing society.
Throughout the country, White counselors were expected to help Black clients; Black counselors
were expected to help White clients. It was out of the new clienteles and the different cultures they
represented that a new interest area emerged in the counseling profession. Paul Pedersen was among
the first educators to take the lead in helping counselors and psychologists to meet more effectively

the needs of clients who came to be referred to as culturally different. As I got to know Paul, I
recognized that he was visionary and just the right person to convene a panel of counselors, counselor
educators, and psychologists to discuss cross-cultural counseling at the 1973 convention of the
American Psychological Association in Montreal. Out of the panel presentations came the first
edition of Counseling Across Cultures, published in 1976. Becoming a classic in cross-cultural
counseling, it has contributed significantly to what is now the fastest-growing movement in
counseling. I am proud to have been one of the participants on the APA Montreal panel and a chapter
contributor to the first edition of the book.
After the Montreal panel presentation, I conceptualized a model of culture designed to help
counselors meet the needs of their culturally challenging clients. I argue that most human beings are
molded by five concentric cultures: (1) universal, (2) ecological, (3) national, (4) regional, and (5)
racio-ethnic. The human being is at the core of these cultures, which are neither separate nor equal.
The first and most external layer is the universal culture, or the way of life that is determined by the
physiology of the human species. People are conceived in a given way, they consume nourishment to
live, they grow into adulthood, they contribute to the group, and they grow old and die. These and
other ways of life are invariable dimensions of human existence. During the course of the social
development of the species, people learn to play a variety of roles essential for survival. These are
internalized and transmitted from one generation to another. It seems important that counselors
recognize themselves and their clients as members of this culture that is common to all humanity. The
recognition helps counselors to identify with and assist all clients, regardless of their cultural and
socioeconomic heritage.
Human existence is also shaped by the ecosystem, which is the lifeline for everybody. Climatic
conditions, indigenous vegetation, animal life, seasonal changes, and other factors determine how
people interact with nature and themselves. People who use dogsleds to go to the grocery store
experience life differently from those who need only to gather foodstuffs from the trees and plants in
their backyards. Inhabitants of Arabian deserts wear loose body coverings and headgear to protect
themselves from the dangerously hot rays of the sun and from unexpected sandstorms. The way of life
that people develop in order to survive in a specific geographical area of the world may be called the
ecological culture, the second layer of culture.
The third environment that molds human beings is the national culture. It is reasonable to
conceptualize a national culture for several reasons. Most people are born into particular nations. In
general, each country has a national language, basic institutions, and a form of government, and the
residents of the country have a way of seeing the rest of the world and particular values and attitudes
about themselves and their fellows. Individuals born within the confines of a countrys borders are
usually socialized to adjust to the rules and regulations of that country. They learn to fit into the
prevailing way of life. People first start learning to fit into the national social order in the home, and
they continue their socialization in school and other settings. Although a country may contain several
national subcultural groups, members of all such groups cannot escape the influence of the
overarching national culture.
A fourth influence on the lives of people is regional culture. In many countries, individuals identify
not just with the national culture but also with the cultures of specific parts of their countries. For

example, Americans who live along the U.S.Mexico border may feel as Mexican as they do
American. Many such residents speak Spanish and enjoy the food, music, and way of life common to
Mexico. Regional cultures are evident in many African countries. In the north of Nigeria, where the
country borders Niger, the Housas, one of the countrys largest ethnic groups, straddle the border that
separates the two countries, thereby causing the same regional culture to exist in both countries.
The final layer is racio-ethnic culture. It is based on the recognition that racially or ethnically
different groups often reside in areas separate from those in which a countrys dominant racial or
ethnic group live. People inhabiting such racial or ethnic enclaves usually develop and maintain
cultures that are unique to the communities in which they live. Although citizens of and participants in
the national culture, they may also identify strongly with their racial or ethnic group and its way of
life. For example, because of their slave heritage, African Americans have developed and continue to
maintain a culture that is in many ways different from the national culture. Many institutions, such as
the Black church, which dates back to slavery, contribute to the continuation of a Black culture in
some communities.
The fivefold concentric conception of culture indicates that people are the products of several
influences over which they have little or no control. No individual should be considered only a
member of a single national, racial, or ethnic culture. People are often simultaneously members of
several culturesthey are individually multicultural. Even so, across all cultures, people are more
alike than they are different. Counselors who recognize the commonalities that humans share are apt
to be more effective in helping all clients than those who focus on perceived cultural differences.
Universal and ecological cultures unify the human group more than regional, national, or racio-ethnic
differences separate the species.
Readers who compare this seventh edition of Counseling Across Cultures with the earlier editions
will be able to appreciate how much the study of culture and counseling has evolved over the years.
One thing that I notice is how many more clienteles described as needing cross-cultural intervention
exist today than in 1973. Culture is no longer just an esoteric concept discussed in sociology classes
and texts. It has now become an idea appreciated, espoused, expanded, and exploited by most
counselors and counselor educators. In graduate school, I mentioned to my major professor an interest
in writing my dissertation on a topic related to the effect of culture on the outcomes of counseling. He
discouraged me from pursuing that research topic and added, Everybody knows that counseling is
counseling. Feeling downhearted, I pursued a dissertation topic more in keeping with his view of
what was an appropriate research idea. However, since receiving the PhD in 1965, I have written
countless articles, chapters, and books on how culture influences the counseling process. Culture has
become the linchpin of counseling throughout the world.
Having devoted my career to studying the relationship of culture and counseling, I am understandably
pleased to write the foreword to this significant contribution to the increasingly large literature on
cross-cultural counseling. The seventh edition of Counseling Across Cultures is a historical
landmark. It is noteworthy because it, along with the previous editions, provides a long view of
culture and counseling as they have evolved in a rapidly changing profession. It is evident that culture
has taken on a more inclusive meaning today than it had more than 50 years ago, when I was in
graduate school. Then, some of my sociology professors talked unabashedly about certain segments of

our society being culturally deprived or disadvantaged. Being the only African American in most
of my classes, I was shocked and hurt to hear such assertions, because I had learned in undergraduate
school that everybody has a culture. I now understand that my professors were talking about the
culture of White Americans. It was their way of being, not that of most Americans of Native, Asian,
African, or Hispanic descent, or a host of other citizens who were identified with a hyphen in their
group designations to set them apart from the dominant cultural group.
Counseling has also evolved since the formation of the American Counseling Association in 1952 as
the Personnel and Guidance Association. Subsuming the National Vocational Guidance Association,
the National Association of Guidance and Counselor Trainers, the Student Personnel Association for
Teacher Education, and the American College Personnel Association, the newly formed organization
extended the work of social workers, teachers, and vocational counselors. Today, ACA consists of 20
chartered divisions and 56 branches in the United States and abroad. The divisional membership
breakdown usually reflects the clienteles in which the various professionals specialize. Moreover,
there are wide variations in how counselors identity themselves. Some see themselves as guidance
counselors similar to how most school counselors saw themselves in the 1950s. Others consider
themselves psychologists. Still others identify with psychiatrists. In spite of the broad definitions of
culture and counseling and the wide range of counselor identifications, multiculturalism became what
Paul Pedersen calls the fourth force in counseling. It continues to be the most important thrust of
counseling in the 21st century. This new edition of Counseling Across Cultures is, in effect, a status
report on this very important aspect of counseling. The chapters in this book were written by some of
the most outstanding counseling authorities in the United States and abroad. The information contained
in them is a godsend for graduate students, professors, and therapeutic professionals working in a
variety of settings.
Clemmont E. Vontress, PhD
Professor Emeritus of Counseling
George Washington University

Our Deepest Thanks to Paul B. PedersenFriend, Scholar, and

Paul Pedersens fervent passion about counseling across cultures began at a time when few
psychologists and mental health practitioners considered the importance of the cultural dimension in
any significant way. The inclusion and subsequently the infusion of the cultural dimension in
counseling and clinical psychology became a longtime commitment for Paul when he was a graduate
student and quite possibly even before then. In the late 1960s, Paul developed and carefully nurtured
what he eventually called the triad training model of counseling, which emphasized the training of
counselors in settings where cultural similarities and differences were the centerpiece for counselor
education. It was controversial at the time, yet it resonated with many who were the early innovators
and leaders in the emerging field of cross-cultural psychology. In essence, Paul describes triad
training as a self-supervision model in which the counselor processes both positive and negative
messages a client is thinking but not saying in counseling. Articulating these hidden messages and
checking out their validity helps the counselor (1) see the problem from the clients viewpoint, (2)
identify specific sources of resistance, (3) diminish the need for defensiveness, and (4) identify
culturally resonant recovery skills.
If there was a pivotal moment in the history of counseling across cultures, it happened at the 88th
annual convention of the American Psychological Association, held in September 1980 in Montreal,
Canada. Paul organized what we believe was the first, and certainly the most visible, symposium
focusing on counseling across cultures. The hour-long symposium involved several psychologists
who were making seminal contributions to the field, including Edward Stewart, Walt Lonner, Julian
Wohl, Joseph Trimble, Juris Draguns, and Clemmont Vontress. In 60 short minutes the panel discussed
various cross-cultural counseling topics. Eventually all of the panelists wrote chapters for the seminal
cross-cultural counseling textbook that we now present in its seventh editionwhat we believe to be
a record for a book of its kind.
Pauls career-long commitment to promoting the importance of culture in psychology was sparked by
his early travels hitchhiking across Europe and his academic appointments beginning in 1962 as a
Visiting Lecturer in Ethics and Philosophy and the Chaplain at Nommensen University in Medan,
Sumatra, Indonesia. He studied Mandarin Chinese full-time in 1968 in Taiwan. From 1969 to 1971,
Paul was a part-time Visiting Lecturer in the Faculty of Education at the University of Malaya; also,
he was the Youth Research Director for the Lutheran Church of Malaysia and Singapore. While in
Indonesia and Malaysia Paul quickly realized that what he had learned about conventional counseling
in graduate school didnt accommodate the worldviews of Malaysians, Chinese, and Indonesians,
among many others. The daily dose of rich and deep cultural experiences combined with the
challenges associated with understanding culturally unique lifeways and thoughtways quietly planted
the seeds for his plans to develop, advocate, and promote the value and significance of considering
cultural differences in the counseling and clinical psychology professions.
In 1971, Paul accepted the position of Assistant Professor in the Department of Psycho-educational
Studies at the University of Minnesota in Minneapolis; he also held a joint appointment as an adviser

in the International Student Office. Drawing mainly on his experiences in Indonesia, Malaysia, and
Taiwan and his daily counseling sessions with international students at Minnesota, Paul became
increasingly concerned about the relevance of conventional counseling approaches and began to
consider more culturally sensitive counseling strategies. As an alternative to the use of conventional
counseling education approaches, Paul devised and implemented his aforementioned triad training
In 1975, Paul became a Senior Fellow at the Culture Learning Institute at the East-West Center in
Honolulu, Hawaii. In 19781981, he was director of a large predoctoral training grant from the U.S.
National Institute of Mental Health titled Developing Interculturally Skilled Counselors. With eight
predoctoral trainees, Paul conducted training programs that emphasized cross-cultural counseling
approaches through use of the triad training model. Paul closely maintained his Hawaiian
appointments and ties for the rest of his illustrious career by serving as a Visiting Professor of
Psychology at the University of Hawaii, Manoa, and as a Fellow at the East-West Center.
In 1982, Paul accepted an appointment at Syracuse University as Professor and Chair of the
Department of Counselor Education. In 1995, he earned the title of Professor Emeritus at Syracuse
and subsequently became a Professor in the Department of Human Studies at the University of
Alabama, Birmingham. In 2001, after a year as a Senior Fulbright Scholar at Taiwan National
University, Paul formally retired from academic life and moved back to his much beloved Hawaii to
continue his writing, traveling, and scholarly interests. He retained his appointment as a Visiting
Professor in the Department of Psychology at the University of Hawaii, Manoa.
Pauls remarkable career includes the publication of more than 40 books and more than 150 book
chapters and journal articles; the concept of culture is the common thread that runs through all of them.
In reviewing Pauls extraordinary accomplishments, one quickly realizes that he is imaginative,
farsighted, and truly a pioneer in the field of multicultural counseling.
Scholars in the counseling and psychotherapy fields generally consider Pauls edited book
Multiculturalism as a Fourth Force, published in 1999, to be a milestone in the history of
psychology. The book surveyed the prospect that we are moving toward a universal theory of
multiculturalism that recognizes the psychological consequences of each cultural context. Paul and his
colleagues argued that the fourth force supplements the three forces of humanism, behaviorism, and
psychodynamism for psychology.
Service to the professional community is an important value for Paul, and thus he has found time to
serve on numerous boards and committees. His activities have included 3 years as President of the
Society for Intercultural Education, Training and Research (SIETAR), Senior Editor for the SAGE
Publications book series Multicultural Aspects of Counseling (MAC), and Advising Editor for a
Greenwood Press book series in education and psychology. Additionally, Paul is a Board Member of
the Micronesian Institute, located in Washington, D.C., and an External Examiner for Universiti Putra
Malaysia, University Kebangsaan, and Universiti Malaysia Sabah in psychology. In the American
Psychological Association, Paul was a member of the Committee for International Relations in
Psychology (CIRP) from 2001 to 2003. In 2010 he was the recipient of CIRPs Distinguished
Contributions to the International Advancement of Psychology Award. In 1994 he was invited to give
a master lecture at the American Psychological Associations annual meeting in Los Angeles. Paul

also is a Fellow in Divisions 9, 17, 45, and 52 of the American Psychological Association.
About a decade ago Paul was unfortunately stricken with Parkinsons disease. His mental abilities
and all of his fine personal qualities remain intact, but the affliction has affected his vision and ability
to type or use computers effectively. With Pauls permission, we want all who do not yet know about
his condition to understand why his work on this edition of Counseling Across Cultures has been
somewhat curtailed. In discussing this with Paul we lamented the fact that in this edition there is no
chapter that deals directly with what could be called something like the culture of the afflicted.
Chapters 19 and 20 get into some of these concerns and matters, dealing as they do with health issues.
However, Paul reminded us of an intuitively insightful fact: When one is burdened with a physical
condition that has no known cureParkinsons is an excellent and tragic exampleone enters a new
and entirely unexpected culture. Adjustments must be made, old and familiar abilities must be
replaced by new ones, and ones interpersonal network can be radically changed. In a very real
sense, then, Pauls condition has given him, through us, the opportunity to seize another teaching
moment. Paul, a magnificent teacher and adviser throughout his career and this project, would
appreciate that characterization.
By all professional and personal standards, Paul is a visionary. He has contributed significantly to the
emergence of multiculturalism in psychology and in related disciplines. His commitment to
multiculturalism extends well beyond the mental health professions. In thinking about the future of
multicultural counseling and social justice, Paul firmly believes that the multicultural perspective will
evolve into a perspective that acknowledges how people may share the same common-ground
expectations, positive intentions, and constructive values even though they express those expectations
and positive intentions through different and seemingly unacceptable behaviors. He also maintains
that we must generate a balanced perspective in which both similarities and differences of people are
valued and at the same time hope we can avoid partisan quarreling among ourselves and get on with
the important task of finding social justice across cultures.
We dedicate this seventh edition of Counseling Across Cultures to our dear friend and colleague Paul
Bodholdt Pedersen, a true trailblazer, mentor, and leader in making counseling cultural.
Walter J. Lonner
Juris G. Draguns
Joseph E. Trimble
Mara R. Scharrn-del Ro

Introduction Learning From Our Culture Teachers

This seventh edition of Counseling Across Cultures is largely guided by the fundamental premise that
it shares with most books at the interface of social realities and psychological principles: All
behaviors and thoughts are learned in specific cultural contexts. If you can accept that simple premise
you are ready to tackle one that is much more complex: While people are much more similar than they
are different, the differences are fascinating and sometimes difficult to understand without
considerable exposure to and interaction with people from different cultures and ethnic groups.
How do these similarities and, especially, differences come about? Paul Pedersen has used a colorful
image that is based on the idea that all humans have culture teachers, and while some of these
teachers have similar characteristics, each is also totally unique. Capture, suggests Pedersen, a
panorama of a thousand persons sitting around you. The large gathering consists of some people you
have chosen, or who have chosen you, over a lifetime of many interactions. This gathering of people
includes parents, siblings, grandparents, close friends, teachers, enemies, heroes, heroines, scientific
pioneers, religious figures, political leaders, revolutionaries, poets, entertainers, athletes, individuals
with disabilities, and many others who have influenced you in sometimes subtle but often profound
ways. Either directly or indirectly, they have all helped to shape who you are. They will likely
continue to do so, even those who have been dead for years. Getting to know another person well is a
riveting, complex, and exhausting process, but it can also be exhilarating and fulfilling.
We believe, therefore, that before we can make accurate assessments, provide meaningful
understanding, and offer appropriate interventions, we must learn more about our own cultural
contexts and the culture teachers who shaped our lives. Reciprocally, in interactions with othersand
especially in counseling and therapeutic relationshipsit is imperative that we learn as much as we
can about each person with whom we interact. To ignore an individuals culture teachers and the
cultural context that shaped his or her life is to invite little or no progress in professional
interventions. You are probably reading this book because, either intuitively or from direct
experience, you already know this to be true. Moreover, you probably agree with us that it would be
impossible for a counselor to know, in depth and in great detail, everything about all clients with
whom he or she interacts. However, by using the precepts of inclusive cultural empathy (ICE), which
is a theme running through this book and a concept explained in Chapter 1, we can emphatically
endorse the idea that we try to understand each and every client. Such understanding does not
necessarily have to be in great depth. In many cases it may be close to impossible to understand the
worldviews, values, and background of a client in a short period of time. It may be difficult to fathom
the plight of a homeless person, or an immigrant from Vietnam, or a transvestite, or a religious zealot.
Despite these scenarios and hundreds others like them, it is imperative that we employ ICE and make
a sincere attempt to know the other person, even if it is through a glass, darkly. Consistent with the
demands of what can be a challenging task, it is our job as the editors of this volume, as well as the
job of the chapter authors, to help hone your skills and talents in our shared kaleidoscopic
multicultural world. All the chapters in this book have been written by dedicated professionals who
can inform and advise you. Welcome them all as newcomers to your circle of culture teachers.
Covet their advice.

Since the first edition of Counseling Across Cultures was published in 1976, thousands of
publications and research projects have increased our understanding of the roles of culture teachers.
Many of these sources are listed in the reference sections of the chapters in this book. We owe a great
debt to our culture teachers for the wisdom we have gained from them, and we are pleased to
introduce them to you. As recently as 1973, when we presented a seminal symposium at the American
Psychological Association titled Counseling Across Cultures and subsequently planned the first
edition of this book, the terms cross-cultural and multiculturalism were largely neglected or
unknown to counseling professionals. The University of Hawaii Press agreed to publish that initial
book, provided we waived royalties. The book went through five printings the first year and then
through five more editionsin 1981, 1989, 1996, 2002, and 2008. This, the seventh edition, gives
testimony to the continued popularity of counseling across cultures, which has evolved into a
burgeoning and multifaceted enterprise.
The culture-centered or multicultural perspective provides us with at least 12 uniquely valuable goals
and outcomes:
1. Accuracy: All behaviors are learned and displayed in specific cultural contexts.
2. Common ground: The basic values in which we believe are expressed through different
attitudes, behaviors, and worldviews across cultures and ethnic groups.
3. Identity: We learn who we are from the thousands of culture teachers in our lives as we
integrate these multiple threads of experience.
4. Health: Our socio-ecosystems require a diversified gene pool.
5. Protection: Psychology has been culturally encapsulated through much of its history, and we
need to identify our own biases to protect ourselves from failure.
6. Survival: Our best preparation for life in the global village is to learn from persons who are
culturally different from ourselves.
7. Social justice: History documents that injustices can be expected when a monocultural,
dominant group is allowed to define the rules of living for everyone; shifting to a multicultural
orientation curbs this tendency.
8. Out of the box thinking: Progress in understanding the problems of others is often
constrained by traditional linear thinking; we should frequently consider nontraditional,
nonlinear alternatives. A multitude of insiders and outsiders perspectives can help us develop a
more differentiated and flexible view of the world.
9. Learning: Effective learning that results in change is also likely to result in our both
experiencing and overcoming culture shock and adapting to innovation and transformation.
10. Spirituality: All humans experience the same Ultimate Reality in different ways; there is no
single right way, and it is ethnocentric folly to assume that there is.
11. Political stability: Some form of cultural pluralism is the only alternative to either anarchy or
12. Competence: Multiculturalism is generic to a genuine and realistic understanding of human
behavior in all counseling and communication.
Above and beyond these 12 points, culturally informed counseling can be likened to a bridge that
helps transcend the gulf or chasm of differences in practices, expectations, and modes of
communication that separate persons whose backgrounds and outlooks have been molded by their

respective cultures. That is the reason a photo of a bridge adorns the cover of this book. Effective
multicultural counseling will likely not obliterate the need for the bridge, but it may shorten the
journey substantially.
The present edition includes many new authors and a new coeditor52 individuals in alland
offers ideas that have emerged since the appearance of the sixth edition, which was published in
2008. Like the sixth, this edition is divided into five parts and a total of 24 chapters. Each part
opening features an introduction that briefly surveys the content of the chapters within the part. All
chapters begin by identifying primary and secondary objectives, and all (with the exceptions of
Chapters 1 and 2) include critical incident discussions to illustrate key points at the hypothetical
case level. Most of the critical incidents are highlighted at the ends of the chapters, but some are
integrated into the text in other ways. Discussion questions are also included. We concede that not all
of the incidents presented are critical in the strict sense of the term. All are, however, designed to
make abstract concepts concrete and to exemplify, often in a vivid way, the interface between culture
and counseling. In addition to this feature, the contributors to the present edition have been liberal in
describing instances and offering vignettes of culturally distinctive ways of presenting personal
dilemmas, seeking relief from distress, and, in the optimal case, reducing suffering and resolving
quandaries and problems of living. On the theoretical plane, the authors of these chapters have
contributed several explicit models of culturally sensitive intervention in a variety of contexts.
Moreover, the results of several major multinational research projects have been brought to bear on
the current multicultural counseling enterprise. In this manner, the contributors to this volume have
endeavored to narrow the gap between basic cross-cultural research findings and culturally
appropriate intervention at the case level.
In what ways is the current edition different from its predecessors? For one, it is more case centered.
As already alluded to above, several of the chapter authors have gone well beyond critical or
illustrative incidents to build their contributions around a limited number of detailed case studies, an
approach that has enabled them to explore cultural issues in counseling in depth. For example,
Chapter 20 includes a detailed account of a client overcoming clinical problems by recapturing the
themes and values of his original culture. In the process of presenting this account, the authors bridge
the gap between culture teaching and therapy. Chapter 23 highlights the traumatic effect of culture
loss, or deculturation, and, conversely, demonstrates how the previously suppressed strands of
cultural experience may help a counselee achieve more effective functioning and more rewarding
experience. Chapter 14 relates the experiences of two international students as they seek and find
their way through the maze of the host culture, illustrating the vicissitudes of culture learning and the
impact of a multiplicity of culture teachers.
The second theme that receives increased emphasis in the current edition is that of promotion of
social justice. There was a time when many counseling and mental health professionals considered
their interventions to be sharply distinct, or even mutually exclusive, from the work of the advocates
for persons in various disadvantaged, oppressed, or poorly understood cultural categories. The
recognition that the reformist and the therapeutic thrusts of improving the lives of culturally
distinctive counselees are compatible and mutually complementary pervades this edition, and is
especially prominent in Chapters 59, 1011, and 1417.

A third theme that is also highlighted in this edition is the importance of considering and examining
the intersectionality of identities, privileges, and oppressions. Many of the chapters challenge the
reader to critically examine and consider the impacts of intersecting systematic oppressions and
privileges in themselves and in their clients as a key step in ICE. Becoming aware of our own
privileges and how they affect our lives and our clinical work can be an overwhelming task.
Privilege protects those of us who hold it from a lot of psychological struggle (i.e., not having to deal
with external and internalized oppression), but it also robs us of gaining knowledge about the world
and about ourselves in relation to the world. Privilege is a blind spot in our awareness that slows
down the road toward ICE; thus, many of the chapters in this book provide readers with information
and questions that can help them to bridge this gap in awareness, knowledge, and empathy.
Concurrent with the promotion of ICE, this edition also emphasizes the increasing role of culturally
adapted evidence-based procedures, a topic to which Chapter 4 is principally devoted. In several
other chapters, the authors describe specific evidence-based procedures that have been successfully
applied in various domains of counseling across culture. As these approaches spread and multiply,
the challenge is to combine demonstrated effectiveness with empathetic cultural sensitivity, fusing
subjectivity with objectivity. Not an easy task, to be sure, but not an unattainable goal either.
Although this edition introduces many new topics and approaches, it also reaffirms the relevance of
major contributions from earlier editions. In the fourth edition of Counseling Across Cultures, David
Sue and Norman Sundberg contributed an important chapter titled Research and Research
Hypotheses About Effectiveness in Intercultural Counseling. It contained 15 research hypotheses that
have held up remarkably well across the intervening decades. For that reason, we reproduce them
1. Entry into the counseling system is affected by cultural conceptualization of mental disorders and
by the socialization of help-seeking behavior.
2. The more similar the expectations of the intercultural client and counselor in regard to the goals
and process of counseling, the more effective the counseling will be.
3. Of special importance in intercultural counseling effectiveness is the degree of congruence
between the counselor and client in their orientations in philosophical values and views toward
dependency, authority, power, openness of communication, and other special relationships
inherent in counseling.
4. The more the aims and desires of the client can be appropriately simplified and formulated as
objective behavior or information (such as university course requirements or specific tasks), the
more effective the intercultural counseling will be.
5. Culture-sensitive empathy and rapport are important in establishing a working alliance between
the counselor and the culturally different client.
6. Effectiveness is enhanced by the counselors general sensitivity to communications, both verbal
and nonverbal. The more personal and emotionally laden the counseling becomes, the more the
client will rely on words and concepts learned early in life, and the more helpful it will be for
the counselor to be knowledgeable about socialization and communication styles in the clients
7. The less familiar the client is with the counseling process, the more the counselor or the
counseling program will need to instruct the client in what counseling is and in the role of the


Culture-specific modes of counseling will be found that work more effectively with certain
cultural and ethnic groups than with others.
Ethnic similarity between counselor and client increases the probability of a positive outcome.
Within-group differences on variables such as acculturation and stage of racial identity may
influence receptivity to counseling.
Credibility can be enhanced through acknowledgment of cultural factors in cross-cultural
In general, women respond more positively than men to Western-style counseling.
Persons who act with intentionality have a sense of capability and can generate alternative
behaviors in a given situation to approach a problem from different vantage points.
Identity-related characteristics of White counselors can influence their reaction to ethnic
minority clients.
Despite great differences in cultural contexts in language and the implicit theory of the
counseling process, a majority of the important elements of intercultural counseling are common
across cultures and clients.

The infusion of multiculturalism into the theory and practice of counseling is a long process that
requires the understanding of new rules. Clients in counseling and psychotherapy come from a
multitude of cultures and ethnicities, each with his or her own unique assortment of culture teachers.
The imposition of a one-size-fits-all approach to counseling is no longer acceptable for clients who
represent a substantial number of diverse cultural contexts. The counselor who thinks there are only
two people involved in a transactionthe client and the counseloris already in great difficulty.
In addressing these wide-ranging and key issues, we seek to articulate in this volume the positive
contributions that can be realized when multicultural awareness is incorporated into the training of
counselors. Properly understood and applied, this awareness of our culture teachers will make our
work as counselors easier rather than harder, more satisfying rather than frustrating, and more
efficient rather than inefficient and cumbersome.
Paul B. Pedersen
Walter J. Lonner
Juris G. Draguns
Joseph A. Trimble
Mara R. Scharrn-del Ro

Part I Essential Components of Cross-Cultural Counseling

A quick look at the table of contents of this text reveals that almost 80% of the chaptersthe 20
chapters that make up Parts II through Vfocus on specifically targeted perspectives and topics that
are systematically spread across important clusters of interrelated chapters. Thus, the operative
phrase that they share is specificity of function. All of these 20 chapters feature topics that can, if one
desires, be read as unified independent presentations. For instance, if a counselor wishes to review
key aspects of counseling Asian clients, or refugees, or issues pertaining to families, specific chapters
can serve as informative packages in and of themselves. The operative phrase in Part I, in contrast, is
foundational perspectives. The intent of this beginning group of four chapters is to provide a broader
view that will help form a coherent basis for the rest of the text. We strongly believe that all
approaches used in cross-cultural counseling are best implemented when important generic areas,
fundamentally related to all other counseling-oriented topics, are woven into the fabric of counselors
specific purposes. In that sense, Part I has an integrative function for the text. We recommend reading
it first. In this introduction we present only fragmentary comments on the four chapters.
Chapter 1 focuses on inclusive cultural empathy, or ICE. Empathy, like related concepts such as
sympathy and compassion, is a human universal. It has almost certainly been part of the collective
human psyche across countless millennia. A temporary state of emotional symbiosis seems to
characterize empathy. One has only to study Rembrandts 17th-century masterpiece The Return of the
Prodigal Son to see and even feel that acts of empathy, compassion, and sympathy predate the
introduction of the root German word Einfhlung, which means in-feeling or feeling in. It was
first used more than a century ago in the psychology of aesthetics. Robert Vischer and then Theodor
Lipps introduced it as an interpersonal phenomenon. Freud and others employed the term extensively.
Thus it is useless to argue whether or not we have the capacity for empathy. Rather, the question is, To
what extent do we have it? That leads to other questions, such as Can it be enhanced by experience
and training? and Is too much of this feeling in dangerous in counseling relationships?
Culture-oriented perspectives in psychology are currently popular and inclusive, and we believe they
will remain that way. Whether it is cross-cultural psychology, cultural psychology, indigenous
psychology, psychological anthropology, or multiculturalism, psychology has become much more
inclusive. Gone are the hegemonic days of Western-based psychology that largely ignored the
phenomenon of culture and its multitude of forms. Leave culture in the hands of anthropologists was
a frequent directive issued by orthodox behaviorists. That narrow vision has almost entirely
disappeared. Many of the basic principles of psychology remain, as well they should, because
psychology is an important academic and practical discipline with transcendent conceptual and
methodological principles. Organized cross-cultural psychology, one of the antidotes to scholarly
myopia, is now half a century old, with new developments certain to continue. (For a chronological
overview of initiatives that have been heavily influenced by culture-oriented psychologists, see
Lonner, 2013.) Inclusive cultural empathy is a concept that stands on the shoulders of these efforts.
ICE is such a compelling idea that it serves as the hub for the several spokes that constitute the
remaining chapters in this text. In Chapter 1, Paul B. Pedersen and Mark Pope take the experience of
empathy, with its roots in Western conceptualizations of self, values, and other popular constructs that
make up personhood, to a level made possible by the contributions of thousands of psychologists and

counselors throughout the world.

Pedersen and Pope note that inclusion comes from research in the hard sciences, where something
can be both right and wrong, good and bad, true and false at the same time through both/and
thinking. This supplants the rules of exclusion, which, as they point out, have depended on
either/or thinking, wherein one alternative explanation is entirely excluded and its opposite is
entirely accepted. Thus, from this quantum perspective, empathy is both a pattern and a process at
the same time. It is elegantly clear, therefore, that in counseling across cultures, taking both the
perspective of the counselor and that of the client, much more can be gained by adopting a two-way
attitude than by accepting a traditional either/or perspective. Psychotherapy is not a laboratory
experiment in which a null hypothesis is either accepted or rejected. This dichotomy would mean that
accepting one perspective (usually the counselors) over the other would block progress. No doubt
thousands of counseling sessions have ended abruptly when one in the dyad (usually the counselor)
looked at the problem through culture-colored glasses. It was out of these procedural concerns that
Pedersen developed his well-known triad training model. ICE is also central to Pedersens idea that
multiculturalism is a fourth force in psychotherapy and, as such, is as influential as behaviorism,
humanism, and psychodynamic approaches. These pioneering viewpoints are briefly discussed in
Chapter 1.
The intent of Chapter 2 is to examine the basic elements of counseling and to explain how counseling
in any cultural setting can be effective. In the chapter, Juris G. Draguns gives examples of classic
definitions of counseling, all of which can readily be applied to counseling across cultures. The idea
that counseling is principally concerned with facilitating, rather than more directively bringing
about, adaptive coping in order to alleviate distress, eliminate dysfunction, and promote effective
problem solving and optimal decision making is sufficiently transcendent to be used in any
relationship that can be described as counseling. An additional comment Draguns makes, that
counseling proceeds between two (or sometimes more than two) individuals and is embedded in
distinctive sociocultural milieus, correct as it is, must be considered in connection with ICE, for
two, and not just one, cultural milieus will inevitably be involved. This is the sauce that gives
meaning to the notion of cross in cross-cultural counseling, for these relationships cut both ways.
Draguns gives cogent examples of what Pedersen has told us: that a multitude of culture teachers
have strongly influenced, and continue to influence, all culture-oriented counselors. Like homunculi
sitting on a counselors shoulder during counseling sessions, these teachers affect what is said and
done in each and every encounter. This analogy is in line with the broad sweep of ICE. The more
influence these teachers have in a counseling session, the more likely it is they will contribute to a
successful outcome. Another consideration of empathy is that it works best if understood as a
constantly reciprocating relationship. The counselor will have to be attuned to the many ways that the
client has learned his or her own culture, and the client will have to pay attention to what the
counselor says and does, for just as the counselor has culture teachers, so does the client. This is
part of what the therapeutic alliance is all about.
Chapter 2 also covers a range of other considerations that to varying degrees cut across all the other
chapters in the text. Culturally adapted cognitive-behavioral therapy and its possible convergence
with evidence-based treatments have entered culture-oriented counseling. The issues surrounding this

convergence are discussed. The latter part of the chapter shifts from the nature of cross-cultural
counseling as a process that differs from routine counseling to several generalizable characteristics
of clients. While it is true that each individual is unique, there are certain domains of personhood that
transcend culture and ethnicity. Foremost among these domains is the construct of self. Consistent
with aspects of self that are important in assessing persons (see the discussion below regarding
Chapter 3), in culture-oriented counseling it is important to keep in mind that the nature of a clients
self is largely shaped by cultural and ethnic factors that leave their indelible imprints on everyone.
The most widely researched aspect of the self places all of us on a continuum. On one end we find
those who are highly independent and autonomous in thought and action (think of the stereotypic
strong male, or of the notion of self-sufficiency). The other end is populated by individuals whose
selves are conditioned by a strong sense of belonging to some sort of collectivity, such as a caste,
clan, family, or other group (think of the stereotypic female, for whom family, friends, and community
come first). The continuum of allocentrismidiocentrismor group orientation as opposed to selfreliancehas been used as another way to view opposing configurations of personality traits that
help explain how individuals differ. Highly related to this useful concept is the dichotomy of
individualism and collectivism. A number of culture-oriented psychological researchers have spent
most of their careers studying the roots and dynamics of this hypothetical continuum, which is mostly
used at a high level of abstraction, such as a clan or an entire country. It is such a robust construct that
one can envision it as being highly related to the bifurcation of extroversion and introversion, an oftused dichotomy that operates at the level of the individual. Draguns also discusses four other
dimensions that Hofstede and a large network of fellow researchers have used in hundreds of
research projects. He closes the chapter by discussing universal, cultural, and individual threads in
counseling. He also includes a helpful list of brief dos and donts that can help guide counselors in
their interactions with clients whose cultural or ethnic backgrounds differ from their own.
Chapter 3 gives an overview of issues, problems, and perspectives in the area of psychological
assessment. The assessment or appraisal of a person who, for any reason, becomes a counseling
client begins the instant that counselor and client meet. The assessment can be quick and
impressionistic, involving no formal assessment procedures. On the other hand, it can, and usually
does, involve an array of psychological tests and other measurement devices and procedures that help
the counselor understand the clients abilities, personality, values, and virtually any other dimension
of personhood that the counselor deems important. Perhaps the key question to be asked and answered
is the one that the author of the chapter, Walter J. Lonner, proposes: Is the assessment of this person,
in these circumstances, with these methods, and at this time as complete and accurate as possible?
The field of psychological measurement and testing has a rich and lengthy history, and it is one of the
more ubiquitous areas in the discipline. Lord Kelvin once made a claim that cements the importance
of tests and measurements: If you havent measured it you dont know what you are talking about.
Years later, E. L. Thorndike backed him up with this well-known proclamation: If a thing exists, it
exists in some amount; and if it exists in some amount, it can be measured. Thus, one dimension in
assessmentand arguably the most important in the area of professional counselinginvolves
carefully planned psychological testing. All counseling clients, regardless of presenting problems and
the focus of counseling, are assessed in some fashion, and many of them will be required or asked to
take one or more psychological tests. Tests that measure aptitude, abilities, intelligence, personality,
interests, values, and other aspects of the person are most common. Most of these psychometric

devices originated in the United States, Canada, and their territorial extensions, such as Great Britain,
Australia, New Zealand, and Western Europe. Furthermore, most of them were originally conceived
by academic psychologists and educational experts who represent a fairly narrow swath of vast
populations and normed on captive audiences or samples of convenience. And therein lies a
question that begs an answer in almost any counseling encounter with people for whom the tests may
not have been originally normed: What must be done to ensure that the test results are equivalent and
unbiased? The ideas of fairness and cultural validity are pervasively on the minds of cross-cultural
psychologists, whose careers have been dedicated to the assessment of various dimensions of
personhood. As Lonner points out, numerous technical resources are readily available in the literature
to help therapists translate and otherwise adapt psychological tests for use in counseling.
Counselors can choose between quantitative (nomothetic) and qualitative (idiographic) methods in
assessment or use some combination of the two. Because both of these approaches have attractive
features, the use of mixed methods is steadily increasing, especially in counseling and clinical work.
Neuropsychological testing, briefly surveyed in Chapter 3, is often important in the assessment of
acculturating or displaced individuals who have been victims of wars, physical or psychological
abuse, malnutrition, or other horrid human conditions.
The overriding theme of inclusive cultural empathy that characterizes this book can be extended to
inclusivity in empathetic assessment. For this reason, Lonner suggests the use of knowledge-based
assessment (KBA). Usually having nothing to do with more traditional and formal assessment
devices, KBA includes the knowledge that the counselor has accumulated in all walks of life and
especially from reading and becoming familiar with culture-oriented research that, for years, has
focused on hypothesized universal personality traits and the ways in which culture helps to shape
various dimensions of self as well as values. A clients personality, conceptions of self, and
preferences for certain values over others will always be among the mixture of things that emerge in
the process of counseling. The counselors ability to use the results of a great deal of culture-driven
research in such areas of personhood extends the notion of psychological assessment beyond its more
formal and traditional techniques.
Counseling across cultures as a recognized professional activity has a lengthy history but a short past.
One can imagine thousands of scenarios in the distant past where a person from, for example, Homer,
Alaska, was discussing a personal problem presented by an immigrant from rural Norway. The
counselor may have little or no psychological background, and both the counselor and the client may
have limited fluency in the others language. These kinds of conundrums take us back a few pages in
this introduction to our brief discussion of assessment across cultures. Thus, in this hypothetical
context, one can ask: Is my counseling of this person, in these circumstances, with the methods at my
level of competence, and at this time and place as practicable and ethical as possible? The authors of
Chapter 4 ask this multifaceted question in the context of a fundamental issue in multicultural
counselingan issue that transcends all 20 chapters in Parts IIV. Timothy B. Smith, Alberto Soto,
Derek Griner, and Joseph E. Trimble summarize the current status of research on multicultural
counseling. As they note, research in this area has increased exponentially over the past several
decades. Clearly, even as recently as 1976, when the first edition of this book appeared, very little
research had been conducted bearing on the effectiveness of counseling across cultures. This is
especially true with respect to evidence-based psychological treatments, which are currently at a

Focusing primarily on the powerful method of meta-analysis, in which the findings of numerous
individual studies are integrated prior to analysis in an effort to make sense of the effectiveness (or
lack thereof) of counseling across cultures, Smith et al. look into the characteristics of counselors
who demonstrate competence in the field. Intercultural competence is clearly the silver chalice for
anyone who aspires to reach a recognized level of effectiveness in multicultural competence. An
increasing array of research and literature on the topic is coalescing to an extent not heretofore
reached. For instance, in 2013 the Journal of Cross-Cultural Psychology published a special issue
containing nine articles that are fine examples of current thinking in this area (Chiu, Lonner,
Matsumoto, & Ward, 2013). The issue focuses on cross-cultural competence in general, with a
decided nod in the direction of cross-cultural competence in the international workplace (among
managers, consultants, negotiators, and so on), and not specifically multicultural counseling
competence. However, sensitivity, open-mindedness, social initiative, flexibility, cultural empathy
(which in this book is essentially equivalent to ICE), critical thinking, emotional stability, emotion
regulation, awareness, abilities, knowledge, and skills are descriptors that often surface in attempts to
pinpoint the components of cross-cultural competence. It seems to us that if a person is crossculturally competent, that competence should transfer well across all domains of interpersonal
interaction. The package of the above descriptors a person possesses would, if realized in sufficient
quantities, define ICE. Numerous attempts to measure the concept have been attempted (Deardorff,
2009; Matsumoto & Hwang, 2013).
While all chapters in this book can be enhanced and informed by this foundational chapter, perhaps
the contribution that is closest to Chapter 4 conceptually and practically is Chapter 18, which focuses
exclusively on acculturation, a topic that by definition is saturated with an assortment of counseling
needs. This is especially true in North America, which for generations has been the promised land
for many. Smith et al. mention this as well. A high percentage of the works cited in the abovementioned special issue come from journals such as the International Journal of Intercultural
Relations; just a handful are journal articles and books that typically are read by counselors and
clinicians. With so much to offer each other, readers of this text are encouraged to do something about
this unfortunate territorial bifurcation. The latter pages of Chapter 4 discuss a number of factors that
have been researched by culture-oriented practitioners. They include racial and ethnic matching of
client and culture and ways in which general theories of counseling have been adapted for
multicultural counseling.

Chiu, C. Y., Lonner, W. J., Matsumoto, D., & Ward, C. (Eds.). (2013). Cross-cultural competence
[Special issue]. Journal of Cross-Cultural Psychology, 44(6).
Deardorff, D. K. (Ed.). (2009). The SAGE handbook of intercultural competence. Thousand Oaks,
CA: Sage.
Lonner, W. J. (2013). Foreword. In K. D. Keith (Ed.), The encyclopedia of cross-cultural psychology.
Hoboken, NJ: Wiley-Blackwell. (Also in Online Readings in Psychology and Culture,

Matsumoto, D., & Hwang, H. C. (2013). Assessing cross-cultural competence: A review of available
tests. Journal of Cross-Cultural Psychology, 44(6), 849873.

1 Toward Effectiveness Through Empathy

Paul B. Pedersen
Mark Pope

Primary Objective
To provide an overview of the significance and importance of inclusive cultural empathy

Secondary Objectives
To reframe the counseling concept of individualistic empathy into inclusive cultural empathy
To develop a more relationship-centered alternative based on Asian ways of knowing and
Good relationships in counseling psychotherapy emerge as a necessary but not sufficient condition in
all research about effective mental health services. Good relationships depend on establishing
empathy. Empathy occurs when one person vicariously experiences the feelings, perceptions, and
thoughts of another. Most of the research on empathy is predicated on the shared understanding of
emotions, thoughts, and actions of one person by another. In Western cultures, psychologists typically
focus exclusively on the individual, whereas in traditional non-Western cultures, empathy more
typically involves an inclusive perspective focusing on the individual and significant others in the
societal context. This chapter explores the reframing of empathy, based on an individualistic
perspective, into inclusive cultural empathy, based on a more relationship-centered perspective, as
an alternative interpretation of the empathetic process (Pedersen, Crethar, & Carlson, 2008).
The world has changed to make us totally interdependent on a diversified model of society, requiring
us to find new ways of adaptation. Globalization, migration, demographic changes, poverty, war,
famine, and changes in the environment have led to increased diversity across the globe. Our
responses to that diversity, through sociotechnical changes, competition for limited resources, and
anger and resentment at the intranational and international levels, all of which depend on conventional
Western models, have been inadequate:
Powerful global efforts to reduce diversity conflicts by the hegemonic imposition of Western
economic, political, and cultural systems is not a solution to the emerging diversity conflict
issues. Rather, the global monoculturalism being promoted represents an exacerbation of the
problem as evidenced by the growing radicalization of individuals, groups, and nations seeking
to resist the homogenization pressures. (Marsella, 2009, p. 119)
In this context, empathyreframed as inclusive cultural empathyprovides an alternative

perspective to conventional individualism. We believe that psychologists are part of both the problem
and the solution to this dilemma, and we call upon the field to take leadership around the world in
applying this inclusive cultural empathy model.

Cultural Foundations
Moodley and West (2005) integrated traditional healing practices into counseling and psychotherapy.
They described a rich healing tradition from around the world, going back more than 1,000 years, that
is being used today alongside contemporary health care. They
explore the complexities of the various approaches and argue for the inclusion and integration of
traditional and indigenous healing practices in counseling and psychotherapy. This need to look
outside the boundaries of Western psychology is a direct result of the failures of multicultural
counseling or the way psychotherapy is practiced in a multicultural context. It seems that
multicultural counseling and psychotherapy is in crisis. (Moodley & West, 2005, pp. xvxvi)
Mental health care providers and educators can no longer pretend that counseling and psychotherapy
were invented in the last 200 years by European Americans in a Western cultural context. The
recognition of indigenous resources for holistic healing and the search for harmony have been
recognized in the literature about complementary and alternative medicine. The true history of mental
health care includes contributors from around the world during the last several thousand years,
although these progenitors are seldom if ever mentioned in the textbooks for training mental health
care providers. This omission, however unintentional, is inexcusable and has resulted in violations of
intellectual property rights and unnecessary misunderstanding. Although Asia and Africa have been
struggling to interface traditional approaches with Western approaches for a long time, this task has
only recently emerged as a priority in the United States (Incayawar, Wintrob, & Bouchard, 2009).
The practice of psychotherapy is a political action with sociopolitical consequences. Psychologists,
counselors, and scholars from Western cultures have presented a history of protecting the status quo
against change, as perceived by people in minority cultures (i.e., racial minorities, women, and those
who perceive themselves as disempowered by the majority). The lack of trust in people who provide
counseling services and the belief that the status quo is being protected are documented in the
literature about scientific racism and European American ethnocentrism (Pedersen, Draguns,
Lonner, & Trimble, 2008; D. W. Sue & Sue, 2003). Cultural differences were explained by some
through a genetic deficiency model that promoted the superiority of dominant European American
cultures. The genetic deficiency approach was matched to a cultural deficit model that described
minorities as deprived or disadvantaged by their culture. Minorities were underrepresented among
professional counselors and therapists, the topic of culture was trivialized in professional
communications, and minority views were underrepresented in the research literature. Members of
the counseling profession were discredited among minority client populations because they viewed
counseling as a tool to maintain the boundary differences between those who had power and/or
access to resources and those who did not.

These cultural differences have resulted in racial microaggressions in the everyday contacts between
groups. Racial microaggressions are brief and commonplace daily verbal, behavioral, or
environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory,
or negative racial slights and insults toward people of color (D. W. Sue et al., 2007, p. 271).
Inclusive cultural empathy seeks to minimize or eliminate racial microaggressions from multicultural
contacts by emphasizing the importance of context.

Alternative Indigenous Psychologies

There are already indigenous alternatives to individualistic psychotherapy. China provides examples
of indigenous alternatives that de-emphasize individualism. Yang (1995, 1999), Yang, Hwang,
Pedersen, and Daibo (2003), and Hwang (2006) conceptualized the Chinese social orientation in two
waysfirst as a system of social psychological interactions and second as a pattern of inclinations or
natural tendencies based on past experience. This interaction between the person and the
environment is demonstrated in the tension between isolated or independent tendencies and relational
or connected tendencies. Although the individuated approach works well in some cultures to facilitate
measurement and treatment, for example, it excludes valuable data from other cultures.
Santee (2007) described an integrative approach to psychotherapy that bridges Chinese thought,
evolutionary theory, and stress management. This approach provides an
opportunity to view the culturally diverse perspectives of Buddhism, Daoism, and Confucianism
in a context that will allow for the integration of these teachings into Western counseling and
psychotherapy. This integration will, it is hoped, contribute to resolving the problems facing
contemporary counseling and psychotherapy caused by its own ethnocentric perspective and the
need to access cultural diversity. It is a move toward embracing a new paradigm. It is a bamboo
bridge. (Santee, 2007, pp. 1011)
The family orientation metaphor constitutes the core building block of Chinese society, rather than
the isolated individual, as in Western cultures. The Chinese people tend to generalize or extend their
familistic experiences and habits acquired in the family to other groups so that the latter may be
regarded as quasi-familial organizations. Chinese familism (or familistic collectivism), as
generalized to other social organizations, may be named generalized familism or pan familism
(Yang, 1995, p. 23). This family perspective is significantly different from Western psychologys
focus on the scientific study of individual behavior.
Yang had the dream of an alternative to using inappropriate Western psychology to understand balance
in Chinese society. He described the consequences of imposing Western psychology on non-Western
What has been created via this highly Westernized research activity is a highly Westernized
social science that is incompatible with the native cultures, peoples and phenomena studied in

non-Western societies. The detrimental over-dominance of Western social sciences in the

development of corresponding sciences in non-Western societies is the outcome of a worldwide
academic hegemony of Western learning in at least the last hundred years. (Yang, 1999, p. 182)
Liu and Liu (1999) pointed out that interconnectedness is a difficult concept to pin down because it
involves synthesizing opposites, contradictions, paradox, and complex patterns that resemble the
dynamic, self-regulating process of complexity theory: In Eastern traditions of scholarship, what is
valued most is not truth. In broad outline, the pursuit of objective knowledge is subordinate to the
quest for spiritual interconnectedness (p. 10).
Yang (1997) described his thinking as it evolved toward understanding North American psychology
as its own kind of indigenous psychology, developing out of European intellectual traditions but much
influenced by American society. He developed a list of seven nos that a Chinese psychologist
should not do so that his or her research can become indigenous:
Not to habitually or uncritically adopt Western psychological concepts, theories, and methods;
Not to overlook Western psychologists important experiences in developing their concepts,
theories, and methods;
Not to reject useful indigenous concepts, theories, and methods developed by other Chinese
Not to adopt any cross-cultural research strategy with a Western-dominant imposed etic or
pseudo-etic approach . . . ;
Not to use concepts, variables, or units of analysis that are too broad or abstract;
Not to think out research problems in terms of English or other foreign languages; and
Not to conceptualise academic research in political terms, that is, not to politicise research. (pp.
Along with the seven nos Yang (1997) also suggested 10 yes assertions to guide the psychologist
in a more positive direction:
To tolerate vague or ambiguous conditions and to suspend ones decisions as long as possible in
dealing with conceptual, theoretical, and methodological problems until something indigenous
emerges in his or her phenomenological field;
To be a typical Chinese when functioning as a researcher [letting Chinese ideas be reflected in
the research];
To take the psychological or behavioural phenomenon to be studied and its concrete, specific
setting into careful consideration...;
To take its local, social, cultural, and historical contexts into careful consideration whenever
conceptualizing a phenomenon and designing a study;
To give priority to the study of culturally unique psychological and behavioural phenomena or
characteristics of the Chinese people;
To make it a rule to begin any research with a thorough immersion into the natural, concrete
details of the phenomenon to be studied;
To investigate, if possible, both the specific content (or structure) and the involved process (or
mechanism) of the phenomenon in any study;

To let research be based upon the Chinese intellectual tradition rather than the Western
intellectual tradition;
To study not only the traditional aspects or elements of Chinese psychological functioning but
also the modern ones...;
To study not only the psychological functioning of contemporary, living Chinese but also that of
the ancient Chinese. (p. 72)
The consequences of extreme individualism in psychotherapy are very dangerous to modern societies.
Westernized values that became popular in the 19th and 20th centuries have sponsored destructive
attitudes and lifestyles; to prevent an ecological disaster, urgent changes are needed in these values.
Howard (2000, p. 515) identified nine killer thoughts based on Western psychological values and
assumptions: (a) Consumption produces happiness; (b) we dont need to think (or worry) about the
future; (c) short-term rewards and punishments are more important than long-term goals; (d) growth is
good; (e) we should all get as much of lifes limited resources as we can; (f) keeping the price of
energy low is a good thing; (g) if it aint broke, dont fix it; (h) we dont need to change until
scientific proof is found; and (i) we will always find new solutions in time to expand limited
resources. The dangers of exclusively imposing dominant-culture values have led psychotherapists to
better understand the values of other, contrasting cultures.
One example of imposing Westernized, individualistic, dominant-culture values is the primacy of
self-interest. Miller (1999) examined the self-interest motive and the self-confirming role of
assuming that a norm exists in Western cultures that specifies self-interest both is and ought to be a
powerful determinant of behavior. This norm influences peoples actions and opinions as well as the
accounts they give for their actions and opinions. In particular, it leads people to act and speak as
though they care more about their material self-interest than they do (p. 1053). The more powerful
this norm of self-interest is assumed to be, the more self-fulfilling psychological evidence will be
found to support that premise.

Inclusive Cultural Empathy

The importance of inclusion comes from research in the hard sciences, where quantum physics
demonstrates the importance of opposites, proving that something can be both right and wrong, good
and bad, true and false at the same time through both/and thinking. The rules of exclusion have
depended on either/or thinking, in which one alternative interpretation is entirely excluded and the
opposite is entirely accepted. From this quantum perspective, empathy is both a pattern and a process
at the same time.
The intellectual construct of empathy developed in a context that favored individualism and described
the connection of one individual to another individual. However, globalization is changing that
perspective. The individuated self, which is rooted in individualism, is being overtaken by a more
familial concept of self, best described by Clifford Geertz (1975):
The Western conception of the person as a bounded, unique, more or less integrated motivational
and cognitive universe, a dynamic center of awareness, emotion, judgment and action organized

into a distinctive whole and set contrastively both against other such wholes and against a social
and natural background is, however incorrigible it may seem to us, a rather peculiar idea within
the context of the worlds cultures. (p. 48)
In the more collectivist non-Western cultures, relationships are defined inclusively to address not
only the individual but the many culture teachers of that individual in a network of significant
others. Being empathetic in that indigenous cultural context requires a more inclusive perspective than
that found in the typically more individualistic Western cultures. In identifying the individual, the
question should not be Where do you come from? but rather Who do you come from?
Inclusive cultural empathy is an alternative to the conventional empathy concept applied to a culturecentered perspective of counseling (Pedersen, Crethar, & Carlson, 2008). Conventional empathy
typically develops out of similarities between two people. Inclusive cultural empathy has two
defining features: (1) Culture is defined broadly to include culture teachers from the clients
ethnographic (ethnicity and nationality), demographic (age, gender, lifestyle broadly defined,
residence), status (social, educational, economic), and affiliation (formal or informal) backgrounds;
and (2) the empathetic counseling relationship values the full range of differences and similarities or
positive and negative features as contributing to the quality and meaningfulness of that relationship in
a dynamic balance. Inclusive cultural empathy describes a dynamic perspective that balances both
similarities and differences at the same time and was developed to nurture a deep comprehensive
understanding of the counseling relationship in its cultural context. It goes beyond the exclusive
interaction of a counselor with a client to include the comprehensive network of interrelationships
with culture teachers in both the clients and the counselors cultural contexts.
The inclusive relationship is illustrated by the intrapersonal cultural grid shown in Table 1.1. This
visual display shows how a persons behavior is linked to culturally learned expectations that justify
the persons behavior and the cultural values on which those expectations are based. Table 1.1 shows
how each persons cultural context influences that persons behavior through the thousands of culture
teachers from which each person has learned how to respond appropriately in different situations. To
understand the persons behavior, one must first understand the cultural context.

Empathy is constructed over a period of time during counseling as the foundation of a strong and
positive working relationship. The conventional description of empathy moves from a broadly

defined context to the individual person convergently, like an upside-down pyramid. Inclusive
cultural empathy moves from the individual person toward inclusion of the divergent, broadly defined
cultural context in which that individuals many culture teachers live, like a right-side-up pyramid.
The conventional definition of empathy has emphasized similarities as the basis of comembership in a
one-directional focus on similarities that does not include differences (Ridley & Lingle, 1996; Ridley
& Udipi, 2002). The new construct of cultural empathy presented in much of the literature appears to
be indistinguishable from generic empathy except that it is used in multicultural contexts to achieve an
understanding of the clients cultural experience (Ridley & Lingle, 1996, p. 30). Inclusive cultural
empathy goes beyond conventional empathy to understand accurately and respond appropriately to the
clients comprehensive cultural relationships to his or her culture teachers, some of whom are similar
to and others of whom are different from the counselor.
By reframing the counseling relationship into multicultural categories, it becomes possible for the
counselor and the client to accept the counseling relationship as it isambiguous and complex
without first having to change it toward the counselors own neatly organized self-reference and
exclusionary cultural perspective. This complex and somewhat chaotic perspective is what
distinguishes inclusive cultural empathy from the more conventional descriptions of empathy. We can
best manage the complexity of inclusive cultural empathy in a comprehensive and inclusive
framework. This comprehensive and inclusive framework has been referred to as multiculturalism.
The ultimate outcome of multicultural awareness, as Segall, Dasen, Berry, and Poortinga (1990)
suggested, is a contextual understanding: There may well come a time when we will no longer speak
of cross-cultural psychology as such. The basic premise of this fieldthat to understand human
behavior, we must study it in its sociocultural contextmay become so widely accepted that all
psychology will be inherently cultural (p. 352). During the last 20 years, multiculturalism has
usually become recognized as a powerful force, not just for understanding specific groups but for
understanding ourselves and those with whom we work (D. W. Sue, Ivey, & Pedersen, 1996).

Increasing Multicultural Awareness

Cultural patterns of thinking and acting were being prepared for us even before we were born, to
guide our lives, to shape our decisions, and to put our lives in order. We inherited these culturally
learned assumptions from our parents and teachers, who taught us the rules of life. As we learned
more about ourselves and others, we learned that our own way of thinking was one of many different
ways. By that time, however, we had come to believe that our way was the best of all possible ways,
and even when we found new or better ways it was not always possible to change. We are more
likely to see the world through our own eyes and to assume that others see the same world in the same
way using a self-reference criterion. As the world becomes more obviously multicultural, this
one-size-fits-all perspective has become a problem.
During the last 20 years, multiculturalism has become a powerful force in mental health services, not
just for understanding foreign-based nationality groups or ethnic minority groups but for constructing
accurate and intentional counseling relationships generally. Multiculturalism has gained the status of a
generic component of competence, complementing other competencies to explain human behavior by

highlighting the importance of the cultural context. Culture is more complex than these assumptions
suggest. Imagine that there are a thousand culture teachers sitting in your chair with you and another
thousand in your clients chair, collected over a lifetime from friends, enemies, relatives, strangers,
heroes, and heroines. That is the visual image of culture in the multicultural counseling interview.
Psychotherapy in the not-so-far-away future promises to become an inclusive science that routinely
takes cultural variables into account. In contrast, much of todays mainstream psychotherapy routinely
neglects and underestimates the power of cultural variables. Soon, there will appear in connection
with many psychological theories and methods a series of questions:
Under what circumstances and in which culturally circumscribed situations does a given
psychological theory or methodology provide valid explanations for the origins and maintenance
of behavior? What are the cultural boundary conditions potentially limiting the generalizability
of psychological theories and methodologies? Which psychological phenomena are culturally
robust in character, and which phenomena appear only under specified cultural conditions?
(Gielen, 1994, p. 38)
The underlying principle of multicultural awareness is to emphasize at the same time both the culturespecific characteristics that differentiate and the culture-general characteristics that unite. The
inclusive accommodation of both within-group differences and between-groups differences is
required for a comprehensive understanding of each complicated cultural context.

Comprehending Multicultural Knowledge

Accurate information, comprehensive documentation, and verifiable evidence are important to the
protection of the health sciences as a reliable and valid resource. Knowledge requires an inclusive
understanding of all our multiple selves. By defining culture broadly to include ethnographic
variables, demographic variables, status, and affiliations, the construct multicultural becomes
generic to all counseling relationships. The narrow definition of culture has limited multiculturalism
to what might more appropriately be called multiethnic or multinational relationships between groups
with a shared sociocultural heritage that includes similarities of religion, history, and common
ancestry. Ethnicity and nationality are important to individual and familial identity as aspects of
culture, but the construct of culturebroadly definedgoes beyond national and/or ethnic
boundaries. Persons from the same ethnic or nationality group may still experience cultural
differences that include a variety of within-group differences.
This collectivist understanding of culture is more commonly found in non-Western cultures. There are
several assumptions that distinguish non-Western therapies (Nakamura, 1964): (a) Self, the substance
of individuality, and the reality of belonging to an absolute cosmic self are intimately related. Illness
is related to a lack of balance in the cosmos as much as to physical ailments. (b) Asian theories of
personality generally de-emphasize individualism and emphasize social relationships. Collectivism
more than individualism describes the majority of the worlds cultures. (c) Interdependence or even
dependency relationships in Hindu and Chinese cultures are valued as healthy. Independence is much

more dysfunctional in a collectivist culture. (d) Experience rather than logic can serve as the basis for
interpreting psychological phenomena. Subjectivity as well as objectivity are perceived as
psychologically valid approaches to data. In spite of these differences, Western and non-Western
approaches are complementary to one another as psychotherapies increasingly include attention to
non-Western therapies.
Therapies based on non-Western worldviews provide examples of inclusion in understanding the
context for any therapeutic intervention: Ayurvedic therapies from India combine the root of the
words for life, vitality, health, and longevity (dyus) with the word for science or knowledge (veda)
and focus on promoting a comprehensive and spiritual notion of health and life rather than healing or
curing any specific illness. Ayurvedic treatments are combined with conventional therapies more
frequently in Europe than in the United States. Health is treated as more than the absence of disease
and involves a spiritual reciprocity between mind and body. Western-based research has documented
the efficacy of Ayurvedic therapies.
Yoga has a history of thousands of years as a viable therapy. The word yoga is based on the Sanskrit
root yuj, meaning to yoke or bind the bodymindsoul to God. Yoga has its main source in the
Bhagavad Gita in understanding the connection of the individual to the cosmos. Research on yoga has
demonstrated its benefits in lowering blood pressure and stress levels through meditation, personality
change, and therapeutic self-discovery.
Chinese therapies include an elegant array of approaches based on the concepts of the Tao, or the
way; chi, or the energy force; and yin/yang, or the balance of opposites. The various systems of
Chinese therapies are grounded in religion and philosophy by the mystical union with God or the
cosmos and nature. The Tao describes those patterns that lead toward harmony. Chi describes a
system of pathways called meridians in the body through which energy flows. Yin/yang describes the
balance of paradoxes, each essential to the other.
Buddhist therapy is based on the absence of a separate self, the impermanence of all things, and the
fact of sorrow. People suffer from desiring and striving to possess things, which are impermanent.
The cure is to reach a higher state of being to eliminate delusion, attachment, and desire in the
interrelationship of mind and body. Elements of cognitive restructuring, behavioral techniques, and
insight-oriented methods are involved in the healing process.
Sufism is the mystical aspect of Islam addressing what is inside the person. The outward dimension,
or sharia, is like the circumference of a circle, with the inner truth, or haqiqa, being the circles
center and the path, tariqa, to that center going beyond rituals to ultimate peace and health. The goal
in Sufism is to enable people to live simple, harmonious, and happy lives. Jungs analytical
psychology and Freuds interpretation of the fragmented person are similar but more objective in their
emphasis than Sufism, which seeks to go beyond the limited understanding of objective knowledge.
Japanese therapies of Zen Buddhism, Naikan, and Morita focus on constructive living, and their aim
is for people to become more natural. Morita was a professor of psychiatry at Jikei University School
of Medicine in Tokyo who developed principles of Zen Buddhist psychology. Yoshimoto was a
successful businessman who became a lay priest at Nara and developed Naikan therapy in the Jodo
Shinshu Buddhist psychology. Morita therapy is a way to accept and embrace our feelings rather than

ignore them or attempt to escape from them. Naikan therapy emphasizes how many good things we
have received from others and the inadequacy of our repayment.
Shamanism encompasses a family of therapies involving altered states of consciousness in which
people experience their spiritual beings to heal themselves or others. Shamanism is found in cultures
from Siberian and Native American cultures to Australian and African cultures, going back perhaps
25,000 years in South Africa. The focus is healing through spirit travel, soul flights, or soul journeys,
which distinguish shamans from priests, mediums, or medicine men. These altered states include
psychological, social, and physiological approaches that constitute perhaps the worlds earliest
technologies for modifying consciousness.
Native American healers recognize four main causes of illness: offending the spirits or breaking
taboos, intrusion of a spirit into the body, soul loss, and witchcraft. Illness can be a divine retribution
for breaking a taboo or offending divine powers, requiring that the patient be purified with song,
prayers, and rituals. In the same way, the removal of objects or spirits from the body by a healer
restores health. When the soul is separated from the body or possessed by harmful powers it must be
brought back to energize the patient, and sometimes the shaman must travel to the land of the dead to
bring the soul back. Finally, witchcraft causes illness by projecting toxic substances into the patient.
Elements of dissociative reaction, depression, compulsive disorder, and paranoia are present.
African healing, as described by Airhihenbuwa (1995), is based on cultural values and is available,
acceptable, and affordable; even today African divinities, diviners, and healers continue to be
popular in a religious or psychosocial dimension of health care that goes beyond medical care.
Beliefs include symbolic representations of tribal realities, illness resulting from hot/cold imbalance,
dislocation of internal organs, impure blood, unclean air, moral transgression, interpersonal struggle,
and conflict with the spirit world. Health depends on a balance both within the individual and
between the individual and the environment or cosmos. Similarities with allopathic medicine are
A great variety of other non-Western systems of health care exist, such as Christian mysticism,
homeopathy, osteopathy, chiropractic, herbalism, healing touch, naturopathic medicine, qigong,
curanderismo, and Tibetan medicine, among many others. Each of these systems is, in turn, divided
into a great variety of different traditions. However, many of the same patterns of spiritual reality,
mindbody relationships, balance, and subjective reality run through many if not all of these nonWestern therapies.
The cultural context provides a force field of contrasting influences, which can be kept in balance
through culturally inclusive empathy. There are several implications of considering culturally
inclusive empathy to be necessary for competent counseling to occur. Each implication contributes
toward a capability for understanding and facilitating a balanced perspective in multicultural
counseling. Can a counselor hope to know about all possible cultures to which the client belongs?
Probably not, but the counselor can still aspire to know about as many cultural identities as possible,
just as in aspirational ethics the counselor tries always to do good but never expects to achieve
absolute goodness.
Westernized perspectives, which have dominated the field of mental health, must not become the

exclusive criteria of modernized psychotherapy. While non-Western cultures have had a profound
impact on the West in recent years, many less industrialized non-Western cultures seem more
determined than ever to emulate the West as a social model. There is also evidence that the more
modernized a society, the more its problems and solutions resemble those of a Westernized society.
Although industrialized societies are fearful of technological domination that might contribute to the
deterioration of social values and destroy the meaning of traditional culture, less industrialized
societies are frequently more concerned that Western technology will not be available to them. The
task for psychologists is one of differentiating between modernized alternatives outside the Western
model. Otherwise we end up teaching Westernization in the name of modernization. We need
indigenous, non-Western models of modernity to escape from our own reductionistic assumptions.

Inclusive Cultural Empathy Skills

Developing appropriate social action skills depends on accurate assumptions and meaningful
knowledge to promote a balanced perspective. Balance involves the identification of different or
even conflicting culturally learned perspectives without necessarily resolving that difference or
dissonance in favor of either viewpoint. Healthy functioning in a multicultural or pluralistic context
may require a person to maintain multiple conflicting and culturally learned roles or viewpoints
without the opportunity to resolve the resulting dissonance.
Chinese indigenous psychologists have worked to adapt Americanized individualism to make it
applicable in both the Western individualistic and the Asian collectivist contexts. David Ho (1999)
used the term relational counseling to describe the uniquely Asian indigenous perspective based on a
relational self in the Confucian tradition:
This relational conception takes full recognition of the individuals embeddedness in the social
network. The social arena is alive with many actors connected directly or indirectly with one
another in a multiplicity of relationships. It is a dynamic field of forces and counter-forces in
which the stature and significance of the individual actor appears to be diminished. Yet, selfhood
is realized through harmonizing ones relationships with others. (p. 100).
Hwang (2000) has also written extensively on relationalism in his face and favor model as a
manifestation of Confucianism as part of indigenous psychology in China. The process of indigenizing
psychology has become a powerful force for psychological change in counseling (Kaitibai, 1996).
Western counseling and psychotherapy have promoted the separated self as the healthy prototype
across cultures, making counseling and psychology part of the problem, through an emphasis on
selfishness and a lack of commitment to the group, rather than part of the solution.
Inclusive cultural empathy recognizes that the same behaviors may have different meanings and that
different behaviors may have the same meaning. By establishing the shared positive expectations
between and among people, the accurate interpretation of behaviors becomes possible. The
interpersonal cultural grid shown in Table 1.2 is useful in understanding how cultural differences
influence the interaction of two or more individuals (Pedersen, 2000b). It is important to interpret

behaviors accurately in terms of the intended expectations and values expressed by those behaviors.
If two persons are accurate in their interpretations of one anothers expectations, they do not always
need to display the same behavior. The two people may agree to disagree about which behavior is
appropriate and may continue to work together in harmony in spite of their different styles of
Table 1.2 provides a visual display of these relationships. In the first quadrant, two individuals have
similar behaviors and similar positive expectations. There is a high level of accuracy in both
individuals interpretations of one anothers behaviors and expectations. This relationship would be
congruent and probably harmonious. We are focusing exclusively on positive expectations here. If the
two individuals share the same negative expectations (I hate you) and behavior (attacking the other
person), the relationship may be congruent but certainly not harmonious.
In the second quadrant, two individuals have different behaviors (loud/soft, direct/indirect,
casual/formal, and so on) but share the same positive expectations. There is a high level of agreement
that the two people both expect trust and friendliness, for example, but there is a low level of
accuracy because each person perceives and interprets the other individuals behavior incorrectly.
This relationship is characteristic of multicultural conflict, in which each person is applying a selfreference criterion to interpret the other individuals behavior in terms of his or her own expectations
and values. The conditions described in Quadrant II are very unstable, and unless the shared positive
expectations are quickly made explicit, the relationship is likely to change toward that in Quadrant III.

In the third quadrant, two people have the same behaviors but differ greatly in their expectations.
There is actually a low level of agreement in positive expectations between the two people even
though similar or congruent behaviors give the appearance of harmony and agreement. For example,
one person may continue to expect trust and friendliness while the other person is secretly distrustful
and unfriendly. Both persons are, however, presenting the same smiling, glad-handing behaviors.
If these two persons discover that the reason for their conflict is their differences in expectations, and
if they are then able to return their relationship to an earlier stage in which they did perhaps share the
same positive expectations of trust and friendliness, for example, then their interaction may return to
the type described by the second quadrant. This would require each person to adjust his or her
interpretation of the others different behavior to fit their shared positive expectations of friendship
and trust. If, however, their expectations remain different, then even though their behaviors are similar
and congruent, the conflict is likely to increase until their interaction moves to one described by the
fourth quadrant.

In the fourth quadrant, the two people have different behaviors and also different or negative
expectations. Not only do they disagree in their behaviors toward one another, but now they also
disagree on their expectations of friendship and trust. This relationship is likely to result in hostile
disengagement. They are at war. If the two persons can be coached to increase their accuracy in
identifying one anothers previously positive expectations, however, there may still be a chance for
them to return to an earlier stage of their relationship in which their positive expectations were
similar even though their behaviors might have been very different, as in the second quadrant.
The perspectives of two persons may be and usually are both similar (in expectations) and different
(in behaviors). In this way, the interpersonal cultural grid provides a conceptual road map for
inclusive cultural empathy to interpret another persons behavior accurately in the context of that
persons culturally learned expectations. It is not always necessary for the counselor and the client to
share the same behaviors as long as they share the same positive expectations.
The psychological study of culture has conventionally assumed that there is a fixed state of mind
whose observation is obscured by cultural distortions. The underlying assumption is that there is a
single universal definition of normal behavior from the psychological perspective. A contrasting
anthropological position assumed that cultural differences were clues to divergent attitudes, values,
or perspectives that were different across cultures and based on culture-specific perspectives. The
anthropological perspective assumed that different groups or individuals had somewhat different
definitions of normal behavior resulting from their unique cultural contexts. Anthropologists have
tended to take a relativist position when classifying and interpreting behavior across cultures.
Psychologists, by contrast, have linked social characteristics and psychological phenomena with
minimum attention to the diversity of cultural viewpoints. When counseling psychologists have
applied the same interpretation to the same behavior regardless of the cultural context, cultural bias
has resulted (Pedersen, 2000a).
Try to imagine a dimension with conventional psychology anchoring the extreme end of the scale on
one end and conventional anthropology anchoring the extreme other end of the scale. The area
between these two extremes is occupied by a variety of theoretical positions that tend to favor one or
the other perspective in part but not completely. There is a great deal of controversy about the exact
placement of these theoretical positions. Multiculturalism encompasses a collection of different
potentially salient perspectives all along the dimension.

The Triad Training Model for Interpreting Self-Talk

Our internal dialogues are perhaps the most meaningful indicators of our culture, as we listen to our
different culture teachers, accepting some of those teachings and challenging others in our internal
conversations with them. A measure of empathetic competence is the ability to hear what the client
is thinking as well as talking about. The more cultural difference there is between the counselor and
the client, the more difficult it will be for the counselor to hear what the client is thinking. The triad
training model (TTM) helps prepare counselors to be more accurate in their hypotheses about what a
culturally different client is thinking but not saying.
In the triad training model, a four-person role-played interview is presented to a counselor trainee in

which three conversations will be heard. First, the client and counselor will have a verbal
conversation that they both hear. Second, the counselor will have her or his own internal dialogue
exploring related and/or unrelated factors that the counselor can monitor but the client cannot hear.
Third, the client will have her or his own internal dialogue exploring related or unrelated factors that
the client can monitor but the counselor cannot hear. The counselor does not know what the client is
thinking, but the counselor can assume that some of the clients internal dialogue will be negative and
some will be positive.
Internal dialogue is not a new idea. The works of Vygotsky (1962) and Luria (1961) in Russia during
the early 1930s on the connection between thought and behavior provided the basis for analyzing
private speech. The idea of an inner forum (Mead, 1934), self-talk (Ellis, 1962), and internal
dialogue (Meichenbaum, 1977) goes back at least as far as Plato, who described thinking as a
discourse the mind carries on with itself. As mentioned earlier, each persons behavior is influenced
by as many as a thousand culture teachers in the clients experiences. The triad training model
provides limited access to the influence of these culture teachers by including a procounselor and an
anticounselor in the role-played interview. Through immediate and continuous feedback from the
anticounselor, the counselor hears the negative messages a client is thinking but not saying. Through
continuous and immediate feedback from the procounselor, the counselor hears the positive messages
a client is thinking but not saying.
In the triad training model, the role of the anticounselor is deliberately subversive; the anticounselor
exaggerates mistakes by the counselor during the interview by pointing out differences in behavior
that drive the counselor farther apart from the client. The counselor trainee can be expected to gain
insight in cultural self-awareness as perceived from the clients culturally different viewpoint. The
procounselor is a deliberately positive force to articulate the clients positive unspoken messages that
emphasize the common ground between the counselor and client. The persons who are role-playing
the procounselor and anticounselor are ideally as culturally similar to the client as possible. As a
result of participating in a role-played four-person TTM interview, the counselor can be expected to
(a) see the problem more accurately from the clients cultural viewpoint, (b) recognize culture-based
resistance in specific rather than vague general terms, (c) reduce his or her need to be defensive when
confronted by a culturally different client, and (d) learn recovery skills for what to do after having
done the wrong thing with a culturally different client (Pedersen, 2000a, 2000b).

Multiculturalism as a Fourth Force

There is a great deal of controversy surrounding the term multicultural: Thus, in the current debate,
some advocates in the field strongly support the relevance and necessity of multiculturalism in theory
and practice with diverse populations, whereas others have suggested that multiculturalism is of
minimal importance and should be treated as a fringe interest so as not to interfere with meaningful
research and practice (Reese & Vera, 2007, p. 763). In this chapter we suggest that multiculturalism
influences psychotherapy to the same degree that humanism, psychodynamics, and behaviorism
influenced psychotherapy in the past and that it therefore presents a fourth force or dimension to
modern psychotherapy.
A culture-centered perspective that applies cultural theories to the counseling process is illustrated in

a book on multicultural theory by D. W. Sue et al. (1996). The books approach is based on six
propositions that demonstrate the fundamental importance of a culture-centered perspective:
Each Western or non-Western theory represents a different worldview.
The complex totality of interrelationships in the clientcounselor experiences and the dynamic
changing context must be the focus of counseling, however inconvenient that may become.
A counselor or clients racial/cultural identity will influence how problems are defined and
dictate or define appropriate counseling goals or processes.
The ultimate goal of a culture-centered approach is to expand the repertoire of helping
responses available to counselors.
Conventional roles of counseling are only some of the many alternative-helping roles
available from a variety of cultural contexts.
Multicultural theory emphasizes the importance of expanding personal, family, group, and
organizational consciousness in a contextual orientation.
As these multicultural theory propositions are tested in practice, they will raise new questions about
competencies of multicultural awareness, knowledge, and skill in combining cultural factors with
psychological processes. How does one know that a particular psychological test or theory provides
valid explanations for behavior in a particular cultural context? What are the cultural boundaries that
prevent generalization of psychological theories and methods? Which psychological theories, tests,
and methods can best be used across cultures? Which psychological theories, tests, and methods
require specific cultural conditions?
Culture is emerging as one of the most important and perhaps most misunderstood constructs in the
contemporary counseling and psychotherapy literature. Culture may be defined narrowly as limited to
ethnicity and nationality or defined broadly to include any and all potentially salient ethnographic,
demographic, status, or affiliation variables (Pope, 1995). Given the broader definition of culture, it
is possible to identify at least a dozen assets that are available exclusively through the development
of a multicultural awareness of culture-centered psychology (Pedersen, 2000b; Pedersen & Ivey,
First, accuracy, because all behaviors are learned and displayed in a cultural context.
Second, conflict management, because the common ground of shared values or expectations
will be expressed differently in contrasting culturally learned behaviors across cultures, and
reframing conflict in a culture-centered perspective will allow two people or groups to disagree
on the appropriate behavior without disagreeing on their underlying shared values.
Third, identity, as we become aware of the thousands of culture teachers we have
accumulated in our own internal dialogues from both friends and enemies.
Fourth, a healthy society, through cultural diversity, just as, by analogy, a healthy biosystem
requires a diverse gene pool.
Fifth, encapsulation protection, because we will not inappropriately impose our own
culturally encapsulated self-reference criteria on others.
Sixth, survival, with the opportunity to rehearse adaptive functioning across cultures for our
own future in the increasingly global village where we will live.
Seventh, social justice, because applying measures of justice and moral development across

cultures helps us differentiate absolute principles from culturally relative strategies.

Eighth, right thinking, through the application of quantum thinking and complementarity, in
which both linear and nonlinear thinking can be applied appropriately.
Ninth, personalized learning, because all learning and change involves some culture shock
when perceived from a multicultural perspective.
Tenth, spirituality, because the multicultural perspective enhances the completeness of
spiritual understanding toward the same shared ultimate reality from different paths.
Eleventh, political stability in developing pluralism as an alternative to either authoritarian
or anarchic political systems.
Twelfth, a more robust psychology, because psychological theories, tests, and methods are
strengthened by accommodating the psychological perspectives of different cultures.
The culture-centered perspective describes the function of making culture central rather than
marginal or trivial to psychological analysis (Pedersen, 2000b; Pedersen & Ivey, 1993). Much of the
political controversy surrounding the term multicultural can be avoided by the culture-centered
description without diminishing the central importance of culture to psychology.
There is considerable resistance to characterizing multiculturalism as a fourth force. Tart (1975)
claimed that transpersonal psychology was the fourth force in psychology, and transpersonal
psychologists sometimes resent the movement to describe multiculturalism as a fourth force. Stanley
Sue (1998) identified other sources of resistance to the term multiculturalism as a fourth force. He
pointed out the tendency to misunderstand or misrepresent the notion of multiculturalism and the
dangers of that misunderstanding. Since all behaviors are learned and displayed in a particular
cultural context, accurate assessment, meaningful understanding, and appropriate intervention require
attention to the clients cultural or, perhaps better yet, multicultural context. All psychological service
providers share the same ultimate goal of accurate assessment, meaningful understanding, and
appropriate intervention, regardless of cultural similarities or differences.

We are at the starting point in developing culture-centered balance as the criterion for inclusive
cultural empathy in our comprehension of effective counseling and psychotherapy. Only those who are
able to escape being caught up in the self-referential web of their own assumptions and maintain a
balanced perspective will be able to communicate effectively with persons from other cultures. The
dangers of cultural encapsulation and the dogma of increasingly technique-oriented definitions of
social services have been mentioned frequently in the recent rhetoric of professional associations in
the social services as criteria for competence (Pedersen, Draguns, et al., 2008).
Moodley and West (2005) attributed recent explorations of traditional ways of healing to failures in
the ways that we are practicing multicultural counseling and psychotherapy. We think that such
explorations are a direct result of the maturing of such practice and, as such, are not an attack on the
fundamentals. Even the proponents of multicultural counseling are not immune to criticism for their
failures to have a larger, more international worldview that transcends European American theories
and techniques. The inclusive cultural empathy skills and approach that we have described here are a
way forward. Mental health care providers and educators have pretended for too long that counseling

and psychotherapy were invented in the last 200 years by European Americans in a Western cultural
context. Successful global leadership by psychologists must come from an understanding of the
complexity of our planet, of the limits of our own worldviews, and of the necessity for redefining our
historically quite narrow interpretation of empathy. This, however, is only the beginning of cultural
sensitivity and knowledge in our field.
Arthur and Pedersen (2008) provided examples of 19 case incidents of counseling from different
national contexts along with two reactions to each incident articulating positive and/or negative
feedback to the counselor for how each case was presented. At least two dozen nontraditional
approaches to counseling were included in the case examples incorporating indigenous
characteristics of each context. One consistent theme throughout the book was the importance of
balance in harmonizing relationships and discovering inclusive cultural empathy. The notion of
balance is familiar in Asian culturesfor example, the harmonious tension between yin and yang and
the female and male principles of Chinese philosophy. This emphasis on harmonious balance of
forces once more underlines the basic theme of this chapterunderstanding human behavior in Asian
countries requires an understanding of relational units as an alternative to the individualistic
assumptions of Western psychological theories (Kim, Yang, & Hwang, 2006).
Inclusive cultural empathy as described in this chapter involves increased awareness to prevent false
assumptions, increased knowledge to protect against incomplete comprehension, and increased skill
to promote right actions. The temptation is to define boundaries in psychology artificially in a
homogenization of theories or, worse yet, to impose an Americanization model that presents a partial
perspective as the whole field, thereby excluding alternative perspectives. Psychology then becomes
only a subset of national/political interests.
While we cannot hope to accumulate all relevant knowledge across national/cultural boundaries
broadly defined, we can still aspire to take on the complex task as best we can. The task of being
inclusive is to acknowledge the validity of a complex and dynamic balance of tendencies that a
competent counselor or psychotherapist can manage in order to measure competence. Like the Greek
god Janus, who has two faces, one laughing and the other crying, the Janusian skills required for
inclusive cultural empathy involve managing a comprehensive balance of essential similarities and
differences at the same time. Our task is the saving of psychology from the psychologists! Special
interests have come dangerously close to capturing and domesticating the field of psychology by
excluding the inconvenient data from a larger international context. Mental health care providers and
educators have pretended for too long that counseling and psychotherapy were invented in the last
200 years by European Americans in a Western cultural context. Successful global leadership by
psychologists must come from an understanding of the complexity of our planet, of the limits of our
own worldviews, and of the necessity for redefining our historically quite narrow interpretation of
empathy. This, however, is only the beginning.

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Editors Note: Paul B. Pedersen received the Award for Distinguished Contributions to the
International Advancement of Psychology. Award winners are invited to deliver an award address at
the APAs annual convention. The original article was prepared for presentation as an award address
at the 118th annual meeting, held August 1215, 2010, in San Diego, California. Articles based on
award addresses are reviewed, but they differ from unsolicited articles in that they are expressions of
the winners reflections on their work and their views of the field. The original reference citation is
as follows: Pedersen, P. B., & Pope, M. (2010). Inclusive cultural empathy for successful global
leadership. American Psychologist, 65(8), 841854. Copyright 2010 by the American
Psychological Association. The article is reprinted as a chapter in this edited book with the
permission of the American Psychological Association.

2 Counseling Encounters in Multicultural Contexts An

Juris G. Draguns

Primary Objective
To help make counseling both more effective and more culturally sensitive

Secondary Objectives
To respond to the challenge of evidence-based treatments in counseling within and across
To emphasize the importance of relationship-based aspects of culturally oriented counseling,
such as the therapeutic alliance and empathy
To highlight the importance of cultural adaptations of counseling in delivering services to
culturally diverse populations
To narrow the gulf between research and practice by encouraging the further investigation of
independent versus interdependent self, individualismcollectivism across and within cultures,
and other relevant topics
To integrate universal, cultural, and individual strands of counseling into a practically
applicable model of delivering human services to a culturally heterogeneous population

Preliminary Considerations
The Nature of Counseling
In Launganis (2004) pithy definition, the gist of counseling has been equated with helping people to
help themselves (p. 97). Although the contemporary repertoire of counseling interventions features a
great many specific and directive techniques, its ethos remains unchanged: Counseling is principally
concerned with facilitating, rather than more directively bringing about, adaptive coping in order to
alleviate distress, eliminate dysfunction, and promote effective problem solving and optimal decision
making. The more general and ambitious objectives of counseling are the fulfillment of personal
aspirations and the actualization of personal potentials. Counseling achieves all of these goals by
marshaling the persons own resources while scrupulously trying to avoid the imposition of the
counselors solutions, values, and attitudes on the client. The counselors role can then be likened to
that of a catalyst; his or her actions are geared to help the counselee seek, find, and apply his or her
own most fitting answers to the dilemmas of living.
Together with the gamut of overlapping and interrelated human helping services, such as
psychotherapy, guidance, and personal coaching, counseling is prototypically an interpersonal

experience between a professional counselor and a help-seeking counselee.1 Encounter and dialogue
are the two cardinal features of counseling. Counseling proceeds between two (or sometimes more
than two) individuals and is embedded in distinctive sociocultural milieus. Each participant in a
counseling project brings to it his or her assumptions, expectations, aspirations, and apprehensions,
and many of these are widely shared within the participants respective cultural settings. The cultural
component, then, can be plausibly construed as an interpersonal experience between a counselor and
a counselee extended over time, in which culture is the third, implicit and silent, yet essential,
participant (Draguns, 1975).
Two Canadian psychologists, Arthur and Collins (2010), have introduced the new term cultureinfused counseling, which they describe as the conscious and purposeful infusion of cultural
awareness and sensitivity into all aspects of the counseling process (p. 18). This definition is
especially apposite to the culturally diverse environments in Canada and the United States that are the
focus of this book, which is primarily addressed to and designed for the practitioners and students of
counseling in these two countries who work with culturally diverse clienteles.

Multicultural Diversity: The Populations to Which It Pertains

Cultural diversity is prominently manifested in the provision of counseling services to persons in the
major ethnoculturally distinctive groupingsNative Americans, Asian Americans, African
Americans, Latina/os, and Arabs and other Middle Easternersto which Chapters 59 are devoted.
Challenging and stressful cultural transitions across time and space, exemplified by voluntary
migrations or forcible displacements, discussed in Chapter 15, and by extended sojourns abroad by
international students, discussed in Chapter 14, bring to the fore special problems in counseling and
demand innovative solutions. So do the experiences of trauma and disaster, naturally caused or
human-made, that are addressed in Chapter 16. Population segments that have been historically
excluded from full participation in the American culture, such as lesbians and gays, now seek to
assert themselves in dignity and freedom and to benefit from appropriate and sensitive counseling
services, as discussed in Chapters 10 and 13. Programs have also been developed and applied to the
broader categories of culturally marginalized persons, addressed in Chapter 11, and even though the
population of North America and elsewhere is more or less evenly divided between males and
females, counseling and other helping services began as a male-dominated endeavor. The current
state of the efforts to correct this imbalance is the subject of Chapter 10, while the special problems
and challenges in counseling families are presented in Chapter 21, and those encountered in the
school setting are the focus of Chapter 12. The process of acculturation, or coming to terms with a
new and different culture, is the subject of Chapter 18. Finally, the authors of Chapter 19 remind us
that not only psychological but also physical symptoms are the result of the interaction between
stressful experiences and ethnocultural factors as they present a rich panorama of research
approaches and findings.

The Ubiquity of Cultural Concerns

Pressing as these various concerns are, they do not exhaust the relevance of culture in the conduct and
delivery of counseling services. Especially in countries such as the United States and Canada,

composed of both native populations and multiple waves of immigrants over several centuries,
several strands of cultural memory and tradition intertwine in complex and unique ways to shape
experience, conduct, and adaptation. Oftentimes, these threads find their way into counseling
encounters. Paul Pedersen has proposed that culture is transmitted by a multitude of culture teachers.
His key statement, from the introduction to the sixth edition of Counseling Across Cultures, is
reproduced here:
Capture the visual image of a thousand persons sitting around you. People that you have chosen,
or have chosen you, over a lifetime from friends, enemies, heroes, heroines, mentors, family
members, and fantasy figures that influenced you in sometimes subtle but often profound ways.
As these culture teachers talk with one another and sometimes include you in their
conversations, they provide a vivid and concrete image of multiculturalism. Many if not all
our decisions are controlled or at least influenced by imagined conversations with our culture
teachers. They broadly define the cultural context in which we live through ethnographic,
demographic, status-oriented, and personal affiliations. All behaviors are learned and displayed
in specific cultural contexts. (Pedersen, Draguns, Lonner, & Trimble, 2008, p. xi)2
In the course of culturally sensitive counseling the lessons of culture teachers are brought to light,
disentangled, reassembled, and integrated, presumably in the service of a more fulfilling selfexperience and more effective coping. Thus, all personal counseling stands to benefit from cultural
exploration and inquiry, and culturally sensitive services should become the norm in North America
and throughout the multicultural societies of the world. Assessment procedures should not only
encompass a persons family background but also attempt to incorporate some of the diverse threads
of cultural influence, perhaps by expanding on Kleinmans (1992) Eight Questions and, more
generally, on knowledge-based assessment procedures, as discussed in greater detail in Chapter 3.

The Scope of This Chapter

Beyond the specific concerns related to assessment, this introductory chapter seeks to identify the
humanly universal, culturally distinctive, and personally unique aspects of counseling. In pursuit of
this goal, I shall attempt to convey information on recent developments in the investigation of
counseling and psychotherapy, especially as these pertain to cultural variations. I will introduce and
partially explicate the complexities of the concept of culture and then proceed to deal with some of
the key features of multicultural counseling, especially as they pertain to the self, individualism, and
other cultural dimensions and personality traits. I shall then conclude by attempting to integrate the
current state of knowledge on counseling with the culturally diverse North American environment.

Cultures: Multiple, Complex, National, and Global

Culture is a complex concept with an elusive core and fuzzy boundaries. Most social scientists start
with two prototypes: the traditional tribal cultures investigated by the pioneering anthropologists of
the 19th and 20th centuries, and the cultures of the current and historic nation-states, from Somalia to

Iceland and from Thailand to Portugal. In both cases, culture refers to the distinctive, human-made
part of the environment (Herskovits, 1948) that encompasses both the artifacts created by the human
species and the mental products that have accrued over many millennia. Marsella (1988) has
elaborated on these two aspects as follows: Shared learned behavior which is transmitted from one
generation to another for purposes of individual and societal growth, adjustment, and adaptation,
culture is represented externally as artifacts, roles, and institutions, and is represented internally as
values, beliefs, attitudes, epistemology, consciousness, and biological functioning (pp. 89).
Consonant with the above statement, Hofstede and Hofstede (2005) have equated culture with the
software of the mind, and Brislin (2000) has construed culture as enabling its members to fill in
gaps in their observations and impressions on the basis of shared and accumulated knowledge and
As described, the concept of culture is primarily applicable to the geographically removed and
linguistically separate national cultures, including that of the United States. The term culture is,
however, also frequently extended to the ethnically, linguistically, and/or racially distinctive segments
of the American society. Thus, we often refer to Mexican Americans, Lebanese Americans, and other
groups, labeled on the basis of their historical and linguistic descent. In dynamic multicultural
societies an additional issue must be faced. Individuals in Canada, the United States, and other
pluralistic countries have been socialized both within their respective ethnocultural milieus and
within the inclusive national culture. Thus, multiculturalism exists not only in interpersonal contacts
but in intrapsychic experience as well. In the course of counseling, it is important for the therapist to
ascertain the impact on the client of both the generic or dominant American culture and the persons
distinctive cultural heritage.
Finally, globalization is a vague, if often invoked, term that refers to a number of trends toward
worldwide convergence and homogenization that often engender a sense of insecurity and threat and
pose a challenge to traditional modes of adaptation rooted in specific cultures. Globalization may
first affect persons whose work and family lives require shuttling between two or more sites in as
many countries, with concurrent demands to adapt to several cultures and to balance simultaneously
multiple contacts, practices, and relationships. Such situations may tax the resources of even highly
adaptable and flexible individuals (Hermans & Kempen, 1998). At the same time, the speed and
spread of global communications technology produces virtually instant opportunities for awareness,
contact, and communication, generating something like a virtual global village that in the optimal case
could provide meaningful sources of needed personal, social, and economic support (Marsella,
1998). Although there has been much speculation on the pathogenic and maladaptive consequences of
globalization, I have not yet seen any systematic clinical documentation of such problems.

Culturally Oriented Counseling: Its Current State

Evidence-Based and/or Culturally Sensitive Services: Isolation,
Divergence, or Integration
The last decade and a half has been an eventful period in the development, adaptation, and
application of culturally sensitive services. At the beginning of the new millennium, Hall (2001)

noted a curious disjunction in the field of culturally sensitive mental health services: Empirically
supported treatments had only rarely been investigated for their effectiveness in culturally diverse
populations, while culturally adapted treatment approaches had been infrequently subjected to
examination concerning their efficacy and effectiveness. More than a decade later, this gulf has begun
to be bridged.
Two developments should be noted: Evidence-based treatments (EBTs) have spread and multiplied,
making the uniform application of therapeutic procedures feasible across space and time (APA
Presidential Task Force on Evidence-Based Practice in Psychology, 2006; Chambless & Ollendick,
2001; Kazdin, 2008; Norcross, 2011), and meta-analyses of culturally modified psychotherapy
programs have demonstrated a moderately strong contribution of culture to the effectiveness of
psychotherapy (Griner & Smith, 2006; Huey & Polo, 2008; Smith, Domenech Rodrguez, & Bernal,
2011). The details of these findings are the central topic of Chapter 4, and I will also address their
implications later in this chapter. At first glance, culturally oriented counseling appears to be
simultaneously pulled in two opposite directions: toward homogeneity and toward cultural
variability. To elaborate, in some observers minds EBT is prototypically equated with the
standardized and manualized application of therapy techniques. At the same time, cultural adaptations
of therapy evoke, perhaps in an oversimplified manner, a thoroughgoing transformation of the
therapists modus operandi in both techniques and conceptions of psychotherapy. In fact, there are a
lot of shades of gray between these two extremes and a lot of room for rapprochement and
The official and oft-quoted definition by the APA Presidential Task Force on Evidence-Based
Practice in Psychology (2006) describes EBPP as the integration of the best available research with
clinical expertise in the context of patient characteristics, culture, and preference (p. 273). Culture
has been explicitly incorporated into this statement as a contextual variable that must be taken into
account in the actual application of EBTs. Norcross and Wampold (2011a) conclude that evidencebased practice rests on three pillars: best available research, clinical expertise (of the practitioner),
and patient characteristics. In fact, evidence-based practice resides at the intersection of overlap of
these three evidentiary sources. The patient, the therapist and the research all need to be in an
alignment on the same page (p. 27).
It should be added that the patient (or client) characteristics within this triad prominently include
those mediated by the individuals ethnocultural background and experience. Norcross and Wampold
(2011b) completed a prodigious number of meta-analyses of psychotherapy in order to identify
relationships that work. To this end, they ascertained the effect sizes for the numerous likely
components of the therapy relationship. The results point to empathy and the therapeutic alliance as
the two major contributors to variance, both of them moderate in size. These two variables appear to
be linked to culture, a point that remains to be explored further.

Relationships That Work: The Therapeutic Alliance

The therapeutic alliance is a venerable clinical concept that is traceable to Freuds pioneering
contribution, although it has acquired increasing prominence as a subject of systematic research over
the last four decades (Horvath, Del Re, Fluckinger, & Symonds, 2011). According to Horvath et al.

(2011), the therapeutic alliance encompasses the constructive, reality-based, aspects of the
relationship between the therapist (or counselor) and the client. Bordin (1976) describes its three
interconnected foundations: agreement on therapeutic goals, consensus on the tasks that make up
therapy, and a bond between the client and the therapist.
In counseling relationships that are established across a cultural barrier, a special effort may be
required to assure a collaborative stance on these three issues. For example, an anxious, confused,
highly traumatized immigrant may be intensely motivated to seek immediate relief and may be baffled
and confused by the therapy process, including the quest for biographical and personal information.
What does that have to do with my feeling wretched and miserable, helpless and inadequate? he or
she may well ask. Wolfgang Pfeiffer (1996), a prominent German transcultural psychiatrist, identified
several clashes of expectations between Turkish guest workers and German therapists. The clients
sought relief from counseling here and now; their therapists insisted on a more extensive exploration.
The clients also expected authoritative guidance and directions; their therapists emphasized personal
choices. The clients expressed distress in somatic terms (see Chapter 19); their therapists focused on
feelings and personal experiences.
A therapeutic alliance may be difficult to establish because of lack of trust on the part of ethnocultural
and racial minority members, who in many instances may have experienced rejection, insensitivity,
and misunderstanding from majority group members, including those in the helping professions (Sue
& Sue, 2008). Being interviewed by a member of ones own cultural group may facilitate the
formation of a therapeutic alliance, especially in its early stages. Recent case studies of two women,
a severely traumatized American Indian (King, 2012) and an anxious Mexican immigrant (Salgado,
2012), illustrate the confidence-building process during and following intake that helps to solidify the
therapeutic alliance. In both cases, therapists expanded their roles to include active advocacy on
behalf of their clients; such action is often helpful in demonstrating the genuineness of a therapists
concern for the clients well-being.
On the therapeutic plane, it is important to separate the therapeutic alliance from the better-known, but
less rational and conscious, manifestations of transference and countertransference that may obtrude
upon and complicate the therapeutic relationship and may require resolution. The results of metaanalyses, though based on a small number of studies, suggest that ruptures of the therapeutic alliance
should be promptly repaired; uncorrected disruptions of the tie between the therapist and client may
lead to further, cumulative, complications (Safran, Muran, & Eubanks-Carter, 2011).

Empathy: A Pivotal Component of Therapeutic Influence

In further meta-analyses, therapists empathy with the client, broadly defined as the ability to tune in
to and experience and communicate another individuals emotional and cognitive states, was found to
be a moderately strong predictor of therapy outcome (Elliot, Bohart, Watson, & Greenberg, 2011).
Rogers (1957) posited the experience and communication of empathy as one of the necessary
conditions of therapeutic personality change, and empathy has had a history of investigation extending
over several decades (Bachellor & Horvath, 1999; Bohart & Greenberg, 1997; Draguns, 2007; Duan
& Hill, 1996). Empathy has transcended the phenomenological framework within which it originated
and is now widely recognized as a major active ingredient of psychotherapy and counseling by

psychologists of diverse theoretical orientations (Clark, 2007).

Several aspects of empathy may differ across cultures. Heinz Kohut (1971), the foremost
psychoanalytic conceptualizer of empathy, proposed that empathy declines as the agents and
recipients of therapy become less similar, and in my own work I have suggested that empathy may not
travel well beyond the empathizers accustomed sociocultural milieu (Draguns, 1973). These
assertions have not yet been systematically or rigorously tested in cultural counseling or
psychotherapy situations. Practitioners should be observant and perceptive of the vicissitudes of
communicating and experiencing empathy in culturally relevant helping relationships, yet be cautious
and tentative in their case-based conclusions.
Researchers have made noteworthy contributions in helping practitioners to employ empathetic
sensitivity and responsiveness beneficially across cultural gulfs and barriers. Scott and Borodowsky
(1990) developed a training procedure for enhancing culturally sensitive therapy by means of role
taking. They also introduced techniques designed to overcome obstacles based on unfamiliar language
styles, distinctive ethnic identities, divergent expectations, and discrepant values and worldviews.
Ridley and Udipi (2002) have urged counselors to address and work through any prejudices they may
harbor against some or all of their culturally diverse clientele, some of which may be hidden but
deeply ingrained in cultural environments in which, until recently, discriminatory practices and
prejudicial attitudes were the norm (Sue & Sue, 2008). Even though stereotyping should not be
equated with prejudice (see Jussim, McCauley, & Lee, 1995), Ridley and Udipi (2002) warn against
unchecked stereotyping of social and cultural groups in the course of counseling a culturally diverse
clientele. More recently, Ridley, Ethington, and Heppner (2008) broke new ground in helping
counselees explore their place in the world in order to confront their cultural values and identify and
resolve conflicts within them.
These novel and possibly controversial extensions of the concept of empathy go well beyond the
classic modes of intuitively experiencing and communicating empathetic understanding. In a sense, the
techniques that encourage counselees to work toward the development of coherent cultural value
systems within themselves anticipate Pedersen, Crethar, and Carlsons (2008) development of
inclusive cultural empathy (ICE) as a series of systematically trainable counseling skills. The details
of this major contribution are presented in Chapter 1. It should be pointed out, however, that ICE
constitutes the first set of empirically pretested training procedures that make it possible for
counselors to incorporate empathy systematically as a major culturally sensitive component of
therapeutic influence. ICE is explicitly designed to scale all cultural barriers: ethnic barriers to be
sure, but also those based on race, gender, class, sexual orientation, disability, and stigma. Thus,
empathy has been transformed from a somewhat unpredictable, spontaneously occurring, phenomenon
into a set of interpersonal competencies that can be systematically applied in counseling and
elsewhere without any loss of authenticity in the process. In line with this recognition, Elliott et al.
(2011) state: We encourage psychotherapists to value empathy as both an ingredient of a healthy
therapeutic relationship as well as a specific response that strengthens the self and deeper
exploration (p. 147).

The Impact of Culture on Mental Health Services

Cultural accommodation of mental health services is increasingly being implemented in the United
States and elsewhere (McCabe & Christian, 2011; Tanaka-Matsumi, 2011). Until recently, however,
there was relatively little information on the effectiveness of such procedures. Griner and Smith
(2006) completed a landmark meta-analysis of 76 studies of culturally adapted mental health
treatment programs with a total of 25,255 participants. Exceeding expectations, they obtained an
average random effect size of 0.45, indicative of a moderately strong effect of culturally modifying
mental health treatment programs. The implications of these findings are thoroughly discussed in
Chapter 4. At this point it is worth noting that the effects on outcomes were more substantial when the
adaptations were targeted to ethnoculturally specific groups rather than to a generic composite of
various ethnicities. Moreover, interventions offered in the clients first or preferred language were
twice as effective as those that were presented in English. Griner and Smiths (2006) findings were
confirmed and extended in further meta-analyses by Smith et al. (2011), who found that the
effectiveness of adapted treatment programs increased with the greater number of cultural
adaptations. Smith et al. also reported that older clients and Asian Americans were more responsive
to culturally adapted treatments than other segments of the culturally and demographically diverse
research population, and they concluded that culturally adapted mental health services are
moderately superior to those that do not explicitly incorporate cultural considerations and should be
considered EBPs (p. 172). McCabe and Christian (2011) distinguish three degrees of such
adaptation, from minimal, in which only a few features, such as language and interpersonal style, are
adjusted to clients needs and expectations, through substantial modifications of a great many therapy
techniques, to treatment programs that incorporate culturally meaningful and fitting components that
are unique to a circumscribed cultural milieu.
As yet there are no systematic data indicating what degree of modification is optimal for what kind of
group with what kinds of treatment needs and presenting problems. In the initial interview, these
options must be faced, negotiated, and bilaterally resolved on the basis of the clients needs and
expectations and the counselors professional expertise and judgment (Tanaka-Matsumi, 2011).

Culturally Adapted Cognitive-Behavioral Therapy and EBT: A

Case of Convergence
A remarkable degree of affinity exists between EBTs and the modi operandi of the investigators and
practitioners of cognitive-behavioral therapy (CBT). A high proportion of techniques designated as
EBTs for specific categories of mental disorder are CBTs (Roth & Fonagy, 2005; Tanaka-Matsumi,
2011). Both CBTs and EBTs proceed from the same premise: They are based on systematic collection
of empirical data, and they eschew speculation. Functional analysis is the privileged procedure in
CBT; it involves pinpointing links between a persons behavior and her or his environment or, more
specifically, between a response and its antecedents and consequents. The major tool for investigating
EBTs is meta-analysis; its objective is to establish the relationship between the components of
psychotherapy and outcome.
In preparing for the application of culturally sensitive CBTs, van de Vijver and Tanaka-Matsumi
(2008) proposed systematically collecting comprehensive information on such topics as cultural
identity and acculturation, conflict over values, modes of expressing distress, explanations of causes

of presenting problems, metaphors of health and well-being, motivation for change, and social
support networks. This information is elicited by means of the Culturally Informed Functional
Assessment (CIFA) structured interview schedule (Tanaka-Matsumi, Seiden, & Lam, 1996). Its
originators regard CIFA as a process of negotiating between the therapist and the client that continues
throughout CBT. An extensive body of writing has accrued on the adaptation of CBT to the various
ethnically distinctive components of the U.S. population (Hays & Iwamasa, 2006; Hinton, 2006;
Hwang, Wood, Lin, & Cheung, 2006; Tanaka-Matsumi, 2008, 2011; Tanaka-Matsumi, Higginbotham,
& Chang, 2002). Collectively, these studies document the variety of flexible and innovative uses of
the cognitive-behavioral framework with culturally diverse help seekers, many of whom have found
themselves in new and unfamiliar environments as refugees and immigrants. Thus, traumatized
Cambodian and Vietnamese newcomers present a mixture of somatic and mental symptoms with many
folk explanations that therapists should take seriously and use as points of departure in initiating CBT
and monitoring its effects (Hinton, 2006).
Beyond CBT, the notion of assessment as a process that is contiguous with treatment and not just a
prelude to it is consistent with the basic tenet, discussed in Chapter 3, of regarding the counselee as
an active participant in, rather than an inert object of, preintervention planning. The counselee
voluntarily contributes information; he or she does not passively allow the counselor to extract it.
Objectives and procedures of counseling are decided jointly through negotiation and explanation
rather than imposed on the basis of the counselors authority or expertise.

EBT and Culturally Sensitive Approaches: Toward Resolving

Issues and Arriving at Conclusions
Across several theoretical frameworks of service delivery, Gallardo, Parham, Trimble, and Yeh
(2012) endorse evidence-based practice in psychology for the culturally diverse portions of the
counseling clientele, with the proviso that EBPP be initiated from the bottom up and be developed on
the basis of observations and data within the communities in which the clientele resides. Gallardo,
Parham, et al. warn against the top-down importation of EBTs developed within the mainstream
Caucasian American culture without modification or pretesting at the new site. The skills
identification model (SIM) that these authors propose aspires to provide the highest standard of
service for counseling and mental health services for the culturally distinctive segments of the U.S.
population. In their edited book, Gallardo, Yeh, Trimble, and Parham (2012) include 10 case studies
and eight general chapters that illustrate SIM and elaborate on it. It is impossible to do justice to this
complex and multifaceted model within the scope of the present chapter. Gallardo, Parham, et al.
(2012) emphasize that, within SIM, social issues of justice and power are considered inseparable
from personal concerns with competence and well-being. Particularly informative and useful for both
majority and minority counselors is Gallardo, Parham, et al.s Table 1.1, which is designed to
represent the five domains of cultural characteristics (pp. 911).
A major dilemma that confronts counselors and clinicians in applying EBTs has been pointed out by
Zeldow (2009). Especially when EBTs involve prescriptive manualized application and when they
are used in preference to other, less empirically grounded forms of intervention, reliance on EBTs
reduces flexibility, interferes with spontaneity, and impedes reflection, which, according to Zeldow,

is the crux of the therapists activity. The professional judgment of a seasoned counselor may
supersede the research-validated course of action recommended in EBT, especially in the unforeseen
and ambiguous situations that are inevitably encountered in therapy. Zeldows points are not explicitly
advanced in relation to helping services for culturally distinctive clients, but they are relevant to such
services. As Petermann (2005), a German psychologist, has stated, EBTs should be an aid, not a
shackle. They should enable, and not constrain, professionals working with a multicultural clientele.
In fairness, however, it should be added that through their brief history EBTs have grown in flexibility
and have in large measure transcended their early limitations.
The tension between technique and relationship and between rules and context, articulated as a major
theme of psychotherapy conceptualization and research by Wampold (2001), has not been definitively
resolved, although the balance has been tipped toward context and flexibility. Yet, as Norcross and
Wampold (2011b) remind us, practitioners can become overly flexible without any research
evidence or when adapting a treatment in ways that would markedly deviate from its established
effectiveness. While the research supports adaptation in many cases, the research also recommends
fidelity to treatments as found effective in controlled research. We need to balance flexibility and
fidelity (pp. 428429). Specifically, Norcross and Wampold encourage practitioners to adopt a
person-centered, open-ended style of inquiry combined with readiness to adapt interventions to
clients needs. There are also therapy relationships and techniques that demonstrably do not work and
should be avoided. These include confrontation as well as expressions of hostility, criticism,
rejection, or blame. Moreover, such interventions may have especially negative consequences in
multicultural contexts, laden as they are with the potential for misunderstanding and the risk of
premature termination. Further, some clients may require more information and guidance about the
specifics of the counseling experience, while others may want to cut short such preliminaries. In
general, the less familiar the nature of the service and its setting, the greater the need for the initial
orientation. In no case should the counselor authoritatively and unilaterally impose the structure on the

Counseling in Multicultural Contexts: An Overview of General

The preceding sections emphasized counseling with the multicultural clientele of the contemporary
United States. I now propose to shift the perspective and proceed from counseling to the person. To
this end, I introduce below the central concept of the self, followed by individualism and other
interfaces between the person and culture. I shall then conclude with the presentation of an integrative
model of counseling and psychotherapy within culture.

Self in Culture
The self is a key concept at the borderline between psychology and philosophy. It is not amenable to
observation or measurement and is exceedingly difficult to define. William Jamess (1891/1952)
classical description of the self as all that a person can call his (p. 188) is overinclusive and bears
the mark of its place and time. Contemporary psychologists have generally shied away from this task
and have less ambitiously limited themselves to defining the self-concept. Miserandino (2012) simply

describes the self as the set of ideas and inferences we hold about ourselves (p. 405). In cultural
psychology what matters is not only the nature or content of the notions of the self but also the mode
and manner of how they are held.
A multiplicity of proposals, presented in greater detail in Chapter 3, have sought to capture the
characteristic features of self-construal and self-experience across cultures. One of the most farreaching and influential such formulations, by Markus and Kitayama (1991, 1998), juxtaposes the
independent or autonomous self purportedly prevalent in Euro-American countries with the
interdependent or relational self-concept that allegedly holds sway in East Asia and in many other
non-Western regions of the world. This contrast should not be regarded as dichotomous or absolute.
Rather, these two modes of experiencing oneself are expected to vary in prevalence in their
respective regions. Over the past several decades, the contrast between the interdependent self and
the independent self has dominated conceptualization and investigation in cross-cultural psychology
and has spilled over into applied areas, including counseling and psychotherapy. It is not yet known to
what extent this axis of appraisal is pertinent to the ethnocultural macrocosm of North America. In
their summary representation of cultural characteristics of the five principal nonmajority groups in
North America (African, Latino/a, Asian, American Indian, Middle Eastern), Gallardo, Parham, et al.
(2012) assign an interpersonal orientation and imply a relational self to all of these population
segments. This characterization should be regarded as plausible but hypothetical. It should be
seriously and systematically pursued in both research and practice without any assumptions regarding
the universality of interpersonal self experience in all clients of these ethnic backgrounds.
In metaphorical terms, the interdependent self can be likened to a bridge, and the independent self, to
a wall; the former connects, the latter separates (Chang, 1988). The independent self is crystallized,
explicit, differentiated, and slow and difficult to change; the interdependent self is malleable in
response to situations and experiences. Interdependent selves are primarily based on bonds,
allegiances, and commitments to persons, families, and communities; independent selves shelter the
unique attributes of the person. In the multicultural context of the United States conflict may be
experienced within the person, pitting the nationally dominant push toward independence against the
predilection for interdependence favored within the individuals ethnocultural group. Alternatively
and more benignly, the two strands of self-construal may coexist within the person and may be
integrated into his or her personality and identity. Thus, a person may feel American in his or her
strivings for the realization of professional goals and personal aspirations and may at the same time
experience a virtually inextricable sense of belonging to his or her nuclear and extended family and
ethnic community.

IndividualismCollectivism in Persons and Cultures

In one of the largest psychological studies ever conducted, both in numbers of participants and in
numbers of countries included, Geert Hofstede (1980), an international industrial organizational
psychologist based in the Netherlands, succeeded in identifying four statistically independent factors
that accounted for intercountry differences in work-related values. In the ensuing decades, Hofstedes
findings sparked worldwide interdisciplinary research on the correlates of these four dimensions and
their implications. More than 20 years after the appearance of his original monograph, Hofstede
(2001) reviewed and interpreted the aggregate of these accumulated findings.

Of the four factors that Hofstede identified, the bipolar axis of individualismcollectivism has
generated the greatest amount of interest among researchers and theoreticians alike. In the words of
Hofstede and Hofstede (2005), Individualism pertains to societies in which the ties between the
individuals are loose; everyone is expected to look after himself or herself and his or her immediate
family. Collectivism as its opposite pertains to societies in which persons from birth onward are
integrated into strong cohesive in-groups which throughout peoples lifetimes continue to protect them
in exchange for unquestioning loyalty (p. 78). Across nations, the United States leads the pack in
individualism, followed by Australia, the United Kingdom, Canada, the Netherlands, and New
Zealand. East Asian, Middle Eastern, most Latin American, and several Mediterranean cultures
cluster toward the collectivistic end of the continuum.
In my own work, I further hypothesized that counseling in individualistic cultures would be focused
on intrapsychic factors and would aim at increasing self-understanding or insight; counselors in
collectivistic settings would place emphasis on social harmony and on enhancing intrafamilial and
other close human relationships (Draguns, 2004). Individualists counseling experiences would
revolve around the uniqueness and primacy of the counselees inner lives, while the collectivists
concerns would center on social acceptance and harmonious human relationships. These predictions,
however, have not been systematically or extensively tested.
In addition to Hofstedes research, another major investigator in social psychology, Harry Triandis
(1995), has pursued a systematic program of studies on individualismcollectivism for several
decades. According to Triandis, collectivism holds a number of advantages in social interaction
within small groups, such as teams and families. Individualists, in contrast, tend to function more
effectively in impersonal institutions such as corporations and government offices. However, they
tend to be susceptible to alienation and loneliness, whereas collectivists may feel thwarted in the
realization of their personal aspirations. Triandis (1995) has observed that we need societies that
would do well both in the citizen-authorities and person-to-person fronts, that provide both freedom
and security, that have something for their most competent members, but also for the majority of their
members (p. 187). This reasoning also applies to counseling. It may be helpful for counselors to
encourage some of their individualistic, but unfulfilled, clients to become more aware of their
submerged and overlooked affiliative strivings, while their collectivistic counterparts may derive
benefit from working toward the realization of their habitually subordinated individualistic
Historically, an individualistic ethos has been deeply ingrained in American counseling since its
inception (Katz, 1985). Pioneers of American counseling proceeded from the assumption that
individuals are the primary recipients of intervention and that they are responsible for their
circumstances. In the counseling process, the individual is helped to exercise mastery over the
environment. Thus, independence and autonomy are prized; personal problems are construed as
intrapsychic and are often traced to the formative socialization experience early in life. Counseling is
viewed as work that requires energy, effort, and perseverance. Passivity is decried and
interdependence de-emphasized. These values may sometimes be imposed on counselees whose
socialization may not be compatible with them.
Culturally sensitive counselors urge greater awareness of the assumptions on which mainstream

American culture rests. They advocate an open-ended and flexible counseling process in which
counselees set their own goals proceeding from their cultural outlooks, sometimes coupled with a
recognition of the need to come to terms with the expectations of the mainstream culture. These
recommendations are consonant with the suggestions developed earlier in this chapter on the basis of
recent research on promoting effective therapy relationships.

Hofstedes Other Dimensions

A few words should be added about Hofstedes other four dimensions. Although the relevance of
these four factors for the realm of counseling and psychotherapy has not yet been demonstrated,
predictions have been made about the roles they may play in clinical practice (Draguns, 2008). These
will be spelled out below. First, however, these dimensions must be defined. To this end, we turn to
Keiths (2011) concise and informative description:
PD [power distance] reflects the degree to which the group members accept an unequal
distribution of power, or the difference in power between more or less powerful members of the
group; UA [uncertainty avoidance] is the degree to which a group develops processes to reduce
uncertainty or ambiguity, or to deal with risk and unfamiliarity in everyday life; MA
[masculinity] is the extent to which gender roles and distinctions are traditional, and masculine
(e.g., aggression) or feminine (e.g., cooperation) traits are viewed favorably; and LTO [longterm orientation] suggests the level of willingness of members of the culture to forego short-term
rewards in the interest of long-term goals. (p. 13)
I have posited that high PD would be expected to be associated with emphasis on counselors
officially recognized expertise, authority, and credentials, and low PD with emphasis on such
personal qualities as authenticity, egalitarianism, and informality (Draguns, 2008). High PD and
social distance would go hand in hand, as would low PD and low social barriers. High UA would
bring with it the valuation of scientifically demonstrated effectiveness of treatment, with
comprehensive and rigorous legal and administrative control over counseling services. I would
venture the prediction that biologically or behaviorally oriented interventions would hold sway over
psychodynamic and humanistic ones. At the low end of UA, a multiplicity of orientations would not
only be accepted but also celebrated, along with subjective, intuitive, and artistic approaches to
human services. High-MA cultures would promote responsibility, conformity, competence, and
efficiency; in low-MA or feminine cultures, caring, sensitivity, and compassion would be cultivated.
High LTO would concentrate on social harmony and self-subordination; low LTO (or short-term
orientation) would accord greater importance to subjective experience, self-assertion, and the pursuit
of pleasure. These ideas, however, remain to be subjected to systematic research scrutiny.

Toward Integrating Universal, Cultural, and Individual Threads in

Leong (1996) has reminded us of Kluckhohn and Murrays (1949) dictum that each person is like all

other persons, like some other persons, and like no other person. The interplay of the universal,
cultural, and individual components poses a special challenge for a counselor dealing with a
culturally heterogeneous clientele. In response to this challenge, Leong (1996) has proposed and
Leong and Lee (2006) have expanded a comprehensive model of counseling and psychotherapy. In
their formulation, culture accommodation is focused on two variables that have also been emphasized
in this chapter: self-construal and individualismcollectivism. To these, Leong and Lee have added
the persons current and specific self-defined identity and his or her communication style, high or low
in context. High-context communication is characterized by avoidance of confrontation and of verbal
assertiveness; low-context communication features a freer, more spontaneous, and less controlled
style of expression.
Leong (1996) cautions counselors against imputing homogeneity or similarity to their clients from a
specific ethnocultural group. At the same time, he emphasizes complementarity, which calls for a
differentiated and fitting response to the needs that a counselee brings to the counseling relationship.
Culture matters to different degrees and in different ways across individuals, and the counselor
should at all times maintain awareness of the unique interaction between a counselee and his or her
culturally mediated experience. Leongs argument is exceedingly subtle and complex, and it defies
being adequately recapitulated within the confines of this chapter. With the practical concerns of
working counselors in mind, it may be useful to recapitulate the following implications of Leongs
1. Do not assume that the presenting problems of a culturally distinct client are necessarily related
to or centered on his or her cultural experience or background.
2. Be prepared to switch levels, from cultural to individual and/or universal, and vice versa, as the
clients needs and situation may require.
3. The extent and nature of a persons relationship to his or her culture or cultures is likely to be an
important area of inquiry in the course of counseling.
4. Complementarity involves empathy, sensitivity, and responsiveness to the client in the context of
the counselors and counselees respective roles within the counseling transaction;
complementarity also involves the application of the counselors expertise and skill in
effectively and fittingly responding to the clients experience of distress.
5. In the optimal case, counseling may represent human interaction at its most subtle and sensitive,
and there is no effective way to simplify it without distorting or reducing its impact.
6. Maximal flexibility, spontaneity, openness to experience, and authenticity are called for during
all counseling experience.
7. Do not limit yourself to a single perspective or irrevocably commit yourself to a specific
hypothesis or explanation.
8. Remember at all times that each person is unique, yet shaped by his or her culture, and is like all
other persons both biologically and existentially.
9. Be aware of the clients multiple distinctive facets, but do not lose sight of the fact that he or she
is a whole and integrated human being.

Increasingly, counseling across cultures is based on a growing number of thoroughly investigated

evidence-based procedures, which, however, are sometimes applied to culturally distinct populations
in which they have not been adequately tested. At its source, however, counseling rests on the
encounter between two individuals engaged in a subtle and genuine personal contact. The two aspects
of counseling, the empirically researched and the subjectively experienced, remain to be fused and
integrated. They do not necessarily pull counseling in divergent directions, nor do they invariably
operate in tandem. For that to happen, human sensitivity has to fuse with systematically acquired
replicable knowledge. In its probably relatively infrequent stellar moments, counseling may represent
the actualization of human potential for a genuine encounter: two human beings interacting at their
best, and one of them, the counselee, significantly benefiting from the experience.
Research evidence has accumulated to demonstrate that empathy and the therapeutic alliance are two
of the major active ingredients of therapeutic change. Techniques, interventions, and procedures
certainly matter, but they are secondary to the bond between the counselor and the counselee and to
the counselees experience of being genuinely understood. Researchers and practitioners have
proposed and implemented a multitude of approaches aimed at making the benefits of counseling
available to all of the culturally diverse segments of the population of the United States, Canada, and,
presumably, a host of other multicultural nations around the world. It has been amply demonstrated
that cultural adaptations increase the effectiveness of counseling and that counseling programs work
best if the community of the potential users participates in planning, designing, and executing these
services. On the individual level, negotiation between a potential counselee and his or her counselor
is the procedure of choice, much preferred to the unilateral or authoritarian imposition of services on
an overtly compliant, yet possibly reluctant and/or bewildered, client.
Research-based information has also accrued on what kinds of clients benefit from, and prefer, what
services. Researchers and practitioners now know that the persons self, the aggregate of her or his
personal experience, is relevant to the counseling transaction. Is the self construed as a loose network
of bonds and links to the significant persons in an individuals life, as is apparently the case in many
Eastern cultures? Or is the self a tightly enclosed nucleus of cherished attributes that contains
everything that is deemed to be essential about the person? And, of course, there is plenty of room
between these two metaphoric extremes.
As yet, little is known about the personality traits of individuals or about the dimensions and
attributes of cultures that are associated with preferences for and responsiveness to the various modes
and experiences of counseling. This topic and many others remain to be investigated as the enterprise
of multicultural counseling continues on its slow progression of disentangling that which is universal,
particular, or unique about the human experiences of distress and dysfunction and as the
armamentarium of techniques, procedures, and approaches for the relief of human suffering gathers
momentum and increases in both sensitivity and effectiveness.

Discussion Questions
1. What are the relationships that work as demonstrated on the basis of the meta-analyses of
psychotherapy research? What is the relevance of these findings for culturally oriented
2. How can the concept of culture teachers be incorporated into all counseling so as to make it



more culturally sensitive and personally effective?

What is the role of empathy in culturally oriented counseling? What kinds of adaptations and
modifications, if any, may the expression and communication of empathy require in the delivery
of counseling services across cultures?
Are the experiential and evidence-based aspects of culturally oriented counseling necessarily in
conflict? If they are not, how can they be reconciled and integrated?
Are Hofstedes five dimensions relevant to multicultural counseling in the United States and
Canada? What is their potential and what are their limitations?
What are the counseling implications of working with members of a culturally diverse clientele
whose selves differ on the independent versus interdependent axis?
How can the goal of helping immigrants and sojourners adapt to U.S. culture be combined with
the goal of helping them to preserve their cultural distinctiveness and identity?

1. Because of their extensive overlap in meaning and usage, the terms counseling and psychotherapy
and their derivatives are used interchangeably throughout this chapter.
2. This quotation is from the introduction to the sixth edition of Counseling Across Cultures by the
four editors. The passage quoted, however, was written by Paul B. Pedersen and represents the gist of
the concept of culture teachers that he originated.

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3 Assessment of Persons in Cross-Cultural Counseling

Walter J. Lonner

Primary Objective
To present a general overview of contemporary issues and perspectives associated with the
assessment of individuals whose cultural or ethnic origins differ from those of the professional
counselors conducting the assessment

Secondary Objective
To provide counselors and other professionals with resources designed to increase their
competence in a broad spectrum of culture-sensitive assessment
Half a century ago there was an unprecedented flurry of activity involving the translation of many
popular, and almost entirely American, tests, scales, and inventories for first-time use in other
countries and among U.S. ethnic groups (see Lonner, 1976, in the first edition of Counseling Across
Cultures, for an earlier description of this activity). Much has been learned since then about how such
adaptations should be done correctly and fairly. But, despite its importance, psychological testing is
not the only perspective that will be discussed in this chapter. Psychological assessment in various
facets of the mental health field should not be limited to Western-based psychometric devices that
employ a variety of formats designed to provide information that can be analyzed statistically and, of
utmost importance, help counselors understand their clients. As they conduct their multifaceted jobs,
mental health professionals are constantly assessing and evaluating clients in numerous ways, many of
which have little or nothing to do with measurement of the kind traditionally used by test-oriented
psychologists. Additionally, professional counselors should be assessing and monitoring themselves
in terms of possible biases or prejudices that may surface in specific cases. Assessment across
culturestestingis still a necessary and vibrant activity in the field of counseling, but assessment
in general has become much broader and more informed, thanks to advances made by thousands of
culture-oriented psychologists.

Chapter Orientation
Psychological practitioners use a variety of formats to measure such things as a clients personality,
values, intelligence, and mental health status. To avoid mistakes in adapting any one of thousands of
devices chosen to assess persons who belong to myriad cultures and ethnicities, practitioners must
recognize the paramount importance of the answer to one crucial question in regard to each unique
client: Is the assessment of this person, in these circumstances, with these methods, and at this
time as complete and accurate as possible?
A wide range of conceptual and methodological hurdles involving the assessment of persons crossculturally has challenged both practitioners and theorists persistently for more than half a century
(Brislin, Lonner, & Thorndike, 1973; Dana, 2005; Paniagua, 2010, 2013). Below is a small sample of
the questions that counselors who interact with clients from different cultures or ethnic backgrounds
will want to consider:
To what extent can intelligence tests originally developed by White American psychologists
be validly used with individuals who identify with different ethnic groups, or who hail from
other cultures? Should such tests be used at all? If not, what, if anything, should replace them?
Are components of personality, self, or values so meaningful and tangible across cultures and
ethnic groups that they lend themselves to accurate measurement?
In educational settings, are tests of achievement and abilities fair to all children and adults
who take them, including many whose cultural or ethnic backgrounds may emphasize different
learning styles, or who may object to invasive psychometric probing?
While the basic issues in traditional cross-cultural assessment remain remarkably stable, the
accessibility and sophistication used by researchers and practitioners to explore them have increased
dramatically (Byrne et al., 2009). Many texts that have been written to help educate and inform
counselors about the range of problems and issues in multicultural counseling have grappled with the
question of psychological assessment and where it belongs in the counselors toolbox for gathering
meaningful information. When culture, ethnicity, religion, sexual orientation, and other ways to
differentiate people from each other enter the picture, a variety of quandaries are certain to surface.
How practitioners approach and resolve these quandaries will greatly affect culturally appropriate
assessment as well as counseling strategies.
The goal of assessment is to contribute to the counselors professional competence when dealing with
diverse clientele (Deardorff, 2009; Lonner & Hayes, 2004; Paniagua, 2010; Sternberg & Grigorenko,
2004; Sue, Arredondo, & McDavis, 1992). This process aims to bring people who are culturally or
ethnically diverse (the clients) together with psychologists and others in the helping professions
(the experts) who themselves differ from the clients culturally or ethnically. Counselors and
therapists should be acutely aware of the responsibility they have in the assessment of persons as
well as in the proper delivery of their professional skills (American Psychiatric Association, 2000,
2013; American Psychological Association, 2003; Draguns, 1998).

The Enigmatic Other

Human beings are often perplexing, even to insightful scholars. The late esteemed cultural
psychologist Ernest Boesch noted that any personthe enigmatic other, he called her or himis
forever difficult for even highly trained professionals to understand completely (Lonner & Hayes,
2007). For Boesch, the other (a patient, a client, a confused student, an anxious immigrant) is
always encapsulated in his or her unique world of thoughts, emotions, reflections, and behaviors, all
of which are shaped by the culture(s) or ethnic group(s) in which the individual was nurtured. The
enigma can be considerably compounded when the other is from a nonisomorphic cultural or
ethnic group that, as explained below, may be radically different from the culture of another, thereby
presenting a secondand quite possibly the most complexlevel of difficulty in professional
A common problem faced by professionals who attempt to assess and diagnose other people lies in
the imperfections that all humans experience, both as clients and as experts. Human beings tend to be
complex and enigmatic, and so are human cultures and the wide assortment of ethnicities that are
found in any pluralistic country. Unraveling these complexities and enigmas is a constant challenge.

The Cultural Isomorphism of Human Assessment

A frequent lamentation of culturally oriented psychologists is that most of the pioneering work in this
area involved a rather narrow slice of humanity (Segall, Lonner, & Berry, 1998). Psychologists have
dealt primarily with readily available and opportunistic samples of convenience from the WEIRD
worldthat is, from Western, educated, industrialized, rich, and democratic nations (Henrich, Heine,
& Norenzayan, 2010). The language and reasoning used by members of the scientific establishment in
such efforts are generally mutually understandable, dealing as they do with the lingua franca of the
guild and the people in the guild whom they serve. In other words, the great similarity in form and
function shared by professionals and their clientstheir isomorphism, or the extent of their
congruency in thought and actionminimizes some important barriers. Common sense tells us that the
most effective counseling takes place in settings that are culturally isomorphic (White clients and
White counselors living in rural Kansas, for instance, or Hispanic clients and Hispanic counselors
living in New Mexico). This has been called the cultural compatibility hypothesis. High
isomorphism (high compatibility) seemingly ensures that individuals, when all barriers are minimized
or eliminated in such relationships, will generally be on the same page. High compatibility would
obviously facilitate (but not guarantee) accurate assessment and communication, even if the presenting
problems are complex. At its best, this facilitation would be enhanced because those in the
therapeutic relationship would have learned the same language, been socialized in the same country
or culture, and shared a common fate in a similar social, ecological, economic, familial, and
political milieu in which the counseling relationship takes place. But this clinical matching
hypothesis may not always be the best route. The universalist position argues that assessment, as well
as treatment, is independent of any issues involving cultural or ethnic differences. Some researchers
have addressed the compatibility versus universalism issue (see Paniagua, 2013, Chapter 2;
Zane, Hall, Sue, Young, & Nunez, 2004). Chapter 2 in this book discusses this topic in more detail. In
any case, all professional interactions should involve accurate assessment and sensitive
understanding of the other in his or her unique and enigmatic form, all of which is shaped by
cultural and ethnic forces.

An Example of Radical Nonisomorphism/Incongruence

A case study wonderfully told by Anne Fadiman in her award-winning book The Spirit Catches You
and You Fall Down (1997) provides an excellent example of radical incongruence between patient
and doctor. Fadimans book is structured around the problems that a Hmong child, Lia Lee,
experienced in her adopted United States and the clash of two medical systemsessentially two
worldviewsin their attempts to explain the childs behavior. Lia, who died in August 2012, had
severe epilepsy (a uniformly accepted condition in the modern world with a number of known
symptoms and behaviors). To her refugee parents, however, she suffered from quag dab peg, a
culture-bound illness in which the spirit catches you and you fall down. Fadimans book has
become required reading in many medical schools.
This fascinating case study challenges the efficacy of two systems of causalitythe Western
paradigm and the Hmong belief system. Getting out of the WEIRD box, which can seriously constrain
thinking, is the key to progress. The case study serves as a showcase for what have been called
Arthur Kleinmans (1992) Eight Questions. These questions are often used as a tool of preliminary
assessment in many intake interviews, where the beliefs held by different cultures and ethnicities may
clash with the Western model:

What do you call the problem?

What do you think has caused the problem?
Why do you think it started when it did?
What do you think the sickness does? How does it work?
How severe is the sickness? Will it have a short or long course?
What kind of treatment do you think the patient should receive? What are the most important
results you hope the patient will receive from this treatment?
7. What are the chief problems the sickness has caused?
8. What do you fear most about the sickness?
These questions emerged in the context of exotic ethnopsychiatric conditions and anthropological
perspectives. Except for those who work with people who are in various stages of acculturation, not
many professional mental health workers in the Western world routinely confront the problems faced
by an unacculturated Hmong child. Kleinman (1980), after all, has spent a career in ethnopsychiatry
and medical anthropology. His model for cultural assessment was designed to cover all facets of a
clients cultural experience (Kleinman, 1992). Also containing eight points, the model has been useful
in professional interactions where cultural differences may be relevant. But the eight questions can be
modified slightly for use in various relatively modern and Western counseling settings rather than in
specific and exotic ethnopsychiatric circumstances where baffling medical conditions may be
involved. Words such as patient and sickness can be replaced by client and psychological condition,
thus making the eight questions part of an appropriate and somewhat more isomorphic assessment tool
in virtually all multicultural counseling settings. Perhaps accurate answers to these questions could be
used as criteria for successful assessment and empathetic understanding in any counseling scenario,
regardless of how radically incongruent a given setting may be.

Four Approaches to Assessment in Multicultural Counseling

There are four different approaches in the assessment toolbox with which all culture-oriented
practitioners are involved to varying extents: quantitative, qualitative, mixed-methods, and
knowledge-based approaches. Which of these, or combination thereof, a counselor takes will depend
on the nature of the individual case as well as on the background and intentions of the counselor.
Traditionally, the two main approachesqualitative (or idiographic) and quantitative (or nomothetic)
have been centerpieces in an ongoing debate about which is better (Draguns, 1996; Draguns &
Tanaka-Matsumi, 2001; Ponterotto, Gretchen, & Chauhan, 2001). This debate is the entire focus of
Meehls classic 1954 book Clinical Versus Statistical Prediction, which notes that both approaches
have had strong supporters and outspoken opponents. For instance, the clinical (qualitative) method
has been described as rich, contextual, sensitive, open-minded, deep, genuine, insightful, flexible, and
meaningful. It has also been pejoratively described as mystical, hazy, unverifiable, sloppy, crude,
primitive, and intuitive. On the other hand, the statistical (quantitative) approach has been described
by its adherents as communicable, testable, reliable, rigorous, precise, and empirical. Its detractors
use such adjectives as mechanical, forced, superficial, rigid, pseudoscientific, and blind.
Historical and scientific posturing aside, psychology as a field is moving toward a third approach in
assessment, which usually is considered to consist of mixed methods in research and evaluation.
Similarly, assessment usually involves both quantitative and qualitative perspectives. Further, the
guidelines for practice endorsed by the American Psychiatric Association (2013), the American
Psychological Association (2003), and the American Counseling Association (2005) all emphasize
that in working with culturally different clients, it is very important for counselors to use culturally
impressionistic approaches to identify the clients norm groups, so that quantitative assessments can
be conducted ethically. Effective assessment involving individuals from other cultures or ethnic
groups can be accomplished only after the persons doing the assessment have accumulated significant
knowledge about the histories, customs, and modes of interaction of the groups in question. That kind
of assessment, the fourth approach, is here called knowledge-based assessment (KBA) because it
relies on the accumulation of increasingly deep understanding of a clients cultural background. The
knowledge-based approach draws heavily from the work of cultural and cross-cultural psychologists
who have offered numerous ways to understand entire cultures as well as individuals within them.
Much of the remainder of this chapter is built around these four dimensions and the issues that have
followed them.

The Quantitative Approach

Guided by logical positivism, nomothetic (putatively universally lawful) approaches tend to be
favored by most psychologists, whether or not their focus is on culture or ethnicity. Psychological
testing can provide the counselor with the kind of data-oriented information that conforms to the
canons of orthodox psychological science. A preference for normative objective data over
idiographic clinical interpretation, standardization in both method and scoring, and efficiency of
administering and interpreting tests and scales over on-the-spot constructivist approaches tend to be
some of the hallmarks of this dimension in the assessment of persons. Some call it the gold standard
in assessment.

Methodological Culture-Centered Concerns in Quantitative

Numerous problems have been found to be associated with the use of the many data-gathering devices
that are designed to assess clients from various cultural and ethnic groups. The measurement of
intelligence, for example, continues to be fraught with considerable difficulties when particular tests
are applied to individuals from different cultures or ethnic groups (Suzuki, Naqvi, & Hill, 2014). In
short, the quest for a truly culture-fair intelligence test has been severely damaged on the rocky
shoals of rigorous examination. While concepts such as cultural intelligence (CQ), emotional
intelligence (EI), and street smarts are currently in vogue, they too demand explication and some
kind of measurement. In the domain of personality assessment, psychologists who favor such widely
used devices as the NEO Personality InventoryRevised (NEO-PI-R), the five-factor model
(McCrae & Allik, 2002; McCrae & Costa, 1997), the Minnesota Multiphasic Personality Inventory
(MMPI; Butcher, 1996), and various values scales (see Dana, 2005) have been especially careful to
address the methodological problems of such multi-item scales and inventories when these are
extended to other cultures.
Methodological concerns tend to center on two major areas: (1) the equivalence (mutual
meaningfulness) of assessment devices and (2) the bias that may be inherent in many, if not all,
quantitative approaches. Bias and equivalence are highly related because they are mirror concepts,
with bias being synonymous with nonequivalence and, conversely, equivalence referring to the
absence of bias (van de Vijver, 2001). In their edited volume devoted to cross-cultural counseling,
Gerstein, Heppner, gisdttir, Leung, and Norsworthy (2009) correctly assert that many conceptual
and methodological issues face counselors across the globe. A chapter in that text by gisdttir,
Gerstein, Leung, Kwan, and Lonner (2009) and a popular online readings article by He and van de
Vijver (2012) summarize the essence of equivalence and bias in their various forms. Similarly,
Kwan, Gong, and Maestas (2010) and van de Vijver and Leung (2011) provide overviews of
significant concerns facing scholars and practitioners who wish to adapt psychological tests for use in
multicultural counseling. The same concerns must be addressed in research using any kind of
psychological measurement involving the admixture of culture/ethnicity and individual differences.
The following section summarizes the essence of these issues.

Types of Equivalence
Conceptual (or Construct) Equivalence
Psychological concepts or constructs may never have totally equivalent meanings across different
cultures or ethnic groups. Many diagnostic categories, descriptions of syndromes, and adjectives used
to describe people do not transfer well across different groups in such a way that their meanings are
identical. Even in a homogeneous culture there will be individual differences in understandings of
certain words or phrases, or in attaching certain meanings or emotions to them. We should, therefore,
expect even more such variation between individuals in different cultural or ethnic groups. In
culturally sensitive psychological assessment the goal is to find enough equivalence between

disparate cultural or ethnic groups so that the elimination of any bias that favors one group or
individual over another is possible.
Hofstede (2001) asserts that culture is the collective programming of the mind that distinguishes the
members of one group or category of people from others (p. 9). In other words, every culture, either
explicitly or implicitly, teaches its citizens to process concepts and constructs in ways that may differ
substantially from those used by members of other cultures. If differences are present, one of the
counselors tasks is to try to understand why and how this cultural programming occurs and to
assess people accordingly. For instance, cultures that are highly individualistic tend to foster
autonomy and independence among their citizens. The concept of dependency, therefore, when
manifested by a client socialized in the individualistic Western world, could be viewed as weak or
as indicating an adjustment problem. In contrast, in cultures that do not nudge people toward
autonomy and independence, dependency and conformity may be the norm.
Even specific cultures and ethnic groups within multiethnic societies are usually not homogeneous.
There can be, and often are, subtle variations in cultures between regions in specific countries. For
instance, Vandello and Cohen (1999) found patterns of individualism and collectivism within the
United States, with people in the Deep South being generally more collectivistic than the typically
more individualistic residents of the Midwest and Far West. The main theme of a recent best-selling
book by the historian and journalist Colin Woodard (2011) is that the United States is not one large
and undivided monolithic nation but rather 11 nations, each with its own historical roots that go back
centuries. For instance, Woodward names among them the Left Coast, Yankeedom, Greater
Appalachia, and the Deep South, where some are still fighting the Civil War. He even includes
large parts of Canada in his argument (e.g., First Nation and New France). In multicultural
Canada one can find plenty of differences in attitudes and other variables between the Francophones
in Quebec and the Anglophones in British Columbia or Saskatchewan. In any pluralistic society one
can generally expect to find numerous differences among individuals from different native groups,
geographic regions, or generations of immigrants. In fact, one line of contemporary research on values
suggests that there may be more differences within than between cultures (see below in the discussion
of values). A caution: While these demographic and historical perspectives are generally interesting
and broadly historically informative and insightful, it may be a stretch for counselors to rely on them
to assess any given individual who resides in one particular culture or identifies with one particular
ethnic group. To do so may be to perpetuate stereotypes.
Before a counselor uses any data-gathering device to assess or diagnose an individual from another
culture or ethnic group, he or she should consider the extent to which his or her own definitions of
important concepts, both intrapersonal and interpersonal, match those of the client. In other words,
cultural validity and meaningfulness should be established. Unfortunately, there is no objective
checklist to guide the counselor in establishing such validity. However, most tests and scales
designed or adapted for use in cross-cultural research have a significant body of research to guide the
professional counselor. A search of the literature will usually pay off. Dana (2005), for instance,
provides an excellent overview of multicultural assessment. Likewise, Gamst, Liang, and DerKarabetian (2011) present an extensive list of multicultural measures. These researchers pedagogical
goal was to place as many multicultural instruments summaries as we could create within one text;
at the same time, however, they note that such one-stop shopping can often yield a double-edged

sword; convenience must be tempered by the realization that any multicultural measurement
compendium is but a beginning of a serious and thorough literature review (p. xvii). Gamst et al.
touch on many of the salient dimensions that will be of some interest in virtually any multicultural
counseling encounter. They describe measures of counselor competence, racial and ethnic identity,
and acculturation, as well as racism- and prejudice-related, gender-related, sexual orientation
related, and disability attitude measures.

Structural (or Functional) Equivalence

Structural equivalence is satisfied if an instrument measures the same construct in different cultural or
ethnic groups. Somewhat similar to conceptual equivalence is linguistic, or translation, equivalence
this area addresses all aspects of the language(s) used in assessment devices. Psychologists who
plan to make comparisons across cultures, and others who simply want to render tests or scales
usable in particular cultural or ethnic settings, often spend a great deal of time translating the devices
to be used. Back-translation is an almost obligatory procedure to ascertain the linguistic equivalence
of scales. Brislin (1986) and Hambleton and Zenisky (2011) provide overviews of the problems
associated with translating and adapting tests for use across cultures and ethnic groups. Extensive
cross-cultural adaptations of the famous MMPI incorporate lessons learned over many years in this
domain of test adaptation (see, for example, Butcher & Williams, 2009).

Measurement Unit Equivalence

As Marsella (1987) notes in his discussion of depressive experience and disorder across cultures,
virtually everyone in Western society is exposed to Likert-type scales, Thurstone scales, truefalse
ratings, and other efforts to quantify life experiences, opinions, attitudes, and behavior patterns (p.
387). Moreover, it is usually assumed that people will readily rate themselves and others, and that
they have the ability to be self-reflective, with little or no regard for their right to privacy or concerns
about how culture has influenced the individuals tendency to disclose themselves to strangers or
counselors. Van de Vijver and Leung (1997) give a cogent example of this problem that employs two
different scales used to measure temperaturethe Kelvin and Celsius scales. If used for two groups,
the measurement unit would be identical. However, the origins of the scales are not. As van de Vijver
and Leung explain it, By subtracting 273 from the temperatures in Celsius, these will be converted
into degrees Kelvin. Unfortunately, we hardly ever know the offset of scales in cross-cultural
research (p. 8). Suppose, for example, that a scale to measure anxiety is developed in Canada and is
subsequently translated and administered to recent immigrants from Vietnam. The original (Canadian)
scale may contain a number of implicit and explicit references to the Canadian culture. These
references will put Vietnamese respondents at a disadvantage. As a consequence, van de Vijver and
Leung note, the (supposedly) interval-level scores in each group do not constitute comparability at
the ratio level (p. 8).

Scalar Equivalence, or Full-Score Comparability

Scalar equivalence, the highest level, is the only type of equivalence that permits direct cross-cultural

comparisons. It can be achieved only with methods or scales that use the same ratio scale in each
cultural group, because this would allow one to conclude that scores obtained in two cultures or
ethnic groups are different or equal. Van de Vijver and Leung (1997) use the measurement of body
length or weight (using any standard measure in either case) as an example. In a similar context, van
de Vijver and Leung (2011) point out that scalar equivalence assumes both an identical interval or
ratio scale and an identical scale origin across cultural groups. Psychological constructs are often
opaque and slippery. Perhaps scalar equivalence across cultures can be most reliably achieved with
biometric scales such as blood pressure readings or eye pressure tests for glaucoma. For reasons
already given, it would be much more problematic to develop a totally useful psychological scale to
measure, for example, feelings of inferiority across cultural or ethnic lines.

Bias in Assessment and Appraisal

A large number of unwanted nuisance factors can threaten the validity and therefore usefulness of
assessment devices when they are used with cultural and ethnic groups other than those for which they
were developed. Bias is the general term used to refer to such threats. Van de Vijver and Poortinga
(1997; see also van de Vijver & Leung, 1997, 2011) assert that there are three types of bias:
construct, method, and item.
Construct bias can occur, for example, when
definitions of a construct across cultures do not completely overlap;
there is poor sampling of all relevant behaviors (such as in short questionnaires or scales); or
there is incomplete coverage of the construct.
Method bias is a potential problem when, for instance,
those who take a test are unequally familiar with the items;
the person giving the test has differential effects on the participants, such as in communication
the samples are incomparable; or
the physical conditions or test administration procedures differ.
Item bias occurs when, for instance,
one or more items are poorly translated;
there is complex wording in items; or
there are incidental or inappropriate differences in the content of test items (e.g., the topic of
an item in an educational test is absent in the curriculum of one of the cultural groups).
Detailed information about the use of tests across cultures, as well as in research designs requiring
the use of tests, is readily available. The International Test Commission (ITC) is one highly
recommended source of such information. In 1999, the ITC formally adapted guidelines for test usage,
and the European Federation of Professional Associations Task Force on Tests and Testing endorsed
the guidelines that year. Copies of the current guidelines can be obtained from the ITC website

(http://www.intestcom.org). A recent book edited by Matsumoto and van de Vijver (2011) contains
numerous chapters by specialists in cross-cultural research. Among the topics it covers are the
translation and adaptation of tests, sampling, survey research, and multilevel modeling, as well as an
assortment of other concerns and problems. Gamst et al. (2011) cover some of this ground as well.

The Qualitative Approach

Qualitative assessment relies heavily on idiographic, informal, impressionistic, and often
unstructured procedures or approaches. In-depth interviews and autobiographies are classic
examples. This approach almost completely eschews traditional psychometrics and techniques that
tend to objectify and reduce people to standard scores, percentiles, personality profiles, or points
on Likert-type scales.
The qualitative approach includes the assessment of what may well be the most important aspect of a
persons mode of thought and behavior: his or her worldview. Koltko-Rivera (2004) defines
worldviews as sets of beliefs and assumptions that describe reality (p. 3). (See also the Scale to
Assess World View, a social psychological instrument; Ibrahim & Kahn, 1987; Ibrahim, RoysircarSodowsky, & Ohnishi, 2001.) A persons worldview (Weltanschauung), which is certainly shaped by
culture, encompasses a wide range of topics, including morality, appropriate social behavior,
political stances, ethical matters, the nature of the universe, ad infinitum. Yet, while a person is the
child of one specific culture, he or she of course does not necessarily represent a pristine example of
everyone in that particular group. On the other hand, it is highly likely the worldviews of most people
from a given culture will be more similar than different. Recent research on social axioms supports
the view that there is widespread agreement among people in a given culture regarding how the world
works. Conceptually similar to the measurement of cultural syndromes (Triandis, 1996) or the
popular mode of dimensionalizing cultures via work-related values (Hofstede, 2001, 2011), social
axioms represent a way to assess a persons view of the world (Bond et al., 2004; Leung et al., 2002;
Malham & Saucier, 2014). According to Leung et al. (2002), social axioms are generalized beliefs
about oneself, the social and physical environment, or the spiritual world, and are in the form of an
assertion about the relationship between two entities or concepts (p. 289). Detailed, multicultural
factor analysis has unearthed a quintet of social axioms:
Cynicism: a negative view of human nature, a belief that life produces unhappiness
Social complexity: a belief in multiple ways of doing things
Reward for application: a belief that hard work and careful planning will lead to positive
Spirituality (or religiousness): a belief in a supreme being and the positive functions of
religious practice
Fate control: a belief that life events are predetermined and that people have some influence
over the outcomes
Qualitative approaches include the notion that the person and the culture in which he or she lives are
co-constructedthey literally define each other. Constructivist assessment emphasizes local
(emic) as opposed to universal (etic) meanings and beliefs shared by individuals in a
circumscribed culture (Neimeyer, 1993; Raskin, 2002); it also embraces a fluid and flexible style in

constructing meaning.
More than a decade ago, Carr, Marsella, and Purcell (2002) noted that interest in the use of
qualitative research methods was on the increase. This continues to be true. The key ideas shared by
those who tend to favor such methods include a strong desire to preserve and study life in its genuine
and earthy form, to examine the essence and nature of things, and to understand the dynamics of
phenomena in their natural and nonmanipulated settings. The cultural psychologist Cole (1996) argues
that the analysis of everyday life events, the fact that individuals are active agents in their own
development, and the examination of mediated action in a context are, among other factors, quite
important. Cultural psychologists and constructivists in general tend to reject, as Cole puts it, causeeffect, stimulus-response, explanatory science in favor of a science that emphasizes the emergent
nature of mind in activity and that acknowledges a central role for interpretation in its explanatory
framework. He also endorses the use of methodologies from the humanities as well as from the
social and biological sciences (p. 104). Cultural psychologists are far more likely to use qualitative
methods than are their cross-cultural colleagues (also see Shweder, 1991). The phenomenological
nature of the human being and the belief that there are multiple realities rather than a uniform and
completely objective and well-ordered world are other themes in qualitative approaches in general
(Denzin & Lincoln, 2011) and also in research methodology (J. Smith, 2003).

Mixed Methods and Models of Assessment in Multicultural

Many culture-oriented practitioners use both quantitative and qualitative methods. Several models
and approaches have recently evolved that are additive. Essentially, this represents the collective
thinking of researchers (Dana, 1998; Karasz, 2011).
The earliest modular framework took the form of Kleinmans (1992) Eight Questions to guide the
assessment process (as listed above). Kleinman developed these questions to understand the clients
explanatory rationale for the problem in both physical and mental health. This approach was quite
revolutionary at the time because it included the client in the problem-solving process, focusing on
understanding what the client believed was the genesis of the problem, what function it was serving in
the clients context, and how it might be treated. This model has provided the framework for ethical
cross-cultural diagnosis and assessment such as the cultural formulation of the clients problem
espoused by the American Psychiatric Association (2000, 2013). Castillo (1997) expanded on
Kleinmans questions to include the client and the context as the central components in the assessment
and diagnosis process.
A closely related approach is the ADDRESSING framework proposed by Hays (2001). The letters of
the ADDRESSING acronym serve as prompts for the counselor to address, if desired: age,
developmental and acquired disabilities, religion and spirituality, ethnicity, socioeconomic status,
sexual orientation, indigenous heritage, national origin, and gender.
Mixed methods and models help to clarify what is normal and abnormal in specific cultural contexts,
thus reducing fears of misdiagnosis and cultural malpractice. The counselor must make key decisions

in planning his or her assessment strategy when using tools of this kind. The decisions pertain to
identifying the most salient features for the client that must be assessed before an intervention can be
conducted. The determination of key variables depends on several factors, such as deciding if the
issues the client is facing are relevant to his or her core values and culture.
Dana (2005) has developed an ethnically sensitive model he calls the multicultural assessmentintervention process (MAIP). Using a seven-step procedure, this model incorporates a process
whereby the counselor must make frequent and careful selections from among traditional and
appropriate psychometric devices (see Figure 3.1). Using MAIP, the therapist
1. identifies the clients cultural identity;
2. determines the clients level of acculturation;
3. provides a culture-specific service delivery style in which he or she phrases questions in
accordance with cultural etiquette;
4. uses the clients language (or preferred language), if possible;
5. selects assessment devices or modes that are culturally appropriate to the client or that the client
prefers; and
6. uses culture-specific strategies in informing the client about the results of the assessment.
The MAIP has been used in conjunction with the California Brief Multicultural Competence Scale
(CBMCS). It also includes the possible use of traditional psychological tests, especially in steps 3
and 4. Dana (2005) reports that Ponterotto et al. (2001) have identified the MAIP as his six-step
cultural assessment model. He further notes that Morris (2000) has expanded his model to propose a
hybrid model for African Americans that combines MAIP with Helmss (1990) racial identity
development process (see also Spengler, Strohmer, Dixon, & Shivy, 1995).

Figure 3.1 Schematic Flowchart of MAIP Model Components

Source: Gamst, G. C., Liang, C.T.H., & Der-Karabetian, A. (2011). Handbook of multicultural
measures. Thousand Oaks, CA: Sage.
Ridley, Li, and Hill (1998) have proposed a model they call the multicultural assessment procedure
(MAP). It focuses on the incorporation of the clients culture in the assessment decision-making
process. In addition, Ridley et al. emphasize the role of cognitive flexibility in clinical judgment and
practice, as well as the role of language in assessments. The main goal of MAP is to enhance the
cultural competence of psychologists and other mental health professionals in culture-sensitive
assessment. One of the biggest strengths of this model is that it actively engages the client in the
assessment process. This can help to avoid misunderstandings and culturally biased judgments by
helping therapists engage their clients and get an accurate sense of the clients issues and symptoms.
Paniagua (2010) notes that the American Psychiatric Association endorses a five-step assessment
protocol: (1) Identify the clients primary racial or ethnic group, (2) record the origin of how the

client explains the presenting mental disorder or condition, (3) determine how cultural factors in the
psychological environment (e.g., family, church) affect the client, (4) note any potentially significant
differences between the counselor and the client that could affect assessment and diagnosis, and (5)
summarize major findings in the assessment that appear to be related to culture and ethnicity. Paniagua
also discusses how the mental status exam can play a role in assessment and diagnosis.

An Interim Perspective: Neuropsychological Assessment and

An important approach that merits consideration is neuropsychological assessment. From a medical
perspective, assessing patients from diverse cultural and linguistic backgrounds presents unique
ethical challenges (Brickman, Cabo, & Manly, 2006) as well as many potentially complex
measurement problems (Pedraza & Mungas, 2008). Many neuropsychological measures do not meet
acceptable standards when used with most if not all ethnic groups in the United States.
Recognized as a specialization within the field of clinical neuropsychology, this type of assessment
generally focuses on brain disorders. Many individuals in need of some kind of professional
psychological help are foreign-born and not fluent in English (or the dominant language where the
professional encounter occurs); they may be victims of human-made or natural disasters or of
physical or mental abuse and may be severely malnourished. Several chapters in this book discuss
counseling with peoplesuch as immigrants, the impoverished, the marginalized, and substance
abuserswho may be in desperate need of neuropsychological evaluation. Unfortunately, most
counseling psychologists do not receive detailed training in this highly specialized area.
Consequently, they often have to refer clients to medical facilities for proper assessment, diagnosis,
and treatment. Counselors are advised to learn as much as possible about such resources in their
communities. Assessment in this domain features the use of specialized neuropsychological tests. As
such, the same issuesvalidity, reliability, equivalence, and biasthat are part of routine
quantitative procedures must be considered in the assessment of brain disorders, along with unique
challenges and how they may interact with culture-mediated factors. Judd and Beggs (2005) note that
a number of specific cultural factors are most relevant to neuropsychological evaluation; these
include worldview, values, religion and beliefs, family structures, social roles (age, gender, class,
and so on), recent history, epidemiology, differential responses to psychotropic medications, attitudes
and beliefs about health and illness, communication and interpersonal style, and the nature of any
educational system that the client has experienced.
Nell (2000) presents an overview of culture-sensitive neuropsychological assessment. Currently
more than 500 tests are available to the clinical neuropsychologist. It would be easy to dismiss the
universalist argument in the use of any of these devices. It is nearly certain that some cultural
differences can be found in the employment of all of these tests. However, finding differences is not
that important. What is important is whether the differences are based on solid methodology and, if
they are, why the differences exist. This inherently challenging domain of clinical assessment and
diagnosis is on the radar screen of neuropsychologists, many of whom are aware of the various
problems associated with the measurement of cognitive abilities across diverse cultural, racial, and
ethnic groups (Pedraza & Mungas, 2008). This includes attention given to the multicultural

neuropsychological assessment of children (Byrd, Arentoft, Scheiner, Westerveld, & Baron, 2008).
Because culture or ethnicity may mask neuropsychological conditions, professional counselors should
enhance their competency by becoming familiar with the current literature in this area, as well as with
local medical resources. Important sources of information are the Handbook of Cross-Cultural
Neuropsychology (Fletcher-Janzen, Strickland, & Reynolds, 2000) and Assessment and Culture:
Psychological Tests With Minority Populations (Gopaul-McNicol & Armour-Thomas, 2002).
Neuropsychology and the Hispanic Patient: A Clinical Handbook (Pontn & Len-Carrin, 2001) is
an excellent methodological and forensic resource for counselors working with Hispanic clients, as is
Minority and Cross-Cultural Aspects of Neuropsychological Assessment (Ferraro, 2002). More
broadly, the International Handbook of Cross-Cultural Neuropsychology (Uzzell, Pontn, & Ardila,
2007) is a helpful source of information regarding progress in this relatively new field. The website
of the National Academy of Neuropsychology (http://www.nanonline.org) is also an excellent
resource in this area of individual assessment. The academys Culture and Diversity Committee is
especially active in such efforts. The American Psychological Association, American Psychological
Society, and Canadian Psychological Association are good sources of information, as is the
California Association of Psychologys Cultural Neuropsychology Subcommittee of Culture and
Diversity. Brickman et al. (2006) address ethical issues in cross-cultural neuropsychology.

Knowledge-Based Assessment
A fourth type of culture-centered assessment is offered as a more general path to competent crosscultural assessment. It usually does not rely on traditional modes of psychological testing. Instead, it
draws on the rapidly increasing efforts of culture-oriented psychologists over several decades (Berry,
Poortinga, Breugelmans, Chasiotis, & Sam, 2011; Keith, 2013; Lonner, 2013; Matsumoto & Juang,
2008; P. B. Smith & Best, 2009; Valsiner, 2012). By becoming familiar with contemporary
developments in the psychological study of culture, counselors can greatly enrich their interactions
with clients who are culturally different from themselves.
KBA is highly related to a number of recent models of and perspectives on cross-cultural
competence, several of which focus on motivation, skills, and knowledge (Deardorff, 2009), which
are, in turn, related to cultural intelligence, or CQ (Ang & Van Dyne, 2008). A special issue of the
Journal of Cross-Cultural Psychology (Chiu, Lonner, Matsumoto, & Ward, 2013) addresses a
variety of theoretical and measurement perspectives on cross-cultural competence. This type of
assessment also embraces the profound simplicity of what Kahneman (2011) reminds us is part of our
biological and cognitive endowment: an ability to evaluate crucial features of present circumstances
so that proper action may take place. Knowingly or unknowingly, we always appraise and assess
those we meet. Such evaluation, done broadly and deeply and linked to contemporary research, will
contribute immensely to empathetic assessment.
Predicated on the proposition that counselors appraisal of their clients potentially involves all facets
of their lives, KBA is informed by the knowledge that counselors have gained over the years in
various academic disciplines; in their travels; in the books, poems, movies, and music they have
appreciated; in the conferences they have attended, the classes they have taught, and the friendships
they have madein other words, life as it evolves over time and place, life as it is lived in the raw

context of everyday discourse, not as it is represented by static and often lifeless psychometric
devices. Additionally, interviews, systematic observation in naturalistic settings, personal documents
and archives, and unobtrusive measures are aspects of this approach. The assessment of persons
regardless of settingis a dynamic, automatic, and constantly ubiquitous human process. Abundant
knowledge accumulated by the counselor enhances and enriches other forms of assessment. The
chapters in this text are excellent examples of the input needed for this type of assessment.

Patterns, Categorization, and Dimensionalizing

Most culture-oriented psychologists tend to gravitate toward, and create, frameworks or perspectives
designed to categorize and dimensionalize culture-related patterns of behavior. While it is often
practical to use such frameworks, even if only heuristically, this is a perilous approach in an
increasingly complex and globalized world (Hermans & Kempen, 1998; Stewart & Bennett, 1991).
When assessing patterns of behavior based on a persons culture or ethnic group, a counselor must
address a problem. This problem includes the unwarranted assumption that the highest level of
abstraction (e.g., an entire culture or ethnic group) translates directly to the lowest level of
abstraction (the unique individual and his or her specific behaviors). It is tempting, as P. B. Smith
(2004) cautions, to test the plausibility of hypotheses by thinking about how the variables of interest
[at the country or ethnic group level] relate at the individual level of analysis (p. 9). To do so is to
commit what Hofstede (2001) calls the ecological fallacy, for there is no logical reason why
relationships between any two variables at one level of analysis should be exactly the same at
another level of analysis (Hofstede, 1980; Leung, 1989). Nor is there any convincing reason to use
such descriptions as national character or the typical Asian or the modal Hispanic personality
pattern in assessing individuals. There is just too much diversity, too much shifting from region to
region, and too much interplay between and among people to be so sweepingly reductionistic. It may
be tempting to inch toward unwittingly committing an ecological fallacy. To avoid this, the counselor
would be wise to believe that the individual and his or her unique behavioral tendencies trump all
higher levels of abstraction. The higher the level of abstraction (e.g., Asia), the greater potential for
errors at the lowest level (a specific Asian student).
The search for patterns of behavior that may be related to culture embraces a research tradition in the
social and behavioral sciences that has been central to the understanding of persons for many decades
(Lonner, 2009, 2011). One example of this search for regularities is the recent research on social
axioms, described earlier. Three other examples of this culture-oriented research are summarized
below: understanding personality traits, grappling with the nature of self, and mapping human

Understanding Personality Traits

The NEO-PI-R purports to measure the everyday Big Five dimensions of personality within the
general framework of the five-factor model (FFM). The five components of personality emerged from
dozens of factor analytical studies showing that consistent regularities, or patterns, were evident in
numerous measures of personality. Arguably, the five derived factors are universal and therefore

transcend languages, making all items in the 240-item inventory relatively easy to translate. The five
factorsOpenness, Conscientiousness, Extroversion, Agreeableness, and Neuroticismare often
referred to with the acronym OCEAN (see McCrae & Allik, 2002; McCrae & Costa, 1997, 2008;
McCrae, Terracciano, et al., 2005).
Proponents of the FFM believe that these components of personality are as universal and real as
blood type or other biological markers. In assessing personality, perhaps counselors, who also share
these traits to varying degrees, quite naturally cue in on manifestations of these factors in everyday
interactions as well as in counseling sessions. After just one session with a new client the adept
counselor could probably construct a convincing profile of the client by using these salient commondenominator factors, which may help constitute a lingua franca of interpersonal understanding. But
because of the plasticity of personality and the cacophony of cultures and ethnic groups, it is difficult
to confirm the universality of these factors and even more difficult to exclude other factors that may
prove to be equally robust. Nevertheless, all sentient humans may well be hardwired to assess
people by using these facets of personality.
A counselor will only occasionally have a clients NEO-PI-R profile in front of him or her before or
during a counseling session. So how does this relate to this dimension of KBA? One answer is that by
considering patterns of these traits, a counselor can enhance his or her knowledge of a client and the
clients cultural background. For instance, Americans, Canadians, New Zealanders, and Australians
tend to be high on Extroversion and at midscale on Neuroticism. Knowing that these patterns exist, at
least in the academic world, may provide a counselor with some confirmatory evidence about the
general nature of a particular client in a counseling setting.

Grappling With the Self

It is quintessentially human to comprehend, reflect upon, and assess oneself. Theory and research on
selfself-concept, self-efficacy, self-enhancement, self-disclosure, and self-esteem, among many
other aspects of self-nesshas received enormous attention from scholars for centuries. Counseling
obviously concerns the clients self and all of its philosophical and psychological underpinnings.
Tell me a little about yourself is a common opening gambit that professional counselors use. Many
attempts to assess aspects of self have dotted the literature for decades. One of the most popular
devices, and one of the simplest, is the twenty statements test, or TST, which simply asks a client or
student to complete the phrase I am ______ 20 times, after which this self-report is analyzed. Since
its development (Kuhn & McPartland, 1954), the TST has been used in countless projects, many of
which have looked into cultural and ethnic aspects of self-construal (e.g., del Prado et al., 2007).
The most prevalent perspective on matters relating to culture and self has involved the highest level
of abstraction: culture. The heavily studied concept of individualism versus collectivism is
everyones favorite example. Within this great divide, individualist and collectivist orientations
tend to comprehend self quite differently. Generally, a person from a highly individualistic culture
such as the United States or Australia will likely differ substantially from a person who grew up in a
collectivistic culture such as China or Egypt. The heart of the difference is that the individualist will
be primarily concerned about his or her self while the collectivist will tend to focus more on the
group(s) to which he or she belongs. Within the increasingly complex contemporary American

culture, however, care should be used in employing the individualismcollectivism bifurcation

(Vargas & Kemmelmeier, 2013). Counseling strategies that aim to promote self-actualization and selfenhancement, as might typically be employed in individualistic settings, may not work so well in
settings where the group, and especially the family, is central to the conceptualization of self.
Hofstedes other cultural dimensions, incidentally, include power distance, uncertainty avoidance,
and masculinityfemininity. A fifth dimension, long-term versus short-term orientation, was added
more recently. The cultural dynamics associated with these dimensions in counseling encounters
would be worth studying (see also Chapter 2).
Somewhat along the same lines are the polarities of the independent self versus the interdependent
self. Markus and Kitayama (1991) have argued that an individuals motivation, emotion, and
cognition differ depending on the extent to which the persons culture or ethnic group has fostered a
self-construal that is independent (self-centered) as opposed to interdependent (group-centered).
By contrasting a rugged individualist farm boy from rural Iowa with a group-centered boy raised
in an interdependent and clannish Native American tribe, one can easily see how counseling
strategies would have to be altered. Similarly, Nisbett (2003) and Nisbett, Peng, Choi, and
Norenzayan (2001) have addressed the matter of differences in thought as a function of geography
(which is a reasonable proxy for culture). Thus, we have the polarity of alleged holistic thinking
among Asians versus Western analytic thinking. However, caution must again be urged regarding the
use of such facile dimensionalizing and pigeonholing. As explained earlier, assessing an individual
strictly on the basis of his or her belonging to some demographic group, culture, caste, or clan could
be an error with unfortunate consequences. But culture does matter, and how an individual has been
socialized certainly affects how that person thinks about him- or herself, especially in interpersonal
relationships. Markus and Conner (2013) make everyday use of such dimensionalizing, pointing out
that culture clashes (as they call them) involving polarizing demographic end points are genuine.
But the world is not structured along neat dichotomies such as independentinterdependent, East
West, BlackWhite, richpoor, religiousagnostic, malefemale, or any other demographic
bifurcation. Such dichotomies can, however, be salient talking points whenever and wherever
interpersonal interactions, such as counseling, take place.

Mapping Human Values

Either explicitly or implicitly, counseling involves the interplay of human values, the third example of
the KBA perspective. Scholars who study human values assert that they are points of view taken by a
culture, or members of that culture, that influence action toward both desirable means and ends. A
common conception of human values is that they are beliefs and transsituational goals that, while
varying in importance and activation, serve as guiding principles throughout the lives of persons (see
Schwartz, 2011, 2012; P. B. Smith & Schwartz, 1997). Cross-cultural research on values has shown
that values often differ across cultures, but differences in values held by people within a society are
typically larger than differences found between societies (Berry et al., 2011, p. 92).
While there have been hundreds of attempts to define and measure valuesthe individualism
collectivism paradigm discussed earlier is one of the most influentialcurrently the most popular
approach is that taken by the Israeli psychologist Shalom Schwartz. Using his Value Survey, Schwartz
suggests a prototypical structure of 10 universal values: Power, Achievement, Hedonism, Stimulation,

Self-Direction, Universalism, Benevolence, Tradition, Conformity, and Security.

These values are arranged in circular order, whereby juxtaposed values such as Power and
Achievement or Benevolence and Universalism are highly correlated, and oppositional juxtaposed
values such as Security and Self-Direction or Benevolence and Achievement receive low
correlations. Research with the Schwartz model has been robust, especially on an international scale
(see P. B. Smith & Best, 2009). In recent refinements of this model, 19 values have been posited
(Cieciuch, Schwartz, & Vecchione, 2013; Schwartz et al., 2012; for further details, see Keith, 2013,
Vol. 3). The Schwartz paradigm has not yet played a significant role in multicultural counseling
research and practice. However, given the importance of values in clinical and counseling practice,
there is no reason why it should not.
The intent of this brief overview of culture-oriented perspectives and research in three important
areas of scholarshippersonality, self, and valuesis to underscore how important they are in the
clinic, in interviews, and in the general assessment of a persons life and current circumstances.
Learning more about them will certainly enhance a counselors competence. However, nothing in the
broad domain of human assessment can replace the skill with which the empathetic counselor
understands the essence of humanness and how it plays out in the frequently tangled and unique
circumstances of an individuals life.

Summary and Conclusions

The unbiased and accurate assessment of clients who have been socialized in cultures or ethnic
groups that differ from that of the counselor presents a number of formidable problems. Regardless of
culture of origin, ethnic identity, and other dimensions of human diversity that contribute to a persons
unique identity, the usual psychometric concerns, such as validity, reliability, practicality, and ethical
treatment of clients, are involved in all psychological assessment. Added to these concerns are
specific, culture-related considerations regarding appropriateness, meaningfulness, and equivalence
of numerous constructs, syndromes, and psychological dimensions that counselors and clinicians use
in their attempts to understand their clients. Professionals must be constantly aware of these
interactions and of all the methodological and conceptual factors that contribute to how clients must
be understood and respected, regardless of their cultures of origin or how their ethnic identities were

Critical Incident
Suppose that a multicultural counselor wants to assess possible differences in self-concept(s)
between two of her female clients, both 19 years old, who recently enrolled in a Wisconsin
community college. One client is from a rural Black community in Alabama, the other an immigrant
from Sri Lanka who reportedly was the victim of poverty and abuse when she was younger. Neither is
doing well in her studies, despite getting reasonably high scores on aptitude and achievement tests
routinely taken by incoming students. Also, both clients have taken the same inventory, which purports
to measure various facets of self. The young woman from Alabama took the original inventory, which
was developed by a counseling psychologist from the University of Kansas and normed on freshmen

at that university. A British-trained counseling psychologist who was on sabbatical leave in Sri Lanka
had earlier translated the inventory into Tamil, one of Sri Lankas major languages, and normed it on a
small sample of Tamil-speaking students. The Sri Lankan student, who was not yet fluent in English,
took that version. Both clients took the inventory in their senior year in high school. The present
counselor notes that the young womens scores on the inventory strongly suggest that the client from
Alabama has a much higher self-concept than does the Sri Lanka student.

Discussion Questions
This brief, fictional example encompasses some important issues and problems associated with
cross-cultural assessment. If you were the counselor in the community college that these two young
women are attending, how might you handle the following questions?
1. Considering the problems associated with equivalence and bias in psychological assessment, do
you think that the two versions of the same measure are fair? If not, what concerns you the most?
2. Do you think the test has low or high cultural validity? Why?
3. How important is the discrepancy between the scores of the two students? Do you think the
difference is significant enough to examine in further detail?
4. If you completely discounted the validity of the two measures but were still interested in looking
into how the two students seem to differ substantially in self-concept, what steps might you take
to complete more trustworthy pictures of their individual perceptions of self?
5. Do you think that the counselor should learn more about Sri Lankan culture, or perhaps consult
with Tamil-speaking adults?
6. Of the four approaches to assessment outlined in this chapterquantitative, qualitative, mixed
methods, and knowledge-basedwhich would you trust most to help you pinpoint the reasons
for the differences in the two students scores? What are the strengths and weaknesses of each?

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4 Multicultural Counseling Foundations A Synthesis of Research

Findings on Selected Topics
Timothy B. Smith
Alberto Soto
Derek Griner
Joseph E. Trimble

Primary Objective
To review and synthesize selected multicultural counseling research regarding counselor
attributes, client attributes, and counseling methods to illustrate how research can inform
counseling practice

Secondary Objectives
To provide research evidence regarding the effectiveness of multicultural training for
counselors to reduce personal biases and enhance their multicultural competence
To identify and describe how clients experiences of acculturation, racial and ethnic identity,
and perceived racism can affect their well-being and perceptions of counseling
To present research evidence regarding clients and counselor match according to race and
ethnicity and regarding cultural adaptations to counseling that facilitate positive client outcomes
Riza had never attended counseling and was nervous. She had trusted the advice of a coworker
and made the appointment, but now that she had entered the counselors office, she did not know
what to say. Her problems seemed impossible to overcome and were so complex. She loved her
husband, but they fought bitterly. Her husbands family entrusted her with caring for two
nephews, who had become like sons to her. She had felt sadness since the boys parents died, yet
the children provided her with some joy. Most of all, she felt terribly alone since emigrating
from her native country. Would the counselor understand anything of her Filipino culture, her
religious faith, and her secret yet to be shared?
Effective counseling requires trust and mutual understanding between counselor and client. A client
cannot be expected to trust the counselor automatically, so the counselor is primarily responsible for
facilitating a relationship of trust. Trust is enhanced when the counselor demonstrates understanding
of and sensitivity to the multiple cultural contexts influencing the well-being of the client. What would
happen if the counselor in the scenario above did not understand Rizas experiences that intersect
cultural and religious values relative to her family dynamics and social introversion? Counseling that

is congruent and resonant with Rizas worldview would be counseling that she could understand and
If you have engaged in counseling, you can relate to Rizas initial dilemma: Should I engage or not?
The following questions might be others that Riza contemplates: Can a male counselor help me
respond to the sexual harassment I experience in public as a woman? Can a White counselor validate
my pain from racial prejudice in the workplace without assuming that Im overly sensitive? If I chose
to remain with my verbally abusive partner, how will my counselor respond? Differences between
client and counselor are inevitable. Enabling counselors to understand and work across value
differences to promote the well-being of their clients is one principal aim of this book. Helping
counselors to understand some of the research-based foundations for doing so is the fundamental aim
of this chapter.

Research on Multicultural Counseling

Professional counseling practices are based on psychological theories that have received research
support. More than a century of accumulated scientific evidence supports the effectiveness of
professional counseling (e.g., Beutler, Forrester, Gallagher-Thompson, Thompson, & Tomlins, 2012),
with the profession increasingly emphasizing evidenced-based psychological treatments (McHugh &
Barlow, 2010).
Which counseling methods work best with different populations? How can counselors best acquire
the skills necessary to work effectively across different populations? Answers to questions such as
these will help improve client utilization of services, client retention after initiating counseling, and
ultimately, client well-being. Thus, research findings can help to improve the practice of multicultural
counseling (Trimble, 2009).
The amount of research on multicultural issues in counseling and psychology has increased
exponentially over the past several decades. For example, the number of citations found in PsycINFO
that reference African Americans or Blacks increased from fewer than 2,000 during the years 1960
1969 to almost 29,000 during 20002009 and 4,500 in 2012 alone. Since the year 2000, more than
1,800 articles have referenced acculturation and mental health, more than 4,000 have referenced
ethnicity and mental health, and more than 10,000 have referenced culture and mental health. Both
scholars and practitioners can benefit from these scholarly findings.
However, much of the multicultural counseling literature remains disorganized. There can be so many
research findings in a given topic area that trends in the data may be difficult to discern accurately.
Students, instructors, and practitioners could all benefit from a concise summary of existing research
Given the large volume of research studies on multicultural counseling available in the professional
literature, traditional narrative review methods are inadequate to summarize the data accurately.
Meta-analytic methods offer clear advantages over qualitative, interpretive summaries of research

Meta-analysis... [is] the statistical analysis of a large collection of analysis results from
individual studies for the purpose of integrating the findings. It connotes a rigorous alternative to
the casual, narrative discussions of research studies which typify our attempts to make sense of
the rapidly expanding research literature. (Glass, 1976, p. 3)
We rely on the findings of meta-analyses to provide summaries across topics in this chapter.
However, the multicultural counseling literature includes many facets of human experience, including
macro-level social dynamics (e.g., sexism), environment and circumstances (e.g., access to resources
and residential status), and personal attributes (e.g., age), and we cannot even attempt such broad
coverage in this chapter. So, after first examining the general concept of multicultural counseling
competence, we limit our discussion to race and ethnicity. We have chosen to focus on race and
ethnicity because they receive the greatest attention in the multicultural research literature and
because they clearly influence many of the other conditions and circumstances that receive specific
attention in other chapters of this book. In this chapter we describe selected aspects of multicultural
counseling research relevant to counselor attributes, client attributes, and the counseling context itself.

Selected Multicultural Counseling Research on Counselor

In this section we explore how attributes of the counselor may affect the quality of counseling
provided for culturally diverse clients. Specifically, we consider the impacts of multicultural
competence and multicultural training.

Counselor Multicultural Competence

Mental health professionals have an ethical responsibility to provide effective interventions to all
clients, which necessarily entails adjusting their practices to align with the needs of people who are
culturally different from themselves (S. Sue, 2003; Trimble, 2010; Trimble & Fisher, 2006). Although
few, if any, counselors would intentionally mistreat clients of different racial and ethnic backgrounds,
many counselors are unfamiliar with other groups worldviews, lifestyles, and experiences (Gone &
Trimble, 2012). Even with substantial professional attention to multicultural issues, contemporary
counseling continues to reflect Western cultural values (e.g., Benish, Quintana, & Wampold, 2011).
Counselors may give inadequate consideration to contextual factors such as gender, sexual
orientation, race and ethnicity, socioeconomic status, religion, and environment (e.g., Chao & Nath,
2011; S. Sue & Zane, 1987).
To improve counseling utilization, retention, and outcomes among clients from historically
disadvantaged backgrounds, scholars and professional associations have repeatedly emphasized the
need for multiculturally competent mental health practices (American Psychological Association,
2003; Arredondo & Toporek, 2004; S. Sue, 2003). Multicultural competencies include awareness,
knowledge, and skills (e.g., Constantine, 2002), each of which we describe briefly in the following
paragraphs; full descriptions are readily available in the literature (American Psychological
Association, 2003; Arredondo et al., 1996).

A counselors multicultural awareness includes an understanding of his or her own assumptions,

biases, values, worldview, theoretical orientation, privileges, and so forth. Without this awareness,
counselors may unintentionally project their own values and assumptions onto clients, fail to realize
how their own actions are perceived by their clients, misinterpret clients actions/intentions, and so
on. For instance, a counselor who fails to account for his or her own discomfort about working with a
client originally from Ghana who speaks English with an accent could conjecture that the client would
prefer counseling in another language and raise that topic in session, insulting the client who has
spoken English since early childhood. Examples of counselor multicultural awareness include the
following (Arredondo et al., 1996):
Understanding how ones own cultural heritage shapes ones personal values, assumptions,
perceptions, and biases toward clients and their work in therapy
Awareness of how ones theoretical orientation and treatment approach may affect work with
people from various multicultural backgrounds
Awareness of ones own discomfort, effectiveness, and defensiveness when working with
A counselors multicultural knowledge involves an understanding of the experiences and worldviews
of other people, specifically the differences and similarities across persons of different
races/ethnicities, genders, sexual orientations, religions, and so on. Without this knowledge,
counselors cannot accurately contextualize or interpret the meanings of others actions/perceptions.
For instance, a counselor unfamiliar with traditional Din (Navajo) communication styles may
incorrectly conclude that a Din client lacks social skills because of the clients infrequent eye
contact and brief speech with frequent pauses. Examples of counselor multicultural knowledge
include the following (Arredondo et al., 1996):
Knowledge of how psychological theory, methods of inquiry, and professional practices are
historically and culturally embedded
Knowledge of clients family structures, roles, values, and worldviews, including the history
and manifestation of prejudice that they have encountered
Knowledge of the attitudes and perceptions clients have about mental health services
A counselors multicultural skills involve the ability to work effectively with others while applying
multicultural awareness and knowledge (Arredondo et al., 1996). Without these skills, counselors
may fail to adapt their work to the needs of culturally diverse clientele. For instance, a counselor who
unintentionally offends a client from another race or ethnic group may lack recovery skills to repair
the therapeutic relationship. When the counselor cannot adapt to the needs/experiences of the client
and maintain a strong therapeutic alliance, counseling can be both frustrating and ineffective. The
following are some of the multicultural skills recommended by Arredondo and colleagues (1996):
Ability to see individuals holisticallyaccounting for historical, sociopolitical, and economic
Ability to show respect for client beliefs and values that differ from ones own beliefs and
Ability to modify assessment and treatment methods according to the needs of multicultural

Research findings on counselor multicultural competence.

Abundant research has shown that the therapeutic alliance between client and counselor improves the
effectiveness of counseling (e.g., Wampold, 2001). Multicultural competencies are essential for
enhancing the quality of the therapeutic alliance and bridging the gap between traditional
psychotherapy and the needs of culturally diverse clients (e.g., Arredondo & Arciniega, 2001; Ito &
Maramba, 2002; S. Sue, 1998). However, limited research has specifically investigated the
association between counselors multicultural competence and the counseling outcomes of clients.
Across 11 studies with data that we located in the literature, the average correlation coefficient
between counselor multicultural competence and client ratings of the counselor was r = 0.30,
indicating a moderately strong relationship. When counselor multicultural competence was correlated
with client outcomes, the value was r = 0.15, which indicated a very modest association, but it should
be kept in mind that only about 8% of variance in client outcomes is attributable to counselors (e.g.,
Kim, Wampold, & Bolt, 2006). In any case, additional research on counselor multicultural
competence is clearly needed to ascertain which specific competencies are most conducive to
positive client outcomes in counseling.

Implications for counseling practice.

Counselors can move toward multicultural competence by reviewing the specific qualities listed in
professional guidelines (e.g., Arredondo et al., 1996) and then systematically improving their
abilities through ongoing professional development. For instance, counselors can learn about and
practice different styles of communication that are effective with clients whose preferred methods of
communication differ from the counselors own.
In acquiring multicultural competence, there is no substitute for experiential learning. Self-reflection
is an essential part of that learning, but even self-reflection must be based on concrete experiences to
be useful. Purposefully seeking out professional consultation and supervision that attends to
multicultural issues can help (Constantine, 2001; Lassiter, Napolitano, Culbreth, & Ng, 2008), as can
engaging in cultural immersion experiences (Tomlinson-Clarke, 2010). Reading, engaging in dialogue
with culturally different peers, and attending multicultural community events and activities, such as
film screenings and public forums, can help raise awareness and knowledge. Counselors unfamiliar
with particular cultural groups can identify community leaders or other key stakeholders within those
communities and proactively seek consultation. Irrespective of the methods they use to acquire
multicultural competencies, counselors should keep in mind that gaining such competencies is an
ongoing process involving emotional, cognitive, and experiential components, not simply an
academic endeavor. This learning continues across a lifetime. No one is free from bias.

Multicultural Training for Counselors

Professional associations require graduate training programs to address multicultural issues, and
training in multicultural competencies requires specialized instruction (Cates, Schaefle, Smaby,
Maddux, & LeBeauf, 2007). Hence, graduate and postgraduate classes and workshops in multicultural
counseling constitute one of the primary strategies for improving counselors capacity to serve

diverse populations effectively (Abreu, Chung, & Atkinson, 2000). Multicultural education for mental
health professionals has become commonplace; as Ponterotto and Austin (2005) observe, The
critical importance of training psychologists and mental health professionals for work in an
increasingly multicultural society is unquestioned (p. 19).
A key assumption is that that awareness, knowledge, and skills surrounding multicultural issues can
be taught and learned (Abreu et al., 2000). To what degree is this specialized instruction in
multicultural issues effective? How much do students gain by taking a typical class in multicultural

Research findings on multicultural training for counselors.

Just as there is no single form of counseling, there is no single type of training to enhance
multicultural competence. There are a multiplicity of effective training sequences that vary in their
content, format, duration, intensity, and techniques (Ponterotto & Austin, 2005). The majority of the
published literature addresses graduate program coursework; however, the research is clear that it is
essential for practicing clinicians to engage in ongoing professional development in this domain
(Rogers-Sirin, 2008).
A meta-analysis of studies of multicultural education for mental health students and professionals
yielded a large average effect size of d = 0.92 (Smith, Constantine, Dunn, Dinehart, & Montoya,
2006), meaning that there is a strong correspondence between training and multicultural sensitivity
and competence. Mental health professionals clearly benefit from multicultural education.
Counselors and trainees self-reported abilities, self-reported racial attitudes, and clinical
performance (as rated by observers or clients) all improve as a result of multicultural education,
although there is substantial variability in the quality and effectiveness of the training provided across
programs. On average, the effectiveness of multicultural education does not differ depending on
whether it is required or voluntary, a finding that provides indirect support for the position taken by
professional associations that multicultural education must be required in accredited graduate
programs. Similarly, no significant difference was found between participants who were trainees and
those who were working professionals. Multicultural education benefits both equally, although
training explicitly based on multicultural theories is much more effective than training not grounded in
the professional literature.

Implications for professional development.

Although multicultural education has been shown to be on average at least moderately effective, it is
important to reemphasize the finding that the quality of such training varies substantially across
settings and programs. Given the variability in training quality, trainees should seek out (or request)
training that focuses explicitly on the development of multicultural competence. Obtaining
multicultural competence is the objective of participation in multicultural education (e.g., Abreu et
al., 2000; Ridley, Mollen, & Kelly, 2011), and aspects of multicultural education that do not directly
facilitate multicultural competence should be replaced with more specific learning objectives and

The development of multicultural competencies is more than an academic pursuit. Experiential and
performance-based evaluations can help ensure that skills are internalized. Case studies, service
learning, and training accompanied by supervised practice can be useful to that end. Regardless of the
specific methods used, training programs should emphasize general factors conducive to personal and
professional development (e.g., high student expectations about their own competence, positive
relationships between instructors and trainees, immediate application of material learned).
In addition, a common limitation of multicultural education needs to be addressed squarely:
Multicultural education should emphasize how counselors can work effectively with
ambiguity/complexity; it should not reinforce categorical thinking that perpetuates stereotypes. Often,
when trainees acquire general knowledge about a cultural group with which they have had limited
prior experience, such as immigrants from Haiti, they tend to believe (falsely) that having learned the
material is sufficient for them to work effectively with members of that population, and they may
attempt to apply their new knowledge without careful consideration of the individual client. Not all
members of a given group hold or even value the attributes common to that group. Not all Haitian
immigrants have experienced trauma, for example. Hence, multicultural education must teach not only
culturally specific elements but also dynamic sizing and scientific-mindedness so that trainees know
how to individualize counseling appropriately (S. Sue, 1998).
Too many multicultural training programs focus on awareness and knowledge to the exclusion of
incorporating skill development (Pieterse, Evans, Risner-Butner, Collins, & Mason, 2009). Rather
than simply talking about historically oppressed groups or promoting trainees insight into their
personal feelings about those groups, effective training encourages counselors to gain the skills they
need to work effectively with clients from diverse groups. An honest self-evaluation of multicultural
competence can help students identify areas in which personal skill development is needed
(Arredondo et al., 1996; D. W. Sue, Arredondo, & McDavis, 1992). Ultimately, the best multicultural
training helps fill gaps in personal skills.

Selected Multicultural Research on Client Characteristics

Can I let myself enter fully into the world of his feelings and personal meanings and see these
as he does?... Can I sense it so accurately that I can catch not only the meanings of his
experience which are obvious to him, but those meanings which are only implicit?
Carl R. Rogers, On Becoming a Person, 1961
In this section we direct attention to the subjective world of clients of color, whose daily experiences
and cultural worldviews may be misunderstood by counselors from other racial and ethnic
backgrounds. We ask three questions related to these clients unique racial or ethnic experiences:
What effect does received racism have on client well-being? What is the relationship between racial
and ethnic identity and well-being? To what degree is the clients level of acculturation to Western
society associated with perceptions about and experiences in counseling?

Received Racism and Client Well-Being

The landscape of North American society has changed drastically over the past several decades in
terms of racial and ethnic relations. Few readers of this book will recall the passage of the Civil
Rights Act of 1964, let alone the preceding decades/centuries of overt racial discrimination, such as
forced resettlement of Native Americans on federal reservations, and the associated struggle for
liberation, such as the civil rights marches held in the South. These events have been relegated to
history books. Given that such dramatic improvements in racial relations have taken place over time,
why should we consider the psychological effects of racism in our contemporary society?
First, we must candidly admit that racial prejudice and stereotypes have not yet been eliminated.
Many neighborhoods, schools, and occupations show clear divisions along racial and ethnic lines. It
is true that racism is becoming less overt over time, yet it persists in our institutions, our educational
system, and our workplaces (Blume, Lovato, Thyken, & Denny, 2012; D. W. Sue et al., 2007; Yosso,
Smith, Ceja, & Solrzano, 2009). People of color may be asked, What are you? by someone
attempting to ascertain race/ethnicity, or they may often hear, Where are you from? or You speak
English so well! These and many other seemingly harmless questions or forms of praise produce
negative emotional reactions: The subtle messages of differentiation are insulting. Scholars have
called these events racial microaggressions, a social maintenance of racial hierarchy (D. W. Sue et
al., 2007). Although this kind of treatment may be subtle, how many of these microaggressions does a
person of color experience in one week? If counselors are truly to enter the personal worlds of their
clients, they must be sensitive to the experiences those clients have with discriminatory acts. Even the
most mundane, nuanced hint of racial or ethnic hierarchy can result in psychological distress, selfdeprecation, anger, withdrawal, and so forth.

Research findings on the association of perceived racism with well-being.

Self-reported perceived racism has been shown to be associated with higher blood pressure,
maladaptive coping strategies such as binge drinking, lower self-esteem, and higher levels of
psychological distress and anxiety (Blume et al., 2012; Huynh, 2012; Moradi & Risco, 2006; Steffen,
McNeilly, Anderson, & Sherwood, 2003). While perceived racism has adverse effects on members
of all ethnic and racial groups, experiences with perceived racism differ across groups. Specifically,
African Americans tend to report higher levels of exposure to racial discrimination than do members
of other racial and ethnic groups (Pieterse, Carter, Evans, & Walter, 2010; Thompson, 2006).
Latinas/os tend to have experiences with perceived racism based on assumptions regarding their legal
status, language abilities, and level of acculturation (Moradi & Risco, 2006). Other groups, such as
Arab Americans, experience racism based on false stereotypes and misinformation specific to their
particular groups. Regardless of the uniqueness of the perceived racism, several meta-analytic
findings support the connection between perceived racism and psychological distress across various
racial and ethnic minority groups. One study found an adverse relationship between perceived
discrimination and mental health (r = 0.16) across 105 studies (Pascoe & Smart Richman, 2009).
Another found a correlation of r = 0.23 between perceived racism and psychological distress in
Asian and Asian American participants in 23 studies (Lee & Ahn, 2011). A third found that perceived
racism correlated r = 0.20 with psychological distress across 66 studies with African American
participants (Pieterse, Todd, Neville, & Carter, 2012). Although the association between perceived

racism and well-being is consistently negative, indicating adverse psychological outcomes, there is
great variability in the degree to which individuals and groups cope effectively with such racism, thus
counselors should seek to understand the experiences and reaction of their clients.

Implications for counseling practice.

A professional counselor must first consider how his or her own actions may unwittingly perpetuate
perceived racism or microaggressions. Will the client see the counselor as yet one more
professional to mistrust (Moody-Ayers, Stewart, Covinsky, & Inouye, 2005)? Understanding
received racism will help counselors to foster a deeper level of understanding between their clients
and themselves; by opening dialogue about received racism, counselors can better understand the
experiences of their clients of color and thus be able to help these clients confront and otherwise cope
with the negative events. A counselor may also, after establishing sufficient rapport, ask the client
about possible microaggressions that have occurred in counseling (Constantine, 2007). Perceived
racist events matter to the client, even if they appear to the counselor to be small or taken out of
context, so the counselor should avoid perpetuating them, such as by denying their existence. In
addition, the counselor can help the client develop a strong sense of community and an affirmative
ethnic identity, which can help to buffer some of the adverse effects of received racism
(Mossakowski, 2003; Yosso et al., 2009). How a strong ethnic identity may facilitate client wellbeing is the topic we consider next.

Racial and Ethnic Identity Development and Well-Being

What does it mean to be a Latino/a, an Egyptian American, a White/European American, or an Alaska
Native? Is the notion of racial and ethnic identity important in a diverse society? As one example of
how race/ethnicity continues to matter in contemporary settings, Peggy McIntosh (2003) has written
about how being White in North America confers on her unearned privileges that benefit her daily life
and psychological well-being. She acknowledges that it took purposeful examination for her to
identify these privileges, but people of other races/ethnicities likely see them more easily. We can see
in others what we have difficulty seeing in ourselves, and our own racial or ethnic identity is
influenced by our interactions with others (Smith & Draper, 2004).
As clients of color negotiate responses to mainstream White culture, they simultaneously negotiate
identification with their own racial or ethnic groups. When they act in ways appreciated by Whites,
they may sometimes diminish the cultural values of their own groups (e.g., autonomy/assertiveness
versus respectful deference to elders), creating problems in their interactions with members of those
groups. The balance and trade-offs between relating with Whites and relating to people of their own
groups can make identity issues quite prominent for people of color (Murray, Neal-Barnett,
Demmings, & Stadulis, 2012).
Scholars have differentiated ethnic identity and racial identity as two distinct constructs. Racial
identity refers to the development of an identity within a particular racial group (e.g., African
Americans); the construct of racial identity takes into account social oppression and an internalization
of certain preconceived notions about the racial group (Helms, 1990). Ethnic identity, on the other
hand, is not unique to a particular racial group and can be defined as the subjective sense of

belonging to a group or culture; this sense of belonging tends to center on the sharing of cultural
values or beliefs (Phinney, 1990; Phinney, Horenczyk, Liebkind, & Vedder, 2001). Whereas racial
identity focuses on the influence of societal oppression on a particular racial group, and how the
individual associates him- or herself within that racial group, ethnic identity takes into account a
broad range of cultural values that contribute to identity (language, religion, race, and so on).
Encounters with racism may trigger explorations of what it means to be a member of a particular
racial group (Cross, 1991), but prolonged exposure to perceived racism can contribute to a persons
downplaying his or her racial or ethnic background (Romero & Roberts, 1998). Scholars have
suggested that racial/ethnic socialization, learning from family members, peers, and role models, can
encourage an individuals internalization of racial or ethnic heritage, with an accompanying sense of
belonging (Bennett, 2006; Seaton, Yip, Morgan-Lopez, & Sellers, 2012).

Research findings on the association of racial and ethnic identity with well-being.
Researchers have explored the protective nature of racial and ethnic identity and have sought to
establish the relationship between a strong racial or ethnic identity and psychological well-being. For
instance, African American individuals who report a higher level of racial identity development tend
to display less depressive symptoms and report higher levels of well-being; in addition, a strong
racial identity has been shown to lessen the effects of race-related stress and to predict mental health
(Franklin-Jackson & Carter, 2007; Seaton, Scottham, & Sellers, 2006). Scholars have also suggested
that ethnic identity may serve as a predictor of positive self-esteem for Latino adolescents and
African American college students, as well as serving as a protective factor against depressive
symptoms for Latino adolescents (Phelps, Taylor, & Gerard, 2001; Umaa-Taylor & Updegraff,
A recent meta-analysis found that individuals strength of ethnic identity was mildly positively related
(r = 0.18) with their psychological well-being (Smith & Silva, 2011). There was substantial
variability across studies, such that ethnic identity was more predictive of well-being in some
circumstances than in others. Ethnic identity was not strongly related to measures of distress or
symptoms of mental illness; thus, it may not provide as strong a buffering effect as had been
previously believed. Overall, the research findings about ethnic identity and well-being suggest that
the relationship is not as straightforward as had been previously thought; counselors must rely on
individual clients experiences rather than on clear-cut trends in research findings.

Implications for counseling.

Clients from all backgrounds vary in terms of their ethnic or racial identity development. How
strongly a client associates with her or his racial or ethnic group depends on several factors,
including prior socialization, current social networks, and local intergroup dynamics. Taking these
factors into account, the counselor can actively consider: How does my client relate to his or her own
racial or ethnic background? Additionally, how does my client benefit, or possibly stand to benefit,
from a strong(er) racial or ethnic identity? The counselor might facilitate rapport and open
exploration about racial and ethnic identity development through self-disclosure (e.g., social
reciprocity is normative in Latino cultures) or by exploring with the client potentially valued topics,

such as family, friends, and even music and entertainment preferences. Every client has a story to tell,
and the counselors taking the time to ask the client what it means to be a part of his or her racial or
ethnic group can possibly facilitate counseling.

Client Acculturation and Counseling Utilization/Outcomes

What is life like for a person who is faced with adapting to a radically different culture? Individuals
who move to locations with cultural norms different from their own, whether through
emigration/immigration or simple relocation from one neighborhood to another, often struggle to
adapt to their new cultural surroundings. Imagine individuals who find themselves living in places
where the foods, customs, and perhaps even languages are very much different from what they were
accustomed to previously. These individuals cannot simply expect for others to understand their
customs or values, so often they undergo the difficult process of trying to adjust and fit into their new
Acculturation is the process of cultural adaptation that occurs when a person encounters a culture that
is different from his or her own and begins to internalize some of the values or customs of the new
environment (Berry, 1997). This process can be different across racial, ethnic, and national groups,
as some individuals may need to acculturate only toward the values and customs of their host country,
while others may have to adopt the language of the majority. The pressure to adapt to the customs of
the majority culture may lead some individuals to speak their native language only at home and to
abandon some of their prior customs/values. Scholars have termed this pressure acculturative stress
(Cervantes, Padilla, & Salgado de Snyder, 1991). This stress is not solely due to social pressure and
values conflicts; even small tasks, if unfamiliar, may be stressful to individuals adjusting to a new
culture. For instance, when they go to the bank, will the teller be bilingual? The acculturative process
pervades daily life.

Research findings on the association of client level of acculturation with wellbeing and experiences with mental health services.
Abundant research has examined the association of the acculturation process and acculturative stress
with a wide range of behaviors/indices of psychological well-being. With regard to acculturative
stress, researchers have found a positive relationship between such stress and anxiety, depression,
and body image disturbance (Menon & Harter, 2012; Revollo, Qureshi, Collazos, Valero, & Casas,
2011). Additionally, acculturative stress has been shown to be associated with suicidal ideation,
suicide attempts, maladaptive stress responses (e.g., binge drinking, eating disorders), and lower
reported qualities of life (Belizaire & Fuertes, 2011; Cachelin, Phinney, Schug, & Striegel-Moore,
2006; Gomez, Miranda, & Polanco, 2011).
With regard to the acculturation process itself, acculturation to Western society has been shown to
affect psychological well-being, increasing the incidence of depression and elevated blood pressure
(Steffen, Smith, Larson, & Butler, 2006; Torres & Rollock, 2007). The process of acculturation is
stressful, and individuals with low levels of acculturation may feel culturally incompetent because of
lack of language mastery, understanding of social systems, and so on.

Level of acculturation can influence how individuals perceive professional counseling. Professional
counseling is rarely used outside Australia, New Zealand, Europe, and North America. Moreover,
cultures have different beliefs about mental health and the disclosure of mental illness to strangers,
with great variability in the degree to which someone unfamiliar with Western modes of counseling
will actively engage in it. For instance, differences in parent and adolescent acculturation levels (i.e.,
the adolescent is more acculturated while the parent is less so) are associated with weaker treatment
outcomes across depression and delinquency, indicating that a large difference in parentchild
acculturation levels can pose a threat to treatment outcomes (Crane, Ngai, Larson, & Hafen, 2005).
Treatments for positive behavior changes (i.e., smoking cessation) have been shown to be less
effective for less acculturated individuals (Hooper, Baker, de Ybarra, McNutt, & Ahluwalia, 2012).
However, among clients who have made the commitment to attend therapy, acculturation levels do not
seem to be associated with levels of client attrition or nonattendance of initial intake appointments
(Akutsu, Tsuru, & Chu, 2004; McCabe, 2002). Overall, our meta-analytic review of more than 60
studies revealed a high degree of variability in research findings, with the overall association
between clients levels of acculturation and their experiences in and perceptions of mental health
counseling being negligible, except among immigrant populations. Hence, counselors need to attend to
individual clients perceptions and experiences in counseling rather than make general assumptions
about how acculturation may influence those perceptions and experiences.

Implications for counseling.

By seeking to understand how the acculturation process influences the clients well-being, the
counselor can facilitate a stronger therapeutic alliance and a more holistic conceptualization of the
presenting problem(s). How has the client coped with unfamiliar environments and ways of doing
things? What supports have been most helpful in the clients adjustment process? Seeking that kind of
information will be more helpful for both counselor and client than counseling that focuses
exclusively on the presenting problem and thus ignores critical life circumstances, existing methods of
coping, and support systems.
Clients with low levels of acculturation may benefit from outside referrals/resources that can assist
them with adjustment processes. By providing information that decreases language barriers,
facilitates financial management, or supports clients religious/spiritual well-being, counselors can
help clients access resources that they may not have known existed.
Counselors should also address differences in parentchild acculturation levels. For instance,
attending a parentteacher meeting may be a very novel situation for a less acculturated parent and
possibly embarrassing for the more acculturated child when the parents expectations differ from
those of the teacher.
Counselors must also keep in mind that they may have to work to overcome a clients negative
preconceived notions about therapy or mental health providers that could affect the therapeutic
alliance (Vasquez, 2007). Particularly, counselors may find that clients from diverse racial and ethnic
backgrounds may benefit from culturally adapted methods of counseling.

Selected Multicultural Research on Counseling Factors

The previous sections have described how counselor and client characteristics can influence clients
experiences in counseling and their psychological well-being. In this section, we consider the
interaction between counselor and client. Specifically, we ask two questions about counseling itself:
Does it matter whether the client and counselor share the same race/ethnicity? Does it matter whether
the counseling content and processes explicitly align with the clients culture?

Racial and Ethnic Matching of Client and Counselor

Professionals have consistently emphasized the need for cultural congruence between counselors and
clients (Pope-Davis, Coleman, Liu, & Toporek, 2003). So, does this mean that clients have better
counseling outcomes when they work with counselors who share their own racial or ethnic
backgrounds? Who better than a counselor who has immigrated herself to understand the experiences
of a client who recently immigrated? The benefits of racial and ethnic matching of client and
counselor seem obvious: The counselor has instant credibility with the client and deep understanding
of the nuances of the clients lived experiences that should enhance the therapeutic alliance and client
But is it that simple? Interpersonal differences (e.g., socioeconomic status, religion) remain even
when counselor and client have identical racial or ethnic backgrounds. Thus, a presumption of client
counselor similarity based on race/ethnicity alone can cause overidentification, countertransference,
and so on, which may frustrate or at least disappoint the client, particularly when client and counselor
have incongruous values and experiences, as illustrated in the following account from a graduate
student counselor:
As a Native American woman raised on a reservation but later residing in many regions of the
country, I have for many years negotiated the nuances of racial and ethnic diversity. I admit to
having felt very confident in working with people across a broad range of differences. My
confidence completely failed me when I met with my first Native American client. I thought I
could build a strong therapeutic alliance with her because we shared similar experiences, right?
When I spoke about the reservation and cultural dances, I learned that she had never participated
in cultural dances and had no experience with reservation life at all. All of my assumptions had
been wrong. Most of that first session was spent rewinding and starting over again, and again,
and again.
Individuals make inaccurate assumptions about how similar they are to others (Kenny & West, 2010).
People of the same race/ethnicity may not share the same worldview, and people of different
races/cultures may have compatible worldviews. There is greater variability within racial and ethnic
groups than individuals typically conjecture.
Exact similarity of client and counselor is impossible. It is also undesirable. Differences in
perspectives promote insight, facilitate reframing, and so on. Effective counseling relationships entail
similarities and differences. The issue of racial and ethnic congruence in counseling requires careful
consideration, and an accurate understanding relies on an examination of research findings.

Research findings on racial and ethnic matching of client and counselor.

Evidence cited by reviews and meta-analyses conducted in previous decades generally indicates that
even though people prefer counselors of their own race/ethnicity, matching clients and counselors on
race/ethnicity does not improve client outcomes (Coleman, Wampold, & Casali, 1995; Karlsson,
2005; Maramba & Hall, 2002). A recent meta-analysis examined the issue in detail using a much
broader base of research findings than had been considered previously (Cabral & Smith, 2011).
Across 52 studies of individuals preferences for counselor race/ethnicity, the average effect size was
d = 0.63, indicating a moderately strong preference for a counselor of the same race/ethnicity. Across
81 studies of clients perceptions of their counselors as a function of racial and ethnic matching, the
average effect size was d = 0.32, indicating a tendency for participants to evaluate matched
counselors as somewhat better than unmatched counselors. Across 53 studies of client outcomes in
counseling under matched versus unmatched conditions, the average effect size was d = 0.09,
indicating minimal improvement in outcome when clients were matched with counselors of their own
race/ethnicity. In general, individuals tended to prefer having counselors of their own race/ethnicity
(who they likely imagined would share their own worldviews), but once they entered a therapeutic
relationship, the counselors race/ethnicity made only a little difference in how positively they
evaluated the counselors and only a very small difference in how much they benefited from the
treatment provided.
The notable exception to the overall findings of the meta-analysis just cited concerned African
Americans. On average, African Americans not only strongly preferred to be matched with African
American counselors and evaluated African American counselors more positively than other
counselors but also had mildly improved outcomes in counseling (d = 0.19) when they were matched
with African American counselors. This finding may be attributable to strong racial or ethnic
identification and concerns about bias in the mental health services provided by White counselors
(e.g., Snowden, 1999). Nevertheless, we must keep in mind that the magnitude of the observed
difference (d = 0.19) was small, explaining less than 1% of the variance in client outcomes.

Implications for counseling practice.

Despite evaluating counselors of their own race or ethnicity more positively than those of dissimilar
backgrounds, on average clients (and counselors) appear to be able to negotiate differences in
race/ethnicity such that the outcomes experienced in counseling are minimally affected. Clients
benefit from counseling with counselors whose race/ethnicity differs from their own despite their
initial preferences and despite their evaluations of the counselors traits and skills being somewhat
affected. By implication, the greatest relevance of racial and ethnic matching occurs during the initial
sessions of counseling, when the therapeutic alliance is being formed. When client and counselor
differ in race or ethnicity, the difference is immediately obvious to both. Yet in that first encounter, the
counselor and client remain unaware of the many similarities they already share. When working
across race or ethnicity, a counselor should neither become anxious about obvious differences nor
ignore them, as in so-called color-blindness (Neville, Spanierman, & Doan, 2006). Neither extreme
will engender trust in the client. The key is for the counselor to leverage sufficient interpersonal
rapport for the client to engage wholeheartedly in counseling, with the counselor seeking
understanding of and bridging differences.

Because group biases persist in society and in counseling, some clients may request to see counselors
of their own races/ethnicities, and such requests can be appropriately met. Nevertheless, professional
agencies should generally avoid policies that automatically match clients with counselors of the same
racial or ethnic background (Alladin, 1994). It is more practical to provide in-depth training for all
counselors to help them acquire multicultural competencies and thus work more effectively across
cultures. The focus of cross-cultural counseling needs to remain on its effectiveness (S. Sue, 1998),
with primary emphasis placed on the alignment of the counseling with the clients worldview.

Culturally Adapted Counseling

Many counseling strategies and techniques are based on general theories (e.g., behaviorism,
psychoanalysis, cognitive therapy), but general theories do not account for individual variation.
Clients differ in their attributes and differ in their alignment with the methods used in counseling. No
single treatment can meet the needs of every client, so it is no surprise that client factors explain most
of the variance in treatment outcome (Bohart & Tallman, 2010), much more than the type of treatment
provided (e.g., Asay & Lambert, 1999). Hence, counselors must consider client contexts and provide
treatment that is an optimal fit for each client (Beutler et al., 2012).
Counselors must adapt their own methods to align with the needs, abilities, and worldviews of
individual clients. For instance, a counselor would use different methods with a young girl
demonstrating externalizing behaviors after experiencing bullying in elementary school than she
would with a young woman demonstrating internalizing behaviors after experiencing cyberbullying;
differences in developmental status and symptoms/behavior obviously require adaptation, even when
some client characteristics remain constant (in this case, gender and encountering inappropriate
aggression). The same principle applies to differences across cultures. Counselors should align their
work with clients cultural worldviews and experiences, such as when depression is conceptualized
in terms of somatic symptoms (i.e., lack of energy, headaches, insomnia) among Chinese populations
less exposed to Western psychologization (Ryder et al., 2008). Counseling practices must account for
How does a counselor adapt counseling based on a clients culture? First, the counselor must
accurately understand the clients worldview. How does the client conceptualize the problem(s) and
previous attempts to address the problem(s)? Often, those conceptualizations will be filtered through
the lenses of cultural values. For instance, if a Guatemalan American client continually references
interpersonal relationships, that would likely reflect cultural values (familismo, personalismo,
respeto, and so on) rather than what might be incorrectly labeled enmeshment from a
White/European American perspective. Accurate understanding of a client thus requires counselor
knowledge of cultural values, but it also requires differentiation skills: What is true in general may
not be true for the individual. The Guatemalan American client might be excessively enmeshed in
relationships, particularly if the clients Latino/a peer group is reacting as if the individual is
inappropriately dependent. The counselors accurate understanding of the clients worldview and
experience necessarily informs treatment decisions.
Cultural adaptations of counseling range from superficial to extensive. To avoid superficiality,
counselors can follow professional guidelines and models for cultural adaptations of counseling

(Barrera & Castro, 2006; Bernal, Bonilla, & Bellido, 1995; Hwang, 2009; Lau, 2006; Leong, 2011;
Whitbeck, 2006). These models are multidimensional, inclusive of language (using the clients
preferred language and communication styles), goals (focusing on the clients preferred outcomes),
content (using wording and concepts familiar to the client), and methods (using procedures aligned
with the clients values/experiences). An example of culturally congruent goal setting: If a college
student from Pakistan repeatedly worries about his parents opinions, the counselor might
appropriately explore ways to increase the clients mutual trust with the parents (and thus decrease
anxiety) but should not suggest a counseling goal of assertiveness toward authority figures, because
that goal would align with the cultural value of the counselor (individualism) but not necessarily with
the values of the client unless explicitly stated. An example of culturally adapted content: Counseling
involving bibliotherapy with young Hispanic/Latino(a) Americans could be based on cuentos, folk
stories with Hispanic/Latino(a) hero/heroine models (Costantino, Malgady, & Rogler, 1986). Naikan
therapy and Morita therapy are examples of culturally adapted treatment methods from Japan that can
be modified for Japanese Americans with traditional Japanese worldviews. Naikan therapy
emphasizes introspection about relationships, and Morita therapy emphasizes acceptance of emotion
and taking constructive action (Hedstrom, 1994). All counseling methods, such as cognitivebehavioral therapy (CBT), can incorporate culturally congruent methods, such as mindfulness and
visualization with Vietnamese Americans (Hinton, Safren, Pollack, & Tran, 2006) or faith-based
coping and deconstruction of the Black superwoman myth among African American women (Kohn,
Oden, Muoz, Robinson, & Leavitt, 2002). The aim of any cultural adaptation, whether it involves
language, goals, content, or methods, should be to better align counseling with client

Research findings on culturally adapted counseling.

A preliminary quantitative review of research indicated that culturally adapted mental health
treatments are effective (Griner & Smith, 2006). Two subsequent meta-analyses have confirmed this
conclusion. In one of these, culturally adapted treatments compared with any type of control group
yielded an effect size of d = 0.46 (Smith, Rodrguez, & Bernal, 2011). In a more rigorous analysis,
culturally adapted treatments compared directly with other bona fide treatments (e.g., culturally
adapted CBT compared to CBT as usual) yielded an effect size of d = 0.32 (Benish et al., 2011).
Counseling is more effective when it is adapted to the cultural background of the client. And the better
those adaptations, the better the outcomes (Smith et al., 2011), particularly when they align with the
clients perceptions/explanations about the illness (Benish et al., 2011).

Implications for counseling practice.

Treatment outcomes are consistently more effective when counselors work to align themselves with
the cultural beliefs of their clients. Counselors should specifically work to align themselves with their
clients beliefs, perceptions, and explanations of their presenting illnesses. At a minimum, this entails
asking the clients about their beliefs about the nature and causes of their presenting problems, what
they have experienced as a result of their presenting problems, and how these experiences may relate
to their environments and to their cultural beliefs. With this information, counselors can identify
goals, content, and methods of counseling that are culturally appropriate for individual clients. The
key is cultural congruence: Does the client experience the counseling as appropriate, rather than

irrelevant to or disrespectful of the clients heritage and values?

Cultural adaptations to counseling should be as specific to the client and the clients cultural
worldview as possible; counselors should avoid implementing a generic approach across various
racial and ethnic groups. Counselors should follow professional guidelines for culturally adapting
counseling (Barrera & Castro, 2006; Bernal et al., 1995; Hwang, 2009; Lau, 2006; Leong, 2011;
Whitbeck, 2006). Examples of adaptations include using cultural metaphors/sayings, sharing
culturally relevant literature/quotations/legends, using different mediums of expression such as art,
and acknowledging specific cultural values that are either relevant to the presenting problem or
conducive to coping (e.g., holistic conceptualizations of experience, denoted by the medicine wheel
for many American Indian clients). When a counselor is unfamiliar with culturally appropriate
adaptations, he or she should consult with knowledgeable professionals, explore the clients
perceptions about helpful ways of coping with the presenting problem, and closely monitor the
clients experiences in counseling to avoid misalignment. Therapeutic approaches may need to change
over the course of the counseling, and the counselor should be prepared to make those changes based
on client feedback (Lambert, 2010).

For several decades scholars and practitioners have affirmed that counselors should focus attention
on the cultural values and worldviews of their clients. Research findings provide support for that
assertion. Culturally congruent counseling practices are more effective than practices that do not
account for clients cultural contexts. Counselors who are unfamiliar with their clients cultural
backgrounds can learn to work with them effectively and demonstrate multicultural counseling
competence. Counselors need not necessarily be of the same race/ethnicity as their clients to be
effective, but they do need to adapt their own practices to meet the needs and experiences of their
clients. Thus, culture should be a primary, not secondary, consideration in counseling, with the
information provided across the other chapters in this book building on a solid foundation of
accumulated research evidence.

Critical Incident
Steve is an experienced licensed professional counselor working in a community clinic. He is by
nature outgoing, has friends from many walks of life, and feels confident about his many years of
practice with diverse clientele. He recently completed a protracted divorce from his wife of seven
years and has no children. A fourth-generation Japanese American, Steve was raised in an uppermiddle-class area of the West Coast. When he glanced at the intake form completed by Riza (the
female client described at the start of this chapter), Steve immediately felt concerned about how a
recent immigrant from the Philippines might react to him, given that the Japanese occupation of the
Philippines in the 1940s must have affected the clients parents and extended family.
In session, Riza haltingly described her difficulties in adjusting to life in the United States. Steve
observed that Riza had adopted a coping strategy of avoidance of contact with most Americans after
several poignantly negative experiences in which she went away feeling incompetent, despite her high

level of occupational qualifications. Riza maintained close contact with friends and family members
in the Philippines via the Internet, but she did not socialize with anyone outside her immediate family
after work hours.
Steve observed that Rizas strongest emotional reactions occurred when she spoke about her husband.
She described circumstances that were very similar to those Steve had experienced in his marriage,
but when asked whether she had considered divorce, Riza strongly affirmed her commitment to her
husband and his family.
Steve was at first surprised that many of Rizas decisions stemmed from her sincere faith in
Catholicism. He fought against his initial reaction to judge Rizas daily devotions and prayers, and he
directed conversations back to what he believed were the central issues for Riza: her social isolation,
passivity, and excessive guilt, which seemed to be the primary causes of her depressed moods. Even
after specific questioning about those issues, Riza seemed to be holding something back.
Steve then raised the issue of their different ethnic backgrounds as part of checking Rizas perceptions
about how things had gone during their initial session together. Riza acknowledged that her maternal
grandfather had died during the Japanese occupation, but she said that her family seldom recounted
the past and she understood that neither Steve nor his family had any connection to her own past. In
fact, she believed that her being assigned to work with Steve was a spiritual metaphor: Having a
counselor of Japanese ancestry meant that God brought them together to prove that all things can be
After the session, Steve recognized that his personal beliefs about taking the initiative in social
settings and about family roles and divorce had made it difficult for him to follow up on Rizas
perspectives. After consultation with a Filipino colleague, Steve started to gain appreciation for the
cultural contexts influencing Rizas actions.

Discussion Questions
1. How did Steves initial assumptions and personal beliefs affect his work with this client? What
do you think about his decision to dwell on his own personal experiences and how they may
have influenced his relationship with Riza?
2. What specific strategies could Steve use to understand Riza better from her own perspective
during subsequent sessions?
3. What might be some effective strategies that Steve could use to address Rizas social
withdrawal, which seems to be associated with judgmental/prejudicial social encounters she has
4. What specific multicultural counseling competencies will facilitate additional trust between
Riza and Steve?
5. Ethnic and racial identity and acculturative status are often noted as major factors in a clients
response to counseling, but research indicates wide variability in how those variables relate
with well-being and experiences in counseling. Discuss how those two constructs may affect a
counselors work with Riza in light of the meta-analytic findings presented in this chapter.
6. After becoming more familiar with Catholicism and Filipino culture, list a series of culturally

sensitive adaptations to counseling that might enable Steve to work effectively with Riza.

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Part II Ethnocultural Contexts and Cross-Cultural Counseling

The focus of the five chapters in Part II is an acknowledgment of the substantial contributions to the
multicultural perspective made by Arabs and Muslims, African Americans, Asian Americans,
Latinos, and Native Americans, the ethnocultural groups featured in this section. Most of the early and
contemporary writings in the field of multiculturalism have approached ethnicity from the perspective
that the persons who make up these groups are members of ethnocultural minority groups. The very
term minority, however, has become divisive and contentious because of the implicit stigma
sometimes associated with it and the fact that these groups are increasing in size; together, their
population will soon exceed that of what was once considered the majority group in the United
The U.S. Census Bureau (2013) predicts that by 2050, the U.S. population will reach more than 600
million, about 47% larger than in the year 2010. The primary ethnic minority groupsnamely,
Latinos, African Americans, Asian Americans, American Indians, Alaska Natives, Native Hawaiians,
and Pacific Islanderswill constitute more than 50% of the population. About 57% of the population
younger than age 18 and 34% older than age 65 will be members of these groups. The demographic
profile based on the 2010 census indicates that during the preceding decade, the Latino population
grew at a rate eight times faster than that of Whites. Asian Americans and Pacific Islanders also had
rapid growth rates, in part due to immigration from Southeast Asia. For Latinos, increased
immigration and high birthrates explain the population increase. Projections for the year 2020 suggest
that Latinos will be the largest ethnic group, second only to White Americans, and followed by
African Americans.
Considering the increasing ethnic and cultural diversity occurring in the United States, attention
should be given to the growing Muslim population. According to a recent survey, Muslims constitute
about 2% of the U.S. population. A 2011 study conducted by the Pew Research Center found that the
majority of Muslims in the country are African Americans, Arabs, and Asians, and that overall
Muslim Americans come from 77 different countries. The U.S. Census Bureau does not collect
information on individuals religious affiliations or preferences, hence the census tallies on the
Muslim population are estimates. Most Muslims in the United States are members of immigrant
populations, and thus their cultural backgrounds contribute to the nations growing diversity.
On the 2000 and 2010 census forms, individuals had the option of marking more than one race
category and so were able to declare identification with more than one group. For example, whereas
less than 3% of the total U.S. population chose to do so, more than 5,220,579 individuals who chose
to mark multiple categories marked American Indian and Alaska Native along with one or more
others. The race alone or in combination count is much higher than the race alone count of
2,932,248 (U.S. Census Bureau, 2010). The discrepancy raises the question of which count is more
accurate or representative of the true Indian population, 2,932,248 or 5,220,579.
People with mixed ethnic backgrounds present interesting ethnic identity cases, as they have at least
two ethnic groups from which to claim and negotiate an ethnic declaration. Based on extensive
interviews with people of mixed ethnic backgrounds, the clinical psychologist Maria P. P. Root

(1992) identified four basic reasons why multiethnic persons would choose to identify with particular
groups regardless of how others may view them. According to Root: (a) Individuals enhance their
sense of security by understanding distinct parts of their ethnic heritage; (b) parental influences,
stimulated by the encouragement of grandparents, promote identity, thereby granting permission to the
offspring to make their choices; (c) racism and prejudice associated with certain groups lead to
sharing experiences with family, which helps multiethnic individuals to develop psychological skills
and defenses to protect themselves (the shared experiences help to build self-confidence and create
the sense of an ability to cope with the negative elements often associated with particular groups);
and (d) gender alignment between parents and children may exert influence on ethnic and racial
socialization particularly when they have good relationships and are mutually held in esteem (p. 15).
The Census Bureaus introduction of the new multiracial item created contentious debates and
problems for all who rely on the use of census outcome data. The addition of the multiracial category
presents difficult tabulation and reporting problems for health care professions, economists,
demographers, social and behavioral scientists, and others who use racial categories for their
In earlier writings in the field of multicultural psychology, the groups that are the focus of Part II were
written about through the use of a broad ethnic gloss, where attention was given to the groups as
though they were homogeneous entities. They are notin fact, there may well be more heterogeneity
within these groups than within North Americas majority Euro-American population (Trimble &
Bhadra, 2013). Perhaps at one time that approach was necessary to draw general attention to
particular groups ethnic and cultural differences. However, and fortunately, the entire field of
multicultural and cross-cultural counseling has matured to such an extent that scholarly attention must
now focus on the between- and within-group variations of ethnocultural populations and the
challenges they present for counselors and clinicians. The authors of the five chapters in Part II take
that position and more as they lay out the psychological and sociocultural intricacies of their
respective populations to illustrate the increasing challenges faced by the groups and how counselors
and clinicians can respond to them in an efficacious manner. Moreover, the reader will be challenged
to consider conventional self and identity conceptualizations and how they pertain to people from
distinctive ethnocultural populations; a deep, thorough exploration of the self-construct has profound
implications for the delivery of counseling services to people who straddle multiple ethnic identities.
The following five questions serve as a constructive and summative way to introduce the chapters in
this section:
1. How adequately do conventional psychodynamic, humanistic, and behavioral approaches relate
to cross-cultural considerations in the provision of counseling services for ethnocultural
2. How does the concept of principled cultural sensitivity influence and guide the conduct of
research and the delivery of counseling services in traditional ethnocultural communities?
3. What are the influences of historical trauma and delayed grieving and their effects on the
provision of counseling services for oppressed and exploited populations?
4. How do degrees of client acculturative status, ethnic identification, and self-esteem or sense
of self-worth influence a counselors approach to providing counseling services for the groups
discussed in this section?
5. What evidence exists for the influence of cultural encapsulation in counselors understanding of

and ability to work effectively with clients from unique ethnocultural populations?
Indeed, some of these questions pertain to other topics and themes covered in this seventh edition of
Counseling Across Cultures. Moreover, there is a good chance that many readers have experienced
some or all of the circumstances and problems embedded in these questions as well as those posed
for the other sections of this book. Perhaps the discussion presented in the forthcoming chapters can
help them come to the realization that others acknowledge and avow their experiences and that there
are effective and constructive ways of dealing with them. We now turn to a summary of the topics and
themes covered in the five chapters in this part of the book.
Chapter 5 provides a description of the essential sociocultural factors that lead to effective strategies
for counseling with American Indian and Alaska Native clients. Within a specific framework, authors
John Gonzalez and Joseph E. Trimble emphasize the counselor characteristics that demonstrate
effectiveness in counseling North American indigenous peoples.
In Chapter 6, Frederick T. L. Leong, John Lee, and Zornitsa Kalibatseva address the counseling of
Asian Americans, carefully describing the cultural factors related to client and therapist variables that
may play a significant role in the provision of effective counseling for these clients. Along with this
important information, an extensive literature review provides bridges for the existing knowledge
base from research to clinical practice.
Chapter 7 presents a detailed description of the psychological, cultural, and sociopolitical issues that
counselors need to consider in working with clients of Black African ancestry. Ivory Achebe Toldson,
Kelechi C. Anyanwu, and Casilda R. Maxwell discuss unique techniques and strategies for providing
effective counseling services to African Americans and other clients of African descent.
In Chapter 8, J. Manuel Casas, A. Pati Cabrera, and Melba J. T. Vasquez advise counselors and
practitioners on how they can become more competent in working with Latino/a clients. They provide
guidance for those who work with this rapidly growing population and present an outline of a
theoretical approach that unifies theories of person, environment, and the counseling situation. They
also offer a culturally sensitive and appropriate framework that practitioners can use to direct and
drive their work with Latino/a clients; the framework includes likely sources of both friction and
possibility and how counselors can respond to them.
Finally, the last chapter in this section focuses on counseling and psychotherapy with Arab and
Muslim clients. Marwan Dwairy and Fatimah El-Jamil emphasize that practitioners will note that
Arab and Muslim clients are more family or community-oriented and therefore less individually
oriented than most Western clients. Terms such as self, self-actualization, ego, opinion, and feeling
have collective meanings for them. Arab and Muslim clients may be preoccupied by family issues,
duties, expectations, and the approval of others; in conversing with them, counselors may find it
difficult to distinguish between their personal needs or opinions and those of their families. Matching
the therapist and client on cultural or religious background needs careful attention also. As Dwairy
and El-Jamil point out, some Arabs and Muslims prefer therapists of the same ethnic identity in order
to ensure a process free of stereotypic judgments, whereas others may fear being judged or blamed by
Arab Muslim authorities as they may be in their own families. Clients in the latter group may
actually prefer therapists who are different in background from themselves.

Pew Research Center. (2011). Muslim Americans: No signs of growth in alienation or support for
extremism. Washington, DC: Author.
Root, M. P. P. (1992). Back to the drawing board: Methodological issues in research on multiracial
people. In M. P. P. Root (Ed.), Racially mixed people in America (pp. 181189). Newbury Park, CA:
Trimble, J. E., & Bhadra, N. (2013). Ethnic gloss. In K. D. Keith (Ed.), Encyclopedia of crosscultural psychology. New York: Wiley-Blackwell.
U.S. Census Bureau. (2010). National population by race, United States: 2010. Retrieved from
U.S. Census Bureau. (2013). Newsroom: All releases from 2013. Retrieved from

5 Counseling North American Indigenous Peoples

John Gonzalez
Joseph E. Trimble

Primary Objective
To describe the essential sociocultural factors that lead to effective strategies for counseling
with American Indian clients

Secondary Objectives
To describe counselor characteristics that demonstrate effectiveness in counseling American
To present a framework designed to guide counselors in making culturally resonant choices
when counseling American Indians
Indian life is tough. It is hard to be Indian. But, I am happy to be born an Indian. As
Anishinaabe, we want a good lifemino-bimaadiziwinbut there are always challenges. To
have mino-bimaadiziwin you must follow a certain path, like the stem of an eagle feather. As
you travel this path, there are many struggles, difficulties, and choices you must makewhich
are the barbs of the feather. Sometimes we wander off the stem of the feather and find
ourselves stuck on those barbs. It is then we must seek help and guidance to find our way
back to mino-bimaadiziwinto live a good life.
Jim Ironlegs Weaver
This quote is a reflection of a storymany stories, in fact. Stories of hardship and struggle. Stories of
genocide and oppression. Stories of loss. But also stories of pride. Stories of resilience. Stories of
hope. There are as many stories as there are American Indians, which speaks to the variable lifeways
and thoughtways of American Indians in the 21st century. What it means to be American Indian, or
what American Indian culture is, is a very difficult question to answer. We do not claim to answer this
question, but we can say that American Indian and Alaska Native cultures and the lives of every
single American Indian living today are affected by the sociopolitical history of North America. And
these things have shaped the stories embedded within the quote above. Learning about this history,
learning about those stories, and understanding the diversity in those stories will be the main tasks of
the professional counselor looking to work with and provide services to American Indian persons
and communities.
Each American Indian and Alaska Native (AI/AN) cultural group has developed a sophisticated and

elaborate set of beliefs, values, rules, and customs to help guide a person to have minobimaadiziwin. This is part of the definition of culture. In addition, each group has developed healing
practices to assist a person when he or she is out of balance, stuck on a feather barb, and needs to find
the way back to live a good life. Some of these healing practices are simple and can be done by any
tribal member, such as offering tobacco, saying a prayer, singing a song, and the burning of sage,
sweet grass, or cedar. But other more complex ceremonies and uses of medicines are to be practiced
only by trained healers who have been delegated by the spirits, often as a birthright. These
ceremonies and healing rituals vary by tribal nation and sometimes even within tribes by geography
this is a reflection of the importance of time and space for AI/AN (Deloria, 2003). These ways of
living continue to be endorsed and practiced by most AI/AN tribes today.
Mental health and wellness are integral parts of the good life for indigenous peoples, and healing
ceremonies are also performed to help individuals maintain or achieve wellness. However, not all
AI/AN choose or have the opportunity to participate in such ceremonies, owing to a number of
factors, including orthodox religious convictions marked by conformity to doctrines or practices held
as right or true by some authority, standard, or tradition or distrust of traditional healers and their
practices. Other factors might include the geographic distance of traditional healers from their home
villages or communities or lack of access to traditional healers, especially in urban settings. Finally,
an individual may lack awareness of the availability and effectiveness of traditional practices, or may
be confused concerning the choice between traditional healing and use of mental health services.
Certainly, the reasons vary from one person to another. For those who choose not to seek the services
of traditional healers, the only available alternative is to seek the assistance of professionals in the
conventional mental health fields; that choice, too, can be compounded by numerous factors, including
distrust, misunderstanding, apprehension, and the real possibility that mental health practitioners may
be insensitive to the cultural backgrounds, worldviews, and historical experiences of Native clients.
The main issues for these clients are concerns that their presenting problems may be distorted by
the results of psychological tests that are incongruent with their cultural worldviews and that
professionals may arrive at clinical diagnoses grounded in psychological theories that do not value
and consider their culture.
A variety of intercultural and interpersonal issues can arise when a counselor working with AI/AN
clients lacks the necessary cultural awareness, knowledge, and experiencethe pillars of
multicultural counseling (Sue, Ivey, & Pedersen, 1996). There is ample evidence, however, that by
using particular techniques, counselors can promote client trust and improve the counselorclient
relationship, both in general and with American Indian and Alaska Native clients specifically.
Matters relating to trust and other counseling considerations form the basis of this chapter; in the
pages that follow, we provide information aimed at helping to stimulate effective cross-cultural
contacts between mental health counselors and American Indians.

Overview: Providing Counseling to American Indians and Alaska

Contrary to stereotypes, not all Indians are alikea full and wide range of individual differences
exist among members of any ethnocultural group. This is very true for both indigenous persons who

follow their tribal lifeways and those who only marginally identify with their indigenous cultures
(Fryberg, 2003; Fryberg & Markus, 2003; Trimble, 1988). The concept of acculturation provides a
useful context for understanding this and suggests different paths that minority individuals and groups
may follow when functioning in the mainstream context. In the concepts simplest form, minority
group members have four options: integration, in which they maintain their culture of origin and also
adopt the culture of the majority, so that they function biculturally; assimilation, in which they
primarily function according the lifeways of the majority culture; separation, in which they maintain
their culture of origin with very little adoption of majority culture; and marginalization, in which they
may not strongly maintain their culture of origin or adopt the ways of the majority (Berry, 1980,
With all these possible differences in identity, is it possible to provide culturally resonant mental
health services to AI/AN populations? Is there a common set of strategies known to be effective?
How can a Western-trained counselor prepare for working with members of indigenous communities?
We will try to answer these questions, and more, below as we discuss the many factors that facilitate
successful counseling services as well as the factors that work as impediments to providing
successful mental health services to Native clients. We will present a summary review of the writings
in AI/AN mental/behavioral health, along with our own insights organized around the following
themes: the nature of AI/AN communities, counselor characteristics, client characteristics,
worldviews and values, and counseling styles, which includes the role of traditional healing
A critical component of multicultural and cross-cultural counseling is the counselors knowledge
about the group of people with whom he or she is working. Such knowledge is especially important
for counselors working with AI/AN communities, given their unique status in North America (Duran,
Firehammer, & Gonzalez, 2008; Herring, 1992; LaFromboise, Berman, & Sohi, 1994). This
knowledge cannot just come from a book, movie, or some other type of media; becoming
knowledgeable requires experience and time. Newcomers or outsiders will inevitably be met with
some suspicionin any culture. Counselors need to take the considerable time required to learn from
the community and to understand their role within it. Along the way, trust, an essential component in
all human relations, can develop. The mistrust that members of indigenous communities have for nonNatives is based on the sociopolitical historical and contemporary relations between Natives and
Whites, often described as historical or intergenerational trauma and the unresolved and continuing
grief associated with such trauma.

Historical Loss and Grief

It is vital that mental health professionals learn and understand how indigenous people have
experienced and continue to experience tremendous trauma and suffering as a consequence of
European contact. There is a cumulative sense of trauma as a result of centuries of massacres,
disease, forced relocations, forced removal of children, loss of land, broken treaties and other
betrayals, unemployment, extreme poverty, and racism. One of the most destructive forms of trauma
was perpetrated by the government- and church-run educational systems in Canada and the United
States. Thousands upon thousands of indigenous children were taken from their parents, families, and
communities and sent to residential boarding schools that were hundreds, sometimes thousands, of

miles away from their homes. Children as young as 6 were stripped of their culture and identity, and
many experienced unspeakable physical, sexual, and psychological abuse (Gonzalez, Simard, BakerDemaray, & Iron Eyes, 2014; Millar, 1996). Chrisjohn and Young (1997) discuss the long-term
effects of the residential school program in Canada and how it continues to contribute to the
unresolved grief of former residents and their children. The White Bison organizations Wellbriety
Movement is devoted to addressing the traumatizing impacts of this government policy (Coyhis &
Simonelli, 2008).
Several scholars have posited that postcolonial historical and intergenerational trauma contributes to
the high levels of social and individual problems in Native communities, such as alcoholism and
substance abuse, suicide, homicide, domestic violence, and child abuse (Brave Heart & DeBruyn,
1998; Duran, 1999, 2006; Duran & Duran, 1995; Duran et al., 2008; LaDue, 1994). We want to
emphasize here the need for counselors to acknowledge and seek to understand this intergenerational
trauma from the Native worldview. In addition, counselors should be aware that attempting to treat
the symptoms or manifestations of the trauma by using only conventional Western psychological and
psychiatric approaches often does more harm and perpetuates the trauma. Duran et al. (2008) argue
that counselors must work with Native clients to reconstruct their personal and community histories,
seeking the course of the trauma. This is important and is related to how conceptualizations of time
and history may differ between Native and Western cultures. In many Native cultures, the past,
present, and future are viewed as being unified and continuous, whereas in Western culture time and
history are not seen as having such continuity. For example, in the Ojibwe language, the word for
time, ishise, is a verb, and ishise acts upon us; in the English language time is a noun, and time is seen
as something that we possess.
Historical trauma and unresolved grief are, in part, reactions to cultural loss and involuntary change.
Although culture as a construct has multiple meanings, it represents the essential lifeways and
thoughtways of ethnic and national enclaves; culture provides meaning, structure, and direction. In
relation to trauma and grief experiences, culture serves a psychological function by providing a buffer
against terror (Salzman, 2001). If an indigenous communitys lifeways and thoughtways are under
assault, community members will turn to their rituals, ceremonies, and healers to restore balance,
fend off destruction, and protect traditions. However, when traditional lifeways and thoughtways are
suppressed or stolen, the resulting trauma may be irresolvable and subsequently may be passed along
from one generation to the next.
In response to the existence of historical trauma and unresolved grief, cultural recovery movements
are occurring among indigenous people throughout the world to reconstruct a world of meaning to act
in... and to recover ceremonies and rituals that address lifes problems (Salzman, 2001, p. 173). For
example, to illustrate how tribal rituals promote a sense of community and continuity for troubled
individuals, Brave Heart and DeBruyn (1998) and Duran, Duran, Brave Heart, and Yellow HorseDavis (1998) describe the effectiveness of a tradition-based psychoeducational intervention intended
to resolve historical trauma and grief. Results from this four-day group experience point to positive
and long-term changes that assist individuals in dealing with racism, grief contexts, and the resolution
of grief. Similar cultural recovery programs are being offered in various parts of North America, as
are Native-sponsored conferences devoted to the topic of cultural recovery. The Wellbriety
Movement is an example of one of these cultural recovery programs; it uses a healing forest

metaphor and blended medicine wheel teaching (Coyhis & Simonelli, 2008).
Morrissette (1994) has called for more clinical and counseling attention focused on the parenting
struggles of those Natives who have experienced residential-school syndrome. Gone and
colleagues have written extensively on the idea that culture is treatment in general, and in particular
in relation to addressing historical trauma and its manifestations (Gone, 2008, 2013; Gone & Calf
Looking, 2011; Hartmann & Gone, 2012; Wendt & Gone, 2012; Wexler & Gone, 2012). The value of
culture and all it represents is being elevated to a higher level of significance as community voices
gain influence and power. As Salzman (2001) points out, Empowering political movements tend to
accompany cultural recovery movements and [thus] should be supported by mental health and social
workers (p. 173). Thus, cultural recovery movements are increasingly viewed as effective responses
to the existence of historical trauma and unresolved grief among indigenous peoples throughout the
Recently, we have witnessed the work of the Idle No More movement (http://www.idlenomore.ca)
and groups like the Last Real Indians (http://lastrealindians.com), which, although not directly related
to mental health services, are framed in a decolonization paradigm and are having a positive impact
on historical trauma grief. Idle No More started in Canada in response to the Harper administrations
legislation that would open protected lands and waterways for oil and mineral exploration and
essentially eliminate the water rights and protections of the First Nations peoples. It soon spread to
the United States and then to indigenous communities around the world. Last Real Indians is a
grassroots group of writers and activists from across North America that brings awareness to policies
and issues affecting Native communities. This group and one of its cofounders, Chase Iron Eyes, were
instrumental in the Lakota/Dakota Nations purchase of Pe Sla, the sacred site at the center of the
Black Hills in South Dakota.

So You Want to Work With Native People

The first pillar of multicultural counseling is awareness. A critical part of this awareness should be
self-awareness. Counselors need to examine their motives for wanting to work in mental health
settings that serve Native peoples. Related to this, they must become aware of and acknowledge their
own biases and assumptions, because everyone has biases. Helms and Cook (1999) put it succinctly:
How can counselors resolve the different manners in which counselors and clients conceptualize
mental health problems if the counselors and clients come from different culture-related life
experiences? They add, To the extent that the therapists and clients socialization histories in either
the racial or cultural domains of life have been incongruent, then one would expect differences in the
ways in which therapists and clients conceptualize the problem for which help is sought, as well as
what they consider to be appropriate treatment for the problem (p. 7). Counselors cannot ignore or
minimize these multicultural factors without jeopardizing counseling relationships and successful
A counselor working cross-culturally may begin to wonder if conventional methods and styles might
be legitimate and/or effective for working with culturally diverse clients. This is a fair question, and
one that a counselor should consider when working with any client. The research on therapeutic
interventions both in general and cross-culturally does provide some guidance. Effective counselors

possess personal characteristics that promote positive relationships with clients, regardless of
cultural backgroundthis is the foundation of any healing or helping process. For example,
characteristics such as empathy, genuineness, warmth, respect, congruence, and availability are likely
to be effective in any setting, including Native communities. In fact, these same characteristics often
exemplify the spiritual healers in indigenous communities (Mohatt & Eagle Elk, 2000). Reimer
(1999) collected information from Inupiat members of an Alaska Native village concerning the
characteristics they found desirable in a healer. Her respondents indicated that a healer is (a)
virtuous, kind, respectful, trustworthy, friendly, gentle, loving, clean, giving, helpful, not a gossip, and
not one who wallows in self-pity; (b) strong physically, mentally, spiritually, personally, socially, and
emotionally; (c) one who works well with others by becoming familiar with people in the community;
(d) one who has good communication skills, achieved by taking time to talk, visit, and listen; (e)
respected because of his or her knowledge, disciplined in thought and action, wise and understanding,
and willing to share knowledge by teaching and serving as an inspiration; (f) substance-free; (g) one
who knows and follows the culture; and (h) one who has faith and a strong relationship with the
Creator (p. 60). Thus, counselors working with Native clients do not need to abandon their
conventional counseling styles, but they must show a willingness to pay attention to what their clients
value in respected healers. Moreover, having the ability to suspend disbelief is helpful for counselors
working with Native clientsthat is, counselors need to be willing to listen to and hear whatever
clients may say without judging the credibility of the belief systems associated with healing
ceremonies, Indian medicine, and spiritual quests (Duran, 2006; Duran et al., 2008).
The critical lesson for counselors is that they should not make assumptions or rush into treatment
plans before listening to their clients. This lesson is further highlighted by the results of a qualitative
study by Yurkovich, Clairmont, and Grandbois (2002), who found that clinicians ability to be
culturally responsive varied and was dependent on their awareness of their own personal culture and
the diversity within and between American Indian cultures. For example, some of the mental health
providers were themselves Native and therefore perceived the client as Native and automatically
assumed they were providing culturally responsive care. Another group of providers (Native and
non-Native) acknowledged potential differences in cultural background between client and counselor
based on their own, but provided culturally relevant care only if the client requested it. Finally, a
third group of providers fully acknowledged cultural differences and actively assessed the clients
preferred treatment approach. Although some of the Native mental health providers were not of the
same tribal affiliation as the client, they still perceived the client as similar to them and seemed to
ignore the diversity that exists within Native cultures. These findings serve as reminders of several
issues discussed above. Counselors working with Indian clients need to become aware of the clients
individual as well as collective cultural backgrounds while examining their own preconceptions,
biases, and attitudes about Indians. Counselors also need to examine and be aware of their own
cultural backgrounds and how these influence the clienttherapist relationship. Such self-examination
gets at the core of what it takes to become a cross-cultural counselor.
Working in Native communities requires flexibility and the ability to be comfortable with Native
communication styles and patterns. This includes being comfortable with silence, long pauses in
responses, and what is sometimes referred to as reservation or village English. Counselors
lacking knowledge about these communication styles of Native clients often misinterpret them as
noncompliance or as evidence of cognitive deficits. Counselors must have the flexibility to allow

clients to engage in thought processes at their own pace; such flexibility is enhanced by counselors
awareness of culture-based differences in dyadic relationships (Herring, 1999; Lockhart, 1981).
There is a debate in the profession concerning whether Native clients are best served by counselors
who are Natives (Darou, 1987; Dauphinais, Dauphinais, & Rowe, 1981; M. Johnson & Lashley,
1989; Lowrey, 1983; Uhlemann, Lee, & France, 1988). Bennett and BigFoot-Sipes (1991) note that
Indian clients might actually prefer counselors whom they perceive as having attitudes and values
similar to theirs, instead of counselors who are necessarily of the same ethnicity. Indian clients who
are involved in their cultural heritage, however, have much stronger preferences for Indian counselors
and non-Western methods than do those who are not so involved or who do not identify strongly with
their Indian heritage (Gone, 2007, 2008; M. Johnson & Lashley, 1989).
As noted above, counselors who plan to work with Native clients need to have some advance
knowledge of the clients cultures (see Thomason, 1991, 2011). As part of accumulating this
knowledge, counselors should learn about what the community or potential clients believe about nonNative counselors and counseling. Native people also have biases, often as a result of actual
oppression, thus it is important that counselors inquire about and understand these biases (Peregoy,
1999). A counselor can accomplish such an assessment in many ways, formal and informal. The key
is for the counselor to engage community members in genuine conversation and to learn from them;
this allows the counselor to gather information while at the same time building trust and rapport.
Working in Indian country is more than a 9:00-to-5:00 job, and counselors need to get out of their
offices and attend events and functions in the community. As they do so, they are likely to discover
some general beliefs that (a) outsiders tend to interpret behavior and emotions in terms of norms
and expectations not shared by the tribal community, and (b) counselors will attempt to convert
Indians to a better culture or try to get them to act and think according to the outsiders worldview
(Anderson & Ellis, 1995). A final consideration we should note before moving on is that counselors
must engage in inner self-assessment and evaluation and be prepared to adjust their own values,
beliefs, and practices accordingly, to accommodate the bicultural or cultural expectations and
perspectives of their Native clients (Matheson, 1986; Thomason, 2011).

An Indian in the Room

The Native communities of North America are as culturally and psychologically diverse as any group
in the United States or around the world, and this diversity presents potential challenges for any
counselor (Gone & Trimble, 2012; Lee, 1997; Sage, 1997). Indigenous persons differ from one
another in many ways, including in acculturation status, physical appearance, and Indian ancestry. M.
T. Garrett and Pichette (2000) and Gone (2006, 2008, 2011) emphasize that counselors must conduct
an assessment of each Native clients degree of acculturation, as physical appearance may be
misleading. Degree of acculturation may influence how a particular client responds to a typical
counseling session. Some researchers have observed that Native clients who come from traditional
backgrounds are not likely to maintain direct eye contact, may avoid personalizing and disclosing
troubled thoughts, and may act shy in the presence of non-Indian counselors (Attneave, 1985). Very
traditional clients might tell counselors that Indian doctors have tended to their problems and that
they have no need for any advice or consultation. Clients whose acculturation leans more toward
mainstream U.S. culture may have a good idea of counseling goals and procedures and what is

expected of them as clients.

For any client, Native or non-Native, counseling can evoke strong emotions; in fact, this is often the
purpose of counseling. However, for the Native client working with a non-Native counselor an
additional layer of emotions may be present, related to both historical events and individual personal
experiences. Many indigenous people have had a multitude of personal experiences with White
culture that have left them feeling suspicious of outsiders offering help. There is a long, unfortunate
history of such experiences negatively affecting Indian people and communities (Deloria, 1969). A
counselor must be patient with client concerns and wait for trust to develop. A counselor in this
situation may often feel that the client is testing him or her; in fact, this is probably accurate. The
client may gradually become more self-disclosing, but only when the client senses that his or her
experiences are being heard and respected will full disclosure likely occur. Although such reluctance
to disclose has been cast as a cross-cultural issue, it occurs with many non-Indian clients as well; it is
best resolved through use of competent counseling skills and approaches (see Marsiglia, Cross, &
Mitchell-Enos, 1998).
A final note: Counselors should keep in mind that many, but not all, indigenous peoples emphasize the
importance of living in harmony and maintaining balance in life and with the environment. This may
result in a tendency to wait for the situation or the environment to offer a solution to a problem. This
tendency will vary from community to community, and counselors should consult with local
community members on what is considered the norm in this area.

Worldviews and Values

At the core of any culture are the ways the cultures members see and interpret the world around them
and the values they espouse. We all have sets of values and worldviews that guide and affect
everything we do, often in very subtle and unconscious ways. As noted above, a Native persons
degree of acculturation, as well as his or her tribal affiliation, will mediate that individuals value
system and worldview. However, there are some values and beliefs that are widely held among
Native peoples that are important to note here. Most indigenous persons and tribes are inherently
collectivistic, such that they emphasize the group over the individual, placing importance on keeping
harmony and maintaining balance in their relationships and the world around them. This value can
affect many areas of their lives as well as other values they hold. For example, family and extended
family relationships can take precedence over an individuals own needs and motivations. Many
Native people view it as natural and necessary to take time off work to attend family events, such as
when a distant relative passes into the spirit world or a cousin gets married, but doing so can create
conflicts with the non-Native world they live in. Time orientation is another value and part of
worldview that influences behavior in many ways. The Native orientation toward time is sometimes
referred to as Indian time, which unfortunately has been misconstrued to mean that Indians are
always late. The real meaning behind this orientation is that, in the Native worldview, things will
happen when they are supposed to happen. This can have profound effects on behavior in many areas
of life that conflict with Western or mainstream American values. For example, part of Indian time
acknowledges that time is really circular rather than linear, as it is viewed in Western thought. Thus,
Native people will live for the present moment, with less emphasis on, or indifference toward,
planning for the future. This can translate into the idea that if there is a future, it will take care of

itself. This concept is often in direct conflict with the Western American value that time is money or
that time is something we possess.
Sometimes value conflicts take place within individualsfor example, in Indians who leave
reservations or villages to live in cities or urban areas. Even among such urban Indians, however,
many have a strong desire to retain their Indianness while they struggle with daily contact in nonIndian lifeways and thoughtways (Witko, 2006). Thornton (1996) suggests that urban Indians can
internalize typical Native values, with some modifications, and tend to become characterized by panIndian ideologies. While pan-Indian ideologies can and do occur in urban areas, value orientation
conflicts do not necessarily occur for those who have relocated to or were born in urban settings.
Affiliation, maintenance of traditional ceremonies, and opportunities to visit ancestral homes may
reinforce the retention of traditional values. For example, some of the best drum groups and dancers
at powwows have their homes in the cities.
Many Natives exhibit a pattern of movement back and forth from the city to the reservation, often
staying for extended periods of time that may even necessitate changes in employment. This pattern
has often been interpreted as a way of avoiding stressful life events and in that sense has been seen as
a negative behavioral response. Although this is always a possibility and must be assessed as part of
the counseling process, it is also very likely that this type of mobility is adaptive. The essential lesson
here is that counselors must be sure to examine any value differences with Native clients. A careful
analysis of client worldview and value system may allow both client and counselor to discover
whether it is a value conflict that is leading to the clients difficulty.

Counseling Approaches
While we have provided some basic information and suggestions thus far for counselors working
with Native clients, we cannot offer a simple and specific recommendation regarding which
counseling style, orientation, or technique is most effective. There is an ongoing debate in Native
communities and the mental health profession on whether traditional healing methods or Western
counseling methods should be used with Native clients (for some discussions in this debate, see
Duran, 2006; Duran et al., 2008; Gone, 2010; Gone & Trimble, 2012; LaFromboise, Trimble, &
Mohatt, 1990). There are philosophical, professional, practical, and ethical reasons for such a
debate, but a thorough and in-depth discussion of these reasons is beyond the scope of this chapter. A
quick example may help. Many in the Native community believe that mental health (all health) has a
spiritual component, such that any treatment or healing needs to be embedded within the culture by
means of some type of ceremony or traditional healing process that should be performed only by a
person who has the power and authority to do so. While there is surely some validity to this, where
does this leave the non-Native counselor or practitioner who does not have the power or authority to
perform such treatments or ceremonies?
Instead of attempting to provide a recommendation regarding the most effective counseling approach
for work with Native clients, we present below a review of the limited literature on counseling and
mental health services with Native clients and communities by means of both Western and traditional
healing methods, offering our own suggestions and examples when appropriate. As noted above, in
the section on counselor characteristics, the foundation for any counseling approach utilized must

include some basic skill sets and the ability to show warmth, empathy, genuineness, and respect for
the Native clients cultural values and beliefs.
Arguably the most frequently cited work recommending a specific approach to counseling with
Native clients is that of LaFromboise et al. (1990). These scholars strongly advocate the use of a
directive style, presumably in the form of more cognitive or behavioral brief counseling. This
position matches with clinical experience: The directive style seems to be more effective because
many Indian clients, especially more culturally traditional ones, are likely to be reticent and taciturn
during the early stages of counseling, if not throughout the entire course of treatment. Quite often,
traditional Indian clients are very reluctant to seek conventional counseling because they may
perceive the experience as intolerable and inconsistent with their understanding of a helping
relationship. At that point, they may feel very helpless and burdened. It is important to note that
traditional Native clients initial expectation of the counseling experience may be that it will offer
them an opportunity to obtain advice from elders (those with greater wisdom and knowledge). For
this reason, by beginning with brief, directive therapy, counselors may be more apt to meet such
clients expectations concerning the helping relationship.
Similarly, Renfrey (1992) and McDonald and Gonzalez (2006) provide evidence that cognitivebehavioral approaches can be effective with Native clients. These directive approaches appear to be
effective when the counselor relies on the cultural context of the clients thoughts and behavioral
patterns. This blends well with aspects of the indigenous worldview discussed above, those
concerning balance, harmony, and all things being related, including thoughts, behaviors, and the
environments or situations in which they occur. In these studies, the clinicians did not rigidly apply
Becks or Elliss frameworks in a manualized manner. For example, if a client has thoughts that
others are always watching him or her, the counselor does not simply discount this as irrational.
Perhaps there is a cultural and spiritual nature to these others, thus the counselor engages in a
discussion with the client on whether this is a thought that needs to be changed and/or how this fits
within the clients worldview and can potentially have positive influences on other aspects of his or
her life.
Given that clients problems are often situational and contextual, Trimble and Hayes (1984)
recommend that non-Indian counselors of American Indians attempt to understand the cultural contexts
in which their clients problems are embedded. Familial patterns, peer group relationships, and
community relationships are a few of the ecological processes that counselors need to understand and
incorporate into their intervention plans (Trimble & LaFromboise, 1985). Family counseling, thus, is
an approach that makes a good deal of sense. Attneave (1969, 1977), McWhirter and Ryan (1991),
and C. Johnson and Johnson (1998) recommend that counselors and therapists account for the social
and network characteristics of Indian families and involve family members in the counseling process.
Napoli and Gonzalez-Santin (2001) describe an intensive home-based wellness model of care for
families living on the reservation. This four-phase model seeks input and assistance not only from
nuclear family members but also from extended family and community members. While this approach
can certainly apply to non-Indian families and communities, a counselor would greatly benefit from
acknowledging this cultural factor when working with Indian clients.
The use of counseling strategies and techniques that resonate with Indian traditions and customs can

be effective. Herring (1994) recommends that counselors use humor, especially in the form of
storytelling. M. T. Garrett, Garrett, Torres-Rivera, Wilbur, and Roberts-Wilbur (2005) provide a
brief discussion of humor in Native cultures and offer recommendations for incorporating humor into
counseling sessions with Native clients. Others note the importance of art for Indian clients and its
role in promoting well-being and healing (Appleton & Dykeman, 1996; Dufrene & Coleman, 1994).
Humor and art are important parts of many traditional healing practices. Thus, these recommendations
make good sense because they tie counseling procedures to the clients traditions and customs.
The majority of recommendations proffered by the scholars cited above and others tend to be based
on a view of Indian clients taken together; that is, they make no distinctions based on individual
Indians unique psychological conditions and physical characteristics. Degree of ethnic identity and
acculturation, residential situation, and tribal background are but a few of the areas that counselors
must account for in determining suitable counseling techniques. In addition to these client descriptors,
counselors must consider gender, sexual orientation, disability, and history of sexual and physical
abuse. Black Bear (1988) draws attention to the special case of counseling with Indian women,
whose situations often include child-care and family responsibilities as well as additional layers of
oppression. For example, in researching Native ethnic identity, Gonzalez and Bennett (2000) found
that Native women reported feeling less valued by mainstream society than their male counterparts.
This finding is highlighted by Malone (2000), who discusses the importance of counselors integrating
feminist theory with multicultural counseling perspectives when working with Native women, in large
part because these clients presenting problems have as much to do with gender issues as with
cultural ones. Mangelson-Standers (2000) work with Indian women in recovery from personal
trauma amplifies this recommendation. Mangelson-Stander also found differences between urban and
reservation women in their participation in traditional spiritual practices, activities provided by
recovery centers, and in the value of family members providing care for the womens children while
they were in recovery.
Finally, Indian clients with alcohol and drug abuse problems also may require unique attention
(Moran & Reaman, 2002; Oetting & Beauvais, 1990; Trimble, 1984, 1992; Trimble & Beauvais,
2000). Intervention and treatment techniques that follow the recommendations made earlier in this
chapter may be effective in many cases, but because of the complexity of the problem of substance
abuse among Native populations, treatment effectiveness may be compromised. An example of the
unique attention this problem may require is that substance abuse counselors may need to develop a
respect and appreciation for the spirituality that is strongly entrenched in indigenous communities.
Research has shown that infusing spirituality in alcohol recovery programs for Natives, coupled with
a multicultural counseling perspective, can enhance outcome effectiveness (M. T. Garrett & Carroll,
2000; Hazel & Mohatt, 2001; Navarro, Wilson, Berger, & Taylor, 1997; Noe, Fleming, & Manson,

Native Healing Approaches

Related to the discussion above on substance use and alcohol treatments with Native clients is the
emphasis that culture as treatment should be the paradigm of choice for counseling with Native
individuals and communities (Gone, 2008, 2011; Gone & Calf Looking, 2011; Herring, 1999;
Pedersen, 1999). The argument is that counselors should not focus on how to adapt or use Western

models of therapy; rather, they should use traditional healing methods from the Native perspective
(M. T. Garrett, Garrett, & Brotherton, 2001; Lewis, Duran, & Woodis, 1999; Tafoya, 1989;
Thomason, 1991). As we noted earlier, this leaves non-Native counselors in a conundrum, as they are
not knowledgeable in such healing methods or authorized to conduct them. We recommend that nonNative counselors establish working relationships with traditional healers and spiritual advisers in
Native communities. Such collaboration with an indigenous healing system can take several forms:
The counselor may (a) support the viability of traditional healing as an effective treatment system, (b)
actively refer clients to indigenous healers, or (c) actively work together with indigenous healers.
Increasingly, researchers have been examining the worth of introducing Native beliefs and
ceremonies into the conventional counseling setting (Dufrene & Coleman, 1992; M. T. Garrett et al.,
2001; Gray, 1984; Heilbron & Guttman, 2000; Roberts, Harper, Tuttle-Eagle Bull, & HeidemanProvost, 1998). In general, the recommendations and examples arising from this research follow the
wisdom and advice offered by LaFromboise et al. (1990) concerning the importance of blending
culturally unique and conventional psychological interventions to advance the goal of Native
A few counselors working with Native clients have achieved a modicum of success by incorporating
spirituality in counseling sessions. J. T. Garrett and Garrett (1998) describe the use of the sacred
circle and its related symbolism in an inner/outer circle form of group therapy and discuss how
the Native perspective can facilitate client progress. Lewis et al. (1999) used a variant of processoriented training grounded in spirituality and found that the technique can allow therapists to enter
into a non-Western-based reality with their clients, thus enhancing their sensitivity to and respect for
Native worldviews. Heilbron and Guttman (2000) used a traditional aboriginal healing circle with
nonaboriginal and First Nations women who were survivors of child sexual abuse and found that both
groups responded favorably to the approach. Hodge and Limb (2010a, 2010b) discuss a set of tools
that counselors may use to assess the spirituality of Indian clients as well as the processes counselors
should consider before, during, and after such assessment.
Simms (1999) describes the use of a blended counseling approach in which an integrated relational
behavioral-cognitive strategy was combined with traditional healing approaches, including talking
circles, sweats, and participation in cultural forums. The client that Simms describes was
experiencing cultural identity, self-confidence, and academic problems that could not be resolved
through the use of a straightforward conventional counseling technique. Similarly, McDonald and
Gonzalez (2006) describe the weaving of cognitive-behavioral therapy with traditional Lakota
healing practices for a veteran experiencing posttraumatic stress disorder. Here again, there were
cultural circumstances related to war and battle that necessitated the inclusion of Native ways of
knowing and healing. The use of sweat lodges and talking circles as means for promoting client
participation and retention has received some attention in the multicultural counseling literature (M.
T. Garrett & Osborne, 1995). Specifically, Colmant and Merta (1999) describe the effectiveness of
incorporating a sweat lodge ceremony in the treatment of Navajo youths who were diagnosed with
behavioral disruptive disorders. They show how the ceremony has considerable overlap with
conventional forms of group therapy and thus merits consideration in the treatment of Native youths.
Although incorporating traditional spiritual and healing methods such as the sweat lodge and talking
circles can facilitate counselor effectiveness, client retention, and progress under controlled

circumstances, counselors must exercise a high degree of caution in deciding to use such techniques.
LaDue (1994) strongly recommends that non-Indian counselors abstain from participating in and using
such practices, asserting that they should not promote or condone the stealing and inappropriate use of
Native spiritual activities. Doing so may invoke ethical considerations, as Native spiritual activities
and practices are the sole responsibility of recognized and respected Native healers and elders.
Indeed, there is currently high interest in spirituality worldwide, and part of this growing interest
involves the exploitation and appropriation of traditional Native ceremonies without the consent of
indigenous communities. Matheson (1986) maintains that non-Native individuals who use traditional
American Indian spiritual healing practices are under mistaken, even dangerous, impressions and, as
a consequence, are showing grave disrespect for the indigenous origins, contexts, and practices of
these traditions by Native peoples. If the essence of the counseling relationship is built on trust,
rapport, and respect, then the exploitation and appropriation of indigenous traditional healing
ceremonies and practices for use in counseling sessions will undoubtedly undermine a counselors
efforts to gain acceptance from the Indian community and the client. These last points are not meant to
discourage the non-Native counselor from exploring and learning about Native ways of knowing and
healing. Rather, they are meant to bring us full circle to how we began this chapter, with a discussion
of the historical trauma and spiritual loss that many Native communities have experienced.
To close out this section, we quote Gone and Trimble (2012), who reviewed the past years of
literature on the provision of mental health services to AI/AN clients. Their summative observations
capture the current state of affairs:
The effort to remedy evident disparities in AI/AN mental health status through clinical
interventions has not been well studied for these culturally distinctive populations. Although
AI/ANs can, in theory, avail themselves of the usual array of mental health programs and
treatments, disproportionate levels of impairment, poverty, lack of insurance coverage, and
limited availability of treatment options ensure that far too many AI/ANs with diagnosable
distresslike most Americans with these problemsdo not obtain effective help in times of
need. (p. 149)

The literature on counseling with American Indian and Alaska Native clients yields a number of
themes. First and foremost, when working with Indian clients counselors need to be adaptive and
flexible. This is usually true for counseling in any setting, but it is especially so in Indian country.
Herring (1999) says it best in making the following recommendations: (1) Address openly the issue
of dissimilar ethnic relationships rather than pretending that no differences exist; (2) schedule
appointments to allow for flexibility in ending the session; (3) be open to allowing the extended
family to participate in the session; (4) allow time for trust to develop before focusing on problems;
(5) respect the uses of silence; (6) demonstrate honor and respect for the clients culture(s); and (7)
maintain the highest level of confidentiality (pp. 5556).
As a Native clinician who has lived and worked in Indian country his whole life, the first author of

this chapter would like to add to and elaborate on a few of Herrings recommendations. First,
counselor and client should discuss racial and cultural differences early; this relaxes the client and
tells him or her that the counselor has put some thought into the matterthe counselor may not be an
expert, but he or she cares enough to learn. Second, the idea of flexibility extends beyond time and
encompasses relationships and how the counselor conducts him- or herself in the community.
Boundaries and ethics that are taught in graduate school may not apply the same way in Native
communities. It is important for the counselor to get out of the office and be seen in the community
this is how relationships and trust are developed. Only when trust has been established will clients
and community members begin to tell the counselor what they really think and feel.
Third, culture and context are importantthis cannot be emphasized enough (Duran, 2006; Gone,
2004, 2008; Salzman, 2001). Counselors should respect Native cultures and worldviews as
superseding psychology and psychological conditions; without culture there would be no psychology.
As Salzman (2001) notes, counselors should (a) promote interventions emphasizing meaning
construction at the community level and support the collective (community) and individual
construction of meaning that sustains adaptive action; (b) support and assist individuals and
communities in the identification of standards and values within the cultural worldview they identify
with that promote adaptive action in current realities; and (c) support and assist communities in
cultural recovery through collaborative content analysis of traditional stories (pp. 189190).
Finally, counselors need to assess acculturation and ethnic identity levels with every Native client
(and sooner rather than later). How a client responds (or does not respond) is not necessarily a
function of his or her being Native; it may instead be a function of that persons Nativeness. Where
and how the person grew up and was raised are very important factors. Does the person speak his or
her Native language? How active is the person in ceremonies and other spiritual activities? What is
the ethnic and cultural makeup of the individuals social environment? The answers to these and other
questions can give the counselor a sense of what counseling approaches and treatments might be
appropriate. Like the members of other ethnic minority and cultural groups, Indians experience a full
range of acculturation.

Critical Incident
Case Study of Donna Little
Donna Little is a 39-year-old Indian woman who has a history of substance misuse and has struggled
with reunification with her adolescent children over the last 6 years. She was in residential school
from the age of 6 to 16 years old. She has a history of domestic violence in her previous
Donna was the youngest of four children in her family. Her parents, siblings, and herself were raised
in the same small northern reservation. Both her parents had gone to residential school in the early
1950s, as did her grandfathers and grandmothers on both sides of her family system in the late 1910s.
Donna was raised in an environment of violence and mayhem in her early childhood, which she has
talked about quite extensively in counseling. Although her parents abused alcohol, she emphasizes

repeatedly that her family was quite ceremonial and participated in the big drum feast and singing
within the community.
When Donna was 6, an Indian agent wearing a red, white, and black checkered jacket gave her candy
and took her to the residential school. She never had the opportunity to say good-bye to her mom and
dad, who died of tuberculosis while she was in the residential school. Donna reflects on her
residential school experience with a despondent look.
While in the residential school, she had only one friend she could count on. Her siblings, who were
also at the school, were older and thus not allowed to play with her or sleep near her at the residence
dorms. This created an incredible loneliness that Donna did not know how to fill, and often she
would use alcohol to help numb that pain. She did not like to drink, but it helped her to stop her
thinking badly about the past.
Donna was a victim of sexual abuse in the residential school, primarily by the Roman Catholic priest
who was in charge. The first time she was assaulted she was 7; the last assault occurred right before
she ran away at age 16. When Donna had attempted to tell the head nun in charge of her dorm what
was happening to her, she was beaten severely, to the point of unconsciousness. Donna recalls it was
her friend, Sue, who nursed her back to health.
Donna describes her life as difficult. She went home to her community, only to find a partner who
turned out to be as violent toward her as her father was to her mother. She loves her children and
cares for them deeply. She breast-fed her three children and still today can feel that connection to
them. When her children were taken from her home after the last time her husband beat her, she
spiraled out of control. Donna has had long periods of abstinence, has a home in her community that is
well cared for, and now has a partner who loves her deeply. Donna is on welfare but hunts and fishes
to help with sustenance. Donna and her partner have been together for 10 years, however, they both
misuse alcohol on occasion. Donnas present partner is nonviolent and a former residential school
survivor as well.
Note: Special thanks to Estelle Simard, MSW, director of the Institute for Culturally Restorative
Practices and a member of the Couchiching First Nation, for providing this case study.

Discussion Questions
1. What is the culturally relevant history a therapist needs to understand when working with a client
such as Donna?
2. What are some of the culturally relevant techniques a counselor can use when working with
Native clients who have been abused by people in positions of power, such as priests?
3. How can a therapist connect a Native client back to his or her culture and its various institutions
and practices?
4. How might Donnas therapist help her to reconnect with her family in a manner that promotes
wellness for everyone?

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6 Counseling Asian Americans Client and Therapist Variables

Frederick T. L. Leong
D. John Lee
Zornitsa Kalibatseva

Primary Objective
To inform the reader about some cultural factors related to client and therapist variables that
may play a significant role in the provision of effective counseling for Asian American clients

Secondary Objectives
To expand and update the earlier literature review provided by Leong (1986)
To contribute to the process of bridging the gap between research and clinical practice in the
existing knowledge base
With the growing cultural diversity in the United States, it is inevitable that mental health service
providers will increasingly encounter clients with widely varying cultural backgrounds who may also
present with clinical issues that are different from those generally seen among members of the
mainstream culture. In response to this demographic shift, it is important for counselors and
psychotherapists to increase their levels of cultural awareness and competency in working with a
diverse clientele. The development of cross-cultural counseling is a continual process, and the
purpose of the present chapter is to contribute to that process by updating and bridging gaps within the
knowledge base on counseling across cultures.
In 1986, Leong published a comprehensive review of the literature related to counseling Asian
Americans that covered client and therapist variables as well as counseling process and outcome
variables. Since that review appeared, the field has seen a substantial increase in research efforts
with attention focused on Asian Americans. For example, in a bibliography on Asians in the United
States published by the American Psychological Association in 1992, 1,057 relevant studies were
identified (Leong & Whitfield, 1992), compared with more than 10,699 studies identified in a recent
search on PsycINFO regarding Asians in the United States. Three particular research trends are
evident in this burgeoning literature: (1) research on specific Asian ethnic groups, (2) research on
specific psychological issues (e.g., severe psychopathology) as these relate to Asian Americans, and
(3) international research comparing Asians in the United States with Asians in other nations. These
trends indicate that researchers are making appropriate efforts to gain deeper understanding of how
therapists can best meet the mental health care needs of Asian Americans, especially given the
heterogeneity within this population. Due to space limitations, the current review will cover only
client and therapist variables as they relate to the counseling of Asian Americans. (For an updated
review of counseling process and outcome variables concerning Asian Americans, see Leong, Chang,

& Lee, 2007.)

While we use the term Asian Americans throughout this chapter, we acknowledge that this general
term encompasses many Asian ethnic subgroups, and the information provided may not always be
generalizable across all Asian ethnic groups and all Asian individuals. We use this broad term
primarily because of the space limitations of this survey chapter, but it is also important to note that
our use of the term mirrors the limitations of the current research literature. We incorporate research
findings on specific Asian ethnic subgroups throughout the chapter to enhance the applicability of the
information to clinical practice.

Client Variables
It has long been recognized that client characteristics interact significantly with therapist
characteristics and theoretical orientations to influence psychotherapy outcomes (Lambert, 2013).
Therefore, understanding the personality characteristics and worldviews of Asian Americans from
the cultural perspective is critical for an accurate understanding and assessment of how Asian
Americans may respond to counseling and psychotherapy.

Personality Characteristics Within Cultural Context

Research has found that Asian Americans exhibit distinct personality characteristics that are often
different from those exhibited by European Americans and members of other racial ethnic minority
groups (Uba, 1994; Vernon, 1982). Asian Americans personality characteristics are influenced not
only by their heritage cultures but also by the interactions of those cultures with the cultures of
Western society (D. Sue, 1998). The Asian American worldview emphasizes humility, modesty,
treating oneself strictly while treating others more leniently, obligation to family, conformity,
obedience, and subordination to authority. Other factors that are important in the cultural context of
Asian Americans include familial relations and emphasis on interpersonal harmony versus honesty,
role hierarchy versus egalitarianism, and self-restraint versus self-disclosure (Chien & Banerjee,
2002). Asian Americans tendency to exhibit lower levels of verbal and emotional expressiveness
than do Euro-Americans, for example, can be accounted for by the cultural context as described (Uba,
1994; Vernon, 1982). Recognizing and understanding the cultural context of these characteristics can
enhance therapists appreciation for why Asian Americans may respond to psychotherapy differently
from those with different worldviews.
Given this culturally different worldview, which emphasizes role hierarchy and respect for authority,
Asian Americans often exhibit greater respect for counselors than do Euro-Americans, whose
worldview places less emphasis on deference based on role hierarchy (D. W. Sue & Kirk, 1973). As
such, Asian Americans have shown strong preference for a counselor who is an authority but is not
authoritarian (Exum & Lau, 1988). For example, Chinese Americans have been found to be more
likely than their European American counterparts to expect counselors to make decisions for them and
to provide immediate solutions (Mau & Jepsen, 1990). Research shows that not only do Asian
Americans prefer structured situations and immediate solutions to problems, but they also prefer
directive counseling styles because they exhibit lower tolerance for ambiguity than Euro-Americans.

Given this, Asian Americans are likely to have some difficulty with the Western model of counseling
and psychotherapy, which is filled with ambiguity by design and is typically conducted as an
unstructured process. It has been observed that Asian clients tend to prefer crisis-oriented, brief, and
solution-oriented approaches rather than insight- and growth-oriented approaches (Berg & Jaya,
1993). The mismatch of Asian Americans, who tend to be less tolerant of ambiguity, with insightoriented psychotherapy may account for the high rates of early termination and underutilization found
among these clients. Underutilization and premature termination of therapy are the twin problems of
mental health care for Asian Americans (Leong & Lau, 2001).
When using an appropriate cultural lens with Asian Americans, researchers and counselors are
vulnerable to making false assumptions and inappropriate comparisons across populations. More
specifically, Western worldviews and perspectives should not be used as the norms against which
characteristics and behaviors of Asian Americans are interpreted. Without taking the Asian cultural
context into account, counselors may potentially view as negative any characteristics of Asian
Americans that differ from those of Euro-Americans. For example, Asian values of reserve, restraint
of strong feelings, and subtleness in approaching problems may come into conflict with the values of
Western counselors who expect their clients to exhibit openness, psychological-mindedness, and
assertiveness. A Western counselor may assume that an Asian American client is repressed, inhibited,
or shy rather than simply exhibiting characteristics aligned with his or her culture (S. Sue, 1981).
Such an ethnocentric and culturally biased approach, sometimes offered under the rubric of culture
blindness, tends to contribute to the two problems of underutilization and premature termination from
mental health services.
Etics are defined as universals, but sometimes pseudoetics are imposed on Asian Americans. This
can result in erroneous inferences about Asian Americans when their personality characteristics are
interpreted with the Euro-American culture viewed as the norm. Such errors can also be found in the
arena of career counseling. For example, Asian Americans historically report significantly higher
parental career expectations and parental involvement in the career decision-making process than
Euro-Americans (Castro & Rice, 2003). When making career decisions, Asian Americans are more
likely than Euro-Americans to be influenced by their families and cultural values (Tang, 2002). From
an Asian cultural perspective, involving family in career decisions is congruent with cultural norms
and values, whereas from a Western perspective, an individuals concern with parental expectations
and wishes regarding career choices may be interpreted as immature and maladaptive. In a study by
Hardin, Leong, and Osipow (2001), career decision-making measures indicated that Asian Americans
exhibit less mature career choice attitudes than do European Americans. As the authors note, the
results may not be accurate indicators of maturity because the measures designed to assess maturity in
career decision making were biased toward the cultural norms and expectations of the Western
culture. Again, it is important for counselors to consider the worldview of Asian Americans and use
that worldview as the normative measuring rubric rather than a biased measure from another
worldview. Therapeutic errors result from the application of culturally incongruent worldviews,
values, norms, beliefs, and expectancies.
Consistent with the cultural congruence model (Leong & Kalibatseva, 2011), the complexity of how
cultural values affect the lives of Asian Americans is being explored continuously. Research suggests
that gender and racial identity have influenced the cultural values held by Asian Americans (Yeh,

Carter, & Pieterse, 2004). A strong preference for distinct cultural value orientations could reflect
both traditional Asian and European American cultural values. The unique personality characteristics
of Asian American women (True, 1990) and Asian American men (D. Sue, 2001) have also
constituted an area of intensive research focus. Factors such as socialization of gender roles, societal
pressures, acculturation, and traditional Asian cultural values have been explored for how they relate
to the personality development of Asian American women and men. For example, for traditionally
oriented Asian American males, reframing and discussing culture conflicts can help resolve issues of
living up to cultural expectations. For acculturated Asian American males, a more didactic
presentation that includes a discussion of Asian males in American society might be a better first step
than introspective techniques in the consciousness-raising process. Understanding the unique
characteristics of the two sexes provides context for which psychologists can offer therapeutic

Emotion of ShameLoss of Face

Emotions are important to our understanding of human behaviors because they provide energy for and
guide behaviors. Because emotions serve these motivational and communicative functions,
understanding cultural variations in the meaning, experience, and expression of emotions in the
therapeutic relationship is critical to effective cross-cultural counseling. Shame and shaming are the
mechanisms that traditionally help reinforce societal expectations and proper behavior in Asian
culture. The fear of losing face can be a powerful motivational force pushing individuals to conform
to family and societal expectations. Losing face and the resulting shame are especially salient for
Asian American clients because loss of face is often a dominant interpersonal dynamic in Asian
social relations, particularly when the relationship involves seeking help for personal issues (Zane &
Yeh, 2002). In Asian American culture, the emotion of shame and the experience of losing face
involve not only the exposure of the individuals actions for all to see but also the withdrawal of the
familys, communitys, or societys confidence and support. Feelings of shame are painful for
members of collectivistic cultures (e.g., Asian cultures) because of the social consequences (Yeh &
Huang, 1996). The web of obligation and fear of shame are frequently crucial parts of the lives of
East Asian and Asian Americans who seek or are referred for treatment. These feelings can affect
their behavior and perceptions of the world and their presentation of material in therapy. Such
feelings can envelop the relationship with the therapist in ways that the therapist does not understand
unless he or she is familiar with the cultural relevance of shame for the clients particular Asian
American group.
In a study by Peng and Tjosvold (2011) concerning behavioral strategies in conflict avoidance and
how they are related to social face concerns, Chinese employees were asked to recall an incident
where they avoided a conflict with their supervisors. Confirmatory factor analysis of the responses
revealed yielding, outflanking, delay, and passive aggression as approaches to avoiding conflict.
Interestingly, the associations of social face concerns and avoidance were stronger among employees
who interacted with Chinese managers compared with those working for Western managers. This
study provides some important indications of how Asian American clients may manage conflict and
face concerns with European American versus Asian American counselors.

From the early days of the Whorfian hypothesis (Carroll, 1956) regarding language and thought,
cross-cultural psychologists have pointed to the constraining effects of language in cross-cultural
communication and understanding. It is therefore not surprising that many investigators have identified
language as an important client variable to attend to when counseling Asian Americans. Language
may be the source of several kinds of barriers to effective cross-cultural counseling, including
misinterpretations and false assumptions. For example, Asian Americans with bilingual backgrounds
may be perceived as uncooperative, sullen, and negative (D. W. Sue & Sue, 1972). Asian Americans
who speak little or no English may be misunderstood by their counselors. The use of dialects or
nonstandard English may interfere with the effective exchange of information or even stimulate bias
on the part of the therapist. Given such language-related problems, Asian Americans may attempt to
communicate their concerns nonverbally, which in turn may be misinterpreted by counselors (Tseng &
McDermott, 1975). The use of interpreters with non-English-speaking Asian clients can result in
interpreter-related distortions (Marcos, 1979).
Consistent with the Whorfian hypothesis (Carroll, 1956), problems with intercultural communication
are not limited to the use of different languages but also stem from differences in thought patterns,
values, and communication styles (Chan, 1992). The communication styles of Asian Americans are
significantly different from those of Euro-Americans. Asian Americans tend to communicate in a
high-context style, with context as the primary channel for communication. Direct and specific
references to the meaning of the message are not given. In interpreting the meaning of the message,
receivers are expected to rely on their knowledge and appreciation for nonverbal cues and other
subtle affects. The Euro-American culture tends to focus on communication through a low-context
style, in which words are the primary channel for communication. Direct, precise, and clear
information is delivered verbally. Receivers can expect to take what is said at face value.
The high-context communication style can be seen as an elaborate, subtle, and complex form of
interpersonal communication. This communication style enables Asian Americans to avoid causing
shame or loss of face to themselves and others, and thus to maintain harmonious relations. In fact,
Asian Americans might consider any form of direct confrontation and verbal assertiveness to be rude
and disrespectful. The use of direct eye contact may be limited because direct eye contact may imply
hostility and aggression and be taken as a rude gesture.
Mental health service providers must be aware of and sensitive to these communication style
differences to prevent cross-cultural misunderstandings. An individuals preferential communication
style (high or low context) could influence how he or she perceives others who use the opposite style.
Those who prefer high-context communication may perceive those who use low-context
communication to be too direct, insensitive to context, and minimally communicative. Those who use
a low-context communication style may, in turn, perceive high-context communicators as indirect,
lacking in verbal skills, and even untrustworthy. Cultural awareness and accommodation of different
communication styles has positive impacts on the therapy process and on the therapeutic alliance
between therapist and client. More recent work on culture and cognition by Nisbett and colleagues, as
exemplified by Nisbetts 2003 book The Geography of Thought, provides additional insights into
how Asians and Westerners think and reason differently. The research Nisbett summarizes in his book

warrants careful study by counselors and therapists working with Asian American clients.
Related to the role of language in counseling is a study by Hall, Guterman, Lee, and Little (2002),
who examined childrens and adolescents counseling outcomes to determine if clients of different
backgrounds benefit from being matched with counselors on ethnic, gender, and language factors. The
multivariate analyses performed by the investigators found that general psychological functioning and
other variables differed between groups in which clients and counselors were matched on these
factors and nonmatched groups. The researchers concluded that ethnicity, language, and gender
matches led to improvements in treatment outcomes.
Language has also come to play a significant role in recent approaches to cultural adaptations in
psychotherapy (Bernal & Domenech Rodrguez, 2012). For example, in a review of cultural
adaptation of treatment, Bernal, Jimnez-Chafey, and Domenech Rodrguez (2009) point to the
growing interest in whether and how psychotherapies can be adapted to take into account the cultural,
linguistic, and socioeconomic contexts of diverse ethnocultural groups. According to these scholars,
the root of the debate is whether evidence-based treatments (EBTs) developed within particular
linguistic and cultural contexts are appropriate for ethnocultural groups that do not share the same
language, cultural values, or both. Bernal et al. review the considerable evidence regarding the
relationships between cultural contexts and various aspects of the diagnostic and treatment process.
They also review the available published frameworks for cultural adaptations of EBTs and various
conceptual models for adapting existing interventions to produce more positive therapeutic outcomes.

Whereas anthropological research has found the family to be a common kinship organization across
most cultures, the meaning and importance of the family may vary. Given Asian Americans
collectivistic value orientation, it has long been observed that the family plays a critical role in Asian
American culture. As such, the family and its cultural dynamics are considered to constitute another
important client variable, especially in relation to the mental health of Asian Americans. While Asian
families may emphasize connectedness among family members, Western norms prioritize separateness
and clear boundaries in relationships, individuality, and autonomy (Tamura & Lau, 1992). Mental
health service providers should note that the preferred direction of change for Asian American clients
may be toward a process of integration rather than a process of differentiation. Within the Asian
American cultural context, family constancy, equilibrium, duty, obligation, and appearance of
harmonious relations are important factors.
Family dynamics and related factors that practitioners should also consider when working with Asian
Americans include immigration history, adaptation experiences, cultural values, and generational
differences related to acculturation experience (e.g., B. S. K. Kim, Brenner, Liang, & Asay, 2003; J.
M. Kim, 2003). More specifically, immigrant families may face problems with social isolation,
adjustment difficulties, and cultural and language barriers. Issues such as language and cultural
barriers may contribute to parentchild conflicts within immigrant families. Family organization,
roles and functioning, and cultural values across generations are also important to explore within
Asian American families. Studies have shown that for Asian Americans, immediate and extended
family are important loci of identity formation, social learning, support, and role development. Asian

culture also places higher value on males than on females, which could result in boys and men
holding a disproportionate share of power within the family (Cimmarusti, 1996).
Parenting styles received may also explain personality development and life experiences of Asian
Americans (Lim & Lim, 2004). In a study of Korean American families, H. Kim and Chung (2003)
found that authoritative parenting behaviors were most common, followed by authoritarian behaviors,
then permissive behaviors. They also found that authoritative parenting style and greater number of
years lived in the United States were predictive of higher academic competence. Authoritarian and
permissive parenting styles were predictive of lower self-reliance, whereas greater number of years
lived in the United States was related to higher self-reliance. As with any population, among Asian
Americans families have the potential not only to facilitate mental health but also to serve as potential
mental health stressors. It is important to note that not all families are alike, and clinicians should
expect as much variation among Asian American families as among families in other ethnic groups.
In a study examining family influences on mental health, Leu, Walton, and Takeuchi (2010) used data
from the first nationally representative psychiatric survey of immigrant Asians in the United States (N
= 1,583) to demonstrate the importance of understanding acculturation domains within the social
contexts of family, community, and neighborhood. They found that among immigrant Asian women, the
association between family conflict and mental health problems is stronger for those with higher
ethnic identity. For immigrant Asian men, community reception (e.g., high everyday discrimination) is
more highly associated with increases in mental health symptoms among those with poor English
fluency. Leu et al. conclude from their findings that it is important for practitioners to consider both
individual and social domains of acculturation and adaptation. Moreover, these relationships between
acculturation and mental health may vary by gender and context.
Given the critical need for more culture-specific measures, Wang (2010) describes the development
and psychometric evaluation of the Family Almost Perfect Scale (FAPS), which measures the
perceived level of perfectionistic standards and evaluation from an individuals family. In the first
study, which used a sample 283 college students, Wang conducted exploratory factor analysis to
determine the FAPS scale items. In the second study, the FAPS was cross-validated through
confirmatory factor analyses with an Asian/Asian American sample (N = 252) and a European
American sample (N = 386). These two samples were compared on various target variables, and
Asians/Asian Americans reported modestly higher personal and family discrepancy and lower selfesteem. Wang also grouped the participants into different perceived perfectionistic family types.
Those participants who perceived themselves as having maladaptively perfectionistic families
reported greater depression and lower self-esteem. The FAPS appears to be a promising new
measurement tool that will help increase understanding of the role of family dynamics in mental health
among Asian Americans. The personal and family discrepancies revealed in the FAPS may prove to
be valuable foci for counseling with Asian Americans with mental health problems.

Broadly, acculturation is a multidimensional construct that involves adaptation to the norms (i.e.,
values, attitudes, and behaviors) in a new culture and maintenance of the norms of the indigenous
culture (e.g., Berry, Trimble, & Olmeda, 1986). We use the term acculturation here to represent the

degree to which Asian Americans are identified with and integrated into the Euro-American majority
culture. Acculturation has important implications for Asian Americans physical and mental health,
academic performance, and response to counseling and psychotherapy (Suinn, 2010). In general, low
levels of acculturation have been associated with more psychological symptoms, assuming that low
acculturation is also related to academic and financial difficulties and social isolation. However, high
levels of acculturation have been linked to difficulties in psychological adjustment in the presence of
family conflict and acculturative family distancing (Hwang & Wood, 2009).
Asian American families often experience generational differences as later generations internalize
Western norms and values more than their parents or grandparents do (third versus first generation;
Connor, 1974). A few studies of Asian American families have found that intergenerational
discrepancy in acculturation, especially as perceived by the adolescent children, is associated with
higher depression scores (Ying & Han, 2007). Caught between Western standards and the traditional
cultural values of their parents, Asian Americans may experience mental health problems related to
the acculturation process as well as interpersonal conflicts.
Based on their clinical experience with Asian Americans, D. W. Sue and Sue (1972) developed a
conceptual model for understanding how Asian Americans adjust to culture conflicts. They observed
that Asian Americans exhibit three distinct ways of resolving the culture conflicts they experience.
First, the traditionalist is one who remains loyal to his or her own ethnic group by retaining
traditional Asian values and living up to expectations of the family. Second, the marginal person is
one who becomes overly Westernized and rejects traditional Asian values; this individuals pride and
self-worth are defined by his or her ability to acculturate into Euro-American society. Third, the
Asian American is one who rebels against parental authority but at the same time attempts to integrate
bicultural elements into a new identity by reconciling viable aspects of his or her heritage with the
present situation. Asian Americans may attempt to resolve the cultural conflicts associated with
acculturation by integrating into both cultures and developing a sense of ethnic identity (Cheryan &
Tsai, 2007).
Level of acculturation has been associated with Asian Americans likelihood of seeking mental health
services, therapy duration, and therapy outcome. More acculturated individuals tend to seek
professional psychological help more often, whereas less acculturated individuals may rely more on
community elders, religious leaders, student organizations, and church groups (Solberg, Choi, Ritsma,
& Jolly, 1994). Individuals who are more acculturated are most likely to recognize the need for
professional psychological help because they are more open to discussing problems and more
tolerant of the stigma often associated with seeking psychological assistance (Atkinson & Gim,
1989). In more recent research, enculturation to Asian values has been found to be inversely
associated with professional help-seeking attitudes (B. Kim, 2007), and higher values of
acculturation paired with lower values of enculturation have been found to predict more positive
attitudes toward seeking professional psychological help (Miller, Yang, Hui, Choi, & Lim, 2011). It is
important for clinicians to be cognizant of the impact of acculturation and provide services that
address the impact of acculturation in conjunction with other factors, such as acculturative stress,
acculturative family distancing, and enculturation.

Counseling Expectations

The counseling expectations and conceptions of mental health of Asian Americans are important
client variables that have been examined empirically. Studies of the effects of Asian students cultural
conceptions of mental health on expectations of counseling found that Asians generally tended to view
counseling as a directive, paternalistic, and authoritarian process (Arkoff, Thaver, & Elkind, 1966) or
an advice-and-information-giving process (Tan, 1967). Consequently, Asian Americans were more
likely to expect a counselor to provide advice and recommend a specific course of action. Studies of
counseling expectations found that, compared with U.S. students, Asian international students
reported more expectations for directiveness, empathy, nurturance, and flexibility from counselors
(Yoon & Jepsen, 2008; Yuen & Tinsley, 1981). A group of Chinese students also expected more
expertise from the counselor and believed that clients should possess lower levels of responsibility,
openness, and motivation. These findings suggest that mental health clinicians may need to examine
Asian American clients expectations for therapy openly and address them in the beginning of
treatment as one way to prevent the premature termination that can result from differing expectations.

Help-Seeking Attitudes
Asian Americans have continuously underutilized mental health services (U.S. Department of Health
and Human Services, 2001). Explanations for the low utilization rates include deterrents to
participation such as cognitive barriers (e.g., stigma), affective barriers (e.g., shame), Asian value
orientation (e.g., collectivistic nature), and physical barriers (e.g., access to resources; Leong & Lau,
2001). Furthermore, in some cultures, psychological therapy may not exist as a concept; therefore,
utilization of mental health services may not be viewed as a treatment option. In recent years,
researchers have begun to explore ways in which mental illness might be appropriately explained to
Asian Americans to increase understanding of the concept and reduce stigma among this population
(Yep, 2000). Stigma and lack of understanding can account for the low frequency of mental health
care self-referrals among Asian Americans; studies have shown that Asian Americans are more likely
than Euro-Americans to be referred to therapists by friends and through health and social service
agencies (Akutsu, Snowden, & Organista, 1996). A recent study found that Asian American students
most preferred methods of addressing their mental health concerns were, in order of preference,
taking classes on mental health issues, visiting the health center, finding information online, and
visiting the counseling center (Ruzek, Nguyen, & Herzog, 2011). These help-seeking preferences may
be associated with the students fear of losing face and desire to maintain group harmony and their
perception of reporting physical problems as more appropriate than reporting mental health problems.
Preferred use of traditional Asian healing practices can also account for underutilization of
professional psychological services.
Level of acculturation also plays an important role in Asian Americans attitudes toward mental
health services (Zhang & Dixon, 2003), such that Asian Americans with high acculturation levels are
more willing to seek help than those less acculturated. One study found that Chinese, Japanese, and
Korean individuals with high acculturation levels were more likely to recognize the need for
professional psychological help, more tolerant of stigma, and more open to discussing problems with
a psychologist than were individuals who were less acculturated (Atkinson & Gim, 1989).
Additionally, Asian American women have been found to be more willing than Asian American men
to seek psychological services (Gim, Atkinson, & Whiteley, 1990).

To reduce service underutilization and premature termination among Asian Americans, mental health
providers must recognize the influences of the Asian cultural context on these clients cultural values,
attitudes, beliefs, and help-seeking behaviors. Finally, service providers should identify cultural gaps
and blind spots in existing Western models of psychotherapy and accommodate treatment to their
Asian American clients needs (Leong, 2007). Health professionals should openly explore their own
vulnerabilities to ethnocentrism and cultural uniformity myths that may hinder their full appreciation
of the worldviews of their ethnically different clients.

Experiences of Psychological Distress and Coping Mechanisms

Asian Americans can experience mental health issues similar to those experienced by members of
other racial and ethnic groups (Takeuchi, Mokuau, & Chun, 1992). Despite the model minority
stereotype, prevalence rates of mental health problems among Asian Americans are noteworthy. A
large amount of literature and research attention has been devoted to understanding and describing the
unique mental health needs and experiences of Asian Americans (Cheng, 2012; Yang & WonPatBorja, 2007). Awareness of cultural context and appropriate personenvironment fit may facilitate
mental health practitioners understanding of Asian Americans experiences and expression of
symptoms of distress, enabling them to provide culturally congruent treatment (Leong & Kalibatseva,
2011). One of the most widely circulated claims in cross-cultural psychopathology has been that
people of Asian descent tend to somatize psychological distress. Some of the characteristics cited in
support of this claim are the denial or suppression of emotions, stigma toward mental disorders, and
lack of bodymind dualism in Asian cultures. However, recent studies suggest that Asians and Asian
Americans may tend to report somatic symptoms initially, employing a widely used cultural idiom of
distress, but they acknowledge the presence of emotional issues, too (Ryder et al., 2008). Thus,
clinicians need to pay particular attention to initial symptom reports in assessment, diagnosis, and
The worldview of Asian Americans is further contextualized by an understanding of their ethnic
identity. Experiences of racism and discrimination can have negative impacts on Asian Americans
mental health and coping strategies. In addition, experiences of racial discrimination may hinder the
therapeutic process, especially if the counselor is Euro-American and the client has had a negative
cultural experience. One study found that racial discrimination stress significantly predicted
depressive symptoms over and beyond perceived general stress and perceived racial discrimination
among Asian American college students (Wei, Heppner, Ku, & Liao, 2010). Furthermore, immigration
experiences may be a source of mental health problems as Asian Americans seek to adjust to living in
the United States (F. K. Cheung, 1980). Acculturative stress, for example, is a direct result of the
acculturation adaptation process for first-generation immigrants, and bicultural stress is a response to
the pull of maintaining ethnic ties in second and later generations and has significant predictive
effects on mental health symptoms (Yeh, 2003).
Research findings about the need for psychological and social support among Asian Americans have
been mixed. Some studies have found that Asian Americans in general may have less of a need for
psychological and social support than do Euro-Americans (Wellisch et al., 1999), whereas others
have found that Asian American adolescents specifically have higher levels of depressive
symptomatology, withdrawn behavior, and social problems than Euro-American adolescents (Chang,

2001). Social support from friends, family, and even international student offices can buffer the stress
related to racism and cultural adjustment (Chen, Mallinckrodt, & Mobley, 2002). It is well
documented that social support is an instrumental tool for coping among many Asian Americans.
Understanding the cultural worldview of Asian Americans can help mental health providers
recognize the coping strategies their Asian American clients use when experiencing psychological
distress. These strategies may tend to emphasize sharing with family and friends rather than with
professionals such as counselors and doctors. Collectivistic coping may be prevalent among Asian
Americans, given that it emphasizes the importance of close relationships and family bonds in dealing
with stress. More specifically, among the ethnic groups examined in one study (Chinese, Korean,
Filipino, and Indian), Korean Americans were found to be more likely than those in other groups to
cope with problems by engaging in religious activities (Yeh & Wang, 2000). Finally, Asian
Americans may use coping resources based in their heritage cultures. For example, traditional folk
healing practices, spiritual identification, and religious practices such as Buddhism are primary
resources for support among Asian American communities.

Therapist Variables
What therapist characteristics affect the provision of mental health services to Asian Americans?
Generally speaking, Asian American clients prefer therapists who have attitudes and personalities
similar to their own, who have more education than they have, and who are older than them
(Atkinson, Wampold, Lowe, Matthews, & Ahn, 1998). Zhang and Dixon (2003) have also found that
counselors who respect and are open to learning how to relate to people from different cultures are
rated by Asian international students as more expert, attractive, and trustworthy than counselors who
are not culturally responsive.
Regardless of the specialization or discipline, it is a professional expectation that therapists develop
competencies to work with people from different cultures (American Psychological Association,
2003). The actual nature of such competencies is being debated, but it is obvious that the mastery of
culturally sensitive skills is imperative for mental health service providers in todays shrinking world
and global economy. To work successfully with clients who are perceived or identify as Asian
American, clinicians should be proficient in three areas: (1) knowledge of Asian cultures and
ethnicities, (2) awareness of race and racialization among Asian Americans, and (3) skills to respond
appropriately to or to broach the subjects of culture, ethnicity, and race during the counseling process.

Knowledge of Cultures and Ethnicities

Therapists who work with Asian Americans should be familiar with the variety of cultures and
ethnicities that exist under the umbrella of the U.S. governments Equal Employment Opportunity
Commission (EEOC) category Asian. Learning about cultures and ethnicities from Asia and India
and their history in the United States is essential for counselors development of cultural competency.
The similarities among Asian ethnicities have been outlined earlier in this chapter, but the
differences are very important to individuals. Therapists who do not know the differences between
Chinese, Japanese, Korean, Vietnamese, East Indian, and other Asian cultures and their separate

histories in America are susceptible to ethnic and racial stereotyping, which can disrupt the
therapeutic alliance and discredit the therapists credibility (Berg & Miller, 1992). Unfortunately, one
study found that practicing counselors showed degrees of cultural stereotyping similar to those found
in the general population (Bloombaum, Yamamoto, & James, 1968). Therapists are not immune to the
ethnocentric and racist attitudes that are a part of American educational systems and popular culture
(Loewen, 1995; Mok, 1998).
An often-cited example of how cultural knowledge can be important for therapists working with
Asian Americans is how Euro-American clinicians who make a firm split between body and mind
can underestimate the presence of psychological and relational stress in their Asian American clients.
Due to philosophical, religious, and familial traditions, Asian Americans may tend to focus more on
physical discomforts than on emotional symptoms. This somatization of psychological stress can
result in the underestimation of the amount and degree of anxiety and depression among Asian
Americans (Okazaki, 2002). In a study that examined the degree to which primary care physicians
recognize psychiatric distress in Asian and Latino patients, Chung et al. (2003) found that while 42%
of the Asian patients exhibited depressive symptoms, only 24% of them were diagnosed with
psychiatric conditions. Such discrepancies can lead to the underestimation of both the incidence and
the degree of mental health problems among Asian and Asian American communities, thus affecting
public funding of mental health services and service delivery (see Omi, 2010).
A therapists ability to utilize interventions that match a clients needs or circumstances is essential in
most clinical settings. As noted earlier in this chapter, some studies have suggested that Asian
American clients expect and respond more favorably to directive modes of counseling. Therapists
who see Asian American clients should also appreciate that there are several traditional healing
practices in Asia. The Thai Pa Sook model of counseling (Pinyuchon, Gray, & House, 2003), the
Filipino practice of Santo Nio (Lin, Demonteverde, & Nuccio, 1990), and forms of the Japanese and
Morita and Naikan therapies (Morita, 1928; Yoshimoto, 1981) can be found in the United States.
Sandhu (2004) describes a synergetic collaboration between South Asian Sikh religious healing
resources and modern medicine. Counselors should be cautioned to stay within their ethical
boundaries of competence and recognize any liabilities that they incur when working with or making
referrals to practitioners who utilize methods other than those recognized by American licensing

Awareness of Race and Racialization

Therapists who work with Asian Americans should also be aware of how people of a variety of
cultures and ethnicities who immigrated to the Americas from Asia, India, and the islands of the
Pacific came to be thought of and treated as Asians in the United States. This process of
racialization differs for each group, and the degree of racialization varies from person to person
(see Omi & Winant, 1994; Takaki, 1998). Racism, or the institutionalization of the belief in White
supremacy, is a crucial element in the histories of all Asians in AmericaChinese, Japanese,
Koreans, Cambodians, East Indians, and others (see Lopez, 1997). That is, in addition to being aware
of the role of racism in the histories of Asian American groups, therapists need to be aware of how
the Chinese, Japanese, Filipinos, and others began to think of themselves and their experience in
America using racial constructs. Awareness of the events and conditions that led to Chinese,

Japanese, Vietnamese, and other groups marching together as Asian Americans and adopting the
label that the U.S. government used to classify them is important (see Wu, 2001). Counselors who
work with Asian Americans can increase their understanding of their clients and the probability that
their clients will perceive them as credible if they know these narratives. It is important to note that
developing this awareness involves making firm distinctions among the constructs of culture,
ethnicity, and race (see Fish, 2000; Helms, Jernigan, & Mascher, 2005; Helms & Talleyrand, 1997;
Lee et al., 2013).
Being aware of how the different Asian cultures have negotiated ethnocentrism and racism in the
United States enables counselors to appreciate the sociopolitical contexts of the presenting problems
Asian Americans bring to counseling. Understanding how individual clients are negotiating culture
and race can help therapists gain insight into their family dynamics, socialization and acculturation,
political postures, and religious beliefs. That is, Asian American clients cultural (D. W. Sue & Sue,
1972) and racial identities (West-Olatunji et al., 2007) can inform clinical conceptualizations and
intervention strategies, especially for clients who may be perceived as Asian but identify as mixed
or multiracial (Suyemoto, 2004). Probably more important than the clients racial identity is how the
therapist navigates culture and race in his or her own life. Day-Vines and colleagues (2007) have
proposed that a therapists racial identity is predictive of his or her ability to broach the subjects of
race, ethnicity, and culture appropriately during the counseling process.

Skills to Broach the Subjects of Culture, Ethnicity, and Race

The therapist and the client are both human beings. It is clear from anthropological and genetic
research that human beings are similar, different, and unique. The challenges for a therapist are to
establish rapport with a client based on similarities between therapist and client, to take into account
the differences that exist between them, and to honor the fact that they are both unique individuals. It
is the therapists responsibility to acknowledge and, when appropriate, address the similarities and
differences between therapist and client. These similarities and differences may be cultural (e.g.,
language, religion, socioeconomic class), ethnic (e.g., dialect, denomination, region), and racial (i.e.,
identities and positionalities). A therapist raised in a rural American culture would be wise to pay
attention to the culture of a client raised in Beijing, China. A gay male counselor from Chicago might
have to consider what ethnic differences are operative when he is working with a heterosexual female
from Los Angeles. And a White-identified therapist should be attentive to when it may be helpful to
broach the topic of race when working with a client who identifies as Asian or Asian American.
Certainly, the therapist must recognize the intersections of an individuals multiple identities. For
example, in a counseling relationship between a White, Euro-American, middle-class, heterosexual
Christian female therapist from Kansas and an Asian American, upper-class, gay Jewish male from
New York, there will probably be interactions worth discussing. A body of research has emerged that
demonstrates that the acknowledgment of cultural and racial differences during the counseling process
enhances counselor credibility, client satisfaction, the depth of client disclosure, the working alliance,
and client willingness to return for follow-up sessions (Zhang & Burkard, 2008).
The research findings on the impact of race on the counseling process are mixed. A racial match
exists when the counselor and client are both perceived to be from the same racial group.1 Racial

matches have been found to be associated with increased utilization, favorable treatment outcomes
(i.e., global assessment scores), lower treatment dropout, and increased counselor credibility and
empathy (Flaskerud & Lui, 1991; Gamst, Dana, Der-Karabetian, & Kramer, 2001; Gim, Atkinson, &
Kim, 1991). Other studies, however, have demonstrated no effect of racial match on treatment
processes (Watkins, Terrell, Miller, & Terrell, 1989) or outcomes (Gamst, Dana, Der-Karabetian, &
Kramer, 2004). This research is controversial, because the popular view of race is that it should not
matter in interpersonal relationships. The notions that the United States is a postracial society and
that people should be color-blind have been argued by scholars and popular media (see Vo, 2010).
However, research on the counseling dyad has repeatedly demonstrated that race can matter in this
Meyer, Zane, and Cho (2011) offer an explanation for why and how racial match can have positive
impacts on the counseling process for Asian Americans. Using an analog experimental design and a
large sample of Asian American undergraduate students born in the United States, they found that
when a counselor and client had similar racial characteristics (i.e., skin tone, facial features, and hair
texture), the participants assumed that the counselor and client also had similar attitudes and
experiences. That is, individuals racial phenotypes were assumed to reflect culture or background.
Meyer et al. summarize:
Racial match produces greater therapist credibility and this effect was mediated by life
experience similarity. This suggests that racially matched Asian American clients may perceive
that their counselor has undergone similar life experiences and/or has come from a similar
culture, and this leads them to evaluate the therapist to be more credible. Thus, racial match
could be considered a viable therapeutic possibility when this option is possible at a counseling
center. (p. 342)
However, Asian American counselors are not always available, and the therapeutic relationship
involves much more than race. Language, culture, ethnicity, class, religion, age, size, disability,
gender, sexual orientation, educational background, geographic location, marital or relationship
status, work experience, military service, and hobbies/recreational activities are all variables that
influence the clients and counselors perceptions and behavior. Experienced therapists take all these
variables into account when doing therapy. Just because race is only one of many factors in a
counseling relationship, however, that does not mean that it can be denied or ignored. The research
suggests that to neglect the meaning that therapists and their clients give to race could be to omit an
important element from the therapeutic process.
When therapists who are not racially identified as Asian work with clients who identify as Asian
or Asian American, they should have not only some knowledge of the clients ethnicities and racial
identities but also the skills to develop rapport and establish some credibility across racial lines.
Having similar attitudes and life experiences can go a long way toward bridging a racial divide, but
members of different racial groups in the United States do not always have similar experiences and
values. For therapists, knowing how to respond appropriately to how they are perceived by clients
because of their phenotypes associated with race is an important skill. How counselors negotiate how
they are racially perceived has been referred to as racial responsiveness (Lee et al., 2013).

Discerning when and how to broach the topic of racial differences during the counseling process can
be difficult and confusing. Therapists need to develop this skill through the processes of experienced
supervision and the understanding of their own cultural, ethnic, and racial identities.

Summary and Conclusions

As an update to Leongs (1986) review of the literature on counseling Asian Americans, this chapter
has highlighted the culturally relevant client and therapist variables that shape the counseling
relationship. A growing body of psychological research on Asian Americans has demonstrated the
ways in which clients subjective experiences and expressions of distress, openness to formal mental
health services, expectations of providers, therapeutic goals, and interpersonal and communication
styles are shaped by culture and context. Specifically, the cultural socialization of many Asian
Americans has contributed to the salience of an interpersonal orientation that values interdependence,
conformity, emotional self-restraint, humility, and respect for authority. Research studies with an
indigenous measure of Chinese personality found a Chinese factor of personality above and beyond
the Big Five (F. M. Cheung, Cheung, Leung, Ward, & Leong, 2003). Originally labeled the Chinese
tradition factor, it was renamed interpersonal relatedness following expansion of the research
program beyond Chinese samples (F. M. Cheung, Cheung, Wada, & Zhang, 2003). This factor points
to the existence of a relational self among Asians that is consistent with research on individualism
collectivism (Triandis, 1995) and independentinterdependent self-construal (Markus & Kitayama,
Given this relational self, it is not surprising that studies have shown that Asian Americans expect a
counselor to play the role of an authority figure who provides structured guidance in problem solving
as well as empathy, nurturance, and flexibility. However, individual differences are also important to
acknowledge, particularly with regard to how Asian Americans reconcile the conflicting norms and
values of their cultures of origin and those of mainstream U.S. society. Individuals who are more
culturally identified with Western norms and values may be more responsive to mainstream helping
approaches, whereas more traditionally oriented individuals may require culturally modified
approaches. The impact of acculturation on Asian American clients mental health may need to be
addressed in relation to acculturative stress, acculturative family distancing, and enculturation.
Regardless, the literature suggests that the tensions inherent in resolving different cultural
expectations may affect the majority of Asian Americans, many of whom find themselves straddling
two (or more) different cultural worlds, often within their own families.
As highlighted in the present chapter, the worldview of a traditional Asian American client may differ
quite dramatically from that of a Euro-American therapist or a therapist of color who has been trained
primarily in Western models of psychotherapy. The greater the cultural distance between client and
therapist, the greater the potential for inaccurate assessment of the presenting problem and difficulties
in establishing a strong working relationship. These interpersonal barriers are thought to contribute to
the tendency of Asian Americans to underutilize mental health services and to terminate treatment
prematurely once it is initiated. Specifically, counselors lack of culturally relevant knowledge and
susceptibility to popular ethnic stereotypes have been linked to inaccurate assessment and
misdiagnosis. Moreover, counselors may need to identify cultural blind spots (e.g., assumptions about
individualism or Western ways to communicate distress) in existing Western models of psychotherapy

and accommodate treatment to individual clients needs.

Because many Asian Americans are hesitant to seek formal mental health services, those who do may
be particularly sensitive to therapists failure to meet their help-seeking expectations. By now, there is
convergent evidence that Asian Americans as a whole tend to favor more structured and problemfocused interventions over unstructured, exploratory approaches. The good news is that modifications
of mainstream therapeutic approaches as well as culturally grounded interventions are being
developed to complement traditional Asian American clients cultural values and illness constructs.
Therapists working predominantly with Asian clients may seek training in newly developed culturally
grounded approaches that respect the hierarchical structure of traditional Asian families and integrate
religious healing rituals with psychological interventions.
Therapists who are sensitive to the acculturative stressors faced by recent immigrants and their
children may also achieve greater credibility due to their ability to empathize and recommend
specific coping strategies. In addition, awareness of the cultural roots of traits such as modesty,
conformity, and emotional self-control may minimize the risk of overpathologization and improve
therapists ability to connect with their Asian clients.
Finally, given space limitations, we have restricted our coverage in this chapter to the recent
literature on client and therapist variables affecting Asian Americans in counseling and therapy.
Readers who are interested in a review of research studies concerning the therapy process and
outcomes involving Asian Americans are referred to Leong et al. (2007).

Future Directions
Despite the rapid growth of research in Asian American mental health to include children and
families, college students, and community members, more research is needed to capture the cultural
diversity of the Asian American community. As discussed, the field is showing favorable signs of
representing the complexity of the Asian American identity by exploring how racial and ethnic
identity, generational status, and gender interact to shape mental health and mental health care.
Another exciting development is that the field is now moving beyond studies of individual-level
acculturation to examine the processes by which families and communities change as a result of
exposure to diverse cultural systems. This is an important new research area given the bidirectional
nature of acculturation; immigration flows are dramatically changing the social and cultural landscape
of American society just as immigrants themselves are changed in the resettlement process.
Leong and Kalibatseva (2011) have proposed a cultural congruence model for integrating the various
strands of research on counseling and psychotherapy among Asian Americans. They posit that cultural
congruence can serve as an integrative framework for accommodating the heterogeneity within the
Asian American population. In essence, effective psychotherapy for Asian Americans will have to
take into account cultural differences in beliefs, values, needs, and norms. Leong and Kalibatseva
propose that the underlying principle of effective psychotherapy for clients of color, including Asian
Americans, is a culturally congruent approach that matches the client and therapist in terms of a
variety of cultural variables and individual differences.

To the extent that cross-cultural psychotherapy is a complex process, Leong and Kalibatseva (2011)
propose their cultural congruence model as a bridging element to be joined to the cultural
accommodation process outlined by Leong and Lee (2006). An important factor in effective
psychotherapy for Asian Americans is therapists understanding of the unique cultural values, beliefs,
needs, and expectations of Asian American clients. Whereas Leong and Lees cultural
accommodation model has delineated the need for therapists to accommodate cultural differences in
order to provide effective psychotherapy for Asian Americans, the cultural congruence model
provides a theoretical rationale for making such accommodations. Borrowing from the field of
interactional psychology and personenvironment fit models, the cultural congruence approach is
predicated on the hypothesis that culturally congruent (versus incongruent) processes and goals will
lead to positive therapeutic outcomes.
Of course, the proposal that cultural congruence underlies effective psychotherapy for Asian
Americans or members of other racial/ethnic minority groups will need to be subjected to research in
terms of effectiveness and efficacy (Leong & Kalibatseva, 2011). Finally, in light of recent efforts to
develop clinical training models that are flexible enough to address the needs of diverse client
populations, empirical studies are needed to examine the effects of such curricula on therapists
ability to meet the needs of their Asian American clients.

Critical Incident
Failing a Course
Simon Ho is a 19-year-old Chinese American sophomore attending a midwestern university. He has a
good academic record, with a 3.25 grade point average, but he is having difficulty understanding
various concepts in his advanced chemistry class. With a big exam approaching, Simon is not only
increasingly worried but also experiencing headaches and stomach troubles. Fearing the possibility of
failing the exam and disappointing his family, Simon decides to seek assistance from his chemistry
professor. Upon approaching the professor, he is greeted happily and courteously. His professor
spends more than an hour with him, reviewing some of the material for the exam. After this review,
Simon feels a bit more confident about his understanding of the concepts. Unfortunately, Simon
receives a D on the exam. Disappointed by his poor performance, he begins to skip class to avoid his
professor and never seeks his professors assistance again.

Discussion Questions
1. Why does Simon not ask his professor for further assistance or guidance? Choose the best
1. Simon thinks that the professor would have written on the test that it was necessary to see
him, if he really cared.
2. Simon feels that chemistry is no longer important in his life.
3. Simon is too ashamed to see his professor again.
4. Simon is upset with his professor for not reviewing the necessary material with him.

2. How might Simons cultural context help to explain his headaches and stomach troubles?
3. What other cultural factors could also account for Simons experience?

1. A racial match does not necessarily mean a cultural or ethnic match. For example, a Chinese
American counselor working with a Korean international student is a racial match, but not a cultural
or ethnic match. A cultural match would be a counselor and client who were both born and raised in
the United States. An ethnic match might be a counseling dyad in which both people (regardless of
skin tone or phenotypes) are middle-class Christian Korean Americans who grew up in Seattle.

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7 Counseling Persons of Black African Ancestry1

Ivory Achebe Toldson
Kelechi C. Anyanwu
Casilda Maxwell

Primary Objective
To teach counselors how to identify and make reasonable accommodations for the unique
psychological traits and sociocultural background of persons of Black African ancestry

Secondary Objectives
To describe psychological, cultural, and sociopolitical issues that counselors might consider
before working with clients of Black African ancestry
To propose enhanced techniques and strategies for providing effective counseling services to
African Americans and other clients of African descent
The purpose of this chapter is to help counselors explore practices and procedures that appreciate the
culture, nomenclature, history, and clinical preferences of clients and counselor trainees of Black
African ancestry. The chapter emphasizes ways in which counselors can enhance the quality and
integrity of their services by developing a better understanding of (1) specific cultural norms and
folkways, (2) how sociocultural power differentials manifest within a therapeutic context, and (3)
how Black/African psychology tenets can shape clinical practice.
In many counseling settings, routine practices and compliance standards often diminish the quality of
care for Black clients. Some counselors report that they often alter standards and bend rules, not only
to enhance Black clients services but also to protect them from maltreatment (Williams, 2005). For
example, one Black counselor reported that he instructs his Black adolescent clients to use the title of
Brother instead of Mr. when addressing him. Another counselor described the dissonance she felt
when she frankly told her client to just ignore that label... thats not who you really are, when
referring to her clients treatment plan diagnosis. Yet another counselor encouraged her client to call
out the name of a deceased loved one to keep his memory alive and not merely to let go of the past.
Finally, a counselor admitted that he applauded his clients tough confrontation of her sons drug use.
When used in traditional counseling settings, all of the above interventions may appear refractory and
audacious, yet a body of literature supports their legitimacy for Black clients (Ayonrinde, 2003;
Bhugra & Bhui, 1999; Brody et al., 2006; Harvey & Coleman, 1997; Herrick, 2006; Leavitt, 2003;
Reiser, 2003; Toldson & Toldson, 1999; Wills et al., 2007).
Notably, nothing heretofore stated should be casually considered a counseling strategy for African
Americans or any other client of Black African ancestry. Throughout this chapter, the authors will

resist the impulse to directly suggest counseling strategies and hope that readers will not intuit
counseling methods that they will try out on a Black client. The literature is replete with novel
techniques to address the unique counseling needs of persons of African descenttoo many to
reiterate in this chapter but no less deserving of consideration.
However, counseling strategies are not the primary problem when working with Black clients. No
counseling strategy offers a recipe for healing all persons of African descent. Several articles have
warned against using a cookie cutter approach to working with Black clients (Bowie, Cherry, &
Wooding, 2005; Estrada, 2005; Respress & Lutfi, 2006; Taylor-Richardson, Heflinger, & Brown,
2006). Helpers must be self-aware and able to use themselves as agents of change (Sheely & Bratton,
2010). Moreover, the millions of Black people who exist are more different from one another than
they are collectively different from other races (Jackson et al., 2004). In fact, the practice of force
fitting Black people into a category reflects a Eurocentric paradigm that relies heavily on taxonomies
to understand complex material (Leong & Wong, 2003).
Afrocentric approaches de-emphasize classification systems and guidelines and highlight relativity
and rhythm (Cokley, 2005; Washington, Johnson, Jones, & Langs, 2007). In this view, counseling
strategies are not rules that match a specific taxonomy of clients and their problems. Rather, the
relative importance of a counselors strategy depends on the rhythm and context of a session. The
purpose of this chapter is to help counselors use their strategies within a context that appreciates
Black peoples common folkways and collective struggle. In North America and abroad, persons of
Black African ancestry share common folkways that evince their African origin, cultural adaptations
to colonial autocracies (e.g., language and religion), and a collective struggle against racism and

History and Nomenclature

Persons of Black African ancestry live as citizens, foreign nationals, and indigenous populations on
every continent as a result of immigration, colonialism, and slave trading. With an estimated
population of 38.9 million, 12.6% of the total population of the United States, African Americans
constitute the second largest non-White ethnic group in the country (Ruggles et al., 2009). According
to the American Community Survey, in the United States, 80% of Black males and 83% of Black
females age 25 and older have completed high school or obtained a GED. Forty-five% of Black
males and 53% of Black females have attempted college, and 16% of Black males and 19% of Black
females have completed college (Ruggles et al., 2009).
Today, most Black people in the Americas are the progeny of victims of the transatlantic slave trade.
From 1619 to 1863, millions of Africans were involuntarily relocated from various regions of West
Africa to newly established European colonies in the Americas. Many different African ethnic
groups, including the Congo, Yoruba, Wolof, and Ibo, were victims of the transatlantic slave trade.
The Black American population is the aggregate of these groups, consolidated into one race, bound by
a common struggle against racial oppression, and distinguished by cultural dualism (Toldson, 1999).
Importantly, the historic legacy of Black people in the Western Hemisphere is not limited to slavery.
The Olmec heads found along the Mexican Gulf Coast is evidence of African colonies in the

Americas centuries before Columbus arrived in the Caribbean (Van Sertima, 2003). Black people
were also responsible for establishing the worlds first free Black republic, and only the second
independent nation in the Western Hemisphere, with the Haitian Revolution (Geggus, 2001). In the
United States, almost 500,000 African Americans were free prior to the Civil War and were
immensely instrumental in shaping U.S. policy throughout abolition and beyond. Post-Civil War,
African Americans influenced U.S. arts, agriculture, foods, textile industry, and language and invented
technological necessities such as the traffic light and elevators as well as parts necessary to build the
automobile and personal computer. All of these contributions were necessary for the United States to
become a world power by the 20th century.
Racism and oppression are forces that have shaped the experiences and development of Black people
worldwide. Although European colonialists initially enslaved Black people because of their
agricultural expertise and genetic resistance to diseases, they used racist propaganda to justify their
inhumane practices (Loewen, 1996). During periods of slavery and the Scramble for Africa,
European institutions used pseudoscience and religion (e.g., the Hamitic myth) to dehumanize Black
people. The vestiges of racism and oppression survived centuries after propaganda campaigns ended
and influence all human interactions, including counseling relationships.
Today, racism is perpetuated most profoundly through the educational system. Loewen (1996) pointed
out that students are taught to revere Columbus, who nearly committed genocide against the native
population of the Dominican Republic, and Woodrow Wilson, who openly praised the Ku Klux Klan.
Although many of these facts are not well known and purposefully disguised in history texts, children
often leave traditional elementary and secondary education with the sense that aside from a few
isolated figures (e.g., Martin Luther King and Harriet Tubman), Black people had a relatively small
role in the development of modern nations (May, Willis, & Loewen, 2003).
Contemporary literature on the health and economic status of Black people, especially in the United
States, is dismal. Evidence is often presented indicating that African Americans have the highest
incidence of any given mental or physical disorder, are more deeply impacted by social ills, and
generally have the lowest economic standing. While most of the statistics are accurately presented,
rationales are usually baseless and findings typically lack a sociohistorical context. In addition,
studies on African Americans unfairly draw social comparisons to the social groups that historically
benefited from their oppression.
Historical distortions accompanying dismal statistics have resulted in many counselors perpetually
using a deficit model when working with Black clients (Jamison, 2009). The deficit model focuses on
clients problems, without exploring sociohistorical factors or institutional procedures. Persons of
Black African ancestry have a distinguished history, are immeasurably resilient, and have developed
sophisticated coping mechanisms throughout centuries of oppression. Appreciating and celebrating a
clients legacy, contextualizing problems, and building on strengths instead of focusing on deficits are
universally appreciated counseling strategies that merit greater attention when working with Black
clients (Amatea, Smith-Adcock, & Villares, 2006).

Barriers to Cross-Cultural Counseling With Persons of Black

African Ancestry
Before a person, particularly those who are not familiar with Black culture, can successfully work
with Black people in counseling settings, he or she needs to be aware of a range of cultural and
cognitive dispositions. This section explains common barriers to effective counseling with persons of
Black African ancestry.
Cultural encapsulation is the practice of disregarding the influence of culture on therapeutic
processes, which can lead to ineffectiveness with connecting with Black clients. Several authors have
noted the effects of cultural encapsulation in psychotherapy (Estrada, Frame, & Williams, 2004;
Leuwerke, 2005). Culturally encapsulated counselors may (a) define reality with one set of cultural
assumptions and stereotypes about Black people, (b) be insensitive to cultural variation and view
only one culture as legitimate, (c) have unfounded and unreasoned assumptions about other cultures,
(d) overemphasize clinical techniques that they apply rigidly across cultures, and (e) interpret
behaviors from their own personal reference (Ponterotto, Pedersen, & Utsey, 2006).
White privilege, or conferred dominance, describes the unearned societal rewards that Whites
receive based on skin color (McIntosh, 1998). Unrecognized or poorly understood White privilege
can diminish counseling relationships with Black clients. According to McIntosh, most White people
are unaware of privileges because they are maintained across generations through denial. Neville,
Worthington, and Spanierman (2001) posited that White privilege is an insidious and complex
network of relationships among individuals, groups, and systems that operates in a racial social
hierarchy. On the surface, it would appear that Whites reap only benefits from unearned racial
privilege. However, there are a number of social and emotional consequences associated with
receiving White privilege (Helms, 1995; Neville et al., 2001; Pinderhughes, 1989; Thompson &
Neville, 1999). For example, Thompson and Neville (1999) reported that a group of White
counseling psychology graduate students who had become aware of their unearned racial advantage
experienced feelings of guilt, shame, and sadness. According to Pinderhughes (1989), people who
realize White privilege may experience uncertainty and a sense of entrapment.
In cross-cultural counseling supervision, White privilege is associated with many racial issues, such
as White supervisors being culturally unresponsive to African American supervisees and White
supervisees becoming insubordinate with African American supervisors. In counselor training, Utsey,
McCarthy, Eubanks, and Adrian (2002) observed that White privilege often manifests as White
trainees speaking for themselves, in contrast to Black trainees who are often called on to speak for
their entire race. In addition, Helms and Cook (1999) found that supervisors often attribute clinical
errors to a clients pathology rather than to a White trainees clinical skills in cross-racial counseling
White trainees who have an enhanced sense of their White privilege are more effective in negotiating
cross-racial counseling situations (Utsey, Gernat, & Hammar, 2005). Helms (1997) posited that White
counselor trainees can develop a nonracist White identity by accepting their Whiteness and
acknowledging ways in which they benefit from White privilege. Therefore, the task for counselor
trainees is to become aware of how subtle White privileges are relevant to their experiences and
impact their clinical work with African American clients (Utsey et al., 2002).

Color-blindness refers to racism that is reflected in color-blind racial attitudes typified by ignorance,
denial, and a distortion of the reality that race plays a role in peoples lived experiences (Neville et
al., 2001). Bonilla-Silva (2002) identified the following four major schematic characteristics of
color-blind racism: (a) principles of liberalism are extended to racial matters, (b) social and
economic racial disparities are explained in societal terms (e.g., dysfunctional family structure,
deficient environmental conditions, etc.), (c) racial stratification (e.g., residential and school
segregation) is viewed as a naturally occurring phenomena, and (d) racism is asserted to be a thing of
the past.
In the context of counselor training, White counselor trainees color-blind racial attitudes are often
manifest in the attitude that Black clients are no different from racial majority group clients (Utsey et
al., 2005). When using color-blind attitudes, the White counselor trainee risks overlooking the role of
racism and discrimination in relation to the clients presenting problem. Utsey et al. (2005) noted that
color-blindness is unethical, since the Ethical Principles of Psychologists and Code of Conduct
(American Psychological Association, 2010) mandates that practitioners address issues related to
racism and discrimination as potential sources of distress for racial minority clients. White counselor
trainees who adopt a color-blind posture toward their racial minority clients also tend to minimize
the influence of their Whiteness on the counselor-client relationship. In addition, color-blindness is a
major cause of the disproportionate number of Black people being diagnosed with severe pathology
(Ridley, 1995).

Psychological Development of Persons of Black African Ancestry

Essentially, three forces make up the identity of persons of Black African ancestry: (a) expressions of
African consciousness, (b) resistance to racism and oppression, and (c) adaptations to colonialism
(Toldson, 2008). These three forces are omnipresent among continental and diasporic Black Africans.
Within each force, there are countless manifestations through Black persons personality, psyche, and

Expressions of African Consciousness

African consciousness embodies archetypal and ancestral wisdom in Black peoples collective
memory. Predisposition toward vital emotionalism, spontaneity, rhythm, naturalistic attitudes,
physical movement, style, and creativity with the spoken word are cultural expressions that form the
core of African consciousness. These characteristics interact to produce human behavior that
registers images, sounds, aromas, and euphoria to the senses (Toldson & Toldson, 2001).
Expressions of African consciousness heavily influence Black peoples subjective worldview. As a
construct, African consciousness helps persons of African descent to attain optimal self-concept, selfesteem, and self-image (Constantine, Myers, Kindaichi, & Moore, 2004). African consciousness is
the archetypal background from which diasporic Africans must formulate answers to questions of

Who am I? How do I see myself? Who defined my image, and was my image defined in a way to
help me challenge, confront, and overcome adversity? Who do I come from? What can I do?
What do I believe about my lineage and myself? Where am I going in life? And what does it
mean when I become ill (sick, fail, transgress, addicted)? (Toldson & Toldson, 2001, p. 405)
Black communities use elements of African consciousness as an essential influence to serve as a
balance or counterpart to the mind and body (Cervantes & Parham, 2005). This balance secures
harmony, proportion, and symmetry with nature, self, and others. Spirituality is the basic underlining
or constituting entity of the African conscious, embodying essential properties, attributes, and
elements indispensable to their subjective worldview. The spirit is an immaterial sentient part of
Black persons, providing inward structure, dynamic drive, and creative response to life encounters or
demands. Recognition of the African consciousness, and the distinct way it manifest under various
circumstances, is essential to African-centered therapeutic interventions. This holistic perspective
makes healing a collective undertaking. Accordingly, the construction of reality is inseparably
spiritual and material is essential to the African consciousness (Hatter & Ottens, 1998; Mphande &
James-Myers, 1993; Tyehimba, 1998).
Contrarily, Western psychology emphasizes a material view of reality that focuses on awareness
through the five senses. The Eurocentric perspective sees the world as an infinite number of
discreetly different manifestations presenting as observable, material phenomena. Simply stated,
while the Eurocentric paradigm might suggest, Seeing is believing, the Afrocentric paradigm would
suggest, There is more than meets the eye.
Consistent with Afrocentric perspectives, many contemporary physicists and psychologists believe
that a material conception of reality is outmoded (Cunliffe, 2006; Davis, 2005; Nelson, 2006). Spirit,
in the African cosmos, rhythmically shapes things, ideals, animals, and human beings together in a
representative whole of its essence (Cervantes & Parham, 2005; Constantine et al., 2004; Herrick,
2006; Toldson & Pasteur, 1972). When this rhythm is disturbed, the spirit is unsettled and manifests in
the individual as anxiety, depression, or other mental or physical disorders (Blackett & Payne, 2005).
Restoring this rhythm to achieve an integrative harmony within the self is the goal of African-centered
approaches to therapy. These approaches form the backdrop to culturally appropriate therapeutic
services delivered in the African American community (Vontress, 1991, 1999).
The absence of a balanced focus in modern-day medicine places the typical African American
client in an etiological dilemma with respect to acquired illnesses. Finch (1990) insists that among
traditional African people, Without the psycho-spiritual curewithout reestablishing this sensitive
harmonythe medicinal cure is considered useless (p. 129). Finch goes on to say that African
medicine has baffled scholars because it completely integrates the magico-spiritual and rational
elements. The spiritual aspect of healing has been discredited among the modern-day scientificminded scholars (Finch, 1990). However, Finch explains, modern medicine acknowledges that 60%
of illnesses treated by physicians have a psychological basis, and interventions quite often involve
pharmacologically inactive drugsplacebos.
In the Afrikan and Zulu worldview, ones values and purpose is placed on their being in the
community/world rather than obtaining possessions. The quality of ones inner essence is

determined by evaluating his or her behaviors and spiritualityultimately defining his or her worth to
the community. Afrikan worldview psychologists (Ubuntu psychologist),
overall function would be to (1) recognize Spirit in all aspects of life, (2) appreciate peoples
spiritual journey, (3) facilitate movement towards becoming one with the Creator, (4) help
increase peoples strength from their experiences, (5) keep people aligned with their purpose,
and (6) acknowledge that people have purpose. (Washington, 2010, p. 37)
Zulu thought also suggests that certain disorders can specifically occur in Afrikans and they must be
understood within context in order for balance and harmony of the self and community to exist
(Washington, 2010).

Resistance to Racism and Oppression

Kessler, Mickelson, and Williams (1999) conducted a telephone survey that explored the impact of
racism on mental health. The study revealed that the lifetime prevalence of major discrimination
was 50% for African Americans, in contrast to 31% for Whites. In addition, major discrimination
was associated with psychological distress. The authors concluded that racism and oppression
adversely affect mental health and place African Americans at risk for mental disorders such as
depression and anxiety.
The influences of racism and oppression on the psychological development of Black people are
twofold. First, racism and oppression contribute to behavioral responses that signal concern about
survival, which can either increase psychological distresses or promote unconventional survival
mechanisms (Clark, Anderson, & Clark, 1999). In this view, Black people are not collectively
injured by racism and oppression. Using ego defense mechanisms to illustrate, when responding to
racism and oppression, some Black people might take a middle-of-the-road stance such as denial,
intellectualization, or humor. A more harmful mechanism might be displacement, where a Black
person will unconsciously redirect resentment for the oppressor to less threatening targets such as the
family and community. Contrarily, sublimation is a healthy and productive reaction to racism, which
involves refocusing negative feelings into healthy outlets of expression, allowing for creative
solutions to problems.
In addition to extrapolations of psychoanalytic theory, several African theories have emerged to
explain the impact of racism and oppression on Black peoples psychological functioning. Cultural
trauma, for example, describes slavery, lynching, and legal discrimination beyond their past
institutional manifestations and asserts that these experiences are embedded in the collective memory
of present-day Black people (Alexander, 2004; Eyerman, 2001). The legacy of cultural trauma is
manifested in the destructive activities that occur in African American communities, including
violence and substance abuse, which are also associated with symptoms of posttraumatic responses
(Whaley, 2006). Post-traumatic slave syndrome asserts that positive and negative adaptive
behaviors survived throughout generations of Black people from the transatlantic slave trade and
other atrocities. Leary (2005) suggests reevaluating those adaptive behaviors and replacing

maladaptive ones to promote healing in Black culture.

Other models of racism and oppression focused on more contemporary manifestations of racism.
Invisibility syndrome for example is a more subtle form of racism and White privilege that engenders
race-related stress (Franklin & Boyd-Franklin, 2000; Franklin, Boyd-Franklin, & Kelly, 2006).
Finally, the presence of historical hostility resulting from slavery and discrimination is reported to
contribute to a unique psychology among African Americans that may result in tension and mistrust
of non-Black counselors (Vontress & Epp, 1997).
The second consequence of racism and oppression is more directly related to postcolonial
institutions, including organizations that provide counseling services (Fairchild, 1991; Fairchild, Yee,
Wyatt, & Weizmann, 1995). Mental health in American has roots in racism and oppression. During
slavery, mental health professionals diagnosed runaways with drapetomania, meaning flight from
home mania (Fernando, 2003). Black people who were content with subservience were considered
mentally healthy.
Today, the attitude that persons of Black African ancestry should have psychomotor restrictions
continues to pervade mental health systems. African American patients are more frequently
involuntarily committed to psychiatric hospitals and administered psychotropic drugs (Schwartz & K.
Feisthamel, 2009). In addition, persons of Black African ancestry continue to receive labels of
borderline intellectual functioning and mental retardation on the basis of psychometric scales that
were constructed based on a Eurocentric paradigm and normed primarily on persons of European
descent (Hilliard, 1976, 1980).
Many conscious counselors are aware that current mental health systems are failing Black clients. In a
counseling psychology doctoral class at an urban university, a professor asked his students in a Black
psychology class to raise your hand if youve ever oppressed your client. More than half of the
students dejectedly raise their hands. With remarkable insight, the students realized that by simply
following the rules of their employers, they were participating in less than optimal practices that
contributed to their clients oppression. Ways in which counselors and other mental health
professionals routinely oppress their clients include (1) using biased psychological tests to inform
counseling decisions, (2) writing or endorsing reports that emphasize deficits, (3) endorsing the use
of psychotropic medication to suppress culturally or developmentally appropriate behaviors, (4)
using the majority culture as the basis for behavioral norms, and (5) adhering to diagnostic
classification systems without regard to cultural considerations (Toldson, 2008).

Adaptations to Colonialism
Persons of Black African ancestry have had to adapt to the language, customs, religious practices,
educational pedagogy, economic philosophies, and geopolitical systems of European colonial tyrants
(Loomba, 2005; Lyons & Pye, 2006; Turner-Musa, 2007; Valls, 2005). For centuries, European
colonial empires extended its sovereignty over territory beyond its homeland, using Black African
slave labor to cultivate the Americas and native Black Africans to build dependencies, trading posts,
and plantation colonies. The colonizers imposed their sociocultural mores, religion, and language on
Black people and adopted a corrupt set of values, including racism, ethnocentrism, and imperialism,

which aim to justify the means by which colonial settlements were established.
In the relatively recent history of Black people achieving equal rights under the law in the Americas
(i.e., 1964) and sovereign nationhood in Africa (i.e., 1950s1970s), Black people have adapted,
mastered, and innovated traditional European systems. Black people have added words and dialects
to European languages, established educational institutions based on Eurocentric pedagogy, and
maintained financial institutions based on lassie faire capitalism. A Eurocentric mind-set will lead
many to assert that Black people are obliged to adapt and that adaptation should be effortless. In
reality, adaptation is a cultural imposition to Black people worldwide. Imagine White Americans
having to adapt to a system in which oratory mastery was required for college admission, bartering
was the primary method of exchange, and laws were determined by a council of elders.
In the postcolonial era, there have been many critiques of the impact of colonialism and whether
colonialism exists today. Colonialism permanently changed the social-cultural, geographic, political,
and economic landscape of the world. Persons of Black African ancestry in Africa and the Americas
continue to live as second-class citizens, whereas generations-old businesses and banks that financed
acts of genocide and other atrocities reap residual benefits from the legacy of colonialism.
Colonialism has implications for counseling practice and research on Black people. First, the
psychological impact of colonialism and survival of indigenous values among colonialized people
influences counseling relationships. Second, cultural imperialism is a natural by-product of
colonialism, leading many counselors to make assumptions about a clients traditions and values that
are shaped by the majority culture. In addition to cultural imperialism, ethnocentrism, racism, White
supremacy, and pseudo-scientific theories used to justify colonialism have lingered well past
decolonialism and influence counseling research and practice.
Understanding the impact of colonialism requires investigating the environmental, historical,
political, and social contexts to determine how Black psychology has developed over time (Jamison,
2009). Afrocentric and Eurocentric approaches, even with their contrasting views, provide insight
into understanding African Americans (Belgrave & Allison, 2006).
Collectively, the three forces of Black peoples psychological development embody the infinite
diversity and the omnipotent potential of persons of Black African ancestry. These are the archetypal
forces providing definition to their inner structures, mechanisms of endurance, dynamic drive, and
ability to adapt to foreign environments. They represent the whole of Black people, illustrating past
preeminence, and ensuring present perseverance and future consummation.

Mental Health
Conceptualizing Mental Health Problems
Successful treatment of a psychiatric disorder ushers in an accurate conceptualization and assessment
of the problem. Difficulties conceptualizing Black peoples mental health problems typically arise
from the tendency of mental health professionals to assume individual autonomy, which suggests that

individuals problems originate and are perpetuated within each individual (Atkinson, Morten, & Sue,
1997). This assumption undermines the complexity of Black peoples mental health problems.
A competent assessment of Black problematic behavior should not be limited to a description of
mental and emotional deficits or to observations of externalized abnormal behaviors. Instead, an
accurate assessment should extend to describe inherent responses to social and environmental
conditions, in which the abnormal behavior might be a normal reaction. In other words, Black
behavioral pathology is sometimes best explained as a consequence of dynamic ecological systems
rather than the result of intrapsychological deficits.
On a basic level, when considering the mental health status of Black people, one must be mindful of
the universality of diagnoses, aware of biases in mental health procedures, and sensitive to diversity.
Universality is the idea that disorders found in some cultures may manifest differently or be obsolete
in other cultures (Lee, 2002). However, to achieve true authenticity in conceptualizing the mental
health status of Black people, professionals must relate to their subject with the holism that is
consistent with African-centered perspectives and its Western adaptations, such as existentialism (De
Maynard, 2006; Epp, 1998) and positive psychology (Strmpfer, 2005, 2006).
Nontraditional approaches might require clinicians to grasp a clients mental health using insight and
intuition, intellectual creativity, and abstract reasoning. This might sound irrational to a staunch
adherent to the scientific method. However, in practice, using strict logic to understand mental health
often reduces the client to a blunder of fragmented inferences, rent asunder from the whole in which
he or she belongs. The mental health status of Black people should be viewed within the context of
their history and nomenclature and of the complex of forces that influence their cultural identity.

Specific Mental Health Challenges

Prevalence of Mental Health Disorders.
The Epidemiological Catchment Area studies (ECA) and the National Comorbidity Survey (NCS)
have been used to assess the prevalence rate of mental health disorders across cultures (Galea &
Cohen, 2011). The ECA indicated that Black people have an overall higher prevalence of mental
health disorders; however, when controlling for socioeconomic factors, most differences are
statistically eliminated. Both the ECA and NCS found that African Americans were less likely to
suffer from depression. The ECA indicated that African Americans are more likely to suffer from
phobia than were Whites.
Using several studies, the Department of Health and Human Services concluded that African
Americans are overdiagnosed with schizophrenia and underdiagnosed for depression and anxiety
(Snowden, 2012). Schwartz and Feisthamel (2009) found 27% of African American clients were
diagnosed with psychotic disorders, compared with 17% of all European American when presenting
for treatment. Schizophrenia and affective disorders specifically are uniquely associated with forces
that shape Black peoples psychological development and must be carefully examined within a
cultural context.

Fernando (2003) revealed that reports suggesting high rates of schizophrenia among African
Americans began to appear in the 19th century. By the mid-1900s, the overdiagnosis of schizophrenia
was firmly established, while the diagnosis of bipolar disorders began to decline. Interestingly,
British studies during the same time period revealed similar diagnostic trends, although reports of
schizophrenic behavior in Africa were rare (Fernando, 2003). Recent findings suggest that the
overrepresentation of Black people with schizophrenia is primarily due to diagnostic biases rather
than to true differences in the population. Today, the excessive and inaccurate diagnosis of
schizophrenia may be attributed to Black peoples nonmaterial conception of reality, spirituality or
religiosity, and/or healthy paranoia, originally defined as a generalized reaction to racism, which is
perceived as necessary for normal adaptive functioning in oppressive environments (Metzl, 2009;
Whaley & Hall, 2009).
Racial biases that permeate mental health systems may also contribute to the underdiagnosis of
depression. Fernando (2003) noted that in the past, the lower incidence of depression among African
Americans has been attributed to frontal lobe idleness, which caused Black people to lack higherorder emotional functions (Carothers, 1953) and resulted in a tendency for Black people to respond to
adversity with cheery denial (Bebbington, Hurry, & Tennant, 1981). These blatantly racist
explanations are comparable to recent findings that clinicians tend to minimize emotional expressions
by African Americans (Das, Olfson, McCurtis, & Weissman, 2006), which leads to fewer Black
people being diagnosed with depression. Das et al. (2006) suggested that clinicians circumvent
cultural influences by examining somatic and neurovegetative symptoms rather than mood or
cognitive symptoms (p. 30). This approach undermines Black peoples psychological functioning
and implies that clinicians should ignore symptoms that they do not understand rather than broaden
their cultural lenses.

Research on suicide within the African American community has continued to increase. African
Americans generally have lower suicide rates when compared to Caucasians, despite significant
economic and social disparities within the Black community (Davidson & Wingate, 2011; U.S.
Department of Health and Human Services, 2001). Recent research found that African Americans
significantly indicated higher levels of protective factors against suicidal behavior than did
Caucasian counterparts (Davidson & Wingate, 2011).
However, after a review of literature, Spates (2011) concluded that in African American women who
suffered a history of particular mental disorders, depression, physical and emotional abuse, and
alcohol and substance abuse have all demonstrated to considerably increase the risk of suicidal
behaviors. Walker, Alabi, Roberts, and Obasi (2010) found that college students who were more
African centered along with experiencing depressive symptoms disclosed having fewer reasons to
live. Additional findings, contradicting previous literature, indicated that hopelessness was not
associated with suicidal behaviors among African American young adults (Walker et al., 2010).

Exposure to Violence and Posttraumatic Stress.

African Americans are more likely to be a victim of a violent crime than any other ethnic or racial

group. McDevitt-Murphy, Neimeyer, Burke, Williams, and Lawson (2012) found that a
disproportionate number of murder victims in the United States are African American, which
compounds other public health concerns such as grief, loss, and trauma. African Americans
significantly experience clinical outcomes such as posttraumatic stress disorder (PTSD), complicated
grief, depression, and anxiety (McDevitt-Murphy et al., 2012). Extended social supports, properly
strict parents, and a hearty self-assurance contribute to resiliency among Black youth (Thompson,
Briggs-King, & LaTouche-Howard, 2012).

Vulnerable Segments of the Population.

Persons of Black African ancestry are susceptible to a variety of mental health problems because they
are overrepresented in the most vulnerable segments of the population. Although only 13.8% of the
U.S. population, African Americans make up between 38% and 44% of the homeless population
(Cortes, Henry, de la Cruz, & Brown, 2012) and nearly half of state and federal inmates (Carson &
Sabol, 2011). In addition, African Americans are at a greater risk for mental health care disparities
because they are less likely to have health insurance and less likely to obtain proper mental health
treatment (Simning, Wijngaarden, & Conwell, 2011).
Simning et al. (2011) found that African Americans residing in public housing had a higher lifetime
prevalence of mental illness than African Americans not residing in public housing. Results also
indicated that African Americans residing in public housing had higher levels of anxiety and
substance use disorders than African American non-public housing residents (Simning et al., 2011).
Additionally, a recent study found that among African American sexual assault survivors, there is
increased poverty linked to discriminating negative mental health outcomes such as depression,
PTSD, and illicit drug use (Bryant-Davis, Ullman, Tsong, Tillman, & Smith, 2010).
Furthermore, there is increasing evidence that persons who experience discrimination have an
elevated risk for psychological distress and mental issues; researchers have found higher percentages
among African Americans who have experienced discrimination than among other minorities
(McLaughlin, Hatzenbuehler, & Keyes, 2010). Moreover psychiatric disorders constitute another
important factor that exposes African Americans to adverse social situations (Jin et al., 2008).
Schwartz and Feisthamel (2009) indicated that African American participants had a significantly
greater chance of being diagnosed with childhood disorders than did European American
participants. Results of this study also demonstrated that counselors disproportionately diagnose
African Americans with psychotic and childhood disorders (Schwartz & Feisthamel, 2009).

Educational Issues.
Education is the key to correcting longstanding social and economic racial disparities in the United
States. One in three African Americans without a high school diploma lives below poverty, and less
than 10% achieve a middle-class income (Jackson, 2010). If black male ninth graders follow current
trends, about half of them will not graduate with their current ninth-grade class (Jackson, 2010), and
about 20% will reach the age of 25 without obtaining a high school diploma or GED (Ruggles et al.,

The High School Longitudinal Survey asked parents a variety of questions that related to their ninthgrade childs potential to complete high school (LoGerfo, Christopher, & Flanagan, 2011). When
comparing each variable across race and gender, Black students are at the greatest risk for not
completing high school. Specifically, Black males are more than twice as likely to repeat a grade and
be suspended or expelled from school as White males. Black males were also more likely to receive
special education services and have an individualized education plan (IEP) and the least likely to be
enrolled in honors classes. Parents of Black students were the most likely to have the school contact
them because of problems with their sons behavior or performance (Toldson & Lewis, 2012).

Healing Practices and Experiences With Mental Health Treatment

Community-Based Treatment.
Comprehensive mental health treatment programs endorse rendering services in the clients homes,
schools, and communities (Bennett, 2006; Teicher, 2006; Toldson & Toldson, 2001). Communitybased approaches could address Black peoples reluctance to seek professional mental health care in
traditional settings, reduce the ethnocentric biases among care providers, and help care providers to
have a better context for clients problems. From an African-centered perspective, community-based
interventions could represent a progressive step toward communalizing the process of mental health

Group Therapy.
Group therapy and community-based interventions are more consistent with the African values of
collectivism and communalism (Toldson & Toldson, 1999; Vaz, 2005). The group combats the sense
of isolation that is a product of individualism, while it promotes a sense of oneness, consistent with
the African ethos of oneness of being. The idea of universality (Yalom & Leszcz, 2005) comes close
to the African idea of oneness of being, and creating this sense within the group requires culturally
appropriate interventions and procedures.

Collectivism in Counseling.
Black peoples collectivist orientation is evident in their healing preferences. Specifically, persons of
Black African ancestry are more likely to rely on family and friends to cope with personal difficulty
(Logan, 1996; Ruiz, 1990). The brotherhood/sisterhood concept among African Americans elevates
family extensions to the status of core family members, and solutions to personal difficulties often
involve meaningful exchange throughout the extended family. Thus, Black people in therapy may feel
compelled to elevate the status of the clinician to an extended family member before actively
engaging in the therapeutic process.

Naturalistic Healing.
This is another value evident in mental health healing practices among Black people. In a review of
the literature, U.S. Department of Health and Human Services (2001) found that African Americans

prefer counseling to drug therapy and are more likely to have concerns about the side effects,
effectiveness, and addiction potential of medications (Cooper-Patrick et al., 1997; Dwight-Johnson,
Sherbourne, Liao, & Wells, 2000). Research has also revealed that African Americans tend to take an
active approach to facing personal problems and are less likely than Whites to use any professional
services to deal with mental health issues (Bean, Perry, & Bedell, 2002). In this view, Black people
might prefer a process of healing that feels more natural, emphasizing normal adjustments to life
transitions and less intrusive or technical approaches, such as medication or a formal brand of

Summary and Conclusions

Psychological health care must begin to affirm a biomedical ethic that is sensitive to perspectives of
Africans and diasporic descendants. The process can be enhanced by making accommodations for the
expression of belief patterns, thoughts, and sociocultural customs indicative of the presence of an
African identity in the behavior of African people. These must be woven into theoretical points of
departure in the provision of quality psychological health care.
The impact of the interrelationships among environmental conditions and sociopolitical dynamics on
the definitions of normal mentally healthy behavior of oppressed Africans must be accounted for in
diagnostic decision making relative to clients of African descent.
It is essential to increase the presence of psychological health care providers, who embrace the
understanding that it is therapeutically relevant, if not necessary, to develop an African identity in the
psyches of African people. These providers should understand the sociopolitical influences of the
dominant perspective of psychology in order to help affirm a bioethical perspective that is sensitive
to the African ethos.
Recognizing group identity and collective responsibility as real and deducible phenomena within the
culture of African American people is consistent with the embrace of an African ethos. This can be
made operational by soliciting consent for biomedical involvement of the individual from relevant
groups, including the family, church, social/civic organizations, associations, friends, fraternal and
sorority societies, and/or sociopolitical organizations (the tribe) with which the individual affiliates
in the manifestation of his or her identity as a group member. Such a procedure is advisable, not only
out of respect for these African values but also in recognition of the low power quotient afforded the
ordinary citizen of African descent.
Additionally, it is important to recognize that most African Americans have to be, at least to some
extent, bicultural and that this status creates a unique set of mental health issues related to self-esteem,
identity formation, and role behavior to which systems of psychological health care must
appropriately respond. Differentiating between the symptoms of intrapsychic stress and stress arising
from sociopolitical powerlessness and limited economic resources is an essential clinical skill of the
psychologist who claims sensitivity to a biomedical perspective that is consistent with the African
Learning the culturally different indicators for depression, anxiety, attachment and loss, identity

confusion, and other less inflammatory diagnostic indicators to more accurately replace those that are
excessively used such as schizophrenic, borderline personality, oppositional defiant, conduct, and
attention deficit disorders in African American clients is a diagnostic imperative. Moreover,
subscribing to diagnostic nomenclature introduced by African American psychologists, which also
defines accommodationist behavior of the acculturated African American as maladaptive, must be
considered in diagnostic formulations about the mental health of African Americans.
Accepting spirit and unseen forces as meaningful phenomena in the life realm and decision-making
processes of the majority of African people is significantly important. Spirit is an entity that has to be
reconciled and/or accommodated in formulas for clinical insight and understanding.
In behavioral, as in biomedical research, there is a tendency to recruit participants disproportionately
from particular groups within the social system (Toldson & Toldson, 2001). Groups that are
dependent or powerless by virtue of their age, their physical and mental condition, their minority
status, their social deviance, or their condition of captivity within various institutions are heavily
recruited as research participants.
Given the African American power deficiency within the social system, the truly voluntary nature of
consent becomes problematic for Black research participants. The exploitation of Black research
participants, usually to demean the Black community, is a situation that must be brokered at the
sociopolitical level. Power bases in the Black community to sign off on matters of consent would
rightfully bring the control of such research within the bounds of the African American community in
concurrence with its collective nature.
The medical-based professions emanate from Africa, brought to excellence in antiquity by the
Egyptians (Finch, 1990). Racism within the biomedical sphere of intelligence must be confronted and
purged. Purgation should be followed by an impregnation with the spirit of Africa. The degree of
confrontation, purgation, and impregnation will be measured by the degree of African consciousness
that is cultivated within the African American community.
African and diasporic scholars, and others of goodwill, who are possessed with the ethos of doing
what is good, right, fair, and just in the interest of the physical and mental health of African people
everywhere must cultivate clinical procedures that promote comfort with the existence and
therapeutic desirability of an African consciousness in the psyches of African descendants.
Cultivating its expression is consistent with good and right action in the delivery of quality mental
health care to citizens of African descent.

1. In this chapter, the terms persons of Black African ancestry or Black people are used to describe
persons worldwide whose ancestors were indigenous to sub-Saharan Africa. The term African
Americans is used to describe Black people in America, usually the United States of America.


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York: Basic Books.

8 Counseling the Latino/a From Guiding Theory to Practice

J. Manuel Casas
A. Pati Cabrera
Melba J. T. Vasquez

Primary Objective
To assist counselors and practitioners in becoming more competent in their efforts to work
with persons who are ethnically, racially, and/or culturally different from themselves,
particularly those identified as Latino/a

Secondary Objectives
To provide a brief demographic overview of the diverse Latino/a population in the United
To provide the outlines of a theoretical approach that would unify theories of person,
environment, and the counseling situation
To present a framework that practitioners can use to direct and drive their work with Latino/a
clients, including identifying likely sources of both friction and possibility
The subtitle of this chapter Adelante!translates loosely as Moving forward! The decision to
include this subtitle was not made arbitrarily. After much thought, we decided that this term best
conveys the major spirit that underlies our purpose in this chapter, which is to portray Latino/as, the
largest ethnic minority group in the United States, as a significant and resilient portion of the
American population; Latino/as continue to move forward in their efforts to overcome challenging
social and economic living conditions. With this spirit as a driving force, this chapter is intended to
help mental health practitioners, educators, and researchers become more culturally competent in
their efforts to understand accurately and, in turn, work more effectively with members of this
population. Underscoring a major challenge associated with such efforts, we first provide a
demographic overview of Latino/as in the United States. We pay selective attention to educational
and economic issues because of the important socially determining roles that these play in the mental
health and well-being of Latino/a individuals and communities.
Throughout the chapter we make every effort to steer clear of suggesting cookbook or cookie-cutter
approaches. Instead, we provide a theoretical perspective, guidelines, and a framework that can help
counselors to conceptualize presenting challenges and problems and, in turn, facilitate the
identification and use of the most culturally appropriate and clinically effective strategies and
interventions with Latino/a clients.

Finally, we note that Latino/as have many different ways of describing their identitiesincluding
pan-ethnic terms like Hispanic and Latino, the term American, and terms that refer to their families
countries of origin. Given this fact, and in line with the prevailing literature, we have opted to use the
gender-responsive term Latino/a to refer to individuals of diverse Hispanic-based national origins,
including Mexico, the countries of Central America (e.g., Guatemala, Honduras, Costa Rica, El
Salvador, Nicaragua, and Panama), the Spanish-speaking countries of South America (e.g., Colombia,
Venezuela, Peru, Chile, Ecuador, Uruguay, Paraguay, and Argentina), the Spanish-speaking countries
of the Caribbean (e.g., Cuba, the Dominican Republic), and the U.S. territorial island of Puerto Rico.
Having made this caveat, we alert the reader to the fact that in referring to works by varied authors on
Latino/as in this chapter, we have made an effort to retain the original terminology used by these

General Attributes and Trends

According to the U.S. Census Bureau, as of May 2011 Latino/as numbered 50.5 million, or almost
16% of the total population. Latino/as make up the fastest-growing racial/ethnic group in the United
States (Ennis, Ros-Vargas, & Albert, 2011). Given this rate of growth, it is likely that by the year
2050, Latino/as will number 102.6 million (U.S. Census Bureau, 2004, 2006).
While the Latino/a population continues to grow, it bears noting that since 2009, the rate of growth of
this population has decreased significantly. According to the Pew Hispanic Center (2012a), this
decrease has been primarily the result of plunging immigration from Mexico, the birthplace of more
U.S. immigrants than any other country. At this time, more Mexicans may be leaving the United States
than arriving for the first time since the Great Depression, due to weakness in the U.S. job market, a
rise in deportations, and a decline in Mexicos birthrate (Pew Hispanic Center, 2012a).
In spite of the decrease, two phenomena are largely expected to account for the continued growth of
the Latino/a population: the relative youth of the U.S. Latino/a population in general and the
prevalence of high birthrates among several Latino/a subgroups (e.g., Mexican Americans and Puerto
Ricans) (Martin et al., 2006; U.S. Census Bureau, 2004, 2006). The Latino/a population is
significantly younger than its non-Latino/a White counterpart (U.S. Census Bureau, 2006). The U.S.
Census Bureau (2012) indicates that the overall fertility rate among this young population is
approximately 40% greater than the rate among non-Hispanic Whites. It should be noted that this rate
of growth is already having an impact in the political arena. In the 2012 presidential election,
Latino/as gave the significant majority of their votes (71%) to help reelect President Barack Obama,
and political analysts spoke with surprise at how Latino/as will shape the political landscape across
the country for the next few years (Mixner, 2012).

Sociocultural Common Ground

In a recent survey that focused on Hispanics and their views of identity, the Pew Hispanic Center
(2012c) found that when asked whether Latino/as in the United States share a common culture, just
29% of Latino/as agreed; 69% said that Latino/as in the United States have many different cultures.
Depending on the definitional parameters (e.g., historical versus regional ethnic) placed on the term

culture, there is evidence to support both perspectives. With respect to this chapter, we are working
from the widely accepted perspective that the majority of Latino/as share a common sociohistorical
cultural experience and Spanish as a heritage language. In addition, they also share pervasive
psychosocial characteristics that reflect their Hispanic origins. Such characteristics include but are
not limited to the following: familismo, a close-knit sense of family within a hierarchical structure
(Coohey, 2001); personalismo, a very intense sense of privacy and protectiveness (Rossell, Bernal,
& Rivera-Medina, 2008); a profound religious faith (Farley, Galves, Dickinson, & Perez, 2005); and
machismo, mens sense of leadership, loyalty, and the responsibility to provide for and protect their
families (in comparison to the negative attributes commonly associated with this cultural factor)
(Crockett, Brown, Iturbide, Russell, & Wilkinson-Lee, 2009). Although much more could be said
about these and other characteristics, we mention them only briefly here for illustrative purposes.
(For more details regarding these characteristics, see Villarruel et al., 2009.)
Most of the information on Latino/as in the United States focuses on the three largest ethnic/national
groups within the U.S. Latino/a population: Mexican Americans, Puerto Ricans, and Cuban
Americans. Latino/as of Mexican origin are clearly the largest national subgroup, accounting for 64%
of the total Latino/a population (Pew Hispanic Center, 2012a, 2012b; U.S. Census Bureau, 2006).
Representation among the other national and/or geographically designated subgroups is as follows:
Central and South Americans, 13.1%; Puerto Ricans, 9.0%; Cubans, 3.4%; and other Latinos/as,
who listed census identification labels such as Spanish, Spanish American, and Latino, 7.7% (this
group includes many Latino/as of Mexican origin who live in the Southwest, especially New Mexico;
U.S. Census Bureau, 2006).
Diversity among Latino/a groups and individuals can vary across numerous mutually nonexclusive
and frequently interacting variables that can affect the mental and physical well-being of members of
the subgroups. These include but are not limited to the following: (1) demographic variables (e.g.,
racial makeup, age, family size and composition, geographic distribution); (2) sociohistorical
variables (e.g., length of time in the United States, impetus for immigration to the United States,
experiences with racism); (3) sociopolitical variables (e.g., immigrant/citizen status, level of
political participation); (4) socioeconomic variables (e.g., educational attainment, labor force
participation, individual and family income); (5) social-psychological variables (e.g., acculturation
level, actual and perceived power and self-entitlement, intragroup similarity and cohesion); and (6)
physical and mental health status variables (e.g., prevalence of illnesses and problems, access to
health insurance and treatment facilities). It is noteworthy that, although differences along these
variables are evident across the Latino/a population as a whole, the data clearly show that it is
frequently possible to differentiate particular ethnic or national groups along many of these variables
(e.g., fertility rate, age, educational attainment, income, geographic distribution) (Ennis et al., 2011).
A subgroup within the Latino/a population that, given its size and the prevailing social political times,
merits specific attention is the immigrant population. Approximately 55% of the entire immigrant
population in the United States (39.9 million) is from Latin America. More specifically, one-third of
the foreign-born population in the United States is from Mexico (U.S. Census Bureau, 2011a), and
most documented and undocumented immigrants are from Mexico (Passel & Cohn, 2012). Until
recently, the prevalent trend had been that inflow of undocumented immigrants exceeded arrivals of
legal permanent residents. This is no longer the case (Pew Hispanic Center, 2012a). While the

geographic distribution of Latino/a immigrants has traditionally been concentrated in states such as
California, New York, Florida, Texas, and Illinois (Congressional Budget Office, 2011), this too is no
longer true; immigrants are currently settling throughout the rest of the country (Passel & Cohn, 2012).
Contrary to negative depictions of Latino/a immigrants in the media (Massey, 2010) and, in particular,
in political discourse (Carter, Lawrence, & Morse, 2011), Latino/a immigrants continue to
demonstrate pervasive culturally based resilience factors that assist them in overcoming risks and
adversity (American Psychological Association [APA], 2007; Chiswick, 2011). (For more detailed
information on Latino/a immigrants, see APA, 2012b.)

Educational and Economic Well-Being

Given the significant socially determining role that educational and economic factors play relative to
the social and psychological development and well-being of both individuals and their communities
(Center on the Developing Child, 2010), we focus attention here on selective facts that are integral
parts of these two factors. However, before doing so, we would like to reiterate that while the
information provided is applicable to the vast majority of Latino/as, given the diversity that exists
within this population, it may not be so for certain Latino/a subgroups. (For greater detail on the
applicability of the information to specific subgroups, see Ennis et al., 2011.)

Educational Well-Being
The number of Latino/as graduating from high schools across the United States increased by 20%
from 1972 to 2009 (Chapman, Laird, Ifill, & KewalRamani, 2011). Concomitantly, while their school
dropout rate has also decreased nationally, Latino/as continue to drop out of high school at rates that
are higher than those of any other major group in the United States (Chapman et al., 2011; Pew
Hispanic Center, 2010; U.S. Census Bureau, 2008). Taking gender into account, researchers for the
U.S. Department of Education found that Latinas have higher high school dropout rates than do girls in
any other racial or ethnic groups (Chapman et al., 2011). From available evidence, the high dropout
rate is primarily attributed to immigrants, who drop out at the alarming rate of 46.2% (APA, 2012a).
Consequently, Latino/as in general remain the second least formally educated and least economically
successful Americans (when compared to non-Hispanic African Americans) (DeNavas-Walt, Proctor,
& Smith, 2011).
While low rates of high school completion account significantly for the underrepresentation and poor
performance of Latino/as in higher education (Aud et al., 2010), there is evidence that the
representation of Latino/as in higher education is improving, which may suggest that those graduating
from high school are continuing to further their education. According to the Pew Hispanic Center
(2011), college enrollment among young Hispanics increased by 24% in the period 20092010. To
put this increased enrollment rate into perspective, note that it reflects the fact that a significant
portion of such enrollment occurs at community or two-year colleges.
Another statistic that bears noting is the Latino/a college dropout rate, which continues to exceed 50%
(U.S. Census Bureau, 2008). Recent data suggest that only 57% of Latino/a college students
nationwide complete a bachelors degree, compared to 81% of White American college students

(Pew Hispanic Center, 2004). Given these college dropout rates, it is not surprising that only 7.9% of
Latino/as hold bachelors or higher degrees, whereas 71.8% of non-Latino/a Whites hold such
degrees (Aud et al., 2010). Unfortunately, at the graduate level, in the period 20072008, Latino/as
received only 5.9% and 3.6% of masters and doctoral degrees, respectively. The same figures for
non-Latino/a Whites were 65.5% and 57.1%, respectively (Aud et al., 2010). Thus, with the
exception of Native Americans and Alaska Natives, Latino/as have the lowest rates of representation
at the graduate level (Aud et al., 2010). (For more information regarding the variables associated
with the educational disparities between Latino/as and other racial/ethnic groups, see APA, 2012a.)

Economic Well-Being
Latino/as represent a large and growing segment of the labor force in the United States. At nearly 23
million, they represented 15% of the labor force in 2010. By 2018, they are expected to constitute
18% of the labor force (U.S. Department of Labor, 2012). However, they concomitantly continue to
face elevated unemployment levels compared to other workers. In March 2011, the unemployment
rate for Hispanics was 11.3%, which was greater than that of the total U.S. population (8.8%).
Given the educational statistics presented above, it is not surprising that Latino/a employees are
disproportionately employed in service and support occupations. The fact of the matter is that most
Latino/as are employed in construction (24.4%), health and social services (10.9%), and educational
services (9.5%), with only 7.1% employed in professional, scientific, and technical services (U.S.
Department of Labor, 2012).
With respect to economic well-being, in 2009, the Latino/a median household income was $38,039.
In comparison, the median household income for White families was $54,461. According to the U.S.
Census Bureau (2011b), 12 million Latino/as were counted as poor in 2009. Unfortunately, to the
detriment of the future economic advancement of the United States, children make up a significant
segment of the Latino/a population living in poverty. The share of all U.S. children who are Hispanic
has grown steadily, from 7.5% in 1976 to 22.7% in 2009. Over the same period, the share of all poor
children who are Hispanic grew from 14.1% to 36.7%. It is estimated that by 2030 Hispanic children
will make up 44% of all poor children in the United States (U.S. Census Bureau, 2010).

Theory of Person and Environment

We now direct attention to a theory that seeks to understand the behaviors of persons as being the
products of the interactions that occur between persons and the diverse culturally imbued
environments in which they find themselves at any given time. More specifically, we begin with the
idea that any individual is embedded in a life space comprising the individual in interaction with a
specific environment or environments; the individual and the environment(s) are interdependent and
mutually constitutive.
This theory rests heavily on the foundations laid by Kurt Lewin (1935, 1936), whose field theory tells
us that all psychological events are differentially and interactively dependent on both psychological
states and environmental factors. Lewins famous equation, depicted in rough mathematical terms,

presents this idea of life space as a contention that individual behavior (B) is a function (f) of the
individual person (P) in interaction with his or her psychological environment (E), so B = f(P, E).
The reality is, of course, always more complicated than formulas and figures can represent.
Individuals live and grow within and across multiple environments. In describing his theory of the
ecology of human development, Bronfenbrenner (1977) refers to the progressive, mutual
accommodation, throughout the life span, between a growing human organism and the environments in
which it lives (p. 514). In addition to noting the self-evident fact that people interact with different
environments over a life span and even over the course of a single day, Bronfenbrenner proposes that
the human experience is a result of reciprocal interactions between the individual and his or her
environments, varying as a function of the individual, his or her contexts and culture, and time
(Bronfenbrenner & Morris, 2006). Giving greater specificity and clarity to his theory, he describes
the various levels of systems and structures that make up these environments. These include a
hierarchy of the following: the microsystem, consisting of the immediate physical setting and its
collection of individual actors (e.g., workplace, schools, family, peers); the mesosystem, comprising
the interrelations among settings; the exosystem, an extension of the mesosystem embracing other
specific social structures, both formal and informal... that impinge upon or encompass the
[individuals] immediate settings (e.g., public policies such as pathways to legal immigrant status,
health care and educational policies); and the macrosystem, which includes the overarching and
historical patterns of the culture or subculture (e.g., economic, historical, and cultural context,
xenophobia) (p. 515). Working from the foundation laid by Bronfenbrenner, we suggest that these
various systems be understood as levels of context, preliminarily defined as follows:
1. Interpersonal contexts, including both the number and quality of relationships, as well as the
more immediate contexts built up of ongoing emergent interactions
2. Social contexts, where individuals must manage their lives in multiple social systems and
networks (For a discussion of the interrelated peer, family, and school social worlds of
children, see Hartup, 1979.)
3. Institutional contexts, including schools, local governments, and the maze of everyday
4. Economic and political contexts, where the individuals place in the larger economic system and
relative access to resources are deeply consequential
The interdependent relationships among these contexts are more important than their independent
influences on individual behavior and experience. While we may consider them separately in many
phases of our research and practice, we must keep in mind that these contexts never in fact exist
independent of each other. Figure 8.1 offers one way of depicting these multiple, overlapping
contextual environments.
We hope to capture the following points in our graphic/visual representation. First, the individual
person still rests at the center of the figure, and he or she is always already embedded in a set of
contexts. These contexts are depicted as nested circles, all of which share a side. By presenting these
circles as sharing a side, we intend to convey our understanding that contexts are mutually constituted,
as parts of each other.

Figure 8.1 A Person in Interaction With His or Her Multiple Mutually Constituted Environments
What about culture? We work from the presumption that any individual is continuously situated in
culture (e.g., personal, local, global). This cultural situatedness of person and mind means that a
persons individual history as a member of various ethnic, linguistic, national, class, or other groups
always colors the persons experience within and across multiple contexts and, most important, the
way those various contexts are interdependent.
Reflecting this perspective, Comas-Daz (2012) directs attention to the ever-present nature of culture
within the social context of counseling. She contends that culture is like the proverbial elephant sitting
in the middle of the counseling setting; it cannot be ignored. On the contrary, if culture permeates the
entire therapeutic process, it must be understood and directly addressed throughout the process. In
support of this perspective, Comas-Daz strongly argues that culture influences how people become
distressed, interpret their maladies, seek help, and eventually heal. Similarly, culture shapes how
clinicians view themselves, their clients, and their clinical practice (p. 3). Comas-Daz contends that
when clinicians recognize this all-encompassing role of culture they develop an approach to clinical
care that examines the impact of context(s) on clients, themselves, and the world.
For the purposes of this book and chapter, the theory we have outlined already requires elaboration:
How might we think of these persons-in-environments (including the counseling environment) within
a counseling frame? A person experiences these environments in the dynamic ebb and flow of
everyday life, in relations with other persons, and in practical efforts to get things done. Said another
way, these person-environment relations are only ever potential and must be activated and
reconstructed and transformed in real-life situations. Which person-environment relations or
experiences are immediately relevant depend on the dynamic, unfolding situations in which persons
find themselves. The counseling session is one such situation in which the person-in-environment
phenomenon occurs simultaneously for the counselor and the client (see Figure 8.2). With respect to
the counselor, seeing the client from this perspective constitutes a move away from an essentializing
and trait view of person/personality (e.g., She is Latina and Latinas experience the world in such
and such a way) to a situated state view (e.g., While she is Latina, the problems that she is
presenting are not solely reflective of her culture but are also tied to other social factors with which
she is currently dealing).

A Guiding Framework for Counseling Practice

As a preface to this section, we underscore the fact that in order to maximize the effectiveness of

using the framework described below, it is imperative that the counselor have some training in
multicultural counseling. More specifically, at minimum, the counselor should be culturally competent
in the following areas: He or she should be able to identify the varied sociocultural environments that
have affected and/or may continue to affect the client; should have strong cultural self-awareness
(e.g., being aware of how he or she reacts to culturally different individuals); and should be able to
listen to clients with a multicultural ear (e.g., allowing the clients to tell their storiesstarting
where they want to start and ending where they want to end) and see clients through a multicultural
lens (i.e., recognizing and gathering all relevant information from which to understand the clients
culturally situated stories) (see Comas-Daz, 2012).

Figure 8.2 A Situated Perspective on a Persons Interaction With His or Her Environment
The practical framework we offer here builds on the theoretical approach outlined above, describing
in more concrete terms those particular concerns that contextually cut across interacting environments
and that are most likely to be relevant to cross-cultural counseling. The framework represents an
evolution of thinking from the framework initially proposed by Casas and Vasquez (1989). Figure 8.3
depicts this framework.
We have placed the counseling situation at the upper center of the figure. On the far-left and farright sides of the figure, we list a small collection of person-environment factors that may influence
or be activated in a given counseling situation. Their location at the far edges of the figure reflects our
understanding that these person-environment factors are relatively distal to the actual counseling
situation. These factors take shape in the counselors and clients orientations to the counseling
situation. We locate these orientations closer to the situation, as they are relatively proximal.
For both counselor and client, person-environment factors and orientation to the counseling
situation are uniquely and integrally related. The double-sided arrows near the tops of these sections
are designed to represent this relationship.

Figure 8.3 A Framework for Approaching Cross-Cultural Counseling

Extending below the counseling situation, we have listed as situational variables a few of those
variables that are undetermined until both counselor and client mutually construct the counseling
situation. Although we have been temped to characterize these variables as matters within the
counselors control, we realize that both counselor and client have control over their own behavior.
The point, in fact, is not who has control over these variables but that these variables remain
variables throughout a counseling situation. That is, they vary in ways that are responsive to and
constructive of the live, unfolding situation.
Although we are convinced of the general usefulness of this framework, we have not provided an
exhaustive list of all the person-environment factors that could be relevant to the counseling situation.
Nor have we described in detail all the various orientations or identified all possible situational
variables. We have identified only those factors and orientations that are most likely to be sources of
both frictionpositive or negativeand possibility in cross-cultural counseling.
In the sections that follow, we describe in greater detail the orientations of counselor and client as
likely sources of friction (and possibility) for cross-cultural counseling. It is in these descriptions that
we draw out specific implications for the counseling of Latino/as.

The Counselor
Many clinicians believe that theirs is an impartial helping profession in which practitioners relate to
the essential humanity in each client. This is a dangerous and most often plainly false belief (ComasDiz, 2012). In fact, the practice of counseling in the United States is anything but impartial (ComasDaz, 2012; D. W. Sue & Sue, 2008). Like all other human beings, counselors are encapsulated by the
beliefs inherent in the diverse environmental contexts (e.g., social, ethnic) in which they were

nurtured and/or currently exist (Wrenn, 1962). To this point, Comas-Daz (2012) contends that while
counselors may have been trained to be aware of the monocultural assumptions in the mainstream
society, they tend to be much less aware of the assumptions prevalent in the counseling profession.
When all is said and done, the fact of the matter is that counseling is a cultural activity replete with
dominant cultural assumptions and beliefs.
To counsel Latino/a clients effectively, counselors must develop an awareness of how their
acceptance of and adherence to specific personal, mainstream, and professional assumptions, beliefs,
and values may have significant impacts on their interactions with such clients as well as clients from
other diverse backgrounds. After all, many Latino/as from diverse backgrounds may find such
assumptions, beliefs, and values to be at odds with their own thinking and experience. Concomitantly,
a counselors interpretation of a clients behavior in terms of the counselors own assumptions,
beliefs, and values, whether personal and/or professional, can lead to poor assessment and diagnosis
(e.g., continued use of ethnocentric diagnostic tools), which, in turn, can result in ineffective or even
destructive interventions (Comas-Daz, 2012; Marsella & Yamada, 2007).
In the paragraphs that follow, we selectively identify and discuss a few value-based assumptions and
beliefs that are rooted in mainstream U.S. society and more specifically in the norms of typical
contemporary professional training that serve as sources for potential clientcounselor friction. (For
additional discussion of such assumptions and beliefs, see Comas-Daz, 2012.)

What counts as normal is widely understood and universally accepted.

Many counselors accept a more or less universal definition of normal behavior. This assumption
can lead counselors to assume that describing a persons behavior as inherently normal is
meaningful and implies a recognizable pattern of behaviors by the normal person. However, what
is considered normal is better evaluated and understood within the context of that behavior, including
the cultural background(s) of the persons involved, the time during which the behavior is being
displayed and observed, and preceding and subsequent actions. Rather than ask if an observed belief
or behavior is normal, we ought to examine the circumstances of that belief or behavior so that we
can determine how reasonable and sensible it is (Marsella & Yamada, 2007).

Individuals are the building blocks of society; everyone is autonomous; the

individual person is the unit of change; everyone has his or her own identity;
individualism is more appropriate than collectivism.
It is not surprising that a good number of the beliefs and assumptions identified herein focus on the
construct of individualism.
Contemporary U.S. culture makes a hero of the independent, self-sufficient person, deliberately freed
from the limitations of family, community, and circumstances. Counselors who share this assumption
have as a primary goal the development of the individual as an independent person. This assumption
works to the detriment of many Latino/as who have learned to give greater importance to the external
self, the other-directed and interdependent individual (i.e., those from cultures that put family or
other designated social units above the individual), a self that is best understood through its

contextual and historical linkages (Vasquez, 2007).

Complementing the high value placed on individualism in traditional counseling theories and practice
is the assumption that independence has value and dependence does not. Closeness and dependence
must be understood within specific cultural contexts and not merely as pathological forms of
enmeshment. Counselors who attempt to assess the appropriateness of relationships among and
between Latino/a clients must consider other possibilities, including the positive health functions
served by an individuals reliance on others (Niemann, 2001). More specifically, effective
counselors of Latino/as must understand the value of connecting, supporting, and cooperating within a
Many counselors perceive the individual person as the unit of change and as such understand their
duty to be that of changing individuals to fit society rather than changing society to fit individuals (for
details, see Cushman, 1992). Counseling interventions tend to focus on the individual and how the
individual should take the initiative to change, regardless of the possibility that the individually
experienced problem may have more to do with the persons environment (D. W. Sue & Sue, 2008).
Latino/as in the United States experience second-class citizenship, oppression, and discrimination to
varying degrees (Gallardo, 2012). Given such experiences, the effective counselor may need to
assume nontraditional roles to actively validate and support Latino/a clients efforts to change the
environmental factors that prevent them from attaining their personal goals (see Atkinson, Thompson,
& Grant, 1993; Freire, 1973).

History is irrelevant; what matters is the here and now.

As Pedersen (1987) has observed, some counselors are most likely to focus on the immediate events
that created crises in their clients lives. When clients begin talking about their own histories or the
histories of their people, such counselors are likely to stop listening and wait for the clients to
catch up to current events. For many Latino/as, the past and the present interrelate in such a
complex manner that it is impossible for anyone to understand a total individual without also
understanding and appreciating his or her sociohistorical experience (Comas-Diz, 2012; McNeill et
al., 2001).

The Client
Latino/a clients are neither blank slates nor mere extrapolations of the statistically derived average
Latino/a found in the literature. In line with the person-environment theory described above, the
Latino/a client brings with him or her unique personal and social cultural characteristics and a trove
of life experiences in and with multiple, overlapping, and interacting environments. Such
characteristics and experiences might be as mundane and normal as family size, birth order,
childhood illnesses, and family mobility. Or, as is the case with many Latino/as, they can include such
stressful and often devastating experiences as racism, segregation, xenophobia, discrimination (Pew
Hispanic Center, 2009), poverty, psychological trauma associated with the immigration process
and/or immigration status (APA, 2012b), significant educational disadvantages (Surez-Orozco,
Surez-Orozco, & Todorova, 2008; Fuligni, 2012), unequal access to health and social services
(APA, 2012b; McNeill & Cervantes, 2008; Rodrguez, Valentine, Son, & Muhammad, 2009), unfair

employment (or unemployment) practices, and political disenfranchisement.

Unfortunately, there is no question that stressful experiences such as those noted above have a high
potential for causing negative psychological consequences (i.e., mental healthrelated problems)
(APA, 2006, 2012b). Given the high propensity to encounter such experiences within the Latino/a
community, there is a pressing need for counselors to understand and address them in a culturally
competent manner within the counseling process. In the paragraphs that follow, we describe a few of
the person-environment factors identified in the framework presented above that are especially
relevant to counseling Latino/as.

Experience with racism and/or discrimination.

When the client is a member of an ethnic or linguistic minority group, she or he is likely to have had
some personal experience with racism or other forms of discrimination (APA, 2012c; Pew Hispanic
Center, 2009). For Latino/as in particular, experience with linguistic discrimination, or linguistic
profiling (Vinokurov, Trickett, & Birman, 2002), may be as common as discrimination on the basis
of race or class. Personal experience is often but need not be firsthand experience; the stories a
person hears from family and other minority group members can build a sense of an experienced
history that includes sharedand therefore personalinstances of discrimination.
Frequently, these experiences are formative for the client, carried forward as personal orientations to
everyday encounters. Unfortunately, from a more severe perspective, there is evidence to show that
they are frequently associated with mental health problems, including depression, anxiety, substance
abuse, and suicidal ideation (Cheng et al., 2010; Tummala-Narra, Alegra, & Chen, 2012). (For more
information regarding the toll exacted by systematic biases, stereotypes, and discrimination, as well
as strategies to reduce those mechanisms, see APA, 2012c.)

Acculturation pressures.
Acculturation is a major factor that contributes to the dynamic, ever-changing nature of the Latino/a
population. In its original and still quite acceptable definition, the term acculturation refers to the
phenomena that result when groups of individuals from two different cultures come into continuous
firsthand contact and experience subsequent changes in the original patterns of either or both groups
(Redfield, Linton, & Herskovits, 1936). Although originally perceived from the perspective of the
group, acculturation occurs both in groups and in individuals.
A variety of factors determine the direction and rate of acculturation, as well as the pressures an
individual may experience as a result of acculturation processes. Among these are contextual changes
in the racial or ethnic demographics of a community or region, proximity to the individuals native
homeland, prevailing sociopolitical attitudes and policies (e.g., segregation), economic conditions
and practices (e.g., means and opportunities for improving employment and economic status), and
access to high-quality, advanced education. According to Kurtines and Szapocznik (1996),
differentially available opportunities and the continued prevalence of traditionally prescribed gender
roles cause acculturation rates to vary by generation and gender. The rate is faster for younger
generations (Birman, 2006).

Acculturation pressures can constitute a risk factor for an individual when they occur in an
environment that lacks relevant support networks among family, teachers, friends, and counselors;
these pressures can and often do create conflict, stress, and loss of self-esteem as the individual
struggles with an inevitable clash of values. When acculturation pressures confront especially strong
ethnic identification, a persons mental health may be put at increased risk (Torres, Driscoll, & Voell,
2012). In relation to resilience, Yeh, Arora, and Wu (2006) contend that, with support from significant
others, an individuals choice to maintain important aspects of his or her sociocultural background
can create a healthy aware individual who can function effectively across cultures and settings.
(For thorough coverage of the acculturation process from a psychological perspective, see Torres et
al., 2012.)

Role expectations.
Every client enters the counseling situation with expectations about the roles she or he and the
counselor might take up. These roles are often organized around questions of authority and trust. For
many clients, the mere act of sitting down with a counselor involves handing over an uncomfortable
level of authority for their own well-being. Progress through one or more counseling sessions
requires that the counselor and client establish (and consistently reestablish) trust. To the extent that
Latino/as from various backgrounds learn to value discretion in personal matters, they may be
especially disinclined to take their personal struggles public. In such cases, the counselors careful
management of authority relations and constant work to establish trust are extraordinarily important.

Credibility given to the counseling process.

General attitudes toward counseling and the credibility given to the counseling process among
Latino/as remain largely unexplored areas of research on multicultural counseling. That said,
anecdotal evidence from a broad spectrum of counselors and caregivers encourages, at least, a
question about widely held skepticism regarding psychological treatment, including counseling,
among Latino/as. That a particular individual may carry this skepticism into the counseling situation
is only one possibility. Whether or not a client is skeptical her- or himself, she or he may be having to
deal with skepticism from a spouse or partner, family members, or friends.

Strengths and resilience.

One of the most important strategies for counselors to employ in working with persons of color is to
identify their clients strengths and areas of resilience. Fortunately, the psychotherapeutic process
generally provides counselors with ample opportunities to become intimately acquainted with the
strengths and resilience of their clients.
Latino/as have a wide range of strengths and resilience. For example, a 2012 report issued by the
National Center for Health Statistics indicates that Hispanics live longer than White or Black
Americans (Minio & Murphy, 2012). Generally, mortality is correlated with income, education, and
health care access, so we would expect the Hispanic population to have a higher mortality, similar to
the Black population. This unique resilience of Latino/as given the usual negative health outcomes of
poverty and other psychosocial challenges, such as infant mortality and low birth weight, as seen in

non-Latino Whites and other groups, has been called the Latino/a paradox. The specific pathways
or protective factors that may buffer Latino/as and enhance their mental health have not yet been
identified, but they are hypothesized to include familismo and spirituality. Both these factors may
foster positive social support that protects individuals against depression, even in the face of
substantial environmental risk.

The Counseling Situation

The central category of our framework focuses on variables within the counseling situation itself. The
way we conceive this category includes those behaviors and positionings that are most clearly in the
direct control of both counselor and client. Rather than prescribe an appropriate sequence of
behaviors, organization of physical space, or proximity, we turn to Atkinson et al.s (1993)
description of the diverse roles that a counselor may assume in the counseling situation. (For
information on the aforementioned variables, see Ponterotto, Casas, Suzuki, & Alexander, 2010; D.
W. Sue & Sue, 2008; S. Sue, Zane, Hall, & Berger, 2009; Vasquez, 2007.) Before we address the
diverse roles that a counselor may assume, we should note that, given the space limitations here, our
focus is on generic counseling roles and not on specific therapeutic theories and approaches.
(Readers interested in such information should see Casas, Raley, & Vasquez, 2008.)
Atkinson et al. (1993) propose a three-dimensional model that focuses on the diverse roles that
counselors may have to assume when counseling racial/ethnic minority clients. Within the proposed
model, Atkinson et al. suggest that in the process of selecting roles and strategies when working with
these clients, counselors need to take into consideration three factors, each of which exists on a
continuum: (1) client level of acculturation to the dominant society (high to low), (2) locus of
problem etiology (external to internal), and (3) goals of helping (prevention, including
education/development, to remediation). Just as the roles themselves are interactionally constituted,
so are the clients particular locations on any of these continua. That is, the extent to which
acculturation pressures matter, the location of the problem, and the specific goal for counseling may
vary from one moment to the next and will certainly vary over the long haul of multiple sessions. The
point bears repeating: The appropriate counselor role may vary even within a single counseling
session, as the counselor works with every available sense to decide how to think and act for the
clients well-being.
Atkinson et al. (1993) identify eight therapist roles that interact with each of the three continua
extremes. Specifically, the therapist serves as the following:
1. Advisor: When the client is low acculturation, the problem is externally located, and prevention
is the goal of treatment.
2. Advocate: When the client is low in acculturation, the problem is external in nature, and the goal
of treatment is remediation.
3. Facilitator of indigenous support systems: When the client is low in acculturation, the problem
is internal in nature, and prevention is the goal of treatment.
4. Facilitator of indigenous healing systems: When the client is low in acculturation, the problem
is internal in nature, and remediation is the treatment goal.
5. Consultant: When the client is high in acculturation, the problem is external in nature, and

prevention is the treatment goal.

6. Change agent: When the client is high in acculturation, the problem is external in nature, and
remediation is the goal of treatment.
7. Counselor: When the client is high in acculturation, the problem is internal in nature, and
prevention is the primary goal of treatment.
8. Psychotherapist: When the client is high in acculturation, the problem is internal in nature, and
remediation is the goal of therapy.
As is evident, the framework we have presented does not attempt to identify and describe specific
counseling strategies and interventions that have been shown through research and/or practice to be
effective with Latino/a adults and children. We believe that at this point in time such interventions are
too numerous for us to address adequately within the parameters of this chapter. (For examples of
such strategies and interventions, see Kataoka et al., 2003; Santisteban & Mena; 2009; Smokowski &
Bacallao, 2009.) However, wishing to help readers select those interventions that may be most
clinically effective and culturally appropriate, we highlight the following guiding principles: (1) Use
an ecological perspective (Bronfenbrenner & Morris, 2006) to develop and guide interventions, (2)
integrate evidence-based practice (Kazdin, 2008) with practice-based evidence (Birman et al.,
2008), (3) provide culturally competent treatments (APA, 2002), (4) use comprehensive communitybased services (Birman et al., 2008), and (5) use a social justice perspective as a driving force for
all services (Corey, Corey, & Callanan, 2011). (For more details relative to these principles, see
APA, 2012b.)

In this chapter we have asserted the essential importance of counselors cultural knowledge and
awareness of the social, institutional, political, and economic experience of clients who are members
of ethnic minority groups. If counselors understand the relevant cultural values, norms, and behaviors
of their clients, as well as the unique stresses that the clients face, they may propose interpretations of
their clients behaviors that are different from those they might otherwise apply.
In addition to culturally sensitive or modified approaches to counseling and therapy with Latino/as,
counselors must employ other frameworks and perspectives beyond those traditionally used, many of
which have been based on remedial models (i.e., treating the client after a specific problem has
surfaced). Romano and Hage (2000) strongly assert the need for a much greater emphasis on and
commitment to the science and practice of prevention in counseling psychology. Preventive
interventions forestall the onset of problems or needs through anticipation of the risks and challenges
faced by persons across their multiple environments. To this end, we suggest the incorporation of such
interventions for enhancing the quality of life of Latino/a groups. Following the outlines of the theory
described in this chapter, preventive environmental interventions (Banning, 1980) designed for
members of ethnic minority groups may be included.
A business-as-usual mentality will not work with Latino/as or other minority clients. The challenges
that such clients bring to counseling sessions demand that counselors employ careful ways of thinking
that are regularly refreshed through explorations into new theoretical, cross-national, and crossdisciplinary terrains (see Daz-Guerrero, 1995) as well as genuine contact with the dynamic, diverse

real world. We have provided a road map for such exploration, including the outline of a
framework that identifies a range of possibly relevant variables. In the journeys that counselors may
take with their clients, we have anticipated a few likely challenges and encouraged a preventive,
resilience-based orientation that will help Latino/a clients to move forward in their efforts to
overcome challenging psychological, social, and economic living conditionsadelante.

Critical Incident
We present the counseling situation below in order to outline some potential implications of our work
for counselors real-life practice. Although hypothetical, the situation draws on an actual case
described in greater detail elsewhere (Raley, Casas, & Corral, 2004).

The Case of Liliana

Liliana, who is 24 years old, is voluntarily seeking counseling for relationship issues. She has
lived in Californias San Francisco Bay Area for most of the time since her family emigrated with
undocumented status from Mexico. Recently married, Liliana currently lives within a few miles of her
mother and sisters. Lilianas family of origin is economically poor. She has met but does not have
ongoing contact with her biological father, who is somewhere in Mexico. Her mother and two older
sisters are deeply committed to the Apostolic Christian Church, but Liliana does not attend services
regularly. Liliana speaks reverently of her grandmother, although relations between the two were
tense for a time. Liliana and her grandmother were not speaking to each other because of her
grandmothers rejection of Lilianas younger sister. According to Liliana, her grandmother could not
accept that her sisters biological father was African American. Despite a very difficult time in
public school, Liliana was able to succeed at a small private high school, and she was accepted by an
Ivy League university. She left the university after her sophomore year to raise her own family. She is
currently working for a successful technology firm as she completes her degree.
Lilianas sense of humor engages young people and adults, her penetrating insights guide
conversations, and she is well liked by those who know her well. She continues to defy authority
when she feels that it is unjustifiably imposed, is occasionally impatient with what she perceives to
be the irrelevance of other peoples emotions or reasoning, and sometimes balks at what she sees as
unnecessary or unimportant work.
How might the framework described in this chapter be useful to a counselors efforts to improve
Lilianas mental health? The framework does not provide a script that Lilianas counselor might
follow. In fact, the framework is designed to discourage a search for solutions, pointing instead to
better questions to guide a counselors practice. Some of these guiding questions might become
actual questions that the counselor could ask Liliana. Others could guide the counselors attention
during their meetings, helping the counselor discern those important ecological factors, identify the
particulars of Lilianas orientation to the counseling situation, and design and cocreate a safe physical
and social space. The discussion questions that follow provide a limited example of guiding
questions, organized according to the broad categories of variables described in our framework.

Discussion Questions
Person-Environment Factors
1. What sorts of experiences, if any, has Liliana had with racism and other kinds of discrimination?
How have these contributed to the way Liliana sees herself and her lived world? How do race,
language, class, gender, and so on matter to Lilianas beliefs?
2. What are Lilianas own conceptions and explanations of her economic situation and that of her
3. What is Lilianas take on her experiences as an immigrant?

Orientation to the Counseling Situation

1. Has Liliana been in counseling therapy before? What was the experience like? Have any of her
family members been in therapy? For what reason, and with what perceived results?
2. What concerns does Liliana bring to the present counseling situation?
3. How, if at all, does the ethnic, racial, linguistic, or economic background of the counselor matter
to Lilianas orientation to the counseling situation?

Situational Variables
1. What is the most neutral arrangement of space and materials?
2. What are Lilianas observable responses (linguistic, behavioral, and so on) to the counseling
situation, including especially the specific behaviors of the counselor?
3. Given what the counselor is learning about Lilianas environment and orientation, what roles
might the counselor take on to best meet Lilianas needs? And under what conditions might such
roles usefully vary?

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9 Counseling Arab and Muslim Clients

Marwan Dwairy
Fatimah El-Jamil

Primary Objective
To assist counselors in understanding the historical and cultural background they need to be
effective in professional encounters with Arab and/or Muslim clients

Secondary Objectives
To encourage counselors to revise or modify psychological theories and practices related to
the development and assessment of mental health to fit Arab/Muslim beliefs and cultures
To aid in the development or conceptualization of new mental health assessment and
intervention tools that are suited to Arab/Muslim clients
A psychotherapist or counselor who works with Arab and Muslim clients may notice that these clients
are more family or community oriented and therefore less individually oriented than most Western
clients. Terms such as self, self-actualization, ego, opinion, and feeling have a collective meaning
for them. These clients may be preoccupied by family issues, duties, expectations, and the approval of
others; as such, in conversing with them, counselors may find it difficult to distinguish between their
personal needs and opinions and those of their families. These primary psychocultural differences
between Arab and Muslim clients and Western clients will be expanded upon in this chapter. While
taking these differences into consideration, readers are advised to keep in mind both the large
diversity that exists among Arabs and Muslims and the fact that they share many characteristics and
features with members of other collectivistic cultures. Before we discuss these commonalities and
differences, however, we offer a brief overview of the historical, cultural, and religious background
of Arabs and Muslims. Such knowledge will help to clear up some of the many misunderstandings
Arabs and Muslims have faced since the infamous attacks on New York City and Washington, D.C.,
on September 11, 2001.

Arab and Muslim History, Culture, and Religion

Arabs are the descendants of Arabic tribes who lived in the deserts located in what are now known
as the Saudi peninsula, Iraq, and Syria. In the early 7th century (ad 610), Islam emerged in Mecca and
became one of the great monotheistic religions. At this time, the Prophet Muhammad began to exhort
men and women to reform themselves morally and to submit to the will of God, as expressed in the
divine messages revealed to the Prophet. These revelations were later embodied in the holy book
called the Quran. About 285 million Arabs are spread over 22 Arab countries in North Africa and
the Middle East today (Encyclopdia Britannica Almanac, 2003). Although the majority of Arabs

are Muslims, Christian and Druze minorities exist in Arab populations.

Muslims today number about 1.3 billion people worldwide, living in more than 100 countries on all
continents. The largest Muslim populations are found not in Arab countries but rather in Asian
countries such as Indonesia, India, Malaysia, Pakistan, and Bangladesh (Encyclopdia Britannica
Almanac, 2003). Despite the fact that Islam has been adopted by many non-Arab nations, the Arabic
language and history remain central to Muslims because Islam was revealed in the Arabic language to
Muhammad in Mecca, a city in Arabia (Dwairy, 2006).
The word Islam means submission and comes from the Arabic root that means peace (Kobeisy,
2004). The five fundamental tenets of Islam that are shared by all Islamic groups are as follows:

Shahada: The profession of faith (There is no God but Allah, and Muhammad is His Prophet.)
Siyam: Fasting in the holy month of Ramadan
Salah: Prayer five times a day
Zakah: A tax devoted to providing financial help to the poor
Hajj: The pilgrimage to Mecca

These tenets direct Muslims to submit and pray to one God (shahada, salah, and hajj), to learn to
control their instincts (siyam), and to empathize with the poor and offer them help (zakah). A true
believer is expected to adhere to and fulfill these five principles, which are meant to promote a
greater connectedness to God and to other believers. Antagonism and hostility directed toward the
West are far divorced from any true Islamic fundamental beliefs. On the contrary, Islam is very clear
about the need to accept and respect others, including those who practice other monotheistic
religions, such as Christianity and Judaism. In fact, the same spiritual source, Abraham, is considered
the father of these three monotheistic religions, as they all emerged from his descendants.
After the death of the Prophet Muhammad, the issue of who should be his successor became a most
pressing problem. Ali, who was the Prophets cousin and son-in-law, presented himself as the person
most eligible for the job, but he was turned down by the majority at the time. After the death of the
third Rashidi caliph, Othman, Ali appeared as the first among many contestants, but again he was
opposed bitterly by many groups. This issue of leadership ended in fierce battles and divisions among
Muslims. This era in Islamic history, called the greatest civil strife, resulted in the death of Ali and
later his son, Hussein. Alis followers and all those opposed to the winning groups were deeply and
tragically moved by their losses and gathered themselves together. That was the beginning of the Shia
sect of Islam, the name of which literally means the supporters. The majority group was called the
Sunni, or the followers of the way of the Prophet (Badawi, 1996). All Muslims, whether Sunni or
Shia, follow the main pillars of Islam and the Quran, with minor differences in their interpretations
of the Quran that developed over the years. Even though the Islamic empire disintegrated over time
into different nationalities and countries, the two main sects of Islam remain, along with their struggle
for authority in the Islamic world, the same struggle that began in the 14th century.
A set of very strict laws called the Shariaa was later developed. These laws are based on specific
interpretations of the Quran and on what is known about the Prophets life, the Sunna. The Shariaa
provides directives according to which an individuals personal, familial, social, economic, and
political life must be led. The Shariaa is practiced in almost every Arab country, although in some

countries (such as Saudi Arabia and Qatar) it is fully enforced as law, while in others (such as
Lebanon) it is only partially enforced and then only on Muslim citizens. Therefore, Islam not only
involves faith and prayer to God but also provides legislation pertaining to almost every aspect of
life. Islam can be described as a social religion that attempts to promote a balanced order in society,
since it encompasses all the needs of the human being from the spiritual to the physical.
The impression that the West has of sexuality in Arab Muslim societies has received much attention
and debate in the media, particularly given the very conservative dress known as the abaya and the
veil known as the hijab, which are often shown in the media. Sexuality is one of the many aspects of
day-to-day life that Islam addresses. For example, Islam directs both male and female believers to
avert their gaze from members of the opposite sex and to safeguard their gender, as this is more
decent for them (Khalidi, 2008). Islam also describes grave punishments that believers will endure
for engaging in sex outside of wedlock, and adultery is considered the greatest of sexual
transgressions (Khalidi, 2008). Islam, however, also provides legal sexual vents for men within the
context of wedlock. Polygamy, which is a concession that is not predominant in todays Arab cultures,
serves as one of those legal vents. Divorce is another example of a legal vent that permits both
women and men the practical means to deal with irreconcilable conflicts associated with changing
physical or emotional needs.
The hijab, as well as other conservative dress as currently practiced by Muslim women, is an
expression of Islamic identity and faith and serves to protect women from the sexual advances of men.
However, among more moderate-minded Muslims, it is also viewed as a form of control imposed by
Islamic institutions to limit the sexual appeal of women. Among Islamic countries today, only Saudi
Arabia and Iran enforce the veiling of women, and in countries such as Tunisia and Turkey, state laws
prohibit veiling. Regardless of societal laws, however, the dress code in Islam is conservative.
Arabs and Muslims also have a very specific political history that shapes the way they experience the
West. For many decades, Arab Muslims were acquainted with Westerners as colonialists or
occupiers in Africa and Asia. Their biggest and most devastating defeat, however, was the Zionist
movement in Palestine, backed by the West. More recently, they know the West as supporting or
condoning the Israeli occupation of Palestinian land and launching the war on Iraq without clear
indication of threat. In the past few decades, particularly since the war on terrorism began, the
relationships between Arab Muslim societies and the West have become particularly tense, with the
West often seen as a threat to the Arab and Muslim societies sovereignty and their collective
character. While these views are not shared by all Arabs and Muslims, many do remain apprehensive
about Western regimes and foreign policies, particularly after having endured decades of political
instability in their home countries (Erickson & Al-Timimi, 2001).
Furthermore, because of sociopolitical issues, including the dictatorships and monarchies in various
Arab countries of North Africa and Asia and poverty within rural areas, religious fundamentalism
grew as a result of peoples disempowerment. Some Muslims thought that they could improve their
lives by returning to their religion the way it was practiced during the golden age of Islam.
Otherwise they would have to follow in the steps of the powerful nations that defeated them. This was
the beginning of what the West has termed Islamic fundamentalism. However, the fundamentalists
reactions to world events have become more desperate and hate-fueled with time, veering away from

the tenets of Islam and toward political ends. The events of the Arab Spring, initially motivated by the
masses, were also reactions to these sociopolitical issues, but fundamentalist religious groups have
further taken advantage of these revolutionary movements that began during the Arab Spring to gain
power in countries such as Tunisia, Egypt, Syria, Iraq, and Libya.
Despite having negative feelings toward the West, many Arabs are also fascinated by Western culture,
technology, and science. They consume Western products and watch and listen to Western media, and
Arab scholars often adopt Western theories. There is no doubt that exposure to Westerners, through
travel, media, science, and technology, has introduced many Arab Muslims to new individualistic
values that challenge their collectivist traditions and beliefs. Attitudes toward the West are therefore
often a mixture of rage and antagonism on one hand and identification and glorification on the other.
Arab and Muslim immigrants of course vary in the proportion of their resentment versus their
identification with the West (Dwairy, 2006), as we will discuss in the following sections.

Arab Americans
Estimates of the population of Arab Americans residing in the United States range from 1.7 million to
5.1 million. Arab and Muslim Americans are found in all social classes, at all education levels, and
in urban and rural settings. Their levels of education and income are usually higher than the averages
for the total U.S. population (Arab American Institute, 2012), in part because educational
achievement and economic enhancement are highly valued in Arab cultures (Abraham, 1995). Many
are also multinational and multilingual, with the Arabic language as their mother tongue and usually
English or French as their second language. Arabs may travel to and settle in Western countries for
higher education and employment opportunities, or they may be seeking refuge from war, political
instability, economic hardship, or, in some cases, religious persecution (Abi-Hashem, 2008, 2011). In
general, Arab Americans integrate well into mainstream U.S. society, but some Arabs and Muslims
do remain separate and unable to integrate into the American social system (Abi-Hashem, 2011).
They may consciously or unconsciously resist assimilation into the American culture.
Many factors play roles in facilitating or inhibiting acculturation and/or the development of a
cohesive, individual, Arab ethnic identity (Erickson & Al-Timimi, 2001). First, there is great
religious and political heterogeneity among Arabs. Some Arab Americans align themselves with
conservative Republican values, while others, particularly immigrants, who tend to be dissatisfied
with American foreign policy, lean toward more left-wing liberal values (Abraham, 1995). Islamic
religious identification also varies greatly: Some Arab Muslims adhere to all the fundamental beliefs,
tenets, and practices of Islam; some identify as believers without strict practice; and still others
consider themselves Muslim solely for purposes of identity or sense of belonging. Second, the lack of
recognition by the United States of Arab Americans as an ethnic minority group greatly affects their
identity. Some Arabs, for this reason, identify as White, while others insist on placing themselves
in an other category in order to assert their separate ethnicity. Third, Arab Americans have
experienced racism, discrimination, and social stigma to varying degrees, with some reporting direct
harm and others completely unacknowledged as Arabs or Muslims (Abi-Hashem, 2011; Erickson &
Al-Timimi, 2001). Such realities challenge Arab Muslims ease of assimilation or acculturation to the
host American culture.

Authoritarian and Collective Culture

The social systems in both the traditional Arab and the Muslim worlds tend to be collective and
authoritarian: The individual and family are interdependent, and the family is ruled by a patriarchal,
hierarchical authority. Despite some progress in the past few decades, democratic values and
political rights remain limited in most Arab Muslim countries, and the citizens still, for the most part,
rely on the family rather than on the state for their survival, including in matters related to child care,
education, jobs, housing, and protection (United Nations Development Programme, 2002). In the
absence of a state system that provides for the needs of the citizens, the individual and family continue
to be interdependent. Individuals depend on their families for survival, and family cohesion,
economy, status, and reputation are in turn dependent on individuals behavior and achievements. The
individual is expected to serve the collective (family or community) in order to receive the familial
support needed for his or her survival.
In such a social system, two polarized options are open to individuals: (1) to be submissive in order
to gain vital collective support or (2) to relinquish the collective support in favor of self-fulfillment.
Arabs and Muslims are split in terms of the choices that they make between these two poles and can
be roughly divided into three societal categories: authoritarian/collectivistic, mixed, and
individualistic. The majority of Arabs and Muslims are found in the first two categories. The
individualistic minority is typically made up of those who were raised in educated, middle- to upperclass urban families and have had much exposure to Western culture. Of course, these categories are
dynamic and contextual: An Arab persons orientation can be more collective in terms of one issue,
such as family life, and less collective in terms of another, such as business activities and related
For most Arab and Muslim individuals, choices in life are collective matters, and therefore the family
is always involved in major decision making. Decisions concerning clothing, social activities,
education, career, marriage, housing, size of the family, and child rearing are often made within the
family context, and at times the individual has only minimal space for personal choice. Within this
system, an individual learns to be more reliant on others and consistently assesses whether personal
initiatives and challenges are worth embarking on if they counter the wishes of the family. To maintain
its cohesion, the collective system may not welcome authentic self-expression of feelings; instead,
individuals are often expected to express what others anticipate. This way of communicating within
the collective is directed by values of showing respect (ihtiram), fulfilling social duties (wajib), and
pleasing others and avoiding confrontations (mosayara).
Given that societal, cultural, and religious norms as described above greatly affect an individuals
psychological development, counselors and psychotherapists who work with Arab and Muslim
clients may need to revise their theoretical understanding of mental health and adapt their methods of
assessment and therapy to the specific needs of this population.

Psychosocial Development
Western theories of development emphasize a separationindividuation process that normally ends

with the individual developing an independent identity after adolescence. While they may use
different terminology, all theories of development agree that normal development starts with
symbiosis or complete dependence and ends with independence and autonomy. Freud claimed that
after the fifth year of life, children already possess, through a process of identification with the samesex parent, an almost independent personality structure. After age 5, children unconsciously repeat
and transfer their early relationships with their parents to their present interpersonal relationships
(Freud, 1900, 1940/1964). Erikson (1950) asserted that the formation of an independent ego identity
is a necessary stage in the normal development of children. He described the stages that lead to
autonomous ego identity: First, children attain basic trust (birth to 1 year), then seek autonomy (13
years) and move toward initiation (36 years) and industry (612 years), until they achieve ego
identity in late adolescence. Object relations theory also focuses on analyzing the process of
separationindividuation in the first 3 years of life (Mahler, Bergman, & Pine, 1975) and its
continuance into adolescence (Blos, 1967), until the individuation of the self is achieved.
These theories of development actually describe the ideal development in Western society.
Accordingly, the mentally healthy adult is independent, autonomous, individuated, internally
controlled, and responsible for him- or herself. In an individualistic society, dependence in an adult
may be considered a disorder (e.g., dependent personality disorder) or a sort of fixation or
regression. Conversely, in societies where collective/authoritarian norms and values continue to be
the major generators of behavior, personal development does not occur in the same way as it does in
primarily individualistic societies. Assuming complete autonomy and independence is inappropriate,
because individuals remain embedded in the larger family context and society (Hofstede, 1986; Sue
& Sue, 1990). Adolescents continue to be emotionally and socially dependent on their environment;
only later, as older adults, do individuals become more interdependent with their environment. In fact,
in societies that adopt authoritarian parenting styles, Arab adolescents are not expected to act out,
become egocentric, or engage in nonconformist or rebellious behavior (Racy, 1970). Indeed, Timimi
(1995) has postulated that Arab youth do not experience identity crises in adolescence or achieve
individual autonomy because their individual identities are part of the larger family identities to
which they are always loyal.
When the ego identity of Arab Palestinian adolescents was measured, it was found to be more
foreclosed and diffused than that of American youth (Dwairy, 2004a). Foreclosed or diffused
adolescents do not experience a crisis period but rather adopt commitments from others (usually
parents) and accept them as their own without shaping, modifying, or testing them for personal fit.
These adolescents do not experience a need or desire to explore alternatives and/or deal with the
question of their identity. Furthermore, the identity of male Arab Palestinian adolescents was found to
be even more foreclosed than that of their female counterparts. Additionally, the interconnectedness
with their parents was of a higher level than that found among American youth. Arab Palestinian
adolescents, for instance, displayed higher levels of emotional, financial, and functional dependence
on their parents than did American adolescents (Dwairy, 2004a).
Authoritarian parenting and psychological dependence and interdependence are frequently
misunderstood by Western counselors working with Arab and Muslim clients. Some studies indicate
that Arab children and youth are satisfied with authoritarian parenting (Hatab & Makki, 1978).
Additionally, other studies indicate that authoritarianism is not associated with any detriment to the

mental health of Arab youth (Dwairy, 2004b; Dwairy & Menshar, 2006). Examining these
psychocultural features among Turkish families, Fisek and Kaitibai (1999) commented that
authoritarianism should not be considered as oppression, emotional connectedness as enmeshment or
fusion, or the collective familial self as constriction or developmental arrest. Similarly, Western
counselors and therapists who work with Arab and Muslim families should be attentive to
psychosocial dependence and interdependence as appropriate and functional behavior that is based
on correct reality testing and the understanding of the social reality in Arab and Muslim societies, and
not as a fixation, regression, or sign of immaturity.

The concept of personality emerged along with the development of individualism in the West.
Personality theories arose to explain the internal dynamics that rule the individuals behavior. Most
personality theories assume an intrapsychic construct (ego, self, trait, drives) and processes
(conflicts, repression, self-actualization) according to which behavior is explained (Dwairy, 2002).
In contrast, in most collectivistic societies, where the personality continues to be other-focused
(Markus & Kitayama, 1998), norms, values, rules, and familial authority can largely explain the
behavior of the individual. In these societies, such as Arab Muslim ones, the concept of personality
must therefore go beyond the intrapsychic constructs and processes and focus on the social layer,
because the intrapsychic structures are dependent on the external, social layer of personality.
The main dynamic in the personal life of the Arab Muslim individual is in the interpersonal or
intrafamilial domain rather than the intrapsychic. Most sources of struggle are primarily external, a
conflict between personal needs and social and familial control. To contend with and manage this
common conflict, individuals require specific social coping skills. Central to these skills, which
prevail naturally in Arab societies, are mosayara (or mojamala) and istighaba. Mosayara is to align
oneself with others needs by verbalizing what is expected and concealing ones true feelings and
attitudes. It is an essential expectation in Arab Muslim societies because it helps maintain harmony
within the family and society. Istighaba, on the other hand, allows feelings, attitudes, and needs that
are not expressed because of mosayara to be expressed in the absence of familial or social
knowledge. Socially unacceptable behavior is expressed in solitude, away from the eyes of the
society, to avoid punishment or isolation. These are two complementary skills often used to cope
within the collective Arab society (Dwairy, 1997b, 1998).
Therefore, the two main entities of the collective personality are the social layer of personality versus
the private layer. The social layer is the component that is exposed to others and communicates with
them according to norms and values while using coping skills such as mosayara. The private layer is
the component that enables ventilation of unacceptable needs or expressions away from the scrutiny
of social control, while using coping skills such as istighaba. Neither layer is independent, but rather
is or is not conveyed according to the presence or absence of social, external control. Thus, the
collectivistic personality, as compared to the individualistic one, tends to act contextually rather than
consistently across social situations. Individual differences among Arabs and Muslims may be
displayed within two main factors: (1) the individuation of the person (the more individuated the
person, the less dominated by the social layer he or she is), and (2) the social status (individuals
behave differently according to their social roles, gender, age, and profession). These two factors

help explain and predict differences in behavior among Arabs and Muslims (for further discussion of
these factors, see Dwairy, 2002).

Since the typical intrapsychic structures of personality, such as ego, self-concept, and conflict, are
interpersonal rather than individual among many Arab and Muslim clients, to understand a clients
personality, the clinician needs to assess its other, more relevant components. Most important, the
clinician should assess the clients level of individuation to understand whether the social or the
private layer predominates, to know the context in which each component is activated, and to know
how effectively the client uses his or her social coping skills. The conventional battery of tests that
focuses on intrapsychic components of personality does not meet this need; therefore, the clinician
needs to seek out additional assessment tools that can assess the clients level of individuation,
values, adherence to norms, coping skills, and need to be understood within the family context.
A structured interview such as the Person-in-Culture Interview (Berg-Cross & Chinen, 1995) is one
example of a tool that could provide the therapist or counselor with the information he or she requires
to understand the needs, attitudes, and values of the individual as opposed to those of his or her
family. In such an interview, the client is asked to identify his or her attitudes and feelings concerning
a certain issue and then to identify his or her familys reaction to that same issue. This enables the
therapist to better understand similarities and differences between the clients values and attitudes
and those of the clients family.
Talking about a significant object (TASO) is another innovative technique that directs the client to talk
about him- or herself through a significant object the client identifies from his or her home. This
technique is based on the understanding that people in traditional cultures have strong emotional
attachments to their physical environments; therefore, talking about a significant item brought from the
home environment reveals significant memories and events pertaining to the clients life and family
(see Dwairy, 1999, 2001).

Psychopathology, according to Western personality theories, is considered a dysfunction within the
intrapsychic domain that causes suffering, impairment in functioning, somatic complaints, or
detachment from reality (American Psychiatric Association, 1994). Arabs and Muslims, however,
may display these symptoms because of a dysfunction within the individual-family relationship. The
main sources of psychopathology are often dysfunction between the social and private layers of
personality and the failure or misuse of social coping skills. For instance, an imbalance between
mosayara and social approval or the discovery of the istighaba by the family may cause severe
psychosomatic and social distress.
Furthermore, since the individual and the family, the mind and the body, and, at times, reality and
illusion are not easily distinguishable entities among many Arabs and Muslims, a disorder is
displayed in all of these domains in a diffused rather than stylistic way. Patterned disorders that are

described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV-TR) are not displayed clearly among Arabs and Muslims. For instance, major depression,
considered in the West to be a mood disorder characterized by sad feelings, hopelessness, and
helplessness, may be manifested among Arabs and Muslims only physically in somatic complaints,
frequently with no feelings of sadness, hopelessness, and helplessness (Al-Issa, 1989; Baasher, 1962;
Racy, 1980).
Additionally, many Arabs and Muslims have a different concept of reality from that of Westerners.
They may at times consider visions and dreams to be the true reality (Al-Issa, 1995; Dwairy, 1997a),
and on the basis of dreams and visions, they may make crucial decisions in their lives. This
difference in the concept of reality challenges reality testing as a criterion for mental disorder, as
adopted by the Western nosology. In addition, in the diagnosis of schizophrenia, the conventional
DSM-IV nosology does not aid in differentiating between cultural hallucinations and psychotic ones.
A typical psychotic disorder among Arabs and Muslims is acute, precipitated by familial or social
distress, and polymorphic, involving a large range of symptoms. Many recover mental health within a
year, even without any medication, and typically have no family history of psychosis (Okasha, Seif El
Dawla, Khalil, & Saad, 1993).
There is also an increasingly debated issue around the prevalence and quality of posttraumatic stress
in the Arab region. An epidemiological study conducted in Lebanon highlighted the fact that despite
ongoing wars, political turmoil, and civil unrest, rates of posttraumatic stress disorder, based on
DSM-IV-TR diagnostic criteria, are low and similar to rates found in the United States (Karam,
Noujeim, Saliba, & Chami, 1996). PTSD symptomatology such as intrusive flashbacks or nightmares
may not be the central problem area that Arabs present with. Other studies conducted in Lebanon and
Palestine have found higher rates of depression, anxiety, aggression, and socially avoidant behaviors
after exposure to sustained, repeated, or multiple war traumas (Cloitre et al., 2009; Karam, 1997;
Khamis, 2008). These symptoms may more adequately describe the traumatic reactions of Arabs in
the region. Therapists in the West must be careful not to assume a diagnosis of PTSD based on past
trauma alone, as there may be other, more pertinent, issues and symptoms that need direct attention.

Psychotherapy and Counseling

Working with Arab and Muslim clients requires careful attention and sensitivity to the major
psychological, social, and cultural issues described above. Each phase of therapy has its own
particular set of challenges and concerns.

Choosing a Psychotherapist or Counselor

Although research has found that matching therapist and client on gender and ethnicity does not change
therapy outcome (Zane, Hall, Sue, Young, & Nunez, 2004), these two factors should be considered
with Arab and Muslim clients. Among very religious or conservative Arabs and Muslims, there are
limitations to how freely the opposite sexes can interact with one another, particularly with strangers
(Kobeisy, 2004). In addition to the individuals own religious, cultural, and social beliefs, the issue
for which counseling is sought is a very important consideration (Kobeisy, 2004). Arab and Muslim

clients sitting with therapists of the opposite sex may find it very challenging to discuss certain
personal issues, and this may facilitate resistance to the process.
Matching therapist and client on cultural or religious background needs careful attention also. Some
Arabs and Muslims prefer therapists of the same ethnic identity in order to ensure a process free of
stereotypic judgments. However, some Arabs and Muslims who particularly value the confidentiality
that comes with the therapy process may want to avoid having someone from their own community
becoming aware of their personal secrets. They may fear being judged or blamed by an Arab Muslim
authority as they may be in their own families. Such clients actually prefer therapists whose
backgrounds are different from their own (Kobeisy, 2004). Thus, Arab and Muslim clients seeking
services should be asked directly about their preferences in this area before psychotherapy begins.

The Beginning Phase

Before embarking on a specified therapeutic path, the therapist should consider several aspects of the
clients experience. The therapist should demonstrate a thorough understanding of the clients
background before deciding on the treatment plan. First, the therapist must assess the clients comfort
with communicating in English. Arabic is a rich language with many words that refer to varying
intensities of the same emotions, and Arabic speakers make frequent use of metaphors. Speaking in
ones mother tongue naturally elicits a wider emotional response and complexity. Just because clients
may be able to communicate rather well in English does not mean that they can express themselves in
that language with the same level of clarity as they can in Arabic (Sayed, 2003b). In such cases,
therapists need to exercise patience in communication and ask their clients questions that facilitate
both interest in and acceptance of what the clients are saying and how they are saying it. The use of an
interpreter can be an option when the struggle to articulate appears to interfere with the therapy
process and emotional expression. However, the therapist must assess the need to use an interpreter
carefully, because doing so can lead to complications. While a client may initially welcome the idea
of having an interpreter in session, later the presence of a third party who is similar to the client in
cultural and/or linguistic background may create increased feelings of shame or unease for the client.
Thus, in order to save face, the client may form a coalition with the interpreter that interferes with an
honest and open therapy process (Sayed, 2003b).
Second, the therapist should assess the clients level of acculturation to Western society and norms, as
there is much heterogeneity among Arab and Muslim communities and within individual families in
terms of acculturation (Abi-Hashem, 2011; Al-Krenawi & Graham, 2000; Erickson & Al-Timimi,
2001). An immigration history may also be pertinent, particularly if the client has endured any
psychological trauma, such as armed conflict or persecution, in his or her country of origin, or if the
client has experienced any discrimination or prolonged mourning in the host country (Abi-Hashem,
2008; Nassar-McMillan & Hakim-Larson, 2003).
In addition, immigration to the West challenges the cultural features mentioned earlier. After
emigration, a fundamental cultural revision and change may take place in the mind of the Arab and
Muslim individual. The Western, liberal, individualistic life may seem too permissive and therefore
threatening to traditional Arab and Muslim values concerning family, women, and child rearing.
While Arab and Muslim immigrants may want to be part of the Western society, they may be afraid of

becoming enmeshed and losing their values and identity. Therefore, at some initial stage after arrival
in the host country, Arabs and Muslims may become more committed to certain cultural norms and
values that had only a marginal position in their way of life before emigration. Many may find refuge
in their cultures of origin and become more nationalistic or religiously fundamentalist than before.
Other first-generation Arab and Muslim immigrants live in two polarized worlds and are torn
between two conflicting cultures, struggling to define themselves. Counselors and psychotherapists
need to be sensitive to these two seemingly contradictory goals of Arab and Muslim clients: the need
to adapt to Western society and the need to retain their own cultures (Abi-Hashem, 2011).
Third, the therapist or counselor should assess the internal resources available to the client versus the
power the social environment exerts on her or him. Level of individuation from the family, ego
strength, and the control of the family are three major factors that should be assessed before any
therapy takes place (Dwairy, 2006). On the basis of this assessment, the counselor may decide
whether to apply therapies that reveal unconscious contents and end in greater self-actualization or to
apply therapies that focus on basic problem-solving and communication skills. The higher the level of
the clients individuation, the stronger the ego, the greater the flexibility of the family, the more
apposite it is for the counselor to apply insight-oriented interventions. With a client who is
unindividuated, has weak ego strength, and lives in a strict and traditional family, the counselor will
want to adopt short-term and problem-focused interventions.

The Psychotherapy Process

Because the distresses of clients from collective cultures are commonly related to intrafamilial
disorder, counselors and therapists need to work on restoring this order. With more traditional Arab
Muslim clients, working on revealing unconscious contents and helping the clients align themselves
with their own personal needs and values can be counterproductive, in that it may change the clients
behaviors in ways that clash with the clients social and religious environments and meet with family
disapproval. Assuming also that clients are typically the most vulnerable members of their families, it
seems unrealistic to expect that they will be able to endure the conflicts within their families or
communities that would result from their expressing forbidden feelings and needs.
At the same time, children of Arab Americans who were born in the West may experience increased
tension between the demands of their families and those of the society of their host country. In some
cases, severe power struggles emerge between these children and their parents. It is sensible in such
cases for counselors to determine if any differences in religiosity and cultural identity exist between
parents and children (Springer, Abbott, & Reisbig, 2009). Therapists working with such families
need to support both the parents demands and their childrens struggles while aiming for increased
communication, understanding of positions, and compromises between parents and children.
Counselors and therapists should try to understand the rationale of these families systems from
within, to listen to both the stresses and anxieties that the parents experience and the stresses of their
children, to express empathy with their conflicts, to harness resources that exist from within Islam and
their beliefs, and to encourage and empower those progressive components in the parents value
system and religion that may facilitate therapeutic changes. Counselors should remember that their
role is to serve the needs of their clients within the clients own families and value systems rather

than to serve only the clients individual needs and values.

Integrating positive religious coping strategies into therapy with Arab and Muslim clients has been
demonstrated to yield positive clinical outcomes (Abu-Raiya & Pargament, 2010, 2011), particularly
because for most of these clients religious identity is a primary source of comfort. Pargament, Koenig,
and Perez (2000) define positive religious coping strategies as methods an individual uses to develop
a safe and secure relationship with God, a higher meaning to his or her life, and a sense of spiritual
connection to others; as such, therapists may find it useful to encourage their Arab and Muslim clients
to draw on their religious coping resources. Another study found that integrating knowledge of the
Quran and the Hadith (sayings and customs of the Prophet) into an evidence-based therapy program,
such as cognitive-behavioral therapy, rapidly improved anxiety symptoms in Muslim patients with
strong religious backgrounds (Razalli, Aminah, & Khan, 2002). In general, because evidence-based
therapies disregard individual and cross-cultural differences, it is imperative that counselors working
with Arab and Muslim clients modify such therapies so that they are culturally sensitive.
Another important aspect of therapy with Arab and Muslim clients is the need to improve clients
communication with their families. Even though a counselor or therapist may be working individually
with a client, family sessions or direct work with some members of the clients family may prove
essential (Al-Krenawi & Graham, 2000), despite the fact that such an approach is contraindicated in
traditional individual therapy. A therapist may misconstrue a clients wish to involve his or her
family, or the familys wish to be involved, as codependency, overinvolvement, overprotection, or
enmeshment, whereas the client may see the therapists failure to understand the need for family
involvement as professional neglect (Al-Krenawi & Graham, 2000). Thus, counselors and therapists
who work with Arab and Muslim clients should give special attention to understanding the
relationship dynamics of the family (conflicts, coalitions, and force balances) and the status of the
client within the family in order to restore the family order. A counselor who ignores the influence of
the family and focuses instead on the clients personal issues may miss the point and make a client
who appears enmeshed in the family feel misunderstood. In addition, a counseling approach that
threatens familial authority or the clients faith may result in premature termination of the counseling
process and leave the client to suffer the consequences. Drawing on family systems theory allows the
therapist to embrace all the significant subsystems that make up the clients world without placing
blame on any one element of the system (Nichols, 2012).

Problems of Transference and Countertransference

Arab and Muslim clients may manifest ambivalence toward the West explicitly or implicitly in
therapy with Western counselors, and this ambivalence may be displayed through transference and
countertransference processes. Many Arab and Muslim clients bring their cultures to their counseling
sessions and consider Western counselors to be representative of all that the West means for Arabs
and Muslims. An Arab and Muslim client may express submissiveness and idealization to a Western
counselor not only as transference of the childparent relationship but also as transference of the
Arab and MuslimWest relationship. Expressions of anger and rage on one hand and feelings of
inferiority or fear on the other are expected components of an Arab and Muslim clients transference
toward a Western counselor. For some Arab and Muslim clients, the American therapist may
represent the whole American regime and its attitude toward the Arabic and Islamic nations. This

transference may be expressed in terms of we (the Arabs) and you (the Americans). The therapist
should not take any accusation personally but rather should help the client to differentiate among the
therapist, Americans in general, and American foreign policy. An inquiry such as When you say
you, do you mean we the Americans or me the therapist? may help the Arabic client to be aware of
the differences between Americans in general and the therapist as a particular person. An open and
honest discussion of the impressions the client carries about the United States and other Western
countries may prove helpful in facilitating the therapeutic alliance, and this process may demand
similar disclosure on the part of the therapist before the patient can truly trust the therapist.
The Arab clients perception of the therapist can also affect the transferential relationship. The client
may appear submissive as a result of his or her perception of the therapist as all-knowing, someone to
be afforded the highest status and respect. Such a client may place all trust in the therapist and
initially give him or her full control over treatment and decision making (Sayed, 2003a). Other Arab
and Muslim clients, in contrast, may generally mistrust counselors or therapists altogether and tend to
prefer to seek psychological help from family members, elders, or clergy (Abi-Hashem, 2011). Part
of this mistrust has to do with the fear of being labeled as crazy, and this fear is compounded by the
notion among some Arabs and Muslims that people who suffer from mental illness have a weak self
and weak faith (Sayed, 2003a).
Western counselors need also to be aware of their own biases and assumptions regarding Arabs and
Muslims, as these will affect their countertransference toward Arab and Muslim clients and families.
They need to be open to listening to and learning about the client and family, divesting themselves of
any stereotypic notions and prejudices they may have absorbed from the Western media (AbiHashem, 2011; Sayed, 2003b). For example, Western counselors may find it difficult to understand
the rationale of the traditional Arab and Muslim parenting style, not having experienced the vital
individual-family interdependence that exists where state-provided care is absent. Counselors may
easily find themselves opposing the authority of Arab and Muslim families and employing therapeutic
or even legal means in attempts to create a liberal, egalitarian order in these families. They may need
to make a great conscious effort to avoid judging the behaviors and attitudes of their Arab and Muslim
clients and their families according to Western norms and values.
Arab and Muslim clients can be helped best by counselors or therapists who empathize with their
collective cultural, political, and social values. By manifesting acceptance, tolerance, and
unconditional positive regard toward clients families, their traditions, and their beliefs, counselors
may help these clients trust and relinquish anger, mistrust, or feelings of inferiority. Empathy and
acceptance that are limited to the individual client and do not encompass the family and culture do not
suffice and, in some cases, may be counterproductive or threatening. Additionally, pushing a client to
confront her or his family may prematurely place the client in an irresolvable familial conflict.

A therapist working with an Arab and Muslim client may want to apply a within-culture therapy and
employ culture to facilitate therapeutic change. In order to achieve this, the therapist must identify
subtle contradictions within the belief system of the client and employ cultural aspects that may
facilitate change. Similarly to how a psychoanalyst analyzes the intrapsychic domain and brings

conflicting aspects to consciousness (e.g., aggression and guilt) to mobilize change, a culturanalyst
analyzes the clients belief system and brings contradicting aspects to consciousness to create a
revision in attitudes and behavior. The assumption that underlies culturanalysis is that culture
influences peoples lives on an unconscious level. When a therapist inquires and learns about a
clients culture, he or she may find some unconscious aspects that are dissociated from the clients
conscious attitudes with which a conflict exists. Once the therapist brings these aspects to the
awareness of the client, the client starts to revise his or her conscious attitudes, and a significant
change may be effected.
Culturanalysis can be understood from different theoretical perspectives. In the same way that a
humanistic (Rogersian) therapist establishes an unconditional positive regard for and empathy with
the individual to facilitate the expression of the authentic self, a culturanalyst establishes positive
regard for and empathy with the culture and facilitates the recognition of more and more aspects of
the culture that were denied and that may be employed to accomplish change. Alternatively, one can
understand this process in terms of generating a cognitive dissonance within the clients belief system
that necessitates change. For example, Samer, a 22-year-old religious Muslim client struggling with
depression, was, as many individuals with depression do, focusing on negative events in his life and
denying many positive ones. He tried with no success to protect himself from negative events by
praying more frequently. When confronted with his own religions beliefs, he was prompted to
examine the ways in which he truly appreciated the grace of God as a Muslim man. The therapists
employment of the clients religious belief system made change for Samer easier and more stable.
(For more examples, see Dwairy, in press.)

Indirect Therapies
Arabs and Muslims, like members of many other cultures, have a concept of reality that differs from
that of Westerners. The positivistic concept of reality in the West is associated with a literal reality.
The Arabic language, in contrast, is very metaphoric (Hourani, 1983, 1991), and therefore many Arab
and Muslim clients may express their problems through metaphors and images. Given these cultural
characteristics, therapists should facilitate these clients use of imaginative and metaphoric
conceptions over positivistic conceptions. Approaches such as metaphor therapy may be especially
useful with Arab and Muslim clients.
Since more traditional Arab and Muslim clients are likely to feel uncomfortable with addressing their
family lives directly, and because they primarily use metaphoric language to express distress,
therapists and counselors should enter these clients metaphoric world and facilitate metaphoric
solutions. When a client who is trying to say that her family does not understand her suffering
expresses herself using a proverb such as Elli eidu belmay mesh methl elli eidu bennar (The one
whose hand is in water is not like the one whose hand is in fire), the therapist can work through this
metaphor without addressing the familial relationship directly.
Kopp (1995) describes a three-stage approach to metaphor therapy in which, first, the client is asked
to select a metaphor that describes the problem in concrete terms; next, the client is asked to change
the metaphor in such a way that it describes the solution to the problem; and finally, the client is asked
what she or he has learned from the metaphoric solution and what practical implications can be

deduced from it that she or he can use to cope with the problem. Bresler (1984) describes a
metaphoric technique designed to help chronic pain sufferers control their pain by controlling images
in their minds. First, the client is guided to draw a picture of the pain, then to draw the state of no
pain, and then to draw the pleasure state. In the second stage, the client learns to control the images in
his or her mind and to retain the pictures (images) of no pain and pleasure. Through these three
images, the client processes the pain experience metaphorically. Let us return to our example about
the feeling of a hand in water versus the feeling of a hand in fire. If this metaphor describes the
problem, the therapist may suggest that the client draw (or imagine) the metaphor and then create a
new picture that describes the relief of finding a solution. The fact that the client is involved in
imagining a metaphor-based solution influences his or her real experience.
Metaphor therapy is a suitable intervention when the aim of the therapist is to avoid dealing directly
with repressed contents. Other indirect therapies that may be useful with Arab and Muslim clients
include guided imagery therapy, art therapy, and bibliotherapy (Dwairy & Abu Baker, 1992). In all
these therapies, the client processes the problem and finds solutions or new coping strategies on a
symbolic, imaginative level, influencing the psychosocial level of experience. (For more discussion
of the metaphor model of therapy, see Dwairy, 2006, Chapter 11.)

Arabs are the descendants of Arabic tribes who once lived in the deserts of the Saudi peninsula, Iraq,
and Syria and today number about 285 million living in 22 Arab countries. The Islamic religion
appeared in one of the main Arabic tribes in the 7th century and has now been adopted by 1.3 billion
Arab and non-Arab people worldwide. The Arab and Muslim worlds share the ethos of tribal
collectivism and Islamic values, but they are also influenced by their exposure to Western culture.
The social systems in both worlds tend to be collective and authoritarian: The individual and family
are interdependent, and the family is ruled by a patriarchal, hierarchical authority.
Within this collective system, many Arab and Muslim youth do not become psychologically
individuated from their families. Their personalities continue to be collective and directed by
external norms and values rather than by internal structures and processes. These Arabs and Muslims
often come from traditional and religious families where collective values are highly enforced and
the standards or expectations placed on males of the household differ from those placed on females.
The clinical picture of Arab and Muslim clients may differ from that described in the DSM-IV-TR.
Counselors and therapists who work with these clients should be aware of the challenges of dealing
with unconscious, personal, and/or repressed contents without acknowledging the importance of the
family belief system and the real restrictions that may be placed on the individual. Arab Americans
face the additional struggle of managing the demands of their families along with the demands of the
culture of their host country. Individuals often require assistance in allowing themselves to adopt new
values from the host country without feeling that their cultural identity is being threatened. Throughout
this process, clients family members also require assistance in communicating their needs and fears
to one another so that the family system itself does not feel threatened either. Therapists and
counselors who work with Arab and Muslim clients should modify their therapies by incorporating
cultural and religious norms and beliefs and by including the use of family therapy, metaphor therapy,
and other indirect therapies.

Critical Incident
Self-Fulfillment Within the Family Culture
Sawsan, a 17-year-old girl, was brought by her father to counseling because she had withdrawn
herself from family meetings and activities during the past 2 months, instead spending most of her
time listening to music in her bedroom. Lately, she had complained about headaches that lasted all
day with no relief, despite the use of painkillers. The familys medical doctor had told Sawsans
parents that she may be passing through a stressful period and referred them to counseling.
At the initial intake meeting with Sawsan and her father, the father dominated the conversation, and
Sawsan displayed approval of his views. The father described her as a perfect girl who always met
her parents expectations in school and in social behavior. The change in her behavior made her seem
to him as not her. He tried to attribute this change to bad friends or bad readings. He also
denied that Sawsan was experiencing any stress and emphasized how much the family loves Sawsan
and cares for her needs. He said, Nothing is missing in her life. Weve bought her everything she
wants. She couldnt be passing through any stress.
Knowing that most Arab girls find it very difficult to express their feelings in front of their fathers (or
both parents), after listening to the father the counselor asked to be allowed to have a private
conversation with Sawsan, and the father agreed. At the beginning of this conversation, Sawsan
continued to go along with her fathers views, describing how much her parents love and support her
and denying any stress. Only after the counselor validated to her that she indeed has good parents was
she ready to reveal a conflict that had been raised recently concerning her desire to study at a
university located far from her village, which would necessitate her living in the student dorms. Her
father rejected the idea of his daughter living away from the house, far away from his immediate
control. In an attempt to compensate for this, he bought her a new computer and suggested that she
study at a nearby college. She insisted that she wanted to study at the university and tried to push until
her father became angry, claiming that she was imitating bad girls who sleep away from their
homes. As she described this conflict, she continued to remove any accusation from her father, saying,
He did this because he is worried about my future, and He is right and I should understand this.
The counseling process lasted for five sessions, during which the counselor met with only the father
three times in order to establish a positive joining with his position and worries. The counselor
then revealed to the father some contradictions within his belief system regarding the importance of
education, as described in culturanalysis. After that, the counselor met with both father and daughter
and encouraged Sawsan to explain to her father why she felt she needed to study at the university and
to express her commitment to her family values. The counselor also encouraged the father to express
his care and worry to Sawsan and then to discuss a compromise that may be accepted by both of them.
He agreed to allow his daughter to study at another university, in a city where she could live with her
uncles family. In a follow-up meeting, Sawsan and her father expressed satisfaction. Sawsan had
returned to normal interaction with the family and no longer complained of headaches.

Discussion Questions

Sawsans case illustrates several issues that are typical of those facing Arab Muslim youth and their
1. Arab Muslim clients usually approach counseling or psychotherapy after they have visited
medical doctors. How might this affect the counseling process?
2. Young Arab Muslim clients are typically brought to counseling by their parents and take a
passive and submissive role in the first meeting, when their parents are present and dominate the
conversation. Should a non-Muslim counselor try to alter this interaction? If so, what steps might
the counselor take?
3. Sawsan had expressed her distress passively (withdrawal) and somatically (headaches). How
central are these forms of expression for her case?
4. Traditional Arab Muslim parents are typically not sensitive and empathic to their childrens
emotional needs and do not understand why their children are distressed as long as their
materialistic needs (e.g., Sawsans new computer) are supplied. How might the counselor deal
with the parents if and when such beliefs and attitudes emerge?
5. For Arab Muslim parents, traditions and values are more important for decision making than
their childrens feelings. Can or should the counselor try to ameliorate this tendency?
6. Arab Muslim parents tend to attribute bad behavior to external entities such as bad friends or
bad readings or, in some cases, bad spirits. Is this something that the counselor may want to
address with the parents?
7. The behavior of Arab children in the presence of their parents (external control) is often
extremely different from their behavior when they are away from external control. It is not that
one behavior is real and the other is false; rather, the two behaviors represent two different yet
real components of the childrens personalities. As a counselor, how would you deal with this?
8. It is often difficult for Arab children to criticize their parents in conversations with foreigners,
such as Western counselors, and they typically feel the need to emphasize that the intentions of
their parents are good. Should the counselor avoid discussing the clients parents with the client?
9. The main conflict that needed resolution in the above case was an intrafamilial rather than an
intrapsychic one; therefore, counseling was focused on the family relationship in order to
accomplish change in the relationship that fits the needs of both the identified patient (Sawsan)
and the family belief system. Do you agree that change was possible only after the counselor had
established a positive relationship with the father?
10. Counseling with Arab and Muslim families should not seek to change or confront the family
culture or the family structure; rather, it should be aimed at finding better solutions within the
fabric of that culture. Explain how the counselor might use a familys internal resources and
strengths to change this situation for the better.

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Part III Counseling Issues in Broadly Defined Cultural Categories

Major shifts have occurred in the United States and around the world within the past decade that
relate to the four chapters in this section. The global economic recession has adversely affected most
countries, and the United States is experiencing a widening income gap that is increasing the number
of people displaced to the margins. Tensions around immigration have increased globally as well, as
many people are leaving their countries of origin to seek employment and other opportunities. The
landscape of U.S. demographics has been significantly affected by these trends: By 2050, it is
projected that Whites will no longer be a numerical racial majority in the United States, and the 2010
census results suggest that more than half of the growth in the total population within the previous
decade resulted from the increase in the Latino population. As a result of all these changes, the need
to address the diversity and inequalities in American school systems has become even more pressing,
with educational disparities still on the rise despite numerous so-called educational reforms and
accountability initiatives.
In addition, the LGBQ and trans* communities have increased their visibility, and struggles for
LGBTQ rights have gained traction, with some advances in legislation to protect people from
discrimination based on sexual orientation, gender identity, and gender expression across the United
States and around the world. We have also seen the extension of marriage benefits to same-sex
couples in some locations. These changes have not been uniform, however; constitutional bans on the
recognition of same-sex marriages have proliferated, and some countries have officially criminalized
the LGBTQ community.
Given these changing realities, we need to rethink how we approach our work with clients from
diverse cultural populations. Thus, Part III of this edition of Counseling Across Cultures includes
many new authors and addresses new approaches to the topics of gender, sexual orientation,
marginalization, and school counseling.
Michi Fu, Joe Nee, and Yin-Chen Shen (Chapter 10) are new contributors who discuss current gender
issues in counseling from a nonbinary, transinclusive, and intersectional perspective. They begin by
examining relevant definitions and deconstructing the prevalent binaries that continue to perpetuate
privilege (e.g., hegemonic masculinity, cisgender privilege) and oppression (e.g., sexism,
heterosexism) around gender. They present different types of sexism and briefly explore gender at the
intersections of race/ethnicity, social class, and sexual orientation. They finish their discussion of this
important topic with a series of recommendations for counselors and clinicians who are dealing with
gender issues in their practice.
Returning to Counseling Across Cultures is Melanie M. Domenech Rodrguez, joined on this
occasion by Melissa Donovick and Kee J. E. Straits, with a revised and updated chapter on
counseling marginalized populations (Chapter 11). These authors discuss the process and politics that
lead to marginalization and examine how the definitions and the experience of marginalization are
relative to context. They also highlight the importance of context in counseling with people who have
intersecting marginalized identities. The authors consider the interplay among privilege, power, and
marginalization. They challenge counselors to shift their conceptualizations and reframe their practice

by centering the margins, and they provide a set of guiding questions for an approach that
counselors can use in working with clients from marginalized populations. The authors illustrate this
approach using undocumented immigrants as a case example.
Cheryl Holcomb-McCoy and Ileana Gonzalez, new contributors, present the chapter on school
counseling (Chapter 12). They propose a shift in school counseling practice and policy that is rooted
in cultural competence and social justice principles and where advocacy is central to the school
counselors role. They discuss some of the challenges of 21st-century school counseling, which
include multiple dimensions of inequality and violence that many public school students face: mental
health disparities, achievement inequalities, college access and dropout disparities, lack of access to
STEM (science, technology, engineering, and mathematics) preparation, and peer victimization,
among others. The authors describe the professions standards for multiculturally competent practice
and present various frameworks for approaching school counseling from a social justice stance.
Eliza A. Dragowski and Mara R. Scharrn-del Ro bring a new approach to the discussion of sexual
orientation to this edition of Counseling Across Cultures. This shift is reflected in the revamped title
to Chapter 13, Reflective Clinical Practice With People of Marginalized Sexual Identities. The
authors use marginalized sexual identities as an umbrella term to refer to the identities of people
who fall outside heteronormativity, many of whom identify as lesbian, gay, bisexual, and/or queer
(LGBQ). From these authors perspective, in order to engage in multiculturally competent practice,
mental health practitioners need to engage in critical self-reflection, personal examination of their
social locations, and the deconstruction of dominant norms. Dragowski and Scharrn-del Ro
emphasize the importance of counselors being aware of the intersectionality of identities, privileges,
and oppressions, and they elaborate on the intersection of sexism and heterosexism and its
significance to counseling work with marginalized sexual identity populations. Moreover, they argue
that counselors should develop an advocacy position with regard to the social inequalities and
oppression faced by marginalized sexual identity populations.
The four chapters in Part III consider issues of systematic privilege and oppression and emphasize
how important it is for mental health professionals to engage in critical self-reflection on their own
identities and examination of their own areas of privilege and oppression. These chapters also
address issues of intersectionality of identities and present various approaches that counselors might
use to engage in multiculturally competent practice with the populations discussed. Finally, all of the
chapters stress the importance of counselors adopting an advocacy position as part of multiculturally
competent practice with these populations. These elements are all important and necessary to
counseling in increasingly diverse environments.

10 Gender, Sexism, Heterosexism, and Privilege Across Cultures

Michi Fu
Joe Nee
Yin-Chen Shen

Primary Objective
To discuss the impacts of gender, sexism, and heterosexism on privilege across cultures

Secondary Objectives
To introduce a discussion of various forms of privilege (e.g., male privilege, nontransgender
To explore gender at the intersections (e.g., race, social class, and sexual orientation)
In this chapter we aim to explore the intersections of gender with other aspects of identity, such as
social class, sexual orientation, and race. How do these variables influence privilege? We begin by
offering terminology consistent with the expanded framework. We then invite the reader to consider
how different forms of privilege are viewed from both the marginalized and the privileged
perspectives. We also consider and examine multiple intersections of gender with other aspects of
identity. Finally, we address the clinical implications of privilege and offer recommendations to
counselors working with clients who are dealing with the issues raised in this chapter.

Defining Gender-Related Concepts

When first embarking on a discussion of gender and different forms of privilege, it is useful to
develop a common understanding of operating definitions. Therefore, we offer definitions of sex,
gender, gender identity, gender role, and transgender at the outset to reduce potential confusion, as
these are the basic terms we use throughout this chapter.
Sex refers to physical markers that are typically used to define humans as male or female. The
specialized reproductive cells of a developing embryo begin to develop into specific organs (e.g.,
penis, clitoris, vagina, testes, and ovaries) based on X and Y chromosomal makeup as well as the
combination of testosterone or estrogen hormonal interactions in uterus (Blackless et al., 2000).
Gender, in contrast, is a learned behavior and social construct influenced by gender role, personality
traits, attitudes, values, and the relative power that society assigns in a specific culture (Looy &
Bouma, 2005). As a social construct, gender is an acquired identity and set of behaviors that are
learned over time, and is independent of sex (Mar, 2010). In other words, sex is fixed and based in
nature; gender is arbitrary, flexible, and based in culture (Goldstein, 2001, p. 2).

Gender identity is ones perception of ones own gender (e.g., man, woman, boy, girl, nongendered,
bigendered, transgender, genderqueer), and such perception may or may not be congruent with the sex
assigned at birth. Money (1994) defines gender identity as the sameness, unity, and persistence of
ones individuality as male or female or androgynous, in greater or lesser degree, especially as it is
experienced in self-awareness and behavior. Gender role is everything that a person says and does to
indicate to others or to the self the degree that one is either male or female or androgynous (p. 169).
Hence, gender identity is expressed through gendered behaviors and is connected to ones sense of
affiliation to a gender group such as male or female.
At the core of the work that Sennott and Smith (2011) do is the awareness that gender goes beyond the
traditional binary, and that there is a continuum of identities ranging from more feminine to more
masculine. Furthermore, ones identity can only be named by the person claiming the identity
(Sennott & Smith, 2011, p. 220). The Identity Continuums are tools created to educate people about
the differences among phenotypic sex, gender identity, gender expression, and sexual practices
(Sennott & Smith, 2011, p. 221). First on the Identity Continuums, the sex continuum denotes that
phenotypical sex goes beyond the penis (male) and vagina (female) and expands across more than 40
different intersex conditions, of which three-fourths can be distinguished as separate using genetic,
chromosomal, or hormonal testing (Sennott & Smith, 2011).The second continuum, the gender
continuum, is experienced internally and cannot be labeled by persons other than the individual. As
Mandlis (2011) points out, The deeming of someone male or female is based on a single doctors
individual discretion through a brief genital examination; the deeming of man or woman occurs many
times a day through interactions between people that depend on the interpretation and discretion of the
individuals involved (p. 233). The third Identity Continuum is gender expression, which has a
number of different levels between the distinct end points of feminine and masculine. Femininity or
masculinity can be conveyed through choices of clothing, gestures, verbal communication, and body
language, and can be expressed differently throughout the day depending on whom the individual is
interacting with. Similarly, the interpretation of gender expression by others can vary from moment to
moment, as it depends on the interpretation and discretion of the individuals involved (Mandlis,
2011, p. 233).
Transgender (trans, trans*) is an umbrella term often used to refer to people who experience their
gender identities as being different in some way from the sexes they were assigned at birth (Gay,
Lesbian & Straight Education Network, 2013). Transgender identity can be claimed by a very diverse
group of people, some of whom may or may not want to alter their bodies permanently to match their
gender identities and presentation.

Expanding Beyond a Binary Framework

When considering gender identity in relation to many of their clients, it is critical that mental health
professionals move beyond the binary framework, although this can be challenging because the
framework is so deeply ingrained in many societies. Traditional notions of sex and gender promote
the belief that gender is determined genetically and is recognized at birth based on the appearance of
the external genitalia. This belief rests on the assumption that an individuals visible sex organs are
the exclusive determinant of that persons gender identity, and that only two valid gender identities
exist. Based on the social categorization framework, the categories of male and female are viewed as

representing a fundamental divide of the natural world (Macrae & Bodenhausen, 2000, p. 113) and
serve as norms to help people maneuver and function. With the establishment of these norms, those
who fall outside them are often seen as in violation or are categorized as part of the outgroup, and
therefore are subject to discrimination, prejudice, and even condemnation. Such division not only
creates restrictions on the diversity of gender identities people experience (e.g., transgender,
genderqueer, or bigendered), but it also limits all other gender expressions that lie within the
feminine-to-masculine continuum (Sennott & Smith, 2011).
Since society provides few opportunities for variations in gender expression, gendervariant/nonconforming/questioning and transgender youth often experience enormous pressure to
conform to social expectations. This conformity may lead to feelings of confusion and isolation
(Gagne & Tewksbury, 1998). Discrimination and prejudice are major contributing factors to gendervariant and transgender peoples experience of psychological distress and other negative life
outcomes. These can include depression, anxiety, and other emotional and behavioral difficulties;
family and peer relationship problems (Di Ceglie, 2000); inability to perform at school or at work;
low self-esteem and negative self-image (Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005);
campus and classroom bias rejection (Case, Stewart, & Tittsworth, 2009); and school dropout
(Sausa, 2005).

Privilege and Oppression

Within gender, there are two areas of social and institutional privilege: the privilege of the masculine
over the feminine and the privilege of nontransgender (or cisgender) individuals over those who
are gender variant or nonconforming or who identify as transgender.

Sexism and Male Privilege

Individuals experiences of gender and gender-based oppression are largely determined by their
cultural roots as well as by the mainstream societies in which they find themselves. The latter may or
may not diverge significantly from the former. These systems are inherently difficult to identify, and
often the first step toward addressing problems of gender-based oppression is to develop an
awareness of them. While racism and discrimination are usually easily recognizable as acts
committed among individuals, the concept of privilege is less visible (McIntosh, 1988). Privilege,
according to McIntosh, occurs when one group has something of value that is denied to others simply
because of the groups they belong to rather than because of anything theyve done or failed to do
(quoted in Johnson, 2001, p. 23). An example of male privilege is the fact that a man can travel crosscountry alone with less fear of being sexually assaulted than a female traveler would face. Another
example might be that it is legal for men to be in public shirtless, whereas in most jurisdictions in the
United States it is a criminal offense for a woman to do the same. An additional example is that men
are expected to be competent in the fields of science and mathematics, while it is assumed that
competence in these areas is unusual for women.
The fact that privilege is unearned and afforded to the dominant social group at the cost of denying the
same to the oppressed group makes it a difficult topic to address. Identifying privilege for what it

really is, an unearned advantage, is often difficult for those who have long enjoyed the benefits of
privilege and, as a result, are unaware of the nature of the problem (Coston & Kimmel, 2012;
McIntosh, 1988). Male privilege is a power structure that exists across most cultures and
multicultural populations. An example is the influence of Confucianism in many East Asian cultures,
which dictates that males possess the power in their families.
Men and women tend to be socialized differently in the world. In the United States, boys and girls are
oversaturated with guidelines and expectations based on gender, even before birth. What it means to
grow up as a male is very different from what it means to grow up as a female. For example, the
saying Boys dont cry may mean that males grow up learning not to express their emotions freely. It
may also mean that an individuals value as a person is determined by how much he or she embodies
the masculinized ideal, such that even girls who cry are subject to ridicule.
Privilege is encountered and experienced at the individual level, but it is maintained and facilitated at
the institutional level. Individuals experience socially constructed privileges, which are socially
constructed discourses or guidelines followed by the majority of individuals and which arrange
individuals relative to others in power relations (Winslade, Monk, & Drewery, 1997). Discourses are
formal ways of thinking that provide the basis for how societal messages are interpreted, endorsed,
and maintained by the dominant group. These discourses lay the foundation for the ways people act in
the world and the ways in which the world, in turn, acts towards people. Robinson (1999) notes that
even though individuals may not have specific membership in privileged or oppressed groups, they
mistakenly perceive themselves to be immune to the effects of oppression. While individuals may not
be aware of the results of privilege or in fact consider themselves to be neutral, they occupy the same
physical space and face the same societal ills as those who are marginalized.
Men are socialized as gendered beings to embrace and/or be influenced by rigid and sexist
discourses in which they are oriented toward success and competition (Coston & Kimmel, 2012).
This orientation is positively reinforced or rewarded for males but punished or discouraged for
females. Recognition of privilege due to anticipated benefit and shame/fear in admitting the privilege
is a potential barrier to addressing the impact of male privilege on men and women (Robinson,
1999). Individuals who enjoy the benefits of privilege often do not recognize that their benefit is
unearned or feel that their privilege is a source of guilt, particularly as they have something to lose.
Gender privilege can thus be invisible to those who benefit from it (Good & Moss-Racusin, 2010).
Individuals who believe strongly in the ideal of gender equality may be blind to the privilege they
enjoy (i.e., men, cisgender people) or to the privilege denied to others (women, gender-variant
people, trans* people). Males are taught not to recognize male privilege, as whites are taught not to
recognize white privilege (McIntosh, 1988). Men may stand to acknowledge that women are
disadvantaged, but this may not necessarily mean that they are able to acknowledge their own status
of being more privileged. These individuals may work to promote the rights of women and advocate
on womens behalf, all without suggesting that they should limit or relinquish their own privilege
(McIntosh, 1988). By understanding and confronting male privilege, men can become assets in the
process of changing social inequalities. Men cannot become partners in this process if they refuse to
engage in dialogue, reject diversity efforts, and are never challenged about their privilege (Vaccaro,
2010). Privilege occurs whether people are consciously aware of it or not: In working against sexism

and for gender equality, it is not enough for men to claim that they do not directly take part in the
oppression process; they must acknowledge the advantages awarded to males.
Privilege may also have unintended negative consequences for men in regard to their emotional
development and perception of roles. Mankowski and Maton (2010) define male privilege as an
unearned advantage granted to men that entails both potential benefits and potential damages. Positive
consequences for males include social, economic, and political benefits because of their gender.
Negative consequences may include the inability of males to express a full range of emotions
(Robinson, 1999). Men are traditionally socialized to be the breadwinners, to fulfill the role of being
financially responsible for their families. Emotional expression is often discouraged in males, with
the exceptions of anger and aggression. With societal and individual pressures to compete and
succeed, males are increasingly at risk for high rates of psychological distress. Compared to women,
men tend to be limited in their ability to express a range of emotions (Robinson, 1999). The argument
could be made that women are more in tune with their emotions not because of biological differences
but because of differences in socialization and societal discourses for females and males.
Males differ among themselves in their access to the power afforded through male privilege based on
race, sexual orientation, social class, and other identities (Coston & Kimmel, 2012; Mankowski &
Maton, 2010). Mankowski and Maton (2010) found that men who tended to strongly endorse or were
more conflicted about gender expectations generally scored lower on measures of well-being and had
increased problem behaviors. Adhering to gendered norms could be a source of continual
psychological distress for men, which could affect their quality of life. For example, McLeod and
Owens (2004) found that African American boys who experienced expectations of hypermasculinity
may have had greater psychological burdens that presented a challenge for healthy identity
development. These researchers also found that persons in lower status positions tended to
experience more negative feedback from others and compared themselves less favorably to others.
Males are generally privileged in relation to females, but they can be marginalized in other aspects of
their identities. Men who experience such marginalization include, but are not limited to, disabled
men, gay men, and working-class men (Coston & Kimmel, 2012). Male privilege may not be an
absolute and uniform advantage, as other factors influence the extent of a persons power over others.
Furthermore, male privilege may even be overshadowed by other aspects of marginalization. For
example, a White heterosexual male may experience privileges not experienced by an African
American gay male. Disabled men may not meet the idealized standards of attractiveness, which may
influence their social position, and their relative lack of agency over their physical capabilities may
be perceived as a reduction of masculinity (Coston & Kimmel, 2012). Male homosexuality has long
been considered effeminate and deviant from traditional concepts of masculinity. Similarly, the
concept that gay men are not real men is rooted in sexism (Coston & Kimmel, 2012). Working-class
men, on the other hand, fit within the expectations of strength and are acclaimed for their physical
prowess, but they may be considered dumb brutes (Coston & Kimmel, 2012). Among men,
working-class status has implications for mental health, well-being, and family life. There is a
stereotype that working-class men produce hypermasculinity by relying on blatant, brutal, and
relentless power strategies in their marriages, including spousal abuse (Pyke, 1996, p. 545).
The combination of multiple minority statuses may exacerbate an individuals feelings of oppression

and privilege. Studies indicate that members of racial and ethnic minority groups experience higher
levels of psychological distress than do members of the majority group. Specifically, minority women
are exposed to disproportionately high levels of stress and have access to fewer resources than do
their nonminority counterparts (Beale, 1970; Essed, 1991; McLeod & Owens, 2004). This has been
referred to as double minority status or double jeopardy (Beale, 1970). Social distance may exist
between individuals of different socioeconomic statuses within races as well as between members of
different races (Yancey & Kim, 2008). Potentially furthering the power structure within
socioeconomic status, some individuals may adopt strong racial identities as a means of
distinguishing themselves from others. Individuals with multiple minority statuses may be at risk for
mental health difficulties as they struggle to come to terms with the many different aspects of their
identity. For example, a Latino gay male experiences forms of oppression that a White gay male may
not have to face, such as racial barriers, language barriers, and cultural differences.
Mens gender socialization may contribute to high-risk sexual behavior, reduced involvement in
parenting, violence toward intimate partners, and alcohol abuseall behaviors supported by the
pressure for men to distance themselves from anything perceived to be feminine. Scholars have long
recognized that race, class, and gender inequalities are linked through underlying factors (Yancey &
Kim, 2008). Aosved and Long (2006) examined various forms of discrimination and their relation to
the endorsement of the rape myth. They found that higher levels of racism, sexism, homophobia,
ageism, classism, and religious intolerance were associated with higher acceptance of the myth
among both men and women, with sexism and attitudes toward gender accounting for the greatest
variation in acceptance. Further analyses revealed that all of the examined constructs were related to
one another: Prejudice against one group increased the likelihood that an individual would be found
to have rigid and intolerant cognitive perspectives overall. It is important to understand how attitudes
and cultural norms permeate everyday life to facilitate the tolerance of sexual violence and
oppressive beliefs. Greater awareness of male privilege may lead individuals to actions based on
their increased awareness, as seen with how individuals respond to awareness of White privilege
(Case, 2007).

Transphobia and Cisgender Privilege

As Scott-Dixon (2006) writes, Gender privilege, the privilege of being normatively and
unambiguously placed within a mainstream gender system, despite its constraints, is a great social
privilege enjoyed by most people who are not trans (p. 20). Transphobia is defined as societal
discrimination and stigma of individuals who do not conform to traditional norms of sex and gender
(Sugano, Nemoto, & Operario, 2006, p. 217). Transphobia ranges from fear, disgust, or hatred toward
transgender or transsexual persons to fear, disgust, or hatred toward cross-dressers, feminine men,
and masculine women (Nagoshi et al., 2008, p. 521).
Using the analogy of investment, Mandlis (2011) explains the privileges associated with being a
nontranssexed individual. First and foremost, the authenticity of the transsexed body requires an
authority figure from within the juridical regime, such as a doctor or government official, to vouch for
it (p. 222). Transgender persons thus appear to have little agency to determine their own identities
and even less agency over their bodies. For example, a nontransgender woman does not need to
present a letter from a psychologist or a psychiatric diagnosis in order to undertake breast

augmentation surgery, nor does she have to undergo counseling to ensure that she is of sound mind and
body to make such a decision. But a transgender woman seeking the same surgery does have to obtain
such validation from external entities. Furthermore, regardless of whether or not she receives a
medical diagnosis, a transgender womans breast surgery is not covered by Medicaid and is almost
never covered by private insurance. Moreover, traditional notions of gender (which subscribe to a
hierarchical binary) are subsidiary to biological sex; whether an individual opts for (or has access to)
any form of gender reassignment surgery or hormone replacement, the trans individual is deemed
devious, in that s/he is deceiving people in regards to his/her true sex (Mandlis, 2011, p. 222).
Indeed, results from studies of gender differences and transphobia suggest that one of the possible
reasons for transphobia in men is anger toward the deceiving genitals of female-to-male
transgender individuals and the change of power relationship in the male-to-female body (Bettcher,
2007; Nagoshi et al., 2008).
Bailey (2003) perpetuates the stereotype that many male-to-female transgender individuals are in fact
gay men who became women as a way to attract straight men. The view that Bailey depicts suggests
that trans women are sexual deceivers and that the gender identities of trans people are mere forms
of sexual preference. Ultimately, transgender individuals pay the price for the perpetuation of the
deception stereotype. The 1984 case of Ulane v. Eastern Airlines exemplifies how transsexual
individuals are dehumanized as a result of such stereotyping. As Lloyd (2005) observes, In the
courts eyes, Karen Ulane was not a man or a woman, but rather a transsexuala sort of monstrous,
repulsive intermediate deemed all the more appalling because she chose this embodiment (p. 163).
Mandlis (2011) notes:
In embodying her transsexed body, Karen Ulane not only excludes herself from responsible
citizenship, justifying the courts lack of protection toward her, but she also becomes a monster
not because of an incongruence between the sex she was natally assigned and the sex she
currently embodies, but because her choice to live her sex in the flesh is understood as her own
invocation of a sovereign exclusion that renders her abject. (p. 225)
On a societal level, since ancient times women have held a lower position than men in the status
hierarchy, and this status differential between males and females is still evident in many cultures,
places, and situations. According to Morrison (2010), within this gender hierarchy there lies a sacred
space established solely for female empowerment, which does not wish to be tainted by male
presence: Some consider this threat of male infringement to be presented by transwomen, believing
that even when identifying as female, transwomen will carry inextricable maleness into an otherwise
purely female place of safety (p. 652). Along the same line of safety, Mizock and Lewis (2008)
observe that many shelters for the homeless are designed for the convenience of a gender-binary
population, with group showers, open restrooms, and bunk beds available to segregated male and
female groups; such arrangements place transgender people at risk of nonconsensual disclosure (p.
346) and can also expose transgender individuals, particularly adolescents, to physical assaults and
even rape.
Before the recent inclusion of transgender people under the protection of health care reform
legislation, transgender persons in the United States who sought care often experienced refusal or

termination of treatment, inappropriate documentation, inadequate privacy protection, and offensive

and dehumanizing statements. Such a health care system failed to protect the well-being of
transgender individuals. Mizock and Lewis (2008) found that transgender individuals report
difficulty deciding on the timing and process by which to disclose their gender identity to doctors,
partially due to concerns with health insurance coverage and prejudice and discrimination on the part
of medical providers and staff at medical facilities (p. 344). Other health care challenges faced by
trans people include privacy concerns, stigma, and inadequate care due to lack of knowledge by
providers, which often forces trans* clients to become experts in the health care system and take up to
role of educators to their medical providers in order to receive adequate services (Mizock & Lewis,
Finally, it is important to note that 32 U.S. states still have no laws preventing employers from
discriminating against employees or potential employees in hiring and firing decisions based on
gender identity and gender expression (Human Rights Campaign, 2014). Further, in many states, legal
forms of identification do not allow for changes to gender designations for individuals who are
transsexual but have not undergone sex reassignment surgery; this creates concerns among these trans
persons when they are involved in such activities as attending bars and clubs, navigating airports,
and interfacing with the police (Mizock & Lewis, 2008, p. 346).

Gender at the Intersections

Race and Gender
Racism is a systematic process of societal subjugation that includes the interaction of racial
stereotypes (i.e., beliefs and opinions), racial prejudice (i.e., attitudes and evaluations), and
discrimination or unfair treatment on the basis of race (Greer, Brondolo, & Brown, 2014; Whitley &
Kite, 2010). Members of a target group may perceive discrimination as unjustified negative behaviors
toward them (Kim, Anderson, Hall, & Willingham, 2010). Lykes (1983) defines racial prejudice in
relation to discrimination as [biased] attitudes held by individuals of another race, and actions and
behaviors which are based on these views (p. 80). Institutional discrimination can occur when
institutional policies facilitate the unequal distribution of benefits across groups or the restriction of
opportunities for members of a target group (Kim et al., 2010).
Racism is one of the most commonly described types of discrimination. Media exposure and
discourses on cultural diversity have highlighted the effects of racism and the recognition of racism
within modern society. Individuals who take a neutral position (i.e., claim to be color-blind) and
those who believe that race and gender are not factors in how individuals are treated underscore the
importance of recognizing that racism and sexism are still prevalent. That some people express the
belief that racism and sexism do not exist is not an indication that oppressed individuals are
experiencing less discrimination. At the university level, female faculty members and administrators
are promoted at slower rates than their male counterparts, and their earnings are lower than those of
their male colleagues (Johnsrud & DesJarlais, 1994). Such inequities are the results of institutional
practices that give benefits to White males at the expense of females and people of color. Females
and people of color working in universities experience stereotypes about their cognitive abilities as

well as differential treatment by students, administrators, and other faculty (Blakemore, Switzer,
DiLorio, & Fairchild, 1997).
In race relations, as in gender relations, those in the dominant position possess the power to classify,
name, and construct the Other (Delphy, 2008)those who are within marginalized groups: women,
people of color, and LGBTQ people. Men and women are designated positions and gender roles
based on socially constructed expectations; men and masculinity are associated with productive
activities and the public arena (leadership), while women and femininity are associated with
reproductive activities and the private sphere (family, caring roles, and so on) (Swim, Aikin, Hall, &
Hunter, 1995). Modern concepts of interlocking systems of domination in racism and sexism have
been explored extensively by female scholars of color (Gianettoni & Roux, 2010). Black and Latina
feminists have highlighted the sexism inherent in the U.S. civil rights movement (Combahee River
Collective, 1979; hooks, 1981; Hull, Scott, & Smith, 1982; Moraga & Anzalda, 1983) and the
racism in the dominant (White) feminist movement of the 1970s (Gianettoni & Roux, 2010). They
have argued that an overemphasis on either racism or sexism allows the domination to continue in the
other domain. To address this predicament appropriately, it is necessary to utilize a process that fights
both racism and sexism.
Racism and sexism are also prevalent in the popular media and in athletic events. Relative to their
male counterparts, female athletes struggle to achieve respectful, high-quality coverage of their sports
in the mainstream news media (Cooky, Wachs, Messner, & Dworkin, 2010). Only 3% to 8% of the
sports coverage on national television and local news programs is focused on womens sports
(Messner, Duncan, & Willms, 2006). Even when such coverage is offered, it often trivializes
womens athleticism and heterosexualizes female athletes (Heywood & Dworkin, 2003). Female
athletes are not praised for their abilities; rather, they are often negatively portrayed in the media as
masculine. In commenting on the Rutgers University womens NCAA basketball team, Don Imus, a
controversial radio personality, described team members as nappy-headed hoes, a clear example of
explicit racism and sexism on national radio. The term ho has been part of pop culture vernacular,
commonly heard in certain forms of rap and hip-hop music, on daytime talk shows such as Jerry
Springer (Cooky et al., 2010, p. 146). Imuss comments reflect a dominant discourse in American
society. Nappy is a derogatory and racist stereotype used to describe the hair texture of African and
African American women, and ho is the shortened version of the word whore (Cooky et al., 2010).
African American women in athletics have been negatively portrayed as both hypersexualized and
less feminine (Banet-Weiser, 1999; McPherson, 2000). Successful female athletes experience sexism
that minimizes their physical skills, and many are marginalized due to their gender. The Womens
National Basketball Associations marketing strategy focuses on portraying the leagues athletes as
models, mothers, or the girl next door, roles that act as reminders of heterosexual aspects of their
identity (Banet-Weiser, 1999; McPherson, 2000), while male athletes enjoy the privilege of being
recognized for their athletic abilities. The strategy implemented by the WNBA also highlights the
hardships that female athletes endure, as if society requires a reminder of the gender of these athletes.
Male athletes do not experience such marginalization, and their physical prowess is praised rather
than ridiculed.
Research in multicultural psychology and studies of issues relevant to communities of color have

been increasing over the years, but little research has looked specifically at the concurrent multiple
oppressions that are associated with multiple minority identities (Szymanski & Stewart, 2010).
According to the American Psychological Association (2007), racial/ethnic minority women both in
the United States and abroad often live in racist and patriarchal cultures, where they are exposed to
various forms of racism and sexism that come from a variety of places, including interpersonal
relationships, workplaces, media, and legal systems.
Multicultural feminist psychology focuses on the potentially mentally harmful consequences of
multiple oppressions in racism and sexism for African American women, referred to as double (or
multiple) jeopardy (Comas-Daz & Greene, 1994; King, 1988; Klonoff & Landrine, 1995). Double,
or multiple, jeopardy occurs when someone holds membership in more than one group that has been
historically marginalized, referred to as a minority group. For example, an African American woman
who identifies as lesbian experiences three different marginalized minority identities: race, gender,
and sexual orientation. Other forms of minority status exist, including, but not limited to, those related
to disability, class, socioeconomic status, religion, language, and nationality.
Two multicultural feminist theoretical approaches to conceptualizing the relationship between
multiple oppressions and African American womens psychological distress are the additive
approach and the interactionist perspective. The additive approach is concerned with how the
individual oppression experiences of a person with more than one minority status (e.g., racism and
sexism) have direct effects that combine to produce negative impacts on psychological health (Beale,
1970; Shields, 2008; Warner, 2008). According to the interactionist perspective, in addition to direct
effects on mental health, one form of oppression may amplify the impact of another form of
oppression experienced by a person of more than one minority status, which may lead to more
psychological distress symptoms (Greene, 1994; Landrine, Klonoff, Alcaraz, Scott, & Wilkins,

Class and Gender

Class and gender intersect in various ways for working-class and poor women and trans people. The
foundation for representation by the government assumes that the individuals who govern should have
knowledge of those for whom they govern (McIntyre-Mills, 2003); however, only the majority will
have their needs met. The process of governance does not take into account those who constitute the
other (Young, 2009)that is, those who are not in privileged positions and are denied benefits that
others are granted. One example of classed sexism can be seen in the gendered notions of labor and
work. Such ideas have historically limited womens access to employment opportunities and fair
wages. The gendered idea that males are to be breadwinners, able to support their families through
their earning potential, influenced the shift in many countries populations from rural to urban areas. In
Britain, this process of gendered thinking was utilized to attract migrant workers in the years
following World War II (Young, 2009). While men relocated to urban areas for work, women were
left with the household responsibilities and the care of the children. The gendered norms of the
migrant family were the result of economic necessity combined with defined gender roles.
Although considerable progress has been made in many countries toward negotiating the underlying
processes of power relations and oppression of women in occupational sectors, inequities still exist.

For example, the retail industry has traditionally hired individuals for particular positions based on
gender (Mujtaba & Sims, 2011). Men are hired and trained for positions that are typically managerial;
such jobs pay more than the positions that women more commonly occupy. Women are more likely to
recognize glass ceilings and unfair consequences (Mujtaba & Sims, 2011). The expectation that men
or women are more appropriate for certain jobs is an example of gender bias.
Members of the dominant culture (White, male, and middle- and upper-class) possess and maintain
their dominance over others through power and the development of policy (Harley, Jolivette,
McCormick, & Tice, 2002). Those in control exert their influence over others through a variety of
domainspsychological, societal, and interpersonaland through systematic institutions. The
psychological implications of being working-class include the recognition of having limited
resources, the stigma of being poor, social exclusion, and classism. Smith (2005) discusses the effects
of poverty on emotional well-being, which research has consistently found to be devastating (Carr &
Sloan, 2003).
Classism is the assignment of individual qualities of value and worth based on social class and the
systematic oppression of subordinated groups (people without endowed or acquired economic
power, social influence, or privilege) by the dominant groups (those who have access to control of
the necessary resources by which other people make their living) (Collins & Yeskel, 2005, p. 143).
It is perpetuated by institutions that facilitate the processes that separate the haves from the have-nots
and extends beyond income, intersecting with other factors such as race, religious affiliation, culture,
sexual orientation, and gender. Classism is similar to the other ismssexism, racism, and
heterosexismin that it is an interlocking system that includes concepts of domination, control, and
resources, where one group has privilege and the others are oppressed (Hardiman & Jackson, 1997;
Smith, 2005).
The discourse underlying male privilege is not based solely on gender differences or success:
Essential to male privilege is to be in a position of power over others, to be a real man (Coston &
Kimmel, 2012). Gendered roles in occupations are delineated, and those who go against these roles
are often marginalized. Nevertheless, even in professions that are considered to be mostly female
(e.g., nursing), men are likely to earn more and to be promoted into leadership roles more quickly
than women (Brown, 2009).
Parental expectations regarding what their children should do and excel at can affect the development
of the children themselves. Many parents tend to have higher expectations for their sons than for their
daughters in math, science, computers, and sports, and these beliefs are further reinforced by
childrens peer groups (Leaper & Brown, 2008). Individuals are socialized according to gender from
a young age to be proficient in certain academic subjects. A young female who is not expected to do
well in math and science could have difficulty believing in her capacity to become an engineer or a
physicist. Males are often discouraged from taking positions that could be considered to be feminine
or beyond the scope of traditionally male-gendered occupations, such as nursing (Brown, 2009).
Young females who experience negative comments about their academic abilities at home from their
parents and siblings often find little comfort at school, as teachers are among the most common
sources of such comments (Brown, 2009). Older girls are more likely than younger girls to report
such sexism, perhaps because of the cumulative effect of hearing negative comments over time

(Brown, 2009). The exposure to negative comments regarding academic abilities is not isolated to
early development; it is a continual process that females are subjected to in multiple facets of their

Sexual Orientation and Gender

Sexism and heterosexism.
Sexism stems from beliefs and behaviors that privilege men over women. Whether at the cultural,
societal, institutional, or individual level, sexism is the mechanism that ensures that women occupy
subordinate roles compared with men and that women-identified values are disparaged (Matzner,
2004). Traditional forms of sexism entail discriminatory, hostile, and violent actions that directly
threaten the well-being of women. Such actions arise from mens efforts to maintain a patriarchal
society that centers on male dominance, thus placing women, gender-variant, and transgender people
in less powerful positions. In order to keep women bound by traditional gender roles, men often
devalue or punish with hostility those women who strive to control men or show signs of masculinity
(such as assertiveness) (Shepherd et al., 2011).
As a result of the womens rights movement and feminist activism, earlier forms of sexism have
evolved to produce a modern version in which the assumption is made that women no longer
experience discrimination, hostility, or unequal treatment, and women are expected to be content with
their current treatment (Cunningham & Melton, 2013). Along with this modern form of sexism is
another that Glick and Fiske (2001) call benevolent sexism. It comes into womens daily lives
subtly and is perhaps the most invisible form of sexism. Benevolent sexism often takes the form of
helping women with certain activities, such as carrying items or holding doors open. The rationale
behind such acts is the belief that women are pure and dependent; therefore, women should
conform to the feminine characteristics of purity and goodness. Benevolent sexism occurs when men
perform tasks for women without seeking their consent. Underlying these actions is the assumption
that women either need or desire assistance from men in performing certain tasks. Benevolent sexism
perpetuates the stereotype that women are in need of male protection.
Despite the apparently chivalrous nature of benevolent sexism, studies have shown that this form of
sexism can be more harmful than the traditional hostile sexism. Seemingly gracious gestures can cause
confusion as the recipient of the gestures often cannot identify the reason for intrusive thoughts or the
source of discomfort, mainly because the underlying discrimination is not as salient as direct hostility.
Such confusion can often lead to self-doubt and low self-esteem, and thus to decreased task
performance (Dardenne, Dumont, & Bollier, 2007).
According to Sibley and Wilson (2004), hostile and benevolent sexism can occur simultaneously,
depending on the group of women and the situation in which they are interacting with men. For
example, men may carry heavy items and open doors for women who conform to traditional gender
roles but behave and speak hostilely to women they perceive as stepping out of their place by being
assertive or by appearing more masculine in dress. Because benevolent sexism is masked as
chivalry, it often goes unchecked; such sexism is an example of the invisibility of male privilege.

Wise (2001) offers the following definition of heterosexism for social work:
Heterosexism reflects the dominance of a worldview in which heterosexuality is used as the
standard against which all people are measured; everyone is assumed to be naturally
heterosexual unless proven otherwise, and anyone not fitting into this pattern is considered to be
abnormal, morally corrupt and inferior. The assumption of heterosexuality and its superiority is
perpetuated through its institutionalization within laws, media, religions, and language, which
either actively discriminates against non-heterosexuals or else renders them invisible through
silence. Just as the concepts of racism and sexism have helped us to understand the oppression
of black people and women, so the concept of heterosexism has assisted us in theorizing lesbian
and gay oppression. (p. 154)
Old-fashioned heterosexism is grounded in the belief that everyone should be heterosexualthe
heterosexual relationship is normal and superior to relationships of other gender configurations,
including same-sex relationships and relationships in which one or more of the partners are
transgender. Similar to traditional hostile sexism, old-fashioned heterosexism is characterized by
name-calling (e.g., homo, faggot) and discrimination, hostility, and violence toward nonheterosexual
persons. The modern version of heterosexism comes in a more subtle form that asserts that gay and
lesbian people make excessive demands for change; that discrimination toward gay and lesbian
people is a thing of the past; and that gay and lesbian people prevent their own acceptance by the
dominant culture by exaggerating the importance of sexual orientation (Eldridge & Johnson, 2011, p.
Along with modern heterosexism is yet another more subtle form of oppression known as
heteronormativity, which Martin (2009) describes as the mundane, everyday ways that
heterosexuality is privileged and taken for granted as normal and natural. Heteronormativity includes
the institutions, practices, and norms that support heterosexuality (especially a particular form of
heterosexualitymonogamous and reproductive) and subjugate other forms of sexuality, especially
homosexuality (p. 190). Martin further notes that heteronormativity includes parents assumption that
their children are heterosexual. With this assumption, parents limit the familys discussions of love,
attraction, commitment, and marriage to heterosexuality, leaving the LGBTQ community absent and
invisible in childrens social world and their understanding, and thus perpetuating heteronormativity
from a very early age.

Marginalization of gender-nonconforming LGB people.

The LGB community is part of larger society, and thus members of this community also struggle with
perpetuating systematic oppressions (e.g., racism, sexism, classism, ableism). Researchers have
documented multiple instances of sexism and transphobia in the LGB community. Weiss (2004) quotes
a lesbian writer who describes trans* inclusion in a pejorative way: Gays and lesbians have
struggled for decades to be able to name ourselves and to BE ourselves. But now in our own
community we are expected to applaud Dykes rejecting womanhood and embrace men taking it over
(p. 49). Dobkin (2000) quotes another writer who would say to a trans man, You are not a
transsexual man, you are a lesbian woman who has mutilated herself in order to change a woman-

loving woman into a more acceptable figure. At the core of both statements is the assumption that
gender is binary, which excludes and vilifies those whose gender identity and expression challenge
that assumption.

Cultural variations in sexual orientation and gender identification definitions.

Not all cultures subscribe to the gender binary: the hijras in South Asia and the faafafine in Samoa
are examples of gender categories that go beyond the binary. Many American Indian/First Nations
groups also recognize a third gender often denominated as two-spirit, whereby a gendernonconforming personwhether nonconforming in gender presentation, role, or sexual orientation
is considered to have a sacred or elevated role in the community (Williams, 2010). Experiences of
homophobia and transphobia among members of these indigenous nations are inextricably connected
to racism and colonization.
As stated earlier, an individuals cultural background can influence his or her concepts of sexual
orientation, gender identification, and gender expression. For example, according to Confucianism, it
is the responsibility of the son to bring into the family a daughter-in-law, and it is the daughters
responsibility to marry into a family and give birth to children, preferably males (Chow & Cheng,
2010). Same-sex attraction is a disgrace to the family, and acting on such attraction clashes with the
Confucian notion of filial piety. Transgender individuals, especially those who transition hormonally
or surgically, are viewed as posing a greater threat to deeply rooted Confucian family values in a
public way; they may be perceived as bringing shame to the family. For some Asian gays, lesbians,
and trans people, living a dual life (keeping same-sex attraction privately but fulfilling the obligations
of husband, wife, parent) may be more tolerable than coming out publicly (Winter & Webster, 2008).
Since culture mediates many of an individuals identities, counselors working with Asian gay,
lesbian, bisexual, or transgender clients should keep in mind that family harmony and filial piety are
two important factors that may influence a clients decision making regarding coming out versus
passing with a heterosexual union.

Clinical Implications
What are the clinical implications of taking privilege into account when addressing gender and its
interactions with other aspects of identity? We offer the following suggestions concerning gender and
sexual orientation, class, race, and other variables for counselors working with clients from
marginalized populations:
1. Develop your awareness of your own racial, gender, and sexual identities, as well as your
notions of privilege. This may be the single most important thing a counselor can do when
working with marginalized populations, since failing to explore these areas of the self can result
in a regressive relationship with clients, in which the clients remains stagnant and unable to fully
develop their racial (and other) identities and maintain a limited understanding of power and
privilege (Carter & Helms, 1992).
2. Use inclusive language. If you are uncertain about how a client self-identifies, ask the person
what his or her preferred pronoun is. If you are uncertain about words a client is using in
session, it is important that you attempt to educate yourself before asking your client. For







example, saying to a client, I know what transgender means but I want to know what it means
to you may fall flat if the client senses that you feel uncomfortable or that you are quite
unfamiliar with the concept.
Educate yourself. Never pretend to understand an issue with which you are unfamiliar, and
realize that it is not sufficient to learn about sexism from one female client, to learn about racism
from one client of color, and so on. Read books, explore websites, and actively engage sources
beyond your clients to learn more about marginalized communities. Admit to your clients when
you do not know something and let them know you are open to learning from them, or from
outside sources. Ask them what it is like for them to hear you say that you do not know about
something they brought up.
Help clients to explore aspects of their identities by actively bringing the topics of gender, race,
and other identities into the room. Clients are not likely to assume that you are cognizant of these
issues unless you explicitly make it known.
Keep a list of safe, knowledgeable, and affirming resources to refer clients to (e.g., physicians).
Examine your own unearned privileges related to gender, or your own experience of gender
Consider your own gender role and gender identity. How did you come to self-identify the way
you do with regard to gender? How did you decide you were a man or woman, for example?
Be prepared to refer clients to reliable sources of information regarding their rights related to
gender identity and sexual orientation. These rights vary from place to place depending on local
laws and ordinances.
Include prompts during intake to invite discussion regarding gender or sexual orientation. For
example, refer to significant others without using gender-specific pronouns to leave open the
possibility of same-sex attraction.
During the onset of therapy, open the door for future exploration of aspects of either the clients
identities or your own.
Serve as an advocate for trans* individuals when working with others who have power over
your trans clients with regard to transition (e.g., health care providers, legal systems).
While it is important to be knowledgeable and open regarding patients explorations of their
gender identities and the evolution of those identities, do not assume that gender is a relevant
issue for a given trans* patient. For many trans* patients, exploring gender identity is
unnecessary in the therapy room, or is less of a priority than other concerns.
Find multiple ways (explicit and subtle) to convey your knowledge, awareness, and attitudes
about gender and sexual orientation. For many LGBT people, listening for language and looking
for visible cues that a person is not homophobic are key survival strategies, allowing them to
stay safe when dealing with health care systems that have often been very discriminatory against
LGB and especially transgender people.

Critical Incidents
Case 1
Jamie is a 31-year-old Korean American female who works in a law firm as a paralegal. She was
referred to counseling by her employee assistance program counselor because of job-related stress.

During the intake session, she disclosed that she feels devalued at work. Her supervisor is a 48-yearold Caucasian male who sometimes makes her feel uncomfortable with statements that he casually
makes about her appearance and work performance. For example, once when she wore a blazer to the
office he told her that he prefers that she wear apparel that highlights her feminine features. During
her last performance appraisal, she was marked down for speaking up in meetings, which confused
her because she feels she usually defers to others in the predominantly male group. She has begun to
wonder if she will ever be recognized for her work performance since some of her male counterparts
have boasted about raises that she has not been offered, despite the fact that she often produces work
that is more accurate than theirs, and she works more quickly than they do. She reported that she has
begun to have difficulty sleeping and wonders if she should quit the firm.
Through therapy, Jamie started to recognize that her supervisors behavior toward her has made her
feel marginalized and devalued based on her gender. She began to focus on empowering herself to
determine whether or not she would be able to make an impact with her immediate supervisor, and
ultimately she decided to speak with her firms human resources department to seek a transfer to
another supervisor.

Case 2
Nikki is a 17-year-old male-to-female transgender client. She was sent to counseling by her parents
because of their concern that she has become more withdrawn in the past few months. They noticed
that she spends much of her time alone in her room and sometimes does not go to school. They are
fearful that she will not be able to graduate and go on to college. Nikki disclosed to the counselor that
she began to be bullied by her classmates after she asked a friend to the Sadie Hawkins dance. Since
then, her classmates have shunned her and she has not felt safe going to school. She mentioned that she
would prefer to be homeschooled or to drop out of school.
During the course of therapy, the counselor spent time validating Nikkis experiences, providing
psychoeducation to her parents about the effects of bullying, and advocating with school
administrators to provide a safe learning environment for her. Nikki eventually was allowed to pursue
independent studies while taking select classes with supportive educators who were able to provide
her a safe space on campus so that she could work steadily toward graduating with honors.

Discussion Questions
1. What are some of the messages you received while you were growing up about the places of
men and women in society? What are some of the messages you have received about transgender
women? Transgender men? What impacts might these messages about gender have on your
clinical work?
2. How might you create space for your clients to explore their gender identities and expressions?
3. How might you convey to a new client during the intake process that you are aware of, open to,
and knowledgeable about the existence of genders beyond male and female?
4. How might you convey to a new client early on in your work together that you are aware of and
knowledgeable about systemic sexism, heterosexism, homophobia, and transphobia? How might




you convey to a client that you are not overtly biased against gender-variant people?
Have you ever encountered a situation in which you did not know another persons gender? If so,
what was this like for you? What internal reactions did you have? How did you respond to the
individual? What might you do if you are unsure about a patients gender?
What types of countertransference might you have when working with clients of various
genders? How do you respond differently to men? Women? Trans men? Trans women? Gendervariant and genderqueer people?
What are some ways in which you could obtain ongoing information to continue to develop your
knowledge and awareness of sexism and gender privilege?
How might you better incorporate issues of gender and privilege in your clinical work?
How do race and ethnicity affect the way you respond to persons of various genders? Notice
what feelings come up for you during your interactions with men, women, gender-variant, and
trans people of various racial and ethnic backgrounds.

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11 Counseling the Marginalized

Melanie M. Domenech Rodrguez
Melissa Donovick
Kee J. E. Straits

Primary Objective
To broaden the conceptualization of marginalization to go beyond the limited range of groups
that currently receive clinical/research attention

Secondary Objectives
To present an approach to counseling people from marginalized groups
To highlight the particular flexibility needed in the application of mainstream counseling
techniques and skills to populations other than the ones they were intended for
Our survival depended on an ongoing public awareness of the separation between margin and
center and an ongoing private acknowledgment that we were a necessary, vital part of that
bell hooks, Feminist Theory: From Margin to Center (2000, p. xvi)
In her introduction to the second edition of Feminist Theory: From Margin to Center, bell hooks
(2000) wrote about the frustrating contrast between Black Americans marginalized status and their
critical importance to the broader U.S. community. By serving as the periphery of a given entity, the
margin demarcates the boundary of that entity. Typically, researchers have focused their work on the
center, the means, the averages. Anything outside the average tends to be considered unusual,
aberrant, or abnormal. By taking this approach, scientists have participated in the creation and/or
perpetuation of perceptions of what is average and what is not (see various essays in Rothenberg,
2011). In the absence of a complex understanding of what places individuals or groups at the center
or the margins, the practice of focusing on a norm can serve unwittingly to mask privilege and create
an illusion of marginality. For example, examining the mental health outcomes of ethnic minorities in
contrast to those of Whites is commonplace practice. White is average, ethnic minority is not. Rather
than examining two groups, comparative research promotes the creation and maintenance of
hierarchies wherein one group is better and another worse. Mental health researchers have
questioned this practice for some time and have called for research focusing on particular groups
without contrasting outcomes with those of Whites or a majority population (Bernal & Scharrn-del
Ro, 2001; Cauce, Coronado, & Watson, 1998). Conducting noncomparative research with

traditionally marginalized persons is a way to challenge the notion that those persons exist only in
relation to a majority group, and that their outcomes are judged also in relation. Yet the practice of
comparative research continues.
In this chapter we seek to inform ethical practice in order to contribute to the clinical competence of
mental health practitioners working with marginalized populations generally. The populations that are
marginalized are many, especially when the intersections of multiple identities are considered. For
illustrative purposes, we provide a case in pointa discussion of undocumented immigrants in the
United States who have intersecting identities (e.g., ethnicity, nationality, socioeconomic status) that
place them among the most marginalized. We also present discussion of a case in which the
intersection of ethnicity (i.e., multiracial) and age (i.e., adolescent) creates a particular context of

Defining the Margin

Marginalization is defined in this chapter as the social process through which individuals, groups, or
communities are excluded from the center (of society) or relegated to the periphery or margins on the
basis of some characteristic (e.g., race, ethnicity, class, gender, sexual orientation) or combination of
characteristics (i.e., intersecting identities). Marginalization by definition is a dynamic concept that
occurs in relation to others. For example, the mentally ill are at the margins of the broader community
from which mental health is defined. Migrants are at the margins of the broader community into which
they have migrated. The obese are at the margins of a group where there is a mean and standard
deviation for weight set within a given geographical boundary. This last example is of interest
because it underscores the importance of going beyond a statistical average to define marginalization;
social reactions toward obese individuals exemplify the social contracts present in the dynamic of
marginalization. Social expectations for behavior and beauty ideals in the United States are such that
it is punishing to be overweight but often desirable to be underweight. This knowledge of cultural
context is of critical importance in defining and understanding marginalization.
A context is created by the people who populate it. So, who defines the center and the margins? Using
poverty as an example, marginalization can be defined in relation to broad social standards. By U.S.
government accounts, a family of four (two adults and two children under age 18) with an annual
family income of $23,050 is considered to be poor (U.S. Department of Health and Human Services
[U.S. DHHS], 2012). In the international arena, poverty for an individual has been defined as living
with earnings of $1.25 a day (World Bank, 2012). However, it is critical for counselors to understand
that such institutional definitions can be quite irrelevant to the daily lives of individuals, who are
likely to define themselves in relation to others in a more tangible way (e.g., all of my neighbors have
televisions and I dont, therefore I am poorer). Institutional definitions may be more relevant for their
consequences. For example, government assistance programs provide goods and/or services on the
bases of federal definitions of poverty. A mother who is enrolled in the Special Supplemental
Nutrition Program for Women, Infants, and Children (WIC) has access to goods that may affect how
she sees herself, her family, and her community. Depending on the context, she may feel marginalized
in relation to women who do not qualify for WIC because of higher earnings, but less marginalized
than a recent immigrant who is not receiving the needed assistance for fear of deportation.

An awareness of the definition of margin (whether self- or other-generated) is critical in a counseling

relationship for a variety of reasons: It places the person(s) and the relationship in a broader
sociopolitical context, and it focuses on external sources of impact on the person(s). Additionally,
knowledge of context can present a first line of intervention in a counseling relationship. Indeed, the
Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for
Psychologists published by the American Psychological Association (APA, 2003) state:
Psychologists are in a position to provide leadership as agents of prosocial change, advocacy,
and social justice, thereby promoting societal understanding, affirmation, and appreciation of
multiculturalism against the damaging effects of individual, institutional, and societal racism,
prejudice, and all forms of oppression based on stereotyping and discrimination. (p. 382)

Living at the Margins

Living at the margins places people in a unique situation. There are two dynamics that are critical to
address in the context of the counseling relationship as it pertains to marginalization: how persons see
themselves and how they are perceived by others (e.g., Trimble, 2000). Specifically, does a person
see her- or himself as marginalized? Do others see her or him that way? If so, which others? Some
have termed marginalization from the viewpoint of the individual subjective marginalization and that
from the viewpoint of those around the individual objective marginalization. A therapist attempting
to understand whether a client is marginalized will want to understand whether the client is in a
position of exclusion, removed from some socially defined center (objective). In addition, does the
client want to be a more central participant (subjective)? A third perspective, contextual
marginalization, takes into account the lens of the larger social, cultural, and political context. The
therapist must be aware of the larger social, cultural, and political lens of the time and where a client
may be perceived from this broader perspective. And finally, in a fourth perspective, reflexivity, the
therapist evaluates his or her own subjective, objective, and contextual marginalization and considers
how that position might influence his or her perspective on and perpetuation of the clients
Seeking answers to these questions can help tremendously to inform practice. For example, a middleclass, well-educated, professional African American woman may be perceived by a counselor to be a
member of a marginalized group by virtue of her African American-ness, yet she may not perceive
herself as marginalized at all. How does the counselor proceed? The next steps have serious practice,
ethical, and social implications. If the counselor decides the client is marginalized and that the
intervention should focus on creating more awareness of the marginalization (i.e., the client is in
denial), the counselor could not only be pursuing an unfruitful course but could also be engaging in
potentially unethical behavior (e.g., APA, 2010, 2.01, Boundaries of Competence).
This example serves as a reminder that people are members of many social groups and that the same
person may be at the margin of one social group and concurrently be in the center of another group.
The intersection of identities leads to a separate set of questions: Which margins? And how relevant
are they to the people who would be categorized? The same African American professional may feel

more marginalized in a context where the majority of African Americans have a low level of
education (and may perceive her as selling out or acting White; Murray, Neal-Barnett,
Demmings, & Stadulis, 2012; Neal-Barnett, 2001; Ogbu, 1991) than in a professional setting where
her peers have the same level of education and income but few are African American. The
predominant stereotypes highlight certain group characteristics while rendering other segments of the
population invisible (Jones, 2003). In the latter situation, the professional may feel more marginalized
by her educational status than by her race. An awareness of the intersection of identities as well as
self- and other-perception of relative placement in (or out of) marginalized groups is critical in a
counseling relationship.

Dimensions of Marginalization
The most commonly identified dimension of potential marginalization is sociocultural status: age,
gender, sexual orientation, race/ethnicity, nationality, class, religion, and so on. Outward
manifestations may include skin color, language, family structure, mannerisms, and clothing, although
sociocultural status is not always visible. For example, an American Indian man with strong
indigenous phenotype who is gay is a visible ethnic minority with a sexual orientation that may or
may not be visible. There are many other dimensions along which we may judge our fellow humans in
relation to the average or acceptable norm. Low economic status, another dimension of
marginalization, is sometimes evident; for example, a person may be on welfare, may be homeless, or
may have limited food access. Other dimensions include educational/occupational status (e.g.,
dropout, unemployed), legal status (criminal history, legality of work/living, incarceration),
developmental status (youth/elder, intellectual disability, helplessness/victimization), geographic
location (rural, reservation, remote), physical and mental health status (disability, mental illness,
chronic or infectious disease), community status (relative to community norms, e.g., music, food,
hobbies, hair, language), and social justice status (experiences of discrimination, oppression).
The intersection of identities must be understood as cumulative and integrated (Lowe & Mascher,
2001), such that individuals are increasingly marginalized the further away they are from the valued
center and the more dimensions along which they are marginalized. Figure 11.1 depicts this
relationship. Persons at the center or mainstream of a particular social group have the utmost
privilege. With every move away from the center, a layer of privilege is removed, and persons who
are at the very edges of the margin (which becomes thinner or less populated at the edges) may be
marginalized by people who are themselves marginalized by others.

Power, Privilege, and Marginalization

Marginalizationor the social, political, geographical, psychological placement away from a center
places persons away from sources of privilege. If enfolded within the embrace of inclusion,
individuals gain access to the necessities of life, such as material, instrumental, social, emotional,
financial, and safety resources. One aspect of being at the center and exercising or being the
recipients of power is that individuals are often unaware of the power in which they reside. For those
relegated to the fringes, the absence of power and privilege makes both more readily identifiable. The
multiple dimensions in which an individual experiences marginalization are likely to vary depending

on the depth (e.g., lack of privilege results in loss of essential resources) and breadth (i.e., the
cumulative effect of lacking privilege in multiple areas) of the marginalization experienced. In a
counseling relationship, a thorough understanding of both depth and breadth of marginalization is

Figure 11.1 Cumulative and Integrated Marginalization

Risk, Resilience, and Marginalization

Marginalization is associated with negative health outcomes, including lower life expectancy,
increased child mortality, and increased rates of diabetes, cancer, obesity, and heart disease (e.g.,
Christopher & Simpson, 2014; Doubeni et al., 2012; Fredriksen-Goldsen, Kim, Barkan, Muraco, &
Hoy-Ellis, 2013). Marginalization is also associated with negative mental health outcomes (e.g.,
Arajo & Borrell, 2006; Seng, Lopez, Sperlich, Hamama, & Meldrum, 2012). Studies of
marginalized populations, including LGBTQ and Native American groups, have found higher rates of
depression and suicide among these groups. Other marginalized groups, such as prison populations,
have been found to experience high rates of substance abuse, past victimization (e.g., child abuse),
learning disorders, and trauma-related mental health issues. Racial/ethnic minorities who have
anomic ethnic identities (versus strong ethnic or bicultural identities) are at higher risk for substance
abuse, depression, and anxiety. Having multiple marginal social identities increases an individuals
risk for negative physical and mental health outcomes. Current evidence-based mental health
interventions may neglect this complex dynamic. Clinicians must be aware of the specific risk factors
associated with clients social contexts in order to assess and treat clients appropriately. At the same
time, therapists cannot rely on assumptions or negative expectations regarding clients perceived
marginalized status.
The literature on resilience demonstrates that moderate amounts of adversity may benefit our mental
health in the long run if we can also access appropriate supports to overcome adversity. Hall,

Stevens, and Meleis (1994) summarize some of the strengths that may be associated with a
marginalized position, including the following: greater awareness of boundaries and their ability to
protect, cultural and personal uniqueness, access to resources through collective awareness and
organization, access to and control of protective information, survival skills and insights gained
through forced reflection regarding ones relative position to the center, and exposure to experiences
that may foster greater empathy. Several investigations have pointed to the potential for individuals to
gain strength by reframing personal marginalization in the context of collective action toward social
justice. Often, being positioned at the margin provides individuals with license for creativity and
innovation, stimulating talents that may be less likely to grow in those who conform to social norms.
A broader position between identities or social worlds can provide greater reflexivity, mental and
social flexibility, and multiple perspectives from which to interpret the world. Marginalized
populations may foster resilient families and communities through strong familial and interpersonal
ties, spirituality, cultural knowledge and traditions, shared language and values, and mutual
The case discussion in the next section provides a framework for therapists to use in approaching the
counseling relationship with clients who are marginalized. This framework requires that the
counselor acquire important knowledge about the individual client and the group or groups to which
the client belongs or with which he or she identifies. The counselor must also acquire self-knowledge
and knowledge of the available tools for engaging effectively in the counseling relationship with a
marginalized client.
The following general questions can guide the counselors knowledge acquisition about the client: (1)
Who is the individual and how does he or she identify? How would the individual be identified by