Katz (1981) suggests that individual treatment should address
the cultural differences between the clinician and the patient as soon as possible
and that prejudice and stereotyping can be bidirectional, that is, that stereotyping
of both the dominant and the minority culture may occur. Clearly, patients should
be evaluated on an individual basis, but therapists may erroneously attribute
to their patients cultural traits that may not be present or may fail to recognize
traits that are.
Pinderhughes (1989) observes that since
the feelings aroused in clinicians who work with patients whose culture differs
from their own "are more frequently than not negative and driven by anxiety,
they can interfere with successful therapeutic outcome" (p. 21). Bradshaw
(1978) calls attention to the fact that the cultural distance between therapist
and client serves to trigger an unconscious use of distancing and defense mechanisms.
Self-knowledge can control such maneuvers and enable the therapist to be more
sensitive toward supervisees of different cultures and races (Pinderhughes, 1989).
values about personal relationships affect the patient- therapist interaction.
In the following excerpt Kunce and Vales (1984) discuss Mexican-American patients:
the counselor becomes viewed as a personal friend, that counselor may later be
rejected for not living up to the client's expectations for overt assistance and
concern. . .
Another prevalent way of relating to persons in
authority is to forestall responsibility or action by responding to requests in
a genial, polite, and accommodating fashion that belies one's true intention of
not conforming. A closely allied strategy is the use of either flattery or saying
what the official wants to hear to divert attention away from one's personal problems....
the Mexican culture being late for appointments and social events is commonplace
and under many circumstances expected. These types of behavior can create considerable
frustration to the counselor who needs to meet schedules." (pp. 104-105)
(1985) suggests that white therapists should examine their underlying prejudicial
beliefs and attitudes. She delineates several unconscious reasons whites may want
to work with minority populations, reasons that, if gone unexamined, could impede
therapeutic progress. These include a desire to resolve identity issues, to cure
social ills, and to achieve a sense of superiority, as they actually view the
minority patient as inferior. She also calls attention to the likelihood that
clinicians, overwhelmed with "white guilt," often wonder about their
own contribution to oppression and may become anxious and preoccupied when treating
the urban poor. Therapists who become distant and detached are unable to listen
sensitively to their patients. They become sympathetic instead of empathic and
must consult a supervisor to resolve these issues.
for conflict exists with culturally homogeneous patient-therapist dyads. Pinderhughes
(1989) notes that clinicians can have a blind spot and may perceive patients from
their own culture as being like themselves. This interferes with treatment, as
these clinicians fail to explore the meaning of events for their patient and assume
the issues are similar to their own.
Many minority patients
must be informed about the purpose of questions pertaining to clinical history,
previous treatment information, family background, and psychosocial stressors
(Tsui & Schultz, 1985). If during the initial assessment the need for a more
psychodynamic approach is recommended, educating the patient about the therapeutic
process becomes important. Patients, particularly immigrant patients, may have
had little exposure to mental health approaches and may view such treatment as
irrelevant to their illness and not return. For example, Yamamoto (1982) contends
that to overcome the barrier to treatment on the part of Japanese-Americans, a
good educational campaign is necessary.
Minority patients may
perceive therapists to be knowledgeable experts who will guide the family's behavior
in the proper course of action. Viewed as authority figures and respected as such,
therapists need to convey an air of confidence and should not hesitate to make
reference to their educational background and work experience (Lee, 1982). It
may prove helpful for therapists to be well informed about the patient's history
and to show the patient that they have considerable knowledge of his or her background.
Thus, "How's your headache?" as the first question may be more sensitive
than "How can I help you?" or "Can you tell me more about yourself?"
working with Asian-American patients must be sensitive to issues of shame and
guilt when probing for personal information. To avoid leaving patients with the
impression that they have "caused" their problems, therapists must help
them understand that supervisees often encounter difficult situations as the result
of inevitable and unavoidable circumstances. In effect, the clinician uses the
cultural belief in "fate to neutralize the client's excessive guilt and responsibility"
(Tsui & Schultz, 1985).
Many Asians express love through
caring or tending to physical needs; consequently, "just listening"
may be interpreted by them as "non-caring" (Hsu, 1983). An active demonstration
of care, such as showing concern over a patient's physical condition or sleep
pattern or prescribing some common remedies for the usual discomforts, is useful
in establishing and maintaining good rapport (Hsu, 1983). Therapists should acknowledge
and treat the patient's reported physical symptoms. A didactic component often
facilitates the therapist's understanding that the patient's suffering is real.
For those Asian-Americans who have not acculturated, comments such as "Your
facial color looks better today" or "You ought to eat more vegetables"
convey concern and care.
When rating the directive style
of counseling, Korean subjects who were born in Korea and presently resided
there provided higher ratings of counselor effectiveness, expertness, attractiveness,
and trustworthiness than when therapy was nondirective (Foley & Fuqua, 1988).
Of course these findings would only be relevant to first-generation Korean-Americans.
The instruments used were the Counselor Rating Form and the Counselor Effectiveness
Franklin (1982), who writes about individual
therapy with urban African-American adolescents, identifies some ways traditional
techniques can be modified to suit this population. Since many youths are referred
by an outside authority figure, he suggests that it is important for the therapist
not to be cast in the same role. To counteract this impression, a more active
role is indicated in order for the therapist to be seen as empathic and caring.
Additionally, therapists need to explain their own role as well as the extent
of the adolescent's responsibility in the therapeutic process.
(1985) makes a similar point and advocates the use of therapy contracts with poor,
depressed, and acting-out African-American male adolescents. The therapist and
youth agree upon a trial period of 6 to 8 weeks of therapy and discuss the adolescent's
goals for therapy. At the end of the trial period the therapist and patient decide
if a continuation of treatment is warranted or desired. Giving the adolescent
an active part in the therapy "defuses dropout as a symbolic gesture of independence"
Franklin (1982) also delineates a series of "roles"
that may be adapted by some adolescents to either test the therapist or stalemate
the process of therapy:
"There are those who become
mummified as a test of strength to endure the stress of silence; you will
also encounter the seducer, who seeks validation from you as they do from their
peers; the starer, who will rivet you with constant eye contact; and the abuser,
who will verbally or physically try to intimidate you. The basic dynamic issue
in the first sessions of therapy with the adolescent is one of control. The streetwise
kid is very adept at maintaining control over the situation by adopting various
roles. (p. 278)"
The literature reports success in the
use of psychoanalytically oriented individual psychotherapy of some inner-city
African-American children (Meers, 1970; Spurlock & Cohen, 1969). The following
vignette illustrates how combining the ego capacity, motivation, and energy levels
of the patient with the motivation of the therapist allowed Carol, a 15-year-old
African-American, to expand her ego and her life.
Carol, the older of two daughters, was referred because of dizzy
spells, mild palpitations, and anxiety attacks in school, where she was entering
her junior high school year. She lived with her parents and sister in a housing
project in the ghetto area. The family was supported by disability and blind assistance
allotments because of the father's failing eyesight. Carol was seen for two periods
of treatment by the same social worker: The first period ended when she completed
high school, one-and-a-half years after referral. The second period was of two-and-a-half
years' duration, from the time she was eighteen-and-a-half until she became twenty-one.
Both parents were seen for the diagnostic evaluation. Neither parent was referred
for treatment. Early in the treatment experience, a marked change in the family
dynamics occurred: With a worsening of his visual problem, the father began to
display paranoid and violent behavior. The mother responded by turning to Carol
with the expectation that her "emergence into the labor market would provide
an exit from life in the housing project ghetto." Carol, always a passive,
compliant child with reaction formation defenses against anger, could not manage
her rage over the obstruction of her long-standing wish to go to college, nor
could she endure the guilt over separation wishes which defended her against sexual
interest in boys. This is not to imply that Carol had no regressive wishes for
the sadomasochistic and dependent gratification available from the mother. However,
she effectively used her therapy to deal with the ambivalence, separation, and
budding sexual interests so as to complete high school, to enter the local teacher's
college, acquire part-time employment, and leave the therapist.
bit over a year after termination of the first period of therapy, Carol called
her therapist with complaints of panic and trembling on the job and in classroom
recitations. She was taken back into treatment immediately, the foci of which
were (1) to mitigate the intense rage and tie to the mother; (2) to support her
against her regressive wishes; and (3) to help her achieve a sense of self-confidence
in her reasonable dating patterns which were opposed by both parents.
passive-aggressive defense against helplessness in the face of parental demands
and social deprivation began to crumble as Carol experienced the therapist's confidence
in her, which was supported by the larger culture. Carol's sense of autonomy expanded,
and she became cognitively aware of the personal and social opportunity to make
choices. Although she made much progress in achieving her goals, she could not
move away from home when invited to do so by friends. (Spurlock & Cohen, 1969,
In the preceding vignette the therapist suggested
that the patient apply for financial assistance as a means of relieving her guilt
about choosing school rather than the full-time employment that would have allowed
her to make a financial contribution to her family. Work with inner-city children,
adolescents, and their families often calls for and involves collaborative efforts
with another service agency to assist with handling pragmatic issues.
have been made to the similarity of goals in individual psychotherapy with African-American
children and those of the dominant group. There may be, however, a need to introduce
parameters. As indicated previously, attention should be directed to specific
culturally related transferences and countertransferences that may develop (Spurlock,
A segment of a resident's notes (minimally revised) provides a glimpse
into psychotherapy with an 8-year-old African-American inner-city boy:
was no need to introduce parameters in the individual treatment (which followed
a period of work in a group). The child responded to confrontations with apparent
interest and eagerness to examine a bit of behavior and readily supplied associations
in the effort to "find other pieces to the puzzles of my life" (this
was a reflection of his long-standing exposure to the television "soaps").
As in other therapeutic encounters, the therapist was supportive of the child's
self-mastery and his movement in the direction of reinforcing those behaviors
which decreased the sense of his inability to control his impulses. (Spurlock,
1985, p. 173)"
In work with inner-city African-American
children, Spurlock finds it helpful to see the patient and parents together
for the initial session for the purpose of providing an explanation about the
nature of the therapeutic process. This procedure is followed regardless of any
previous contact with other staff. The rationale is twofold: to provide specific
information about the process and ample time for questions and clarification and
to grant the patient and the parent(s) an opportunity to size up the therapist
and ask questions (such as "Have you ever worked with other families like
us?"). This kind of orientation is particularly helpful with those families
(regardless of race and ethnicity) who have experienced "investigative interviews"
and are weary of revealing information that might disqualify them from the assistance
The telling of African folk tales is sometimes useful
in work with African-American youngsters. Often, the content of the tale fosters
or reinforces the self-esteem of youngsters who believe primarily negative things
about the African-American culture. The playing of certain audiotapes (e.g., African
American Folktales aula, 1969, read by Brock Peters and Diana Sands) that incorporate
a lesson in the narrative has been particularly useful in work with younger children
as well as in training programs for mental health professionals who are unfamiliar
with African-American culture.
- Canino, Ian and Jeanne Spurlock, Culturally
Diverse Children and Adolescents: Assessment, Diagnosis, and Treatment, The Guilford
Press: New York, 1994.
Supportive Supervision: Promoting Staff and Family Growth
Through Positive Relationships
- Watts, Caroline, Supportive Supervision: Promoting staff and family growth through positive relationships, Children’s Hospital Boston, under the Innovation and Improvement Project grant from the Office of Head Start, Administration for Children and Families, U.S. Department of Health and Human Services. Children’s Hospital Boston, January 2008.
Reflection Exercise Explanation The
Goal of this Home Study Course is to create a learning experience that enhances
your clinical skills. We encourage you to discuss the Personal Reflection
Journaling Activities, found at the end of each Section, with your colleagues.
Thus, you are provided with an opportunity for a Group Discussion experience.
Case Study examples might include: family background, socio-economic status, education,
occupation, social/emotional issues, legal/financial issues, death/dying/health,
home management, parenting, etc. as you deem appropriate. A Case Study is to be
approximately 150 words in length. However, since the content of these Personal
Reflection Journaling Exercises is intended for your future reference, they
may contain confidential information and are to be applied as a work in
progress. You will not
be required to provide us with these Journaling Activities.
Reflection Exercise #1
The preceding section contained information
about culturally sensitive treatment approaches. Write three case study examples
regarding how you might use the content of this section in your practice.
QUESTION 4 Work with inner city clients often requires what practical aspect?
Record the letter of the correct answer the Test