Therapy with Diverse Populations

Don’t forget that Multicultural refers to all diversity (Race, Gender, SES,

Sexual Orientation, Gender Identification, Ability, Age, Spirituality)

Evidence Based Treatmentswith Minority clients

A Meta–Analysis of Evidence Based Treatmentfor Minority Youth

(Huey, 2005-In Press)

Problem Well Established Probably Efficacious Only a few good Studies

Anxiety CBT (Af.A & Latino)

ADHD Meds & Beh. Therapy (Af. A & Latino)

Multi Component Behavioral Tx (Af. A)

Conduct Problems Assertive Training (Af.A)

Multisystemic Therapy (Af. A)

Anger Mgmt (Minority)

Brief Strategic Family Therapy (La.)

Coping Power (A.A.

Multicomponent Intervention (Af. A)

Depression CBT (Latino)

IPT (Latino)

Drug Use Multidimentional Family Therapy (Minority)

Mixed & Co-morbid Problems

Multusystemic Therapy

(Multiracial Asian, Pacific Islander, Caucasian)

Trauma-Related Problems Trauma Focused CBT (Minority)

Resilient Peer Treatment) Af. A)

CBT in the school (Latino)

ROOM OF CONFESSION: AN INVESTIGATION INTO THE CHALLENGES ANDPOSSIBLE APPLICATIONS OF PRIMARY NARRATIVE FOR USE IN

MIDDLE SCHOOL PEER HARASSMENT INTERVENTION(Foote, 2002)

Peer harassment is an omnipresent reality in our schools today. The paper examines harassment and victimization on several levels (e.g., individual behaviors of target and perpetrator, various forms of victimization, group processes, family dynamics, and structural characteristics of larger units such as the classroom and the school). The literature identifies a number of prevention and intervention strategies designed to address this issue in a school setting, with much of the emphasis on the classroom teacher or guidance department. One strategy not found in the current literature is storytelling in the form of primary narrative.

This thesis investigates the use of "harassment tales" told by high school students to middle school students to create a context of confession, enabling the younger students to consider their own roles in harassment and victimization. The purpose of this study is to identify the challenges and possible applications of personal testimonials by high school students as a means of intervention in middle schools. The Study concluded that this form of narrative therapy warrants further assessment.

PROVIDE HANDOUT

Culture-Responsive Elementsof Evidence-Based Treatments

(Huey, 2005, In Press)

• Therapists used client’s strengths across multiple life domains, including “cultural/ethnic/spiritual interests and involvement”

• Staff recruited from local community to match ethnic composition of youth. Also, core program “implemented with prescribed adaptation for . . .cultural diversity.”

• Treatment was “culturally appropriate” in its use of family volunteers and socially high-functioning peers, with common cultural backgrounds and experiences.

• Manual adapted to be “culturally sensitive (e.g., examples changed, alternative situations used, etc.)”

• Individualized treatment plans and assessment of multiple contexts, allows MST to “deal flexibly with sociocultural differences in adolescents’ psychosocial contexts.”

• African American staff involved in development of intervention; in group sessions, participants encouraged to discuss what they already do that works, and those efforts are then used as positive examples; act collaboratively with participants as coaches rather than as teachers

• IPT and CBT “adapted, taking into consideration cultural aspects of the treatments that consider the ‘interpersonal’ aspects of the Latino culture.”

• Cultural background of clinical team representative of client population.

• Use of “Family Resource Specialist” to “help families develop indigenous social supports and to assist the clinical team in understanding the cultures and contexts in which the families were embedded”

• Therapist training involved “sensitizing therapists to issues specific to working with multicultural populations, such as cultural differences in modes of coping, definitions of anxiety-provoking objects or events, and particular parenting styles.

• Treatment addressed intergenerational, cultural conflict. Counselors Hispanic and experience working with Hispanics

Ethnocultural Transference and Counter Transference in the

Therapeutic Dyad(Comas-Diaz, & Jacobsen, 1991)

• Cultural Unconscious (Transference)– “It has been postulated that every culture has its own unique form of

unconscious (Hall, 1981) which may have powerful effects on the process of psychotherapy

• Counter transference reaction (CT)– Complicated by ethnocultural issues such as prejudice, discrimination,

and guilt

• Cultural Behavior (Transference and CT)– “Often makes the evaluation of transference and countertransference

difficult” (Bash-Kahre, 1984, Zaphiropoulos, 1982)– May become a stumbling block (impasse) when the therapist fails to

acknowledge such differences (Varghese, 1983)– Nonverbal communication is inclined to be misinterpreted by both

therapist and client (in terms of their own cultural reality) leading to feelings of estrangement for both.

In Class Activity

• Review Article together and Identify stages in Identity Development that might be reflected in Transference and Countertransference experiences.

Finding YOUR Expression

Helping clients reintegrate their Selves left behind in order to survive in a dominant culture

Language

• Taking away someone’s language thru direction or indirect punishment is one of the first steps in deconstructing their culture and cultural identity

• Language is also used for social judgments, so reclaiming it can be difficult– Classism– Racism– Sexism– Ablisms

• Ex. Deaf Culture

Helping clients find their expressions of self

• Educate on– How the removal of language is a step in the deconstruction of

one’s identity and culture. – How this may be utilized by those in power to ensure continued

power.– How Language is used as a social judgment to maintain the

privilege and power of those who currently hold the power.

• Explore how using their first language was punished • Encourage clients to use first language as needed to

help them fully express themselves in therapy• Encourage clients to Cross-Code in therapy

Therapeutic Ruptures and Impasses and Diversity

Counselor Assumptions that may lead to a rupture/Impass in therapy

(Sue & Sue, 2003)

• Assuming the same level of identity development• Culturally Bound Values

– Focusing on the Individual Identity– Expecting Verbal and Emotional Expression– Focusing on Insight– Expecting self-disclosure of personal information

• Class Bound Assumptions– The world is safe and it is best to trust others– Quietness/ Loudness, direct vs. indirect communication, demeanor,

emotional expression, cleanliness, pleasantness, denial/ignoring conflict• Misapplication of Culture in therapy

– Focusing on diversity when it is not where the client is at or an aspect of the presenting problem

– Missing when the client “drops cues” about aspects of or the importance of their diversity

Class Activity to explore rules and practice active listening around isms to avoid impasses

• Share your own stories about how isms have affected you.

• What were the rules about meeting people for the first time? About personal space? About conversation? Interruptions? Disagreements? Other?

• Their task: Describe an instance of feeling left out because you didn't know "the rules."

Recognizing the Impasse

• Is important because they may lead to attrition or be signs of counselor impairment– Do you feel angry, disappointed, bored or defensive?– Are you producing incongruent behaviors, acting out

anger or annoyance, advance your own agenda, becoming overly directive, talking to much, or shutting down?

– Clients often hide negative reactions by increasing certain cultural styles of behavior. Is your client more silent or agreeable, avoiding eye contact, arriving late or leaving early, starting to dispute therapy goals or tasks, missing appointments?

Checking in with yourself

• What cultural intervention did you make?

• Why did you chose it?

• What was the clients reaction to it?

Resolving the Impasse

• Serves as a model of resolving conflict

• Serves as a way to develop and practice new interpersonal schema

• Helps the client develop more comfort with difficult dialogues and conflict

How to help resolve the impasse

• Hopefully you have developed a strong working alliance (and this impasse may build on this alliance if it is not already built)

• Allow the client to express negative feelings and discuss them without defensiveness

• Attend to the working Alliance– Note the impasse and recognize that the client may want to retain a positive

image of themselves and the counselor for fear of damaging the relationship or losing an important resource, self esteem, etc.

– Be aware of your own feelings, so you can accept responsibility in the relationship

– Look for ways to accept responsibility• Investigate and explore how you may have caused or contributed to the impasse.

Utilize Supervision.• Model taking responsibility for creating a culturally based therapy problem while still

holding compassion for yourself and the other• Model coping with anger, frustration, vulnerability and guilt in this process

– Try to empathize with the client’s experience, imagining yourself in the client’s place

– Attempt to maintain a Participant Observer stance as needed. This can be reframed as creatively looking for ways to create new dialogues with the client to de-escalate tension between you and the client, while always acknowledging your part in creating the rupture and the need for the rupture to be resolved by you and the client together.

– Discuss how you will integrate culture related dialogues into the therapy process.

Can you ignore the issue once a rupture/impasse has occurred?Refusal to address the issue not only complicates the

relationship, but also fits into the larger nontherapy society in which issues of diversity are minimized, avoided, or dismissed at large and in significant relationships

Since you have the power, you have the responsibility to stay with the issue. Remember the person with the power can always choose to abuse this power by withdrawing from the discussion with little personal impact, but the person with less power remains impacted.