Introduction to Clinical Psychology: Professional Issues

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Introduction to Clinical Psychology
Professional Issues EthicsDiversity
Multicultural Competencies

• Tamara D. Warner, Ph.D.
• Research Assistant Professor
• University of Florida, Department of Pediatrics
• November 16, 2007
• warnertd_at_peds.ufl.edu

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• "There is very little difference between one
  person and another, but what little there is, is
  very important.
• William James
•  Don't judge any man until you have walked two
  moons in his moccasins.
• Roman/Indian proverb
• Dedicated to the memory of Jenny Sivinski

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Learning Objectives

• Provide overview of basic assumptions behind the
  movement towards multicultural competencies in
  clinical psychology
• Provide some definitions and a conceptual
  framework to think about cultural issues as they
  relate to clinical psychology
• Have lecturer and students draw upon their own
  personal experiences to increase self-knowledge
  as related to the development of multicultural
  competencies

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Clinical Vignette

• Michael, a bright 13-year-old, was referred to an
  outpatient clinic due to symptoms of anxiety and
  acting-out behavior in school. He had been
  cutting classes, talking back to his teachers,
  displaying an attitude problem, experiencing
  difficulties with his peers and appearing overly
  worried and anxious at home. Michael made good
  eye contact during his first evaluative session.

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Does it matter if ?

• Michaels birth name is Miguel.
• Michaels parents are Nicaraguan immigrants and
  migrant farm workers.
• This is Michaels 3rd school in 2 years.

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Does it matter if .?

• Michael is African-American.
• Michaels mother died of cancer 6 months ago.
• Michael was placed in a foster home with
  European-American parents.
• Michaels foster parents are Catholic, but
  Michael was raised in a traditional Black Baptist
  church.

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Does it matter if .?

• Michael is wearing a Christian cross around his
  neck. A star of David is attached to the back of
  his jacket.
• Michaels parents recently went through a bitter
  divorce including a protracted custody battle.
• Michael mother is Christian and of Irish-American
  heritage.
• Michaels father is Jewish American.

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Does it matter if .?

• Michael recently discovered that he is attracted
  to other boys.
• Michaels older brother caught him and another
  boy holding hands in his room and has threatened
  to tell their father.

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• Basic
• Assumptions

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Basic Assumptions

• U.S. population is become increasingly diverse.
• Globalization (economic, cultural) will continue
  to increase cross-cultural exchanges.
• The field of psychology does not (and will not in
  the foreseeable future) reflect the diversity of
  those we serve.
• Developing competencies regarding assessment,
  treatment and research with diverse populations
  is not just important, but essential.

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Browning of America

• Increasing ethnic diversity in the United States
• By 2050, if not sooner, no group will constitute
  more than 50 percent of the population.
• Ethnic minorities constitute a growing share of
  the population heterogeneity within all ethnic
  groups is growing.
• Changes in the U.S. population stem largely from
  immigration.
• 38 of Hispanics and 61 of Asians in the U.S.
  are immigrants.
• Explosive growth of Hispanics in U.S. increased
  by more than 28 million during past 30 years,
  expected to grow by 55 million in next 20 years

Rand Corp Population Matters Policy Brief RB-5050
(2001) http//www.rand.org/pubs/research_briefs/RB
5050/index1.html
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Psychologists are not diverse

• Minorities are under-represented at all levels of
  the psychology pipeline with under-representation
  increasing as you move up the pipeline.
• At the rate the profession is currently going, we
  will never have enough ethnic minority
  psychologists to meet the need of all of
  Americas children.
• ALL psychologists (and other mental health
  professionals) must be trained to work with
  multicultural populations.

• Maton, K.I., Kohout, J. L., Wicherski, M., Leary,
  G. E., Vinokurov, A. (2006). Minority students
  of color and the psychology graduate pipeline
  Disquieting and encouraging trends, 1989-2003.
  American Psychologist, 61(2), 117-131.

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Why important?

• Failing to address issues related to diversity
• Impedes the effectiveness of psychologists as
  health service providers
• We cannot assume that the phenomenology of
  different disorders is the same in all groups.
• Hinders the progress of psychological science
• 90 of psychological science is based on samples
  that reflect 5 of the worlds diversity (Sue,
  1999)
• Huge generalizability problem!

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Its Who We Are

• Ethical Principles
• (A) Beneficence and Nonmaleficence
• Psychologists strive to benefit those with whom
  they work and take care to do no harm.
• (C) Integrity
• Psychologists seek to promote accuracy, honesty,
  and truthfulness in the science, teaching and
  practice of psychology.

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Its Who We Are

• Ethical Principles
• (D) Justice
• Psychologists recognize that fairness and
  justice entitle all persons to access to and
  benefit from the contributions of psychology and
  to equal quality in the processes, procedures,
  and services being conducted by psychologists.

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Its Who We Are

• (E) Respect for People's Rights and Dignity
• Psychologists respect the dignity and worth of
  all people Psychologists are aware of and
  respect cultural, individual, and role
  differences, including those based on age,
  gender, gender identity, race, ethnicity,
  culture, national origin, religion, sexual
  orientation, disability, language, and
  socioeconomic status and consider these factors
  when working with members of such groups.
  Psychologists try to eliminate the effect on
  their work of biases based on those factors, and
  they do not knowingly participate in or condone
  activities of others based upon such prejudices.

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Basic Assumptions Summary

• It is important.
• All psychologists need to learn multicultural
  competencies.
• It affects our effectiveness as health service
  providers.
• Its a matter of scientific integrity.
• Its part of our core ethical values as
  psychologists.

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• Some
• Definitions

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Some definitions

• Culture - system of shared beliefs, values,
  customs, behaviors, and artifacts that the
  members of society use to cope with their world
  and with one another, and that are transmitted
  from generation to generation through learning
  (anthropologist Franz Boaz)
• Race - physical characteristics, such as skin
  color, facial features, and hair type, common to
  a population. Social construction not a
  biological/genetic reality.
• Ethnicity - characterization of a group by its
  common nationality, culture, or language.
• Multiculturalism broad term encompassing race,
  ethnicity, language, sexual orientation, gender,
  age disability, class status, education,
  religious/spiritual orientation and other
  cultural dimensions

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Culture ? ethnicity

• An identifiable integrated pattern of human
  behavior that includes
• customs, beliefs, values, behaviors,
  communications
• Observed in ethnic, religious social groups
• Affected by age (generation), gender, education
  and socioeconomic status other factors
• Reflects ones level of acculturation

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Within group heterogeneity

• Who are Hispanics in the U.S.?
• Mexico, Puerto Rica, Cuba, El Salvador, Colombia,
  Guatemala, Nicaragua, Ecuador, Peru, Honduras and
  other Central and South American countries
• Who are Asians in the U.S.?
• China, the Philippines, Japan, India, Korea,
  Vietnam, Laos, Cambodia, Thailand, (Hmong)

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Culture is multi-faceted
Religion birth death rituals afterlife?
marriage gender roles holidays
Ethnicity name language/dialect
birthplace/migratory status food
preferences traditions art, literature, music age
gender roles
Socialization name language generation gender educ
ation socioeconomic status geographic region
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Culture is Invisible

• Individuals are generally blind to their own
  culture. Culture is like skin. You are not aware
  of it until certain experiences (texture,
  temperature) bring it into your conscious
  awareness.
• What seems normative or obvious to you is
  probably part of your culture. It may not be
  obvious to individuals who do not share your
  culture.
• Traveling outside the United States
• Privacy and personal distance

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Names as a Cultural Phenomenon

• Names
• Tyler, Connor, Jackson, Mason, Logan, Christian,
  Jordan, Madison

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Whats in a Name?

• Black or African-American names
• Invented or creatively-spelled variants of more
  traditional names.
• Created using fashionable syllables
• prefixes La- or De-
• suffixes -ique or isha
• Also, punctuation marks like apostrophes and
  dashes
• DeAndre, DeJuan, DeShawn, Keyshawn, Latonya,
  LaShonda, Lashawn, TKevah, YaSheema
• Ebony, Precious, Unique are examples of
  vocabulary names commonly used by black
  Americans.
• Imani and Malik are examples of African/Muslim
  names used by black Americans.
• Andre, Darius, Darryl, Maurice and Tyrone are
  more commonly used by black Americans.
• http//www.behindthename.com/glossary/view/african
  american_names

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Multicultural Misunderstanding?

• A white and a black co-worker decide to get their
  toddlers together for a playgroup. Afterwards .

Poor Sarah. Why were her Mama give her such a
common name? There are 4 Sarahs in our preschool
class alone!
Taquarious? Why would she give her child such
an usual name? Its going to make life harder
for him.
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Acculturation
The extent to which an individual has adopted the
values, beliefs and behaviors of the dominant
culture Considered on a continuum
Traditional
Bicultural blended code-switchers
Acculturated Assimilated
Where are you on this continuum? Where is the
person you are communicating with?
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Culture is difficult to pin down

• It will not always be easy to evaluate the role
  that cultural variables play in assessment
  because members of culturally and linguistically
  diverse groups differ in how firmly their adhere
  to their groups cultural traditions and
  practices. Greater diversity exists within any
  group, especially between recent immigrants and
  those who have had more opportunity to become
  acculturated into their new society. Even among
  those who are acculturated, differences exist in
  patterns of acculturation. (Sattler, p. 636)

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Minority Status

• Specific stressors associated with being a
  minority (ethnic, sexual orientation, disability)
• Double consciousness W.E.B. duBois The Souls
  of Black Folk (1903)
• Born with a veil, and gifted with second-sight
  in this American world
• A sense of always looking at ones self through
  the eyes of others, of measuring ones soul by
  the tape of a world that looks on in amused
  contempt and pity. One ever feels his
  two-ness,an American, a Negro two souls, two
  thoughts, two unreconciled strivings two warring
  ideals in one dark body
• Often, it has to do with the fact that your
  experiences contradict the fundamental
  assumptions of the larger culture
• Ethnicity It doesnt matter where you come
  from.
• Sexual orientation When you get married one
  day
• Disability Everyone has equal opportunity.

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Identity Development

• All people go through a process of developing a
  sense of racial or ethnic identity (also true for
  gender, GLBT and other aspects)
• At different stages in the developmental process,
  we assign different degrees of important to the
  concept or race/ethnicity
• Different models for minority/ethnic identity
  than majority/White identity

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Ethnic (Minority) Identity Development

• Sue and Sue (1990)
• Stage 1 Conformity - preference for dominant
  cultural values, self-deprecating of own
  ethnicity
• Stage 2 Dissonance questioning and challenging
  beliefs of the conformity stage
• Stage 3 Resistance and Immersion rejection of
  dominant society and endorsement of minority
  views
• Stage 4 Introspection less rigid resistance of
  dominant society view
• Stage 5 Integrative Awareness appreciation of
  unique aspects of both the minority and dominant
  culture

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White (Majority) Racial Identity Development

• Helms (1984)
• Stage 1 Contact oblivious to racism, minimal
  experiences with minorities, color-blind
• Stage 2 Disintegration become conflicted over
  unresolved racial more dilemmas, increasingly
  conscious of own Whiteness
• Stage 3 Reintegration regression to a tendency
  to idealize own group and dominant ideology, more
  conscious belief in White racial superiority,
  blame minorities for their own problems

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White (Majority) Racial Identity Development

• Helms (1984)
• Stage 4 Pseudo-Independence attempt to
  understand differences and reach out to
  minorities who are similar to self, more
  intellectual than experiential or affective
  approach to race
• Stage 5 Immersion/Emersion search for more
  personal understanding of racism White
  privilege, increased willingness to truly
  confront ones biases become more active in
  combating racism
• Stage 6 Autonomy increasing awareness, less
  guilt, acceptance of ones own role in
  perpetuating racism, knowledgeable about cultural
  differences, no longer fearful, strive to develop
  nonracist white identity

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Unearned Privileges

• Peggy McIntosh (1988) White Privilege Unpacking
  the Invisible Knapsack
• Shift from racism, sexism, heterosexism, able-ism
  to understanding of unearned privileges, which
  most of us are completely oblivious to
• "I was taught to see racism only in individual
  acts of meanness, not in invisible systems
  conferring dominance on my group
• White privilege -- an invisible package of
  unearned assets that I can count on cashing in
  each day, but about which I was "meant" to remain
  oblivious. White privilege is like an invisible
  weightless knapsack of special provisions, maps,
  passports, codebooks, visas, clothes, tools, and
  blank checks.

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Examples of White Privilege

• I can if I wish arrange to be in the company of
  people of my race most of the time.
• I can avoid spending time with people whom I was
  trained to mistrust and who have learned to
  mistrust my kind or me.
• If I should need to move, I can be pretty sure of
  renting or purchasing housing in an area which I
  can afford and in which I would want to live.
• I can be pretty sure that my neighbors in such a
  location will be neutral or pleasant to me.
• I can go shopping alone most of the time, pretty
  well assured that I will not be followed or
  harassed.
• I can turn on the television or open to the front
  page of the paper and see people of my race
  widely represented not as criminals.
• When I am told about our national heritage or
  about "civilization," I am shown that people of
  my color made it what it is.
• I can be sure that my children will be given
  curricular materials that testify to the
  existence of their race.

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More Examples

• I can go into a supermarket and find the staple
  foods which fit with my cultural traditions, into
  a hairdresser's shop and find someone who can cut
  my hair.
• Whether I use checks, credit cards or cash, I can
  count on my skin color not to work against the
  appearance of financial reliability.
• I can be pretty sure that my children's teachers
  and employers will tolerate them if they fit
  school and workplace norms my chief worries
  about them do not concern others' attitudes
  toward their race.
• I can talk with my mouth full and not have people
  put this down to my color.
• I can swear, or dress in second hand clothes, or
  not answer letters, without having people
  attribute these choices to the bad morals, the
  poverty or the illiteracy of my race.
• I can speak in public to a powerful male group
  without putting my race on trial.

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More Examples

• I can do well in a challenging situation without
  being called a credit to my race.
• I am never asked to speak for all the people of
  my racial group.
• I can remain oblivious of the language and
  customs of persons of color who constitute the
  world's majority without feeling in my culture
  any penalty for such oblivion.
• I can be pretty sure that if I ask to talk to the
  "person in charge," I will be facing a person of
  my race.
• If a traffic cop pulls me over or if the IRS
  audits my tax return, I can be sure I haven't
  been singled out because of my race.
• I can easily buy posters, post-cards, picture
  books, greeting cards, dolls, toys and children's
  magazines featuring people of my race.
• If my day, week or year is going badly, I need
  not ask of each negative episode or situation
  whether it had racial overtones.
• I can be sure that if I need legal or medical
  help, my race will not work against me.
• I can expect figurative language and imagery in
  all of the arts to testify to experiences of my
  race.

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Definitions Summary

• Diversity has many dimensions
• Culture (vs. race/ethnicity)
• Acculturation
• Minority status
• Identity development

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• TRANSITION

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Commitment to Cultural Awareness

• All people are multicultural beings all
  interactions are cross-cultural. (APA
  Guidelines, p. 382)
• Guideline 1 Psychologists are encouraged to
  recognize that, as cultural beings, they may hold
  attitudes and beliefs that can detrimentally
  influence their perceptions of and interactions
  with individuals who are ethnically and racially
  different from themselves.
• First multicultural competence
• KNOW THYSELF

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My Personal Experiences
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• B.A., Harvard University, 1992
• M.A., University of Michigan, 1996
• M.S., University of Florida, 1999
• Ph.D., University of Florida, 2003
• African American
• Christian woman and mother originally from rural
  Appalachia, working class background, mostly
  heterosexual, first generation college, divorced
  remarried (first husband was Jewish)

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Growing Up

• Charleston, WV (4 minority in the entire state)
• Both of my parents attended segregated schools
• Blacks on TV
• I was the only African American child in my class
  (with the exception of 1st 3rd grades)
• Grew up in mixed race neighborhood
• One Asian (mixed race) and one Latino family in
  my neighborhood
• No religious diversity to speak of

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The Story of Billy Boy
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Racial/Ethnic Socialization

• I am no Nigger-o.
• Traveling cross-country
• Light skin and good hair (yellow towels)
• Piano lessons and Presbyterian Church
• Barbie Dolls and Baby Christie
• Toni Morrisons The Bluest Eye, A Girl Like Me
  documentary
• Junior High wake-up call
• By graduation proud to be Black?
• You want to major in what?
• Multicultural wedding celebration
• Womens studies and homophobia
• Traveling to Black countries

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Majority At Last
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Self Awareness Exercise

• Take out a sheet of paper and with your
  non-dominant hand, write out answers to the
  following 3 questions
• What is your racial/ethnic background?
• What is a strength that you have drawn upon
  coming from your racial/ethnic background?
• What has been a challenge or weakness coming from
  your racial/ethnic background?
• Think of a specific incident that helped to
  socialize you into your racial/ethnic background.

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Self Awareness Exercise 2

• Think of a time when you were the only one or
  when you were singled out or excluded from an
  event. You may be the only one in your family to
  have done something, or the only American
  traveling abroad, the only one not invited to a
  party, or the only representative of your
  religious tradition.

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Self-Awareness Exercise 3

• List 3 different privileges that you enjoy as a
  result of your racial/ethnic background, gender,
  education, socioeconomic status, appearance and
  able-body status. How can these privileges
  help/harm you ability to function effectively as
  a psychologist (assessment, treatment, research)?

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Self-Awareness Challenge(s)

• Disability status
• As psychologists in health care settings, we must
  increase our empathetic understanding of living
  with a disability
• Mobility-impaired, hemiplegia, blind, deaf,
  speech
• Some random ideas
• Spend one full weekday day in a wheelchair
• Bathing, toileting
• Travel, mobility
• Communicating with other 3 feel lower to the
  ground
• Spend one full weekday not using your
  non-dominant arm
• Go to University Avenue Gale Lemerand Drive and
  get directions to the Reitz Union without using
  speech
• Paint a prominent port-wine stain on the side of
  face neck

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Self-Awareness Challenges

• Attend any ethnic group gathering of group that
  is NOT designed to be a cultural presentation
  (entertainment)
• For one month, learn about the news affecting a
  specific ethnic group -- read print publications,
  TV/radio news programs or email
  newsletter/websites
• Attend a religious service of a different ethnic
  group in a language other than your own
• Gainesville Chinese Christian Church
• Korean Baptist Church of Gainesville
• Iglesia Evangelica Bautista
• Jehovahs Witness (Spanish) Archer Road

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Developing Multicultural Competencies

• Self-awareness is the first step towards
  development multicultural competencies
• Individuals and groups are often blind to their
  own culture and how it affects behavior and
  interactions with others
• You need to be aware of how your own cultural and
  religious background (beliefs, values, and
  biases) differ from others and how it may affect
  your functioning as a psychologist
• The next step is learning about other groups
  (both information and experience)
• You need to be aware of how the beliefs and
  behaviors of others differ from your own
• Find willing partners and allies to assist with
  your education.
• The third step is practice with consultation,
  as needed.

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Developing Multicultural Competencies

• Dont make too many assumptions.
• Use the suggestions re psychotherapy in Cardemil
  Battle, 2003
• Dont be afraid to ask.
• Dont be afraid to make mistakes. Its the only
  way we really learn.

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• "There is very little difference between one
  person and another, but what little there is, is
  very important.
• William James
• Don't judge any man until you have walked two
  moons in his moccasins.
• Roman/Indian proverb

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Discussion Fundamental Tension

• Some authors have argued that, philosophically,
  multiculturalism is fundamentally untenable.
  Multiculturalism holds that all aspects of human
  diversity should be (at least) tolerated and/or
  accepted. This involves a kind of moral
  relativism, which is at odds with the core belief
  systems of some religious traditions.
• For example, some fundamentalist Christians
  believe that, according to the Bible,
  homosexuality is a sin. Psychologists who are
  fundamentalist Christians would argue that they
  cannot and should not accept homosexuality or
  homosexuals.