Counseling the Culturally Diverse

Derald Wing Sue, PhD, is a Professor of Psychology and Education in the Department of Counseling and Clinical Psychology at Teachers College, Columbia University. David Sue, PhD, is Professor Emeritus of Psychology and an associate at the Center for Cross-Cultural Research at Western Washington University in Bellingham, Washington. Helen A. Neville, PhD, is a Professor of Educational Psychology and African American Studies at the University of Illinois at Urbana-Champaign. Laura Smith, PhD, is a Professor of Psychology and Education in the Counseling Psychology Program at Teachers College, Columbia University.

Preface xix

Section 1 The Multiple Dimensions of Multicultural Counseling and Therapy

Part 1 The Affective Conceptual and Practice Dimensions of Multicultural Counseling and Therapy

1 Understanding Resistance to Multicultural Training: Obstacles to Developing Cultural Competence 5

Expections for the Course 6

Reflection and Discussion Questions 6

Reactions to the Course 7

By The Numbers 8

Emotional Self-Revelations and Fears: Majority Group Members 8

Emotional Invalidation Versus Affirmation: Marginalized Group Members 10

A Word of Caution 12

Reflection and Discussion Questions 13

Recognizing and Understanding Resistance to Multicultural Training 13

Cognitive Resistance—Denial 14

Emotional Resistance 14

Did You Know? 15

Behavioral Resistance 17

Cultural Competence and Emotions 18

Implications for Clinical Practice 19

Summary 20

Glossary Terms 20

References 20

2 Multicultural Counseling and Therapy (MCT) 23

Race and Culture Matter 23

Reflection and Discussion Questions 25

Culture-Universal (ETIC) Versus Culture-Specific (EMIC) Formulations 25

Cultural Concepts of Distress 25

Acknowledging Group Differences 26

Being Aware of Collectivistic Cultures 26

Attuning to Cultural and Clinical Clues 26

Balancing the Culture-Specific and Culture-Universal Orientations 27

The Nature of Multicultural Counseling Competence 27

The Harm of Cultural Insensitivity 27

Good Counseling is Culturally Responsive Counseling 28

By The Numbers 28

Understanding The Three Dimensions of Identity 28

Individual Level: “All Individuals Are in Some Respects Like No Other Individuals” 29

Group Level: “All Individuals Are in Some Respects Like Some Other Individuals” 30

Universal Level: “All Individuals Are in Some Respects Like All Other Individuals” 30

Reflection and Discussion Questions 31

Individual and Universal Biases in Psychology and Mental Health 31

The Impact of Group Identities on Counseling and Psychotherapy 32

What is Multicultural Counseling and Therapy? 32

What is Cultural Competence? 33

Box 2.1: Multicultural Counseling Competencies 34

Did You Know? 35

Social Justice and Cultural Competence 36

Reflection and Discussion Questions 36

Implications for Clinical Practice 37

Summary 37

Glossary Terms 38

References 38

3 Cultural Perspectives and Barriers: The Individual Interplay of Cultural Experiences 41

Reflection and Discussion Questions 42

Characteristics of Conventional Counseling 42

Culture-Bound Values 44

Focus on the Individual 44

Verbal/Emotional/Behavioral Expressiveness 45

Insight 45

Self-Disclosure Openness and Intimacy 46

Styles of Communication 47

Did You Know? 48

Scientific Empiricism 49

Distinctions Between Mental and Physical Functioning 50

Patterns of Cultural Assumptions and Multicultural Family Counseling/Therapy 50

People–Nature Dimension 51

Time Dimension 52

Relational Dimension 53

Activity Dimension 53

Nature of People Dimension 54

Language Barriers 55

Class-Bound Values and Perspectives 56

By The Numbers 56

The Damaging Impact of Poverty 56

Therapeutic Class Bias 57

Overgeneralizing and Stereotyping 58

Implications for Clinical Practice 58

Summary 59

Glossary Terms 60

References 60

Part 2 Sociopolitical and Social Justice Dimensions of Multicultural Counseling and Therapy

4 Microaggressions: Implications for Counseling and Psychotherapy 67

Reflection and Discussion Questions 67

Reflection and Discussion Questions 68

Contemporary Forms of Oppression: Racism Sexism & Heterosexism 70

The Evolution of the “ISMS”: Microaggressions 71

Microassault 71

Microinsult 71

Microinvalidation 72

By The Numbers 72

Reflection and Discussion Questions 72

The Dynamics and Dilemmas of Microaggressions 75

Dilemma 1: The Clash of Sociodemographic Realities 75

Dilemma 2: The Invisibility of Unintentional Expressions of Bias 76

Dilemma 3: The Perceived Minimal Harm of Microaggressions 76

Dilemma 4: The Catch-22 of Responding to Microaggressions 77

Did You Know? 77

Therapeutic Implications 77

Microinterventions: The New Therapeutic Frontier 80

Implications for Clinical Practice 82

Summary 82

Glossary Terms 83

References 83

5 Sociohistorical Privilege and Oppression: Implications for Counseling and Psychotherapy 86

An Open Letter to Brothers and Sisters of Color 86

Reflection and Discussion Questions 87

Mental Health Practice and the Reproduction of Oppression 87

Connecting the Dots Between Mental Health Practice and Social Justice: An Overview 89

The Danger of a Single Story: Ethnocentric Monoculturalism 91

Did You Know? 91

Understanding Ethnocentric Monoculturalism 92

Historical Manifestations of Ethnocentric Monoculturalism 94

Ethnocentric Monoculturalism Sociohistorical Oppression and Mental Health 95

Ethnocentric Monoculturalism and Foundational Psychotherapeutic Theory 96

Definitions of Mental Health 96

Connections to the Counseling and Mental Health Literature 98

Pathology and Persons of Color 98

By The Numbers 100

Ethnocentric Monoculturalism and Mental Health Practice: Psychotherapy as a Racial-Cultural Microcosm 100

Reflection and Discussion Questions 101

MCT as a Social Justice Approach to Mental Health Practice 102

Social Justice Advocacy and Cultural Humility 104

Implications for Clinical Practice 105

Summary 106

Glossary Terms 106

References 107

PART 3 Racial Ethnic Cultural (REC) Attitudes in Multicultural Counseling and Therapy

6 Racial Ethnic Cultural (REC) Identity Attitudes in People of Color: Counseling Implications 113

Case Study: Alejandro: Afro-Puerto 113

Racial Awakening 114

Just American to Puerto Rican/Afro-Latino 114

Denial Breakdown 114

The Internal Struggle for Identity 114

Locus of the Problem 115

REC Identity Attitude Models 115

Did You Know? 115

William E. Cross’ Nigrescence Model: Foundational Theory 115

A General Model of Rec Identity 117

Conformity Status 118

Dissonance Status 119

Resistance and Immersion Status 120

Introspection Status 121

Integrative Awareness Status 123

Counseling Implications of the R/CID Model 123

Conformity Status 124

Dissonance Status 125

By The Numbers 125

Resistance and Immersion Status 125

Introspection Status 126

Integrative Awareness Status 126

Value of a General Rec Identity Framework 126

Reflection and Discussion Questions 127

Implications for Clinical Practice 127

Summary 128

Glossary Terms 128

References 128

7 White Racial Consciousness: Implications for Counseling and Psychotherapy 130

Whiteness and Multicultural Counseling 130

Reflection and Discussion Questions 131

Steps Toward an Understanding of Whiteness and White Identity 132

Did You Know 133

Models of White Racial Identity Development 135

The Hardiman White Racial Identity Development Model 135

The Helms White Racial Identity Development Model 136

A Descriptive Model of White Identity: Seven Positions 137

By The Numbers 139

An Antiracist White Identity 141

White Antiracist Identifications 142

Principles of Prejudice Reduction 143

Principle 1: Learn About People of Color From Sources Within the Group 143

Principle 2: Learn From the Examples of Healthy and Strong People of the Culture 144

Principle 3: Learn From Experiential Reality 144

Principle 4: Learn From Constant Vigilance of Your Biases and Fears 144

Principle 5: Learn From Being Committed to Personal Action Against Racism 144

Reflection and Discussion Questions 145

Implications for Clinical Practice 145

Summary 146

Glossary Terms 146

References 146

8 Multicultural Counseling Competence and Cultural Humility for People of Color Counselors and Therapists 149

Interracial And Interethnic Biases 150

Impact On Interracial Counseling Relationships 150

Racial Stereotypes Held by People of Color 150

The Who-Is-More-Oppressed Game 151

Interracial and Interethnic Counseling 151

By The Numbers 152

Reflection and Discussion Questions 152

The Politics of Interracial and Interethnic Bias and Discrimination 153

The Political Relationships Between Groups of Color 154

African Americans and Asian Americans 154

Asian Americans and Latinx Americans 155

Latinx Americans and African Americans 155

American Indians and Black Latinx and Asian Americans 156

Reflection and Discussion Questions 156

Within Group Differences Among Racial/Ethnic Groups 157

Cultural Values 157

Communication Styles 157

Issues Regarding Stage of Ethnic Identity 158

Did You Know? 158

Counselors of Color and Dyadic Combinations 158

Challenges Associated with Counselor of Color and White Client Dyads 159

Situation 1: Challenging the Competency of Counselors of Color 159

Situation 2: Needing to Prove Competence 159

Situation 3: Transferring Racial Animosity toward White Clients 160

Situation 4: Viewing the Counselor of Color as a Super Minority Counselor 160

Situation 5: Dealing with Client Expressions of Racism 161

Challenges Associated with Counselor of Color and Client of Color Dyads 162

Situation 1: Overidentifying with the Client 162

Situation 2: Encountering Clashes in Cultural Values 162

Situation 3: Experiencing Clashes in Communication and Counseling Styles 163

Situation 4: Receiving and Expressing Racial Animosity 164

Situation 5: Dealing with the Racial Identity Status of Counselors and Clients 164

Reflection and Discussion Questions 165

Implications for Clinical Practice 165

Summary 166

Glossary Terms 166

References 166

PART 4 Western and Non-Western Perspectives in Counseling and Therapy

9 Multicultural Evidence-Based Practice 171

Reflection and Discussion Questions 172

Empirically-Supported Therapies (ESTs) 172

Reflection and Discussion Questions 175

Empirically Supported Relationships (ESRs) 175

Did You Know? 175

The Therapeutic Alliance 176

Emotional or Interpersonal Bond 178

Empathy 178

Positive Regard Respect Warmth and Genuineness 179

Therapist Self-Disclosure 180

Management of Countertransference 180

Goal Consensus 180

Reflection and Discussion Questions 181

Evidence-Based Practice and Diversity Issues in Counseling 181

By The Numbers 182

Reflection and Discussion Questions 183

Implications for Clinical Practice 184

Summary 184

Glossary Terms 185

References 185

10 Indigenous and Cultural Methods of Healing Among People of Color: Implications for Multicultural Counseling and Therapy (MCT) 188

Worldviews and Cultural Concepts of Distress 189

The Shaman and Traditional Healer as Therapist: Commonalities 190

Case Study: The Nguyen Family 191

A Case of Child Abuse? 191

Did You Know? 193

The Principles of Indigenous Healing 193

Holistic Outlook Interconnectedness and Harmony 194

Belief in Metaphysical Levels of Existence 194

Acceptance of Spirituality in Life and the Cosmos 195

By The Numbers 197

Reflection and Discussion Questions 198

Radical Healing Among People of Color 198

Examples of Healing Practices Among People of Color 199

Implications for Clinical Practice 200

Summary 200

Glossary Terms 201

References 201

PART 5 Assessment Diagnosis and Treatment Issues in Multicultural Counseling and Therapy

11 Culturally Competent Assessment 207

Therapist Variables Affecting Diagnosis 208

Did You Know? 209

Cultural Competence and Preventing Diagnostic Errors 210

Cultural Self-Awareness 210

Cultural Knowledge 211

Culturally Responsive or Multicultural Skills 211

Contextual and Collaborative Assessment 212

Case Study: Erica 213

Principles of Collaborative Conceptualization 213

Infusing Cultural Relevance into Standard Clinical Assessments 214

Cultural Formulation Interview 214

Culturally Sensitive Intake Interview 215

By The Numbers 216

Implications for Clinical Practice 218

Summary 218

Glossary Terms 219

References 219

Section 2 Multicultural Counseling and Specific Populations

PART 6 Counseling and Therapy with Racial/Ethnic Group Populations

12 Multicultural Counseling Contexts: African Americans 225

Sociohistorical Context 226

Strengths and Resiliences 227

Family and Community 227

Religion and Spirituality 227

Resourcefulness and Resilience 228

Positive Racial-Ethnic Identity or Racial Pride 228

Potential Challenges 228

Racism and Discrimination 228

Racial Socialization: When What and How to Discuss Racism 229

Internalized Racism 229

Challenges for Black Women 230

Counseling and Applied Considerations 230

Case Studies: Johnny: When Extra Familial Help Causes Disruption 231

A Clinical Checklist 233

Summary 234

Glossary Terms 235

References 235

13 Multicultural Counseling Contexts: American Indians/Native Americans and Alaskan Natives 239

Sociohistorical Context 240

Strengths and Resliencies 241

Tribal Community Structure and Relationships 242

Family Structure and Relationships 242

Cultural and Spiritual Values 242

Specific Challenges 243

Case Study: Mary 244

Educational Concerns 244

Acculturation Conflicts 245

Alcohol and Substance Abuse 246

Domestic Violence 246

Suicide 247

Implications for Clinical Practice 248

Summary 248

Glossary Terms 249

References 249

14 Multicultural Counseling Contexts: Asian Americans and Pacific Islanders 252

Characteristics and Strengths 253

Asian Americans: A Success Story? 253

Case Study: Katherine 255

Collectivistic Orientation 255

Hierarchical Relationships 256

Parenting Styles 256

Emotionality 257

Holistic View on Mind and Body 257

Academic and Occupational Goal Orientation 258

Cultural Strengths 258

Specific Challenges 259

Racial-Ethnic-Cultural Identity and Conflict 259

Acculturation Conflicts 259

Expectations Regarding Counseling 260

Racism and Discrimination 261

Implications for Clinical Practice 262

Summary 263

Glossary Terms 263

References 263

15 Multicultural Counseling Contexts: Latinx Communities 266

Cultural Strengths 267

Family and Interpersonal Relationships 267

Religion and Spirituality 269

Additional Cultural Strengths 270

Specific Challenges 270

Xenophobia Discrimination and Ethno-Racial Trauma 270

Racism in the Schools 271

Stigma Associated with Mental Illness 272

Acculturation and Acculturative Stress 272

Gender Role Conflicts 274

Implications for Clinical Practice 275

Summary 276

Glossary Terms 277

References 277

16 Multicultural Counseling Contexts: Multiracial Americans 280

Characteristics and Strengths 281

Multiracial Population in the United States 281

The “One Drop of Blood” Rule 282

Strengths 283

Specific Challenges 284

Racial/Ethnic Ambiguity and Multiracial Identity Socialization: “What Are You?” 284

Intermarriage Stereotypes and Myths 285

Discrimination Racism and Microaggressions 285

Racial Identity Invalidation 286

A Multiracial Bill of Rights 288

Implications for Clinical Practice 288

Summary 290

Glossary Terms 290

References 290

17 Multicultural Counseling Contexts: Arab Americans 293

Demographic Characteristics 294

Sociohistorical Context 294

Potential Challenges 295

Strengths and Resiliencies 296

Counseling and Applied Considerations 296

A Clinical Checklist 297

Summary 298

Glossary Terms 298

References 298

PART 7 Counseling and Therapy with Other Multicultural Populations

18 Multicultural Counseling Contexts: Marginalized Religious Communities 303

Counseling Contexts: Jewish Americans 303

Characteristics and Strengths 304

Spiritual and Religious Values. 304

Ethnic Identity 305

Gender-Related Considerations 305

Cultural Strengths 305

Potential Challenges 306

Prejudice and Discrimination 306

Counseling and Applied Considerations 307

Counseling Contexts: Muslim Americans 308

Characteristics and Strengths 308

Spiritual and Religious Values 309

Gender-Related Considerations 309

Cultural Strengths 309

Potential Challenges 310

Counseling and Applied Considerations 311

Marginalized Religious Communities: A Clinical Checklist 311

Summary 312

Glossary Terms 312

References 313

19 Counseling Contexts: Immigrants and Refugees 316

Demographic Characteristics 317

Sociohistorical Context 317

Cultural Dimensions 318

Potential Challenges 318

Gender Issues and Domestic Violence 319

Refugee Issues and Coping with Loss 319

Strengths and Resiliencies 320

Counseling and Applied Considerations 320

Barriers to Seeking Treatment 321

Linguistic and Communication Issues 322

Counseling Refugees 323

Effects of Past Persecution Torture or Trauma 323

A Clinical Checklist 324

Summary 326

Glossary Terms 326

References 326

20 Multicultural Counseling Contexts: LGBTQ Communities 328

Characteristics and Strengths 329

SOGI Awareness 329

LGBTQ Youth 331

LGBTQ Couples and Families 332

Strengths 333

Specific Challenges 333

Coming Out 333

Prejudice Discrimination and Misconceptions 334

Aging 336

Implications for Clinical Practice 337

Summary 339

Glossary Terms 339

References 339

21 Multicultural Counseling Contexts: Older Adults 343

Demographic Characteristics 343

Sociohistorical Context 344

Potential Challenges 345

Mental Deterioration 345

Elder Abuse 345

Strengths and Resiliencies 346

Sexuality 346

Leadership 346

Counseling and Applied Considerations 347

Physical Limitations 347

Cognitive Limitations 347

Elder Abuse 348

Substance Abuse 348

Social Isolation Depression and Suicide 349

The Benefits of Counseling and Therapy for Older Adults 350

A Clinical Checklist 350

Summary 351

Glossary Terms 352

References 352

22 Multicultural Counseling Contexts: Women 355

Demographic Characteristics 356

Sociohistorical Context 356

Potential Challenges 357

Bias and Schooling 358

Organizational and Workplace Bias 358

Harassment and Violence 359

Sexual Objectification and Its Sequellae 359

Social Pressure Toward Unrealistic Body Ideals 360

Caretaker Overload 360

Incidence of Depression 360

Strengths and Resiliencies 360

Counseling and Applied Considerations 361

Gender Bias and Conventional Practices 361

Body Image 362

Addressing Harassment and Violence 362

Educational and Vocational Issues 362

Depression 363

A Clinical Checklist 364

Summary 365

Glossary Terms 365

References 365

23 Multicultural Counseling Contexts: Individuals Living in Poverty 369

Demographic Characteristics 369

Sociohistorical Context 370

Potential Challenges 371

Social Exclusion 371

Educational Inequities 372

Disparities in the Judicial System 372

Classism and the Minimum Wage 373

Health Care Inequities 373

Strengths and Resiliencies 373

Counseling and Applied Considerations 374

A Clinical Checklist 375

Summary 377

Glossary Terms 377

References 377

24 Multicultural Counseling Contexts: Individuals with Disabilities 380

Demographic Characteristics 380

Sociohistorical Context 381

Models of Disability 381

Potential Challenges 382

Prejudice and Discrimination 382

Strengths and Resiliencies 383

Counseling and Applied Considerations 384

Sexuality and Reproduction 385

Spirituality and Religiosity 385

Family Counseling 385

Environmental and Social Justice Issues 386

Counselors’ Attitudes When Clients have Disabilities 387

A Clinical Checklist 388

Summary 390

Glossary Terms 390

References 390

Index I-1