Handbook of Psychotherapy Integration, Second Edition Part 7 ppt

Integrative Psychotherapy with Culturally Diverse Clients 323 central and essential. The individualistic word view, cultural variables that should be assessed (for both clients and their families) are psycho-self is replace d by self-in-context, self-in-relation, person-in-community (Ogbonnya, 1994), and logical mindedness, attitudes toward helping, and level of acculturation, as well as the fam-being-in-relation ( Jorda n, Kap lan, Baker-Miller, Stiver, & Surrey, 1991). MCT points out that ily’s attitude toward acculturation (Grieger & Ponterotto, 1995). Multicultural assessmentinternal emotional distress is often related to external stressors. So-called disorder is often a should include measurement of group identity variables, like cultural orientation, in order toreaction to disordered social conditions such as racism and oppression (Ivey & Ivey, 1998). Un- decide whether culture-specific assessment tech- nologies are appropriate for a particular clienttil psychotherapy recognizes the centrality of contextual issues and reconstructs the idea of (Dana, 1993). By assessing these cultural variables, integrative psychotherapy can be adapt-the self, it will be difficult to work with the underlying oppression faced by many of our ed to the cultural needs and expectations of diverse clients and psychotherapists can assureclients. MCT’s proposition in this area states: that assessment has been sensitive to the cultural background of individuals. Both counselor and client identities are formed Multicultural therapy involves locating cul- and embedded in multiple levels of experiences ture within a multidimensional model. The (individual, group, and universal) and contexts MCT proposition that therapist and client (individual, family, and cultural milieu). The to- tality and interrelationships of experiences and identities are formed and embedded in multi- contexts must be the focus of treatment. (Sue et ple levels of experience can be compared to al., 1996, p. 15). the recognition of multidimensionality found in some models of psychotherapy integration. For example, Lazarus’s (1997, this volume)This important proposition of MCT reminds us that we need to see the individual in social Multimodal Therapy describes seven modalities of functioning: behavior, affect, sensation,context. Another way to think about this issue is whether or not the problem is in the person imagery, cognition, interpersonal relationships, and biological processes. Similarly, Prochaskaor in the social context. MCT argues that we cannot understand the person without an ap- & DiClemente’s (1992, this volume) Transthe- oretical Approach describes five levels of change:propriate balance of person and environmental issues. Therefore, assessment with culturally di- symptom/situation problems, maladaptive cog- nitions, current interpersonal conflicts, familyverse clients must focus on the external environment as well as the individual’s experience systems conflicts, and intrapersonal conflicts. Although these models of integration are orga-of the environment. From the perspective of multicultural the- nized around important dimensions of human functioning, neither recognize the role of cul-ory, one of the most important contextual issues is oppression. Locke (1992) pointed out ture. In order to integrate MCT with other forms of psychotherapy, culture needs to bethe centrality of racism and prejudice in counseling and defined racism as the combination recognized as a crucial dimension that shapes human functioning and can be the focus ofof prejudiced beliefs with the power to enact those beliefs. Therefore, multicultural assess- psychotherapeutic interventions. Figure 15.1 depicts a multidimensiona l mod-ment should include looking at clients’ experiences with prejudice and racism. For example, el of human functioning drawn from Multithe- oretical Psychotherapy (Brooks-Harris, in press).what may appear as dysfunctional behavior in the dominant culture may best be understood Acknowledging the relationship between cultural contexts and other dimensions of humanas a reaction to prejudice or racism. Multicultural assessment can be used to un- functioning creates a way for integrative therapists to assess the impact of culture on clients.derstand clients’ worldview or to ensure that traditional assessment instruments are appro- Once cultural variables such as worldview and acculturation have been assessed, multiculturalpriate. In order to understand a client’s world- 324 Integrative Psychotherapies for Specific Disorders and Populations Actions Biology Interpersonal Patterns Social Systems Cultural Contexts FeelingsThoughts FIGURE 15.1 Multidimensional Model of Human Functioning but also by the dynamics of dominant-subordi- integration involves assessing the way that cul- nate relationships among culturally different groups. ture impacts psychological dimensions such as The level or stage of racial/cultural identity de- thoughts, actions, feelings and the way culture velopment will both influence how clients and interacts with other contextual dimensions counselors define the problem and dictate what such as biology, interpersonal patterns, and so- they believe to be appropriate counseling/ther- cial systems. apy goals and processes. (Sue et al., 1996, p. 17) The therapist must remember that identity is shaped by contextual dimensions such as The developmental framework for multicul- family, community, and society (Franklin, Car- tural theory rests in cultural identity theory ter & Grac e, 1993; Ivey, Ivey, Myers, & S weeney, (Cross, 1971, 1991, 1995; Thomas, 1971). Cross 2005). Multicultural therapy involves assessing and Thomas independently generated cultural the impact of culture on all other dimensions identity theory as they observed cognitive/emo- of human functioning. A multidimensional, tional development among African Americans multitheoretical perspective acknowledges the who experienced the Black identity movement impact of microsystems, like interpersonal pat- of the 1960s. They both recognized a Black terns and social systems, and the cultural mac- consciousness or racial identity starting in a rosystem on the current experience of humans naı ¨ ve embedded awareness that was then shaken (Bronfenbrenner, 1979). by the discrepancies encountered in a racist society. The most influential model has been that FORMULATION of Cross, who describes the following states and/or stages. An essential part of multicultural formulation is to understand the development of cultural • Preencounter. The in dividual may be locked identity. The third proposition of multicultural into a White perspective and devalues theory highlights the importance of identity de- and/or denies the vitality and importance velopment: of an African American worldview. The goal of some African Americans who take Cultural identity development is a major deter- this perspective may be to be as “White” minant of counselor and client attitudes toward as possible. the self, others of the same group, and the domi- • Encounter. The African American meets nant group. These attitudes which may be mani- the realities of racism in an often emo- fested in affective and behavioral dimensions, are strongly influenced not only by cultural variables, tionally jarring experience. This perturbs Integrative Psychotherapy with Culturally Diverse Clients 325 one’s former consciousness and often lives. Therefore, a multicultural formulation based on a description of a client’s stage ofleads to significant change. • Immersion-emersion. The discovery of identity development can be an important foundation for integrative psychotherapy withwhat is means to be African American and valuing blackness become important, culturally diverse clients. Because development of identity and aware-while often simultaneously denigrating Whites. Emotions can run strong with ness is such an important part of a multicultural formulation, it is helpful to include a de-pride in one’s culture and anger at others. This is often a stage of action for African- velopmental formulation to complement the multicultural formulation. Developmental Coun-American rights. • Internalization. A more internalized re- seling and Therapy’s cognitive/emotional development rests in a postmodern interpretationflective sense of self-confidence develops and emotional experience is more calm of the Swiss developmental epistemologist, Jean Piaget (see especially Piaget, 1926/1963). DCTand secure. This is often featured by “psychological openness, ideological flexibil- emphasizes that development occurs over the life span, that Piagetian constructs reappear inity, and a general decline in strong anti- White fee lings” (Parham, White, & Ajam u, adolescent and adult learning but always in social context. Whereas cultural identity theories1999, p. 49). However, the strength of commitment to the African-American tend to focus on specific groups, DCT takes a narrative approach to the evolution of con-world may even be stronger. Later, Cross (1995) suggested a fifth stage, very similar sciousness. Individuals (and families and groups) have life stories that they tell about themselves,to internalization with the addition of a commitment to action and social change. guiding the way they think and behave. DCT theory asserts that clients come to psychotherapy with varying levels of consciousnessA large number of researchers have vali- dated the sequential stages of cultural identity or meaning-making systems used to understand their world. These consciousness orientationsdevelopment in many cultural settings and ex- tended it to other groups. Important among lead to different styles of thinking and be- having. No one type of consciousness is best,these have been Atkinson, Morten, and Sue’s (1993) general theory of cultural identity devel- although more states and stages permit more possibilities for thought and action. Meaning-opment; Hardiman’s (1982) description of White identity development; and Helms’s (1990, 1995) making can be equated with the development of consciousness. DCT describes four episte-model of African-American and White identity development. Although the language varies, mological styles or stages of consciousness that have interesting parallels to cultural identitythe general sequence of development identified by Cross remains consistent in these theory. emerging models. Initially, cultural identity theory focused its • Sensorimotor consciousness. The client is often embedded in direct experience.central effort on expanding awareness of one’s racial/ethnic identity. Increasingly, we are find- What is seen, heard, and felt is central. External reality can direct inner experi-ing identity theories focused on other multicultural issues. Cass (1979, 1984, 1990), Marsza- ence with little or no reflective consciousness. Cognition and emotion are oftenlek (1998), and Marszalek and Cashwell (1998) have developed theories of gay and lesbian not separated. The person may not be fully able to separate self from situation.identity developmen t. Ivey, D’Andrea, Ivey, and Simek-Morgan (2002) suggested that many • Concrete/situational consciousness. Peop le again are focused on external reality butgroups (e.g. women, cancer survivors, the people with disabilities, and Vietnam veterans) go can talk about their issues with a “sub- ject–object” orientation. Expect concrete,through parallel issues of identity as they dis- cover the power of context in their individual detailed stories of issues. Emotions are 326 Integrative Psychotherapies for Specific Disorders and Populations now separated from cognition, but reflec- nition of culture helped the field recognize that multiculturalism is applicable to all clientstion is not prominent. • Formal/reflective consciousness. The client and that psychotherapy should always address the role of culture. Although MCT suggestsis able to reflect on experience, cogni- tions, and emotions. Much traditional ideas that are applicable to all psychotherapy relationship, it does not suggest a prescribedpsychotherapy theory rests here (e.g., “reflection of feelings”). Individuals are able structure. Therefore, integrative psychotherapy with culturally diverse clients can take manyto notice and think about patterns. Action on the world, often associated with the forms. Most multicultural therapists have concluded that multiculturalism should comple-concrete and dialectic styles, tends to be overlooked. Reflective people are often as ment rather than compete with traditional theories (Corey, 1996; Pederson, 1991). In de-sure of what they think and feel as those who are concrete—while both may fail to scribing integrative psychotherapy with African Americans, Franklin, Carter, and Grace (1993)think about the assumptions on which their thoughts and actions are based. concluded that psychotherapists should integrate various theoretical models when treating• Dialectic/systemic. Two major concepts illustrate this style of meaning-making: Black clients. Therefore, the only prescription is an ongoing attempt to see how culture im-multiperspective thought and awareness of self-in-context. People who think from pacts clients’ thoughts, actions, and feelings, as well as shapes interpersonal and systemic rela-this perspective are able to view informa- tion and emotions from several points of tionships. In this respect, assimilative integration pro-view and to examine and challenge their own assumptions. Though it is possible to vides a useful way to think about integrative psychotherapy with culturally diverse clients.become enmeshed in complex thought, action on oneself and systems is often im- Messer (1992, p. 151) described assimilative integration as an approach that favors a firmportant. grounding in one system of psychotherapy, but with a willingness to incorporate ideas or strate-A formulation based on multicultural development involves assessing and understanding gies from other approaches. When assimilative integration is practiced, techniques from di-cognitive/emotional ways clients make sense of what is happening. Once a client’s preferred verse sources are adapted within the psychotherapist’s primary theoretical framework. Forlevel of meaning making has been identified, the psychotherapist “joins clients where they example, Messer (1992) described the way that a Gestalt empty-chair technique could beare” in their cognitive/emotional understanding and assists expansion of development both adapted to behavioral therapy by focusing on external behavior rather than internal expe-vertically and horizontally. These levels of identity development and cognitive/emotional rience. Other chapters in this Handbook de- scribe assimilative psychotherapy based on psy-consciousness will be revisited later as a way to guide the choice of methods and techniques. chodynamic (Stricker & Gold, this volume) and cognitive-behavioral theories (Castonguay, this volume). The recognition that culture is relevant to all psychotherapy relationships sug-APPLICABILITY AND STRUCTURE gests that MCT may be used as a foundational theory for assimilative integration.Early descriptions of multicultural therapy focused on improving mental health service for Using MCT as a foundation for assimilative integration involves recognizing the primacy ofethnic minorities (e.g., Atkinson et al., 1979). This emphasis shifted when Pederson (1991) culture. “MCT theory combines elements of psychodynamic, behavioral, humanistic, bio-proposed a broad definition of culture that in- cluded demographic variables, affiliations, and genic, and other perspectives to the extent that the perso n’s culturally le arned assumptions shapeethnographic variables. Using this broad defi- Integrative Psychotherapy with Culturally Diverse Clients 327 the unconscious in the psychodynamic view, action leading toward change. The psychotherapy field, individualistic in tradition, faces aact as reinforcing contingencies in the behavioral view, and define the meaning of person- major challenge in the area of social action. Is psychotherapy interested in transforming thecenteredness in the humanistic view” (Sue et al., 1996, p. 14). Culture shapes elements of world? Specific methods for applying Freire’s ideas in psychotherapy have been suggested byhuman experience that are the focus of traditional psychotherapy approaches. Therefore, Developmental Counseling and Therapy (Ivey, 1995; Ivey, Ivey, Myers, & Sweeney, 2004).using MCT as a foundation for assimilative integration involves recognizing the way that cul- DCT argues that any integrative model of therapy that does not inform clients of how exter-ture shapes thoughts, actions, feelings, unconscious conflicts, interpersonal patterns, and nal stressors affect client issues actually is not therapeutic in the long run. Traditional ap-family systems. proaches, whether theory-specific or integrative, that do not include multicultural issues are very much “part of the problem” as theyPROCESSES OF CHANGE work within the cultural status quo. Common Factors Liberation of Consciousness Multicultural theorists have identified a variety of change processes that are frequently acti- Multicultural therapy recognizes common factors as central change processes as well. “Thevated in psychotherapy with culturally diverse clients. One of the most prominent descrip- common factors approach seeks to determine the core ingredients that different therapies sharetions is that of liberation of consciousness, which speaks to helping clients understand how op- in common” (Norcross & Newman, 1992, p. 13). For example, Garfield (1992, 1995) de-pression operates in their lives. MCT theory describes this process of change in the follow- scribed therapeutic variables that are used across theoretical approaches including the therapist–ing way: client relationship, cognitive modifications, and reinforcement. Recognizing common fac- The liberation of consciousness is a basic goal of MCT theory. Whereas self-actualization, discov- tors starts by recognizing liberation of con- ery of th e role of the past in the presen t, or behav- sciousness as a multicultural adaptation of con- ior chan ge have been traditional goals of Western sciousness raising, a common factor described psychotherapy and cou nseling, MCT emphasizes in many models. the importance of expanding personal, family, Two earlier attempts at identifying common group, and organizational consciousness of the factors used in MCT represent examples of this place of self-in-relation, family-in-relation, and type of multicultural integration. First, Pro- organization-in-relation. This results in therapy chaska, Norcross, and Sweeney (1999) identi- that is not only ultimately contextual in orienta- fied a sequence of three therapeutic processes tion, but that also draws on traditional methods that are frequently used in MCT: conscious- of healing from many cultures. (Sue et al., 1996, p. 22) ness raising, catharsis, and choosing. This transtheoretical analysis suggested that MCT frequently begins with consciousness raisingPaulo Freire’s (1972) liberation psychology has been particularly influential by emphasiz- that helps clients “understand how the dominant culture has shaped their views abouting the need to actively intervene in order to transform the world. Psychotherapy focused on themselves and their culture” (Prochaska et al., 1999, p. 422). Then, catharsis is supported inliberation may use a variety of methods to help bring individual and group awareness of the so- which “suppressed anger over discrimination and cultural alienation often comes to the sur-cial context. Freire is particularly inspirational with his focus on situational and concrete face” (Prochaska et al., 1999, p. 423). Finally, MCT involves choosing “how to express andchange. Awareness and consciousness require 328 Integrative Psychotherapies for Specific Disorders and Populations channel their new-found energy” (Prochaska et MCT stresses the vitality of alternative approaches to therapy, particularly those drawnal., 1999, p. 424). Another example of describing common from other cultural frameworks (Nwachuku & Ivey, 1991). The women’s movement, the gay/fac tors i n MCT was proposed by Fischer, Jome, and Atkinson (1998) who described four com- lesbian/bisexual/transgendered movement, and the ethnic/racial identity movements have allmon factors frequently used in MCT that cor- respond to Frank’s classic model (1961; Frank brought us to awareness of the importance of social context in practice. Sad to say, traditional& Frank, 1991). The therapeutic relationship, a shared worldview, client expectations, and a theory and practice s till have a considerable dis- tance to go to provide culturally sensitive andritual of intervention were identified as common factors that could be used to organize aware helping. Community counseling, intervention in systems, encouraging changes in theMCT. These authors suggested that common factors could be used to integrate the universal workplace—these are all examples of an effective contextual approach. Consultation, pre-aspects of healing with the unique cultural affiliations of individual clients. In this way, vention, and training others become central roles of the effective, multiculturally aware pro-common factors would be adapted to a client’s cultural context based on cultural knowledge. fessional. Alternative helping roles have been identified including adviser, advocate, consul- tant, change agent, and facilitator of indige- nous support and healing systems (Sue et al., THERAPY RELATIONSHIP 1998). Specifically, multicultural therapy embrace s Integrative psychotherapy with culturally di- relational adaptation: adapting the therapeutic verse clients should involve the development relationship to the individual needs and pref- of a therapeutic relationship that is consistent erences of the client (Norcross, 1993, 2002; with cultural expectations of clients. Multicul- Lazarus, 1993). Relational adaptation allows tural psychotherapy should not be limited to psychotherapists to create different types of re- traditional, Western models of helping. MCT lationships and use different parts of their per- theory describes the therapy relationship in the sonality with different clients. The multicul- following manner: tural literature has consistently suggested that the therapy relationship should be adapted based on clients’ cultural expectations. Differ- MCT theory stresses the importance of multiple ent cultural groups may be more receptive to helping roles developed by many culturally dif- certain counseling styles because of their cul- ferent groups and societies. Besides the basic tural values about interpersonal communica- one-on-one encounter aimed at remediation in the individual, these roles often involve larger so- tion (Sue et al., 1981). cial units, systems intervention, and prevention. For example, Santiago-Rivera, Arredondo, That is, the conventional roles of counseling and and Gallardo-Cooper (2002) suggested that psychotherapy are only one of many others avail- psychotherapists working with Latino clients able to the helping professional. (Sue et al., should be sensitive to Latino values about in- 1996, p. 21) terpersonal communicatio n that include an orientation to the person, respect, dignity, an easy-going and friendly relationship, trust andMCT begins and ends with a worldview that is contextual, one that demands more than indi- familiarity, as well as a demonstration of en- dearment. They make recommendations aboutvidual, family, or group therapy alone. The psychotherapist needs to work with all three di- adapting the relationship to Latino values by beginning in a formal style and using titles, al-mensions, developing a network of change agents that together reverberate throughout the lowing proximity in seating, maintaining a flexible time frame, and starting with person-total system (Attneave, 1969, 1982). Integrative Psychotherapy with Culturally Diverse Clients 329 able small talk before engaging in serious con- alliance is cultural context and awareness of the self-in-relation. Joining clients where theyversation. Similarly, Parham (2002) suggested that counselors can connect with African- are involves diagnosing levels of consciousness and identity development, respecting that per-American clients by using ritual, sharing music or poetry, exhibiting congruent realness, being son where he or she is, and facilitating expansion of consciousness and culturally appro-in the present, creating ambiance, and being willing to shift the context and setting of ther- priate action in consultation with the client. Parallels between cultural identity develop-apy. Hong and Ham (2001) concluded that Asian-American clients tend to expect quick ment stag es (emphasi zed in Multi cultu ral Coun- seling and Therapy) and cognitive-emotionaland direct relief from symptoms and want ex- pert advice. They point out the importance of developmental levels (emphasized in Develop- mental Counseling and Therapy) that were de-setting short -term goals, discussing traditional Asian healing practices, and consulting with scribed in the formulation section can be used to choose methods when providing integrativeother professionals such as physicians or teach- ers. All of these recommendations are exam- psychotherapy for culturally diverse clients. Each of Cross’s (1995) stages of cultural iden-ples of relational adaptation because of the way psychotherapists are encouraged to adapt their tity development corresponds to a different stage of development drawn from Piaget (Iveycommunication style to match the cultural expectations of diverse clients. & Ivey, 2000). These stages of cultural identity development and cognitive-emotional development can be used to identify focal dimensions (emphasized in Multitheoretical Psychother- METHODS AND TECHNIQUES apy and identified in Figure 15.1) and theoretical approaches that may be most useful in MCT embraces the use of methods and tech- multicultural integration. By recognizing the niques drawn from a variety of psychotherapy way that different stages of cultural identity de- approaches adapted to the cultural values and velopment are related to distinct patterns of expectations of individual clients. MCT de- cognitive/emotional development, DCT be- scribes the use of culturally appropriate meth- comes a blueprint for integrative psychother- ods and techniques with the following proposi- apy with culturally diverse clients. This frame- tion: work for choosing multicultural methods is summarized in Table 15.1. The effectiveness of MCT is most likely en- hanced when the counselor uses modalities and defines goals consistent with the life experience Pre-encounter: Sensorimotor and cultural values of the client. No single ap- During the pre-encounter stage of develop- proach is equally effective across all populations ment, individuals are likely to focus on direct and life situations. The ultimate goal of multi- experiences related to cultural identity. Pre- cultural counselor training is to expand the repertoire of helping responses available to the pro- encounter and sensorimotor thought and emo- fessional regardless of theoretical orientation. tion can be constraining if that embeddedness (Sue et al., 1996, p. 19) is without the ability to take perspective. But, the openness to here-and-now experience can also represent a chance for growth. The focusThis assumption of MCT is a culturally appropriate restatement of traditional psychotherapy is on sensory experiences and observations related to the client’s story. The client might betheory and practice: join the client where he or she is. Therapists are, for the most part, deeply asked to generate an image of the general situation just described, and this image might becommitted to empathy and understanding the client’s frame of referenc e. What has been miss- fleshed out with questions like, “What are you seeing?” or, “What are you hearing?” This fo-ing in traditional writing about the therapeutic 330 Integrative Psychotherapies for Specific Disorders and Populations TABLE 15.1 Identity Stages, Development Levels, Focal Dimensions, and Theoretical Approaches Cultural Identity Cognitive-Emotional Focal Theoretical Development Stages Developmental Levels Dimensions Approaches Preencounter Sensorimotor Observations Encounter Late sensorimotor Actions Behavioral Immersion/emersion Concrete Thoughts Cognitive Immersion/emersion Formal Feelings & interpersonal Experiential & psychodynamic patterns Internalization Dialectic/systemic Social systems & cultural Systemic & multicultural contexts cus on observations and imagery lays a founda- new way of thinking about old ways of being. Helping clients move to new states of con-tion for other types of interventions. sciousness often is facilitated by supportive but challenging confrontation. Pointing out dis- Encounter: Late Sensorimotor crepancies and incongruities in the story or situation, particularly when the story is supportedWhen people meet oppression or difference in a dramatic encounter, they are often unable to by emotionally based here-and-now exp erien ce, is often helpful in moving consciousness. Itseparate self from situation and cannot distin- guish between thoughts and feelings. The con- may be helpful for therapists to encourage clients to share their experience with questionscrete and specific encounter with a racist inci- dent can perturb individuals and helps them like, “Could you share a story of what hap- pened? I’d like to hear it from beginning tomove out of sensorimotor magic thinking patterns and opens the way to concrete conscious- end.” ness. During this stage of development, psychotherapy often focuses on actions, and a Immersion-Emersion: Formal behavioral approach is frequently employed to help clients choose adaptive actions (Ivey, During the latter part of the immersion-emersion stage, reflective consciousness becomes1991/1993). Although there may be a behavioral emphasis on “what to do,” there are also more prominent. Particularly helpful in moving to reflective thought is the summarizationstrong feelings that may need to be processed. of two or more individual stories (which will often contain similar key words) and asking the Immersion-Emersion: Concrete individual or group how the stories are similar. During this stage, there may be an increasedDuring the time when individuals immerse themselves in their own cultural group, there emphasis on feelings and interpersonal relationships. Experiential a nd psychodynamic ther-is often detailed learning as well as concrete awareness of racism and prejudice, accompa- apies may be a useful way to encourage formal reflection. Helpful questions during this stagenied with anger—and, often, specific action to fight oppressive situations. There is frequently include, “How is your story similar to stories you have told me in the past?” and, “Do youa focus on the thoughts that clients are using to try to understand and make meaning out of see this as part of a pattern?” their own cultural experiences. Cognitive approaches like reality therapy, problem-solving, Internalization: Dialectic/Systemic and decisional counseling are often helpful at this stage (Ivey, 1991/1993). Indepth experienc- When people begin to internalize their own cultural values, there is often a shift to reflec-ing of sensorimotor experience may be used to facilitate encounter and the emergence of a tive consciousness—thinking about thinking Integrative Psychotherapy with Culturally Diverse Clients 331 and reflecting on cultural identity. A require- cluded 14 key strategies summarized in Table 15.2. In treatment planning, these strategiesment of internalization is systemic thinking and the ability to take multiple perspectives. can be used to consider a variety of interventions that focus on culture and identity devel-Crucial here is encouraging people to see themselves and their group in systemic rela- opment. Describing practice indicators and ex- pected consequences for each strategy cantion, often through multiperspective thought. This style of consciousness can become heavily make these techniques even more useful in treatment planning as well as training (Brooks-embedded in intellectual thought and abstrac- tion. Thus, attention to action and generalizing Harris, in press). learning to the real word through concrete action may be essential. During this stage, there is increased focus on social systems embedded CASE EXAMPLE within cultural contexts. To address these dimensions, systemic and multicultural interventions are often helpful. Specific questions used Pono is a 25-year-old, gay, Hawaiian male. After attending college and working for a couple of to encourage dialectic/systemic consciousness include, “What rules were you operating under years in Chicago, he moved back to Hawaii 1 year ago. Pono consulted with a physician be- in this situation?,” “Where did those rules come from?,” and “How would external condi- cause he was having trouble sleeping and because he frequently felt “jittery and uptight.” The tions, like racism or sexism, affect what is occurring with you?” physician referred Pono to Dr. K. for psychotherapy. Pono began meeting with Dr. K, a heterosex- Obviously, MCT is technically eclectic— using a broad repertoire of interventions from ual, Japanese-American, male psychologist in his mid-fifties. Pono told Dr. K that he had been ex- a variety of theoretical sources. Psychothera- pists can use multicultural strategies in combi- periencing symptoms of anxiety and depression since moving back to Hawaii. Pono was surprised nation with strategies from other approaches (Ramirez, 1991). Two descriptions of specific at this reaction because, when he was living on the mainland, he frequently dreamed of returning techniques for integrative psychotherapy with culturally diverse clients will be summarized home and hoped he would feel more comfortable back in Hawaii. Pono attended a total of 18 ses- next. Ivey (1995) described psychotherapy as a process of liberation and proposed four specific sions of individual psychotherapy during a 6- month time span. skills that could be used to help clients achieve critical consciousness about the cultures in Dr. K conducted a multidimensional survey of Pono’s life (see Figure 15.1) and concluded that which they live. First, psychotherapists can help clients understand the self-in-relation the change in cultural contexts between Chicago and Honolulu was having an impact on Pono’s more completely and then help them move from naivete or acceptance to naming and re- thoughts and feelings. One of Pono’s recurring thoughts was, “I don’t fit in.” This perception of sistance. Second, therapists can help clients expand their cultural understanding by naming not belonging was associated with feelings of loneliness and despair as well as a physical sen- the contradictions they see and resist oppressive systems. Third, therapists can help clients sation of agitation and restlessness. Although Pono had thought and felt this way in Chicago, reflect on self and self-in-system and redefine themselves in a way that promotes pride. he had assumed that the situation would be different if he returned home. Pono indicated he Fourth, therapists can help clients continue to expand a sense of multiperspective integration was not interested in psychiatric medication un- less things did not improve in response to psycho- that allows them to integrate thought and action as well as appreciate a variety of cultural therapy. Dr. K was interested in Pono’s identity devel- perspectives (Ivey, 1995). Brooks-Harris and Gavetti (2001) proposed opment and gradually formulated a multicultural conceptualization. In Chicago, Pono had felt out another set of multicultural techniques that in- [...]... healing: A comparative study of psychotherapy Baltimore, MD: Johns Hopkins University Press Franklin, A J., Carter, R T., & Grace, C (1993) An integrative approach to psychotherapy with Black/African Americans: The relevance of race and culture In G Stricker & J R Gold (Eds.), Comprehensive handbook of psychotherapy integration New York: Plenum Freire, P (1 972 ) Pedagogy of the oppressed New York: Herder... model Journal of Counseling and Development, 70 , 106– 111 Ogbonnya, O (1994) Person as community: An African understanding of the person as an intrapsychic community Journal of Black Psychology, 20, 75 – 87 Parham, T A (2002) Counseling persons of African descent: Raising the bar of practitioner competence Thousand Oaks, CA: Sage Parham, T., White, J., & Ajamu, A (1999) The psychology of Blacks: An African... identity The mediating goals of treatment will depend on the comorbid conditions of the particular BPD 3 57 patient (e.g., existence of current depression, transient psychotic symptoms), and the particular mix of BPD criteria Treatment Choices Under usual circumstances the borderline patient can be treated on an outpatient basis However, because, many of these patients have episodes of serious self-destructive... (2000) Handbook of multicultural counseling (2nd ed.) Thousand Oaks, CA: Sage Ponterotto, J G., Fuertes, J N., & Chen, E C (2000) Models of multicultural counseling In S D Brown & R W Lent (Eds.), Handbook of counseling psychology (3rd ed., pp 639– 669) New York: Wiley Prochaska, J O., & DiClemente, C C (1992) The transtheoretical approach In J C Norcross & M R Goldfried (Eds.), Handbook of psychotherapy. .. Norcross & M R Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp 1 47 171 ) New York: Oxford University Press Prochaska, J O., Norcross, J C., & Sweeney, M C (1999) Gender- and culture-sensitive therapies In J O Prochaska & J C Norcross, Systems of psychotherapy: A transtheoretical approach (4th ed., pp 399–436) Pacific Grove, CA: Brooks/Cole Ramirez, M III (1991) Psychotherapy and counseling... A theory of multicultural counseling and therapy Pacific Grove, CA: Brooks/Cole Stricker, G., & Gold, J R (2005) Psychodynamic assimilative integration In J C Norcross & M R Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp 221–240) New York: Oxford University Press Tamase, K (1989) Introspective developmental counseling Bulletin of Nara University of Education, 38, 166– 177 Tamase,... diminish family resistance to continuation of the child’s treatment It was particularly well suited to brief treatment of focal problems occurring in the context of the family or marital unit The final goals of family and couple treatments are at times indistinguishable from those of the group and individual treatment formats The mediating goals of family and couple 3 47 treatments are to change the rigid... of the manuals Indeed, the finding that most treatments are equally effective may be related to the common ingredients as noted in an inspection of the manuals (Arkowitz, 1992; Garfield, 1992) Though adherents of the various schools of psychotherapy emphasize their uniqueness, a large body of data suggests that experienced therapists of different persuasions do many things in common (e.g., Frank, 1 973 ;... Fukuhara, M (19 87) Adolescent cognitive development from the viewpoint of developmental therapy Paper presented at the IXth International Society for the Study of Behavioral Development, July 15 Garfield, S L (1992) Eclectic psychotherapy: A common factors approach In J C Norcross & M R Goldfried (Eds.), Handbook of psychotherapy integration (pp 169–201) New York: Basic Garfield, S L (1995) Psychotherapy: ... cooperative, co-constructive fashion with their clients As part of this, the liberation of consciousness will become a regular part of many counseling sessions Multiple interventions co-constructed with the client will be seen as basic to any effective treatment plan The idea of one “right” or “best” theory will finally disappear as new ways of integrating theory and practice evolve “Disorder” will cease . beliefs of college students. Bulletin of Nara University of Education, 48, 161– 172 .assimilative integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psycho- Thomas, C. (1 971 ) integrativeother professionals such as physicians or teach- ers. All of these recommendations are exam- psychotherapy for culturally diverse clients. Each of Cross’s (1995) stages of cultural iden-ples of relational. action. In D. C. Locke,C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 3 57 374 ). Thousand J. Myers, & E. L. Herr (Eds.), The handbook of counseling (pp. 219–236). Thousand Oaks,

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