Cultural Diversity In Clinical Psychology

Cultural Diversity In Clinical Psychology

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Cultural Diversity In Clinical Psychology

cultural diversity in clinical psychology
C cashwell appreciating 1997 - Appreciating Cultural Diversity Through Clinical Supervision

By: Craig S.Cashwell, E.Joan Looby, and Warren F.Housley

Cashwell, C.

S., Looby, J., & Housley, W.(1997).Appreciating cultural diversity through clinical supervision.The Clinical Supervisor, 15, 75-86.

Made available courtesy of Taylor and Francis and Haworth Press: with permission.No further reproduction is authorized without written permission from Taylor and Francis.This version of the document is not the version of record.Figures and/or pictures may be missing from this format of the document.***

Abstract: Structured supervision techniques encourage service providers to increase their knowledge, skills, and self-awareness in providing multicultural services.Structured techniques are described and illustrated.

Article: CLINICAL SUPERVISION The United States has become increasingly diverse and multicultural within the past three decades (Axelson, 1993).

This shift towards multiculturalism has paralleled a shift in perspectives on diverse ethnic populations.The "great melting pot" model of acculturation of American values and customs has been largely replaced by a "salad bowl" model in which diverse ethnic groups strive to preserve their individual cultural identity (Baruth & Manning, 1991; McCormick, 1984).

Demographic projections for the future indicate that more than one-third of the United States will soon be racial and ethnic minorities, and that by the year 2010, these minorities will become a numerical majority (Sue, 1990).Further, social scientists have lamented the deficiencies of most psychological health models to meet the needs of culturally diverse populations (Dillard, 1983; Sue, 1990) and have established multicultural competencies and standards (Sue, Arredondo, & McDavis, 1992).Only recently, however, have multicultural issues in supervision gained attention in the literature (Cook, 1994; Fong, 1994; Leong, 1994; Leong & Wagner, 1994).

According to various authors (D'Andrea & Daniels, 1991; Lewis & Hayes, 1991; Sue, 1991), the societal increase in cultural diversity dictates that service providers (a) increase their level of cultural sensitivity, (b) obtain culturally specific knowledge about different racial/ethnic groups, and (c) develop culturally appropriate helping skills and techniques.Despite the fact that much has been written on the need for multicultural awareness, knowledge, and skills, little practical information exists on approaches to infuse cultural diversity issues into the supervision process (Leong & Wagner, 1994).Authors (Hunt, 1987; Johnson, 1987; Vasquez & McKinley, 1982) have pointed out the need to develop strategies that would move trainees from knowing that cultural differences exist to knowing how to work with culturally diverse individuals.

Recently, Leong and Wagner (1994) drew attention to the fact that multicultural models often fail to provide details, tasks, or techniques for accomplishing cultural exploration.

The purpose of this paper, then, is to provide specific supervision techniques and tasks to help service providers examine issues of cultural diversity in their work.Opportunities for empirical examination of the effectiveness of these techniques also will be discussed.

The focus of this paper is on cultural differences between the service provider and client rather than between the supervisor and supervisee.

While both relationships (service provider-client and supervisor-supervisee) may be multicultural, our goal is to facilitate more effective multicultural services through the supervision process.In an ideal situation, training in multicultural issues would have been provided prior to the onset of supervision.Regardless of previous training, an effective supervisor may challenge the professional to heighten personal awareness of cultural issues.

Over the past four years, these supervision techniques have been used with practicum and intern students at the master's and doctoral level, and with experienced clinicians.

The techniques have been refined based on observation and feedback from supervisees.While supervisees have responded favorably to these techniques, no empirical evidence is available to support the effectiveness of these techniques.This material is thus based solely on the authors' experiences providing supervision.

While this may be a limitation of the current work, it is hoped that supervisors will be encouraged to examine the usefulness of each of these techniques relative to their style and orientation to supervision.

GROUP SUPERVISION TECHNIQUES Several strategies are based in the group supervision experience and draw on collaborative learning and cognitive skill acquisition, skills that may, at times, be better strengthened in a group setting (Hillerbrand, 1989).

Structured Peer Group Borders (1991) developed a systematic approach to group supervision in which supervision group members select or are assigned roles (e.g., client, counselor, significant other in the client's life) and then provide feedback on a reviewed section of audiotape or video-tape from that perspective.Feedback is presented in the first person (i.e., "As the client, I felt that...

).We have found this model to be useful in addressing cultural issues.If a supervision group member from the same ethnic group as the client is available, that group member may be asked to provide feedback from the perspective of the client.

Additionally, one or more group members who are highly sensitive to cultural issues may be helpful in the client role, their own ethnicity notwithstanding.Often, eye-opening experiences occur when a supervision group member hears a "client'' telling him or her of the importance of cultural issues that have not yet been addressed.

The Intercultural Sensitizer The Intercultural Sensitizer, developed by Leong and Kim (1991), also may be used in group supervision to provide trainees with in-depth, culturally relevant knowledge about a particular group.Supervisees are presented with critical incidents that focus on specific cultural differences and difficulties of the target group.

These differences have been identified in the clinical literature, or are based on the clinician's experiences (see Leong & Yim, 1991, for examples).Each incident involves a brief narrative followed by several possible explanations.Trainees are asked to choose the best explanation for the incident.All explanations are discussed, including the correct explanation that is based on the values system of the target group.

The Intercultural Sensitizer discourages stereotyping and encourages the development of culturally relevant knowledge and skills for working effectively with specific cultural groups.One advantage of using The Intercultural Sensitizer in group supervision is that, prompted by the exercise, group members often begin discussing cultural issues in current and past professional helping relationships.

Learning Style Accommodation The group supervisor may instruct supervisees on the importance of accommodating the learning style preferences of clients from different cultures (Griggs & Dunn, 1989).The Learning Styles Model of Dunn and Dunn (1978) has been used to ascertain learning-preference differences between and among various cultures in the environmental, emotional, sociological, physical, and psychological stimulus categories.Sue (1990) maintained that a culturally skilled professional must be able to generate a wide variety of verbal and non-verbal responses in an effort to facilitate the communication process.

It has been posited that attention to auditory, visual, tactile, and kinesthetic preferences of the culturally different client will enhance the therapeutic relationship (Griggs & Dunn, 1989).For example, supervisors can assist supervisees by pointing out the importance of knowing that Native American and Mexican-American clients tend to have strong visual perception whereas African-American and Greek-American clients tend to have stronger auditory preferences (Jalai, 1989).Similarly, Jalai (1989) found that when an Anglo clinician is working with an Asian client, the session should be more formal and structured, with an appreciation of the strength of peer influence.Using this technique in group supervision adds the cultural domain into the case conceptualization process, and challenges supervisees to examine how cultural learning style preferences may influence the therapeutic process.

STRATEGIES FOR INDIVIDUAL SUPERVISION Other strategies are based in the individual supervision experience and emphasize supervisor modeling and experiential learning opportunities for the supervisee.

Role Play Minor (1983) suggested a model for culture specific training in which the trainee conceptualizes the client from the client's frame of reference.

Within the supervision session, it is often helpful to conduct a role play "interview.'' The supervisee takes the role of a specific cross-cultural client and the supervisor stays in the role of supervisor.After encouraging the supervisee to assume the role of a particular client, the supervisor begins the role play by saying something like:

I am supervising (clinician's name) and I want to thank you for taking the time to talk to me about the time you spend with (clinician's name).I'm sure if he/she were here, he/she would thank you, too.I just want to ask you a few questions and I want you to be as honest as possible.

This role play should be structured to meet the specific needs of the supervisee.

However, common questions that we ask supervisees while they are in the role of client include:

1.What can you tell me about your counseling thus far? 2.What do you think about (clinician's name)? 3.

What do you think about the fact that you and (clinician's name) are from different backgrounds? 4.What do you think (clinician's name) thinks about the fact that the two of you have different racial backgrounds? 5.If you could tell (clinician's name) one thing that you would like for him/her to think about in working with you, what would that be? 6.Would/How would you like for your counselor to bring up the issue of cultural differences in the session so that you could discuss your thoughts and feelings about this?

A modification of this technique is for the supervisor to take the counselor role and the counselor to take the client role.Such a modification may be most useful when the supervisor believes the clinician needs a model for talking to clients about cultural issues.

The use of role play encourages the clinician to think about cultural factors, but more importantly challenges the supervisee to a deeper level of empathic understanding of diversity issues through the role-taking experience.Our experiences with this technique suggest that the technique influences not only the intellectual conceptualization of diverse clients, but also the level of compassion expressed toward the client in subsequent sessions.

Interpersonal Process Recall A second useful supervision approach when dealing with diversity issues is Interpersonal Process Recall (IPR).Developed by Kagan (1980), IPR is built on the premise that clinicians behave "diplomatically'' in their counseling relationships by feigning clinical naivete or by tuning out client messages to keep a "safe'' psychological distance from others.

Such a premise has direct implications for why cultural differences may not be discussed in the therapeutic relationship.A thorough overview of IPR is beyond the scope of this paper; readers are referred elsewhere (Bernard & Goodyear, 1992; Borders & Leddick, 1987; Cashwell, 1994; Kagan, 1980) for a more comprehensive overview.

In using IPR for diversity issues, the supervisor preselects a section of the audio or videotape that reflects issues of cultural diversity.After introducing the recall session to the supervisee, the tape segment is played; at relevant points, either the supervisor or the supervisee stops the tape.If the supervisee stops the tape, he/she speaks first about the thoughts or feelings that were occurring at that time in the counseling session.The supervisor encourages the discovery process by asking pertinent open-ended questions (see below).

The challenge as a supervisor is to allow the supervisee to explore thoughts and feelings about the counseling relationship without adopting a "teaching'' role (Bernard, 1989).

Supervisor leads in the IPR session can be used to enhance supervisee's awareness of their cultural blind spots; questions can be worded at the supervisee's level of readiness and capability (Borders & Leddick, 1987).The following inquirer leads are adapted from various sources (Bernard & Goodyear, 1992; Borders & Leddick, 1987; Kagan, 1980).

1.What do you wish you had said to him/her? 2.How do you think he/she would have reacted if you had said that? 3.What would have been the risk in saying what you wanted to say? 4.If you had the chance now, how might you tell him/her what you are thinking and feeling? 5.

How did you want the other person to perceive you? 6.

What do you think he/she wanted from you? 7.What were you thinking about when he/she said that?

The IPR format allows supervisees to examine their internal reactions to culturally diverse clients by reexperiencing the therapeutic relationship in the supervision session, and processing their reactions in a safe environment.

In a supervision session, for example, a supervisee seemed unaware of gender issues that were affecting his counseling work.In describing his work with one married couple, the supervisee used stronger and more pejorative language when describing the wife.Despite confrontation from group members in group supervision, this supervisee seemed resistant to change, despite his knowledge of the gender issue.Through the use of IPR, the supervisor facilitated the supervisee's awareness of this "blind spot'' and how this was affecting his work with this couple.

In a formal written evaluation of the supervision experience, the supervisee indicated that this awareness was crucial in his professional development.

First Person Feedback A third individual supervision technique is for the supervisor to provide feedback in the first person (e.g., "As the client, I am feeling ...

") as suggested by Borders (1991) for group supervision members.Similar to the role play interview described above, such an approach may reduce defensive reactions from the supervisee that may occur if a more traditional didactic approach to supervision is used (e.g., teaching the client about a specific ethnic group).

Metaphor Finally, the use of metaphor to help the supervisee examine the therapeutic relationship often is useful.While the metaphor should be spontaneous, and specific to the client or relationship, there are certain metaphors that we repeatedly find useful for supervision.A metaphor that we find useful is describing the therapeutic relationship as a dance.Descriptions of the type of dance, who is leading the dance, and differences in the styles of the two dancers (counselor and client) are most helpful.A second metaphor that we often use is of skating with a partner on a frozen pond.

Describing the "thin ice" at the center of the lake, the "safe ice" around the edge of the pond, and, at times, the fact that one skater (client or counselor) may be watching from the safety of the bank, unsure of the safety in skating with this partner, is often "eye-opening" to the supervisee.As others have noted (Amundson, 1988; Borders, 1991), use of metaphors often leads to a deeper understanding of the client and the therapeutic relationship.

CONCLUSION It is important to raise the issue of cultural diversity in group or individual supervision when audio/videotape review suggests cultural issues may be affecting the therapeutic process.

Less experienced clinicians may not consider the influence of culture on the therapeutic relationship.

Raising multicultural issues in individual or group supervision encourages self-exploration.One example is a case of supervising a white supervisee who had communicated an interest in multicultural issues.Audiotape review indicated that the counselor was missing (and consequently not responding to) messages from an African-American client about the client's cultural identity.

The supervisor simply raised a question about this in supervision, and the counselor proceeded to address this in the counseling relationship.Both relationships (counseling and supervision) were strengthened by this process.As Bradshaw (1982) asserted, the most common multicultural triad continues to include a minority client, a white counselor, and a white supervisor.To increase their effectiveness when working with multicultural populations, supervisors need to consult with minority colleagues and remain open to increasing their own knowledge, skills, and self-awareness with multicultural populations to increase their effectiveness as supervisors.Cultural heterogeneity within supervision groups, when possible, also is encouraged.

The method of supervision is another important consideration.As others have suggested (Bernard & Goodyear, 1992; Borders & Leddick, 1987), self-reports from the counselor may be unreliable or even biased accounts of counseling sessions; direct methods (e.g., review of audiotapes or live observation) are needed to help clinicians identify issues of cultural blindness or cultural encapsulation.

As mentioned earlier, empirical validation is needed for these techniques.

As service providers move from theory to practice and develop new interventions for working with multicultural populations, it is crucial that these interventions be empirically sound.We hope that this piece will lead to further research on the techniques mentioned here, thereby adding to our clinical knowledge.

Multicultural knowledge, skills, and awareness all may be influenced through effective supervision.Clinical supervisors have the unique opportunity to help supervisees enhance their multicultural awareness, knowledge, and skills.

If supervisors recognize the limitations of traditional supervision and counseling techniques in serving diverse clients and move beyond the boundaries of traditional approaches, new paradigms will emerge from which to understand and work with diverse populations.The techniques discussed here provide some structured approaches for supervision that have been used and refined by the authors over a period of time.It is hoped that these techniques will prove as valuable to other supervisors.

REFERENCES Amundson, N.W.(1988).The use of drawings and metaphor in case conceptualization.

Journal of Counseling and Development, 66, 391-393.Axelson, J.A.

(1993).Counseling and development in a Multicultural Society.Monterey, CA: Brooks/Cole.Baruth, L.G., & Manning, M.L.

(1991).Multicultural counseling and psycho-therapy.New York: McMillan.Bernard, J.M.(1989).

Training supervisors to examine relationship issues using IPR.The Clinical Supervisor, 7, 103-112.

Bernard, J.M., & Goodyear, R.K.(1992).

Fundamentals of clinical supervision.Needham Heights, MA: Allyn & Bacon.Borders, L.

D.(1991).A systematic approach to peer group supervision.Journal of Counseling and Development, 69, 248-25 1.Borders, L.D., & Leddick, G.

R.(1987).Handbook of counseling supervision.

Alexandria, VA: Association for Counselor Education and Supervision
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