Assessing and Treating Culturally Diverse Clients: A Practical Guide

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Freddy A. Paniagua

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  • Multicultural Aspects of Counseling and Psychotherapy Series

    SERIES EDITOR

    Paul B. Pedersen, Ph.D.,

    Professor Emeritus, Syracuse University

    Visiting Professor, Department of Psychology, University of Hawaii

    EDITORIAL BOARD

    Patricia M. Arredondo, Ed.D.

    Arizona State University

    J. Manuel Casas, Ph.D.

    University of California, Santa Barbara

    Harold E. Cheatham, Ph.D.

    Professor Emeritus Penn State University

    William E. Cross, Jr., Ph.D.

    City University of New York

    Candice Marie Fleming, Ph.D.

    University of Colorado

    Mary Fukuyama, Ph.D.

    University of Florida

    L. Sunny Hansen, Ph.D.

    Professor Emeritus University of Minnesota

    Ishu Ishiyama, Ph.D.

    University of British Columbia

    Allen E. Ivey, Ed.D.

    Professor Emeritus University of Massachusetts at Amherst

    Teresa LaFromboise, Ph.D.

    Stanford University

    Jun-Chih Gisela Lin, Ph.D.

    ABPP, Texas A & M University

    Don C. Locke, Ed.D.

    University of North Carolina at Asheville

    Amado M. Padilla, Ph.D.

    Stanford University

    Freddy A. Paniagua, Ph.D.

    University of Texas Medical Branch

    Joseph G. Ponterotto, Ph.D.

    Fordham University

    Derald Wing Sue, Ph.D.

    Columbia University Teachers College

    Norman D. Sundberg, Ph.D.

    Professor Emeritus University of Oregon

    Junko Tanaka Matsumi, Ph.D.

    Kwansei Gakuin University Nishinomiya City, Japan

    Rebecca Toporek

    San Francisco State University

    Joseph E. Trimble, Ph.D.

    Western Washington University

    Melba J. T. Vasquez, Ph.D.

    Independent Practice Austin, Texas

    Clemmont E. Vontress Ph.D.

    Professor Emeritus

    George Washington University

    VOLUMES IN THIS SERIES

    • Increasing Multicultural Understanding (2nd edition): A Comprehensive Model by Don C. Locke
    • Preventing Prejudice: A Guide for Counselors and Educators by Joseph G. Ponterotto and Paul B. Pedersen
    • Improving Intercultural Interactions: Modules for Cross-Cultural Training Programs edited by Richard W. Brislin and Tomoko Yoshida
    • Assessing and Treating Culturally Diverse Clients (3rd edition): A Practical Guide by Freddy A. Paniagua
    • Overcoming Unintentional Racism in Counseling and Therapy: A Practitioner's Guide to Intentional Intervention (2nd edition) by Charles R. Ridley
    • Multicultural Counseling With Teenage Fathers: A Practical Guide by Mark S. Kiselica
    • Multicultural Counseling Competencies: Assessment, Education and Training, and Supervision edited by Donald B. Pope-Davis and Hardin L. K. Coleman
    • Improving Intercultural Interactions: Modules for Cross-Cultural Training Programs, Volume 2 edited by Kenneth Cushner and Richard W. Brislin
    • Understanding Cultural Identity in Intervention and Assessment by Richard H. Dana
    • Psychological Testing of American Minorities (2nd edition) by Ronald J. Samuda
    • Multicultural Counseling Competencies: Individual and Organizational Development by Derald Wing Sue et al.
    • Counseling Multiracial Families by Bea Wehrly, Kelley R. Kenney, and Mark E. Kenney
    • Integrating Spirituality Into Multicultural Counseling by Mary A. Fukuyama and Todd D. Sevig
    • Counseling With Native American Indians and Alaska Natives: Strategies for Helping Professionals by Roger D. Herring
    • Diagnosis in a Multicultural Context: A Casebook for Mental Health Professionals by Freddy A. Paniagua
    • Psychotherapy and Counseling With Asian American Clients: A Practical Guide by George K. Hong and Mary Anna Domokos-Cheng Ham
    • Counseling Latinos and La Familia: A Guide for Practitioners by Azara L. Santiago-Rivera, Patricia Arredondo and Maritza Gallardo-Cooper
    • Counseling Persons of African Descent: Raising the Bar of Practitioner Competence edited by Thomas A. Parham
    • Ethics in a Multicultural Context by Sherlon P. Pack-Brown and Carmen Braun Williams
    • Deconstructing Heterosexism in the Counseling Professions: A Narrative Approach edited by James M. Croteau, Julianne S. Lark, Melissa A. Lidderdale, Y. Barry Chung
    • Culture and Disability: Providing Culturally Competent Services edited by John H. Stone
    • Integrating Traditional Healing Practices Into Counseling and Psychotherapy edited by Roy Moodley and William West

    Copyright

    View Copyright Page

    Series Editor's Foreword

    The continuing theme of the Sage Publications book series Multicultural Aspects of Counseling and Psychotherapy has been the importance of providing practical information of immediate value to readers. This contribution to the series is an excellent example of how a book can be practical and still not oversimplify complex issues.

    This third edition of Assessing and Treating Culturally Diverse Clients: A Practical Guide continues Freddy Paniagua's impressive contribution to the research literature on culture and counseling therapy. This edition breaks new ground in its expanded coverage of contemporary and controversial topics. It helps to prepare clinical and counseling providers for a future in which the standards of multicultural competence will become more important than ever before.

    This edition provides the first extensive discussion in the multicultural literature of the significance for the clinical context of the demographic trends found in the 2000 U.S. Census. By covering the demographic changes that have taken place both within and among the four ethnic groups discussed here relative to the majority culture, this book helps to prepare clinical and counseling providers for the clients they can expect to see in the future.

    This edition also includes expanded coverage of acculturation issues that encompasses discussion of four different models of acculturation and their applicability in clinical contexts. The problems associated with varying levels of acculturation are particularly relevant to clinical and counseling providers, who will be expected in the near future to provide services to a rapidly increasing number of clients who do not speak English. At present, few of those providers are prepared for this future.

    The solid chapters found in the first two editions providing guidelines for the assessment and treatment of African Americans, Hispanics, Asians, and American Indians have been updated and refocused with regard to demographic trends and the complexity of within-group differences. Practical suggestions for dealing with hot-button issues in each ethnic context are specified in ways that will help providers avoid and prevent unnecessary problems.

    This edition also includes discussion of the use of the mental status exam along with case vignettes that illustrate the practical value of providers' attending to issues of cultural competence. Each component of this exam is illustrated with culturally appropriate examples. Another feature of this volume is an extensive discussion of recent empirical findings that support arguments concerning racism's influence on the reported prevalence and incidence of mental disorders among clients from the four ethnic groups addressed here.

    All three editions of this book have made very successful contributions to the multicultural counseling literature. Large numbers of providers and consumers have benefited from the practical suggestions offered in each edition, and each edition has clarified complex issues of assessment, diagnosis, and treatment in multiethnic contexts with minimal rhetorical, theoretical, or philosophical complications. The immediate, practical importance of multicultural competence has been a prominent theme in all three editions. Perhaps that is why this book is listed among the 100 best-selling books in counseling for 2004.

    Of all the books in the Multicultural Aspects of Counseling and Psychotherapy series, Freddy's book does the best job of helping clinicians use diagnostic tools in practical and meaningful ways. This book reaches out to well-intentioned clinicians who are seeking to become more intentional in providing mental health services to their culturally diverse clients. It is with great pride that we include this third edition of Assessing and Treating Culturally Diverse Clients among the other books in this series.

    PaulPedersen, Professor Emeritus Syracuse University, Visiting Professor, University of Hawaii Department of Psychology

    Preface

    Why This Book Was Written

    Four of the major cultural groups that mental health practitioners see in the United States are African Americans, American Indians, Asians, and Hispanics. An important task for practitioners across all mental health disciplines (psychology, psychiatry, social work, family therapy, and the like) is to learn and apply skills that indicate that they are culturally competent in the assessment and treatment of clients from these groups (Pope-Davis & Coleman, 1997). Relevant questions concerning the mental health assessment, diagnosis, and treatment of multicultural clients include the following:

    • What should a practitioner do during the first meeting or session with an African American client versus an Asian client?
    • Should a practitioner treat an American Indian client with the same therapeutic approach used with a Hispanic client?
    • What exactly should a practitioner do differently in assessing and treating members of different cultural groups?
    • What are some examples of cross-cultural skills a practitioner should display to minimize bias in the assessment of clients from different cultural groups?

    Not only are questions such as these clinically relevant, but a practitioner's failure to answer them and to demonstrate knowledge of the answers in clinical practice may be considered an example of a lack of cultural competence and a violation of ethical principles (LaFromboise, Foster, & James, 1996). For example, the American Psychological Association's (1992) code of ethics states that mental health professionals “must be aware of cultural, individual, and role differences, including those due to age, gender, race, ethnicity, national origin, religion,… language, and socioeconomic status” (pp. 3–4; emphasis added). Violations of this principle may be considered to be cases of “unfair discriminatory practices” (p. 3). In addition, the written and oral exams required for licensure in the practice of psychology, psychiatry, social work, and other mental health professions include items designed to measure test takers' understanding and application of cultural variables that might have impacts on their assessment, diagnosis, and treatment of individuals from multicultural groups seeking mental health services.

    An excellent literature is available to help mental health practitioners in the development and application of cross-cultural skills in their clinical contacts with multicultural clients (e.g., Bamford, 1991; Berry, Poortinga, Segall, & Darsen, 1992; Comas-Diaz & Griffith, 1988; Dana, 1993b; Gaw, 1993a; Ho, 1992; Koslow & Salett, 1989; Lefley & Pedersen, 1986; McAdoo, 1993b; Pedersen, 1987, 1997; Ponterotto, Casas, Suzuki, & Alexander, 1995; Seijo, Gomez, & Freidenberg, 1991; Sue & Sue, 2003; Tharp, 1991). In many cases, however, practical guidelines concerning the assessment and treatment of individuals from various cultural groups are either dispersed across the literature (e.g., Comas-Diaz, 1988; Dana, 1993b; Koslow & Salett, 1989) or mixed with discussions of related philosophical, political, and theoretical issues (e.g., Berry et al., 1992; Sue & Sue, 2003). Practitioners interested in self-training to improve their cultural competence in the assessment, diagnosis, and treatment of multicultural groups previously have not had available one comprehensive text that takes an integrative approach and summarizes existing guidelines. In addition, the discussion of multicultural issues in mental health practice (particularly in the areas of assessment and treatment) has been evolving rapidly; practitioners may have a difficult time keeping up with this discussion while engaging in their routine clinical practices. My main goal in this volume is to provide mental health practitioners with an integrative and practical source that will help them understand exactly what they should do or not do to demonstrate cultural competence and avoid unfair discriminatory practices during the assessment, diagnosis, and treatment of African American, American Indian, Asian, and Hispanic clients.

    Overview

    It is important to note that the descriptions of cultural variables provided in this book reflect generalizations; any given characterization may not be true for all members of a group or for all subgroups within a given group (e.g., in the case of Hispanics, the subgroup of Cubans versus the subgroup of Mexican Americans). As Sue and Sue (2003) note, it is erroneous to believe that all African Americans are the same, that all Hispanics are the same, that all Asians are the same, or that all American Indians are the same. Differences within these groups and across subgroups exist in terms of primary language (particularly among Asians), generational status (e.g., early versus later immigrants), acculturation, and socioeconomic status (Sue & Sue, 1987, 2003). The members of these groups, however, do share some cultural variables that are often considered to be relevant in the assessment, diagnosis, and treatment of all members of non-Anglo-American cultural groups, regardless of group identity (e.g., all tend to place special importance on family relationships and to emphasize the extended family rather than the nuclear family). Such shared cultural variables across diverse groups and subgroups might be termed “cultural commonalities” (Chung, 1992). In this volume, I provide summaries of the cultural commonalities that exist across groups (Chapters 2, 7, 8, 9, and 10) and within subgroups (Chapters 3, 4, 5, and 6) that practitioners can use to guide their clinical practices with African American, Hispanic, Asian, and American Indian clients.

    Chapter 1 offers a tentative explanation for the growing use of the terms multicultural and diversity and the decreasing use of the term minority in the literature. Data gathered in the most recent U.S. Census serve to illustrate this point. Chapter 1 also includes a brief discussion of the distinction between race and ethnicity.

    Chapter 2 presents an overview of general guidelines regarding the development of a therapeutic relationship with regard to the four culturally diverse groups discussed in this text. Chapter 2 has been enhanced in this new edition with the introduction of new materials in several sections. For example, the chapter now includes a summary of four models of acculturation (the assimilation, separation, integration, and marginalization models) and their applications in clinical contexts. In addition, a section has been added concerning the use of information from the 2000 U.S. Census in clinical contexts. This section addresses the difficulty that clinicians may encounter when dealing with clients who self-identify as members of more than one race, as permitted by the latest U.S. Census. Box 2.1 and Tables 2.1 and2.2 have been added to illustrate how clinicians might apply their knowledge of census data in their clinical practices. Another area in which census data are relevant for practitioners concerns the numbers of multicultural clients whose native language is not English. Table 2.3 is intended to assist clinicians in estimating how many clients they are likely to encounter in their practices who might report that they speak English “not well” or “not at all” or who say that they speak English less than “very well.” The table illustrates this point with U.S. Census data on individuals whose native languages are Spanish, other European languages, and Asian/Pacific Island languages.

    Chapters 3, 4, 5, and 6 provide updated overviews of the demographic characteristics of African Americans, Hispanics, Asians, and American Indians, respectively, as well as three sets of practical guidelines for each group: guidelines on cultural variables that may affect assessment, diagnosis, and treatment; guidelines for the first session; and guidelines for conducting psychotherapy in subsequent sessions. In the case of Chapter 4, the section on terminology has been significantly enhanced in this edition with a discussion of the various terms currently used to identify Hispanic clients or Hispanics as a group, such as Chicano, La Raza, Latinegro, and Nuyorican, and guidelines concerning the use of these terms in clinical contexts. Chapter 4 also includes a new section on different types of Hispanic families (e.g., intact versus bicultural families) that includes some guidelines that clinicians serving such families will find useful.

    Chapter 7 presents a summary of practical guidelines to help practitioners understand and prevent attrition among clients from the target multicultural groups. Chapter 8 is intended to assist practitioners in the critical review and evaluation of the epidemiological research that has been conducted concerning the prevalence and incidence of mental disorders among members of the four groups discussed throughout this text. An important addition to Chapter 8 in this new edition is a discussion of the emotional problems that clients may experience as a result of their perceptions of racial discrimination.

    Chapter 9 makes an obvious point: that most of the measures, or assessment instruments, that mental health practitioners use today with African American, American Indian, Asian, and Hispanic clients are culturally biased. For various practical reasons, however, it may not be advisable to recommend that practitioners stop using these measures. A better alternative would be to train practitioners to use culturally biased measures in ways that will not harm their multicultural clients. Practitioners need to know how to recognize the biases that exist in the measures they use and how to evaluate the data they gather accurately and appropriately, so that it is meaningful and helpful to them in their work with culturally diverse clients. In this edition, the section in Chapter 9 on examining biases and prejudices has been revised to include a discussion of preliminary empirical findings that support the utility of the Brief Acculturation Scale, an instrument that I developed and that was originally published in the first edition of Assessing and Treating Culturally Diverse Clients (see Paniagua, 1994, 1998). Also in Chapter 9, the discussion of the effects of racism as an explanation for the prevalence and incidence of mental disorders in members of some cultural groups has been expanded with the inclusion of recent empirical findings on this topic. In addition, the section dealing with culture-related and culture-bound syndromes now includes an extensive discussion of the importance of distinguishing between culture-bound syndromes and cultural variations in the diagnosis of mental disorders. Another section of Chapter 9 that has been revised extensively is the one that addresses the use of the mental status exam in a cultural context. This section now includes a brief case vignette, a summary of major components of that exam, and additional examples illustrating the administration of the mental status exam in a culturally sensitive context.

    The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-IV-TR (American Psychiatric Association, 2000), has made a major contribution in terms of the inclusion of specific cultural variables across most psychiatric disorders. The DSM-IV-TR strongly encourages practitioners to use these variables during the assessment and diagnosis of such disorders. These cultural variables, however, are dispersed across the DSM-IV-TR, and they are not recommended across all psychiatric disorders. Chapter 10 summarizes these variables, and the tables in the chapter provide practitioners with a rapid overview. The section in Chapter 10 that addresses cultural considerations when other conditions may be the focus of clinical attention has been expanded in this edition, particularly with the addition of a subsection that encourages practitioners to consider clients' difficulties in dealing with their own cultural identities. Examples of assessment tools that clinicians might use to explore their clients' cultural identities are also provided.

    Acknowledgments

    I am indebted to many individuals whose support and advice have played a major role in the preparation of this book. I want to thank F. M. Baker (University of Maryland) and Sharon Nelson Le-Gall (University of Pittsburgh) for their review of Chapter 3 and for their valuable suggestions. (The affiliations mentioned here, and those below, reflect the affiliations of these individuals at the time of the publication of the first edition of this book in 1994.) Richard H. Dana (Portland State University) reviewed the guidelines involving the use of the epidemiology of mental health literature with multicultural groups (Chapter 8) and the guidelines concerning the use of culturally biased instruments (Chapter 9). He sent me an extensive commentary regarding ways to improve these chapters, and I am grateful to him for his suggestions. Derald W. Sue (California State University, Hay ward) and Anh Nga Nguyen (University of Oklahoma Health Sciences Center) assisted me with Chapter 5, and I also want to thank them for their comments. Derald W. Sue also reviewed Chapter 2; I thank him especially for his help in updating the references on Asian Americans. I thank Stanley Sue (University of California, Los Angeles) for reviewing portions of Chapters 1 and 2, particularly in relation to the discussion on cultural mismatch and racial mismatch.

    Arthur McDonald (president of Dull Knife Memorial College in Lame Deer, Montana) reviewed Chapter 6, and I wish to thank him for making me aware of several sensitive issues in the assessment and treatment of American Indian clients. Lillian Comas-Diaz (independent practice, Washington, D.C.) made substantial revisions to the guidelines for the assessment and treatment of Hispanic clients in Chapter 4, including translation of terms from English into Spanish, a better interpretation of the acknowledgment of spiritual issues by Hispanic clients during the first session, and improvement of the references dealing with the assessment and treatment of Hispanic clients. I thank her for her effort and time in revising these materials.

    Sylvia Z. Ramirez (University of Texas at Austin) and Sylvia Linares were clinical fellows under my supervision at the time I was organizing my thoughts to write this book. I discussed many of the topics in this text with them, and I thank them for their suggestions. I also want to thank Sylvia Ramirez for reviewing Chapters 4 and 8 as well as for her suggestion to include additional cultural variables to contribute to a better understanding of the assessment and treatment needs of Hispanic clients. Victor L. Tan and Angela S. Lew were clinical fellows under my supervision at the time I wrote Chapter 10, and I want to thank them for their comments and suggestions to improve this chapter.

    I have spent many hours over the past 15 years discussing cross-cultural issues with Israel Cuéllar (University of Texas-Pan American). Cuéllar was the first person (as far as I can remember) who encouraged me to write this book. He reviewed Chapters 4, 8, and 9. I thank him deeply for his comments and suggestions on how to improve these chapters.

    I have also spent a significant number of hours over the past 20 years discussing cultural issues with Charles E. Holzer III, and his expertise in psychiatric epidemiology has been extremely valuable to me, particularly during the preparation of Chapter 8. I especially thank Holzer for his suggestions regarding the new section in Chapter 2 on practitioners' use of information from the 2000 U.S. Census in clinical contexts.

    I thank Paul Pedersen, series editor, who was instrumental in the final preparation of this book for publication. He spent many hours reading each chapter and making sure that the book reflects practical guidelines for clinicians interested in the assessment and treatment of multicultural groups and that it contains minimal rhetoric about multiculturalism.

    I also want to thank the staff of Sage Publications for their time and effort in the preparation of this edition. I particularly thank Arthur Pomponio, Veronica K. Novak, Beth A. Bernstein, and Judy Selhorst for their assistance and technical advice. Reviews of the first two editions of this book have been very encouraging, and I have used the critiques that have been offered to correct several points in the present edition. I want to thank the reviewers for their comments. Several readers have taken the time to send to me letters clarifying particular issues, and I have also integrated their clarifications into this edition; I thank these readers for their letters of encouragement.

    I want especially to thank my spouse, Sandra A. Black (Sam), and my son, Robert Alexander Paniagua (Rap), for their support and patience throughout the completion of this book.

    Finally, I want to note that I recognize that the topics addressed in this volume are extremely sensitive and that I am responsible for any errors or misunderstandings readers may find in the text. I will deeply appreciate any comments and suggestions that readers may send me, and I will consider all reader feedback as I prepare future editions of this book. Please send your comments to me care of Sage Publications, 2455 Teller Road, Thousand Oaks, California 91320.

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    Author Index

    About the Author

    Freddy A. Paniagua (Ph.D., University of Kansas; postdoctoral training at Johns Hopkins University School of Medicine) is Professor in the Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch at Galveston, where he teaches cross-cultural mental health seminars with an emphasis on the assessment and treatment of African American, Hispanic, Asian, and American Indian clients. In 1989, he received a 6-year grant from the National Institute of Mental Health to provide training to mental health professionals representing culturally diverse groups, with emphasis on the assessment and treatment of emotionally disturbed clients. He has published more than 40 scientific articles, including reports on basic and applied research as well as theoretical contributions, and two textbooks on multicultural issues that are widely used in mental health training programs in the United States and abroad.


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