Clinical Mental Health Counseling in

Community and Agency Settings

Chapter 3
Clinical Mental Health
Counseling in a Diverse
Society

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Learning Objectives
3.1 Define terminology associated with multicultural
counseling, diversity, and factors that influence the
practice of multicultural counseling
3.2 Understand implications related to counseling distinct
populations in a culturally diverse world
3.3 Describe issues related to sexual orientation and gender
identity
3.4 Discuss issues faced by people with disabilities
3.5 Describe issues related to socioeconomic status and
social class

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Hays (2008) ADDRESSING Model
• Age and generational influences
• Disability (developmental)
• Disability (acquired later in life)
• Religion (and/or spirituality)
• Ethnicity (which may include race)
• Social status (or social class)
• Sexual orientation
• Indigenous heritage
• National origin
• Gender (and gender socialization)
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Culture
• Can be conceptualized as a combination of the following:
• Ethnographic variables (e.g., ethnicity, nationality, religion,
language)
• Demographic variables (e.g., age, gender, place of
residence)
• Status variables (e.g., social, economic, educational
background)
• Formal and informal memberships and affiliations

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Multicultural Counseling
• No universally accepted definition exists
• CACREP definition: Takes into account differences in
areas such as language, social class, race, ethnicity,
gender, sexual orientation, religion, and level of ability
• West-Olatunji’s (2001) definition: Multicultural counseling
refers to “multiple perspectives or multiple cultural
viewpoints within the counseling relationship in which none
are dominant or considered more ‘normal’ than others” (p.
418)

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Etic Perspective versus Emic Perspective
• Etic perspective - emphasizes the universal qualities of
counseling that are culturally generalizable (e.g., good
counseling is good counseling, regardless of culture)
– Criticized for emphasizing universality at the expense
of cultural differences
• Emic perspective - focuses on the indigenous
characteristics of each cultural group that influence the
counseling process and consequently emphasizes
counseling approaches that are culturally specific
– Criticized for overemphasizing specific, culturally
appropriate techniques to facilitate client change

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Five Multicultural Counseling Themes (1 of 2)
• Sensitivity to the significant ways that cultural factors affect
human development
• Awareness of the competencies practitioners need to
acquire to promote the healthy development of clients from
diverse populations
• Giving consideration to the professional training strategies
that help foster the development of cultural competence
among professionals
• Having a broad knowledge of the research findings related
to multicultural findings

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Five Multicultural Counseling Themes (2 of 2)
• Understanding present and future challenges that the
counseling profession faces with a society that continues
to be in a state of rapid flux in its racial/cultural
demography
(D’Andrea & Foster Heckman, 2008, p. 259)

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Worldview
• Refers to the way people perceive their relationship with
the world, including the following:
– Nature
– People
– Objects
– Religious experiences
• Influences people’s thoughts, feelings, behaviors, and
perceptions

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Racism and Prejudice (1 of 2)
• Prejudice - negative bias toward a particular group of
people (Allport, 1954). Mostly attitudinal in nature
• Racism - based on prejudicial beliefs, which maintain that
racial groups other than one’ own are inferior (Casas,
2005). “Extends the negative attitude into behavior that
discriminates against a particular group” (Utsey,
Ponterotto, & Porter, 2008, p. 339)
• Cultural racism - occurs when one cultural group
considers another group inferior, and the first group as the
power to impose its standards o the other group

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Racism and Prejudice (2 of 2)
• Institutionalized racism - refers to established use of
policies, laws, customs, and norms to perpetuate
discrimination and prejudice

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Acculturation, Enculturation, and Cultural
Pluralism
• Acculturation: “cultural adaptation that occurs as a result
of contact between multiple cultures (Miller, 2007, p. 118)
• Enculturation: the retention of one’s culture of identity
(Yoon et al., 2011)
• Cultural pluralism: term used to describe minority groups
who participate fully in the dominate society, yet maintain
their distinct cultural differences (Hays & Erford, 2014)

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Multicultural Competencies
• 31 competencies organized into three categories
– Awareness of one’s own personal worldview and the
effect of cultural conditioning on personal development
– Knowledge of the worldviews of culturally different
clients
– Skills needed to work with culturally different clients
(Arredondo et al., 1996)

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Self Awareness
• Beliefs, attitudes, and feelings associated with cultural differences
– Racism
– Sexism
– Heterosexism
– Other areas of difference (Sue & Sue, 2016)
• Understanding of one’s own cultural values
• Development of self awareness through self exploration
– How do I see myself as a member of my cultural group?
– How do I see other people in my cultural group?
– How do I perceive people who differ fro me?

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Knowledge (1 of 2)
• A base of knowledge that guides clinical mental health
counselors in their work with diverse clients
• C. Lee (2001) offered the following suggestions on how to
increase cultural knowledge:
– Acquire understanding of how social, economic, and
political systems affect the psychosocial development
of ethnic and other minority groups?
– Acquire knowledge of histories, experiences, customs,
and values of diverse groups

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Knowledge (2 of 2)
– Read literature and use the media to learn about
diverse cultures.
– Experience ethnic diversity firsthand by interacting with
people in their cultural environments
– Experience ethnic diversity firsthand by interacting with
people in their cultural environments

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Skills
• Ethnically responsive counselors are able to help people
resolve problems or make decisions in ways that are
consistent with the realities of clients’ cultural experiences
• Factors to take into account when counseling people from
diverse ethnic groups (C. Lee, 2013)
– Kinship influences
– Language preferences
– Gender-role socialization
– Religious/spiritual influences
– Cultural privilege
– Help-seeking attitudes and behaviors
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Conveying Cultural Empathy (1 of 2)
• Chung and Bemak (2002) made the following suggestions
to convey cultural empathy:
– Demonstrate a genuine interest in learning more about
the client’s culture
– Convey genuine appreciation for cultural differences
between the client and counselor
– Recognize the cultural meaning clients attach to
phenomena
– Incorporate culturally appropriate interventions and
outcome expectations into the counseling process

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Conveying Cultural Empathy (2 of 2)
– Understand and accept the context of family and
community for clients
– Recognize the psychosocial adjustment that must be
made by clients
– Be sensitive to oppression, discrimination, racism, and
micro aggressions

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Sexual Orientation (1 of 3)
• An “invisible identity” in many ways
• Also referred to as affectional orientation
• Refers to past, present, and ideal feelings about who is
attractive and desirable in sexual and/or romantic ways.
• Can be heterosexual, homosexual, bisexual, or
questioning
• Multidimensional construct that many believe exists on a
continuum from exclusively homosexual to heterosexual

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Sexual Orientation (2 of 3)
• Gay - men who are sexually oriented to other men
• Lesbian - women who are sexually oriented to other
women
• Bisexual - individuals who are sexually oriented to both
men and women
• Queer - individuals who identify outside of the
heteronormative or gender binary community
• Questioning - individuals who are beginning to explore
their sexual understanding and orientation

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Sexual Orientation (3 of 3)
• Referring to someone as homosexual is discouraged
because of the psychopathological connotations ascribed
to that term in early editions of the DSM
• A person may be erotically attracted (sexual attraction) to
someone of the same sex but engage exclusively in
heterosexual behavior (sexual behavior)
• Includes both the affectional and sexual dimensions of self
that are evidenced by thoughts, feelings, and behaviors
(Palma & Stanley, 2002)

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Homophobia and Heterosexism (1 of 2)
• Homophobia (also called homoprejudice)
– An antigay bias, or a fear of individuals who are
perceived as lesbian, gay, or bisexual
– Homophobic attitudes evidenced by stereotyping and
denigrating LGB individuals
• Heterosexism
– The viewpoint that heterosexuality is the only
acceptable sexual orientation
– A pervasively oppressive institutional preference for
heterosexuality

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Homophobia and Heterosexism (2 of 2)
• Homonegativity
– Encompasses the concepts of both homophobia and
heterosexism
– Negative thoughts and feelings about sexual minorities

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Standard of Care
• Counselors’ refusal to counsel sexual minority clients
constitutes a violation of the standard of care in the
counseling community
• Bruff v. North Mississippi Health Services, Inc., 2001
– Federal appeals court upheld the job termination of a
counselor who asked to be excused from counseling a
lesbian client on relationship issues because the
client’s sexual orientation conflicted with the
counselor’s religious beliefs

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Coming Out Process (1 of 2)
• Coming out:
• Letting other people know that one is lesbian, gay, or
bisexual
• Not a one-time event
• On-going process, affected largely by an individual’s life
circumstances

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Coming Out Process (2 of 2)
• Can have serious consequences, positive and negative
– Can be positively associated with mental health and
relationship satisfaction
– Contributes to identity acceptance, integration, and
authenticity
– Carries risks of abandonment, ridicule, and disapproval
– Can be psychologically painful, as the old sense of self
is grieved before the new sense of self emerges

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Working with Transgender Clients (1 of 2)
• Transgender
– People whose gender identity and expression conflicts
with their biological manifestation of sex
– Male-to-female (MTF) transgender persons are born
with male genitalia but experiences their lives
“gendered primarily as females” (Mostade, 2009, p.
308)
– Female-to-male (FTM) transgender individuals are
born with female genitalia but experience their lives
gendered primarily as males

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Working with Transgender Clients (2 of 2)
• Genderqueer
– Individuals who do not identify with traditional labels of
male and female
• Transsexual
– Individuals who pursue hormonal treatment and/or sex
reassignment surgery so that their externalized gender
identification will match their internal gender
identification

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Gender Dysphoria
• Term used in the DSM-5 to describe individuals who
experience incongruence between their
expressed/experienced gender and their assigned gender
• The term disorder, which implies a mental health
condition and was used in the previous edition of the DSM,
has been eliminated

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Counseling People with Differing Abilities (1
of 2)

• Disability
• A physical or mental impairment that substantially limits a
major life activity (ADA, 1990)
• Three broad categories of disabilities
– Physical disabilities
 Sensory loss, orthopedic impairments, amputations,
congenital disabilities, and chronic illness

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Counseling People with Differing Abilities (2
of 2)

– Cognitive disabilities
 Developmental disabilities, Alzheimer’s disease,
learning disabilities, and other cognitive impairments
– Psychiatric disabilities
 Range of mental illnesses, including mood
disorders, psychoses, and substance abuse or
dependence

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Factors Associated with Increased Rates of
Disability
• Aging
• Poverty
• Medical Advances
• Emerging Conditions
– New syndromes (e.g., chronic fatigue syndrome)
– Increased incidence (e.g., asthma, autism)

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Myths about Disabilities
• The Charity or Helplessness Myth
• The Spread Phenomenon Myth
• The Dehumanization or Damaged Merchandise Myth
• The Feeling No Pain Myth
• The Disabled Menace Myth

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Americans with Disabilities Act
• Enacted to protect people with disabilities from
discrimination in employment, public accommodations,
transportation, and telecommunication
• Counselors must actively seek to understand the laws,
regulations, and programs that affect people with
disabilities

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Goals and Interventions
• Prevention
– Preventing disease or disability before it occurs
– Increasing public awareness of activities or situations that lead to
physical and/or emotional problems
• Intervention
– Direct, time-limited strategies
– Often implemented in crisis-like situations
• Postvention
– Rehabilitation counseling, focused on helping people with
permanent or chronic physical, cognitive, and psychiatric
disabilities cope successfully and adjust to life with disability

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Cognitive Therapy
• May help a client with disability reinterpret life experiences
in a manner that enhances resilience and a sense of
coherence
• A client’s sense of coherence is determined by his or her
perceptions of the following:
– Comprehensibility
– Manageability
– Meaningfulness

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Family Responses to Disability
• Crisis Phase
– Waiting for a diagnosis or have just received one
– Often experience feelings of shock, denial, anger, and depression
• Chronic Phase
– Coping with the day-to-day issues related to the disability (Roland,
1994)
– Degree to which help is needed depends on many factors
including the nature and severity of the disability
• Terminal Phase
– Experiencing a lot of stress, and family interactions may be
strained

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Socioeconomic Status and Social Class
• Socioeconomic status - classifies people according to social and
economic dimensions (e.g., income, education level, access to health
care)
• Social Class - Based on components of SES and is hierarchical in
nature
• Classism - refers to oppression, discrimination, or marginalization
experienced by people who are negatively affected by socioeconomic
disparity (Pope & Arthur, 2009)
• Social Class Privilege - benefit or advantage given to a person by
reason of social position (Liu et al., 2007)
• Poverty Threshold - the amount of cash income minimally required to
support families of various sizes

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Liu’s (2011) Social Class Worldview Model
• Step 1: Help client identify and understand his or her
economic culture
• Step 2: Help client identify the social class messages he or
she has received
• Step 3: Identify client’s experiences with classism and help
him or her move toward developing an adaptive, realistic,
and healthy expectation of self
• Step 4: Help the client integrate his or her experiences of
classism

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Copyright

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