NCMHCE Human Diversity

Welcome to the NCMHCE Exam Review Podcast. I'm your host, Dr. Donnelly Snipes. This podcast is brought to you by Counselor toolbox podcast and allce.com counselor continuing education, where you can get unlimited on demand CEUs for $59 or or unlimited live webinars for $40. Go to allce.com I'd like to welcome everybody to this episode of the NCMHCE Exam Review Podcast. Today we're going to be talking about human diversity. I am Dr. Donnelly Snipes and I am your host. Today we're going to explore issues related to the counseling relationships with people who are culturally different and identify approaches to use with culturally diverse clients. Now you may be thinking, how does this app to the ncmhce? Well, when you get your scenarios, you're going to be reading through them and you may have to make a decision about whether you are the most appropriate clinician to be working with a particular counselor or identify issues that may be related to diversity. Many of the problems experienced by minorities are related to prejudice and discrimination, cultural differences and other experiences associated with minority groups status clients preferences for ethnically similar counselors depends on their ethnic identity, their level of acculturation, their gender, and their trust of the therapist ethnicity. So let's talk about those real quick. If a client is of the same cultural identity, and I won't even necessarily say ethnic identity because there are lots, remember, there's lots of different cultures. Ethnicity is one culture. We also have a religious culture. We also have a culture based on gender. So depending on people's culture, they may have more or less comfort with you as a clinician. So you want to look at their cultural identity. How do they identify themselves? How much are they acculturated to mainstream culture versus their own culture? If they are of a different culture than you are, or different cultures than you are, but they are highly acculturated into mainstream culture, then the differences are not going to be as necessarily prominent and the trust of the therapist's ethnicity and or gender or culture, so to speak. If you want to look at that, just think about if you have a if you're a male and you have a female client coming in and maybe she has been the victim of domestic violence or rape or something else where she may not trust men as much as she trusts women, vice versa. You could have a woman who comes in and has had really bad experiences with other females and may not want to may not be as trusting of females. So we do need to recognize that our presence based on our gender, our culture, everything is going to impact the client's comfort with us and willingness to share with us. Many cultural minorities lack role models and may be rejected or discriminated against. And again, I want to emphasize the fact that culture and minority status is not just related to ethnicity. It can be related to sexual orientation, gender, religion, etc. When we're talking about how much someone is acculturated or not. There are different levels of cultural identity development, and it's important to be aware of those. I don't think it's as prominent on the ncimhce, but this gives you an idea about how a client might feel if they are assigned to you as a therapist. The first level of cultural identity development is conformity, preference for the dominant culture and disavowing their permanent personal cultures. If they are in this one and you are of the dominant culture, then they may be fine with it. If they are in conformity and you are of a minority culture, they may not be fine with it. So it can go both ways. If you are not of the dominant culture, it can also work against you in dissonance. The person prefers a minority counselor and perceives their problems as stemming from their minority status. Therefore, when you are doing your case studies and you are selecting interventions and things, if they see a lot of their problems as stemming from their minority status, then that is going to be a treatment plan issue. The third level is resistance and immersion, in which the person rejects the dominant culture, prefers a racially similar culture or culturally similar culture, and perceives most problems as due to oppression. And again, this gives you an indication potentially about treatment plan issues that you may need to address. And when you're selecting interventions, you're going to want to refer them potentially to organizations and people and support groups, etc. That are similar to their culture. Level four, introspection. The person experiences conflicts about loyalty and responsibility towards their cultural group, as well as personal autonomy. So. So their cultural group has these mores and ideals and everything else, but they also have their own personal autonomy and ideas. And maybe they agree with dominant culture in some ways and they agree with their personal culture in other ways, which creates a lot of conflict. They may feel disloyal at this point. They're often more open to counselors of different backgrounds, though. And the fifth level is synergistic awareness, which is characterized by the person who has developed a personal cultural identity and can objectively evaluate and accept or reject the values of other cultures. At this point, they tend to prefer counselors with similar worldviews, Though worldview is different than culture. So they may be able to look past race, gender, age, socioeconomic status, whatever, and embrace people of all cultures who share a similar worldview. Counseling culturally diverse clients the first thing that we want to do, and I know I've said this a couple of times already, but I want to emphasize that culture is more than ethnicity. We want to look deeper than that. We want to identify the culture, clients, cultural identities and degree of acculturation if they are. We want to look at their gender, their ethnicity, their socioeconomic status, their religion, their, sometimes their employment. You know, there is, if somebody is in law enforcement, that is a culture in and of itself. If they're soldiers, that is a culture in and of itself. We want to understand the client's worldview. It may not be ours, but we need to understand theirs. In order to make sure that we are making appropriate referrals, we need to consider the impact of social, economic and political discrimination and prejudice. And this is true. There's ageism, there's discrimination based on sexual orientation, there's discrimination based on gender, there's discrimination based on, on ethnicity. There are a lot of different ways that minority groups or non dominant culture can experience discrimination and prejudice. Remember that clients from a low socioeconomic status are more concerned with immediate survival than long range goals. That is one of those culturally diverse things. Most of us who are clinicians are probably not in that low SES band. Not saying that that's true across the board, but most clinicians are not. Therefore, you know, we need to remember that people who are in a low SES may not share the same goals that we do. They're not as concerned about self esteem development. I mean, think about Maslow's hierarchy. People at a lower SES are more concerned about paying their bills and keeping healthy and putting food on the table in order to reduce their stress. We want to explore their reactions to a culturally different clinician, identify their perception of the problem and the role of therapy in solving their problem. Instead of talking to them and telling them what causes their problem, we need to ask them if they are native American. They may believe that their problem comes from an imbalance in the harmony in their community. There are a lot of different ideas about the causation of mental distress. We need to understand what their concept is in order to best discern what interventions would be appropriate. We want to explore issues related to cultural discrimination as appropriate. Evaluate positive resources and strengths. What do you have going for you? What resources do you have? You know, let's talk about courage and empowerment and what tools do you have that can you we can use to help you move forward, identify biopsychosocial issues related to the presenting problem and use a time limited problem solving approach. Now that is a very generic to do list with culturally diverse clients. If you're working with African Americans, remember that most often the African American culture embraces a human, humanitarian, people oriented view instead of a power oriented or a possession oriented view. Family is extended past blood relatives. So we need to make sure that when we're talking about family, we are understanding that it's not just the nuclear mom, dad and grandma. Family roles in African American families are often very flexible. Church is often very important and family therapy approaches are usually the treatment of choice when working with African Americans because they are highly involved with their family. If the client is embraces their minority culture and embraces the African American culture, it also is important to involve potentially church leaders or church groups in the recovery process or even consider referral to some sort of pastoral counseling. Working with American Indians Begin small talk by not defending your competence or getting down to business. American Indians are a very. What's the word I'm looking for? They find it offensive if they come into your office and you start spouting off who you are, all your degrees, and you know, let's just get down to this assessment. Make small talk. Help them feel comfortable. Help them feel like they're not just a number. If you're working in a clinic that serves a lot of American Indians or there's a strong American Indian population in your community, it's really important for clinicians to be involved with that community in order to establish a level of trust. Most American Indians prefer a spiritual or holistic approach. If they are embracing their primary culture, they place a greater emphasis on the family and tribe than the individual. They perceive most problems as a result of disharmony in one's life. They view behaviors as motivated by interconnections with others. That's what I was talking about before with the imbalances. Treatment often involves helping to heal the community, and they often prefer the involvement, at least of tribal healers. One thing that you'll learn if you do more research on working with this population, there are a lot of stories and fables that are used for education and guidance in the community that are not permitted to be written down. So there's a strong oral tradition. There's no way that we can know those things, which is why it's important to be plugged into that community. In order to know if some sort of intervention by a tribal elder might be useful. If you go to YouTube.com allceducation I have multiple videos that go way in depth on working with people who are culturally different. So if you need more information about multicultural, you can go there to at least start. SAMHSA also has a treatment protocol. A tip is what they call it out on working with culturally diverse clients. That can be very useful. Working with Asians People who are from Asian cultures typically use high context communication, which means they put a lot of emphasis on nonverbals. They may not say as much. It's more about how they say it, where they say it, et cetera, than exactly what they say. Extended family often lives together in this culture, so you may have grandma, grandpa, mom, dad, kids, grandkids, all living in the same household and family may expect to participate in the assessment and treatment. They may not be comfortable letting one person go in without the rest of the group. There is a strong level of interdependence where people feel a responsibility for those in their family, sometimes to the exception of themselves. Mental illness is often seen as bringing shame on the family, and a lot of people in Asian culture will somaticize their symptoms. So do listen for physical complaints that may indicate a mood issue. They often understate feelings and problems, and modesty and self deprecation are usually not signs of low self esteem. It's a sign of politeness in Asian culture. Many mental health issues, as I said before, are somaticized and it's important to remember that PTSD is not uncommon in refugee populations. With the Asian culture it is important, unlike with the American Indian culture, with the Asian culture it is important to establish credibility with them by sharing information about who you are. Working with. A Hispanic population involves understanding that in this culture there is a preference and a high priority. Put again on interdependence as opposed to independence. So they put the welfare of the family and potentially the community first, before their own welfare sometimes. People who are Hispanic are often uncomfortable sharing very personal information and prefer a concrete, tangible, present, focused approach to life. They may have a relatively external locus of control, believing that things that happen to them or their mood issues or whatever else is going on is due to their higher power or things beyond their control that are punishing them, for example, or are testing them. Which is again why we need to ask, what do you think is causing this issue right now? They too often somaticize their complaints and place importance on personal greetings and small talk. Don't just bring people in. Hopefully with no culture, but especially with cultures that are highly interdependent, place importance on getting to know the person and making sure they don't feel like a number. In the Hispanic culture though, as opposed to the African American culture. In the Hispanic culture, family roles are relatively inflexible and very patriarchal. With this population, you often want to avoid insight oriented approaches and focus more on solution focused approaches to whatever their presenting issue is. When we're working with people who are of a minority sexual orientation, some of the issues that arise include dealing with people to whom the client is not out. So if they're not out to their family, then there may be issues in that relationship. If they are having difficulty dealing with friends or employers who don't know their sexual orientation, that could be a great source of frustration and anxiety. It's important for us as clinicians to understand the lifestyles of people who are LGBTQ2IA. There are a lot of different nuances between the different sexual orientations. You don't want to just assume that everybody who is a sexual minority has the same issues. And for those of you who are unfamiliar, we know lesbian, gay, bisexual, transgender, queer. Two Spirit is a American Indian concept that sometimes people have both a male and a female spirit that reside within them, intersex and asexual. So you know what each one of those abbreviations stands for. For many people with presenting with problems who are of a sexual orientation minority, we want to help them access resources so they can engage with their community or engage to get their needs met. If you're working with a client who's in the process of coming out or dealing with issues related to coming out, it's important to understand the different stages of the coming out process. In stage one, the person experiences identity confusion and they wonder about their sexual identity and may experience denial and confusion about what's going on. They may not be sure if they are of a sexual minority. In stage two, there's identity comparison in which the person accepts the possibility that they may be LGBTQ2IA. You know any sort of different sexual orientation than the majority and face the social isolation that can occur with this new identity. In stage three, the person experiences identity tolerance and they accept their sexual orientation. They accept their sexuality but may feel increased isolation and alienation as their self concept becomes increasingly different from society's expectations of them. At this point, the person may start reaching out to contact members of the LGBTQ2IA community and starting to understand a little bit more about the community. In Stage four, the person experiences identity acceptance and accepts their sexuality and starts having increasing contact with their community. In stage five, people experience identity pride and begin being part of the community and immersing themselves into the culture, sometimes rejecting the heterosexual community. So you start seeing a, in some cases a polarization before they come back to stage six, which is identity synthesis. The rejection of the heterosexual community and the intense pride they have in their own sexuality tend to diminish a little bit and they regress toward the mean. As we would say in statistics. There's congruence between their public self and their private self and their sexuality is integrated with all aspects of their life. They are feeling congruent at work, at home, in their friendship relationships, in their intimate relationships, and in their own skin. Another population that falls under multiculturalism or different cultures are people who are elderly. And many of us who are working with clients who are elderly are not elderly ourselves. So we are of a different culture. And I can tell you from working with people who are older than I am, especially when I first got out of college, working with people who were 50, 60 years old and I'm 24, they're looking at me going, what in the world could you possibly have to offer me? We do need to recognize that people who are older than us have a different perception. They grew up in a different time, they have different values. I mean, the values of the 50s are very different than the values of today. So we need to recognize that people who are elderly face the issues, including identity transition. They go from being potentially a worker to a retired person. That is a huge transition. They may go from being able bodied to having a disability. They may lose their mobility. So there's lots of transitions in identity. Sexuality also becomes an issue because a lot of people who are elderly still have very strong sex drives. And that is not what's assumed or expected by the mainstream community in many cases. So it's really important to help people who are elderly explore their sexuality and what it means to them and what would help them feel whole and healthy. You can expect that they will be experiencing a significant amount of loss and bereavement. They will have friends that pass away. And as they get older, more and more of their friends are passing away. They may lose a spouse, but they also lose friends when they retire. Those people that they engaged with every single day at work, they're no longer engaging with. So there's a lot of loss associated with some of the identity transitions as well. They may need to work on acceptance of death if they are diagnosed with a terminal illness, or if they're just getting older and they need to come to some level of comfort with the fact that their time on earth is about to end. All of these things can contribute to depression, but we also have to remember that changes in the changes in our body as we get older can also contribute to depression, including heart problems, blood pressure problems, copd. All those sorts of things can contribute to depressive symptoms we want to be aware of. Also medication side effects. The older person's liver cannot clear a lot of medications as quickly as the liver of a younger person, so they can build up to toxic levels of certain medications like benzodiazepines really quickly. They may have to deal with issues of cognitive decline and dementia. Cognitive decline is an expected thing to happen in people as they age. That doesn't mean that they have dementia, so to speak. We want to help them separate the two, but we do also want to help them understand that their brain is not going to work quite as quickly anymore as they get older. And that's just natural slowing and, and figure out interventions to help them delay that as much as possible and deal with it when it starts to happen. They have shown in a lot of studies that if people stay mentally and physically active, it delays cognitive decline significantly. They also may be dealing with issues in caregivers and family related to guilt, anger, resentment and anxiety. The elderly person may feel this, and as a clinician, we may also have to address these issues. If son is upset because mom has to move in with him and he feels resentful about that, or has high anxiety because mom was diagnosed with Alzheimer's and is moving in with him and he's not sure if he can handle it or if at a certain point in many families, the elder person has to go into some sort of assisted living because the children are just not equipped to be able to handle all the diverse needs. And that creates a whole lot of guilt and anxiety on the part of the caregivers, as well as frustration and resentment, sometimes on the part of the elder. When working with the elderly, you want to identify current problems. This is not the time to start going back and dealing with the whole litany of stuff for the year, for their whole lifetime. Let's focus on what's going on right now. Allow the person to express their feelings and thoughts, identify past problem solving approaches which could be applied here. If they have to move into assisted living, they have to make a transition that they don't want to move. We may talk about times in the past when they've had to do the same thing. Maybe their spouse got a job and they had to move with their spouse and it wasn't really something they wanted to do. How did they make that transition go a little more smoothly? Do use a biopsychosocial approach when working with the elderly, but paying attention to sleep. Sleep patterns change as people get older. We want to make sure they're getting enough sleep because that will help clear up a lot of cognitive issues if they are getting adequate sleep. When we sleep, our brain clears out the toxins that build up throughout the day, which contribute to confusion and fatigue. So adequate sleep, adequate nutrition. We want to make sure that their medications are not contributing to their mood issues and look at any side effects that they may be having. We want to make sure that they have support, emotional support, as well as support to meet their basic needs. Make sure that they're in environments that are supportive and happy. Nobody wants to live in basically a jail cell without bars. People don't want to live in an institutional environment that is cold and unfriendly. We want to make sure that they are as comfortable as they can be and potentially address mobility issues. This could be everything from ability to get in and out of the bed and get in, in and out of the bathtub to the ability to go to the store on their own. Think about how much freedom you have because you are able to go run errands. You are able to get the things you need. If you need food, if you need toothpaste, you can run down to the store. A person with reduced mobility because of physical issues, you know, their joints aren't working the same way, they have balance issues or their sight is not good enough for them to drive anymore, for example, may experience a lot of depression and a sense of helplessness and feel like they're a burden because they can't do for themselves things that they used to be able to do for themselves. In some cases, reminiscence therapy is appropriate. It helps them look back over their life. This is an intervention that can be used with people who have Alzheimer's because a lot of times they can remember the distant past. It's the recent stuff they have difficulty with, and it can help ground them and help them feel okay about life. If you think about Erickson's stages in the older, in the later stages, they look at generativity versus stagnation and looking at making sure that everybody that they've done their part. And reminiscence therapy can help with that. When working with people with disabilities, we want to again identify the client's perception of their problems. Do they think it's due to their disability or not? If the issues are related to the disability, we may need to explore issues of adjustment, grief and pain. If somebody acquires a disability, then there's going to be a huge adjustment in their life because they may not be able to do things they used to do. If they become a paraplegic or if they are diagnosed with a autoimmune disease, you know, there are adjustment issues. People who are diagnosed with things like Crohn's disease will have a period of adjustment which can include some grief because they can't eat the things they used to. They can't do some of the things they used to. And it can be very frustrating and exasperating. So we want to use this definition of disability as pretty broad. And just as the word says, the loss dis means the loss ability. The loss of an ability or a function that we used to be able to do. All losses involve grief. So we may need to help people work through grief. If they have a physical disability of some sort of. Then there also may be pain involved. And we want to make sure that they are managing their pain as effectively as possible. It doesn't mean necessarily that they are going to be pain free, but we do want to help them manage, make sure that they're working with their doctors to manage their pain as effectively as possible. Make referrals to local support groups as appropriate, especially if a person is having difficulty adjusting to whatever their disability is, and help the client improve their quality of life. So ask them, you know, what does a high quality of life look like to you and how can you potentially achieve that despite having this current disability? People who are blind live very rich and full lives. People who are deaf, people who are lead very rich and full lives. And we do. I do want to mention here, it's probably not going to come up on the test, but it is very insensitive to suggest if that a person needs to reacquire those senses, if they've lost those. There is a strong pride, especially in the deaf community, and a strong attachment within the deaf community. And suggesting that they need to get cochlear implants is considered extremely insensitive. We don't want to assume that they feel that having whatever disability they have is necessarily a. Necessarily a problem. Which takes us back to the beginning. Identify the client's perception of their problems when working with people who are homeless. Now, yes, this is sort of a minority thing. We're talking about different socioeconomic status, but it is, it may come up on your exam, so I just kind of wanted to put it in here. You want to provide service, outreach, engagement and coordination. A lot of times people who are homeless are not going to be coming in to a facility for treatment. However, if you work in a jail or a community mental health center or a detox unit, you may very likely be working with people who are homeless. They need. Think Maslow. Again, their primary considerations at this point are getting their basic needs met and we want to help them to the extent that they want to acquire supportive housing, adequate nutrition, medical care, etc. And engage in meaningful daily activities, that can be a job, that can be volunteerism, whatever it is that helps give their life meaning. I will mention here, and this again probably will not come up on your ncmhce, but it's important to recognize that some people are homeless by choice and they do not want to have a job. They do not want to have a brick and mortar house. They like to live a nomadic lifestyle. Their friends are in the community. People who are homeless often travel in groups and they know each other and they respect each other and they look out for each other. Is it a lifestyle that you or I would choose? Probably not. But for some people that are there, that is, they're there by choice. They're not there because they have a mental illness and they're not oriented. They're not there because they got fired and or were in a bad situation and had to leave their home. They're there by choice. It's important to be aware of the cultural issues impacting clients, and that goes way beyond race and ethnicity. People may embrace multiple cultures such as gender, sexual orientation, ethnicity, disability, socioeconomic status, even occupation. Understanding clients perceptions of what is causing their problems and how therapy can help is essential in providing an effective treatment plan. It may also be necessary to explore the impact of working with a culturally different clinical clinician and ensure, when working with clients from different cultures that you use approaches that are appropriate and or tailored to meet their needs. Don't use something that is highly focused on the individual and with someone from a culture that is strongly interdependent. If you tell them, well, if you don't want to do what your family wants to do, that's your choice and let me empower you to cut ties from your family, well, that's not appropriate in a lot of cultures. And so we do want to be very sensitive to how do they see this best Resolving, as always, we're going to end with a case example. Betty is a 42 year old single mother with a 16 year old son. She's an executive at a local company and has been referred to her EAP due to performance issues. She has insomnia and has been feeling depressed and anxious all the time. She reports for about three months. She's fatigued and has difficulty getting motivated to go to work. Her son recently was caught smoking marijuana on a school campus and her mother was diagnosed two weeks ago with Parkinson's disease and will be moving in with them next month. Betty's mother does not know about her son's drug use and Betty is concerned about the responsibilities of caring for her mother. What diagnoses are you thinking exist for Betty? You know, we're looking at these and we want to figure out if there's depression, anxiety, adjustment disorder and or substance use and substance use is kind of out there on the fringe. But since she has been feeling depressed and anxious all the time for about three months, you know, there's a possibility that she may be self medicating. What things would we, what kind of information would we collect? Information about her family relationships? Yes, we want to understand her relationship with her son and her mother. Her physical health? Yes, we want to have an idea about what might be causing the insomnia. If she had a physical in the past six months or a year, hormone changes could be happening. There could be other things that are contributing to her anxiety that we want to rule out. Her education is largely irrelevant here. Her career objectives, again, largely irrelevant. Yes, she's having difficulty getting to work, but at this point she's talking about depression and anxiety and she's dealing with a bunch of stuff. Her depressive symptoms. Yeah, she said she's depressed, so we need to assess that. Her anxiety symptoms? Yep, need to assess that too. Her sleep history, she reports she's got insomnia. So we need to see when it started and try to figure out what might have triggered that and what might be continue making it. Continue use of alcohol and other substances. Yeah, we want to have an idea if she's self medicating. Her work history. Well, she was referred by the EAP and she's struggling at her job right now. So we do need to understand what's going on there and her mother's prognosis. Now interestingly, this one is one of those gotcha sort of ones. No, we don't necessarily need to know about that right now because her depression and anxiety symptoms kicked in three months ago. Her mother just got diagnosed two weeks ago. So whatever is causing her depression and anxiety originated three months or before. Now, her mother's diagnosis, I'm sure, made things worse. However, that's not necessarily the information we need to collect right now in order to make a diagnosis. And that's what we're at right now. We're trying to make a diagnosis. What types of tests would we use with her? A mental status examination. Yeah, we want to figure out how she's functioning. We don't know how well she's doing, and she's obviously struggling at work. Would we use the sase? Yes. For those of you who haven't reviewed your testing in a while, SASE is Substance Abuse Subtle Screening Inventory. Would we use the bdi? Yeah, that would be one. You could use the Beck Depression Inventory. Would you use the mbti? No. Now, remember, on your exam, you're going to see acronyms. You're going to have to know what these things stand for because generally they will not spell them out, which is one of those tricky little things. The MBTI is the Myers Briggs Type Inventory. So you don't need to know about her personality right now. That's not useful to making a diagnosis. 16 PF. Would you use that? Remember that? 16 personality factors. No, we're not assessing a personality disorder right now. We're not needing that to make a diagnosis. Would you use the stai, which is the State Trait Anxiety Inventory? Yeah. That would give us an idea about how much of our anxiety is trait oriented versus state oriented, and which you use the mast, which is the Michigan Alcohol Screening Test, I think. But it is a screening, it is not a diagnostic tool, and it only screens for alcoholism. I want to know what else she's taking, which is why I would choose the SASI above the MAST for this particular case. I hope that was helpful, and I will see you on the next episode. Thank you for joining me today. Subscribe to the NCMHCE Exam Review Podcast to be notified when new episodes are released. And while you're at it, subscribe to Counselor Toolbox podcast to stay up to date on current trends in counseling and earn your continuing education on the go.