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Cultural Diversity, Sensitivity, and Competency Back to Course Index

 

 

 

 

“Geography is destiny”…at least to a degree. Where we come from, the people, customs, and environment shape who we are and what is “normal” to us.  There isn’t a “right” or “wrong” or a “good” or bad” to it necessarily.  One of the greatest challenges today, and critical for you to better help your clients, is accepting that there are differences among us, and that is ok.  

Historical documents often refer to the United States as a great cultural experiment or a melting pot as diverse peoples are molded and shaped into the American way of life. This can be referred to as cultural diffusion. Cultural diffusion is the process by which cultures influence each other to change.  Historically, this occurred through migration, trade, and other direct interactions; now, this occurs through media, social media, modern communication, and other global means of connection.  My son loves Snapchat.  One of my favorite things to do is open Snapchat, open the map, and then click on the snap videos of individuals in other countries.  I love to see the restaurants, skyline, hear the music, and just have a “snap”-shot picture of life on the other side of the globe at this very minute.  

Cultural diffusion can occur in several ways. A few examples include:

Pizza Effect

The Pizza Effect is when culture is copied imperfectly, resulting in a new culture.  Have you ever said, “oh, it is an “authentic” Italian restaurant, not an Americanized one”?  

Norms

The spread of norms such as shaking hands (no longer a norm!) is an example of a custom that is adopted by cultures across the globe.

Language

The English deja-vu is frequently used but borrowed from the French language.  This common language by the adoption of loan words from other cultures bridges the two.  

 

The term “melting pot” implies that various cultures gradually fade into a more homogenous national identity.  This view is criticized by some who prefer referring to America as a kaleidoscope or tapestry comprised of distinct and vibrant parts, but still part of a larger design.  This criticism has created a trend toward cultural pluralism, a form of cultural diversity where cultures can still maintain their unique qualities and combine to form a larger richer whole, and cultural diversity, a system that recognizes and respects the existence and presence of diverse groups of people within a society, as concepts being advanced to promote the co-existence of various cultural groups, all of who may simultaneously maintain some of their distinctive characteristics. 

However, the various cultures come together though there are conflicts between ethnic and cultural groups, and there is inequality in the social and economic resources available to different groups.  Different general acceptances, power, and prestige issues between ethnic and cultural groups, as well as differences with the majority cultures, have a significant impact on minority persons who may also have a social or community needs.  It is often difficult to separate socioeconomic, ethnic, gender, age, and other variables that influence the behavior and attitude of members of these subpopulations.   Consequently, they often experience multiple jeopardizes, including minority status, parenting problems, physical and mental challenges, age, lifestyles, and other factors.

Individuals who are disadvantaged and sometimes disenfranchised are sometimes labeled as hidden populations and include individuals such as the homeless, chronically mentally ill, criminal and juvenile offenders, prostitutes, runaways, and others.  It follows that less personal and research data are available on these groups due in part to their lifestyles and loss of identity.  They are generally omitted from surveys because they are not living in typical homes, are not always attending school, and may choose not to cooperate with interviewers.   However, many members of these groups have a greater need for social services, medical, food, shelter, and other services than the general population.

Evidence has shown that our current mental health treatment forms have been especially inadequate for ethnic minority populations. Finding culturally competent interventions has been an enduring significant challenge in the psychotherapy community. We have understood for some time now that ethnic minorities tend to underutilize mental health services. Although different efforts have been made to improve mental health services for ethnic minority clients, recent reports continue to document that mental health services are often inaccessible, inappropriate, or poorly delivered.

The provision of culturally competent services enhances outcomes for ethnic minority groups. Cultural competency has been categorized into three basic characteristics of mental health providers, namely:

  1. Cultural awareness and beliefs. A culturally competent counselor or provider is sensitive to her/his personal values and biases and how these may affect perceptions of the client, the client’s problem, and the counseling relationship.
  2. Cultural knowledge. The counselor has knowledge of the client’s culture and expectations for the counseling relationship.
  3. Cultural skills. The counselor is able to intervene in a manner that is culturally appropriate and relevant.

This course will explore how culture and stereotype plays a role in our we see ourselves and others.  We will explore cultural competency through cultural awareness and beliefs, cultural knowledge, and cultural skills.  We will look at the implications for counseling theory, research, practice, and training.  Bridging potential gaps between clients and counselors requires a fundamental commitment to the value of cultural pluralism, trained sensitivity, and concepts to aid in resolving role conflicts.

 

Stereotypes And Bias

Cultural Awareness and Beliefs

A stereotype is an over-generalized belief about a particular category of people. It is an expectation that people might have about every person in a particular group. The type of expectation can vary; it can be, for example, an expectation about the group’s personality, preferences, appearance, or ability.  We have to watch these beliefs for both bias and misunderstanding.  

As you grow up, you can’t help internalizing at least some of the day-to-day messages you receive from family, neighbors, television, radio, news programs, and more.  All day, every day you are “taught” things.  You might have heard your mom yell something in traffic or have heard your dad say something about someone in anger as he slams down the phone.  Maybe you heard jokes at school or work.  All of us are fed these messages.  Old people don’t drive well.  Jewish people are tight with money.  Lawyers are unscrupulous.  People with tattoos are dangerous criminals.  People who don’t speak English aren’t as smart.  These messages are driven in over and over, and they change over time.  This year perhaps you heard Republicans are heartless and only care about their money, or maybe you heard Democrats want to take other people’s money to give to those that refuse to work.

This internalized bias is called implicit bias, and it can affect you in ways completely outside your conscious awareness.  You might catch yourself wondering if you can communicate effectively with your Uber driver based on their accent, or feel yourself picking up your pace when walking to your car as you see a group of young, black men hanging out by their car two rows over.  Automatic stereotypes and biases are often triggered by simple things like the color of another person’s skin, the clothes they wear, or their style of communication.  This is how we have been socialized.

At the same time that we are taught these biases and stereotypes, we are also taught that it is absolutely wrong to have them.  We are then told that we are bad for having them.  So when stereotypes and biases pop into our heads, we pretend they aren’t there.  We get defensive.  Sometimes we outright lie, both to ourselves and to others, to avoid looking bad. 

Watch the following clip from the popular movie Legally Blonde as an example of very different stereotypes and how they don’t understand each other all right here in our country.

 

 

Perhaps instead of pretending like they are not there, we need to acknowledge and challenge them.  We need to acknowledge that we learned this because there was some piece of it that made sense at the time, but that isn’t the entire truth.  The older population frequently has a decline in night vision.  This could lead to some who do not recognize their decline becoming more impaired drivers than someone with perfect vision.  That does not mean that all “old people can’t drive.”

As a counselor, it is important to know yourself.  Know your biases.  Challenge them.  Learn to be sensitive to your personal value systems.  If we don’t recognize what we bring into the therapeutic relationship, it will taint it.  

 

Who is Who

We tend to fall into the mindset that cultural diversity means respecting the differences of other people from different countries and/or nationalities.  There are many different belief systems and norms, even within the same country and even community.  Differences can present from upbringing, and belief systems such as moral, religious, political beliefs, and so forth.  

The United States is a multi-racial and multi-ethnic country. The state officially categorizes its population into six groups: white, African American, Native American/Alaskan Native, Pacific Islander, Asian, and Native Hawaiian. From those groups, Americans identify with ethnic groups that are even more specific. More Americans specify as German than any other ethnicity.

Hispanic and Latino Americans are the largest ethnic minority, comprising an estimated 18% of the population.

Race is described by most as biological, while ethnicity is defined by culture.  In other words, race is often perceived as something that’s inherent in our biology and therefore inherited across generations. On the other hand, ethnicity is typically understood as something we acquire or self-ascribe, based on factors like where we live or the culture we share with others. These definitions are not always agreed upon, though, and the terms are frequently misunderstood by many.

Percentages of Races in America:

German (15%)
Black or African American (12%)
Mexican (of any race) (11%)
Irish (11%)

Asians remain the fastest-growing racial group in the United States. 

With all of that said, the term “minority” in the US usually refers to four major racial and ethnic groups:

  • African American
  • American Indians and Alaskan Natives
  • Asians and Pacific Islanders
  • Hispanics

The need to understand the socio-cultural factors affecting these racial and ethnic groups is crucial for the provision of adequate social services. 

There is considerable variation within racial and ethnic groups, as well as between groups, and there is often a complex relationship between racial/ethnic group membership and socioeconomic status.  A good example of this is if an individual has a high degree of acculturation (language, value systems, career, housing, etc.), then that individual could be rejected by his or her race or ethnic group.

Some minority groups have limited access to social services and are often at higher risk of anti-social behaviors.  This is a consequence of several factors, such as the migration experience, poverty, unemployment, and cultural differences between minority groups and mainstream society. Some low socioeconomic status individuals may engage in high-risk behavior for economic reasons.  For example, some may turn to prostitution and/or drug dealing to support their families due to a lack of education or vocational training and the resulting limited access to employment.

 

 

Cultural Competence

images-1The importance of culture increases in individuals living in a socio-cultural setting other than the one they came from.  Also, for those who have not experienced socio-cultural change, cultural issues may come to the forefront in interactions with individuals who do not share the same culture of origin. Such encounters prompt the realization that different cultures view the world in different ways. 

 

 

 

Cultural Knowledge

A way to help bridge those differences is through the acquisition of knowledge about other cultures.  Cultural knowledge enhances the understanding of different views and also helps to develop more effective problem-solving strategies. 

A cultural competency program is one that demonstrates sensitivity and understanding of cultural differences.  It is a fundamental ingredient that helps develop trust and an understanding of how members of different cultural groups define health, illness, and health care. Consequently, culture is a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities among and between cultural/ethnic groups.

A culturally competent social service provider recognizes and utilizes the client’s strengths, values, and experiences while encouraging behavioral and attitudinal change.  Culturally responsive services generally focus on the following: 

  • Knowledge of the client’s native language
  • Sensitivity to the cultural mores of the client population
  • Staff background similar to clients
  • Treatment/services modalities that include values of the client population
  • Representation of the client population in decision-making and policy implementation.

It has been recommended that cultural competency programs need to implement cultural competence at all levels:  Policy, structure, attitude, staff, and policy.  Stated slightly differently, culturally competent systems include professional behavioral norms that are built into the organization’s mission, structure, personnel, and program design and treatment modalities.

Cultural competence also infers professionals’ willingness and the programs they operate to conduct self-appraisals to develop an understanding of how they may differ from the clients they serve.  Cultural competence also entails the acknowledgment of existing inherent cultural biases on one’s attitude and behavior.  A provider’s discomfort in relating to individuals who are different can be communicated in many non-verbal ways.  Common factors that influence comfort include ethnic and racial characteristics, socioeconomic background, religion, and physical and mental handicaps.  However, cultural competence requires communication that goes beyond language proficiency to focus on meanings and interpretations.  Within a culturally competent framework, knowledge of cultural beliefs and expectations is necessary for effective communication.

 

Cultural Skills

Problems occur when theories are assumed to be universally true when their validity is confined to one culture or population. As said, minorities tend to be underrepresented in most research studies.  Unfortunately, a nasty thing happened on our way to our universal generalizations: culture and context turned out to have a much more fundamental effect on our generalizations than we expected.

Therapists can incorporate cultural sensitivity into their work to accommodate and respect differences in opinions, values, and attitudes of various cultures and different types of people. Cultural sensitivity also allows a therapist to gain and maintain the ability to first recognize and understand one’s own culture and how it influences one’s relationship with a client, then understand and respond to the different culture. The need for this understanding may be based on characteristics such as age, beliefs, ethnicity, race, gender, religion, sexual orientation, or socioeconomic status.

Cultural sensitivity practices can be applied to any type of therapy; these practices may help the client feel more comfortable, making the treatment more effective. Research has helped document the positive effects of cultural sensitivity practices and has also outlined examples of how therapists can be more culturally competent in their interactions with clients of different backgrounds. For instance, one study noted that therapy with Latino clients was less effective when the therapist was misunderstood as distant. Understanding and applying the cultural expectation of disclosing, for example, some personal information may help clients connect with their therapist. Other studies show that certain behaviors, such as familiar use of language and a general display of personable traits, can play an important role in some cultures; avoiding these approaches can alienate clients.

A culturally sensitive therapist follows guidelines for working with diverse groups of people and understands that racial, cultural, religious, gender, and sexual identities interact with one’s beliefs and behavior. The expectation and ultimate goals for both the therapist and the client are notable progress and improvement despite cross-cultural boundaries and differences. Because they have acquired the necessary knowledge and skills, therapists who successfully integrate cultural sensitivity practices into their treatment recognize and respect differences and can communicate and interact successfully with clients from diverse backgrounds.

Although therapists who practice cultural sensitivity may deviate from standard therapeutic methods, they must also adhere to their profession’s ethical guidelines, for example, when it comes to the disclosure of personal information. While some therapists argue that highlighting differences between individuals may offend some clients, and therefore damage the therapeutic relationship, it is generally believed that openly showing respect for someone’s culture and beliefs can result in more effective treatment and a more positive outcome for both client and therapist.

Meta-analytic research has been used to address a very important question in our field: should treatments be adapted to fit clients’ cultural backgrounds? Cultural adaptations – modifying the way modalities are delivered in a way that is responsive to the unique cultural identity of the client – can range from using therapy materials in the client’s native language, to taking into account specific values, beliefs, attitudes, norms, and practices when targeting treatment goals, or conducting therapy within the family’s environment. Ignoring cultural factors and individual needs in psychotherapy can engender miscommunication, discomfort, and client mistrust. As a result, clients may not engage as much in treatment. So it seems intuitive that these therapies would be effective, right? Unfortunately,  the research is mixed on the subject. Some researchers promote the use of cultural adaptions, while others are skeptical about the usefulness of tailoring treatments.

What is the cost of neglecting culture in a therapy context? “My counselor just doesn’t get me.” As counselors, we do not need to be like our clients, but we do need to strive to understand them to bridge a good working relationship. 

The American Psychological Association has specific guidelines in place to ensure that therapists remain culturally competent, which can vary widely in quality and definition. Psychology Today’s “find a therapist” page includes the term “culturally sensitive” within the treatment orientation search criteria; although this does not certify that a provider is culturally competent, it may indicate a level of awareness on the part of the therapist above and beyond that of other “generic” treatment providers.

 

General Barriers to Social Services 

Racial and ethnic populations may face a number of problems (language, transportation, etc.) that may impede their access to social services.  Individuals from racial/ethnic groups tend to under-utilize healthcare, prenatal care, mental healthcare, substance abuse treatment, or seek them as a last resort.  Treatment may be sought only when the resources of the traditional family support network have been exhausted.  At this point, problems may be so chronic and severe that treatment outcomes may be poor.

The individual’s economic status may be a deterrent to the purchase of services.  Racial/ethnic populations are more likely to have lower incomes than those of the mainstream population but are less insured.   

Those needing social services may live in areas where access to providers is limited because of distance or transportation problems.  Also, those with access may often find services that are inadequate or inconveniently scheduled.  Others may not realize they are eligible or may not be aware of what services a local program offers.   Many social services providers cannot address the specific needs of individuals from cultural backgrounds different from their own, even when they speak the client’s language of origin.  This is further compounded when trying to develop written material for linguistic and culturally diverse populations.   Issues such as literacy levels and regional differences (different dialects) need to be taken into account when developing written program material.

Beliefs and attitudes regarding health and illness may act as obstacles keeping racial and ethnic populations from seeking treatment for social problems.   The literature on health and mental health has identified a number of factors that contribute to the underutilization of services.  For example, reliance on folk remedies may cause some underutilization of medical services.  Cultural stigmas attached to psychiatric care, psychotherapy, and counseling may invoke fear of losing status and be judged a failure by the family and the community, thereby contributing to underutilization.   Cultures differ in their characterization and acceptance of abnormal behaviors.  For example, what is considered abnormal behavior in one culture may be accepted or encouraged in another.   For example, the practice of voodoo may be accepted in one group and scorned in other groups. Abnormal behaviors may be attributed to physical or psychological causes, or they may be viewed as the direct result of supernatural or spiritual factors.

Emergency rooms often serve as primary care providers for members of racial and ethnic minority groups in urban areas.  Individuals with long-standing social problems are more susceptible to serious medical problems and are more likely to use emergency rooms.  However, emergency rooms often cannot provide appropriate referrals to social services or provide the follow-up to assure appropriate care is provided.

Regardless of the services required, racism on an institutional or individual level can be a significant barrier to effective treatment.  Institutional racism within a service organization is evident when the program design is oblivious to its client population’s racial, cultural, or ethnic backgrounds, values, and morals.    Latent prejudices on the part of the staff, as well as language and cultural differences, undermine efforts to help patients achieve recovery.

A community in social and economic turmoil may reject social service providers who are outsiders.  Negative experiences with providers who may have lacked respect, awareness, or concern for cultural differences often reinforce unfavorable attitudes and distrust.  For example, some treatment programs may be rendered ineffective if the community has not been involved in their planning and implementation.

 

LANGUAGE CONSIDERATIONS

One of the greatest barriers to mental health treatment is language.  Most early immigrants that came to the US did not speak, read, write, or understand spoken English.  Some of the more recent immigrants have a better command of the English language, but problems still exist, especially with low socioeconomic individuals who migrate to the US to avoid poverty and unemployment in their native country. 19.2 million Americans are classified as Limited English Proficient.  

Counselors often hear conversational English spoken by clients and, accordingly, assume that these clients are able to engage in the counseling relationship with them. Such counselors are not aware that clients for whom English is their second language may neither have the skills nor ability in English to engage in the conversations required for counseling to be helpful.

When clients whose first language is something other than the counselor’s language are struggling to find the words to tell their stories and, especially, to share their feelings, such as grief, sadness, alienation, loneliness, fear, or rejection, they can become anxious.  They might not feel understood.  They may be right.

It is important to really take the time to communicate understanding back and forth with clients whose first language is not your first language.  

 

 

BEYOND RACE AND CULTURE-SPECIAL POPULATIONS 

The world is filled with a vast diversity of people.  Some look differently, some talk differently, some behave and believe differently, and some think differently.  Successful counseling with members of various minority groups, including ethnic background, age, sex, sexual orientation, and disability groups, requires education and self-reflection. There are implications for counseling theory, research, practice, and training.  Bridging potential gaps between clients and counselors requires a fundamental commitment to the value of cultural pluralism, trained sensitivity, and concepts to aid in resolving role conflicts.

Let’s explore some special populations and what to consider.

Age

It has been found that age impacts complementarity in the counseling relationship more significantly than race.  

Specifically, the researchers found that clients who were matched with therapists close in age developed a stronger bond at intake. This could be due to the fact that people of the same age view life events with a similar perspective and have similar ideals. Additionally, major life concerns, such as growing older, divorce, or health issues, are ones that may be dealt with uniquely based on age. Rosen believes that taking these factors into account during the intake session could benefit the levels of adherence. He suggests that therapists address complementarity when they first meet a client by clearly outlining the purpose of the first session and the overall plan of treatment. He also feels explaining expectations for future sessions will enrich the relationship between the client and therapist and help break down any barriers of race or age.

One of the first — and sometimes most challenging — life changes this group faces change in job status. Older adults between the ages of 60 may be considering retirement, transitioning to part-time work, embarking on a new career altogether, or trying to remain in their current position.

Their decisions may be driven not just by personal preference but also by economic circumstances related to the recession and a changing global economy.  The same approach to counseling and coaching young adults 50 or 60 years ahead of them does not work with this population.

When aging adults are ready to retire, the transition can pack more of a punch than most people realize. “Work provides structure, relationships, and relevancy,” Feller says.  Without work, sometimes finding purpose is hard. Seeking meaning, contributing, and mattering is especially important in the new adult phase, where we live 30 years longer than our parents.

Counselors are able to help individuals make sense of these types of transitions and help clients develop a new sense of self and purpose in their lives.

Aging adults need to know they are not alone in their experience; that others have gone through this transition and regained a sense of meaning in their lives. Counselors can help these clients see that they have other talents and are more than the sum of their careers. Retiring can bring time to “redefine” their lives by exploring new interests, developing new hobbies, or spending more time with their family members.

Retirement is not the only challenge aging adults will begin — or continue — to face. In particular, this age group may find themselves confronting family issues such as the need to provide some level of care to grandchildren or even coping with an adult child who has returned home.

Aging adults may also be the primary caregivers of a parent or spouse. Counselors need to remain aware of how much stress these caregivers are under and intervene by helping them find strategies to cope.

Older adult clients may not currently face caregiving issues or have trouble transitioning into retirement, but there is one experience that everyone must eventually face: loss. Although that experience is certainly not restricted to the older adult population, it does become more common as people age.

As adults age, they share similar challenges, but in certain circumstances, the aging path really starts to diverge. Although most people who reach older adulthood have some kind of health complaint, the healthier of this age group generally have minor or manageable conditions. They may have arthritis and other wear and tear, but they are as healthy as can be expected for their age group.

On the other hand, aging adults in poor health are starting to reach the point — if they are not there already — of becoming seriously disabled. In many cases, these aging adults have a “biological” age that is older than their chronological age.  Counselors should be cognizant of these differences and watch for the depression and anxiety that often accompany a loss of ability.

One common issue is aging adults who take numerous medications and are confused about when and how to take them.

Much of the time, elders are concerned about losing their independence and autonomy. With motivational interviewing techniques, the seniors often open up about these fears and process them.

 All aging adults should seek connection with others, but it is especially important for clients from marginalized populations to solidify or build networks with their extended families, close friends, community organizations, or faith-based institutions so they will have supports in place to help them face later-life difficulties.

Narrative approaches to counseling center people as experts in their own lives and view problems as separate from people.  This technique assumes that people have many skills, competencies, beliefs, values, commitments, and abilities that will help them reduce the influence of problems in their lives. ‘Narrative’ refers to the emphasis placed upon the stories of people’s lives and the differences that can be made by re-authoring these stories in collaboration with a counselor.

Many people, aging adults, in particular, are more likely to be open to discussing their lives if the term narrative is used rather than counseling or therapy. We all have a desire to make sense of our lives, and with older adults or others facing mortality, this means integrating the different parts of our life. 

Simply having someone listen to the older adult’s story can be a kind of therapy in and of itself.

It’s hard to overestimate the difference that listening and understanding can make.  

 

Sexual Orientation

Mental health and behavioral health professionals need strategies that promote patient-centered, culturally competent counseling when treating homosexual men, lesbian women, bisexual persons, transgendered individuals, and those questioning their sexual identity.

There have been prevalent negative social attitudes toward sexual minorities. These negative attitudes have been frequently referred to as “homophobia.” The term was coined in 1967 and defined very specifically as “the dread of being in close quarters with homosexuals…the revulsion toward homosexuals and often the desire to inflict punishment as retribution”. Some in the general population believe that the word “homophobia” always includes a component of violence. The condition was classified as a phobia and operationalized as a prejudice. The phobia manifests as antagonism directed toward a particular group of people, leading to disdain and mistreatment of them.  Additional examples of homophobia include when individuals feel: anxious and afraid, thinking that they may be perceived as gay or lesbian by others; anxious or repulsed when they find themselves attracted to a person of their own sex, or fearful that they have homosexual or bisexual tendencies.

Many similarities exist between the LGBTQIA population and the general population related to health and safety concerns. For example, all individuals of any age should feel safe, which is a foundational need. Yet, differences between the populations do exist.

  • Nearly 75% of LGBT students reported that they had been verbally harassed (called names or threatened) because of their sexual orientation.
  • More than 25% of LGBT students reported that they had been physically harassed (pushed or shoved) because of their sexual orientation.
  • Approximately 50% of LGBT students reported that they had been electronically harassed (texts or Facebook postings) because of their sexual orientation.

The American Academy of Child and Adolescent Psychiatry recommends that clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk, including bullying, substance abuse, and suicide.

LGBTQIA may employ many coping strategies in an attempt to understand themselves and their place in society. Some may withdraw physically and emotionally, perhaps in an effort to avoid discovery. Others may turn to substance use or develop eating disorders.

The distress caused by marginalization experiences, stigma, prejudice, discrimination, and internalized homophobia is a consistent theme. Research has suggested that most gay men and lesbians adopt negative attitudes toward their homosexuality early in their developmental histories. The coming-out process has been identified as a source of chronic stress, resulting in psychogenic suppression of the immune response for the LGBTQIA individual. Internalized homophobia has also been associated with high-risk sexual behaviors, such as practicing unsafe sex.

Prejudice and fear of discrimination have resulted in difficulty accessing or avoidance in seeking health care, including mental health services.

The LGBTQIA population may be at increased risk for mental distress, mental disorders, substance abuse, and suicide because of their exposure to stressors related to society’s antigay attitudes. Studies examining the prevalence rates for suicide ideation have shown that the rates are elevated among gay and bisexual men and lesbians, particularly those who grow up in religious households.

Clinical studies have indicated that sexual orientation may be a significant predictor of eating disorders.

Support systems and networks are known to be important to one’s mental health maintenance. While social institutions, such as a church, family, and the legal system, are generally thought to be less supportive of GSM individuals than they are of heterosexual individuals.

Some studies have suggested that substance use rates for gay and lesbian individuals have been reported as high as 20% to 30%, compared to a rate of 10% among the general public. 

The pressure of coming of age in a society that says that LGBTQIA individuals should not exist or act on their feelings contributes to the use of alcohol and drugs.

Tobacco use among sexual minorities may be higher than in the general population, resulting in an increased rate of tobacco-related health problems.

Only when the healthcare professional remains sensitive and aware can culturally competent care be provided for the LGBTQIA individual. LGBTQIA patients’ concerns about sexual identity or sexual orientation may exist or be deeply denied. Healthcare professionals are seeing LGBTQIA individuals of all ages but may not know who these patients are unless the patient realizes his or her sexual identity and is comfortable enough to disclose it. In many health interactions, it is not necessary for the healthcare professional to know who is gay or questioning, but a comfortable setting should be created in which individuals may seek support and help for their concerns.

Professionals can utilize a variety of strategies to promote sensitivity, awareness, and knowledge of the LGBTQIA population. Four communication skill areas may provide a framework for strategies that the healthcare professional can use to be more culturally competent when interacting with the LGBTQIA subculture. The skill areas are:

  • Be able to explain a problem or issue from another person’s perspective.
  • Know what causes the other person to become defensive and resistant.
  • Take actions to reduce defensiveness and resistance.
  • Know recovery skills to use when communication errors occur.

The use of these skill areas may serve as a bridge to meeting professional and legal responsibilities when interacting with the LGBTQIA subculture.

Learning communication recovery skills will help the healthcare professional accomplish more positive outcomes when providing healthcare or health consultation. Recovery skills include apologizing for an error, focusing on another health need until rapport is re-established.

The GSM population is a diverse subculture, representing men and women of all ages and all socioeconomic, ethnic, educational, and religious backgrounds that professionals need to be prepared to provide competent services for.

Disabled

Counselors may find it beneficial to examine their own beliefs and expectations about disability, disability types, and anticipated outcomes when working with this population. 

Providing competent care includes:

  • using proper language to describe the person and the disability
  • identifying personal and societal barriers encountered by individuals with disabilities
  • devising a theoretical framework from which to understand adjustment to disability
  • learning counseling techniques to enhance therapeutic effectiveness
  • being mindful of general counseling tips when working with persons with disabilities.

Language, regardless of intent, is very powerful.  Of particular importance is the awareness and consideration of terminology used to describe and refer to traditionally-marginalized groups, including persons with disabilities. Outdated or inaccurate words can encourage and promote, even if unintentional, poor and negative perceptions and feelings about persons with disabilities, some of which include the words “invalid, suffering, afflicted, victim, handicapped, crippled, and wheelchair-bound.  Furthermore, language and repeated use of negative and disempowering words can influence the ways people view themselves, particularly when such experiences are internalized. The language chosen by others may be affected by how they view themselves and their experience of disability.

Counselors that work with individuals with disabilities and/or their families should be aware of the impact of historical and societal perceptions toward disability and how that affects societal beliefs. In addition, counselors have a professional responsibility to be cognizant of their own word choice and use of terms when referring to persons with disabilities and their potential impact. More specifically, they need to be mindful of whether they view the person as an individual who has the same rights, needs, and desires as anyone else or if they perceive him as incapable, weak, less than, suffering, pitiful, handicapped, or physically/mentally challenged and so forth. 

Counselors are encouraged to learn more about appropriate terminology, including the use of “person-first” language. Although this is not a perfect system, it represents where the profession is at the moment. In most instances, persons with disabilities may be referred to as just that or as “individuals with disabilities.”   

Counselors can enhance their understanding and knowledge of issues relevant to the needs of persons with disabilities and their families by learning about the various forms of personal and societal barriers they often encounter. Of particular importance is for counselors to collaborate with their clients to:

  • identify which barriers are most salient
  • examine the ways the identified barriers inhibit their functioning or prevent them from coping more positively
  • explore which ones are within their control to change
  • determine strategies they can use to cope with and move past them.

This process is not always easy, nor is it particularly linear, and may require some time and effort to resolve. Throughout this process, counselors who do not regularly work with individuals with disabilities first need to become aware of the fact that such barriers are a reality, even if they cannot visually see or understand them. Common barriers referred to through personal accounts and the rehabilitation literature stress the fact that many individuals, regardless of disability type, face attitudinal, architectural, environmental, medical, employment, access, and personal barriers.

Counselors can help individuals uncover the barriers of the way impact their life and determine which ones they can change. Such a process requires counselors to work collaboratively with their clients to differentiate between self-imposed versus other imposed barriers. Self-imposed barriers refer to those experienced by individuals with disabilities, partly in effect, because they are thinking or behaving in ways that contribute to their existence. For instance, individuals may have been told they are not capable of something and start to believe it. As a result, they feel disempowered, become consumed with negative feelings such as apathy or withdrawal, and end up feeling victimized. As a result, they do not behave in ways to help themselves address or move past these negative messages. Other-imposed barriers refer to those created or placed upon individuals with disabilities by other people, agencies, entities, or society. Examples of other-imposed barriers include:

  • negative societal barriers
  • employers’ resistance to hiring individuals with disabilities
  • lack of access to public buildings due to non-accessible architectural structures.

In many instances, reported barriers represent a composite of self-and other-imposed barriers. More specifically, these are those times when someone else imposes a barrier, initially, and this obstacle is further impacted by the practice and implementation of a personally self-imposed barrier. When this occurs, counselors can help individuals determine their part in the issue and select strategies to better cope with the presented barrier.

Counselors who counsel individuals are encouraged to understand the meaning of adjustment, factors that may influence its development and occurrence, and theoretical models of adjustment to disability to provide context to the experience of coping with disability. The process of learning such knowledge and effectively integrating it requires effort on the counselor’s part, especially given that most counseling and psychology programs do not offer extensive training in such areas. Nonetheless, understanding adjustment to disability and theoretical models that help explain the adjustment and adaptation process is very useful. Understanding Adjustment to Disability Adjustment to disability is a phrase used to describe the way individuals are coping and functioning while living with a disability. More specifically, it may refer to the thoughts, feelings, and behaviors of individuals who are trying to reach a place of acceptance and personal integration of the disability into their self-concept. Oftentimes, adjustment to disability is conceptualized as the final phase of accepting one’s disability and moving forward with one’s life. Other times, it is interchanged with the phrase adaptation to disability, although the latter typically deals more with the process that occurs gradually and continually in an effort for individuals to achieve an optimal state of being or personal and environmental. Of most relevance to counselors is the understanding that adjustment to disability takes time and usually involves some sort of adaptation process, which hopefully leads to better functioning and outcomes for individuals with disabilities. Factors Influencing Adjustment to Disability Factors known to influence adjustment to disability are many and are used by counseling professionals to better understand the probability of successful versus unsuccessful adjustment. Those factors that are most salient to each individual may vary; however, counselors need to be cognizant of what they might be. Some of the factors associated with adjustment to disability include:

  • depression
  • locus of control
  • spirituality
  • self-blame
  • unresolved feelings for cause of disability
  • negative feelings and emotional distress
  • self-esteem
  • coping strategies
  • social support
  • gender
  • age of onset
  • familial support
  • socioeconomic status
  • financial health
  • level of education and employment
  • societal attitudes

Other factors include the meaning one ascribes to the disability, the severity of the disability, visibility versus invisibility of the disability, and the amount of stigma experienced and associated with the disability. The adjustment to the disability process is believed to be affected by an individual’s ability to:

  • enlarge or alter one’s personal values following disability
  • live a life that is not dictated by the disability
  • focus on one’s strengths and values rather than comparing oneself to others
  • live in a way that does not focus entirely on one’s physical or personal appearance.

Counseling professionals should understand that some people experience a sense of loss following their disability; thus, they may desire to make sense of it or find meaning. Individuals must learn to view themselves as the whole person with many attributes and abilities for successful adjustment.

Counseling techniques generally focus on changing a person’s thoughts, feelings, and behaviors in relation to themselves, others, or God. Approaches highlight reducing negative thoughts and emotions (i.e., forgiveness, self-compassion) as an essential skill for living well with a disability (i.e., resiliency, self-advocacy, self-concept). Forgiveness, self-compassion, and resiliency are three constructs that have been empirically studied in work with those with disabilities. More specifically, forgiveness and self-compassion have been shown to reduce negative emotions and improve overall functioning and well-being. Both constructs and approaches have much relevance to persons with disabilities lives due to the magnitude of negative experiences and treatment faced by persons with disabilities. Resiliency is an identified skill that has been found to have much relevance to the needs and issues of persons with disabilities and may be taught to enhance functioning.

Counselors may also use techniques pertaining to dealing with difficult emotions, redefining self-concept and self-identity, learning how to self-advocate, and integrating the skills learned to become more empowered. Counselors who are mindful of the following tips will increase their chances of developing an effective therapeutic relationship and understanding of persons with disabilities. Many of the tips are simply based on common sense and related to the art of treating persons with disabilities with respect and as human beings the same as anyone else. Some of the counseling tips she stressed include:

  • being mindful that the expressed negative experiences related to disability are real
  • considering the effects that labels may have on your clients
  • treating persons with disabilities as human beings rather than as their disability
  • building awareness of your own attitudes and biases which may affect the counseling relationship
  • being aware of how persons with disabilities describe themselves;
  • respecting the fact, that persons with disabilities know their own bodies and experiences
  • getting the necessary training and supervision needed to effectively counsel persons with disabilities
  • paying attention to the abilities and strengths of persons with disabilities and incorporating them into the counseling relationship
  • recognizing that most persons with disabilities do not live their life “focusing” on their disability and limitations
  • identifying counseling topics that make you uncomfortable (i.e., sexuality and disability) so you can address these
  • being willing to have an open mind to the shared experiences within the counseling relationship

Disability is an experience typically misunderstood by many, including counselors and professionals who don’t work much with this population. Counselors who employ this information and these recommendations as a part of their therapeutic relationships open themselves up to the possibility of learning about the experience and “voice” of disability. Such efforts have the potential to benefit persons with disabilities, the counseling profession, and the therapeutic relationship.

Research indicates that clients who feel disconnected from the clinician due to cultural, ethnic, or even religious differences are more likely to terminate treatment as early as the first session.  Counselors need to continually improve their approach and knowledge base in order to better serve special populations.

Although it is of critical importance that we as helping professionals develop better skills to address various cultures, It should be noted that many ethnic group members, and other special populations, often demonstrate remarkable strengths despite many obstacles and hardships.  In some cases, powerful religious beliefs help sustain members through difficult situations.  Although family relationships and values may be different, supportive bonds may be formed through extended family members (may include non-related individuals) that are not typically found in the mainstream culture.

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