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Cultural Sensitivity Back to Course Index

 

 

 

 

Introduction

 Historical documents often refer to the United States as the great cultural experiment or a melting pot as diverse peoples are molded and shaped into the American Way of Life.  This undertaking has yielded various shades of success as new citizens adapt to a common language, habits, and values.  The final outcome of the great culture experiment will be determined over the next several generations.  A common view hs4is that we, the people, have made a lot of progress toward accepting people based on their individual merits, but we have a long way to go to overcome all of the cultural barriers.   Recent trends appear to be toward cultural pluralism and diversity 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, there are other conflicts between ethnic and cultural groups, and there is inequality in the social and economic resources available to different groups.  There are also different general acceptances, power, and prestige issues between ethnic and cultural groups, as well as differences with the majority cultures.   These have a significant impact on minority persons who may also have a social or community need.  It is often difficult to separate socioeconomic, ethnic, gender, age, and other variables that influence the behavior and attitude of members of these sub-populations.   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 migratory lifestyles and loss of identity.  They are generally omitted from surveys because they are not living in typical homes, are not attending school, and 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.

The United States remains a nation in which ethnic minorities and other disadvantaged groups (elderly, females, etc.) are often subjected to prejudicial treatment, as well as having to continuously deal with negative life experiences, including language, religion, family relationships, value system, and community norms.  Minority groups and other special subpopulations are disproportionately represented among the economically disadvantaged.  They are more likely to live in urban centers that have higher crime rates, poorer schools, substandard housing, and fewer employment opportunities.  

imgres-1 Ethnic populations are set apart from the mainstream culture by differences in language (whether a foreign language or an English dialect) and create communication difficulties.  The language barrier (includes reading, writing, and verbalizing) increases stress, interferes with psychosocial functioning, and increases the difficulty associated with getting the help they need to successfully integrate themselves into the mainstream of society.   Consequently, additional services are often needed to overcome previous deficiencies and also to accelerate the interventions needed for complex social problems.

 

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.

 

 

The Melting Pot   images-9

 

The Statue of Liberty is the symbol of freedom that greeted Europeans that enter the US at Ellis Island.  The Golden Gate Bridge served the same purpose for Chinese and other Asians who arrived at San Francisco.   The number of Asian immigrants arriving in the US during the 19th Century was significantly lower than immigrants from other parts of the world.  However, thousands did migrate due to political oppression and to take advantage of the economic opportunities that existed in the US.   The following are some of the major immigration movements to the US:

 

Japanese

Over 25,000 Japanese (the vast majority were farmers and farm laborers) immigrated to Hawaii during the late 1800s due to large-scale unemployment, bankruptcies, and other civil discord in their homeland.   Also, there was a concurrent boom in the Hawaiian sugar industry that created a need for additional farm workers.  Most Japanese immigrants choose to remain in Hawaii because race relations were better there than in the mainland US. Initially, the Japanese gained acceptance into society by working as agricultural laborers for lower wages.  The natural process of acculturation was interrupted on December 9, 1941, when the Japanese attacked Pearl Harbor. 

Post World War II Japanese immigration is a different story.  The so-called second generation of Japanese Americans has gained acceptance in all professions at an accelerated rate.   With increased education (or a higher focus on education), the Japanese sought lucrative professions. Consequently, by the 1990s, the Japanese had surpassed the national average per-family income by over 30%.  This economic progress resulted in more acculturation and social acceptance.  For example, by this time frame, a majority of Japanese Americans spoke English exclusively.

An interesting observation can be made from the Japanese immigration experience.  It appears that their willingness to work and their taking advantage of educational opportunities resulted in rapid improvement in their economic condition and an increase in their social acceptance into the mainstream of society. 

 

Chinese

Chinese immigrated to the US during the 18th Century.  The Chinese populations in the US dropped to approximately 60,000 in 1920, due to the Chinese Exclusion Act and other factors.  However, the Chinese are the largest Asian population in the US today.

Merchants and skilled laborers were generally accepted into society.  However, subsequent groups of unskilled workers encountered negative and hostile attitudes toward them.  These Chinese tended to live in large cities and formed ethnic enclaves called Chinatowns.  The general trends in these enclaves were to restore the social norms of their homeland and to somewhat resist integration into the mainstream culture.

As time passed, the cultural division between the Chinese and the Americans diminished.  Chinatowns become a quiet, colorful tourist, attraction and China was an ally of the US during WWII.   This and other factors led to the repeal of the Chinese Exclusion Act.  Consequently, immigration from China resumed.

  

Irish

Approximately 1.5 million immigrated to the US during the mid-1800s to escape a serious potato famine.   Most settled in the Northeast and have made a successful transition into the US culture.

  

Germans

Approximately 4 million immigrated to the US during the mid-1800s in order to escape economic depression and political unrest.  German immigrates have demonstrated a high degree of acculturation into the American way of life.

  

Danes, Norwegians, and Swedes

Approximately 1.5 million immigrated to the US during the late 1800s to escape poverty.  The acculturation experiences have been similar to the Germans.

 

Poles

Approximately 1 million immigrated to the US during the late 1800s and early 1900s to escape poverty, disease, and political repression in their homeland.

 

Jewish

Approximately 2.5 million immigrated to the US in the late 1800s and early 1900s to escape religious persecution.   The Jewish people encountered religious persecution in the US but were able to survive their difficulties and become accepted into the mainstream of American society.  Jewish immigration has continued throughout the last 200 years, with a corresponding increase in their acceptance throughout society.

  

Austrians (Czechs, Hungarians, and Slovaks)

Approximately 4 million immigrated to the US during the late 1800s and early 1900s to escape poverty and overpopulation.

  

Italians

Approximately 4.5 million immigrated to the US in the late 1800s and early 1900s to escape poverty and overpopulation.  They have been very successful in adapting to the American way of life.

  

Mexicans

Approximately 700,000 immigrated to the US in the early 1900s to escape the Mexican Revolution of 1910, as well as the difficult social and economic conditions in Mexico at that time.   Also, approximately 2 million Mexicans immigrated to the US in the mid-1990s to escape unemployment and poverty.

  

Cubans

Approximately 700,000 immigrated to the US in the late 1900s to escape the communist takeover.

 

Dominicans, Haitians, Jamaicans

Approximately 1 million immigrated to the US in the late 1900s to escape poverty and unemployment.

  

Vietnamese

Approximately million immigrated to the US in the late 1900s to escape the Vietnam War.  They have proven to be very adept at conforming to the new experience of living and working in the US.

  

Africans

Africans were brought to this country against their will during the early history of America.  Given these circumstances, they have done an excellent job coping with the socioeconomic issues they have faced.   They have transformed the difficulties and accepted (and have been accepted by) the American way of life.

Although only some of the major immigrations have been addressed, the reader can get a sense of the rich cultural and social diversity that went into building the American melting pot.  It is important to recognize that every culture has strengths and weaknesses, and generally, the composite is made stronger by the interaction of all of the individuals. 

 We tend to fall into the mindset that cultural diversity means respecting the differences of other people from different nations or of different colors of skin.  Differences can also present just from upbringing, belief systems such as moral, religious, political beliefs, and so forth.  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.

 

 

Race/Ethnicity And Other Social/Health Problems 

In the US, there are four major minority racial, ethnic groups:images-3

  •           African Americans
  •           Hispanic Americans
  •           Asian Americans/Pacific Islanders
  •           American Indians/Alaska Natives

 

These four groups make up approximately one-quarter of the total US population.  They also constitute the fastest-growing segment of the population. Consequently, the need to understand the socio-cultural factors affecting these racial and ethnic groups is crucial for the provision of adequate social services. 

The US Bureau of Census revealed that African Americans constitute approximately 13.2% of the population, followed by Hispanic Americans (17.4%), Mixed (2.5%), Asian Americans, and Pacific Islanders (5.4%).  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 the minority groups and the 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 lack of education or vocational training and the resulting limited access to employment.

 

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, and substance abuse treatment, or they 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 imgresservices.  Racial/ethnic populations are not only more likely to have lower incomes than those of the mainstream population but to be 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 are not able to 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, counseling may invoke fear of losing status and of being judged a failure by the family and the community, and, thereby, contribute 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 are unable to provide appropriate referrals to social services or to 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 ocd4rganization is evident when the program design is oblivious to the racial, cultural, or ethnic backgrounds, values, and mores of its client population.    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.

 

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.  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 to develop trust, as well as an understanding of the way 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 an appreciation of cultural differences and similarities within, 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 the willingness of professionals 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.  Consequently, within a culturally competent framework, knowledge of cultural beliefs and expectations are necessary for effective communication.

The conceptualization of a continuum of cultural competence was developed by Georgetown University in 1989.  It can be used to assess the level of cultural competence.  It includes:   

 CULTURAL DESTRUCTIVENESS:  Attitudes, policies, and practices that are destructive to other cultures.

CULTURAL INCAPACITY:  Lacks the capacity to help, but is not intentionally destructive.

CULTURAL BLINDNESS:  Attempts to treat all people as though they are alike.  It infers that one’s color or culture does not matter.  Services are so culturally neutral; they are not relevant to anyone.

CULTURAL PRE-COMPETENCE:  Individuals or agencies realize they have weaknesses in their cultural competence and attempts to improve.  The risk at this stage is that token change may be accepted as sufficient.

CULTURAL COMPETENCE:  Others are accepted and respected for their differences, and cultural knowledge is continually expanded.  In program settings, staff who are committed to their particular culture are hired; staff is encouraged to become comfortable working in cross-cultural situations.

CULTURAL PROFICIENCY:  Different cultures are held in high esteem: agencies and staff advocate and work to improve relationships among cultures throughout society.

The melting pot continues to blend people from all cultures into one person.  I think the great American experiment has proven successful, as we have adopted the strengths of each culture into the mainstream culture.  Again, we have made a lot of progress, but there remains a lot of work to be done.

 

 

LANGUAGE CONSIDERATIONS

imagesOne of the greatest barriers to the acculturation of racial/ethnic groups into the American way of life is language.  Most early immigrants that came to the US did not speak, read, write, or understand spoken English.  Fortunately, 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.  The following paragraphs will introduce the reader to the general language problem:

19.2 million Americans are classified as Limited English Proficient.  An increase of approximately 48% from the 1990 Census. 

Due to these factors and other considerations, OSHA requires that employers establish effective communication with non-English speaking workers. Again, some progress is being made, but there is a long way to go.  One way an employer can bridge the gap is to recognize the need for language interpreting and translation services.  Employers may also hire and train bi-lingual staff and translate safety-sensitive documents into native languages. The employer may also provide cultural diversity training for all staff.

 

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 serve to enrich the relationship between the client and therapist and may help to 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 and 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 a young adult with 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. This age group, in particular, 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 for 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 be facing caregiving issues or having 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 we can 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 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 assist them in reducing the influence of problems in their lives. ‘Narrative’ refers to the emphasis that is placed upon the stories of people’s lives and the differences that can be made through 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 the experiences of marginalization, 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 as well as among lesbians, and 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 the 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 assist individuals in uncovering the barriers of the way impact their life and in determining 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 to 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 assist individuals in determining their part in the issue and in selecting strategies to cope with the presented barrier better.

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 being able to effectively integrate it requires effort on the counselor’s part, especially given the fact 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 in 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 disability. 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 have a desire to make sense of it or to find meaning. Individuals must learn to view themselves as a whole person who has many attributes and abilities for successful adjustment to occur.

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 the lives of persons with disabilities due to the magnitude of negative experiences and treatment faced by persons with disabilities. Resiliency is an identified skill which 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, the 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 which 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.

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