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. Different is not wrong. Different should be understood and respected. 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.
Ethnicity and Minorities
Evidence has shown that our current forms of mental health treatment have been especially inadequate for ethnic minority populations, and culturally competent finding interventions have 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.
Outcomes for ethnic minority groups are enhanced by the provision of culturally competent. Cultural competency has been categorized into three basic characteristics of mental health providers, namely:
- Cultural awareness and beliefs. A culturally competent counselor or provider is sensitive to her/his values and biases and how these may affect perceptions of the client, the client’s problem, and the counseling relationship.
- Cultural knowledge. The counselor has knowledge of the client’s culture and expectations for the counseling relationship.
- Cultural skills. The counselor can intervene in a manner that is culturally appropriate and relevant.
In his edited volume, Mindfulness and Acceptance in Multicultural Competency, editor Akihiko Masuda, Ph.D., asserts that the acceptance and mindfulness models may provide a promising method for promoting cultural competency and addressing social issues. To enhance the potential gains that emerge from acceptance and mindfulness models, Masuda suggests that common pitfalls associated with research and practice in psychology in general and mental health, in particular, must be addressed.
Problems occur when theories are assumed to be universally true when their validity is confined to one culture or population. 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.
Culturally sensitive therapy emphasizes the therapist’s understanding of a client’s background, ethnicity, and belief system. 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 cultural competence, which is 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 a culture that is different from one’s own. 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 with clients from diverse backgrounds.
Advocates for cultural sensitivity believe that it is more effective to vary the therapeutic approach from person to person, depending on a client’s culture group than to simply use the same standard treatment approach for everyone. 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.
As mentioned, unfortunately, children and families of diverse ethnic, racial, cultural, and socioeconomic backgrounds have been historically underrepresented in studies that look at therapy effectiveness. There is much debate about whether interventions that are found to be effective for Caucasian children can be as beneficial for their minority peers, who are frequently assumed to have different needs and responses to treatment.
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 take 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.
Let’s explore some special populations and what to consider.
A strong therapeutic bond is imperative to achieve a successful outcome in psychotherapy. This bond must begin with the initial session. Clients are more likely to terminate treatment as early as the first session when they do not feel the counselor can connect with or understand them.
To understand what factors influence this dynamic, Daniel C. Rosen of the Counseling and Health Psychology Department at Bastyr University led a study examining race/ethnicity and age among a mixed sample of clients and therapists. He focused his research on complementarity, the level of relational harmony, between the client and therapist, to determine which factors were most significantly related to developing a strong therapeutic bond upon intake.
Although he found that ethnicity affected the counseling relationship, he discovered that age impacted complementarity significantly more 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 because 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, 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.
According to Stanford University’s Center on Longevity, during the next 30 years, the U.S. population of those 65 and older will double from 40 million to 80 million. By the time the last baby boomer turns 65 in 2029, one in five Americans will be 65 or older. By 2032, there will be more people 65 and older than the total number of children under the age of 15.
These numbers are more than just statistics; they represent actual people who will be going through major life changes. These potential transitions and challenges could include a second career (whether by choice or out of necessity), the need to give care or be cared for, reduced income, personal loss, physical illness or pain, depression or other mental illness, cognitive decline, terminal disease, facing one’s mortality and confronting ageism.
It is not hard to connect the dots then that as the aging population increases, so does the need for counselors who can help clients with these transitions. “Professional counseling is focused on healthy development over the life span,” says Suzanne Degges-White, president of the Association for Adult Development and Aging (AADA), a division of the American Counseling Association. “This includes working with older adults as they move through both the normal transitions in life and with unexpected difficulties. As adults move into each new developmental stage — and development doesn’t just stop at 18 — they may experience a need for support, guidance, and normalization of the emotional responses to each stage. Personal and professional transitions are important at any age.”
Despite the demonstrable need for help throughout this transitional period, many counselors do not focus on engaging with this population.
However, counselors should be aware that working with aging adults is not all doom and gloom. Surveys and research have found that life satisfaction and happiness increase for many people as they approach their 60s. Older adults also possess more life experience and, in many instances, have accumulated more wisdom and confidence that contribute to greater overall well-being.
When considering aging adults, counselors need to remember that they are not one homogeneous population, says Christine Moll, an ACA member, and professor of counselor education at Canisius University in Buffalo, N.Y. “There are several generations. We have the boomers, the youngest of whom just turned 50 and the oldest are 68 or 69, and then we have Depression-era and World War II babies, people over 69 and up to 100,” she says. “It’s probably the widest range within the life span of development. We’ve got 40-plus years of people that we call ‘older adults.'”
What do I do with the rest of my life?
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 can 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 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 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 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 clients from marginalized populations need 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 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.
Mental health and behavioral health professionals need strategies that promote patient-centered, culturally competent counseling when treating homosexual men, lesbian, bisexual persons, transgendered individuals, and those questioning their sexual identity.
Clear definitions of the concepts related to sexual identity can be helpful. The following is a glossary of terms used throughout this section:
Asexual: An individual who does not experience sexual attraction. There is considerable diversity in individuals’ desire (or lack thereof) for romantic or other relationships.
Bisexual: An adjective that refers to people who relate sexually and affectionately to both women and men.
Cisgender: a gender identity or performance in a gender role that society deems to match the person’s assigned sex at birth. The prefix cis- means “on this side of” or “not across.” A term used to highlight the privilege of people who are not transgender.
Coming-out process: A process by which an individual, in the face of societal stigma, moves from denial to acknowledging his/her sexual orientation. Successful resolution leads to self-acceptance. Coming out is a lifelong process for lesbian, gay, bisexual, and transgender persons and their families and friends as they begin to tell others at work, in school, at church, and in their communities.
Cross Dresser (CD): A word to describe a person who dresses, at least partially, as a member of a gender other than their assigned sex, and carries no implications of sexual orientation. Has replaced “Transvestite.”
Demisexual: Demisexuality is a sexual orientation in which someone feels sexual attraction only to people with whom they have an emotional bond. Most demisexuals feel sexual attraction rarely compared to the general population, and some have little to no interest in sexual activity. Demisexuals are considered to be on the asexual spectrum.
Gay: The umbrella term for persons who are attracted to the same gender. Although it most specifically refers to men who are attracted to and love men. It is equally acceptable and more accurate to refer to gay women as “lesbians.”
Gender and sexual minorities (GSM): A term meant to encompass lesbian, gay, bisexual, trans, queer/questioning, intersex/intergender, asexual/ally (LGBTQIA) people as well as less well-recognized groups, including aromantic, two-spirited, and gender-fluid persons.
Heterosexism: An institutional and societal reinforcement of heterosexuality as the privileged and powerful norm.
Heterosexuality: Erotic feelings, attitudes, values, attraction, arousal, and/or physical contact with partners of the opposite gender.
Homophobia: A negative attitude or fear of homosexuality or GSM individuals. This may be internalized in the form of negative feelings toward oneself and self-hatred. Called “internalized homophobia,” it may be manifested by fear of discovery, denial, or discomfort with being homosexual, low self-esteem, aggression against other lesbians and gay men, or exaggerated gay pride and rejection of all heterosexuals.
Homosexuality: The “persistent sexual and emotional attraction to members of one’s gender” as part of the continuum of sexual expression.
Intersex is a general term used for a variety of conditions in which a person is born with reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male. For example, a person might be born appearing to be female on the outside, but having mostly male-typical anatomy on the inside.
LGBTQIA: An acronym used to refer to the lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex/intergender, and asexual/ally community. In some cases, the acronym may be shortened for ease of use or lengthened for inclusivity. Members of this group may also be referred to as gender and sexual minorities (GSM).
Pansexual, Omnisexual: Terms used to describe people who have romantic, sexual, or affectional desires for people of all genders and sexes. It has some overlap with bisexuality and polysexuality (not to be confused with polyamory).
Polyamory: Denotes consensually being in/open to multiple loving relationships at the same time. Some polyamorists (polyamorous people) consider “polyam” to be a relationship orientation. It is sometimes used as an umbrella term for all forms of ethical, consensual, and loving non-monogamy.
Queer: One definition of queer is abnormal or strange. Historically, queer has been used as an epithet/slur against people whose gender, gender expression, and/or sexuality do not conform to dominant expectations. Some people have reclaimed the word queer and self-identify in opposition to assimilation (adapted from “Queering the Field”). For some, this reclamation is a celebration of not fitting into social norms. Not all people who identify as LGBTQIA use “queer” to describe themselves. The term is often considered hateful when used by those who do not identify as LGBTQIA.
Sexual identity: The inner sense of oneself as a sexual being, including how one identifies in terms of gender and sexual orientation.
Sexual minority youth: Sexual minority youth are those who self-identify with any non-heterosexual orientation or whose gender experience runs contrary to norms. The term is often used to refer to lesbian, gay, bisexual, and transgender youth.
Sexual orientation: An enduring emotional, romantic, sexual, and/or affectionate attraction to another person. Individuals may experience this attraction to someone of the same gender, the opposite gender, or both genders.
Transgender: An umbrella term describing several distinct gender positions and identities, including transsexual, transgender, androgyne, and the states of cross-gender, cross-living, and cross-dressing. Transgender individuals see themselves partly or fully as the gender opposite their sex at birth.
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 sex, or fearful that they have homosexual or bisexual tendencies.
Many LGBTQIA youth become aware that they are experiencing sexual thoughts and feelings different from those of their peers at a time when they are trying to master the developmental tasks of adolescence, including the achievement of identity, self-esteem, and social skills. While gay adolescents must go through the same developmental tasks as heterosexual adolescents, GSM youth have additional identity development factors to incorporate into their self-concept. For example, they are forced to learn to manage a stigmatized identity often without active support and modeling from their parents and family. Thus, a GSM youth is trying to manage at least two tasks simultaneously: human maturation and establishment of self-identity as a sexual minority youth. A GSM youth from a racial minority is working concurrently on a third task related to developing personal identity, that of incorporating a racial identity into the personal identity.
Little research has examined the influence that ethnicity has on sexual identity development. Because the social category of ethnicity includes a complex interaction of factors, such as culture, religion, family, country of origin, and social experience, researchers have found it difficult to identify which of these factors is responsible for the observed differences being studied. To begin to identify general ethnic group differences and to create a foundation for the research of the factors that influence ethnic and sexual minority development, some researchers have begun exploring the aspects of sexual identity development among male youths. They have found that Latino youth may report the earliest awareness of same-sex attractions because of the role that masculinity plays in their culture. For these youth, as well as for African American and Asian American youths, the process of developing one’s sexual identity cannot be well understood through the application of the traditional models discussed earlier. This is because these models suggest a uniform timing and sequencing of “coming out” events that have not been demonstrated in these minority youth populations.
Unique Health and Safety Concerns
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 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 of 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 of seeking health care, including mental health services.
The Joint Commission has defined “family” as “the person(s) who plays a significant role in the individual’s (patient’s) life. This may include a person(s) not legally related to the individual”. The AMA also supports equality in health care for partners and the legal recognition of domestic partners.
In 2010, the U.S. Department of Health and Human Services adopted a rule that requires “any hospital receiving Medicare or Medicaid funds to have written visitation policies that prohibit discrimination based on sexual orientation and gender identity.” The rule also stipulates that a patient must be informed of their right to visitation by anyone they wish, including (but not limited to) a friend, a domestic partner (including a same-sex domestic partner), a spouse (including a same-sex spouse), or any member of their family.
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, 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 the church, families, 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, the healthcare professional doesn’t need 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.
The first cross-cultural communication skill is to be able to articulate and present a problem or issue as it is seen from another’s perspective. To do this, the professional must learn about the culture in question. Understand the terms they use to describe and define themselves.
The second cross-cultural communication skill area involves recognizing defensiveness and resistance and knowing its cause. Problem behaviors arise when the healthcare professional begins to impose personal values on others. Assuming that everyone is heterosexual and demonstrating a lack of knowledge about the health-damaging effects of stigma on the LGBTQIA population are two behaviors that may create defensiveness or resistance. Other problem behaviors involve making hostile or discriminatory statements, using slang, and telling or laughing at derogatory jokes about the GSM community. Because this active form of collusion furthers stereotypes, the healthcare professional should monitor his or her behavior so that he/she remains sensitive and culturally competent.
Disclosing a patient’s sexual orientation without the patient’s permission should be avoided. Not only might “outing” the patient lead to patient defensiveness but information about a patient’s sexual orientation is protected by the Health Insurance Portability and Accountability Act (HIPAA). In situations when a patient’s disclosure may not remain confidential, some reassurance of respect could be provided if the disclosure was always accompanied by the patient’s consent.
Healthcare professionals should also be knowledgeable about the visitation policies of their healthcare agency. Policies and practices that are inclusive of partners and co-parents are valuable measures that demonstrate cultural competence.
The third cross-cultural communication skill area requires taking action to reduce feelings of defensiveness and resistance in oneself and others. One of the most important activities for the culturally competent healthcare professional is to examine one’s feelings, values, and stereotypes regarding culture and, in this case, regarding human sexuality and homosexuality. Examining one’s attitudes does not mean that the professional is approving or condoning homosexual orientation or homosexual sexual behaviors. The healthcare professional need not change personal beliefs about homosexuality to provide culturally competent care.
The healthcare professional must ask: “Can I recognize behaviors in others that may indicate feelings of defensiveness and resistance?”
Practicing nonjudgmental caring, by developing interviewing skills that employ inclusive terminologies, may also help reduce defensiveness.
The fourth cross-cultural communication skill area requires acknowledging that mistakes will be made. Heterosexual bias is not the fault of the individual healthcare professional, so expect to make honest mistakes.
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, and 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 and professionals need to be prepared to provide competent services.
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 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 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 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 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:
- locus of control
- unresolved feelings for cause of disability
- negative feelings and emotional distress
- coping strategies
- social support
- 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 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 the whole person who has many attributes and abilities for successful adjustment to occur. Disability scholars Livneh and Antonak (1997) developed a stage model to explain the process of adjustment to disability. Their model views adjustment to disability according to eight stages:
- Internalized Anger
- Externalized Anger and Hostility
Collectively, this model proposes that individuals may experience some or most of the first six stages, which comprise negative thoughts and feelings before they reach a stage of acceptance and adjustment. However, they also stress the fact that adaptation may not linearly take place, adjustment phases may be skipped or later revisited, individuals’ reactions will vary from one another, and each phase does not occur according to a pre-determined amount of time. Regardless of the chosen model, counselors need to be aware that one model does not fit all experiences of disability or the needs of all individuals; therefore, the more knowledge counselors have about the adjustment to the disability process, the better equipped they will be to select models they can use to explain the coping process of their clients.
Counseling techniques generally focus on changing a person’s thoughts, feelings, and behaviors about 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 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 about 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 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 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 to better serve special populations.
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