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“A Multicultural Approach to Clinical Supervision”
Continuing Education CoursePresented by Shelly P. Harrell, Ph.D.
January 23, 2014 - CSULB
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SUPERVISION AND TRAINING-Psychotherapy supervision is one of the most fulfilling professional activities
-Contributing to the development of future therapists
-Forming mentoring relationships
-Witnessing professional development
-Sharing your knowledge and experience
-Giving back
-Learning and developing ourselves!
“One who teaches, learns.” –Ethiopian Proverb
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What is our ultimate destination?Effective and ethical mental health service deliveryCulturally-informed evidence based practiceMulticulturally-competent mental health practitioners
How will we get there?Professional Guidelines
Ethical Principles for PsychologistsAPA Benchmarks for Professional PsychologyAPA Multicultural Guidelines
Training and PracticePsychotherapy Supervision ModelsMulticulturally-competent supervision
ImportanceCore Issues and Challenges
What is our navigation system?Culture and context of client, therapist-trainee, and supervisorMulticultural awareness, knowledge, and skills
Multicultural Psychology 101Culturally-adapted, Culturally-centered, and Culturally-Specific Practices
What powers the journey?Diversity Principles: Informed Compassion, Contextualized Understanding, Empowered HumilityCore Guidelines: Compassionate Confrontation and Empathic Exploration
What specific path will we traverse today?Harrell’s Multicultural Narrative Approach
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Professional Standards and Guidelines
Models of Supervision
Understanding Culture
Multicultural Awareness, Knowledge, and Skills and Competency Benchmarks
Introduction to the Multicultural Narratives Approach
Applying the Multicultural Narratives Approach
AGENDA
WHAT IS MULTICULTURAL COMPETENCE
FOR MENTAL HEALTH PRACTITIONERS?
The demonstrated ability to consistently and carefully consider the cultural dimensions of
self, other and context, and to engage in ethical and multiculturally-informed behavior and
interactions through the application of multicultural awareness, knowledge, and skills in multiple professional roles (e.g., assessment, intervention, research, teaching, consultation,
supervision, administration, advocacy, collaboration, etc.).(S.P. Harrell, 1997; revised 2002 & 2006)
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TRAINEE COMPETENCE IS RELATED TO SUPERVISOR COMPETENCE
An important goal for today: Contribute to the development of supervisor
multicultural competence
AWARENESS: Increase awareness of self as a multicultural being
KNOWLEDGE: Increase understanding of the meaning of multicultural competence
SKILL: Learn a new approach for integrating multicultural considerations into supervision
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START HERE
ETHICALPRINCIPLES
AND STANDARDS
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FROM PRINCIPLE A: COMPETENCE
“Psychologists...provide only those services and use only those techniques for which they are qualified by education, training, or experience.”
“Psychologists are cognizant of the fact that the competencies required in serving, teaching, and/or studying groups of people vary with the distinctive characteristics of those groups".
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FROM PRINCIPLE D:RESPECT FOR PEOPLE'S RIGHTS AND DIGNITY
"Psychologists are aware of cultural, individual and role differences, including those due to age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, and socioeconomic status.”
“Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone discriminatory practices."
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ETHICAL STANDARDS
1.04- Boundaries of Competence
1.08- Human Differences1.09- Respecting Others1.10- Nondiscrimination1.11- Sexual Harassment1.12- Other Harassment1.15- Misuse of Psychologists Influence
2.04- Use of Assessment in General with Special Populations
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EVIDENCE-BASED PRACTICEAPA’s Definition of Evidence Based
Practice for Psychologists (EBPP)An integration of…
The Best Available Research Clinical Expertise
In the context of:• Patient Characteristics
• Patient Culture• Patient Preferences
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OPERATIONALIZING AND APPLYING EVIDENCE-BASED PRACTICE
What evidence should be considered? What is meant by “best available”?Frequent blurring of the distinction between evidence-based practice and empirically-supported treatments such that acceptable practices are are sometimes perceived as limited to the existence of ESTs for specific disorders
The foundation of ESTs are the randomized clinical trials (RCTs) conducted with largely homogeneous samples with respect to dimensions of diversity (e.g., ethnicity, acculturation, socioeconomic status, religion, sexual orientation, disability status, etc)
What “evidence” is there that these ESTs are efficacious and effective in particular cultural populations outside of those who participated in the RCTs?
These problems are particularly concerning in regards to the trend towards the generation of lists of evidence-based treatments that are inappropriately imposed upon diverse communities that bear no resemblance to the samples in the RCT studies that established the intervention as “efficacious”
What “evidence” is there for modifying ESTs in culturally diverse settings?
There has been some progress examining the applicability of evidence-based psychological practice with culturally diverse, underserved, and marginalized populations. Need for effectiveness studies!
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APA MULTICULTURAL GUIDELINES
Approved as policy by the APA Council of Representatives in 2002
Emphasizes the importance of multicultural considerations in our work
Professional practiceResearchEducation and TrainingOrganizational Change
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FIRST SENTENCE OF APA MULTICULTURAL GUIDELINES
“All individuals exist in social, political, historical and economic
contexts and psychologists are increasingly called upon to understand
the influence of these contexts on individuals’ behavior.”
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APA POLICY GUIDELINESGuideline #1: Recognize that, as cultural beings, psychologists may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves. Guideline #2: Recognize the importance of multicultural sensitivity/responsiveness, knowledge, and understanding about ethnically and racially different individuals
Guideline #3: Employ the constructs of multiculturalism and diversity in psychological education.
Guideline # 4: Recognize the importance of conducting culture-centered and ethical psychological research among persons from ethnic, linguistic, and racial minority backgrounds. Guideline #5: Strive to apply culturally-appropriate skills in clinical and otherapplied psychological practicesGuideline #6: Use organizational change processes to support culturally informed organizational (policy) development and practices
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GROUNDING PRINCIPLES FOR APA’S MULTICULTURAL GUIDELINES
1. Ethical conduct of psychologists is enhanced by knowledge of differences in beliefs and practices that emerge from socialization through racial and ethnic group affiliation and membership and how those beliefs and practices will necessarily affect the education, training, research and practice of psychology 2. Understanding and recognizing the interface between individuals’ socialization experiences based on ethnic and racial heritage can enhance the quality of education, training, practice, and research in the field of psychology3. Recognition of the ways in which the intersection of racial and ethnic group membership with other dimensions of identity (e.g., gender, age, sexual orientation, disability, religion/spiritual orientation, educational attainment/experiences, and socioeconomic status) enhances the understanding and treatment of all people 4. Knowledge of historically derived approaches that have viewed cultural differences as deficits and have not valued certain social identities helps psychologists to understand the underrepresentation of ethnic minorities in the profession, and affirms and values the role of ethnicity and race in developing personal identity5. Psychologists are uniquely able to promote racial equity and social justice. This is aided by their awareness of their impact on others and the influence of their personal and professional roles in society (Comas-Díaz, 2000).6. Psychologists’ knowledge about the roles of organizations, including employers and professional psychological associations are potential sources of behavioral practices that encourage discourse, education and training, institutional change, and research and policy development, that reflect rather than neglect, cultural differences. Psychologists recognize that organizations can be gatekeepers or agents of the status quo rather than leaders in a changing society with respect to multiculturalism. 16
WALKING THE TALK?
Does what we do in practice match what we say about the importance of multicultural issues?
Belief in importance of multicultural competence outpaces behavior
• McKitrick, D.S., & Li, T.S. (2008). Multicultural treatment. In Handbook of Clinical Psychology, Vol. 1. Adults.
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MULTICULTURAL EDUCATION AND TRAINING
Academic Courses
Diverse Clinical Opportunities
SUPERVISION!!!!!
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IMPORTANCE OF INTEGRATING MULTICULTURAL CONTENT AND PROCESS IN CLINICAL SUPERVISION
Demographic Imperative
Ethical Principles
Policy Guidelines
Evidence-based PracticeAPA Multicultural Guidelines
Research Evidence
Culture and Human BehaviorIntergroup RelationsSupervision Research
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APPROACHES TO SUPERVISION
Compose an “elevator speech” description of your
supervision style and approach.
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MODELS OF SUPERVISIONDevelopmental ModelsPsychotherapy Based ModelsBernard’s Discrimination ModelLadany et al’s Interpersonal ApproachFalenderand Shafranske’sCompetency-based ModelMilne’s Evidence-based Supervision Model
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BERNARD’S DISCRIMINATION MODEL
TEACHER “COUNSELOR” “CONSULTANT”
PROCESS
CONCEPTUALIZATION
PERSONALIZATION
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FALENDER AND SHAFRANSKE’SCOMPETENCY-BASED SUPERVISION MODELCompetency-based supervision is an approach that
explicitly identifies the knowledge, skills and values that are assembled to form a clinical competency and
develops learning strategies and evaluation procedures to meet criterion-referenced competence standards
in keeping with evidence-based practices and the requirements of the local clinical setting
Super-ordinate Values
Integrity-in-Relationship
Appreciation of Diversity
Science-informed, Evidence-based Practice
(Falender & Shafranske, 2004)
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IMPORTANCE OF METACOMPETENCE
Metacompetence
Ability to assess what one knows and what one doesn’t know
Introspection about one’s personal cognitive processes and products
Dependent on self-awareness, self-reflection, and self-assessment.
Supervision guides development of metacompetencethrough encouraging and reinforcing supervisee’s development of skills in self-assessment
(Falender & Shafranske, 2007)
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SUPERVISION BEST PRACTICESTHE CLINICAL SUPERVISOR:a) Examines his or her own clinical and supervision expertise and competency; (b) Delineates supervisory expectations, including standards, rules, and general practice;(c) Identifies setting-specific competencies the trainee must attain for successful completion of the supervised experience;(d) Collaborates with the trainee in developing a supervisory agreement or contract for informed consent, ensuring clear communication in establishing competencies and goals, tasks to achieve them, and logistics; and (e) Models and engages the trainee in self-assessment and development of metacompetence (i.e., self-awareness of competencies) from the onset of supervision and throughout.Falender & Shafranske, 2007, p. 238
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TAKE-AWAYS FROM SUPERVISION MODELS
Consider developmental level of the trainee in different areas of competenceAttend to the supervisory allianceFocus on content, process, and personalizationConsider theoretical orientationSupervise purposefully for specific professional competenciesImportance of metacompetence
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CULTURAL DIVERSITY AND SUPERVISION
“Notwithstanding that it is a core component of psychology training, diversity is one of the most neglected areas in supervision training and research” (Falender & Shafranske, 2004,p. 115).
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UNDERSTANDING AND INTEGRATING
CULTURE
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DEFINITIONS OF CULTURE
“The patterns of behavior and thinking that people living in social groups learn, create, and share.” (Bodley, 2002, Microsoft Encarta)
“The vast structure of language, behavior, customs, knowledge, symbols, ideas, and values which provide a people with a general design for living and patterns for interpreting reality” (Nobles, 1978/2006, p. 71)
“Attitudes, values, beliefs, norms, and behaviors shared by a group but harbored differently by each specific unit within the group, communicated across generations, relatively stable but with the potential to change across time” (Matsumoto, 2000, p.24)
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HARRELL’S CONCEPTUALIZATION OF CULTUREThe material, social, and ideological qualities of a group of people woven into the fabric of daily life, which: (1) have emerged, and are maintained, shared, and changed, in the service of collective adaptation to a particular sociohistoricalcontext, and(2) are expressed through ways of thinking and viewing the world, values and behaviors, interpersonal interactions, and social structures.
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ECOLOGICAL AND PSYCHOLOGICAL CULTUREEcological Culture (externalized)
Reflects the expression of culture in the multiple socialization contexts within which we develop, live, and changeThe shared core elements of cultural worldview, beliefs, customs, patterns of behavior, etc., those observable and commonly expressed cultural characteristics of a groupThe essential elements of a group’s way of life passed down from generation to generation
Psychological Culture (internalized)Reflects the conscious and unconscious internal representations of our multiple culture-infused experiences The unique ways that ecological culture is internalized and expressed by each individualThe intentional choices that individuals makes regarding adopting and participating in particular cultural values, customs, behaviors, etc.The meaning of culture to the individual
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CULTURE IS…
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Embedded in our Relational, Socialization, and Environmental ContextsInternalized into our Beliefs, Values, Thoughts, Motivations, and IdentityExpressed through our Preferences, Sensibilities, Behaviors and Interactions
Human behavior is multiply determined and culture is one of those determinants
All behavior occurs in mulitple internal and external cultural contexts – we see, experience, and interpret the world through a cultural lens
Culture provides the external socialization contexts where norms for behavior and for social and interpersonal interactions are learnedCulture provides the internalized context for making meaning of the world and understanding one’s place in it
Broadly defined, culture can be demographically-based (e.g., ethnic culture, gay culture) or experientially-based (e.g., occupational culture, 12-step culture)
Narrowly defined, culture is a reflection of racial-ethnic-worldview intersections
Individuals are exposed to and internalize multiple cultural influences which intersect in particular ways to create identity
The inclusion of culture in the analysis of human experience, behavior, and transformation facilitates the identification of constructs, methods, and strategies that may enhance the effectiveness of applied work in diverse cultural contexts
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The Integrative and Foundational Role of Culture
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DIMENSIONS OF CULTURAL IDENTITY ! = a central and organizing aspect of how I think of myself+ = a less important aspect of my identityx = not at all significant to me? = have not thought much about this dimension
____ Age cohort/Generation _____ Gender
____ Ethnicity or National Origin _____ Race
____ Sexual Orientation _____ Social Class
____ Religion _____ Disability
____ Rural/Urban/Suburban _____ Political Affiliation
____ Creative-Artistic Talent _____ Military Affiliation
____ Leisure Activity, Hobby _____ Profession
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MULTIPLE DIMENSIONS OF DIVERSITY
IntersectionalityThe overlapping and interactive dynamics of multiple dimensions of diversityThe effects of one diversity dimension in our lives is, in part, dependent on one’s status on additional dimensions of diversity
Being an African AmericanBeing an African American womanBeing a highly educated African American womanBeing a highly educated African American woman baby boomer
Ecological niche (Falicov)the place where a one’s multiple contexts and cultural locations converge
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INTERSECTIONALITY AND ECOLOGICAL NICHE
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GROUPS OF 3 OR 4
SIMILARITIES AND DIFFERENCES
HOW MIGHT THESE IDEAS INFLUENCE PSYCHOTHERAPY AND CLINICAL SUPERVISION?
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DIVERSITY DIMENSION ISSUES TO CONSIDER IN THERAPEUTIC AND SUPERVISORY RELATIONSHIPS
Differences in Identity Salience
Differences in Identity Development
Intergroup Dynamics within Dimensions
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CORE DIMENSIONS OF DIVERSITY FOR MULTICULTURAL COMPETENCEGender
Ethnicity/National Origin
Race
Sexual Orientation
Socioeconomic Status
Religion
Disability
Age Cohort/Generation
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IMPLICATIONS FOR MULTICULTURAL PRACTICE
We all live and develop in multiple cultural communities (communities of race/ethnicity, gender, religion, sexual orientation, social class, etc.)
Our clinical work must incorporate attention to the culture and context of these communities, as well as who we are in the context of the cultures of those with whom we work
Application of these ideas requires a unique journey with each client and each community with whom we work
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TERMINOLOGY AND APPROACHES FOR INCORPORATING CULTURE
Culturally-SensitiveCulturally-Appropriate
Culturally-RelevantCulturally-Intentional
Culturally-AdaptiveCulturally-Alert
Culturally-ResponsiveCulturally-Infused
Culturally-CongruentCulturally-Competent
Cultural Resonance (Trimble)
Culturally-Syntonic (Harrell, 2008) 41
WHY CULTURALLY “SYNTONIC”?Syn – with or together
the Greek “suntonos”-- in harmony with – Collins English Dictionary
Emotionally in harmony with one’s environment -Collins English Dictionary
Normally responsive and adaptive to the social or interpersonal environment -Merriam Webster’s Medical Dictionary
In emotional equilibrium and responsive to the environment –YourDictionary.com
Describes somebody who is normally attuned to the environment; used to describe behavior that does not conflict with somebody’s basic attitudes and beliefs –Microsoft Encarta College Dictionary
Characterized by a high degree of emotional responsiveness to the environment; Of or relating to two oscillating circuits having the same resonant frequency -American Heritage Dictionary
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CULTURALLY-SYNTONIC PRACTICE (CSP; HARRELL, 2008/2011)
In the context of psychologically-informed interventions, Culturally-Syntonic Practice involves:
Understandings, processes, activities, and interpersonal interactions
that reflect attunement, harmony, and resonance
with relevant dimensions of collective cultural aspects (ecological culture) and their individual expressions (psychological culture),
such that engagement with, and the effectiveness of, interventions is enhanced and optimized. 43
MORE ON A CULTURALLY-SYNTONIC APPROACH
Characterized by• activities, interactions, and perspectives
-that reflect consistency with and/or responsiveness to a person’s or group’s
• relevant cultural contexts; • internalized cultural meanings, beliefs, values; and • manifested actions and behaviors
-such that there is a “fit” or resonance between the practice and the relevant person-environment transactions, current and historical, for the client
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DIVERSITY PRINCIPLES TO FACILITATE CULTURALLY-SYNTONIC PRACTICE (Harrell snd Bond, 2006)
INFORMED COMPASSIONBalanced integration of head and heartSeeking knowledge and awareness from a place of openness, respect, and caringNot distanced over-intellectualized position nor emotion-driven overidentified position
CONTEXTUALIZED UNDERSTANDINGMultiple levels of analysis: Individual, Microsystem, Organizational, Locality, Identity Group, MacrosystemTemporal contextPerson and interactions among persons are a function of variables at all levels of analysisDecontextualized analysis risks oversimplified and superficial understanding
EMPOWERED HUMILITYProactive engagement grounded in awareness of our vulnerabilities and limitationsAcknowledgement of another’s right to self-determinationUnderstanding that stronger connection and greater empowerment emerges from healthy humility that frees us to be open to see, hear, and learn in unanticipated ways– gives us confidence to walk in unfamiliar terrain and meet the “other” where s/he stands 45
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APA’s COMPETENCY BENCHMARKS FOR PROFESSIONAL PSYCHOLOGY
Six clusters (Professionalism, Relational, Application, Science, Education, Systems) provide the overarching structure for the benchmarks. Within these clusters, there are 16 core competencies, one or more related competencies within each clusterEach core competency contains several essential components of that competencyDevelopmental descriptors and behavioral anchors are delineated for each of the three stages in the education and training sequence (practicum, internship, practice).
http://www.apa.org/ed/graduate/benchmarks-guide.aspx?item=2
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BENCHMARKS CLUSTERS AND CORE COMPETENCIESPROFESSIONALISM CLUSTER:
Professional Values and AttitudesIndividual and Cultural DiversityEthical, Legal Standards and PolicyReflective Practice/Self-Assessment/Self-Care
RELATIONAL CLUSTER: Relationships
SCIENCE CLUSTER:Scientific Knowledge and MethodsResearch/Evaluation
APPLICATION CLUSTER:Evidence-based PracticeAssessmentInterventionConsultation
EDUCATION CLUSTER:TeachingSupervision
SYSTEMS CLUSTER:Interdisciplinary SystemsManagement/AdministrationAdvocacy 47
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INDIVIDUAL AND CULTURAL DIVERSITY (ICD): Awareness, sensitivity and skills in working professionally with diverse individuals, groups and communities who represent various cultural and personal background and characteristics defined broadly and consistent with APA policy.
READINESS FOR PRACTICUM READINESS FOR INTERNSHIP READINESS FOR ENTRY TO PRACTICE
2A. Self as Shaped by Individual and Cultural Diversity (e.g., cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status ) and ContextDemonstrates knowledge, awareness, and understanding of one’s own dimensions of diversity and attitudes towards diverse others
Monitors and applies knowledge of self as a cultural being in assessment, treatment, and consultation
Independently monitors and applies knowledge of self as a cultural being in assessment, treatment, and consultation
2B. Others as Shaped by Individual and Cultural Diversity and ContextDemonstrates knowledge, awareness, and understanding of other individuals as cultural beings
Applies knowledge of others as cultural beings in assessment, treatment, and consultation
Independently monitors and applies knowledge of others as cultural beings in assessment, treatment, and consultation
2C. Interaction of Self and Others as Shaped by Individual and Cultural Diversity and ContextDemonstrates knowledge, awareness, and understanding of interactions between self and diverse others
Applies knowledge of the role of culture in interactions in assessment, treatment, and consultation of diverse others
Independently monitors and applies knowledge of diversity in others as cultural beings in assessment, treatment, and consultation
2D. Applications based on Individual and Cultural ContextDemonstrates basic knowledge of and sensitivity to the scientific, theoretical, and contextual issues related to ICD (as defined by APA policy) as they apply to professional psychology. Understands the need to consider ICD issues in all aspects of professional psychology work (e.g., assessment, treatment, research, relationships with colleagues)
Applies knowledge, sensitivity, and understanding regarding ICD issues to work effectively with diverse others in assessment, treatment, and consultation
Applies knowledge, skills, and attitudes regarding dimensions of diversity to professional work
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EXAMPLE OF DIMENSION-SPECIFIC MULTICULTURAL
COMPETENCIES: RACE
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RACE-RELATED MULTICULTURAL COMPETENCIES IN THERAPY AND SUPERVISIONAwareness, Values, and Attitudes (AVA)
• Competence Goals:• (1) the development of a strong personal awareness of the role and meaning
of race and racial content, and• (2) the cultivation of a set of professional attitudes and values related to
racial material• AVA Core Competencies
• Racial self-awareness• Race-related empathy• Respect for race-related experiences• Race-related bias awareness
• Additional AVA competencies• Self-awareness of thoughts, needs, and internal processes during
interracial and intraracial encounters; self-awareness of interpersonal behavior in both interracial and intraracial interactions; awareness of power and privilege dynamics in one’s own relationships; awareness of ways that one colludes with the maintenance of racism and white privilege; awareness of attitudes and opinions on race-related topics; an attitude of openness to learning about and discussing race-related issues; and valuing the exploration of the relationship of race to psychological experience.
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RACE-RELATED MULTICULTURAL COMPETENCIES IN THERAPY AND SUPERVISIONKnowledge of Theory and Research (KTR)
• Competence Goal:• Familiarity with empirical, conceptual, and applied literature relevant
to race and racial issues• Core KTR Competencies
• Racial identity • Racial socialization• Racism-related stress• Internalized racism • White privilege• Study of aversive racism, implicit prejudice, and in-group bias within
the social cognition literature• Additional Areas of Theory and Research
• Intraracial heterogeneity, intergroup conflict, prejudice reduction and anti-racism strategies, critical race theory, liberation psychology, neuroscience of race, history of race in psychology, and ecological theory (Adams, 2009; Burgess et al., 2007; Comas-Diaz & Jacobsen, 1991)
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MULTICULTURAL PSYCHOLOGY 1011. Terminology (Race, Ethnicity, and Culture)
2. The “Culture” of Psychology
3. Psychological Research and Cultural Diversity
4. Dynamics of Difference
5. Racial-Ethnic Socialization and Identity
6. The Sociopolitical and Sociohistorical Context
7. Immigration, Refugee, Colonization, Genocide, and Slavery Experiences
8. Acculturation, Assimilation, Biculturation, Alienation
9. Collectivism, Communalism, and the Interdependent Self
10. Worldview and Culture
11. Indigenous Psychologies
12. Intersectionality and Ecological Niche
13. The Lived Experience of People of Color
14. Stereotypes, Prejudice, Discrimination and Oppression
15. Racism-related Stress: episodic life events, chronic, microaggressions, vicarious, transgenerational
16. The Physical and Mental Health Effects of Racism
17. Internalized Racism and Colorism
18. White Privilege
19. Intergroup Relations and the Dynamics of Difference
20. Liberation Psychology and the role of Social Justice in Psychotherapeutic Interventions
21. Critical Consciousness
22. Multicultural Competence
23. EBPP and Cultural Diversity
24. Culture and Theoretical Orientation
25. Culturally-Adapted and Culturally-Centered Interventions
26. Language and Psychotherapy
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RACE-RELATED MULTICULTURAL COMPETENCIES IN THERAPY AND SUPERVISIONRace-related Multicultural Competencies: Interpersonal and Professional Skills (IPS)
• Competence Goals:• Demonstration of the application of AVAs and KTRs in the conduct of the
case and therapeutic/supervisory relationship• IPS Competencies
• Authenticity and genuineness in interracial interactions• Demonstration of empathy when experiences of racism are reported• Ability to co-create a safe and open environment for discussion of race-
related content• Recognizing and attending to the specific impact of one’s own race-related
issues on the content and process of interactions• Recognizing and processing the inf luence of the client’s race-related
experiences and perceptions on the therapeutic alliance• Ability to work through and recover from race-related ruptures in the
therapeutic relationship• Inclusion of race-related inquiries during the intake process• Integrating race-related considerations into case formulation• Incorporation of racial content into psychotherapy interventions• Ability to process any overt expressions of racism
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DETERMINANTS OF MULTICULTURALLY-COMPETENT SERVICE DELIVERY FOR THERAPIST-TRAINEES
Therapist-trainee multicultural competenceSupervisor multicultural competenceProgram multicultural competenceInstitutional multicultural competence
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FOUNDATIONAL IDEAS FOR MULTICULTURALLY-COMPETENT SUPERVISION
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CULTURE AND CONTEXTIN PSYCHOTHERAPY AND SUPERVISION
THERAPIST SUPERVISOR
CLIENT
CULTURAL VARIABLES TO UNDERSTAND AS RELEVANT TO THERAPIST, CLIENT, AND SUPERVISOR INDIVIDUALLY AND IN THEIR INTERACTIONS
-Culture of psychotherapy-Dominant Societal Culture-Culture(s) of identity-Dynamics of status, power and privilege-Environmental & sociopolitical context
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CULTURE AND THE DYNAMICS OF DIFFERENCE
We are all AT THE SAME TIME
Like ALL othersLike MANY othersLike SOME others
Like NO others(paraphrased from Murray & Kluckhohn)
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ALL OTHERS Our Common Humanity
MANY OTHERS Majority contexts
SOME OTHERS Identity Group contexts
NO OTHERS Uniqueness of our Story
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AT THE INTERSECTION OF CULTURAL DIVERSITY AND PSYCHOTHERAPY:THE DYNAMICS OF DIFFERENCE (HARRELL, 1990)
People develop ways of managing the threat, anxiety, or discomfort that difference experiences can create
Those in power can establish the norm and define differences from that norm as deviant or unacceptable
Difference dynamics are associated with minority-majority group status and with in-group/out-group dynamics
There is a social press towards conformity and fitting inBeing different is sometimes only acceptable in competitive
situations (being the “best”); difference is typically assigned value (e.g., better than or worse than)
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THE 5 DS OF DIFFERENCE (HARRELL, 1995)
There are 5 basic strategies that people use in difference encounters
DistancingDenialDefensivenessDevaluingDiscovery
THE 5 D’S OF DIFFERENCE:DISTANCING
Strategy:Maintain separation from the difference
Manifestations:1) Physical (avoiding interaction; maintenance of homogeneous environments and social networks)2) Emotional ("pity")3) Cognitive (scientific fascination)
Possible Results:1) Prevents authentic interaction and open/honest communication2) Increases likelihood of perceiving and interacting with others based on stereotypes3) Increases feelings of being dehumanized, alienated, or misunderstood
THE 5 D’S OF DIFFERENCE:DENIAL
Strategy:Minimize the existence or significance of differences
Manifestations:1) Color-blind posture ("people are people")2) Selective attention to similarities-- need for conformity and
sameness3) Disagreement and conflict are actively avoided
Possible Results:1) Increases feelings of invisibility2) Reduces the perceived relevance of learning about diverse
racial/ethnic groups3) Increases the chance that the concerns and needs of diverse groups
will be neglected or overlooked
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THE 5 D’S OF DIFFERENCE:DEFENSIVENESS
Strategy:Adopt stance that "I" have no problem with differences
Manifestations:1) Defensive declaration of not having prejudices or stereotypes2) Identification, overinvolvement, and blurred interpersonal boundaries with oppressed groups 3) Central to one's sense of self is being caring and altruistic with strong values of equality
Possible Results:1) Feelings of rejection, hurt, confusion 2) Ignores the real problems because of idealization of racial/ethnic groups3) "Underpathologizing" bias
THE 5 D’S OF DIFFERENCE:DEVALUING
Strategy:Maintain feelings of superiority
Manifestations:1) Difference is experienced as deviant2) "What's wrongwith those people?"3) "Blame the victim" orientation4) "My struggle is worse than your struggle“
Possible Results:1) Intergroup interactions are often openly hostile2) One's own anger, rage, conflict, and confusion are projected onto the other group3) "Overpathologizing" bias
THE 5 D’S OF DIFFERENCE:DISCOVERY
Strategy:Embrace and seek greater familiarity with differences
Manifestations:1) Differences are experienced as challenges and opportunities
for learning and growth2) Intergroup understanding is valued3) Conflict and disagreement are accepted as a part of dealing
with differences4) Confronting difference is experienced as empowering
Possible Results:1) Non-defensive intergroup interactions2) Resolution of conflicts that may emerge3) Personal growth
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ABOUT THE 5 Ds
We all manifest each of these dynamics at one time or another
The purpose of these strategies is protectiveWe can’t eliminate discomfort with difference
(either our own or others), it is a normal reaction
If we construct our lives to minimize difference experiences then we also minimize the possibilities of understanding others, understanding ourselves, and developing rich relationships
BEYOND IDENTIFYING DESCRIPTIVE DIFFERENCES: SPECIFIC COMPETENCY BEHAVIORS
1. Includes cultural diversity assessment at intake (utilizing Cultural Formulation appendix in DSM)
2. Integrates multicultural factors in theoretically-grounded case conceptualization demonstrating familiarity with the multicultural psychology literature
3. Reviews empirical and theoretical literature relevant to key dimensions of diversity
4. Incorporates multicultural considerations in treatment planning and identifies cultural adaptation goals, culture-centered goals, and/or culturally-specific goals as indicated
5. Implements treatment strategies in a culturally-syntonic practice context
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APPROACHES TO THE INTEGRATION OF CULTURE
Three approaches to the conceptualization and integration of culture into psychological research and practice
Culturally-Adapted - Start with presumably universal constructs, strategies and methods and then make cultural adaptations
Culturally-Centered - Start with constructs, strategies and methods that emerge from multicultural considerations and then integrate culturally-syntonic contributions from multiple traditions as appropriate
Culturally-Specific – Start with the specific ecological culture and design strategies that emerge from constructs relevant to the target group
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SUPERVISOR CULTURAL COMPETENCIES (Falender And Shafranske, 2004, p. 149)
1) A working knowledge of the factors that affect worldview;
2) Self-identity awareness and competence with respect to diversity in the context of self, supervisee, and client or family;
3) Competence in multimodal assessment of the multicultural competence of trainees;
4) Models diversity and multicultural conceptualizations throughout the supervision process;
5) Models respect, openness, and curiosity toward all aspects of diversity and its impact on behavior, interaction, and the therapy and supervision processes;
6) Initiates discussion of diversity factors in supervision.
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INTEGRATING MULTICULTURAL ISSUES IN CLINICAL SUPERVISION
The importance of developing a clear and comprehensive approach to multicultural issues in clinical supervision is particularly critical given the almost inevitable experience of anxiety when topics related to race, ethnicity, and culture are raised in open discussion (Trawalterand Richeson, 2008).
The development of multicultural competence is facilitated by a process that is able to incorporate attention to the emotional, cognitive, and contextual issues related to managing the dynamics and issues related to multiple dimensions of cultural diversity
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USING MULTICULTURAL NARRATIVES AS AN ORGANIZING FRAMEWORK
Narrative theory suggests that our stories are not only created by our lives, but simultaneously contribute to creating our lives (McAdams, 2006). Narratives are related to creating memory, identity, and relational behaviors.
A narrative approach facilitates the integration of the cognitive, affective, and behavioral elements through the use of story.
A multicultural narrative is a story that we have involving one or more dimensions of cultural diversity, attributes of cultural groups, intercultural and intracultural interactions, and/or “isms” connected to diversity dimensions.
The approach can be organized into four general phases: (1) Laying the Groundwork; (2) Timing and Opportunity; (3) Implementation of the Multicultural Narratives Supervision Strategy; and (4) Evaluation
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CORE GUIDELINES: COMPASSIONATE CONFRONTATION AND EMPATHIC EXPLORATION
Both supervisor and supervisee are tasked with confronting and exploring emotionally-charged subject matter while simultaneously maintaining an atmosphere of compassion and empathy for the anxiety, pain, ambivalence, and anger that can accompany the multicultural conversations. These discussions can trigger strong affective and defensive reactions. Successful multicultural dialogues require the ability to tolerate (1) the processing of unacknowledged or undiscovered material related to race-related feelings and experiences, and (2) feelings of uncertainty and unfamiliarity related to “the other” (Tummala-Narra, 2009). The act of non-judgmentally giving supervisees space to share their multicultural narratives provides an in-vivo opportunity to strengthen the supervisory relationship.
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IMPLEMENTATION PHASE I: LAYING THE GROUNDWORK
Conditions necessary for effective multicultural narrative approach
Preparation and competence of the supervisor,Establishment of multicultural competence as part of the supervisory agreementCreation of an open and emotionally safe supervision atmosphere
Difference is the one of the fundamental dynamics operating at the intersection of diversity and psychotherapy
Processing and normalizing the “Five D’s of Difference”
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SMALL GROUP DISCUSSION
What are your thoughts and ideas about how you might more explicitly lay the groundwork and set expectations regarding multicultural issues in clinical supervision?
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IMPLEMENTATION PHASE II: TIMING AND OPPORTUNITY
When should a supervisor pay particular attention to multicultural issues and dynamics?
Ten indicators of potential need to pay specific attention to racial dynamics
• 1. Gaps in self-awareness• 2. Reactivity• 3. Minimization or devaluing the significance of culture• 4. Interpersonal dynamics• 5. Unfamiliarity, inexperience and lack of knowledge• 6. Oversimplification or superficiality• 7. Invisibility of culture and multicultural issues• 8. Guilt, shame, or internalized “isms”• 9. Context minimization error (“blaming the victim”)• 10. Naïve, idealizing
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SMALL GROUP DISCUSSION
Share a supervision experience where there was an opportunity to process multicultural material. Discuss how you did or might have proceeded with the trainee.
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IMPLEMENTATION PHASE III: PROCESSING CLINICAL MATERIAL USING
THE MULTICULTURAL NARRATIVES APPROACH
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BASIC STEPS OF THE MULTICULTURAL NARRATIVES APPROACH FOR WORKING WITH CLINICAL MATERIAL
Step 1: Elicitation/Disclosure • The first step in the process involves eliciting relevant narratives by inviting the
supervisee to process the stimulus issue more deeply• Compassionate Confrontation operates strongly here
Step 2: Deconstruction/Analysis• The second step involves a process of deconstructing the narrative by facilitating
connections to the supervisee’s internal experience and exploring multicultural issues embedded in the narrative (e.g., identity, stigma, privilege, etc.)
• Empathic Exploration can provide grounding in the Deconstruction process
Step 3: Reconstruction /Integration• Guided by the idea that intentional meaning-making of multicultural narratives can
reduce cultural anxiety and result in therapist behaviors that are productive in the management and incorporation of multicultural content and dynamics
• (1) incorporates a reflective normalization of multicultural issues • (2) integrates insights from the deconstruction process • (3) is consistent with values and self-image and can contribute to both personal and
professional growth and development• Integrates multicultural awareness, knowledge, and skill development
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INTEGRATED SUPERVISION
EXAMPLE
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IMPLEMENTATION PHASE III: STEP ONE
Elicitation and Disclosure
Invitation to share personal, family, cultural, or dominant social narratives related to the relevant dimension of diversity; supervisee (and sometimes supervisor) disclosure and description of narratives associated with the stimulus issue or event
“I’m thinking it would be a good idea to pause for a moment and focus in on what happened in the session when_______.”
“I’d like to invite you to take a moment and try to connect any personal experiences involving race that are associated with _______.”
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IMPLEMENTATION PHASE III: STEP TWO
Deconstruction and Analysis
Exploration of the narrative with respect to the supervisee’s internal experience, multicultural issues such as power and privilege, identity, bias, etc., and impact of these on the therapy and/or supervisory process
“I’m wondering if you notice any similarities between your thoughts and feelings associated with your experience and what happened in the session”.
“Let’s explore a bit more about your experience with respect to the role of race in your sense of self and identity as it may have been reflected in your work with this client.”
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IMPLEMENTATION PHASE III: STEP THREEReconstructionand Integration
Facilitation of the supervisee’s process of integrating self, client, and context to form a coherent narrative of the therapy or supervisory event or issue and the supervisee’s developmental process; Connection to relevant Multicultural AVAs, KTRs;and IPSs
“Let’s take a step back now and look at what happened in session in the context of some of what we just processed”.
“How might you describe your experience and understanding from the session until now with respect to the multicultural issues we have identified”?
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DEMONSTRATION
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IMPLEMENTATION PHASE IV: EVALUATION
Evaluation should be guided by observation of indicators of professional behaviors, expressed attitudes, and demonstrated knowledge of the supervisee relevant to multicultural competencies
A variety of multicultural dynamics may interfere with the identification and remediation of multicultural competencies that need further development. Supervisors and trainees may collude to avoid multiculturally-related meta-competence conversations.
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PARTING THOUGHTSThe central purpose of integrating multicultural narratives into supervision is to facilitate the meaningful consideration of multicultural material in the process of therapy, supervision, and professional relationships more generally
It is suggested that supervisors seek consultation from colleagues who have expertise in multicultural issues in order to process ways to deal with challenging multicultural dynamics with trainees, as well as appropriate supervisory strategies with respect to culture in case conceptualization, treatment planning, and treatment implementation.
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PARTING THOUGHTS (CONTINUED)
One of the biggest barriers to facilitating supervisee multicultural competence is the reluctance and/or inability of supervisors to identify important material and bring the issues to the supervisee’s attention
Processing multicultural narratives may trigger unanticipated reactions and potentially expose the supervisor’s own vulnerability The quantity and quality of the supervisor’s previous experience discussing race is also an important factor influencing the implementation of the supervision approach described
Effective supervision and evaluation of trainee multicultural competence is not possible without the ongoing reflective practice and self-assessment of the supervisor
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