NCE STUDY – Understanding LGBT Clients…

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

PART ONE: A Literature Review Paper…

According to research, higher rates of mental health diagnosis, substance abuse and suicidal ideation exist within the LGB by community (Biescheke, et al, 2007, Hays & Iwasama 2006; Herek & Greene, 1998).   With mental health diagnoses concentrated in the areas of anxiety, depression, and suicidal ideation, it is important to note these issues are commonly correlated with “minority stress” in research, (Biescheke, et al, 2007, Hays & Iwasama 2006; Herek & Greene, 1998). Defined as a form of social stress related to stigmatized minority status, it will be essential to start off with a discussion of this concept. (Meyer, 2003, p675).

In this paper, I begin by discussing the concept of “minority stress”. I then discuss key issues common within the LGB community: identity development, coming out, and internalized homophobia. I conclude by providing a summary of how these key issues affect LGB youth and how to develop a treatment plan with these factors in mind.

Minority Stress.

In attempting to understand the concept of minority stress, it is vital to understand how discrimination exists as its cause. With social discrimination bringing about a stigmatized status amongst LGB minorities, the result is the minority stress they are forced to contend with (Herek & Greene, 1998; Meyer, 2003)

Discrimination as Cause.

Firstly in contextualizing the nature of minority stress, it is important to understand the nature of the discrimination they encounter. In a book titled “Stigma and Sexual Orientation” there is a brief review of research that examines the underlying motivations of assaultive acts against LGB victims. The conclusions made from this research are that assaults on LGB individuals can be seen as resulting from motives best defined as “a learned form of social control of deviance”, (Herek & Grene, 1998, p7). In this respect the motives aren’t entirely personal in nature, but simply an extreme form of gender norm reinforcement, (Herek & Greene, 1998).

“To reconcile the apparent contradiction between the socially normative attitudes held by assailants and the visciousness and brutality of their behavior….during the course of my research I came to conceptualize the violence not in terms of individual hatred but as an extreme expression of American cultural stereotypes and expectations regarding male and female behavior…From this perspective, assaults on homosexuals and other individuals who deviate from sex role norms are viewed as a learned form of social control of deviance rather than a defensive response to personal threat.” (Herek & Greene, 1998, p7)

Stigma as Cause of Minority Stress.

With this perspective in mind it is important to note that the definition of stigma is simply a “characteristic of persons that is contrary to a norm of social unity”, (Herek & Greene, 1998, p108). Key aspects of the underlying causes of stigma exist external to the individual. Additionally, when you note that such a stigma is associated with an elemental component of one’s overall identity, the result is minority stress. Understanding the nature of this minority stress as comprising an array of interrelated individual and social factors is essential, and will be discussed next.

The Nature of Minority Stress.

It is clear, when taking time to understand the nature of minority stress, it exists as an interrelated set of social, group, and individual components, (Meyer, 2003). For example, society is comprised of social structures that appear to stand against an LGB minority lifestyle. Additionally, the social environments in which an LGB individual lives often create a meaning system that completely negates their experience (Meyer, 2003).   Against these social factors, are other variables such as family dynamics, social environment, and individual factors that also play a part. For example, individual factors such as methods of handling stress and forms of cognitive appraisal influence the nature these social factors have on a person:

“The more an individual identifies with, is committed to, or has highly developed self-schemas in a particular life domain, the greater will be the emotional impact of stressors that occur in that domain.” (Meyer, 2003, p678)

Distal / Proximal View of Minority Stress

In attempting to bring some clarity to the interrelated factors that comprise minority stress, a research article I found (Meyer, 2003), describes an interesting perspective of stress worth mentioning. Firstly, this research proposed that stress is comprised of three components as discussed in the following quote:

“I have previously suggested three processes of minority stress relevant to LGB individuals. From the distal to the proximal they are (a) external, objective stressful events and conditions (chronic and acute), (b) expectations of such events and the vigilance this expectation requires, and (c) the internalization of negative societal attitudes. (Meyer, 2003 p676)”

While well beyond the scope of this paper, the article then goes on to provide some discussion of how such factors are interrelated.   The crux of this theory’s proposed stance is that such abstract social concepts become relevant psychological through the manner in which we decide to cognitively appraise them (Meyer, 2003, p676).

Common LGB Issues

In attempting to further put into perspective key issues common within the LGB community, a few key observations can be made that help put them into context.   In this section I discuss three key issues in the LGB community: (1) identity formation, (2) coming out, and (3) cognitive appraisal.

Identity Formation.

“In social identity theory and identity theory, the self is reflexive in that it can take itself as itself as an object and can categorize, classify, or name itself in particular ways in relation to other social categories or classifications.” (Stets & Burke, 2000, p224).

As the above quote indicates a person’s identity is essentially an internalized subjective construct of “you”. (Stets & Burke, 2000). In this respect, it can be thought of as a byproduct of our interpretations. For individuals with a sexual minority status, developing a positive identity is problematic as a result. (Bieske, et al, 2007, p19).

Before going further it must be noted briefly, that much in-group diversity exists within the LGB community. For example, contextual factors such as cultural background, sexual preference, and gender orientation influence individual LGB identities. Adding to these factors is the historical context within which a person lives.   Finally, adding to the confusion is the fact that the three components of sexual orientation (same sex identity, same sex behavior, same sex attractions) don’t exist in equal degrees with all LGB identifying persons, (Hays & Iwasama, 2006). Finally, while stage theories help to conceptualize the identity formation process, it must be noted, that identity development isn’t necessarily experienced like that first-hand. Instead often described as a fluid and abstract notion, it is more accurately understood as a lifelong process.

Coming Out.

It is important to note, that unlike many minority groups, LGB individuals have the option of concealing this stigmatized status (Hays & Iwasama, 2006). Early on in the process of LGB identity development, this concealment is often an essential coping mechanism. Having said this it should also be noted that coming out “is associated with lower psychological stress” (Hays & Iwasama, 2006, p224).

Internalized Homophobia.

Another key factor to note, that makes the LGB community unique amongst all minority groups, is their status is often not shared within the family (Hays & Iwasama, 2006). As a result, LGB individuals are often raised within a cisgendered, heteronormative environment to varying degrees (LGBTQA, 2014). The consequence of this is a learned belief system defined as “internalized homophobia” (Hays & Iwasama, 2006). Overcoming this is key in the coming out and identity formation process for LGB individuals.

Counseling LGB Youth.

In taking time to consider what the concept of minority stress means in the daily lives of LGB youth during key developmental years, concepts such as Marsha Linehan’s “invalidation” and Brene Brown’s “shame” come to my mind.

LGB youth, in the early developmental stages of form an adult identity, often deal with the issues above as an internal struggle without little outside guidance.   In doing research for this paper, I found two great resources that were helpful in allowing me to develop a rudimentary understanding of how to begin to formulate a treatment plan for this community of individuals. In providing counseling for any LGB youth, the eclectic counseling perspective mentioned in our Hays textbook, (2006), would be my starting point. Key insights, such as what I discuss from these resources, will be helpful in the ongoing case conceptualization and treatment formulation process.

Early LGB Identity Development.

The first key insights I found beneficial were within the video link provided in the assignment description for this week. Titled, “Working with Gay/Lesbian Youth Clients”, this video provides samples of counseling scenarios with LGB youth clients. What I found most interesting were the varied stages of development displayed within each counseling session.   With each stage of development there exists a unique set of characteristics, and counseling considerations with each stage. I discuss each of these stages briefly below.

Identity Confusion Phase.

During this early phase of LGB identity development, the client is experiencing a growing internal awareness that is not well defined.   As noted earlier, the majority of LGB individuals often hold this minority status alone in the family. Without any family or friends to provide guidance, the growing internal awareness can be experienced at first as just “being different somehow” (Sage Productions, 2014). Often understood within a heteronormative family environment, the growing awareness of homosexuality exists against within an array of denial strategies.   Often not ready to admit such feelings outwardly, or put labels to things, ongoing self-rejection is an early core issue. Key goals during this stage include: (1) empathetic listening, (2) building trust, (3) validating confusion, (4) assessing suicide risk potential, and finally (6) probe for greater specifics regarding situations and associated feelings, (Sage Productions, 2014).

Early Identity Acceptance.

During the early identity acceptance stage there exists a clear awareness of the nature of one’s attraction. With a greater degree of awareness, there still exists much internal confusion and heightened degrees of anxiety in moving forward.   Key goals during this stage include: assessing the use of support systems and providing tools with which to address anxiety in a healthy manner (Sage Productions, 2014).

It is useful to note, in concluding my remarks on this stage with a brief quote from another resource that sheds light on the importance of a support system for LGB youths:

“Through reappraisal, the in-group validates deviant experiences and feelings of minority persons….It is important to distinguish between group-level and personal resources because when group-level resources are absent, even otherwise-resourceful individuals have deficient coping. Group-level resources may therefore define the boundaries of individual coping efforts.” (Meyer, 2003, p677)

Late Identity Acceptance.

With greater internal clarity and awareness of oneself, the process of coming out to oneself and others becomes the overarching goal during this stage. Continuing to assess the degree of clarity, helping clients to forge a new positive identity will be important focuses during this stage of the counseling process.

In concluding this brief discussion on LGB Identity formation, it must be noted that much in-group variation exists. An in depth discussion of this matter is well beyond the scope of this assignment. Therefore, this discussion is just a brief cursory overview that is helpful for me as a useful as a form of rudimentary case conceptualization.

Addressing Key Stressors For LGB Youth.

“Four stressors are of particular importance to lesbian, bisexual and gay youth, (a) overt acts of abuse, harassment, and violence, (2) development of one’s identity as a sexual minority person and related internalized homophobia, (3) disclosure of sexual orientation to others and related lack of adult social support, and (4) development of platonic and romantic relationships with other lesbian, gay male, and bisexual peers.” (Safran, et al, 2001, p217)

Understanding key issues associated with a stigmatized sexual minority status as an LGB youth is one critical matter that cannot go without mention. When you consider the overt expressions of hatred, heteronormative environments along with a scarcity of social support, the heightened risks to an individual’s well being become clear. An article titled “Cognitive Behavioral Therapy with Lesbian, Gay and Bisexual Youth”, lists stress reduction, anxiety, and depression as three key issues for individuals in this community, (Safran, et al, 2001).  I discuss each of these in turn briefly below:

Depression & CBT.

As per the cognitive behavioral perspective, stigmatizing experiences alongside negative environment factors and a “dysfunctional attribution style” are what lead to feelings of hopelessness in LGB a youth (Safren, et al, 2001). Utilizing CBT techniques such as cognitive restructuring are useful in addressing negative preconceptions of any same-sex attraction, (Safren, et al, 2001, p221).   Alleviating thinking errors such as “catastrophizing” (Safrem, et sl, 2001), and self-blame, can help with depressive systems. The importance of this consideration becomes clear in light of the higher rates of substance abuse and suicide associated with the greater prevalence of depression,

Anxiety & CBT.

It’s not surprising that LGB youth experience higher rates of social anxiety when you consider the lack of social support they often receive. In fact, preconceived “what if’s”, (often in the form of worst case scenario conceptions), frequently underlie this anxiety, and can produce an avoidance-based coping style. Ultimately, this fear of self-disclosure and social situations can only limit normal adolescent development.   Assisting LGB youth through cognitive restructuring and varied forms of social support can give these individuals a new frame of reference with which to move forward (Safran, 2001).

Stress Reduction & CBT.

“It is not the stressors themselves that cause depression but that one’s cognitive interpretation plays a mediating role. From a cognitive-behavioral perspective, external acts of homophobia, if occurring chronically, uncontrollably, or unpredictably, can lead to internalized homophobia, as well as helpless or hopeless attributions.” (Safram, 2001, p222).

Addressing one’s ability to cope with daily stressors is yet a final key priority that cannot go without mention. In fact, I find this notion of internalized homophobia as a root cause especially troubling. It will be useful to conclude this paper by discussing internalized homophobia (and the stress that comes with it), from within the framework of the earlier discussion.

Firstly, it is important to note that LGB discrimination is best understood as “a learned form of social control of deviance”, (Herek & Greene, 1998, p7). Stigma resulting from this is simply due to holding a characteristic which “is contrary to a norm of social unity”, (Herek & Greene, 1998, p108). Based on these definitions, internalized homophobia can be thought of as a stigmatized self-concept based on discriminatory experiences. This internalized homophobia, influencing ones identity and belief systems, produces minority stress as a result, (Herek & Greene, 1998; Meyer, 2003).

Having said all this, I conclude with the thought that it seems once belief systems of ourselves become internalized they exist as self fulfilling prophecies. We become what we believe we are and get what we are told is possible. CBT a can become a much-need coping tool in this by helping LGB youth understand they always have the ability to choose otherwise.

PART TWO: Exploratory Exercise Paper….

((ABSTRACT – In this paper I provide a summary of my experiences in joining in with an LGBTQI University Organization Meeting.  I start with a review of relevant literature and end with a discussion of insights gained.  From this experience I have concluded that continued service within this community is essential in order to serve it effectively as an LGBTQI ally.))

Initial Thoughts

Approximately, 33% of females and 37% of males have had a climax with somebody of the same sex after 18 (Rosenthal, 2005).  Additionally about 10% of the U.S. Population identifies as gay & lesbian (Rosenthal, 2005).  A quick literature review shows a higher rate of mental health diagnosis, substance use, and suicide within the LGBT community as a whole (Biescheke, et al, 2007; Herek & Green, 1998).    Additionally, mental health diagnoses heightened in the areas of depression and substance use (Biescheke, et al, 2007; Herek & Green, 1998).  Additionally, a book titled “Stigma & Sexual Orientation (Herek & Green, 1998), makes it clear that discrimination (and the stigma that exists as result) are predominant causes of these high rates of mental health and substance abuse problems.

To understand this discrimination as cause, it is important to step back and understand the concept of identity a bit.  As the above quote alludes to, identity is an internalized construct of the self, based on an interaction with others and the environment.  When you consider how discriminatory acts against one’s very identity, I can only imagine how stigmatizing and shame-inducing and invalidating this might be. Defined as “a characteristic of person’s that is contrary to a norm of social unity” (Herek & Green, 1998, p. 108), stigma can produce a highly problematic identity formation process.  When taken alongside ostracizing reactions of family and friends LGBT individual’s internalized homophobia, transphobia and minority stress are often the norm (Herek & Green, 1998).

Summary of my Experience…

(((Here I provide just brief excerpts from my paper, in order to show, that there is much left to learn.  As I have discovered, intention means little if there is no action to back it up.  Understanding the privilege that comes with being a cisgendered heterosexual is critical.  Ignorance is never an excuse for any shortcomings in my desire to act as an LGBTQI ally as a future counselor)))

The Importance of Community….

“An element included in virtually all sexual-orientation models is finding and developing some sort of connection to the LGBT community. Community is important in helping break the sense of isolation and despair that can occur from being different, which is an early piece of identity development, (Biescheke, et al, 2007, p. 213).”

The first thing that struck me was how welcoming and friendly everyone was.  While I am a cisgendered heterosexual, I felt an immediate belonging and camaraderie within the group.  As a bullied child with few friends, I also struggled in my teens and 20’s.  It is for this reason, that I immediately appreciated the efforts of this organization to provide members a chance to interact with others who implicitly understood them.  The interaction was light-hearted and fun.  We decorated cookies while watching a movie and engaged in casual conversation.

In-Group Trust.

Implicit social norms existed that presumed an understanding of relevant social norms.  These implied social norms appeared to allow a heightened level of trust to exist amongst participants regarding things such as proper rules of preferred pronoun usage for example.   As somebody mentioned to me at one point: “It is simply nice to just hang out and have fun”.  This comment really struck me as I came to appreciate in that moment the privilege of cisgendered heterosexual.   I was able to just be me unselfconsciously.  For example, the idea of being “clocked” as a trans person, puts you constantly on edge.  I came to realize how luck I was to not know what this is like.  The idea of in-group trust stands out as a essential from this perspective.  Community organizations such as this provide participants a chance to be themselves “unselfconsciously” as I live my life 100% of the time.

I left the experience wondering if my own ignorance regarding the LGBTQI community reflected what I’ve witnessed within the extended family as a biracial child.  While I cringed at the thought of this, I reminded myself that all I can do by denying this fact is perpetuate it.  Self-awareness, on the other hand, is ultimately empowering if it leads to change and growth.

“privilege also tends to isolate people, cutting them off from information and experiences related to specific minority groups that could be helpful and enrich their lives…privileged areas are often in those areas in which people hold the least awareness.” (Hays, 2008, p. 42).

Identity as a Foundation of Self

During this meeting I became aware elemental sexual preference and gender identity are as fundamental aspects of daily living.  While conceived of in black and white terms for the cisgendered heterosexuals,  these concepts in reality are much more fluid. This fact helped me understand better why LGBT community in Omaha was so protective.   I left this experience with a profound realization of how being LGBTQI can potentially affect  all aspects of your life.

In-Group Diversity

The LGBTQI community is very diverse and is an umbrella term that comprises many sub-groups.  For example, sexual orientations vary greatly from lesbian, gay, bisexual, and even asexual.  Additionally within the trans community you have concepts such as FTM, MTF, bigender, gender, trans, and genderqueer.

**Here’s a link to a list of terms that I could useful.
**Here are some tips to being a better LGBTQI ally.

In conclusion, it appears there is much left for me to learn.  Developing multicultural competency will be a life-long commitment & personal journey as I increase my understanding of those communities I hope to serve within.  


Bieschke, K.J., Perez, R.M., & DeBord, K.A. (2007). Handbook of Counseling and Psychotherapy with Lesbian, Gay, Bisexual and Transgender Clients. Washington D.C.: American Psychological Association.
Bilodeau, B.L. & Renn, K.A. (2005).  Analysis of LGBT Identity Development Models and Implications for Practice. Gender Identity and Sexual Orientation: Research, Policy and Personality. 111, pp. 25-39.  
Hays, P. (2008). Addressing cultural complexities in practice. (2nd ed.) Washington, D.C.: American Psychological Association.
Hays, P., & Iwasama, G.Y. (2006). Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, & Supervision. Washington, D.C.: American PsychologicalAssociation.
Herek, G.M. & Green, B. (Eds.) (1998). Stigma and Sexual Orientation. (Vol. 4). Thousand Oaks, CA: Sage Publications.
Johnson, R. (2013) Forensic and Culturally Responsive Approach for the DSM-5: Just the Facts. Journal of Theory Construction & testing. 17(1), 18-22.
LGBTQI (2014). About LGBTQI+ In Lincoln, Nebraska. Lincoln, NE: University of Nebraska Lincoln.
Mays, V.M., Cochran, S.D. (2001). Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. American Journal of Public Health. 91(11). 1869-1976.
Meyer, I.H. (2003). Prejudice, social stress and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin. 129(5). 684-697.
Rosenthal, H. (2005). Vital Information and Review Questions for the NCE and State Counseling Exams. Routledge.
Safren, S.A., Hollander, G., Hart, T.A., & Heimberg, R.G. (2001). Cognitive-behavioral therapy with lesbian, gay and bisexual youth. Cognitive and Behavioral Practice. 8. 215-223.
Sage Productions. (2014) Working with Gay/Lesbian and Youth Clients. Retrieved from:
Stets, J. E., & Burke, P. J. (2000). Identity theory and social identity theory. Social Psychology Quarterly, 63(3), 224-237. Retrieved from






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NCE STUDY – Asian American Families

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

Understanding Acculturation…

“Asian Americans represent a wide range of diversity to the extent to which they have adopted the norms of the dominant US culture and retained the norms of the traditional Asian culture” (Trihn, et al, 2009, p. 25).  While enculturation is the process of acquiring the norms and values of a particular culture, acculturation is a process of socialization that occurs when an individual is influenced by two cultures.  With acculturation, immigrants struggle to maintain values from their country of origin, while learning to adapt to the norms of the dominant culture they live in.   The process of acculturation differe greatly from family to family as well as amongst individual members.  Triton, et al, (2009) notes that a “problematic distancing occurs between immigrant parents and children” (p. 27), when varied rates of acculturation occur within each generation.  This is commonly known as a “cultural gap”, wherein “parents tend to cling to values from their culture of origin….[while] children might increasingly adopt the norms of the dominant society (Trihn, et al, 2009, p. 29).  As I have experienced personally within my own diverse extended family, children are often raised hearing mixed message and are left to “figure things out” on their own.  LaFramboise, et al, (1993) define acculturative stress as a “worsened mental health status…anxiety, depression, feelings of marginality, alienation, and identity confusion (p. 29).”  Lee, et al, (1996), describe five types of Asian Families based on the dynamics of this acculturative transition

  • TRADITIONAL FAMILIES: “consist entirely of individuals born and raised in Asia, with little exposure to Western Culture (Lee, et al, 1996, p. 275)
  • FAMILIES IN CONFLICT:  Families in conflict often immigrate to the United States with young children.  As a result, children are acculturated into American society while parents and grandparents tend to uphold traditional values.
  • BICULTURAL FAMILIES:  La Framboise, et al, (1993) defines biculturalism as an ability to operate effectively within two cultures.  As a result, well acculturated parents, who hope to instill in their children a pride and appreciation for their own ethnic identity.
  • AMERICANIZED FAMILIES: All family members adopt mainstream cultural values.  My mother has preferred to adopt this acculturative style, and as a result I know little about her home country
  • NEW MILLENNIUM FAMILIES:  These families go “beyond prior cultural expectations and are forging new identities…’integrate multiple cultures… (Lee, et al, 1996, 275)”  ‘

Values & Belief Systems…

Asian Americans comprise about 3% of the U.S. population, (4,000,000 people), (Rosenthal, 2005).  By 2050 it is estimated that this population will grow to about 8%.  Relatively little is known in literature about Asian Americans.  Rosenthal, (2005) states that “one theory for this is that very few Asian Americans have very few problems and are very successful and thus researchers are not giving this group attention that they deserve.”  What follows is a “quick and dirty” overview of key insights that should be kept in mind when counseling Asian clients..

  1. COLLECTIVIST IDENTITY:  As an American it is important to understand a collectivist identity.  Doing so requires one to set aside, (for the time being) the idea of individualism.  Seeing yourself as part of something greater than yourself is essential.  Identity is constructed based on a different point of reference.  For example, in my mother’s culture life centers around family and plays a central role in daily life.
  2. PATRIARCHAL FAMILY LIFE: The vast majority of Asian cultures have a very patriarchal structure, where the dad has a wealth of authority (Rosenthal, 2005).  However, the degree of patriarchalism that is presented in an Asian family, depends on the degree of acculturation.  Additionally, Asian countries with a greater westernized sociocultural influences tend to be more egalitarian in nature.  This is especially true in the Philippines, where my mother was raised.
  3. GUILT & SHAME:  My mother comes from a collectivist culture in which family life is central to daily living.  For example, she is still called “Nene” which means baby.   Additionally, she discusses the notion of “DUTY” as a responsibility to her family.  This notion of “duty”, while foreign to me is very important to her.  It is by fulfilling this “duty” to family members that she expresses her love as a wife, mother, sister, and daughter.  Integral in this belief system is a form of social control that parents utilize on children to encourage compliance.  Failure to respect your elders and live up to your “duty” can produce feelings of shame and guilt.
  4. COLLECTIVE TRAUMA:  Asian families often have complex migration histories that involve political upheaval and wartime experiences (Lee, et al, 1996).  For example, my mother’s family survived WW2 and eventually immigrated to the United States for a better life.  A complex history of trauma exists within their family history with lasting, profound effects.
  5. ACADEMIC PRESSURE – There is a greater pressure to succeed within Asian families.  For example, Rosenthal (2005) notes that while 41% Asian mothers say academic is critical, only 11% of white mothers hold this belief.
  6. BODILY COMPLAINTS EQUATED WITH EMOTIONAL ILLS (Rosenthal, 2005).  Rosenthal notes that oftentimes Asian cultures equate emotional problems with physical ailments.  As a result, it will be important to investigate all physical complaints thoroughly to develop an understanding of the underlying cause.
  7. LESS LIKELY TO SEEK THERAPY –  Rosenthal, (2008) also notes that Asian Americans are less likely than other demographics to seek therapy.  As a result, when thy do seek therapy, they are often extremely disturbed.  Additionally, Rosenthal (2008) states Asian Americans have a higher incidents of depression than any other minority group.
  8. STOICIM = MATURITY:  In many Asian cultures, a “lack of emotional expression represents maturity…[and] silence is seen as an act of respect.” (Rosenthal, 2008).  As a result, it will be important for therapist to “carry ball more” (Rosenthal, 2008) during therapy and lead the conversation with well-thought out questions.

ADDENDUM:  Exploratory Interview Paper.

In this paper I share the insights gained from an interview with my mother. In addition to learning about my mother’s background, I got to know more of our relationship with one another from her perspective.   I will begin by utilizing the addressing model and move on with a summary of the interview. In addition to sharing insights about my mother’s culture, I will add a bit of personal reflective commentary. At the end of this paper I have provide a transcription of the recorded interview.

Utilizing the Addressing Model

In this section, I utilize the Addressing model, as discussed in our textbook. This model acts as a framework around which to explore the influence of my mother’s culture on her own belief systems. As I have come to understand it, these cultural belief systems, affect many elements of a person’s life. In addition to defining a life perspective it also influences your identity, feelings, thoughts, and interactions with others, (Fortune, 2012; Hays, 2008). The cultural gap has between us has been an ongoing struggle.  The importance of multicultural sensitivity is vividly apparent to me. For the sake of brevity, I discuss the key areas of greatest relevance for my mother, having the biggest impact on her identity. I provide only a brief overview of details relevant to my mother’s life history within each relevant area. In a later section I share these specific arenas of life were relevant to her development in her own words.

Age and Generational Influences.

The Silent Generation. My mother was born in the Philippines in 1938, moved to the states in 1965, and has lived here since.   A member of the silent generation that preceded the baby boomers, my mother’s earliest years were in the midst of a war. While she has little memory of her earliest years of life, according to records she’s uncovered, her dad signed up for the “USAFE” (United States Army of the Far East), just one day after the bombing of Pearl Harbor. The date this occurred was December 8th, of 1941.   With her father away, her mother was left alone with a three year old and five year old.   While completely ignorant of the realities of war in my own life, I have an appreciation of the effects it had on my mother’s family.   They had to develop a toughness that served them well as the war came to a close in their survival.

Extended Family Influences. The Philippines is much more collectivist in its orientation in comparison to the United States which is clearly individualistic (Fortune, 2012; Root, 1997). The extended family is central to one’s life and identity. For example, in the United States the focus is on our own goals their achievement. In the Philippines, on the other hand, the well being of the extended family is a primary consideration (Fortune 2012; Root 1997). This can be seen in the way members of the family, will sacrifice of themselves, for the sake of the family. It can also be realized in the way family harmony and psychological-well being of the extended group takes precedence over individual insecurities and any need to vent pent up emotions (Fortune 2012).

Extended family influences go well beyond one’s degree of personal orientation toward a collective unit. According to my mother, the Philippines is very much a melting pot. While the majority of the country is Catholic, they also display influences from other religions such as Confucianism. As a result of this, it is a well-known but unspoken rule within the family that children display absolute obedience to elders. Any elders, whether strangers, older brothers, parents, uncles are to be shown respect. Finally, one interesting fact seems to illustrate to me how much membership to the family defines your identity. Within the family, siblings do not call each other by name, but by birth order.   My mother was “Nene”, as the youngest in the family, this word in Tagalog means “baby”. My aunt on the other hand was the older sister and was called “Ate”, for big sister.

Developmental Disabilities.

While my mother has no disabilities to speak of, she is a retired Clinical Cytogeneticist and worked in the Center for Developmental Disabilities at the University of South Dakota. One of her tasks was counseling parents of children with developmental disabilities. Her support was very critical when my oldest son was born with a congenital heart defect.   Very ill, needing several heart surgeries, these medical issues affected his childhood development for quite some time. Through her support and educated background, I feel I was able to handle the situation well as a parent of a sick child.

National Origin & Racial Identity.

Racial Identity. As a Filipino who immigrated to the United States in the 60’s my mother is definitely a minority in this culture. Having said this, she does make a point to note that she was raised in the Philippines, and was part of the “majority” there.   Everyone, like her was Filipino, and so race was an inconsequential issue she gave little thought to. Therefore, issues such as “Insidious Trauma”, (defined by Maria Root as “trauma associated by a devalued identity in a dominant culture,” (Hays, 2008, p115)), don’t apply to her.

This isn’t to say she didn’t experience racism, as she will note in her interview summary below. Nonetheless, she has noted a set of coping skills that many who had lived their entire lives as a minority didn’t have.   Part of the problem for many who were raised here, she notes, is the racism experienced, was throughout critical years of childhood development. Nonetheless, she also says there is more to the issue that. While the Philippines and American are both melting pots, she has stated there was a different preconceived reaction to the idea of different groups blending together. Growing up, it was know the Philippines was a melting pot was a non-issue and that everyone there was the byproduct of many blended cultures.   In fact, there are Spanish, and Chinese ancestors in her family. In contrast to this, she felt this culture seemed to hold the idea of differences between various groups as being significant in a way she didn’t understand. For example, the idea of marrying a white man and having mixed kids to her wasn’t a big deal. Despite this, in the late 60’s and early 70’s she felt people reacted sometimes to this in a manner she didn’t quite understand.

National Origin. As an immigrant, my mother’s biggest issues have been associated with attempting to honor her own values while having to learn about a whole new culture. Finding a balance between these two competing value systems is best described as “bicultural competence” (LaFramboise, et al, 1993). The greatest ambivalence she experienced was in raising her two daughters. Living in a small town in the Midwest with few minorities and foreigners, she had little support. Adding to this was the fact that she was separated from her extended family, another critical support system, unavailable to her.

Socioeconomic Status.

My mother’s socioeconomic status and background are quite intriguing to me. Currently, my mother and father are both retired doctors and upper middle class in their background. Additionally, growing up, her extended family was also considered solidly upper middle class.   For example, she notes her parents were able to afford to put two girls through medical school. Without any loan programs, advanced education, was available only to those who could afford it. She was very lucky.

On the other hand, despite this fact, there are a few unique details that differentiate the meaning of social class for my mother.   Firstly, she said, the overall standard of living was different from the United States.   This made her experiences of blending into my dad’s upper middle class background still quite difficult. She didn’t quite understand the materialistic perspective whereby your possessions defined your worth.   Her perspective is really of the need for essentials in life: food, clothing, and shelter. While she does enjoy having things, it was simply for how they reminded her of “back home”. She didn’t feel it reflected on her worth as a person.

Still, having said all this, the critical cultural differences she dealt with go much deeper. In the aftermath of the Second World War, her family lost everything, but “the clothes on their backs”.   Having to work hard and rebuild their lives, she simply states the overall life perspective on things is entirely different, and “hard to put words to”.

Religious Practices.

Spain came to the Philippines in 1400 and ruled there until the late 1800’s. As a result of Spain’s influences: (1) many words in Tagalog are of Spanish origin, (2) many last names are of Spanish origin, and (3) the primary religion practiced by 95% of the population is Catholicism.

Adherence to Catholicism as a member of the church community was vital to my mother’s family. For example, she said they all said the rosary every night. On Sundays all 24 of her cousins went to mass every Sunday, sitting in the same two pews every week with Grandma behind them to ensure they behaved. She warned them of their misbehavior with a flick on the ear.

Gender Roles.

Due to America’s influences, the Philippines has a very egalitarian view of the genders. For example, within the extended family system, the oldest child in the extended family is considered head of family, whether male or female. In fact, my mother said her family was very matriarchal in nature with the last two family heads being female.

After the Second World War, her maternal grandmother was a widow, and left as matriarch of the family until her passing. After her death, my moms own mother became family head as “Ate” of her four younger brothers and sisters. Everybody respected them both as head of the family and did as they said.

Also notable of the matriarchal vibe in the family was the fact that all family resources were devoted to equally toward both men and women pursuing advanced degrees. When you consider the fact that this occurred in the 30’s for my grandmother’s generation, its really quite remarkable.   In conclusion, its also interesting to note that the women surpassed the men in performance, with all finishing their education and even earning advanced degrees.

Cultural Assessment Interview Summary

While the previous section provides a perspective of my mother from within the Addressing Model, this section provides an overview of her life in her own words. At the end of each section I will include a few of my own personal thoughts.

Early Traumas

“I don’t remember much of my early years. I was born in 1938 and the war started in 1941 by the time the war started I was three years old…. I don’t remember much about growing up in a normal sense, such as reading books and going to bed at night since were refugees of the second world war and were living in caves alongside mountains, growing our own food…” (Johnson, 2014)

When the war came to a conclusion, my mother was about six years old.  Life for her in the aftermath of war was very different from life in America.  Nobody had anything and all people were left to rebuild their lives from search.  her parents were educated and were fortunate to find jobs.  Her mother was a schoolteacher.  Her father took advantage of the GI Bill as a former soldier of the USAFE and became an engineer.  While I have been able to talk with my mother about these experiences, I’ve come to understand that some caution needs to be taken when discussing these issues.  There is often an unspoken rule amongst my mom’s family that you aren’t to bring that stuff up, because it is too painful.  Having said that, I am grateful my mother has shared these experiences with me.  It has helped me understand how these early experiences influenced her.

Limiting Emotional Expression.

There are two key characteristics within my mom’s culture that influence how emotions are expressed:

  • RESPECT YOUR ELDERS:  As stated earlier, in my mom’s culture an authoritarian parenting style was the norm.  In the case of war, this was clearly essential for survival.  Absolute respect was essential and meant listing to mom for the sake of survival.
  • FAMILY WELL-BEING IS FIRST:  Thinking of the family collective unit first is essential during wartime.  Within my mother’s family the idea of harmonious family relations was important.  Making this a priority over personal feelings meant suppressing our own private needs for the sake of harmony and to avoid strife.

Material Loss & Gain.

In a recent conversation since our interview, my mother complained about something my sister said recently.  She allowed me to record this portion of our conversation on Skype since it was relevant to the topic at hand:

“You know what Dorene said to me? ‘Kevin and I decided we are not going to have all this stuff’, who a swish of her hand.  She waved her hand out from her chest while holding Audrey…”Stuff” as in all the things in our house.  I thought to myself: ‘Dorene I like them, I collected them.  I crocheted the afghans, I made the quilts, and sanded the refurbished furniture.  It has my guts and soul in it’  I had to say to myself ‘cool it Virginia’… Yet when you think about it, she was absolutely right in her viewpoint.  To her they are meaningless.  Nonetheless for me, understand I wanted frilly homey things.  My take on this, is that I want memories from back home, since I took none of this with me when I moved to the states.  Like my mother’s Queen Anne dining table and chairs.  I couldn’t take it with me.  I left home with two suitcases and only my memories.” (Virginia, 2014)

As I heard of the misunderstanding between my mother and sister, I couldn’t help but think of the things from within the perspective of this assignment.  My mother’s early childhood was filled with tremendous loss.  After the war, at the age of 7 she had to work with her family to rebuild their lives from nothing.  She learned to work hard, remain tough, and as a result is appreciative of what she has.  Additionally, she put much time creating things as her form of “art”.  What’s interesting is that since everybody after the war was in the same situation, nobody was better than anybody else.  The American notion that our material possessions can define our social class wasn’t relevant then.

As a result of all this, today she sees her material possessions as reflective of memories of “back home”  They also reflect all the hard work she’s endured to get to where she is.  They hold value that isn’t quite understood from an American materialistic perspective.

Social Expectations & Generational Influences.

“When you were born what were the social expectations of a person of your identity?…What generational roles make up your core identity? (Ajuoga, 2014).”

The differences between parenting styles and family structure stand at the forefront as key insights that make the Philippines different from the states.  I discuss these below alongside my mother’s struggles to raise two daughters in a foreign culture.

Parenting Styles.  Parenting styles in the United States are very different form where my mother grew up.  While she says we are more friendly, empathetic and familiar, parents are more authoritarian in the Philippines.

As a child in the Philippines you are to be seen but not heard. Crying and whining are not allowed, whether or not you are at home or in public. We are supposed to behave and remain compliant. So parents there were more authoritative and less empathetic….American parents are so much more permissive. In a way it is great at times, but you see American kids whine and whine, until they get their way. Over here kids are so much more familiar…The other thing in America because of all this permissiveness, the spinoff is kids are left disrespecting authority, and are less compliant as a result. In the Philippines kids are compliant, we comply with what our elders tell us, that’s the biggest difference. (Johnson, 2014).

Extended Family Structure.  

…I think it’s also easier in the Philippines growing up because of the extended family system. I had 24 cousins we all lived on Grandma’s piece of land, building five houses on it. It was a communal area we spilled out of the houses, and played together….The family structure in the Philippines, I think this is because we are Southeast Asian. you know of Confucianism? Philippines is a melting pot, Spain came to the Philippines in 1400, so we are Christian, but we do have a lot of Chinese, Japanese, and Indian emigrating to the Philippines. So there is also Confucianism, and it you revere your ancestors. As a matter of fact, there are names for the first-born son. My mother is firstborn, she is called “Ate”, they call her this and not Maria.   The second born is called “Eche”, that is my aunt who is a Physician. You call siblings by birth order. I was “Nene” which means baby for the youngest child. I am the youngest. You are supposed to respect your elders….” (Johnson, 2014)

The above quote points out a critical difference between American and Filipino family structures.  Family order is a critical component of one’s identity.  My mother was called “Nene”.  She was always called this whenever we visited, even as an adult.  In this respect, generational influences carry a greater weight as a component of one’s identity.

Education in Biculturalism.

I was never conflicted in my identity, I just was clueless about much regarding raising kids here. I should have kept up on what went on with your education. I should have been more on top of enforcing you to do well. You guys didn’t tell me anything. I remember a lady in church say jokingly, “I hear Dorene has a boyfriend”.   I just smiled and nodded. I only found out your sister was dating this way.   There are so many different kinds of kids and different kinds of parents.   No one child is the same. Every child has different needs, every parent has a unique set of life experiences. I think in your case you wanted to spare my feelings because I was a foreigner. You didn’t tell me what was going on.

As the quote above indicates, my mother’s greatest difficulty was in trying to figure out how to raise us in a different culture.  With a set of normative values drastically different than what she was familiar with she struggled with an ongoing internal conflict.  She wanted to remain true to her own values while helping us adjust in American Culture.  It’s interesting to note that my mother’s own acknowledgement of my struggles at the end of the quote here.  Very protective of her, I kept many of my struggles in fitting in to myself.

Norms & Values.

“When you were a teenager, what were the norms, values & gender roles supported within your family, peers, culture and in the dominant culture (Ajuoga, 2014)”

Key differences in norms between my mother’s culture and my own appear to be the greatest in the areas of dating, money and parental control.  I provide my mother’s thoughts on these areas below.

Adolescence & Dating.

“The other reality of my upbringing in the Philippines was you didn’t date until College. By the time you are in college you have some degree of maturity and did it then. We didn’t drink in high school, we did not date, we had no car, and there were no extracurricular activities in our public schools. Our society couldn’t afford them as you can here. When you go home you walk or take the bus and your mother was there. The norm was that you maintained your virginity as a girl. I was a virgin for a long time, because I was never propositioned. The boys don’t propositioned the girls.   I don’t think teenage boys that young, are knowledgeable of how to do such things…..There is a strong need in adolescence to be popular and fit in. There is a ladder, like a pecking scale. Teenagers are so insecure it seems like so much to handle at that age….As a girl, we didn’t wear makeup. In college you wear lipstick. This is when you start dating college….. There was really no bullying, because in school, if you are picked on at recess, you have many cousins and relatives to stand up for you. There is always a bigger and older cousin or sibling looking out for you. On the same note, if you are misbehaving, they will also inform adults, and you will be punished. This is because the reputation of the family is important, and protected in this respect. My mother’s family, the Gonzales family, has a good reputation in town. Among all 24 cousins, nobody got in trouble, and we were all upstanding citizens. I all these respects it’s a much safer environment. (Johnson, 2014).”

In my home my mother made the rules, my father was busy with his job much of the time and preferred to leave such issues to her.  As a result, I did suffer quite a bit of difficulty with fitting in.  I felt there existed a notion of ‘normal’ as in how I am supposed to be around my peers but yet I wasn’t taught how to be that.  I stood out.  I didn’t wear makeup, or dress like the other girls.  I was clueless in the realm of dating and didn’t experience my first kiss until my second year of college.  I was entirely on my own in figuring things out in this culture.  With American High Schools centered around fitting it, I was definitely an oddball, and bullied endlessly.

Adolescence and Money.

“there were no extracurricular activities in our public schools. Our society couldn’t afford them as you can here. When you go home you walk or take the bus and your mother was there. The norm was that you maintained your virginity as a girl….We had no money as teenagers.  We didn’t work at McDonalds. Boys and girls have no money. Many families can’t afford a car. We didn’t own a car until High School. We didn’t have a television until High School. We had crushes like everyone. It was never actualized. In the Philippines you did what your elders said and accept their wisdom. We don’t have the high school wisdom, they ‘don’t understand'” (Johnson, 2014).”

With fewer resources available, and entirely reliant of parents, adolescent life in the Philippines was very different. She would struggle with the idea of allowing us to have what we wanted.  For example, she says also makes the following comment in our interview:

“You wanted moon boots or Gloria Vanderbilt jeans, do I relent, yes or no? Just because that’s what everybody else in this culture is doing, does that mean you must as well?” (Johnson, 2014).

Her measuring stick was very different.  With the life of the average middle class family very different in the Philippines, she didn’t understand our desire for “things”.  She always had a problem with the idea that fitting in for girls meant dating and having certain clothes.

Adolescence & Rebellion.  

In the Philippines you did what your elders said and accept their wisdom. We don’t have the high school wisdom, they “don’t understand”, sums up a complaint of American kids. Even if you don’t take the advice, by asking it, they might make you their favorite. They appreciate this…On the same note, if you are misbehaving, they will also inform adults, and you will be punished. This is because the reputation of the family is important, and protected in this respect. My mother’s family, the Gonzales family, has a good reputation in town. Among all 24 cousins, nobody got in trouble, and we were all upstanding citizens. In all these respects it’s a much safer environment.” (Johnson, 2014).

When I was growing up, I remember my mother absolutely hated the Golden Girls and Rosanne.  These two television shows bothered her.  She felt everybody was so disrespectful.  There was a clear standard within our family that you are to be respectful and not allow your emotions to get away with you.  As two intellectual individuals, my parents were very stoic.  I felt they weren’t too interested int he open expression of emotion.

Social Movements in Teens.

“How was your view of the world shaped by the social movements of your teenage years (Ajouga, 2014).”

If there were any social movements which stand out for my mother it was the influence of Hollywood and the influx of American influence into her culture during the Post World-War 2 era:

“We are very westernized as a country and were very much influenced by America. I grew up with Elvis Presley, Patsy Cline, and The Everly Brothers. We saw movies and T.V. too, such as Mission Impossible, Bonanza, and I Love Lucy. American Music influenced me, because you heard it on the radio. We did have magazines, but I didn’t have television until high school. As a matter of fact, Rebecca would write celebrities and receive a signed letter from them. We didn’t have any social movements resulting from teenage angst, or youth rebellion, (Johnson, 2014).”

Educational & Occupational Opportunity.

“When you were a young adult, what educational and occupational opportunities were available to you?” (Ajuoga, 2014).  

“The reason we are compliant with our elders is because you rely on them for education as well as food, clothing, and shelter. In the Philippines it is somewhat a given that the parents pay for the child’s education, if able to at all. If you have the drive and ability, you are encouraged to go to College. Your ability to go to college is ability of your parents to pay. This is because there are no Federally Guaranteed Student Loans.   This is what’s different about America. Anybody here can get an education. Back home, if parents are well off, you stand on their shoulders as they pay your education. If not, you can have the ability, but not the resources to get a degree. It really is also an unspoken fact that when you do finish your education, you better have a marketable skill, career, and you support your elders in their old age because basically they gave up their retirement for your education.   Usually in the Philippines, the parents live in the kids’ house. Grandma then does the babysitting and usually does it for free. That also makes it difficult to get away from things, because Grandma is there to watch over everyone.   The education of your child is your form of retirement, (Johnson, 2014)”

The one thing I remember my mother always complained about growing up, is the issue of popularity in the United States.  It always distressed her how much it seemed peer group interactions influenced our identity as a person.  In her culture, education is available to those who can afford it.  As a result, in a respect, it enforces social class structures there.  Those who can afford, continue sending kids to college, so they have greater work opportunities.  Those who work can’t afford it don’t, and so consequently climbing out of poverty is quite difficult.

As a result of this, in adolescence, academic achievement is higher in importance for kids.  Children are divided into groupings in her school by academic achievement.  The ones in class number one were the high achievers and everybody looked up to them.   She also said the school displayed everyone’s grades in the town center on an announcement board for everyone to see.

Life in the States.

The entire quote below consists of my mother’s concluding remarks regarding how she transitioned to life in the states.  I have nothing to say about what is written below, other than I have a lot of respect for her.  She was quite young and yet very secure in who she was.

“When I moved here back as a resident, I had a good command of the language. the Filipino t.v. Anchors speak American Midwest English. I have trouble understanding other accents, but Midwest accents make sense to me. The thing I had trouble with were idioms such as “the cat’s meow”. I do feel my fellow residence at Baylor treated me fairly, although I was the only female, foreigner, minority in the program.   Although I do believe I imposed this upon myself, I felt I had to be twice as good to be good enough. I felt determined to prove myself. I was over prepared with a goal to do twice as good as anyone else. What did help is my older sister was already a resident at Baylor going to school. We were there together. I do remember people sometimes were surprised I was the housekeeping staff and not the physician in scrubs, so I learned to dress well and look the part. You know if I received discrimination from patients at times who didn’t want me to care for them because of my color. Oftentimes they were minorities like me, which surprised me. Nonetheless, I had to work hard to prove myself over time.   There was a time when I had trouble on the bus system. I took myself at face value, yet there were people who felt I shouldn’t sit here at a certain location on the bus. Since it wasn’t illegal to do so, I would stay there. They were the ignoramuses. I found it hurts only you if you put value upon the opinions of those people. I know who I am and stick to that identity of myself. To tell you the truth today, I don’t think of myself in terms of race, but as a person. The same goes for you, your sister or your father.   We are just a family; people.   I didn’t have the effects of being a minority growing up. While the Philippines is a melting pot country, but it was less “in your face” as an issue. In this country, it is more an issue in an “in your face manner”.   Back home, we are so diverse as people it wasn’t an issue. I, for example, have Spanish and Chinese in my family background, as do you through me….I’m being fair to each child. You give your child what they need, as they need it. Make your own way. Let go of any old gripes they aren’t worth the familial disharmony. Your successes are your own, as are your failures. I see myself as me; I am Virginia first and foremost. Race in a respect is a social construct, not genetic fact.   My identity is a choice of my own that I make it for myself irrespective of what comes at me from the race perspective, (Johnson, 2014).”


Ajouga, P. (2014). Re: MCC 638 Week Four Overview. Retrieved from:
Fortune, B.A. (2012). Acculturation, intergenerational conflict, psychological distress and  stress in Filipino-American families. Regent University, Virginia.
Hays, P., & Iwasama, G.Y. (2006). Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, & Supervision. Washington, D.C.: American Psychological Association.
Hays, P. (2008). Addressing cultural complexities in practice. (2nd Ed.) Washington, D.C.: American Psychological Association.
LaFromboise, Coleman, H.L.K. & Gerton, J. (1993). Psychological impact of biculturalism: Evidence and theory. Psychological Bulletin. 114(3) 395-412.
Lee, E, McGoldrick, Monica, Giordano, J, Pearce, J.K., (1996) Ethnicity and Family Therapy (2nd Ed.), (pp. 227-248) NY, NY: Guilford Press.
N. H. Trinh et al. (eds.), (2009).  Handbook of Mental Health and Acculturation in Asian American Families, Current Clinical Psychiatry, DOI 10.1007/978-1-60327-437-1z
Root, M. P. (1997). Filipino Americans : Transformation and Identity. Thousand Oaks: SAGE Publications.


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NCE STUDY – Counseling Older Adults

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

QUESTION: “How can you develop sensitivity to culturally diverse older adults?”


The first idea that comes to mind, as a result of everything I’ve learned in this course, is the idea of working developing a working knowledge base. This means having a knowledge of various theories and as well as current research.   Admittedly this is not enough in and of itself. Nonetheless having a basis of knowledge to begin assessing and contextualizing client experiences can help provide essential insights to guide the counselor through the therapy process.


The second idea I’ve learned from this course is the idea of learning through direct contact within those communities we hope to serve within. Naturally, you can only so much about human beings, and relevant interpersonal skills through reading and study.


There is one final insight relevant to this question and it comes from two sources. The first insight comes from the following quote in our Hays textbook:

“Eclecticism in psychotherapy can take two general terms. The first involves an integration of diverse theories into one transtheoretical mode. The second, known as technical eclecticism, describes the increasingly common practice of systematically  choosing and using a wide range of interventions and procedures.” (Hays, 2008, p176-177)”

alongside this notion of being somewhat flexible and using a “doing-what-works” method there is another resource I found particularly helpful from my research for our paper assignment for the Latino community. In this research titled “Counseling a Hispanic/Latino Client – Mr. X” by Delgado-Romero (2001), there is an excellent example of case conceptualization. This paper did a good job of showing how using relevant knowledge alongside directly assessed information to form a basic conceptualization of the case. This would be useful as an ongoing hypothesis testing process in a “doing-what-work” approach.

QUESTION: “What are some unique issues faced by these older adults?”


As per our readings, initial obvious issues associated with this community include physical and cognitive decline, caregiver stress, grief and bereavement, and intergenerational stress (associated with variations in acculturation and familial culure gaps), (Hays & Iwasama, 2006).  When taking time to contextualize these developmental changes, I found it helpful to look at Erickson’s lifespan Development theory which discusses Ego Integrity vs. Despair. The key developmental issue at this age occurs as one “comes to terms with life’s successes, failures, and missed, missed opportunities and realizes the dignity of own life” (Broderick & Blewitt, 2010, p10). It must be noted in mentioning factors associated with aging, that it is important to note both positive elements associated with maturity, alongside the above factors.


In a resource titled, “Contextual Adult Life Span Theory for Adapting Psychotherapy with Older Adults” is information on unique influences associated with one’s cohort, (Knight & Poon, 2008).Defined as a birth-year dependent group of individuals born within a 7 to 10 year period” (Knight & Poon, 2008), one’s cohort influences a variety of factors. In addition to the obvious influences of key historical events during one’s developmental years, other less obvious factors exist. For example, a person’s immediate sociohistorical context influences the cognitive abilities most relevantly adaptive to that environment. Additionally, differences along measures of personality are seen to coincide within different cohort groups. Influenced by sociocultural factors, and norms influencing behavior for example personality measures such as extraversion/interversion vary by cohort, (Knight & Poon.) Factors such as these influence the general maturation issues as they are experienced by the client.


Finally, culture also complicates the issue of understanding the general issues associated with the maturation process.   Variations in beliefs and norms, as well as views of illness and help seeking behaviors are obvious key factors, (Hays & Iwasama, 2006). When digging deeper, and understanding the influence of culture it is important to understand the clients experiences of acculturation and enculturation. The problem is further complicated by the need to contextualize this alongside the any potential intergenerational conflicts associated with familial cultural gaps.

QUESTION: “What does research suggest as effective techniques in working with older adults?”  

Our textbook makes a point to mention that while CBT is found to be effective within this community, certain adaptations need to be made. Firstly as per the previously mentioned insights it will be essential to adapt CBT to how older ethnic adults learn and recall information, (Hays & Iwasama, 2006). Secondly, taking time to build a rapport and carefully assess the client will require the case conceptualization / eclectic approach mentioned earlier, (Hays, 2008; Delgado-Romero, 2001). The most convenient example of this is in our assigned readings in which the counselor’s method of assessing affect, shifted in focus to account for generational and cultural differences.


Broderick, P.C. & Blewitt P. (2010). The Life Span: Human Development for Helping Professionals. 3rd Ed. New Jersey: Pearson.
Delgado-Romero, E.A. (2001). Counseling a Hispanic/Latino Client – Mr. X. Journal of Mental Health Counseling. 23(3). 207-221.
Hays, P. (2008). Addressing cultural complexities in practice. (2nd Ed.) Washington, D.C.:  American Psychological Association
Hays, P., & Iwasama, G.Y. (2006). Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, & Supervision. Washington, D.C.: American Psychological Association
Knight, B.G. & Poon, C.Y.M. (2008) Contextual Adult Life Span Theory for Adapting Psychotherapy with Older Adults Journal of Rational-Emotive Behavioral Therapy. 26:232–249


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NCE STUDY – Psychological Testing Bias

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

When you consider what exactly culture is, its not surprising that “culturally bound assumptions…pervade virtually all mental and physical health instruments” (Switzer, et al, 1999).   In fact, during my literature review, I came across an endless list of definitions for culture that repeatedly drove this fact home, (Thomas, 2007; Wakefield, 2006; Mclaughlin, 2002; Sternberg, 2004).

Culture permeates virtually every facet of our development as individuals. As a set of learned values, roles, and behaviors passed from one generation to the next, it consists of external and internal components that tie individuals to their culture, (Wakefield, 2006). Culture ensures its existence through its influence over our personality development by providing members with a value system, and set of social roles for its members (Wakefield, 2006). In turn, through their participation in culture, individuals ensure culture’s functional success in a society (Wakefield, 2006).

A similar interdependence can be seen between mental health, intelligence and culture. Culture provides its members with attitudes, thoughts, knowledge, and “the kinds of cognitive strategies and learning modules that individuals use” (Valencia, et al, 2001, p31). This allows people to develop a set of skills with which to adapt to the daily life, that they then pass to the next generation (Sternberg, 2004).

Most notably though is culture’s influence upon our overall mental health.   As an “internalized system of control for producing adaptive, sane behavior”, (Emmerling, et al, 2008, p40), culture also exerts an influence over our emotions, and adjustment. While well beyond the scope of this brief paper, an interesting concept drives home this fact:

“Group Emotional Competence (GEC) concerns the ability of a group to create a culture that effectively shapes the group’s experience of, and response to, emotion in the group….A group’s culture influences the cognitive processes of its members, the way they interpret events and define appropriate responses…which affect(s) the emotional responses of a group and ultimately its performance.” (Emmerling, et al, 2008, p40-41)

When taking all this into consideration, its clear that “everyone should be assessed in light of relevant sociocultural influences,” (Thomas & Hersen 2007, p55).   Multicultural sensitivity throughout any diagnostic and assessment process means considering biological and psychological factors within a sociocultural context, (Hays, 2008). In this paper I discuss the potential biases in intelligence testing, personality assessment, and mental health status exams. I conclude with a brief outline on how to address such biases.

Intelligence Testing Bias.

“Intelligence cannot be fully or even meaningfully understood outside its cultural context. Work that seeks to study intelligence contextually risks the imposition of an investigator’s view of the world on the rest of the world. Moreover, work on intelligence within a single culture may fail to do justice to the range of skills and knowledge that may constitute intelligence broadly defined and risks drawing false and hasty generalizations”(Sternberg, 2004, p325)

Intelligence Defined.

Our textbook makes a point to note that psychological testing biases have centered around a European American worldview that has been predominant in the field, (Hays, 2008).   With this in mind, Robert Sternberg provides a definition of intelligence that I quite like, (2004). Defined as “a set of skills and knowledge needed for success in life, according to one’s own definition of success, within one’s sociocultural context” (Sternberg, 2004, p326), this view of intelligence acknowledges variations relevant to it for accurate measurement. With this as a starting point, how exactly does culture influence intelligence? Additionally, how do you incorporate these insights into measures of this concept?

The Relationship of Culture & Intelligence.

As stated earlier, culture impacts intelligence by providing a knowledge base with strategies for its attainment so members can successfully thrive (Valencia, et al, 2001). In this respect, the skill and knowledge set that comprises intelligence “depends” on one’s sociocultural context. In fact, cultures define intelligence as those skills needed for adaptive success within a particular social environment, (Sternberg, 2004)

In keeping with this insight, I found it interesting through my literature review, how widely varied intelligence was perceived by different cultures.  For example, while European American standards emphasize quick response as a measure of intelligence, Ugandan culture emphasizes a slow, precise thoughtfulness, (Valencia, et al, 2001). Additionally, while Chinese schools make time for silent mental activities, American school systems promote “group discussion and verbal inquisitiveness.” (Valencia, et al, 2001, p44).

Measures of Intelligence.

 Evolution or Cultural Relativism.

Currently, measures of intelligence vary in how they attempt to reflect the relationship between intelligence and culture. In fact, testing methods vary according to whether they acknowledge cross-cultural difference and if they adapt their instrument accordingly, (Sternberg, 2004). At one extreme, there are theorists who believe that nothing exists “that cannot be measured.” (Valencia, et al, 2001, p27). Theoretical perspectives such as these hold a more evolutionary view of intelligence (Sternberg, 2004). Measures of intelligence based on this perspective view intelligence as culturally unvaried, with one singular method for measurement useful across all sociocultural contexts.

In contrast to this, other measures of intelligence based on a culturally relativistic perspective (Sternberg, 2004). Such theoretical perspectives yield a view of intelligence that “can be understood and measured only as an indigenous construct within a given cultural context.” (Sternberg, 2004).

Ultimately, the issue is one of how to assess biological and psychological characteristics of the individual within a particular sociocultural context (Hays, 2008). On the one hand, focusing on an individual outside of a sociocultural context is what creates bias in intelligence testing (Valencia, et al, 2001). On the other hand, a purely culturally relativistic position fails to acknowledge the individual doesn’t exist except as a cultural byproduct (Sternberg, 2004). With no testing method 100% ideal, I do believe the greatest remedy to this issue falls in the hands of practitioners.

Types of Intelligence.

Varied types of intelligence are posed in literature as a result of the above conundrum.   For example, while academic knowledge is the result of educational pursuits, practical knowledge is more action-oriented and directly relevant to daily life, (Hays, 2008). In contrast to this, emotional intelligence is the ability to understand, perceive emotions in others as well as yourself and then express effectively in a relationship, (Valencia, et al, 2001, p36). Still other theories propose creative intelligence, moral intelligence, and multi-faced intelligence models (Sternberg, 2006; Valencia, et al, 2001). It is clear, understanding the nature of the concept and means of measurement are critical for an accurate assessment of intelligence to occur.

Personality Measures & Bias.

Personality Defined.

In the DSM-IV-TR, personality is defined as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.” (Hays, 2008, p146; Wakefield, 20076). While on the surface, this definition appears useful enough, the same issues arise in how to best depict this concept (Hays, 2008).   Weighing the need for an empirically clear concept against cultural relativism and evolutionary perspectives makes the measurement of this concept difficult.

Personality & Culture.

“Personality is a uniquely important medium within which culture attempts to ensure social coordination among individuals within the culture and produce individuals who will fulfill social roles. The culture’s approach to ensuring the functional success of its members and its own reproduction expresses itself via values, which influence personality formation. Personality is in part essentially cultural and culture in part essentially consists of the purposeful shaping of personality tendencies in what amounts to the creation of a kind of mental artifact.” (Wakefield, 2006, p168)

 As this quote illustrates, the relationship between culture and personality is quite complex. Knowing how to measure personality while accounting for its relationship to culture is complicated. It seems literature holds a similar theoretical divide as was witnessed in discussions on intelligence measures above (Sternberg, 2004; Wakefield, 2006).

There are those in the field who hold an evolutionary and nature-based view of personality as innate. These perspectives uphold an empirical stance that we should focus on the individual as concrete autonomous factor for measurement, (Hays, 2008). On the other hand, some people hold a culturally relativist position. Such views point to the fact that “all personality models are based on concepts of personhood and standards of culturally appropriate behavior…in Anglo-American countries,” (Alik, 2005, p215). Further complicating this matter, is the fact that a measure’s purpose seems to change the focus of this conceptual battle.

Personality Measures & Diagnosis.

There are two primary perspectives within which to assess personality. The DSM utilizes a medical approach and defines personality within a disorder perspective. This perspective on personality focuses solely on problems and dysfunction. On the other hand, personality typology assessments focus on strengths, describing traits relevant to the individual.

 Personality Disorder Diagnosis.

In an article discussing the concepts of personality disorder and culture Jerome Wakefield (2006) provides the following definition of a mental disorder:

“The harmful dysfunction (HD) analysis of the concept of mental disorder…maintains that a mental disorder is a psychological or behavioral condition that satisfies two requirements, (1) it is negative or harmful according to cultural values; and (2) it is caused by a dysfunction (i.e. by a failure of some psychological mechanism to perform a natural function for which it was evolutionary designed.” (Wakefield, 2006 p157)

A few things can be noted about how this concept relates to personality diagnosis. In the case of the evolution versus cultural relativism debate that exists, the underlying issue that complicates matters is one of perceived blame attribution, (Wakefield, 2006).

Evolutionary empiricism. On the one hand, there are those who state a preference of some universal diagnostic criteria over cultural value judgment. Such perspectives claim changes such as these are “a politically correct concession to cultural relativism that illegitimately allows cultural values to intrude scientific definition.” (Wakefield, 2006, p162).

Cultural relativism.  On the other hand, as a counterpoint, there are those who state utilizing some element of cultural value judgment in the diagnostic process is seen as essential. Such perspectives point to the classic notion of personality as “a dynamic organization, that…is not a trait” (Wakefield, 2006, 158), but an overall structure that exists in sociocultural context. Stating it is wrong to misattribute social problems as individual dysfunction, this perspective affirms that sociocultural context is critical to the diagnosis of personality diagnosis, (Wakefield, 2006).

A conceptual solution. In my opinion, the best conceptual remedy comes when understanding how the “harmful dysfunction” definition (Wakefield, 2006), of mental disorder as it relates to personality. According to this perspective a personality disorder exists in the presence of two key factors. Firstly, an element of one’s personality must be harmful according to a cultural value-based perspective (Wakefield, 2006, p157). This standard addresses the need for sociocultural context but naturally isn’t enough by itself. A second critical element for the diagnosis of a personality disorder is the existence of a dysfunctional dimension within the individual, as defined by the DSM, (Wakefield, 2006).

Our Hays textbook adds to this insight by simply stating care needs to be made when diagnosing a personality disorder, stating the following:

“To accurately diagnose a personality disorder, the therapist needs to know the client’s culture well enough to judge whether the client’s behavior represents a marked deviation from it….Because personality disorders by definition involved disturbed interpersonal functioning, and misrepresentations of actions of others the therapist may need information from those who know the client,” (Hays, 2008, p159)

Personality Typology.

In attempting to understand the potential of cultural biases in a personality typology, two facts became clear. Firstly, it is vital to note that many popular tests such as the MBTI (Myers Briggs) and MMPI (Minnesota Multiphasic Personality Inventory) are based on a sampling that is largely Euro-American, and therefore limited in generalizability, (Hayes, 2008). Having said this other testing methods do exist to help account for this cultural bias. Nonetheless it is worth mentioning simply as a matter of further exemplifying the underlying history of bias that exists within the mental field throughout its formation.

A second notable fact in my literature review was also intriguing in helping shed light on the cultural biases through personality typology. Some of the research I uncovered, gathered results from assorted tests attempted to create a societal average or “aggregate personality” (Mccate, 2005, p5). While at first I thought the idea of this as potentially stereotyping, if not conducted thoughtfully, I read further. When reading studies of how personality traits do indeed vary across culture I began to think of how culture defines personality? Additionally, I came to wonder, what these tests actually did measure? After all, if we were to examine Hays’ definition of personality as “enduring ways of perceiving” (Hays, 2008, 146) in a context, it appears culture and personality are intertwined. It would stand to reason, then that such measures might in some respects be reflect an interaction between these two factors.

Mental Status Examination.

Consisting of patient’s subjective experience and observation, the mental status examination is an interview based evaluation of a person’s overall functioning, (Thomas, 2007, p49).   As an interview-style approach, it consists of the following components: Appearance, behavior, motor activity, orientation, attitude, speech & language, affect & mood, thought & perception, insight & judgment, attention & concentration, memory, intelligence and abstraction, (Judd & Beggs, 2005; Thomas & Hersen 2007). While an in depth discussion of each of these elements goes way beyond this assignment’s scope, when reviewing the categories above, the possibility of bias seems clear. Having had the opportunity to witness several mental status examinations in a hospital setting, the degree of bias seems to vary with practitioner. While very useful as a tool with which to diagnose, assess, and create a treatment plan, it isn’t quantifiable, without a normative standard, or defined relative to culture and environment, (Judd & Beggs, 2005). Consequently, open to much clinical judgment and interpretation, a high degree of cultural bias exists throughout the process. As stated earlier, some resistance to the inclusion of cross-cultural factors in mental health assessment and testing exists. In fact, the following quote sheds light on how this exists as a causal factor in the continuing existence of bias in assessment:

“Some experts in mainstream psychiatry believe cross-cultural factors are not relevant if a diagnostic category is valid; instead such factors, they argue, relate only to specific clinical symptom presentations….”(Johnson, 2013, p18).

From this perspective, it seems that such factors are “a nuisance variable in assessment”. (Thomas & Hersen 2007).   The problem in learning how to operationalize and measure such a concept comes in light of the fact that self-awareness is a critical component in the process. Interestingly, attitudes like this which defend empiricism against confounding variables, promote a narrowed view of individuals from a nature-based evolutionary perspective.   At the same time, this isn’t to say those who promote cultural relativism in the field are without blame as well:

“Some naïve psychologists still believe that psychological testing is a universal phenomenon that it can be made culturally fair. There are even tests that incorporate “culture-fairness” in their names. This myth has an unfortunate role in advancing xenophobic and racist agendas.” (Judd & Beggs, 2005, p198)

In the end, whether or not one embraces or refuses to acknowledge the notion of multiculturalism, the issue is one of asking questions, rather than knowing the answers. The simple skills mentioned in our Hays textbook (2008), of humility and critical thinking stand out as key skills for multicultural sensitivity.

Resolving The Potential For Bias

Defining the Problem.

“Tests originate from a European American worldview that permeates procedural norms in the research and development of such instruments. Items are chosen according to the rational analysis and judgments of a panel of experts who usually hold European American perspectives (Rogler, 1999), and instruments are validated through correlation with other instruments based on American cultural views.” (Hays, 2008, p130)

Assessor Bias.

Assessor bias can be thought of as “the homogenization of all clients through the use of the scientific method without critical thought” (Thomas, 2007, p68).   From the perspective of testing and assessment misdiagnosis, and even institutionally based discrimination, are the results. (Thomas, 2007). Issues such as confirmatory bias, (ignoring information not relevant to your predicted hypotheses), certainly highlight the importance of critical thinking and humility in counseling practice, (Hays, 2008). In fact, in a well-known study several researchers gained admission to a hospital to assess the potential of self-fulfilling prophecy in psychiatric diagnosis, (Mclaughlin, 2002). While not having any psychiatric diagnosis on admission, staff nonetheless acted to confirm their expectations based on the assumed diagnosis of researchers (Mclaughlin, 2002). When you consider such clinical errors in judgment and diagnostic bias alongside mental health’s own troubled history lacking in multicultural sensitivity, this problem more complex than one might think.

Instrument Bias.

Biases in diagnostic criterion within assessment instruments further compound assessment bias, (which occurs throughout the gathering and processing of information0.   In light of the history of psychometric testing, an overarching cultural testing bias can found in many instruments, (Valencia, et al, 2001). Issues of context arise when careful consideration isn’t made of the generalizability of an instrument’s results in light of a client’s own sociocultural background (Switzer, 1999). Examining original sample data the testing instrument is based upon is a great start.

Examining the Solution.

How can a practitioner assure that client’s be assessed in light of relevant sociocultural influences while using many of the testing instruments and diagnostic criterion existing today? What follows is an overview of all information found throughout my literature, to reduce biases discussed throughout this paper.

Reducing Instrument Bias.

When utilizing any psychometric instruments a first critical step is cautious test selection. Being aware of contextual issues, as well as the culturally loaded North Euro-American history of mental health overall throughout the utilization and interpretation of such instruments. Further evaluating the degree of reliability and validity of such instruments is also useful. For example, how well do testing instruments utilized really measure what they are purported to? Also, how generalizable are the tests results? What sampling methods were utilized?

When administering any psychometric tests it is important to be aware of the testing environment to assure the client’s comfort level. Conducting thorough clinical and sociocultural interviews to consider alongside psychometric tests helps to contextualize their results, (Hays, 2008). Finally, interpretation of results should occur holistically, considering biological, psychological factors within a sociocultural context. Including clients and family members throughout the process as valuable reference points of client’s subjective experience also bears mention (Mclaughlin, 2002). Considering these factors alongside objective assessment measures and diagnostic criterion, helps further contextualize results, (Mclaughlin, 2002)

Reducing Assessor Bias.

“Multicultural assessment is a logical and necessary extension of standard assessment in which a traditional underemphasis on sociocultural factors is remedied…multicultural clinical interviewing, in addition to its standard functions of gathering medical, psychiatric and social information, ‘ serves as the fundamental medium for gathering cultural information.” (Thomas, 2007, p66).

MAP a Modified Axis-6 Approach. Throughout my research review, the best advice I had found was from two key sources.   Starting with our Hays textbook (2008), chapter 8 is devoted to an Axis 6 approach that encompasses the utilization of the ADDRESSING model she refers to throughout, (Hays, 2008).   While clear adjustments to this process need to be made in light of the DSM-5’s new nonaxial approach. I will still do see great benefit in starting with the ADDRESSING model as a critical component in my initial interview assessments.

Adding to this advice along imilar thought lines is a “Multicultural Assessment Procedure, otherwise known as “MAP”, (Thomas, 2007, p65). Firstly, this assessment divides clinical data into two categories: covert and overt information, (Thomas, 2007, p70). Stressing the importance of an ongoing commitment to multicultural sensitivity, to uncover it, covert data can include cultural values and assumptions, repressed memories, or family conflict. Overt data can include anything clearly expressed within an initial interview in which I intend to utilize the ADDRESSING model, (Hays, 2008; Thomas, 2007).

With this data in hand, an ongoing hypothesis testing process occurs. Developing working hypotheses seeking more information to test and revise it and repeating the process, allows for the gradual development of a sound and accurate assessment decisions, (Thomas, 2007, p70). As a method which stress always asking questions, and seeking more insight, I found it quite useful.

FACTS Method. Also discussed in our assigned readings for this course, I found it blended nicely with the above suggestions. This FACTS method exists as a culturally responsive approach to the DSM (Johnson, 2013). With its empirical basis focusing on individualized dysfunction, a critical sociocultural counterpoint is quite useful. Starting with the formulating questions means keeping in mind relevant sociocultural context might have on symptom presentation (Johnson, 2013; McLaughlin, 2002). Assessing signs and symptoms in light of different diagnostic possibilities and potential comorbidities while including clients throughout the process is critical, (McLaughlin, 2002; Hays, 2008). Including client’s input throughout this process while advocating on the clients behalf with the health insurance system is also critical, (Hays 2008). Doing so allows for a culturally-responsive addressing of relevant issues and understanding how sociocultural context influences DSM-based diagnosis presentation, (Johnson 2013). Designing a treatment plan based on scientific evidence while including patient needs and concerns is a Johnson’s (2013) final suggestion.


Alik, J. (2005) Personality dimensions across cultures. Journal of Personality Disorders. 19(3), 212-232.
Emmerling, R.J., Shanwal, V.K., and Mandal, M.K (2008). Emotional Intelligence : Theoretical  and Cultural Perspectives. New York, NY, USA: Nova.
Geisinger, K.F. (Ed.), (2013). APA Handbook of Testing & Assessment in Psychology: Volume 1. Test Theory & Testing & Assessment in Industrial & Organizational Psychology. Washington, D.C.: American Psychological Association.
Hays, P. (2008). Addressing cultural complexities in practice. (2nd Ed.) Washington, D.C.: American Psychological Association.
Johnson, R. (2013) Forensic and Culturally Responsive Approach for the DSM-5: Just the FACTS. Journal of Theory Construction & Testing, 17(1), 18-22.
Judd, T., & Beggs, B. (2005). Cross-cultural forensic neuropsychological assessment. In Barrett, & W. George (Eds.), Race, culture, psychology, & law. (pp. 141-163). Thousand Oaks, CA: SAGE Publications, Inc. doi:
McLaughlin, J.E., (2002). Reducing diagnostic bias. Journal of Mental Health Counseling. 24(3) 256-269.
Mcrate, R.R. & Terracciano, A., (2005) Personality profiles of cultures: Aggregate personality traits. Journal of Personality and Social Psychology, 89(3) pp. 407-425.
Switzer, G.E., Wisniewski, S.R., Belle, S.H., Dew, M.A., & Schultz, R. (1999). Selecting developing and evaluating research instruments. Social Psychiatry and Psychiatric Epidemiology, 34(8), 399-409.
Sternberg, R.J., (2004) Culture and Intelligence. American Psychologist. 59(5), 325-338.
Thomas, J. C., Hersen, M., Sage Reference (Online, s. (Online service), & Sage Publications. (2007). Handbook of Clinical Interviewing with Adults. Los Angeles: Sage Publications.
Valencia, R.R. & Suzuki, L.A. (2001) Intelligence Testing & Minority Students. Los Angeles, CA: Sage Publications.
Wakefield, J.C., (2006) Personality disorder as harmful dysfunction: DSM’s cultural deviance criterion reconsidered. Journal of Personality Disorders, 20(2) 157-169


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NCE STUDY – Culture & Rapport….

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))
“Counselors are aware of – and avoid imposing – their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselors values are inconsistent with the client’s goals or are discriminatory in nature.” (American Counseling Association, 2014, p4).

Establishing rapport is an essential skill in building a therapeutic relationship with clients. In today’s diverse culture, doing so requires a great deal of multicultural competency. When you consider how this can mean respecting diverse language styles, understanding different value systems, and even communicating respect or empathy, it becomes clear this skill is as much art as science (Hays, 2008).

In this paper, I will review a research article titled “The Relationship of Culture and Empathy in Cross-Cultural Counseling”, by Chung & Bemak (2002). It is intended to provide a theoretical model upon which to begin understanding how culture influences personality development. While I do have some misgivings about it from a theoretical perspective, I do still believe it has much insight that is applicable to my future counseling practice.

What intrigued me about this particular article is it touched upon a personal insight that has stayed with me, since I began this course. Firstly, I’m amazed at how much culture really does define us. It is actually an essential element in the formation of my own identity, value system, worldview, as well as affective style of emotive expression, (Pedersen, et al, 2008; Hays, 2008). Secondly, I’m struck by how much miscommunication can occur when divergent cultural perspectives aren’t fully recognized. In the subtlest ways, cultural differences define our system of meanings, and modes of emotional and verbal expression. When not put into a proper context, we can unknowingly, misapply our own cultural viewpoint and fail to understand what is being communicated.

The following article provides a theory of how culture and personality together affect our emotional styles in a particular culture. Again while I do have some criticisms about the theory, it is worth sharing.

Empathy & Culture

Empathy Defined.

Empathy is a key element of building an effective therapeutic relationship and establishing a solid rapport with clients.   Empathizing with someone means understanding your client as they understand themselves within the context of their own world (Nazir, et al, 2009).   In other words, empathy means putting yourself in your client’s shoes. Based on this definition, it is clear that empathy requires an understanding of your client’s viewpoint (Chung & Bemak, 2002). It also becomes quickly clear that knowledge of your client’s culture is implicitly an integral component of empathy and the establishment of rapport. It appears empathy and cultural sensitivity are indeed interconnected (Chung & Bemak, 2002). Despite this fact, empathy has historically been defined in a “Westernized Euro-American context” (Nazir, et al, 2009, p155) in the Psychology field. This paper is aimed at rectifying the problem by providing a theoretically proposed model of how culture affects personality.

Culture Defined.

Culture consists of a shared system of meanings within society that define modes of expression and communication, (Chung & Bemak, 2002; Nazir, et al, 2009). It influences how we view the world around us and sets the normative standards for behavior (Chung & Bemak, 2002; Nazir, et al, 2009). As a form of “mental programming” (Chung & Bemak, 2002, p282), it defines our value systems and preferred ways of thinking and feeling.

Within this way view of culture, authors Chung & Bemak, (2002) connect culture to personality by stating our mental programming exists at differing levels of uniqueness.   Starting with an innate evolutionary set of instincts, we have universal mental programs that exist in all humans (Chung & Bemak, 2002). Culture provides another set of mental programs relevant to a society (Chung & Bemak, 2002). Finally a personality specific to an individual exists as the result of both inherited and learned influences (Chung & Bemak, 2002).

Hofestede’s Dimensions of Cultural Variability.

With some basic conceptual definitions out of the way, this article moves on to a brief overview of a few theories. Together, it is proposed that these theories can help provide some understanding of how culture and personal are interrelated. The first of these theories is a “Hofestede’s Dimensions of Cultural Variability.” (Chung & Bemak, 2002, p283). This theory describes four dimensions of behavioral variations within culture that can be thought of as existing along a continuum, (Chung & Bemak, 2002).

Individualism & Collectivism.

Individualistic and collectivistic cultures vary in terms of the focus of identity on either individuals or community (Chung & Bemak, 2002). Collectivist cultures focus on community and consequently value harmony, tradition, sacrifice, duty (Chung & Bemak, 2002).   Individualistic cultures focus on the individual and value personal freedom of expression, responsibility, and independence (Chung & Bemak, 2002). It is interesting to note the varied mental programs in personalities that develop for each type of society. Collectivist societies, for example, would more likely promote emotional suppression and sacrifice for the sake of group harmony. Individualistic societies promoting values such as personal freedom would cultivate personality characteristics of emotional expression, and allow a more open expression of opinions.

Uncertainty Avoidance.

Cultures also vary in the degree of uncertainty avoidance. For example, a culture that defines uncertainty as bad would have individuals who are resistant to change in favor of tradition (Chung & Bemak, 2002).   Curbing uncertainty with restrictions to personal freedom and rules of behavior is often the solution (Chung & Bemak, 2002).

Power Distance.

Cultures also vary in terms of power structure and social status organization (Chung & Bemak, 2002).   “High power distance cultures” (Chung & Bemak, 2002, p284) have a more rigid power structure enforced as a basis of society. These societies promote a respect for authority, and its members engage in more formal interaction styles. (Chung & Bemak, 2002).   “Lower power distance cultures” tend to have greater social mobility, a larger middle class, and interaction is more informal (Chung & Bemak, 2002).

Masculinity vs. Feminity.

While masculine cultures promote values such as ambition, assertiveness, and performance feminine cultures promote service and caring for others (Chung & Bemak, 2002).   Again as with the other cultural dimensions, personality development of individuals these cultures reflects these differences.

Individual Mental Programming

With a discussion of culture out of the way, the article now moves to theories related to the individual. This section focuses on personality as a unique mental programing within the individual resulting from both nature and nurture (Chung & Bemak, 2002). From this perspective, personality can be thought of as a set of emotional, behavioral, and thought patterns unique to the person. (Chung & Bemak, 2002).

PSI Model of Emotions.

The PSI model of emotions discusses how people utilize motivation, thought emotion and action in the context of their lives. On the one hand what I didn’t like about this theory, is individuals appear very Pavlovian in nature. Focusing on concepts such as needs, drives, motivation, and arousal, this theory attempts to depict the mind as a system of action and regulation (Chung & Bemak, 2002). While I feel this is a tad too evolutionary in scope, there are some interesting elements that warrant mention.

Emotions as modulators of action.

This theory rejects the traditional notion of emotions as irrational, stating they play a role in decision-making, self-regulation, and motivation (Chung & Bemak, 2002). Rather than distorting our thoughts, they are thought to direct them. Noting that without emotions, humans become robots, this theory focuses on factors that influence our emotional reasoning. (Chung & Bemak, 2002).

Culture & personality as drivers of motivation.

A second element of this theory, which I appreciated, was how easily it helps show how both culture and personality drive human behavior. With these factors defining our value systems and perceived needs, culture and personality act to drive our motivations (Chung & Bemak, 2002). I would add to this by saying it would be logical to say they also direct our plans and goals in response to these needs, as the filter systems through which intake information.

Big Five Personality Theory.

In concluding this discussion on the individual, this article just briefly mentions the Big Five Model of Personality. While ignoring other personality type theories, it offers this one as a model that works well along the theory culture mentioned earlier. This theory comprises five dimensions of personality which also exist along a continuum: (1) openness to experience, (2) conscientiousness, (3) extraversion, (4) agreeableness, and (5) neuroticism.

I have to admit, I was disappointed more time was not discussed on how these factors might correlate with the cultural dimensions mentioned earlier. It would be interesting to see how cultures promoted the development of personality through the usage of such instruments.

Sadly, there isn’t much research in this area What I’ve read is largely speculative, and informal in books such as “Where In the World Do I Belong” by Brent Massey available at Amazon.

Criticisms & Conclusions.

The Positive Insights.

A Cultural Personality.

This paper concludes by providing a theory that depicts culture as a component of mental programming, alongside personality. In other words, it is internalized within us as a component of our personality (Chung & Bemak, 2002). In this respect it has great value in helping us understand how culture and personality correlate.   I would, in fact, be interested in more research that correlates cultural variants discussed with personality development and typology. Having knowledge of in Myers Briggs typology and Jungian psychology, I find this quite interesting.

Emotions Matter & Are Not Illogical.

Based on a theory, which depicts emotions as providing logic that motivates action, it attempts to understand feelings in this context. Understanding our emotions in the context of our decisions, motivations, and forms of reasoning, can only help us understand ourselves and therefore help others more effectively in a therapeutic setting.

Empathy as a Cultural Concept.

A theoretical perspective, that helps us understand empathy as a culturally based notion, is indeed relevant to future practice. If empathy means putting someone in another person’s shoes, cultural considerations are naturally integral to this. Understanding culture as a key factor influencing our personality, (and therefore emotional style), is also very useful.

Negative Criticisms

This article focused too much on a theoretical perspective that depicts individuals as functioning with a set of Pavlovian needs from an evolutionary perspective. Additionally, there was too little time spent understanding the influences of cultural dimensions on personality development.   For this reason, it’s potential to provide insights for direct application in a counseling setting aren’t as great as they could be.

Finally, I have some misgivings about one more item mentioned here.   This article proposes the development of a theory that can create “affective synthetic characters” which are representative of a cultural personality, (Chung & Bemak, 2002). While potentially beneficial to understand how culture influences personality, I’m not certain what the authors mean by “synthetic characters”. If researchers utilize some caution throughout the research process it could be useful, (much as the cultural variables are), in understanding behavior. On the other hand, if one were to use an evolutionary based theory that depicts individuals in a Pavlovian sense I have my concerns. I would worry about a reductionist and stereotypical depiction of personality under the influence of culture, being the end result.


Overall, while the article did have its shortcomings, I did find many of its insights useful. I am very interested in understanding how culture determines personality and the individual. As stated earlier, it seems this field involves as much art as science.   In utilizing insights from this article, the following quote seems most relevant to me:

“….The therapist then engages in ‘a continuous cycle of hypothesis formulation and hypothesis testing about the particular individual. Each item of information…suggests a hypothesis about the person, which will be either confirmed or refuted as other facts are gathered.” (Hays, 2008, 73).

In the end, it seems as if the more I learn in this class, the more I realize I have much to learn. My self-awareness grows, and I become aware that asking the questions is more important than knowing the answer.


American Counseling Association. (2014). Code of Ethics.
Beadling, L. L. (2010). Mommy angst: Motherhood in american popular culture. Choice, 47(9), Retrieved from
Chung, R.C.Y. & Bemak, F. (2002) The relationship of culture and empathy in cross- cultural counseling. Journal of Counseling and Development. (80) pp154-158.
Hays, P. A. (2008). Addressing Cultural Complexities in Practice. (2nd ed.). Washington, D.C.: American Psychological Association
Nazir, A, Enz, S, Lim, M.Y., Aylett, R., & Cawsey A. (2009). Culture-personality based affective model. AI & Society. 24(3) pp 281-293.
Pedersen, P.B, Crethar, H.C. & Carlson, J. (2008). Inclusive Cultural Empathy. Washington, DC: American Psychological Association.

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NCE STUDY – A Cultural Self-Assessment….

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

PART ONE – A Cultural Self-Assessment….

According to our textbook, a bias is simply a “tendency to think, act, or feel in a particular way.” (Hays, 2008, p24). Personal biases emerge as a result of our upbringing and sociocultural background, (Hays, 2008). Our life history provides us a worldview, value system, identity and cultural background that produce the very biases we carry into therapeutic relationships, (Hays, 2008). In light of this fact, a cultural self-assessment is the first step toward developing greater multicultural competency as a counselor. I start this self-assessment by utilizing the Addressing Model to provide a rough overview of my sociocultural history.  I then move on to a series of interview questions, which can help to shed light on areas of privilege, as well as value systems, and identities.

Utilizing the Addressing Model

Age and Generational Influences

My Parent’s Generation.

My mother was born in 1938 and my father was born in 1941. They are members of the “silent generation”, born just prior to the baby boom (Martin, 2004). Their earliest years of life occurred while the world was at war. My mother, from the Philippines, grew up in the middle of war. My dad, an American, was ignorant of war altogether. They were both raised to work hard, get an education, and pursue the American Dream. For my mother’s family this meant gathering resources to put both of their two daughters through medical school and then help them to immigrate to the states. For my father’s family, this meant raising their sons in a strict household, expecting them to work hard, and then put themselves to school. In the end, they all did so, earning advanced degrees.

My Generation.

I was born in 1969, and grew up in a small college town in South Dakota. Unlike many of my generation, I was spared from having to experience divorce first-hand, with divorce rates soaring to 50% in my childhood (Amato & Cheadle, 2005). With everyone in my extended family enjoying long and happy marriages, I have come to value the commitment of marriage and family.

Typical of many women in generation, I am fairly skeptical of the idea of “having it all”; a popular notion existing in westernized cultures in the aftermath feminist movement (Genz, 2010). While very appreciative of the strides made, I’ve witnessed many women struggle to keep up with home and work life in frustration. With many women in my generation have chosen to put off family, or opt out all together, I’ve chosen to put off career pursuits in favor of focusing on my family life, while my kids were young (Genz, 2010).

Developmental Disabilities

            Fortunately, I have no physical disabilities or health issues whatsoever. I’ve had the privilege of ignorance that comes with living in a healthy body, and never having to think about living with disability. (Hays, 2008). Nonetheless, I’ve found plenty of opportunity in my life to learn about living with disability. As a Hospital Tech I have had a great deal of opportunity to work with disabled individuals. As the mother to a son with a congenital defect, I’ve gained insight into experience of raising a child with special needs. I’ve developed an awareness of what it is to deal with physical disability on a daily basis. In fact, I’ve felt a great deal of satisfaction from these experiences, and wish to explore this area as a potential career path.

Religion and Spiritual Orientation

            My religious background is complicated, by the fact that my family isn’t unified in its religious beliefs. My father is an atheist, my mother is devoutly catholic, and my sister considers herself a “born-again” evangelical Christian. As an agnostic, I can see everyone’s point of view and respect each one, as right for that person. I don’t feel it is right for anyone to impose their religious beliefs on others. Nonetheless, I do find the other members of my family disagreeing on matters quite often. My sister and mother disagree with the others beliefs on the grounds that it goes against their own. My father refuses to talk about it altogether and this annoys my mother and sister.

Ethnic & Racial Identity

“The ecological model of racial identity development acknowledges that there are many different ways people of mixed racial heritage may identify themselves….These identities do not necessarily coincide with how other persons identify them. Thus the private identity may be different from the public identity assumed or validated by others.” (Root, 1998, p240).

I am a biracial individual, born to a Filipino mother and White father. A book written about my hometown, by author May-Lee Chai, titled “Hapa Girl” (2007), provides a good depiction of my childhood environment overall.   Also biracial, she was a senior in high school when I was a freshman and endured much of what I did growing up.

My racial identity can be best described as a personal knowledge I hold within.   It isn’t reflected in my phenotypic appearance and consequently is rarely acknowledged in my interaction with others. (Root, 1998). As a result, my identity as biracial is held with pride despite often being refuted and criticized by others. Additionally, because I’ve never been to the Philippines, it isn’t based on any cultural heritage. (Root, 1998) While purely American, from a cultural perspective, I claim both my Asian and American heritage from an identity viewpoint.

Socioeconomic Status

The socioeconomic status of my family of origin is solidly upper middle class. In contrast, my family of procreation would most likely be somewhere in the lower middle class. My husband comes a working class background, and had a rough home life. Adding to this, until recently, I’ve put off career pursuits in favor of family. As a result, I have experienced some downwardly mobile, in a matter of speaking. By marrying someone of a different socioeconomic class, I’m aware of the huge cultural divide between my husband’s family and my own. I feel comfortable in both worlds, yet my husband doesn’t enjoy being around my extended family, (despite getting along with my parents). A quote from a book titled “Reading Classes” by Barbara Jensen (2012) that sums up my husband’s experiences well:

“I knew I wasn’t middle class like some others in the movement, and I believed I wasn’t as smart as they were. I knew my brain worked okay, but they knew more, lots more, and I wanted what they had. They often referred to authors I had never read or even heard of. They used words I didn’t understand, and they often talked about their college experiences, worldly travel, orchestral music, and other things with which I had little opportunity and experience. They appeared to all understand one another, but sometimes I just pretended I understood, and then I felt ashamed of both not knowing and pretending.” (Jensen, 2012, p18)

Sexual Orientation & Gender

Sexual Orientation & Cisgender Status.

Regarding the issue of sexual orientation and gender identity, I happen to be a cisgendered heterosexual.  Being cisgender, I moved through life with a body that matches my gender of identification, (Levy, 2013). Being a heterosexual, I have a sexual preference that is deemed acceptable by all facets of our society (Levy, 2013). I have never felt the need to think about my sexual orientation or gender identity to the extent I have my racial identity. Any thought I do give to such matters has been purely political in nature, since I’ve always been very supportive of LGBT rights. Having said this, I do feel simply believing in equal rights isn’t enough With ignorance, can come a lack of awareness of things such as subtleties of interaction and the imposition of our biases that can indeed be felt as discriminatory, regardless of their intention, (Hays, 2008)

Being Female.

While being a female certainly implies a second-class status, it must be noted that the degree to which this is experience varies by culture. Fortunately, my sociocultural background has been one which values and empowers women.   Having said this, it would be fruitful to learn about the implications of being female in cultures other than my own, as a matter of perspective.

Indigenous Heritage & National Origin.

On the one hand, I’m an American living in the United States and have no experience living in another country. I am neither an immigrant nor of indigenous heritage. On the other hand, with a mother who emigrated from the Philippines, I’ve witnessed a bit of what it is like to balance the influences of two competing cultures. Described best as a biculturalism, or dual identity status, (Framboise, 1993), raising a family in a foreign culture was certainly problematic for my mom. From my perspective, the cultural gap that resulted did require time to work through. Having not occurred until well into my own adulthood, I have a relationship with my mother today, which is very different from that of my childhood.

Cultural Self-Assessment Interview

In this portion of the paper, I move on to a series of self-assessment interview questions. It is my intention to answer each within the Addressing Model framework. I will consider how each question applies to my sociocultural history as described within this model.

“When I was born what were the social expectations for a person of my identity?” (Ajuoga, 2014).

My biggest struggles with social expectations associated with identity, are in the areas of: (1) gender roles, (2) race identity, (3) socioeconomic class, and (4) religious affiliation. Other addressing components such as disability, sexual orientation, and indigenous heritage, have been of little concern. I will address these areas of struggle in turn, leaving female gender roles issues, for later.

Racial & Ethnic Identity. As mentioned already, I have experienced a great deal of confusion regarding my ethnic identity. My own biracial identity has been largely met with messages of disapproval, with others needing to inform me what they believe is the correct one (Root, 1998). It has taken some time, to sort through this issue as I’ve learned to let go of the idea that validation from others is ever a realistic expectation.

Religious Identity. While my mother’s family is devoutly catholic, my father’s family is predominantly agnostic and atheistic. The competing perspectives from this interfaith family background yielded an array of contradictory expectations (McCarthy, 2007). As my sister and I matured, our chosen routes diverged greatly. I came to identify myself as agnostic, while my sister has joined an evangelical church and embraced those ideals. The biggest issues in our family have come as we’ve tried to maintain a sense of integrity while also respecting others’ beliefs (McCarthy, 2007).

Socioeconomic Identity. Maria Root discusses in her work on mixed race identity, that individuals from such backgrounds can often develop negative biases against one side of their family as result of negative treatment, (Root, 1998). Within my father’s extended family I have experienced just this growing up. The ignorance and ethnocentrism they display, alongside the pride, and unwillingness to see any other perspective has been the source of much pain. As a byproduct of this experience, I’ve developed a negative bias against their upper middle class socioeconomic ideals (Root, 1998). It’s only in my adulthood, that I’ve been aware of how much I rejected this component of my identity, while embracing husband’s working class background instead, (Root, 1998). Coming to terms with this will be essential in my growth as a counselor (Hays, 2008).

 “When I was a teenager, what were the norms, values, and gender roles supported within my family, by my peers, in my culture and in the dominant culture” (Ajouga, 2014)

Overall, a great deal of conflict exists regarding norms, values, and gender role expectations within my extended family. In her article an article on biculturalism, Teresa LaFrombroise, discuss the impact of living between cultures (LaFrombroise, et al, 1993). This article mentions feelings of psychological discomfort as the initial result of a dual identity-based conscious that can have potential benefits in the long run, (LaFrombroise, et al, 1993). Having many conflicting identities, as mentioned previously, I’ve experienced much of this discomfort and have likewise developed many fruitful life lessons as a result.

Gender roles.

Within my family, gender roles brought about much confusion as a child.   Conflicting messages existed as a result of complex familial generational and cultural gaps. My dad’s family came from a traditional background, with the belief that women were supposed to stay at home. In contrast, my mother’s family was very forward thinking. Since my maternal grandparents were both teachers, it was very important their daughters go to school. Having two daughters finish medical school was a source of great pride.

These competing perspectives left me with a conflicting and contradictory array of familial gender-based role expectations. Against this backdrop, was the generational influence of being born in the aftermath of the feminist movement, (Genz, 2010). Not feeling the need to having it all, I have instead discovered a path that has worked for me.

Norms and Values.   While there were many conflicting norms and values within my extended family, this wasn’t really the biggest issue in the context of day-to-day life as a child. The greatest source of conflict existed between the values and norms my parents held me to in contrast to what was expected in my hometown. Norms and values regarding: (1) relationships and dating, (2) parental roles, (3) rules of emotional expression, as well as (4) appearance and demeanor stand at the forefront as most problematic.

In keeping with her cultural background, my mother assumed the role of matriarch, and was largely responsible for setting parental limits. My dad, busy at work most of the time, didn’t want to interfere. As a result, my mothers cultural belief systems were the standard we complied with at home. Naturally unbeknownst to them, this key factor resulted in an array of problems throughout my childhood, when it came to fitting in (Chai, 2004; Fortune, 2012).

For example, regarding the issue of appearance, my mother didn’t allow me to shave my legs or wear makeup, and I was bullied endlessly for it (Chai, 2004). In the arena of dating, I was absolutely forbidden from even considering it until we finished college, because that’s how it was for her growing up, (Fortune, 2012). Added difficulties resulted from differences in parenting role expectations between my mom’s culture and my hometown environment, (Root, 1998). Cultural differences such as these, caused many parents and teachers to misunderstand my mother. They often thought poorly of her parenting style, because it was so different from what they knew. This added to my difficulties in trying fitting in at school.

How was my view of the world shaped by the social movements of my teen years?” (Ajouga, 2014)

With a population that was mostly white, middle class, and well educated, my hometown had a very ethnocentric feel to it (Chai, 2004). At school, a large portion of my classmates came from families that called this town home for several generations. This gave many of my classmates the benefit of a large social and familial network, as well as consistent socialization, on how to follow the values and norms of the local culture (Chai, 2004).   Without this knowledge base or support system, fitting in was difficult, and I was bullied throughout much of my childhood, (Chai, 2004). As per Brene’s Brown work on shame, my personal view of the world was based on an underlying identity based on shame as she defines it:

“The definition of shame that emerged from the research is, ‘ an intensely painful or experience of believing we are flawed and therefore unworthy of acceptance, and belonging.” (Brown, 2006, p45)

“When I was a young adult, what educational opportunities were available to me? And now?” (Ajouga, 2014)

While I did enter college with many opportunities for learning, my ability to make the most of them limited by my problematic childhood history.   Nonetheless, having been born into an upper-middle class environment to two highly educated parents, provided me with many privileges I failed to appreciate at the time, (Hays, 2008). Today, after having come to terms with my past through counseling, I’m grateful for the opportunity to make the most of these privileges and pursue this degree.

“What generational rules make up my core identity (eg., auntie, father, adult child, grandparent)?” (Ajouga, 2014)

Key generational roles which are strongly associated with my identity, include my roles as a daughter and mother. In fact, I hold my role as parent before any others in my life. Having nearly lost my oldest after several open heart surgeries and then suffering a miscarriage before giving birth to my youngest, I value my time with my kids greatly. It’s been my goal in life to learn the lessons from my parents, and be there in ways they were not able to. Making sacrifices for my kids, showering them with affection and cherishing our time together are key priorities in my daily life.

Regarding my role as daughter, while I’m not as close to them as I’d wish, I do strongly identify with my duties to them. As the oldest child with a background in health care, its expected that I be there to care for them when they age.   I plan on trying my best to live up to this expectation as a show if respect and love, knowing action and not words work best a communicating such things with them.

PART ONE: Conclusion

In completing this assignment, I’m actually surprised at how much I learned about myself. Rereading my personal history has been quite enlightening, as a much-needed perspective within to contextualize the outcome of my life.   It’s cleared while my complex sociocultural history yielded much stress as a child, its also provided me with wonderful opportunities for personal growth. Inspired by this fact, I am committed to a lifelong process of learning as a counselor and plan to use these insights as I worked completing my degree.

PART TWO:  Becoming a Culturally Competent Counselor

“Every man is in certain respects; (a) like all other men, (b) like some other men, and (c) like no other men” (Leong, F.T.L., 2011, p. 150).  We are inextricably connected to culture, defining it while simultaneously existing as a byproduct of it.  (Leong, F.T.L., 2011).  It is clear that counseling can’t occur in isolation of society at large (Sue & McDavis, 1992), and that counseling interventions are never culturally neutral (Framboise, et al., 1993).  Consequently multicultural competence must be an integral component of  ethical therapeutic practice .   A multimodal approach will be needed to consider varied factors from multiple viewpoints.

Towards a Solution

A quick review of literature reflects the complexity of the issue, with a complexity of approaches encompassing an array of factors to consider from multiple perspectives.   For example, the AMCD Multicultural Counseling Competencies, includes an awareness of one’s own cultural perspective, the clients, as well as knowledge of appropriate interventions based on these factors. (Arredondo, et al., 1996).  Assessing one’s beliefs, knowledge base, and skill set, within these three areas is essential for multicultural competence (Arredondo, et al., 1996).  Adding to this perspective, is insight from an article which says our personal development can be understood from a universal, group oriented and finally individual one (Leong, F.T.L, 2011).   In keeping with the idea that the individual and society at large are mutually definitive and interrelated in a complexity of ways, this perspective can be useful from a variety of theoretical perspectives.  Additionally, it could provide useful insight when utilized alongside the ADDRESSING Model discussed in our textbook (Hays, P, 2008).

A Tentative Plan

With multicultural competence such a complex issue, a plan is essential as a general guide to the development of this skill.  In this section, I provide a tentative outline of how I plan to develop multicultural competence.  In doing so, I will utilize the Bellevue University MCC Graduate Student Disposition Rubric to organize my thoughts (Bellevue University, 2014).  Additionally, in the spirit of this assignment, I believe a more informal and honestly self-reflective discussion is essential to make the most of this exercise.

Professionalism: Maturity & Responsibility.  

“Seeks solutions independently and/or identifies faculty who can assist…uses discretion by discussing the problem with only the appropriate person(s); focuses on solutions rather than blame….is respective to constructive comments….maintains confidentiality….always displays a thorough preparation…always demonstrates behaviors that exemplify honesty, and integrity…” (Bellevue University, 2014).


When reflecting upon the above, I feel my work as a C.N.A./Psych Tech has prepared me fairly well overall.  Confidentiality and discretion are very familiar concepts, (Catholic Health Initiative, 2014).   Additionally, maintaining a sense of integrity is what keeps me going during even the most difficult shifts.  This concept of integrity has meant thinking of the well being of clients first, and doing right by them first and foremost.  In doing so, this has meant letting go of any ego-based need to blame someone else.  Regardless of who is to blame, I have had to learn to understand the perspective of those whom I provide care for.  Adding to this, work-oriented skill development are my personal experiences as a biracial individual.  I’ve developed an understanding of the concept of cultural relativity and feel a heightened self-awareness has been an adaptive response to this experience.  The result is a greater willingness and open-mindedness to idea of understand cultural perspectives other than my own.

Area of Growth.

Being thoroughly prepared from the standpoint of multicultural competency, will have to be an ongoing commitment.   On the one hand, I’m a very self-aware individual, in terms of my own cultural values and biases (Arredondo, et al, 1996)  Additionally, I am very willing to learn about other cultures (Arredondo, et al, 1996).  At the same time, I do need to gain greater knowledge and skills when through interpersonal work within those communities I hope to serve (Arredondo, et al, 1996; Hays, 2008).


Direct interaction with individuals in communities I hope to serve within will need to be a priority.  Finding volunteer work, and opportunities for exposure to other cultures will be important.

Professionalism & Valuing Others.   

“Interactions…respectful of differing opinions.  Treats others with courtesy, respect, and open-mindedness.  Listens to and shows interest in the ideas and opinions of others.  Seeks opportunities to include or show appreciation for those who may be excluded.  Demonstrates concern….” (Bellevue University, 2014).


When considering how this applies to multicultural competence, valuing others will start with a self awareness of my own cultural background (Arredondo, et al, 1996) Being open-minded and willing to respect other cultural perspectives will be vital (Arredondo, et al, 1996)   In these respects, I do believe I’m well on my way to expressing my desire to show I value others.  Nonetheless, a knowledge base and set of interpersonal skills is again essential to add to this attitudinal perspective.  Without it, I can have the best of intentions, but fail to meet my desired mark.

Areas of Growth.

According to an article on biculturalism by Theresa LaFramboise, a culturally competent individuals hold a strong identity, possesses a knowledge of cultural beliefs and values, is able to display sensitivity to the affective, behavioral and language components in a cultural, while negotiating their way through social relationships and institutions in that culture.  (LaFramboise, et al, 1993).  Its clear without these components, serious errors in communication can occur.   Culture can be seen as a paradigmatic foundation in a person’s life, defining not just values and beliefs, but how we feel, think, and relates to others(Hays, P., 2008).  As I’m well aware, within the familial cultural gaps existing in my own extended family, failing to understand this can relate to terrible misunderstandings.


As stated before, developing this skill and knowledge will mean: (1) developing a knowledge base of therapeutic interventions, (2) gaining opportunities to be exposed to other cultures.  While doing so, our Hays (2008) textbook mentions the importance of humility as a critical element to professional growth which I believe will be important throughout the learning process:

“When people are humble, they recognize that other viewpoints, beliefs, and traditions, may be just as valid as their own….people with genie humility are effective helpers, because they are realistic about what they have to offer….critical thinking skills are essential, because they involve the abilities to identify and challenge assumptions….examine contextual influences…and imagine and explore alternatives. (Hays, P., 2008, p29).

Professionalism & Networking.

“Counselor is highly active in professional organizations and views professional organizations as a valuable medium through which ideas and information can be freely and consistently shared.”  (Bellevue University, 2014).

Areas of Growth.

When reviewing the above criterion, it is clear this is an area in which much growth is needed.   I don’t honestly have a lot of opportunity for networking on the job.  I work the weekend night shift in a nursing float pool throughout the  Alegent Creighton Health System.  I also go to school, and have a family, while jet lagged from my night shift hours.

The crucial importance of networking from the perspective of multicultural competence is it provides an opportunity for others to challenge your views offering valuable counterpoints you may not consider on your own.  Without this, I’m leaving a critical opportunity for learning out of the mix, in my educational and career pursuits.


I intend to focus on developing strong supervisory relationships within any  internship and volunteer opportunities while earning my degree.   Getting involved in organizations opportunities as a student therapist is another goal.  Finally, taking time to talk with those in the field, has been an ongoing priority, so I can plan my career path accordingly based on any shared insights.

Professionalism: Appearance & Self Care.

“Reflects upon and revises counseling practices and expertly applies revised practices…consistently seeks out self-care and prevention of burnout…participates in various ongoing educational and staff development activities….Is a role model of professionalism through personal appearance, attire, and cleanliness.” (Bellevue University, 2014).

Areas of Growth.

As is often said amongst caretakers in the field, you have to take care of yourself before you can take care of others.  Making time to engage in adequate self care, is a critical priority in my overall life path.  As someone who spends much time caring for others, I’m at a high risk of burnout.  “Burnout is a state of physical, emotional, intellectual, and spiritual depletion characterized by feelings of helplessness and hopelessness, (Corey, et al, 2011, p69).  The critical problem with burnout and heightened stress, are their ability to rob your ability to care for others with any degree of competence.  You can’t give to others any more than you’re willing or able to give yourself (Corey, et al, 2011).   It goes without saying, that no headway will be made in attaining multicultural effectiveness, if I can’t make this criterion a priority.


First and foremost in my self care regimen, is the need for adequate sleep.  After having switched to a different work schedule, and paying of some lingering debt, I find I’m  able to cut down on my work hours.  As a result, I’m making time to take care of myself, and am currently exercising and eating healthier with the goal to lose weight.  Additionally, I’ve saved up some money, for a more professional wardrobe, since nursing scrubs will no longer be appropriate.

PART TWO:  Conclusion

From the outset, choosing to enter the field of therapy, has been more than a career move.  It is a new life path, and a logical extension, from my past personal life progression of personal growth.   Much of what I’ve learned through this education process, has taken on a very personally reflective quality.  My most critical steps from this point forward will involve taking action, through direct interpersonal experience, as well as consistency in effort and commitment over time.   With my greatest challenges being self care and the need for networking opportunities, these have been my biggest focuses, in moving forward.


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Bellevue University. (2014). MCC Graduate Student Disposition Rubric. [Class Handout]
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Fortune, B.A. (2012). Acculturation, intergenerational conflict, psychological distress and stress in Filipino-American families. Regent University, Virginia.
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Levy, Denise L. “On the outside looking in? The experience of being a straight, cisgender qualitative researcher.” Journal of Gay & Lesbian Social Services 25.2 (2013): 197-209.
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NCE STUDY – Counseling Latino Clients

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

The term Latino/Latina is an ‘umbrella-notion’ that encompasses a wide variety of cultures that can include societies from Central American Indians, to Cuba, and Puerto Rico. Learning more about this minority group is essential when you note the wide diversity found within it. Including a variety of countries, each has its own unique culture and history.   Also notable are the varied stories of acculturation for the many subgroups and individuals in this community. A complexity of sociocultural and individual factors, blend together to determine experiences of acculturation, identity formation, and overall well-being for this minority group. As a byproduct of rich racially-mixed societies, varied socioeconomic histories, and unique degrees of political disempowerment in American society, each Latino individual and family has their own story, (Organista, 2007; Santiago-Rivera, et al, 2002).

In light of all this, I have a few concerns for my future career in counseling with this unique minority group. Understanding the issues at hand for my Latino clients will mean more than understanding factors such as sociocultural history and family background; although this is a good starting point.   I believe these factors can help a counselor to begin to understand how the process of acculturation and identity formation affect overall mental health (Organista, 2007; Santiago-Rivera, et al, 2002). When assessing these issues, it also becomes vital to note variations in value systems and worldview between counselor and client. Understanding how these factors affect ongoing dynamics during the counseling process and any intervention methods utilized, is also important.

In this paper I will begin by discussing key concerns to address during assessment to better understand the client.   I will continue with a discussion of Latino cultural values and worldview. I conclude with strategies and insights that would prevent me from making any overarching assumptions be made about my client’s cultural identity.

Understanding the Problem

“The ecological niche or unique combination of multiple contexts and partial perspectives define each individual’s and each family’s variation on major cultural themes. The ecological niche guides the evolution of values and behaviors…given its link to the social and physical environment…as well as access to power and the resources for healthy development.” (Hays & Iwasama, 2006, P73).

The concept of an ecological niche, as discussed in our Hays & Iwasama textbook (2006), sheds light on a key fact that is the source of concern for me in my future practice. Ultimately it’s the interaction of individual and sociocultural factors that influence the development and overall well-being of an individual.   In the case of the diversity in this group, this factor is that much more critical.

In his book titled “Solving Latino Psychosocial and Health Problems” Kurt Organista provides a historical background for Mexican Americans, Puerto Ricans, Cubans, and Central Americans, (2007). In this discussion the sociocultural histories of Latino communities described as influencing identity and acculturation stressors for individuals.   For example, it is interesting to note the differing degrees of adaptation to American culture between the Cuban and Central American communities, (Organista, 2007; Santiago-Rivera, et al, 2002).   Whereas the Cuban community received unprecedented support the Central American immigrants have been met with high degrees of resistance, (Organista, 2007; Santiago-Rivera, et al, 2002).   It’s also not a coincidence that these differing degrees of support vary with economic background and phenotypic appearance amongst the two groups (Organista, 2007). Examples such as this shed light on the importance of understanding within-group diversity of the Latino population.

In this section I discuss research on concepts of identity formation and process of adaptation for this varied minority group. Having an understanding of such research is a first step to effective counseling and assessment for Latino clients.

Concern One: Cultural & Ethnic Identity Formation

Viewing individuals holistically means understanding the relationship between person and their unique sociocultural context, (Santiago-Rivera, et al, 2002).   This requires more than simply taking time to learn about a clients unique sociocultural history. It also means developing a cursory understanding of identity, as a multidimensional construct with variances in progression between individuals (Organista, 2007).

Identity Defined.

Identity can be thought of as an internalized set of standards regarding beliefs about the self, or self-concept, (Santiago-Rivera, et al, 2002, p156). With this in mind, what follows is a useful definition of ethnic identity:

“Ethnic identity is defined as one of several role identities within the self-concept, eachof which varies in importance depending on the differential context of experience.” (Organista, 2007, p165-166).

With this definition in mind it seems our many roles, as reflected in the “addressing model” fit as components of a fluid ever-changing hierarchy within our self-concept, (Hays, 2008 & Organista, 2007).   It is useful to consider identity as highly personal subjective construct we develop to understand ourselves as individuals in an ever-changing sociocultural context. Understanding the identity formation process as it relates to this diversified minority is vital when you consider their consequences in the following quote:

“I believe that psychological pain is often the result of a lack of integration and that racism; prejudice and oppression are forces that can lead to disintegration of the sense of self. These negative forces can be overt, covert and internally based, or externally, which makes oppression a highly personal and difficult issue to deal with. (Delgado-Romero, 2001, p209.”

Addressing & Dimensions of Personal Identity Model.

The first theoretical perspective that intrigued me is the “Dimensions of Personal Identity Model” (Santiago-Rivera, et al, 2002).   It describes identity as having three key dimensions that appear to coincide well with the Addressing Model discussed in our Hays textbook (Hays, 2008).

  1. Dimension A” (Santiago-Rivera, et al, 2002) consists of factors are least changeable, and are usually ascribed at birth. They consist of factors such as gender, race, physical disability, sexual orientation, social class, and age.
  2. Dimension B” (Santiago-Rivera, et al, 2002) consists of factors that are more developmentally related and include factors such as income, marital status, citzenship and educational background.
  3. Dimension C” (Santiago-Rivera, et al, 2002) consists external sociocultural factors. These factors can include immigration experiences as related to the political-oriented historical context in which it occurred.

RIDM & Helms Models.

While the above model is effective in understanding identity formation as it occurs in a general sense, still other theoretical perspectives are useful in understanding how identify formation occurs for many Latinos. For example, the “Racial & Cultural Identity Developmental Model” describes five stages of identity development including conformity, dissonance, resistance, immersion, and awareness, (Delgado-Romero, 2001). Effective in describing identity development of “oppressed people experience as they try to understand themselves in terms of two cultures” (Delgado-Romero, 2001, p209) it describes identity as a subjective internal construct.   Still other models such as the Helms Racial Identity Model, (Delgado-Romero, 2001), help describe identity development as an interactive process.   With four stages of interaction (parallel, regressive, progressive, and crossed, (Delgado-Romero, 2001)) throughout identity formation process, it effectively contextualizes family dynamics and other common relational patterns. For example in the case of progressive interaction the “counselor operates from a more sophisticated ego status than the client. Energy and growth producing intercourse are the results of this type of relationship” (Delgado, 2001, p210). Conversely, a crossed interaction exists when the “ego status of counselor and client are in direct opposition”, (Delgado-Romero, 2001, p21). As you might guess the results are more problematic.

Concern Two: Acculturation & Adaptation Processes

Alongside issues of identity formation, the manner of adaptation to two sets of cultural influences exists as another important concept. Understanding a person’s overall orientation to their own culture (i.e enculturation) as well as dominant culture (i.e acculturation), (Delgado-Romero, 2001), is also vital.

Dimensions to Cultural Adaptation.

Overall there are a wide variety of potential orientations visible in clients contending with the influence of competing cultures. For example, our textbook briefly describes five models including “assimilation, acculturation, alternation, multicultural and fusion” (Hays & Iwasama, 2006, p10).

“Which form of adaptation an ethnic minority eventually experiences depends on a number of factors, including the original conditions of contact, the degree of conflict between groups, and the dominant society’s tolerance for cultural diversity.” (Organista, 2007, p8).

Further adding to the complexity of the situation are the variations seen as a result of this orientation including unique resultant social experiences, psychological mechanisms utilized and strengths/obstacles, (Hays & Iwasama, 2006, p10).   Understanding how the sociocultural history, family history and individual factors blend together into this adaptive style is also important.

Acculturation Process & Influences.

“acculturation is consistently related to higher levels of a broad array of diagnosable mental health problems…..Mental health differences between Latino groups reflects their acculturation histories, which vary considerable in terms of degree of acculturative stress and challenges to adaption.” (Hays & Iwasama, 2006, p75).

As the above quote conveys, the adaptive processes utilized in relation to American culture have a huge impact on overall well-being and warrant closer examination. Defined as “socialization into an ethnic group other than one’s own” (Delgado-Romero, 2001, p211), acculturation can be thought of as a process including three factors described as follows:

“Contact refers to the conditions under which two cultural groups meet….conflict refers to the predictable tension and fighting that results when one group attempts to dominate another…and adaptation refers to the eventual form of accommodation between groups that is intended to reduce conflict.” (Organista, 2007, p5)

The Latino Model of Ethnic identity helps to contextualize the Acculturation Process for this diverse minority, (Delgado-Romero, 2001, p211). Encompassing five stages (including causal stage, cognitive stage, consequences, working through stage, and resolution), this theory indicates marginality and forced assimilation are negatively correlated with mental health, (Delgado-Romero, 2001). Conversely, promoting a pride one’s identity and freedom of chose are key to effective adaptation (Delgado-Romero, 2001)

With this in mind, trends are visible when examining how acculturative stressors vary within differing Latino subgroups, (Organista, 2007).   As a result of such research, it is clear that acculturative stress inversely correlated with cultural and behavioral similarity, as well as socioeconomic status (Organista, 2007, p8). Additionally it is possible to correlate immigration policies and other political factors at the time of immigration with acculturation stresses (Organista, 2007)

Latino Cultural Values & Worldview

Individual worldviews and value systems exist in us as largely automated and subconscious factors we rarely consider.   In light of this fact, a lack of awareness regarding value differences between clients and ourselves can cause misunderstandings to occur.  With this in mind, what follows are value differences that I would need to be aware of during the assessment process:

  1. Individualism vs. Collectivism: Growing up in American culture my own personal value system is one that emphasizes individualism. In this respect, self-expression, personal rights, and privacy are ideals that are important. Collectivist ideals that emphasize respect, sacrifice, and emotional suppression for the sake of harmony can be easily overlooked.
  2. Verbal Expressiveness vs. Stoicism: This key difference is one that has troubled my relationship with my mother. Stoicism is a value that is often correlated with a collectivist perspective in which harmony is a priority. This can be misunderstood, easily from an American perspective which values verbal expressiveness.
  3. Personalismo vs. Task Orientation: In those instances in which I have cared for Latino clients in a hospital setting, I have been made acutely aware of these value differences. As someone who is task oriented I set about checking things off my to-do list.   This can be experienced as highly impersonal at times from a Latino values perspective. Taking time to provide personal attention, build trust, and simply converse casually, are key in building a therapeutic relationship with Latino clientele.
  4. Egalitarian vs. Traditional Gender Roles: Coming from a highly egalitarian background, it will be important to understand traditional gender roles as they relate to counseling Latino families. Being aware of this factor, gauging interactions and interventions accordingly will be vital.
  5. Science Vs. Religion: Having been raised by two doctors and being agnostic, my value system is clearly one-sided. In an attempt to engage in an honest self-assessment, I will need to further educate myself on the importance of religion in the counseling context. Participating in religious practices, relevant volunteer work and internship opportunities are possible solutions to address this issue

In concluding this section, the above listing of cultural value differences is certainly an overview of key issues and an in-depth self-assessment. This list appears to me as an example of issues that can potentially stand in the way of any culturally sensitive empathy.   Essentially defined as an ability to put yourself in another’s shoes and understand their frame of reference, empathy is definitely culturally relevant (Chung & Bemak, 2002). It entails understanding the internal world, cultural identity, and value systems of clients while simultaneously holding onto my own. Affectively communicating it and addressing issues relative to cultural context also communicate empathy. Clearly, throughout this process, value system differences need to be attended to

Counseling Strategies to Address Therapist Assumptions the Need for Eclecticism In Counseling.

“Eclecticism in psychotherapy can take two general terms. The first involves an integration of diverse theories into one transtheoretical mode. The second, known as technical eclecticism, describes the increasingly common practice of systematically choosing and using a wide range of interventions and procedures.” (Hays, 2008, p176-177)

As is well known, counseling’s history has encompassed a longstanding under-emphasis in sociocultural factors and over-emphasis in empiricism.   Consequently, many traditional theories and techniques are based on a value system that is highly Euro-American in scope. Preventing any assumptions regarding a client’s identity as a member in the Latino community requires a eclectic approach.

While I know this is a slight reiteration of previous paper assignment, there are three theoretical perspectives that provide a great start-off point for multi-culturally competent counseling. Firstly, it will be beneficial to slightly modify the Axis-6 Addressing Model approach as mentioned in our Hays-textbook (2008) for the new DSM-V. Considering sociocultural context alongside a DSM perspective can provide a critical balance of cultural relativism and empirical soundness.

Still other insights from the “MAP – Multicultural Assessment Procedure” (Thomas, 2007, p65) and the “FACTS” Method, (Johnson, 2013) are useful. The Multicultural Assessment Procedure is useful as an assessment that involves a process of continually testing and revising a working hypothesis, (Thomas, 2007).   The FACTS Method is a five part approach that involves (1) formulating questions, (2) utilizing assessment methods, (3) addressing culturally-responsive issues, and (4) providing treatment based on scientific evidence. (Johnson, 2013, p19).

Multicultural Competency & Empirically Based Insight.

In concluding this paper, I feel it is useful to mention briefly an article titled “Counseling a Hispanic/Latino Client – Mr. X.”.   It describes a hypothetical scenario of case conceptualization for a Latino client.   The article begins by providing an overview of relevant theoretical perspectives, while also describing how it is relevant to client “Mr-X”.

Starting out with the first therapy meeting, mention is made of any value-based differences between counselors and Latino clients. Cautioning against the potential for misunderstanding, attending to these differences throughout client interaction is critical, (Delgado-Romero, 2001).

Still other initial considerations in our hypothetical case scenario include addressing issues of cultural and racial identity, and family roles.   Continuing through therapy, there is a description of how identity and acculturation theories, described above, can relate to assessment and effective case conceptualization for “Mr-X”. Finally, therapy goals such as validation and education are vital to help the client understand self-development in a greater sociocultural context. Additional considerations such as providing homework that is culturally relevant are also mentioned.

To summarize, this article is effective in describing how multicultural counseling might occur in an intriguing hypothetical scenario.   I would hope to utilize a very eclectic method that would allow for culturally relevant contextualization of theoretical perspectives of issues such as identity development and acculturation. Additionally, assessing clients in this diverse minority group, would best be served when the utilization of the DSM-5 is put within a culturally relevant context.

“I am about to go to the waiting room and meet Mr. X for the first time. I am feeling nervous, yet excited, especially since I have had time to review a general racial and ethnic identity development theory….I feel that I have reviewed the variable that might be important in conceptualizing, assessing, and treating Mr. X. But an air of mystery still remains, the unknown of how we will work together. I guess that’s why counseling is still an art.” (p220)


Chung, R. C., & Bernak, F. (2002). The relationship of culture and empathy in cross-cultural counseling. Journal of Counseling and Development : JCD, 80(2), 154-159. Retrieved from

Delgado-Romero, E.A. (2001). Counseling a Hispanic/Latino Client – Mr. X. Journal of Mental Health Counseling. 23(3). 207-221.

Hays, P. (2008). Addressing cultural complexities in practice. (2nd Ed.) Washington, D.C.: American Psychological Association.

Hays, P., & Iwasama, G.Y. (2006). Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, & Supervision. Washington, D.C.: American Psychological Association.

Hernandez, A.M., & Curiel, Y.S. (2012). Entre nosotros: Exploring Latino diversity in family therapy literature. Contemporary Family Therapy. 34, 516-533.

Johnson, R. (2013) Forensic and Culturally Responsive Approach for the DSM-5: Just the FACTS. Journal of Theory Construction & Testing, 17(1), 18-22.

Organista, K.C. (2007). Solving Latino Psychosocial and Health Problems: Theory, Practice, & Populations. Hoboken, N.J.: John Wiley & Sons, Inc.

Santiago-Rivera, A.L., Arredondo, P, & Gallardo-Cooper, M. (2002). Counseling Latinos and La Familia: A Practical Guide. Thousand Oaks, CA: Sage Publications, Inc.

Thomas, J. C., Hersen, M., Sage eReference (Online, s. (Online service), & Sage Publications, (2007). Handbook of Clinical Interviewing with Adults. Los Angeles: Sage Publications.

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Generalized Anxiety Disorder

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

What is GAD?

The DSM-5 Manual describes Generalized Anxiety Disorder (GAD) as a “persistent or excessive anxiety…about various domains…that the individual finds difficult to control” (American Psychiatric Association, 2013, p190).  Additionally, the persistent worry associated with GAD includes symptoms of restlessness, perpetual fatigue, irritability, and difficulty concentrating (American Psychiatric Association, 2013).  GAD involves a generalized anxiety that is unrelated to a specific stressor and is psychogenic in nature (Lambert & Kinsley, 2011; Preston, et al, 2013).  In this respect, while GAD’s symptoms have a neurochemical basis, they are a byproduct of nonspecific and imagined threats (Lambert & Kinsley, 2011; Preston, et al, 2013).

Therapy for GAD

It is important to understand that the mental state of GAD involves a chronic anxiety that involves an ongoing prediction that life events are unpleasant and potentially threatening.  For this reason, CBT, meditation, and motivational interviewing techniques are helpful in individuals with GAD (Greene, 2013; Preston, et al, 2013).   This can a allow clients to overcome any ambivalence while developing tools for self-soothing and learning how to rethink about one’s situation (Greene, 2013; Preston, et al, 2013).

Medications for GAD

Medications for GAD can include SSRI’s, Benzodiazepine, Busprione, and Gabapentin (Greene, 2013; Preston, et al 2013). Benzodiazepine acts on GABA receptors that cause the opening of calcium channels, and inhibition of the neuron (Preston, et al, 2013).  Busprione, in contrast acts on serotonin receptors, and while less addictive than Benzodiazepine, its action is delayed (Greene, 2013).  Finally, the anticonvulsant Gabapentin is also used for anxiety.  Originally designed to mimic GABA, Gabapentinis thought to prevent the release of monoamines (Greene, 2013).

Preston, et al, (2013) suggest that since the half-life of anxiolytics tends to be short, the tendency for withdrawal is high.  Additionally, some of these medications have a high risk for addiction.  Patient education of these risks and other potential side effects, is important.  Finally, in order to minimize withdraw, it is important to closely monitor a client’s response to the gradual tapering of dosage levels (Preston, et al, 2013).

Therapist’s Role

In the first week of class, we read several resources that discussed the importance of a multidimensional, biopsychosocialperspective of mental health.  In addition to attaining a comprehensive experiential background, it will be important to collaborate one’s efforts with individuals in other mental health fields  For example, while therapist’s do not prescribe medication, they will need to be aware of what the client is taking.  An understanding of the effects of these medications is essential for properpsychoeducation and their effects on a patient’s overall well-being is also important.  In the case of the anxiolytics, Preston, et al, (2013), suggests that they work best as a short-term solutions.   For this reason, a therapist’s role will involve many of the therapeutic techniques listed above while simultaneously monitoring response to medications.

A Day in my Life

The Overview

I am a married mother to two boys, ages 14 and 8. I work full-time job as a C.N.A. for a large hospital-system float pool. I work three back-to-back 12-hour night shifts, Friday-Sunday, 7:00 p.m. to 7:00 a.m.. I have Monday thru Thursday off and spend the majority of this time on school work and family-related duties. My days vary greatly depending on whether it’s a weekend or a weekday. However, one constant issue in my life is jet-lag, due to an ongoing rotation between day-time and night-time sleep. Additionally, since my husband works 8:00 a.m. through 5:00 p.m., Monday-Friday, we rarely have a whole day to spend together. I make the most of the family time I do have in the morning and evening.

Work-Day Weekends

On the weekends when I work, my husband is home with the kids. I usually arrive home at 8:00 a.m. and have a quick breakfast with the family. I make it a goal to sleep between 9:00 a.m. and 4:00 p.m.   The sleep is usually inadequate since my kids can be noisy and frequently have friends over.   When I wake up, I work on my discussion board post responses and have dinner with my family before leaving for work around 6:30. Since I work for a hospital system float pool, the work varies greatly. Nonetheless, it is usually physically and mentally exhausting. The floors have been short-staffed quite a bit lately. This doubles my patient load from approximately 10 to 20 patients.   I often get one break during the middle of my shift at about 1:00 a.m., otherwise I’m on my feet constantly

Weekdays Off

On my weekdays off, my main goal is to recover from the weekend as quickly as possible. I reserve Monday for this purpose and don’t get much done. I wake up in the morning Tuesday, thru Friday, around 7:00 a.m. and make breakfast then get my kids to school. Since I’m home alone during the day, I try my best to complete homework, but often require a nap. I pick my kids up around 3:00 p.m., make a snack, and get dinner ready. I do my homework on the dining table while my kids after we eat. I try to get to bed between 10-11 p.m.

A Day in My Life with GAD

GAD & SWSD: A Double Whammy

The DSM-5 Manual describes Generalized Anxiety Disorder (GAD) as a “persistent or excessive….worry about various [life] domains…that the individual has difficult to control” (American Psychiatric Association, 2013, p190). Symptoms of anxiety include restlessness, perpetual fatigue, irritability, sleep disturbance, and difficulty concentrating (American Psychiatric Association, 2013). Interestingly, symptoms of GAD are fairly similar to “Shift Work Sleep Disorder” (SWSD), an issue common in night shift workers (Brett, 2005). Symptoms associated with Shift Work Sleep Disorder include: insomnia, fatigue, and difficulty concentrating (Brett, 2005). Additionally, individuals dealing with this issue are at increased risk of heart disease, obesity, anxiety and depression (Brett, 2005).  Adding a GAD to my life would significantly exacerbate the sleep disorder issues I currently deal with. Right now, I’m able to manage effectively by making adequate self-care a priority. As an individual who spends the majority of her time caring for others, I’ve had to learn to put myself first. I try my hardest to get a full 6-8 hours sleep daily. With GAD, this may become an impossible feat, and would require a simplification of my life. This would include either working less or quitting school.

Life Through The Lens of Anxiety

The important thing to note about anxiety, is that it exists independent of logic.   You can’t talk or reason your way out of it. While I don’t have an anxiety, I already have a very stressful schedule. In this respect, I can imagine its effects. For example, when I’m tired, I have difficulty utilizing my prefrontal cortex to think logically about things. As a result, the stress takes over, and I can become irrational when exhausted. I find I’m thinking with my emotions rather than through them. With Generalized Anxiety Disorder, this might occur in a more pronounced manner as the lens through which I experience life. Anxiety would become the mode of being that defines my existence. Every element of my life would become that much more unmanageable.   For example, anxiety may cause me to worry about the effectiveness of my role as a mother. Since my son has a heart condition, and my youngest came only after a miscarriage, these experiences could exacerbat GAD. I would worry about their well-being every minute of the day. The guilt I would feel about the fact that they eat too much junk food and stay up too late, may incapacitate me. Adding the responsibilities of a full time C.N.A. position and school work may prove overwhelming.   Honestly, I’m not sure if I would be able to function in my current life circumstances.

Overall, eliminating some responsibilities from my life would be the easier solution. This would involve working less or quitting school, which I would happily do for the sake of my well-being. The difficult issue regarding GAD pertains to its affect on relationships and the ability to enjoy life. My husband wouldn’t have the partner he does currently, and would need to shoulder greater responsibilities. Everybody would also have to accommodate my GAD symptoms.   Most importantly, I would be trapped inside a mind filled with anxiety while living a life defined by worry.

Raising a Child with GAD

The final question posed in this assignment is how different it might be to parent a child with GAD. As a parent to a child with a congenital heart defect, I have some insights worth mentioning. My oldest son has a congenital heart defect (CHD) called pulmonary atresia. Individuals with heart defects have what can be thought of as a “hidden disability” (CITE). While not readily visible upon initial inspection, the influences of a heart defect do require special consideration. In addition to the obvious physical limitations, there are also less obvious concerns. Social delays in males with CHD result from an inability to participate in sports, alongside prolonged stays in the hospital (Berant, et al, 2001; Horner, et la, 2000). Emotional developmental delays result from the parent-child relationship that occurs when a child is faced with a serious life-threatening illness (Berant, et al, 2001; Horner, et la, 2000).  The most difficult thing about the experience, isn’t just the heightened anxiety and worry, but also the judgment from others (Berant, et al, 2001; Horner, et la, 2000). It requires time to recover from such a trauma, and your relationship with the child is changed. Children with CHD spend a significant time fighting for their life, and don’t have the same opportunities to engage in the normal childhood developmental process. Nonetheless, people may not realize this and simply notice deviations in a child’s level of emotional regulation that are generally expected at a certain age. The hardest part is the idea of wanting to support your child by giving what they need developmentally, in a world that judges them for unpalatable behavior.   While this issue, doesn’t compare to parents of children with a serious mental health issue, this experience has enabled me to develop greater understanding and compassion.


American Psychiatric Association. (2013).  Diagnostic and statistic manual of mental disorders.  (5th ed.).  Washington, D.C.: Author.
Berant, E., Mikulincer, M., & Victor, F. (2001). The association of mothers’ attachment style and            their psychological reactions to the diagnosis of infant’s congenital heart disease. Journal =of Social and Clinical Psychology, 20(2), 208-232.
Brett, A. S. (2005). Modafinil for shift-work sleep disorder. NEJM Journal Watch General Medicine, doi:
Greening, L. (2013). Generalised anxiety disorders. The Dissector, 41(2), 30-32. Retrieved from
Horner, T., Liberthson, R., & Jellinek, M. S. (2000). Psychosocial profile of adults with complex congenital heart disease. Mayo Clinic Proceedings, 75(1), 31-6.
Lambert, K., & Kinsley, C.H. (2011). Clinical neuroscience: The neurobiological foundations of mental health. 2nd Ed., New York, NY: Worth Publishers
Preston, J.D., O’Neal, J.H., & Talaga, M.C. (2013). Handbook of clinical psychopharmacology for therapists (7th Ed.)  Oakland, CA: New Harbinger Publications, Inc
Vrijmoet-Wiersma, ,J.C.M., Ottenkamp, J., van Roozendaal, M., Grootenhuis, M. A., & Koopman, H. M. (2009). A multicentric study of disease-related stress, and perceived vulnerability, in parents of children with congenital cardiac disease. Cardiology in the Young, 19(6), 608-14.

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