Search Results for: cognitive biases

Aaron Beck’s Cognitive Behavioral Therapy

History & Overview

“Cognitive behavioral approaches look at how cognitions and/or behaviors have been learned and can be re-learned….They all believe that after identifying problematic behaviors and/or cognitions, one can choose, replace, or reinforce new cognitions and behaviors that result in more effective functioning” (Newkurg, 2009).

“The basis of cognitive approach to emotion can be traced as far back as Aristotle…and Epitectetus” (Metcalf, 2011, p. 92).  These historical of CBT focus on how individual’s we give our life experiences meaning and make sense of them.  Kant’s concept of transcendental idealism, that things cannot be known outside of how they might appear to us, has also greatly influenced CBT (Corsini & Wedding, 2011).

Cognitive Behavioral Therapy (CBT) was developed by Aaron Beck in the 1960’s as a result of his research on depression when he noted their thought process contained a negative bias (Corsini & Wedding, 2011).   It is based on the idea that an individual’s experiences are shaped by core beliefs, which in turn determine thoughts, feelings and behaviors.   The goal of CBT is to alter the cognitive appraisals that produce emotional distress and maladaptive behavioral responses (Chaplin, et al, 2013).  Adjusting our information processing begins in a collaborative process between therapist and client in which maladaptive cognitions can be tested and re-examined (Corsini & Wedding, 2011).

In order to achieve this goal, CBT focuses on cognitive schemas which comprise perceptions about ourselves and others alongside personal expectations, goals, memories, and prior earning experiences (Corsini & Wedding, 2011).  Contemporary CBT perspectives describe these schemas as modes “networks of affective, motivational, and behavioral schemas that compose personality and interpret ongoing situations” (Corsini & Wedding, 2011, p. 277).  CBT defines psychological disorders as maladaptive cognitive schema that create a systematic bias between oneself and the world.  Psychological disorders such as anxiety encompass primal modes which encompass, rigid, automatic, survival-based thinking.  The solution to these issues involve: (1) symptom relief; (2)  an acknowledgment of any cognitive bias, and; (3) the “correct[ion] of  faulty information processing” (Corsini & Wedding, 2011, p. 290).

CBT vs. Other Perspectives

Psychodynamic Therapy vs. CBT

While psychodynamic theory and CBT both conceive belief systems as influencing our behaviors, the prior conceives beliefs as components of our unconscious mind (Corsini & Wedding, 2011). Beck disagreed with this.  Consequently, CBT does not focus on uncovering hidden aspects of our unconscious from early childhood.  Instead it focuses on understanding the links between any psychological disorders, symptoms, beliefs, behaviors, and experiences (Corsini & Wedding, 2011).  Finally, while psychoanalysis is a long-process involving cathartic free-association in therapy, CBT tends to a short-term and structured.

Ellis vs. Beck

REBT and CBT both conceive cognitions as useful in understanding psychological dysfunction and focus on maladaptive systems of belief.  However, there are a few key differences as delineated below.

An Inductive CBT Approach vs a Deductive DBT Approach

Ellis’s REBT is a deductive approach, that involves beginning with a general theoretical prediction as a starting point from which we make specific observations about the world (Corsini & Wedding, 2011).  In this respect, it follows closely with the logical of scientific research which begins with a hypothesis that it tests in an experiment with the hopes of making observations that might support it.  In contrast, CBT is an inductive approach that states we make specific observations about daily life and use these to form generalized belief systems about our world.  For example, in Beck’s research on depression he notes people develop negative biases about their world as a result of a set of symptoms stemming from depression.

Two Divergent Conceptions of Psychological Disorder.

As a result of his research on depression and anxiety, Beck noted variations in that these disorders had general cognitive biases (Corsini & Wedding, 2011).  Beck’s CBT approach utilizes the “cognitive profiles” (Corsini & Wedding, 2011, p. 279), for these disorders as a guide to understanding how we should address the issue.  In contrast, REBT focuses on the absolutist nature of any beliefs or our “Musterbating”.   For example, while a CBT therapist would focus on addressing perceptual errors an REBT therapist would focus on our “should’s”.

Two Divergent Interpretations of Belief Systems

REBT conceives faulty belief systems as a philosophical error of irrational thinking.  As a result, an REBT therapist would challenge belief systems that are “incongruent with reality” (Corsini & Wedding, 2011, p. 279).  In contrast, Beck disliked the idea that a client’s cognitions be characterized as irrational (Metcalf, 2011).  Rather than conceiving our beliefs as irrational he felt they existed as automatic thought processes triggered by feelings and not events (Metcalf, 2011).

Behavioral vs. Cognitive Interventions

Cognitive Interventions

Cognitive interventions focus on the “content and process of” (Ingram, 2012, p197) an individual’s thoughts. The theoretical underpinnings of these interventions come from a diversity of fields including neuroscience, cognitive development, CBT, and even sociology (Ingram, 2012). This is because the manner in which we construct our understanding of the world varies according to our developmental level, cultural perspective, and brain functioning. Examples of cognitive interventions can include addressing dysfunctional self-talk, utilizing a metacognitive perspective, or DBT skills (Ingram, 2012).

Behavioral Interventions

Behavioral interventions are based on the well-known learning principles from the works of Skinner and Pavlov. Additionally, the textbook notes that learning principles can be found in other forms of therapy including the work of Carl Roger (Ingram, 2012). For example, in contrast to cognitive therapy, a behavioral intervention might utilize the process of behavioral analysis. This involves examining the problem, and defining their causes and consequences in order to determine how to utilize interventions like positive and negative reinforcement, or contingency contracting, punishment (Ingram, 2012, p236).   Cognitive therapy, on the other hand, focuses on our thought processes such as the ABC model in which an event produces thoughts and causes our feelings (Ingram, 2012, p210).

CBT on Personality

CBT “views personality as shaped by the interaction between innate disposition and environment” (Corsini & Wedding, 2011, p. 284).  So what makes us who we are?  Our personality is comprised schematic approach towards the world that is comprised of cognitions, emotions, behaviors, and motivations.  Each individual has unique strengths and vulnerabilities related to their own personality structure (Wedding & corsini, 2011).  Psychological disorders and distress are a consequence of both the environment and predisposition.   In this respect, Beck’s view of our developmental history is consistent with social learning theory.

Dimensions of Personality

In his research, Beck was interested in learning how certain aspects of the personality were related to maladaptive emotional responses like anxiety or depression (Corsini & Wedding, 2011). Beck described a continuum-based set of personality dimensions that could help explain an individual’s susceptibility to depression.

Sociotropy

Beck uses the term “Sociotropy” (Corsini & Wedding, 2011, p. 284).  Sociotropic individuals display high levels of social dependence and experience higher levels of depression during instance of relationship disruption.  “The sociotropic dimension is organized around closeneess, nurturance, and dependence” (Corsini & Wedding, 2011, p. 284).

Autonomy

Autonomous people are highly independent and experience depression when they fail to acheive their goals (Corsini & Wedding, 2011).  Autonomous individuals show a preference for “independence, goal setting, self-determination and self-imposed obligations” (Corsini & Wedding, 2011 p. 284).

Cognitive Distortions

As stated earlier, psychological distress is conceived as a byproduct of both innate and environmental factors.  Beck also noted systematic biases in individuals who experience psychological distress (Corsini & Wedding, 2011).  He used the term “cognitive distortion” (Corsini & Wedding, 2011, p 285), to describe many of our systematic biases.  What follows is a list of examples of common cognitive distortions:

  1. ARBITRAY INFERENCE – “Conclusions made in absense of supporting evidence” (Metcalf, 2011, p. 95).  For example, my son believes he is terrible at math because it is hard, when in fact he just earned a B+.
  2. SELECTIVE ABSTRACTIONS – This distortion involves taking information out of context (Corsini & Wedding, 2011).
  3. OVERGENERALIZATION – Overgeneralization involves utilizing single situation as representing all events of this type.
  4. MAGNIFICATION & MINIMIZATION – “Seeing something as more significant or less significant than it actually is” (Corsini & Wedding, 2011, p. 285).
  5. PERSONALIZATION – Personalization happens when we blame ourselves for external events.   We ignore the aspects of the situation that are beyond our control.
  6. DICHOTOMOUS THINKING – This distortion is often called black-and-white thinking and ignores the gray areas.
  7. TUNNEL VISION – This narrowed focus is characterized by a focuses one’s own selfish interests and sacrifices others’ viewpoints.

CBT on Psychological Disorders

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As you can see in the above photo, (Corsini & Wedding, 2011), Beck conceived psychological disorders as evidence of a systematic bias in an individual’s cognitive schema.  In other words, all symptoms are interpreted in terms of their overall view of the world.  For example, depressed individual’s hold a pessimistic cognitive schema and anxious individuals hold exaggerated views of danger.

Beck on Anxiety…

Click here for a Beck’s Anxiety Inventory…

With anxiety disorders, Beck notes that individual’s act on a “worst-case-scenario” basis that involves an overestimation of a potential outcome and underestimates one’s ability to cope (Corsini & Wedding, 2011).  The body is in flight-or-flight mode as physiological responses to a self-perceived threat.  We can tend to create them even when they might not exist.

Beck on Depression…

Click here for Beck’s Depression Inventory…

In his research, Beck noted depressed individuals display negative beliefs about themselves, the world, and the future overall.  These belief systems influence one’s cognitions and emotional states, making it difficult to see beyond our view of things.  The world is experienced through a pessimistic lens, leading to a sense of hopelessness and motivational paralysis.

Beck on Suicidal Behavior…

Click here for Beck’s Suicidal Risk Assessment…

Beck describes the thought processes associated with suicidal individuals as containing two features: hopelessness and cognitive deficit (Corsini & Wedding, 2011).  Additionally, a suicidal individual’s thought process become rigid with suicide appearing as the only alternative (Corsini & Wedding, 2011).

Overview of Counseling Process

Goals of CBT

The goal of CBT is to “correct faulty information and help patients modify assumptions that maintain maladaptive behaviors and emotions” (Corsini & Wedding, 2011, p. 290).  It treats belief systems as hypotheses that can be tested in a therapeutic setting.  Cognitive changes in one’s belief systems, are thought to lead behavioral changes.  Emotions are influenced by our perception of events.

Therapeutic Relationship

Corsini & Wedding, (2011) describe the therapeutic relationship as a “collaborative empiricism” (p. 277).  Client and therapist share responsibility for therapeutic goal setting.  The therapist is a guide who helps the client better understand their attitudes and belief systems.  This reality testing process occurs within an accepting and empathetic setting where beliefs are tested as hypotheses one has about their reality.

Strategies & Techniques

What follows is a “quick and dirty” overview of techniques often utilized in Beck’s Cognitive Behavioral Therapy.

Guided Discovery

Guided discovery involves a gradual process of discovering threads in one’s thinking like links in a chain (Corsini & Wedding, 2011).  “The therapist guides the client through a scenario, enabling them to understand any cognitive distortions” (Metcalf, 2011, p. 114), by linking linking misperceptions to past experience.

Socratic dialogue

CBT involves the use of reality testing methods that are similar in many respects to a socratic dialogue.  This involves deconstructing our current preconceptions of a matter and analyzing any ignorance.  With this ignorance defined, it can then be possible to uncover its solution – a greater knowable truth that was previously invisible.

Validity Testing

Validity testing involves a critical examination of our beliefs and thoughts and requires the establishment of a solid therapeutic relationship to occur.  “If the client cannot defend their beliefs and thoughts they are said to be invalid” (Metcalf, 2011, p. 108).

Modeling

Clients are given role-playing exercises with the therapist in which they can practice new ways of responding to specific situations (Metcalf, 2011).  This technique is often utilized with autism clients in an effort to develop greater effectiveness in social situations.

Approaches to Dysfunctional Schema

“There are three major approaches to treating dysfunctional modes: (1) deactivating them, (2) modifying their content and structure, and (3) constructing more adaptive modes to neutralize them” (Corsini & Wedding, 2011, p. 278).

Exposure Therapy

Utilized frequently in trauma and anxiety-related disorders this involves addressing cognitive distortions and physiological symptoms when presented with anxiety-related objects.  “By dealing directly with a patient’s idiosyncratic thoughts, cognitive therapy is able to focus on that patient’s particular needs.

Treatment Planning

I dug up another course textbook that provides an interesting perspective, titled “Clinical Case Formulations,” (Ingram, 2012).  It’s purpose is as follows. “A clinical case formulation is a ‘conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions’ (Ingram, 2012 p. viii).”  What I love about this book is it provides clinical hypotheses that are useful in providing “a single explanatory idea that helps us structure data about a given client (Ingram, 2012 p. 11).”  Chapter ten of this textbook discusses “Cognitive Models” (Ingram, 2012), an individual’s cognitive functioning and thought processes.  Several clinical hypotheses are worth mentioning in order to get an idea of how this therapy method can be applied directly to a case.  

(C1) Metacognitive Perspective (Ingram, 2012)

Metacognition is a term which means “thinking about thinking” (Ingram, 2012).  This clinical hypothesis is useful when a person needs to hone their critical thinking skills and gain awareness of their inner experiences.  It is useful in anxiety and trauma-related disorders, or instances in which rumination, and emotional dysregulation are a problem.  However, states five cognitive capacities are critical when using this hypothesis: “(1) nonreactivity to inner experience…(2) able to separate self from thoughts…(3) not giving power or control in thoughts…(4) evaluating one’s thinking in terms of goals…(5) taking the role of executive over one’s own thoughts” (Ingram, 2012, p. 200).

(C2) Limitations of Cognitive Map (Ingram, 2012)

This hypothesis is useful when individuals have maladaptive schemas or self-fulfilling belief systems.  Since these schemas provide a framework of meaning around which they understand their world, it is thought to influence their behaviors, emotions, and experiences (Ingram, 2012).

(C3) Deficiencies in Cognitive Processing (Ingram, 2012)

Useful for clients who display “faulty information processing, poor reality testing, and an inflexible cognitive style (Ingram, 2012, p. 214).  Useful with depression and anxiety disorders, many of Beck’s concepts are discussed here (Ingram, 2012).

Phases of Therapy

Building Rapport

As noted earlier the CBT approach involves a Socratic dialog that includes a collaborative empiricism.  Testing one’s views about the world entails a great deal of vulnerability as an individual’s perceptions are called into question.  For this reason, the initial goal of therapy involves building a solid relationship with the client (Corsini & Wedding, 2011).  “Therapists should be genuine, empathetic, and active listeners” (Metcalf, 2011, p. 114).

WHY SEEKING THERAPY –  “How did you make the decision to come into therapy?…”What are your present concerns in life?” (Ingram, 2012, p. 114).  
UNDERSTANDING THE PRESENTING PROBLEM -“What feelings are you experiencing when you think of these situations…What thoughts make you feel worse? How would you feel if you did not have these thoughts?” (Ingram, 2012, p. 114).

Developing Goals

“In CBT the client’s decide the therapeutic goals” (Ingram, 2912, p. 115).  In this respect, a greater amount of responsibility falls on the shoulders of clients in determining the direction that therapy will take.

Amplifying Change

Corsini & Wedding (2011), notes that change occurs when the client “experiences a problematic situation as a real threat” (p 298).  This is because, when emotions and affective arousal are linked to systems of belief they are easier to access and acknowledge (Corsini & Wedding, 2011).  The therapist is responsible for acting as a guide.  Ingram, (2012) notes that this involves monitoring their improvements and overall functioning.  The therapist notes these changes and inquires about the changes in beliefs and thoughts that coincide with these mood and behavioral alterations (Ingram, 2012).

Termination

CBT is a short-term and goal directed approach to therapy.   In this structured approach, symptom reduction is an initial goal (Godfried, 2002).   Helping clients manage difficult emotions is important in order to begin addressing their underlying causes.   Cognitive therapy helps client’s develop general skills to deal with life’s difficulties. Once the client experiences a reduction in symptoms and has developed skills to address these issues, a new phase of therapy can begin. CBT approaches view “termination as a time of consolidation and preparation for the next phase of independent application” (Prout & Wadkins, 2014, p284). Godfried (2002) describes this as the maintenance phase of therapy. During this phase the therapist monitors a client’s utilization of coping skills when confronted with significant life events. Essentially, in this respect the termination process can be understood as a “relapse prevention model” (Godfried, 2002, p384). The goal is to help clients develop a sense of self-efficacy when utilizing key CBT skills independently in the context of their lives.

References

Charman, T., & Stone, W. (Eds.). (2006). Social and communication development in autism spectrum disorders: Early identification, diagnosis, and intervention. New York, NY, USA: Guilford Press.
Corsini, R. J. & Wedding, W. (2011). Current Psychotherapies. Belmont, CA: Brooks/Cole
Goldfried, M. R. (2002). A cognitive-behavioral perspective on termination. Journal of Psychotherapy Integration, 12(3), 364-372. doi:10.1037/1053-0479.12.3.364
Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.
Metcalf, L, (2011). Marriage and family therapy: A practice oriented approach. New York: Springer Publishing Company
Newkurg, E. (2009) Assessment of Your View of Human Nature and Conceptual  Orientation. Norfolk, VA: Old Dominion University. Retrieved from: http://ww2.odu.edu/~eneukrug/therapists/survey.html
Prout, T.A. & Wadkins, M.J. (2014).  Essential Interviewing and Counseling Skills.  NewYork, NY: Springer Publishing Company.
Rosenthal, H. (2005). Vital Information and Review Questions for the NCE and State Counseling Exams. Routledge.

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A PTSD Survival Plan….

As I may have mentioned earlier in this blog, I have PTSD.  Coming to terms with this diagnosis has required me to develop a greater understand of the symptoms I’m experiencing.  I’ve also had to accept that I’ve had this disorder for much of my life.   My perception of “normal” is therefore skewed and I’m left wondering what it might feel like….

…The other concern which occupies my mind is the fact that this diagnosis has no cure.  Coming to terms with this fact has required me to fully develop a realistic understanding of healing means.  PTSD is managed and not cured.  This has been a bitter pill to swallow.  I mourn what could have been, and feel like a cumulative byproduct of others’ opinions about me.  I have to accept, regretfully, that I allowed the worst of my bully’s words throughout life, to become my truth.  Overcoming the cumulative byproduct of these early traumas has consumed much of my life.  On the alter of healing, a potential of “what could have been” has been sacrificed.  My own personal sense of self, has been consumed by external factors including a socially-relevant idea of my utilitarian value.  I feel like a man in a monkey suit with a scarlet letter sewn on front.  The fact that this perceived value has no basis in reality of my ultimate worth seems pointless.  I protest against the idea that anybody external to myself defines my ultimate worth.  However, by iterating this fact, I feel like that kid in story “The Emperor’s New Clothes”.  At times I speak the truth and yet get crucified for it.  It seems as if the rules of the game in life are set up to drive me mad.  Socially relevant “truths” carry the weight of a collective systems of belief in which the majority of us play by the rules unquestioningly.  Acting otherwise seems like a radical idea to some….

…..And as I read this stream-of-thought, I realize it reflects intrusive memories of recent events that have trigged painful memories, I had naively believed were buried in the past….

A Trigger & Reminder…

“The traumatic event can be re-experienced in various ways.  Commonly, the individual has recurrent, involuntary, and intrusive recollections of the event…depressive rumination…intrusive distressing memories….(American Psychiatric Association, 2013, p. 275).”

The above video, provides a good sampling of the rhetoric I’ve heard during this election.  I brought it up on the November 8th, as the election results began pouring in.  Its worth noting, that my husband and I have divergent political beliefs.  He is an ardent conservative and Trump supporter.  I am a progressive who voted for Hillary in the hopes of preventing a Trump presidency. As I expressed my concerns regarding this hateful rhetoric, memories of a time long ago rendered my brain.   Feelings of shame fell over me as memories of past abuse flashed through my mind.   I began crying uncontrollably, as my husband immediately dismissed my concern, iterating the what he heard that night on the Fox network.

Before I begin, I must admit I’m not a very politically-minded person and this post has nothing to do with who is president.  It is a personal recollection of an experience that points out vividly the lasting impact of PTSD on my daily life.  

Needless to day, shock & panic took over as this year’s election results began pouring in.   Panic & anxiety set in as I struggled to understand his appeal. The very idea that Donald Trump would be president horrified me.   My mind vacillated between shock and horror, panic, and numbness.   As this painful reality set in, I describe how hurtful Trumps words were for me to hear as a trauma survivor.   Rather than providing comfort and an empathic ear, he became defensive and angry.   Misperceiving my concerns as an attack of his own political beliefs began criticizing and attacking everything I said.   This sent me into an emotional tailspin.   I ran headlong into an interaction that was reminiscent of a child that involved a complete dismissal of my thoughts and feelings.

As I struggle to manage the effects of this election on our marriage, I came to realize my symptoms were evidence of a diagnosis and not an ardent political belief system.  I’m coming to the realization that I need to take this PTSD diagnosis seriously.  What is it that causes these emotional flashbacks and the painful distressing memories?  

A Survival Tool-Kit…

What follows is a quick list of steps I can take to manage trauma triggers and the emotional flashbacks that might ensue.  I need a plan of action, to endure the resulting PTSD symptoms should they flood my mind.  Mind you this is something I create for my own benefit.  I’m not an expert here, I’m a sufferer who is learning to cope.  Here’s what I’m doing now & what appears to be working.  In this respect, it is a quick reminder on how to survive emotional flashbacks, should they recur.

STEP ONE:  Find a Psychiatrist.

Currently I’m only seeing a therapist.  I am not taking any medications and don’t have a psychiatrist following my case, since the one who diagnosed me retired.  This first step is much more frustrating that I might have imagined.  However, I’m happy to admit I’ve finally find somebody.

STEP TWO:  Identifying Trauma Triggers.

“Trauma triggers are reminders of a traumatic experience that provoke continued trauma symptoms. Trauma triggers can be internal or external stimuli, (Trauma triggers, 2012).”  At myptsd.com, site owner Anthony, makes a point of arguing the semantics of what is and/or isn’t a trigger, according to his self-imposed expertise (myptsd.com, 2015).  As a sufferer I don’t feel these semantics are of any value.  Instead, for survival purposes, self-awareness is the ultimate goal.  What is it that has produces these painful reactions to reminders of past traumas?  The DSM-5 manual notes the foll0wing about trauma triggers:

“[they can be] events that resemble or symbolize an aspect of the traumatic event, (e.g. windy days after a hurricane, seeing someone who resembles one’s perpetrator”.  The triggering cue could be a physical sensation (dizziness….rapid heartbeat). (American Psychiatric Association, 2013, p. 275).”

“Even though it may sometimes feel like PTSD symptoms come out-of-the-blue, [they] rarely spontaneously occur….cued by something in our internal (thoughts or feelings) or external environment (…a stressful situation). (Tull, 2016a).”  It is for this reason, that the above description from the DSM-5 manual is useful as a jumping off point.   The following questions are posed in an article I found online titled: “How to Identify & Cope with your PTSD triggers?” (Tull, 2016a).

FIRSTLY, “what types of situations are you in (Tull, 2016a)?”

Utilizing the above example, I was in the middle of a conversation with my husband.   Throughout the election, the rhetoric (see video) has been hard for me to take in.  When I expressed my horror that a man with corrupt value system was in office, he became angry.  He began dismissing my perspective and refused to hear my concerns.  A critical aspect of this exchange reminded me of that bad relationship from long ago where my feelings were continually dismissed and belittled.   While not intended, my mind was thrown into a wellspring of negative emotions.  

SECONDLY, “What is happening around you (Tull, 2016a)?”

We were in the basement watching television together.  The kids were upstairs playing.  I remember feeling exhausted, still recovering after a three-day weekend night shift.   I drifted in and out of consciousness, taking cat naps throughout that evening.  Realizing our divergent political belief systems were problematic this election season, we’ve avoided the subject.  That evening we had agreed to not watch the results together.

With an f-d up sleep schedule, I found myself battling insomnia at 1 a.m.  I took out my iPad and decided to read a few blogs I like to follow.  The post I found announcing Trump’s win was unexpected, since this specific blog doesn’t cover the subject of politics.  As I started crying, my husband rolled over and asked me what I was reading.  This is when the conversation happened and things went downhill.

THIRDLY, “What kind of emotions are you feeling (Tull, 2016a)?”

A mixture of anxiety, fear, and depression overcame me.  They were to remain for the rest of the week as I began feeling I was left to “white knuckle it”.  Desperate for a magic “happy pill” to make the feelings go away, I was angry at myself for not finding a new psychiatrist since my last one retired.  Finally, I can’t help but compare my reaction to others’ I know who voted against Trump.  While my parents and sister were shock and worried about the nation’s future, somehow they remained more in control.  Like the above video, they found some ability to remain positive and keep things in perspective.  My mind, on the other hand, began spinning out of control…..

FOURTH, What thoughts are you experiencing (Tull, 2016a)?”

Intrusive and painful memories entered my mind.  I tried willing them to go away, but somehow found this impossible.  The most exquisitely painful memories that still haunt me, aren’t physical abuses, but simply harsh and abusive words.  Nothing can scar your soul more that emotional abuse and an endless barrage of hate and contempt.  The painful aspect of these experiences that still haunts me is that nobody acknowledged my feelings.  They did these mean things to me and let it known to me that it was my fault and I deserved what I got.  Somehow this fucked-up sentiment hurt the worst.

FIFTH, What does your body feel like (Tull, 2016a)?”

My body drifts back and fourth between a state of hyper-arousal and dissociative numbing. At a moments when the emotional pain is literally excruciating, I curse my family and their undying love for me.  If it wasn’t for this, I could just “off” myself and be done with it.  Enduring somehow has felt like a curse.  However, much I want to live and keep going, the struggle has been difficult.

STEP THREE:  Distract First…

When experiencing flashbacks or dissociative symptoms, first distract then challenge.  Distraction techniques involve “coping tools designed to ‘ground’ you in the present moment…so you can retain your connection with the present moment, (Tull, 2016b).”  The DBT distress tolerance and mindfulness skills described in this blog are useful as a jumping off point.  Distracting ourselves from a situation or trigger that can cause us pain, can ground us as we focus on the five senses (Tull, 2016b).  For example, one client I met recently has an aromatherapy glass roll-on bottle which she carries everywhere.  I, on the other hand, have utilized calming music, exercise or mandalas as a tool for distraction.

STEP FOUR:  Challenge Second….

Anthony at myptsd.com (2015), makes a useful point regarding ptsd triggers:

“Categorize your triggers as realistic or unrealistic. You may want outside opinions on this….Review your cognitive biases based on your immediate thoughts and reactions to the trigger, and have counter-statements prepared to confirm the unrealistic aspect of the trigger, (myptsd.com, 2015).”

This suggestion is useful in developing an awareness of how PTSD symptoms often reflect past events or unresolved cognitive biases, and not present situations.  Marsha Linehan’s emotional regulation skills a re useful in challenging our emotions and thoughts.  The ultimate goal here is thinking through them and not with them.

STEP FIVE:  Seek Support.

Tull (2016b), suggests finally, to utilize any support system we have in place.  “If you know that you may be at risk for a flashback or dissociation by going into a certain situation, bring along some trusted support.  Make sure that the person you bring with you is also aware of your triggers and knows how to tell and what to do when you are entering a flashback or dissociative state, (Tull, 2016b).”  My husband, sister, and parents have been a critical first line of defense here.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
myptsd.com (2015, September, 2). PTSD Triggers.  What triggers PTSD symptoms?  Retrieved from:  https://www.myptsd.com/how-to-use-triggers-as-a-means-to-recovery/291/
TRAUMA TRIGGERS. Encyclopedia of Trauma. Jan. 1, 2012.
Tull, M., Phd. (2016a, May, 4)  How to identify and cope with your PTSD triggers.  Retrieved from:  https://www.verywell.com/ptsd-triggers-and-coping-strategies-2797557
Tull, M., Phd. (2016b, September, 6).  Coping With Flashback and Dissociation in PTSD.  Retrieved from:  https://www.verywell.com/coping-with-flashbacks-2797574

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I am an “Other”

INTRODUCTION:  This article is part of a series titled “In My Own Defense”

This series has served as a  writing exercise “of sorts” that can allow me to work through feelings of shame that still remain.  As is typical with a child’s-eye-view of the world, I perceived life as if it revolved around me.  This self-centered viewpoint, made it difficult, to varying degrees, for me to see others’ perspectives.  As a sensitive child, I tended to take all the bullying and ostracism of my childhood personally. By the time I reached high school graduation, all I wanted to do is put as much space (physically and chronologically) from this experience as I could.   I remember leaving for college with huge hopes.  However, it quickly became apparent that this would require a significant amount of effort on my own part.  It’s only in the last decade of my life, that I’ve taken time to look back at these experiences without feelings of self-blame and hatred welling up inside me.  I’ve learned to accept the fact that there are those from my past who may never see me beyond an outdated set of preconceived notions.  In a way, this series represents the final step in the long process of healing, forgiveness, and acceptance.

In the wound-licking phase, I simply began to work through the unresolved hurt instead of burying it…

This process started in my later 30’s when I first sought out a therapist because I felt “Stuck”.  It took a while to understand the nature of this stuckness & what was holding me back.   Until this point, my life was like an invisible minefield.  There were some things – things that reminded me of events I was trying to forget – that became excruciating.  It was all too much, so I spent time going through the motions and checked out on the basement sofa watching t.v. like a mindless blob.  Or I would nap, my other favorite maladaptive coping tool.  I began to see a therapist, I completed a DBT course, worked on the relationship with my sister and slowly, I somehow felt safe in the world.  In time, this healing allowed me to gain some clarity by viewing directly things that had previously been too  I was empowered with a solution the problem that involved action on my part.

However, more needed to be done.  Feelings of shame and invalidation had plagued me.  That is, until my mother recommended I read this book….

PART ONE:  The Consequences of being an “Other” (i.e. biracial / mixed race)…

ME = “One of those things that is not like the other”

I usually call my mother once every two weeks just to see how she’s doing.  At some point in the conversation, I am usually provided an update on the “local gossip”.  During one of these conversations, my mother mentioned an old classmate of mine: May-lee Chai.  She was a senior in high school while I was a freshman.  We didn’t know each other well and I only remember as one of the many faces I passed by in the halls between classes.  At any rate, she asked me if I heard about that book she had written: “Hapa Girl: A Memoir”.  She said bought a copy and urged me to read it, since she felt it might “resonate” with my own childhood experiences….

When I first read it, I remember reflecting on my childhood from a new perspective.  Until this point I thought it was “all my fault”.  This book helped me to contextualize my experiences.  There were forces much larger than me at work…

So where do I start? How can I begin to adequately describe my own experience of being biracial? How have I dealt with the idea that I’m not perceived as I am? What is it like to live between world’s?  What follows are random thoughts, in no particular order….


Click here for a bill of rights for people of mixed race heritage

In the video above, the narrator describes the twins as “black and white”.  Based on phenotype characteristics that each girl carries, they are so labeled.  It amazes me, how people are so quick to forget that the meatsuits we wear, don’t accurately reflect what dwells within us.  In reality, there are four abstract constructs which together are effective in developing a basic understanding of a biracial individual’s experience of race.  Together they explain what it is like to live within an unclear “in-between” space. These constructs are: (1) genotype; (2) phenotype; (3) identity; & (4) culture.  Understanding how they converge within an individual’s life can help quite a bit in explaining their racial identity.  They are useful in understanding the diversity of experiences amongst biracial experiences, as well as the issue of colorism…

FACTORS 1 & 2: Genotype vs. Phenotype…

Genotype refers to the DNA you carry within you.  You get half from your mother and half from your father.  For example, at geneaology.com they studies of populations around the world.  When individuals are isolated historically these populations tend to share genes for traits that are conducive to survival in that area.  When you submit a test at genealogy.com, they tell you what subsets of the human population are present in your genes.

Phenotype has to do with your physical features, how do you look?  What is the color of your skin, your face shape, and hair color?  The point is, you can have the same set of parents, but inherit different subsets.  Therefore, two genetically biracial individuals can have very different appearances.

Critical Point #1 – regarding these two factors, I have a genotype / phenotype mismatch problem.  This means I am not what I am.  Due to the random qualities that define my meat suit, I am classified within a preconceived ideas that do not relate to my own lived experience of self…

FACTOR 3:  What is Identity?

The DSM-5 Manual defines Identity as follows:  “[the] experience of oneself as unique with clear boundaries between self and others; stability of self-esteem and accuracy of self appraisal; capacity for, and ability to regulate, a range of emotional experience.” (American Psychiatric Association, 2013, p823).  As a biracial individual the experience of how others see us diverges from the inner knowing of who they are.  Regarding how others’ experience, I feel as if I’m a man inside a monkey suit wearing upon my being the preconceived notions of others.  I wait for somebody to see within to the real me, but it happens rarely.  R.D. Laing (1990), summarizes this experience succinctly in his book “The Divided Self”.  In contrast, the description of our inner sense of self is best described in my old course textbook (Corsini & Wedding, 2013).

Critical Point #2:  “The usual sense of the self as being who we ‘really are’ and as being continuous and consistent over time seems to be an illusory construction of imprecise awareness….similar to the ‘flicker fusion phenomenon’ by which photographs projected successively on a movie screen…we suffer from a case of mistaken identity. We are not who, or even what, we thought we were. What we take to be our real self is merely an illusory construct” (Wedding & Corsini, 2013, p467).

FACTOR 4:  What is culture?

Culture provides another set of mental programs relevant to a society (Chung & Bemak, 2002). It 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.

Critical Factor #3:  I was given two diverging, (and frequently oppositional) cultural perspectives.  Nobody fully understood this and I was largely left on my own to feel my way in the dark…

Before I continue with this random train of thought, I must apologize.  I’ve made a promise to stop intellectualizing, yet do this a bit in here.  There’s a reason for it – bear with me….

While working on my master’s degree, I was working and had little time for anything else.  On the back burner, I placed everything unnecessary and “survival” became my priority.  I remember reading various articles for homework assignments and being “highly intrigued” by the information I was taking in.  It held information that was interesting personally as well as professionally.  As I work through this blog, I continue digging through files of things I’ve save, with the intention of “bloggging on it” when time would allow.  Here I am about a year later – finally getting around to it.

“individuals who live at the juncture between two cultures and can lay a claim to belonging to both cultures, either by being of mixed racial heritage or born in one culture and raised in a second, should be considered marginal people. Park suggested that marginality leads to psychological conflict, a divided self, and disjointed person” (LaFromboise, et al, 1993, p. 395)

I have these piles of folders divided into subject categories.  Inside them are copies of assorted notes, assignments, and articles that I’ve printed with ideas jotted in the margins.  The quote above does an excellent job of describing succinctly, how I’ve felt as a biracial individual with a broad-based culturally diverse perspective of the world.  The Sesame Street video below describes my experiences as an individual who lives between worlds.  I am both my mother and father, yet I am also like neither of them….

ME = Three of these kids belong together.  Three of these kids are kind of the same.  But one of these kids (i.e. me) is doing his own thing

“The Psychological Impact of Biculturalism”

So without boring you to death, I want to quickly review this article titled: “They Psychological Impact of Biculturalism”, as a jumping off point.  This article begins by describing what individual’s need to be culturally competent to function in a society.

“In order to be culturally competent, an individual would have to (a) possess a strong personal identity, (b) have knowledge of and facility with the beliefs and values of the culture, (c) display sensitivity to the affective processes of the culture, (d) communicate clearly in the language of the given cultural group, (e) perform socially sanctioned behavior, (f) maintain active social relations within the cultural group, and (g) negotiate the institutional structures of that culture.” (Framboise, et al, 1993, p. 395).  

This article the provides an overview of different models utilized in research, to describe the varied transitions that occur between an immigrant and the country he has chosen to reside in. What follows is a “quick and dirty” overview….

  1. ASSIMILATION:  “The underlying assumption of all assimilation models is that a member of one culture loses his or her original cultural identity as he or she acquires a new identity in a second culture.” (Framboise, et al, 1993, p. 396).  
  2. ACCULTURATION:  “assimilation approach emphasizes that individuals, their offspring, or their cultural group will eventually become full members of the majority group’s culture and lose identification with their culture of origin. By contrast, the acculturation model implies that the individual, while becoming a competent participant in the majority culture, will always be identified as a member of the minority culture.” (Framboise, et al, 1993, p. 397).  
  3. ALTERNATION:  “The alternation model of second-culture acquisition assumes that it is possible for an individual to know and understand two different cultures. It also supposes that an individual can alter his or her behavior to fit a particular social context.” (Framboise, et al, 1993, p. 400).
  4. MULTICULTURAL: “The multicultural model promotes a pluralistic approach to understanding the relationship between two or more cultures. This model addresses the feasibility of cultures maintaining distinct identities while individuals from one culture work with those of other cultures to serve common national or economic needs. In this model it is recognized that it may not be geographic or social isolation per se that is the critical factor in sustaining cultural diversity but the manner of multifaceted and multidimensional institutional sharing between cultures. Berry (1986) claimed that a multicultural society encourages all groups to (a) maintain and develop their group identities, (b) develop other-group acceptance and tolerance, (c) engage in intergroup contact and sharing, and (d) learn each other’s language.” (Framboise, et al, 1993, p. 401).
  5. FUSHION:  “The fusion model of second-culture acquisition represents the assumptions behind the melting pot theory. This model suggests that cultures sharing an economic, political, or geographic space will fuse together until they are indistinguishable to form a new culture. The respectful sharing of institutional structures will produce a new common culture.” (Framboise, et al, 1993, p. 402).  

So what’s the need for this list of terms? Why is it necessary?

I simply include it to indicate that the issues that can potentially arise for individuals living in a foreign country are to great to list.  For that matter, there is a high degree of variability amongst immigrants who are trying to make a life in a new country.  Factors such as socioeconomic status, education level, language familiarity, ethnic pride, and local race relations can all have a huge impact an individual’s experience.

My mother and her sister are an excellent example of this…

My mom is from the Philippines and is the youngest of two children. Her sister Rebecca is just 18 months older. Consequently they’ve always had a very competitive relationship. My mom is describes her older sister is much more popular and much more successful in school.  She on the other hand had just a few friends and was very shy. To top this off she kind of had an inferiority complex next to her sister and was never really good in school and didn’t quite catch up to her until about seven to grade.  This sense of insecurity and competition also spilled into the issue of appearance.  My mother always described her sister as the prettier one.  Her sister was always faired skinned and curvy and this made my mother jealous. My mother on the other hand past the paper bag test and your mother I was giving her a hard time about being skinny and was constantly instituting various plans to help her gain weight – all of which never worked.  As a kid, I always found my mother’s insecurity strange, living in a “mostly-white” midwest town.  All my classmates were obsessed with tanning in the summer and could never ever be thin enough.  From this vantage point, it seemed strange to me that anybody would complain about being thin and tan…

However, I’m most struck by how my mother & her sister went about building lives in a new country.

My mother was always the “good girl” and very “values oriented” and in this respect, quiet a bit like her mother.  On the other hand, her sister was a bit rebellious and more socially adept.  She was always popular and much more knowledgeable socially.  Its interesting to now my mothers traditionalism played out in her life and how my aunts rebelliousness played in her own.   These two divergent characteristics affected their experiences as immigrants living in a new country.  My mother was alone in the midwest.  There were only a handful of non-whites so I was never exposed to Filipino culture.  In contrast, her sister lived in Texas and employed several Filipino women.  So my cousin was exposed to her mother’s culture, visited the Philippines several times, and speaks Tagalog.  However my mother’s traditionalism caused her to remain reluctant to understanding what it is like to be an an American Teenager.  This meant that I was not allowed to wear makeup, shave my legs, or wear bikini-style underwear, much less date.  When you consider the fact that I already had few friends and was bullied constantly, this made things very difficult.  I had no social guidance whatsoever.  I was the oldest firstborn of all the cousins and as a result I was kind a like the guinea pig.  My mother decided to raise me according to her own values that she knew and made them a priority. It probably wasn’t until my sister came around that she some understanding of what was needed to help the child survive socially school.   So, I was isolated, overprotected and held to social standards that made fitting in difficult.  My sister was given opportunities to experience things that I didn’t at her age.  While five years younger, she was able to date first, given spending money first, and allowed to be out with friends late – all before me.  Oftentimes, what would happen is they bought her a car and then would think, oh we never got one for Kathleen, lets do that….

So what point am I trying to make here???

I am frustrated with the lack of understanding in my family.  I talk to my mother, and she talks about how I know nothing about her culture and am basically American.  While this may be true in many respects, I blame this fact on my mother who has refused to speak Tagalog in front of me.  It is, however, the case that she held me to standards that were her cultures and not my own.  As somebody who was already bullied and ostracized quiet a bit, I needed guidance.  Yet I got nothing.  I sometimes I sacrificed my childhood and years of social development, so my mother could have her “peace of mind”.  I will never forget when I told my sister about how I had to wear granny panties to P.E.   She laughed and said, “OMG! There’s no way I would allow that to happen!!!”  And in that comment is the problem.  She didn’t have any idea how different they were with her and how she had chances for normalcy I never did.   You see, the problem is the experiences that come together to influence a biracial’s experiences can vary greatly from person to person.

My sister & cousin don’t have a genotype / phenotype mismatch problem, they are “meat-suit matching”. 

“I don’t count” due to the random qualities that define my meat-suit.  My identity feels a farce, and I had to “act as if” I was what others deemed even though this was a lie.

 My sister & cousin were allowed the opportunity to live as a normal American Teenagers.

I was cloistered way like a nun.  I had no friends & was ostracized.  My different-ness stood out like a sore thumb in my small homogeneous town.

The final thought I’d like to make comes from a few articles by Maria Root, who describes racial identity development for individuals of mixed race.   There are a few points she makes about racial identity development amongst biracial siblings that are worth noting:

“Siblings of racially mixed heritage…often identify themselves differently from one another” (Root, 1998, p. 237).
“Phenotype does not determine how people identify themselves” (Root, 1998, p. 238).
“Identity can change over the lifetime” (Root, 1998, p. 238).
“A monoracial framework is usually the guide for interpretation of behavior.” (Root, 1998, p. 238). 

An Ecological Model of Identity

“The identity [options} are (a) accept the monoracial identity society assigns, (2) actively choose a monoracial identity (congruent with the identity society would assign), (3) define self as biracial or multiracial, (4) develop a “new race” identity.” (Root, 2003, p. 115). 

Ecological Models of identity focus on the social and individual factors that influence Identity development. “This model of identity development acknowledges that there are many different ways people of mixed heritage may identify themselves.” (Root, 1993, p. 240).  Mixed race individuals frequently see themselves in a way that diverges significantly from how others tend to.  Root, (2003 & 1998), discusses the following concepts in her ecological model of racial identity:

  1. MACRO LENS: Gender; Social Class; Race Relations; Sexual Orientation.
  2. MIDDLE LENS:  Family Socialization Influences; Temperament; Community Relationships.
  3. PHENOTYPE:  Is a factor that influences many of the factors in the middle lens significantly

A Stage Model of Identity

“Typical behaviors of person’s of mixed heritage are…interpreted as signs of poor adjustment.  Some of these behaviors stem from ways of sorting out the meaning of race…from a mixed perspective….negative adjustment is not [related to] being mixed…but rather conflict rising in the family and environment and the lack of guidance in resolving developmental crises…” (Root, 2003, p. 113).  

Root begins discussing early stage models of racial identity development by reviewing the two primary stages which seem to encompass (1) a desire to adapt to a new culture, (2) response to inherent inequity and racism in American culture.

  1. INITIAL STAGE:   “internalization of white reference group that necessarily is accompanied by devalued messages of [minority group] values and culture.” (Root, 2003 p. 114).
  2. TRAUMATIC EVENT:  “Awakens the individual to the lack of equity and fairness…There is a retreat and immersion into the racial group of origin to gain support and…as part of the process of undoing the harm of internalized racism.” (Root, 2003, p. 114). 

Next, Root provides the following summary of stages that biracial children progress through as they address the idea of “what they are”

“In the first stage, the awareness of race and ethnicity was not necessarily attached to ethnic background….In [the] second stage, people choose a racial identity; their cognitive capacity [in childhood] usually allows a single identtity. The third stage is driven by dissonance between the chosen identity and the incomplete mismatch with ethnic and racial identity.” (Root, 2003, p. 115).

Finally, common questions that arise

  1. Who am I?”  (Idenitity)
  2. Where do I fit in?” (Is there a place in the world I fit with?  
  3. Where is my social role?” (“What cultural standard?)
  4. Who is in charge of my life?” (Who tells me what I am?)
  5. “Where am I going?”  (what goals?)

<h5><span style=”font-size: 45pt;”>Point #3: “In my own defense” the issue of racial identity added to my insecurities.  I felt as if I “didn’t count” for an assortment of reasons.  Additionally, I was dealing with things, nobody could understand when you “live between two worlds.”</h5></span>

References

Benet‐Martínez, V., & Haritatos, J. (2005). Bicultural identity integration (BII): Components and psychosocial antecedents. Journal of personality73(4), 1015-1050.
LaFromboise, T., Coleman, H. L., & Gerton, J. (1993). Psychological impact of biculturalism: evidence and theory. Psychological bulletin114(3), 395-412.
Root, M. P. P. (2003). Multiracial Families and Children: Implications for Educational Research and Practice. In J. A. Banks and C. A. McGee Banks (eds.), Handbook of research on multicultural education (second edition), pp. 110-124. San Francisco: Jossey-Bass.
Root, M. P. (1998). Experiences and processes affecting racial identity development: Preliminary results from the Biracial Sibling Project. Cultural Diversity and Mental Health4(3), 237-247.

Part Two:  Exploratory Paper from MCC 638 “Social & Cultural Issues”

Abstract

The purpose of this paper is to closely examine my personal worldview and sociocultural background. In doing so, the goal will be to understand how this influences my future clinical judgment and client interactions. I will begin by utilizing the Addressing Model, (Hays, 2008), to provide a biographical overview of my sociocultural history. The paper will then conclude with a series of interview-style questions, to help reflect and explore my life history in detail. Any personal understanding of my values, cultural identities, and areas of privilege that come from this activity will be used to direct future growth throughout this program.

Introduction

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 emigrate 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, at the time, soaring to 50% in my childhood (Amato & Cheadle, 2005), I was fortunate to have such a realistically positive view of marriage. The experience of witnessing everyone in my extended family enjoying long and happy marriages, has caused me to place a high value in the commitment of marriage and family.

Nonetheless, I am typical of many women in generation in being 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. Many women in my generation have chosen to put off family, or opt out all together, (Genz, 2010). Still others, such as myself, have chosen to put off career pursuits in favor of focusing on my family life, (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 my 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 downward mobility, 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) 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 have 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, (LaFramboise, et al, 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.

Social Expectation & Identity.

“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, (LaFramboise, et al, 1993).

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).

Norms, Values & Gender Roles.

“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 with norms, values, and gender role expectations in my extended family. Additional conflicts were present between my familial and environmental norms and values growing up.

In an article an on biculturalism mentioned in our textbook, there is a discussion of 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 consciousness that can have potential benefits in the long run, (LaFrombroise, et al, 1993). Having many conflicting identities, values and belief systems has resulted in much of this discomfort as well as many fruitful life lessons.

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 with 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. In the arena of dating, I was absolutely forbidden from even considering it until 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.

Adolescent Development.

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 (Chai, 2004).. This gave many of my classmates the benefit of a large social 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 Brown’s work on shame, my personal view of the world was based on an underlying identity of shame as she defines it:

“The definition of shame that emerged from the research is, an intensely painful 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 roles 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.

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.

References

Ajouga, P. (2014). Re: MCC 638 Week Two Overview. Retrieved from
https://ssoblackboard.bellevue.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_328162_1%26url%3
Amato, P. R., & Cheadle, J. (2005). The long reach of divorce: Divorce and child well-being across three generations. Journal of Marriage and Family, 67(1), 191-206. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/219746544?accountid=28125
Brown ,B., (2006). Shame resilience theory: A grounded theory study on women and shame. Families in Society. 87(1) 43-52.
Fortune, B.A. (2012). Acculturation, intergenerational conflict, psychological distress andstress in Filipino-American families. Regent University, Virginia.
Genz, S., (2010). Singled Out: Postfeminism’s “New Woman” and the Dilemma of Having It All. The Journal of Popular Culture, (43)1, 97-119.
Hays, P. (2008). Addressing cultural complexities in practice. (2nd Ed.) Washington, D.C.: American Psychological Association.
Jensen, B. (2012). Reading Classes : On Culture and Classism in America. Ithaca: ILR Press.
LaFromboise, Coleman, H.L.K. & Gerton, J. (1993). Psychological impact of biculturalism: Evidence and theory. Psychological Bulletin. 114(3) 395-412.
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.
Martin, C.A. (2004) “Bridging the generation gap (s).” Nursing2013. 34(12)62-63.
McCarthy, K. (2007). “Pluralist Family Values: Domestic Strategies for Living with Religious Difference” The ANNALS of the American Academy of Political and Social Science. 612(1) 187-208.
Root, M.P.P. (1998) Experiences and processes affecting racial identity development: Preliminary results from the biracial sibling project. Cultural Diversity and Mental Health. 4(3) 237-247.
Point #3: “In my own defense” the issue of racial identity added to my insecurities. I felt as if I “didn’t count” for an assortment of reasons. Additionally, I was dealing with things, nobody could understand when you “live between two worlds.”

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MCC 670 – Setting Outcome Goals

In the last post, I discuss the problem definition process that occurs during the 1st session of therapy…

“The development of a list of problem titles involves two separate processes…'(Ingram, 2012, p41).  Ingram, (2012), defines a problem as “difficulties, dysfunctions, complaints, and impairments that are identified by the client’ (p. 41)….Additionally, they should be defined as a ‘solvable target (Ingram, 2012, p. 45).  In other words.  what is the desire outcome for this specific problem?  

This post focuses on the process of defining outcome goals when we begin developing our treatment plan.

“Every problem title is paired with an outcome goal, a description of the desired state at the end of therapy – how you will know the problem is solved” (Ingram, 2012, p. 61).   Achievement of outcome goals is the definition of effectiveness.  Therapists gather evidence and progress with outcome goals in mind.  If no progress is made, it may be necessary to reconsider your original case formulation.

Tips for Creating Good Outcome Goals…

Ingram (2012), suggests that outcome goals be specific and measurable in order to guide treatment planning.   Cognitive flexibility and critical thinking are important to help a therapist move from varied levels of abstraction.  Concrete goals can and measurable so success can be recognized.  However, this can limit one’s options at times if goals are too rigid and highly specified.   Other considerations listed in my Ingram (2012), are listed below:

  1. “Be aware of cultural biases and avoid becoming an agent of social conformity” (Ingram, 2012, p. 62).
  2. “Be sure to examine the values related to a stated goal” (Ingram, 2012, p. 62).
  3. “Question whether the client is accepting others’ definitions of happiness” (Ingram, 2012, p. 62)
  4. “How & when are not part of outcome goals….This is in the plan”  (Ingram, 2012, p. 62).

Benefits of Clearly Defined Future Goals…

  1. It can halve a positive effect on the client’s motivation.
  2. Creating a plan with the client can help instill.
  3. Clearly defined goals can help the client progress along the stages of change.
  4. Can help the client clearly define what they want (i.e. choice therapy).

Helping Clients Define Their Goals.

“Client’s usually put forth their problems without difficulty but they often need prodding and a good amount of creativity to put things in terms of a desired future” (Ingram, 2012, p. 63).  What follows are more tips from my textbook:

  1. SMART – Specific, Measurable, Attainable/Achievable, Realistic/Relevant & Time Specific
  2. PUERE – Standards for creating good goals…
    1. Use Positive Terms.  State what you do wan’t not what you don’t want.
    2. Outcome Goals must be Under your Own Control.
    3. Goals must be Evidence-Based, measurable, and operationalized.
    4. Goals must be Realistic and achievable.
    5. They must be ecological and holistic in nature.

Standards for Outcome Goals…

  1. “STANDARD ONE (LOGICAL CONNECTION) – Outcome goals are directly related to the problem title and endorsed by the client” (Ingram, 2012, p. 67)
    1. Should be evaluated for progress regularly
    2. Should ensure align with client’s goals
  2. “STANDARD TWO (THEORETICALLY NEUTRAL) – Do not contain the therapist’s connection” (Ingram, 2o12, p. 69)
  3. “STANDARD THREE: Outcome goals are realistic, attainable, and testable with evidence of real-world functioning.” (Ingram, 2012, p, 70).
    1. Not based on assumption of normal life difficulties.
    2. Not based on client’s agenda to change somebody else
    3. Not based on Utopian Beliefs or Perfectionist Standards.
  4. “STANDARD FOUR: Outcome goals do not contain the how of the treatment plan. People stifle ambitions based on perception of achievability of goals they set” (Ingram, 2012, p. 70).

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC – 670 Defining The Problem

“​The development of a list of problem titles involves two separate processes…”(Ingram, 2012, p41).  Ingram, (2012), defines a problem as “difficulties, dysfunctions, complaints, and impairments that are identified by the client” (p. 41).

FIRST, by gathering data and developing a preliminary list of problems. NEXT, by conceptualizing and giving titles to the problems we can better understand our treatment targets.  If they are defined by the client we refer to them as complaints.  Problems defined by significant others are relationship problems. Problems defined the professionals who counseling are called diagnoses.  Helping the client understand and gain some awareness regarding the nature of this problem is essential.

Step #1: Understanding the Goal

“When the goal is to arrive at a diagnosis, we check the list of criteria to see if there are enough to warrant the diagnosis, as if the criteria are a means to an end. When we think in terms of problem lists, the criteria are the end – they give us names of problems” (Ingram, 2012, p. 42)

The Presenting Problem

The presenting problem consists of the client’s stated reasons for seeking therapy in his/her own words.  It is not uncommon for the client’s presenting complaint to undergo a transformation as they develop a greater understanding of their problems.  For this reason, it is useful to record how it changes over time.

“SHOULD I JUST ACCEPT THE CLIENT’S STATED PROBLEMS OR AM I SUPPOSED TO GO FURTHER AND FIND OTHER PROBLEMS?”

In response to this question, Ingram (2012), describes three different attitudinal perspectives. However, at the end of this discussion, Ingram, (2012), stay

Narrow Position

According to this position, the therapist should simply accept the client’s complaints without attempting to create awareness of needs the client hasn’t mentioned.

Intermediate Position

Here, the therapist focused on the client’s request but if other problems become obvious, they will invite client to consider them.

A Comprehensive List

According to this perspective, the therapist should be concerned about the whole person, and examine all aspects of function in terms of a holistic assessment of the individual.  Just because the client is able to identify some problems, that doesn’t mean they are accepted as critical for treatment. The approach this book upholds is to utilize a comprehensive problem list. It is better to be too inclusive than to miss something important.  Finally, it is important to note that “the therapist’ values inevitably enter the problem-identification process” (Ingram, 2012).

Step #2: Developing A Comprehensive Problem List.

With the attitude of someone who is brainstorming, write down every problem (Ingram, 2012, p43). Complete the following assessments.

THE BASIC SID

  1. BEHAVIOR – What is the person doing, and not doing; what can others observe; the quality of skills?
  2. AFFECT: Internal emotional experience and overt verbal and nonverbal expression of feeling.
  3. SENSATION: Awareness of the body; use of senses; what is seen and heard with minimal filtering through cognition.
  4. IMAGERY: Mental imagery about past, present, or future; fantasies and dreams
  5. COGNITIVE: Constructed meaning; self-talk, beliefs, and schemas; cognitive skills; mental abilities
  6. INTERPERSONAL, SOCIAL, & CULTURAL: Relationships with others; family context; membership in social groups; cultural issues; and issues of social injustice.
  7. DRUG AND BIOLOGICAL: Physiology; biology; genetics; medical issues; use of illegal drugs, including alcohol.

DOMAINS OF FUNCTIONING (WHODAS)

Ingram, (2012) lists several domains of function that can be found in the DSM-IV manual.  “Therapists need to balance a psychiatrists emphasis on pathology with a counselor’s concern for growth and development” (Ingram, 2012, p. 44).
These domains are listed below, (Ingram,2012, p. 44-45).

a. Health and safety
b. Home Management
c. Financial status
d. Life planning
e. Academic
f. Employment
g. Legal status
h. Leisure and Recreation
i. Communication
j. Friendship
k. Family
l. Emotional Intimacy
m. Sexuality
n. Parenting
o. Religion & Spiritual
p. Cultural

Also contained in the DSM-IV is the Global Assessment of Functioning. While it is currently an out-of-date assessment, I’m including a link of it here for the sake of thoroughness. It is important also to note that the new DSM-5 manual focuses instead on the WHODAS-2. I’m also including a link for this instrument, since it is utilized at my current place of employment.

Step #3 Creating The Preliminary Problem List

“The quantity of problems on the preliminary list might make you feel hopeless. Remember you can combine and condense the list until it is manageable”. (Ingram, 2012, p46).

Overall goal

When defining problems it is useful to think about they can describe the target of your future therapeutic efforts. Ingram, (2012) suggests that “the problem title is a brief specific phrase…[and] stay focused on the client’s reason for being in therapy, not yet moving to your conceptualization of the problem” (p 45). Additionally, “avoid using language that reveals our explanations that attribute a cause for their problem” (Ingram, 2012, p 45).  Finally, check to make sure you Problem List is comprehensive.  While it is vital that we address the client’s pain, we must not automatically accept the client’s understanding of the problem without critical examination.

Standards for Problem Definition

  1. Problems should be defined as a “solvable target” (Ingram, 2012, p.45) for therapy. In other words, what is the desired outcome.
  2. Problems must reflect the client’s current level of functioning and capture their real-life problems.
  3. Problems are specific and designed with an individual client in mind based on data gathered.  This will aid in the development of your treatment plan.
  4. Do not include technical jargon, or theoretical concepts.  These things reflect a clinical hypothesis.  Your goal is to summarize findings from your data gathering.  This can allow for a therapist to utilize whatever theory might best apply at a later point.  Ask yourself if what you’re writing down is s hypothesis or a problem definition.
  5. Be cautious of how your values and biases might color your understanding of the client’s problems.  “Does the problem title reflect the client’s values?” (Ingram, 2012,)</h6<
  6. “How do you handle a list of 20 or more problems? The solution is lumping and splitting.  Lumping involves combining separate problems into a single problem” (Ingram, 2011, p. 55).  This is useful if signs and symptoms overlap and stem from common cause.  Occasionally, this might involve the utilization of an umbrella title.  With outcome goals for each sub-Problem.  Splitting involves “dividing one problem into separate problems…” (Ingram, 2912, pp. 56) Instances in which splitting might be useful include those cases in which separate treatments are needed or if this aids in clarity,
  7. Finally, be sure your problem list is complete and comprehensive.  “The omission of problems is a much more serious error than inclusion of too many problems” (Ingram, 2012, p. 60).

Reference

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Data Gathering

Ingram (2012) describes the intake interview as an assessment phase that typically occurs in 1-3 sessions. Oftentimes employers set specific requirements including a timeline for completion along with a predetermined format. However, Ingram (2012) states that the degree of structure and limitations on flexibility affect the client’s ability to engage in a storytelling process. Ingram (2012) defines problem solving as ideally involving minimal influence in order to gather information and identify the goals and problems. Testing a potential hypothesis exists as the initial stage of solution formulation in this process.

​According to Ingram (2012) the Intake Interview occurs in three phases. During the phase one, the client is allowed to tell their story as the counselor remains attentive and expresses understanding. In the second phase of the intake interview process, the counselor directs the clients toward key topic areas in an effort to complete this initial assessment (Ingram, 2012). Two key goals during this stage include determining of a crisis intervention is needed, and testing clinical hypotheses (Ingram, 2012). During the final phase, taking time to summarize progress thus far is important alongside a discussion and overview of the counseling process.This can help the client understand what to expect from therapy.

Ingram (2012) begins by describing the counseling as a problem-solving process that occurs in stages as follows:

  1. STEP ONE – Gather data —>

  2. STEP TWO – Identifying problem–>

  3. STEP THREE – Decide on goals—>

  4. STEP FOUR – Test hypothesis—>

  5. STEP FIVE – Move toward solution—>

Ingram (2012) encourages us to minimizing our influence over the problem solving process in the early data-gathering stage.

Ingram (2012) cautions that predefined approaches shape and restrict the client’s storytelling process and content that is provided – be flexible.  My biggest problem – thus far has been learning to balance a need for note taking with the development of a rapport.  Additionally it is important to be aware of how the process of social exchange can further influence the outcome of the data gathering process.  Ingram (2012) provides the following examples of how our level of influence can vary during the intake interview:

  1. Minimal influence – “allow silence, follow-up questions, encouragers, paraphrasing, reflection of feeling.” (Ingram, 2012).

  2. Mild influence- selective summary, probing topic chosen by the therapist, offer a bunch, reassurance

  3. Moderate influence – challenging questions, give suggestions, confrontation if inconsistence

  4. Maximal influence- interpret, teach, set limits, direct.

Ingram (2012) describes the intake interview as a process that occurs in three stages.

Phase One

Invite clients to tell stories in their own way unobstructed while you track this story and express understanding.  The primary goals are as follows:

  1.  During first session goals
  2. Gather cultural data
  3. Create good rapport & establish credibility
  4. Be sensitive and ask questions rather than rely on assumptions

Phase Two

This is the exploration phase (Ingram, 2012). It involves directing client toward topics of your choosing so you can complete the intake process.  The goals during this phase include   (1) testing the emergency hypothesis, to rule out need for crisis intervention, and (2) testing clinical hypotheses with questions, in order to assess your understanding of the problem.  What follows is a list of tips to minimize your influence during the data gathering portion of the intake interview (Ingram, 2012).

  1. Leading client to areas that you think are important, by blending listening with questioning.
  2. Do not bombard with questions.  Create bridge between client discuss and u r ?’s
  3. No agenda setting at this point.  The focus is on data gathering…
  4. Be aware that some exploratory questions carry advice
  5. Keep in mind, some questions encourage the client to think differently

Phase Three

Closing involves keeping track of time without being distracting and summarizes session. Psychoeducation important along with helping client understanding what to expect, (i.e. informed consent, & intake paperwork).

Data Gathering & The Therapeutic Relationship

Finally, Ingram, (2012), provides a few important suggestions for attending to the establishment of a therapeutic relationship during this phase.

  1. Empathetic listening and nonjudgmental acceptance are critical during this phase since this can impact what the client shares…
  2. Self-Awareness is vital and should be part of your training.  In addition to understanding. how other people perceive and respond to you, be mindful of the impact values, emotional reactions, cognitive filters and defensive tendencies, or cultural biases might have.
  3. Cultural Competence – Counseling doesn’t occur in a vacuum in the sense that we bring to the tables our sociocultural perspective as the filter through which we view life. An understanding of diverse cultures other than your own is especially critical.

Finally, Ingram, (2012) provides a quick overview of a few essential data gathering tools frequently utilizing during the intake process.

  1. ADDRESSING (Age, development, disability, religion, ethnicity, socioeconomic status, sexual orientation, indigenous status, national origin, gender.)
  2. GENOGRAM(Family Tree Diagram) – Includes  three generations using symbols to represent nature of relationships, gender, marriages, Etc
  3. FOUR (problem, outcome, obstacles, and resources)
    1. PROBLEM – what is wrong? Since when? How:
      1. Describe problem
      2. Discuss onset and developmental course.
      3. Progressive deterioration and history….
      4. Past attempts to solve
    2. OUTCOME – What do you want to happen?
      1. Your vision of the future?
      2. Where do you want to be?
    3. OBSTACLESBarriers to what you want?
      1. Internal barrier?
      2. Environmental obstacles
      3. Cultural / Social Issues
    4. RESOURCE & SUPPORT –what would help you get what you want?
      1. Environmental changes
      2. Applying new habits and skills. Etc…
    5. BASIC SID(Behavior, affect, sensation, imagery, cognition)
    6. Check out this description of Multimodal questions…
  4. OTHERS
    1. Evidence-based self-Reporting Instruments – Beck Depression Inventory, etc….
    2. Behavioral Observation Rating – Child-Symptom-Inventory 4
    3. Self-Monitoring Charts – antecendents/consequence/Trauma….

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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NCE Study – Multicultural Competency

“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. 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).

Strengths.  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).

Solutions.  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).

Strengths.  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.

Solutions.  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.

Solutions:  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.

Solutions.  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.

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.

References

Arredondo, P., Toporek, M.S., Brown S., Jones, J., Locke, D.C., J. and Stadler, H. (1996) Operationalization of the Multicultural Counseling Competencies. AMCD: Alexandria VA.
Bellevue University. (2014). MCC Graduate Student Disposition Rubric. [Class Handout]
Catholic Health Initiative. (2014). HIPPA & Privacy Rule.  http://www.chihealth.com/hipaaprivacyrule
Corey, G. ,Corey, M.S., & Callanan, P. (2011).  Issues and ethics in the helping professions.  (8th ed.) Belmont: CA:  Brooks & Cole.
Hays, P. & Iwamasa, G. (2010) Culturally responsive cognitive-behavioral therapy. (3rd ed.) Washington, D.C. American Psychological Association.
Hays, P. (2008).  Addressing cultural complexities in practice.  (2nd ed.)  Washington, D.C.: American Psychological Association.
LaFramboise, T., Coleman, H.L.K. & Gerton, J. (1993) Psychological impact of biculturalism:  Evidence and theory.  Psychological Bulletin.  114, 395-412.
Leahy, R.L. (2008) The therapeutic relationship in cognitive-behavioral therapy.  Behavioural and Cognitive Psychotherapy. 36, 769-777.
Rosenthal, H. (2005). Vital Information and Review Questions for the NCE and State Counseling Exams. Routledge.
Sue, D.W., Arredondo, R. & McDavis, R.J. (1992).  Multicultural counseling competencies and standards:  A call to the profession.  Journal of Counseling & Development.  70, 477-486.

 

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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.

References

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: http://dx.doi.org/10.4135/9781452233536.n10
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 – 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).

Strengths.

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).

Solutions.

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).

Strengths.

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.

Solutions.

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.

Solutions.

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.

Solutions.

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.

References

Ajouga, P. (2014). Re: MCC 638 Week Two Overview. Retrieved from: https://ssoblackboard.bellevue.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_328162_1%26url%3
Amato, P. R., & Cheadle, J. (2005). The long reach of divorce: Divorce and child well-beingacross three generations. Journal of Marriage and Family, 67(1), 191-206. Retrieved from: http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/219746544?accountid=28125
Arredondo, P., Toporek, M.S., Brown S., Jones, J., Locke, D.C., J. and Stadler, H. (1996) Operationalization of the Multicultural Counseling Competencies. AMCD: Alexandria VA.
Bellevue University. (2014). MCC Graduate Student Disposition Rubric. [Class Handout]
Brown ,B., (2006). Shame resilience theory: A grounded theory study on women and shame. Families in Society. 87(1) 43-52.
Catholic Health Initiative. (2014). HIPPA & Privacy Rule.  http://www.chihealth.com/hipaaprivacyrule
Corey, G. ,Corey, M.S., & Callanan, P. (2011).  Issues and ethics in the helping professions.  (8th ed.) Belmont: CA:  Brooks & Cole.
Fortune, B.A. (2012). Acculturation, intergenerational conflict, psychological distress and stress in Filipino-American families. Regent University, Virginia.
Genz, S., (2010). Singled Out: Postfeminism’s “New Woman” and the Dilemma of Having It All.  The Journal of Popular Culture, (43)1, 97-119.
Hays, P. & Iwamasa, G. (2010) Culturally responsive cognitive-behavioral therapy. (3rd ed.) Washington, D.C. American Psychological Association.
Hays, P. (2008). Addressing cultural complexities in practice. (2nd Ed.) Washington, D.C.: American Psychological Association.
Jensen, B. (2012). Reading Classes : On Culture and Classism in America. Ithaca: ILR Press.
LaFromboise, Coleman, H.L.K. & Gerton, J. (1993). Psychological impact of biculturalism: Evidence and theory. Psychological Bulletin. 114(3) 395-412.
Leahy, R.L. (2008) The therapeutic relationship in cognitive-behavioral therapy.  Behavioural and Cognitive Psychotherapy. 36, 769-777.
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.
Martin, C.A. (2004) “Bridging the generation gap (s).” Nursing2013. 34(12)62-63.
McCarthy, K. (2007). “Pluralist Family Values: Domestic Strategies for Living with Religious Difference” The ANNALS of the American Academy of Political and Social Science. 612(1) 187-208.
Root, M.P.P. (1998) Experiences and processes affecting racial identity development: Preliminary results from the biracial sibling project. Cultural Diversity and Mental Health.  4(3) 237-247.
Sue, D.W., Arredondo, R. & McDavis, R.J. (1992).  Multicultural counseling competencies and standards:  A call to the profession.  Journal of Counseling & Development.  70, 477-486.
 

 

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Psychopathology & DSM Diagnosis.

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.  In it, I review information from two papers, one defines the subject of psychopathology and the other is a brief overview of DSM diagnosis.  It is not intended as a substitute for mental health counseling or diagnosis…)))

An Overview of Perspectives

If there is one thing that can be taken away from this week’s readings it is that  a simplified definition of psychopathology is difficult to come by (Maddux & Winstead 2008; Patrick, 2012).   What one conceives of as a mental disorder actually depends upon how one differentiates between normal and abnormal behavior.   While abnormal can be understood as anything that deviates from what is considered “normal”, psychopathology refers to deficits in mental functioning.    These deviations from a norm, require us to first examine how this standard is define.  “Upon what basis is a diagnosis of psychopathology made?”

  1. A social constructionist perspective abnormal might be defined as a deviation from social expectations and cultural norms.  The problem with this perspective is that it does not take into account cross-cultural differences, or even longitudinal changes within an individual culture.  With this in mind, it is worth noting that the DSM manual has been written from a very westernized cultural perspective.
  2. Vernacular criteria, on the other hand, reflect’s a laymen’s perspective that reflects popular opinion, especially within the media.  This viewpoint of psychopathology is often quite disparaging and riddled with stereotypical labels like “crazy”, “nuts”, or “psycho”.
  3. Legally, psychopathology is concerned with the issue of mental competency and criminal responsibility.  This perspective here is guided by whether an individual’s psychopathology allows for the use of an insanity defense.
  4. Finally, the Diagnostic and Statistical Manual (DSM-5) utilizes a medical definition of mental health.  Overall, this perspective might be useful to asses an individual’s ability function comfortably on a daily basis.  In sum, mental health from this perspective can be thought of as an ability to deal with reality on “reality’s terms”.

A Medical Perspective of Psychopathology

The Nature of Psychopathology

Inherent, in our definition of normalcy is a valuation statement of who falls within these parameters (Maddux & Winstead, 2008; Patrick 2012).  A few notable aspects of psychopathology’s nature are worth mentioning.

What is “Abnormal” Anyway?

Acording to Maddux, et al. (2008), “Abnormal literally means away from the norm. The word norm refers to what is typical average.” (p 4).  This implies a comparison of individuals against a standard that dictates what t characterized are considered typical ina  society.   In his article titled “The Perils of ‘Adjustment Disorder’ as a Diagnostic Category”, John Daniels states that a “Disorder is a term that names any variation, perversion, or dysfunction outside the normal order, which is regarded as a proper composition of parts according to the classical scientific paradigm” (p79).

A balanced consideration of general and particular.   

Mental health diagnosis involves an assessment of individual characteristics against an objective standard.   However, behavior cannot be truly understood when separated from the perceptual meaning system of the individual.  While scientific and socially relevant standards are essential for diagnosis, a  holistic perspective of the individual from within their standpoint of understanding is also needed. (Gorostiza & Manes, 2011, p211).  This balance seems at times to reflect a Hegelian dialectic.

Multicultural Competency.

In reality, the issue of psychopathology is quite complex, involving an array of internal and external variables. Understanding the issue in absence of the social context is a disservice to patients. (Maddux & Winstead, 2008, p12).   Multicultural competency is of ever-increasing importance in the global society we live in.

Causal complexity.

The final thing to note about psychopathology, is it is not a static concept readily observed objectively. Instead, it is a continually evolving issue that develops as a result of a complex array of factors.   This creates a problem for a medical perspective that perceives symptoms, as being related to readily understood causal factors (Gorostiza & Manes, 2011, p211). In reality, the issue of cause and effect within the realm of mental health is much more complex (Gorostiza & Manes, 2011, p211).

Psychopathology – A Medical Definition.

According to the medical field, psychopathology can be defined as an inability to function on a daily basis.   Diagnosis is based on observed behavioral and psychological symptom patterns. (Maddux & Winstead, 2008).  From a medical perspective, two key requirements are essential for understanding psychopathology: “(1) concepts must unambiguously refer to observed clinical phenomena, and (2) symptoms, understood as conceptualized clinical data, must be stabilized by a causal account” (Gorostiza & Manes, 2011, p205).

When considering the issue of psychopathology from this perspective the problem of contextual blindness is immediately apparent (Daniels, 78). On the one hand, psychopathology can be best thought of as a mental construct based on personal meaning systems that are highly fluid and complex in nature (Gorostiza & Manes, 2011). On the other hand, a medical perspective very objective and rigid in focus (Gorostiza & Manes, 2011). This contextual blindness has deep historical roots in the origins of medical science.  In reality the concept of psychopathology, extends beyond the limited confines of a medical perspective (Daniels, 1009; Gorostiza & Manes, 2011; Maddux & Winstead, 2008).   To ignore this fact is to miss key “pieces of the puzzle”  In reality, “mental phenomena are referentially open” (Gorostiza & Manes, 2011, 214) as active processes that result from a dynamic interplay of complex factor.  It is in this respect that counseling is a much-needed counterpoint to the medical perspective that predominates mental health.

Mental Health Diagnosis

Initial Thoughts & Reactions

My beliefs about mental health diagnosis have been greatly influenced by observations in acute mental health settings. Overall, I’m pleasantly surprised by the changes made in the new DSM-5 Manual.   My assumptions and beliefs about diagnosis are listed below.

Diagnosis is a Messy Process

“In the real world, patients, like Shakespeare’s sorrows, tend to come not as single spies but battalions” (Morrison, 2014, p. 8). I love this quote from our textbook, because it summarizes my observations about mental health diagnosis. In acute care settings there is often an insufficient amount of time to gather all necessary information for a full evaluation. Currently, the idea of sorting through information in such a context seems daunting. My goal for this class is to develop a good picture of the process overall as it should occur in an ideal setting.   Realistically, learning to apply it in a real world context will come with have to come with practice.

Cultural Relativism Matters

As an individual who was raised in culturally diverse setting, I believe culture permeates every facet of our development. Culture influences not only our values and beliefs, but also how we think, behave, and feel. An assigned reading in my Social and Ccultural Diversity class provides interesting commentary relevant to this discussion. Johnson, (2013) states, “Cultural factors can influence the expression and interpretation of signs and symptoms. For example, practitioners commonly perpetuate racial biases…some examiners using the DSM-5 may function with unexamined assumptions or inadequate training.” (p. 20). On the basis of these observations, I believe it is critical for therapists to consider the influence of culture in their assessments.

Objectivity Trumps Subjectivity

In an acute care setting, diagnosis occurs according to Morrison’s (2014) observation that “signs trump symptoms” (p. 9). For example, clinical observations are used to contextualize a patient’s story. One criticism I have is the over-reliance of this viewpoint in acute care settings. Managing behaviors and assuring safety in this setting is the priority over other concerns.  Patient’s thoughts and feelings are contextualized in terms of a diagnosis. I feel when interacting with patients, time must also be taken to see beyond this diagnosis. As our textbook notes, a client’s “back story…provides meaning that illuminate(s) motives, actions, and emotions” (Morrison, 2014, p7).   While objectivity is important acknowledging a client’s subjective experiences is also critical.

Open-Mindedness is Important

            One final assumption I have about diagnosis and assessment is that they exist as a process and not an event. In this respect, I feel it is important to keep an open mind. Morrison, (2014) confirms this assumption with the following statement: “I want to encourage you to avoid a trap that any clinician can fall into: rushing headlong into diagnostic closure before having all the facts” (xii).

The Process of Diagnosis….

Diagnosis requires an understanding of etiology, the process of development, and possible treatment regimen.  Underlying this information is empirical research and “evidence-based” practice.  First in my old DSM class are notes on a plan of attack….

“The Plan of Attack”

  1. The first step is your initial diagnostic impressions. This involves creating groupings of symptoms into syndromes and simply listing them. This is allows you to form an initial diagnostic impressions, containing a potential list of relevant diagnosis.
  2. The second step is a differential diagnosis. Here, we narrow down our list of potential diagnoses. To accomplish this compare you compare observable symptoms with diagnostic criteria. This will help you decide which disorder (or disorders) best account for the symptoms. In class, we are asked to explain why we keep and reject a specific disorder and the logical underlying our decisions.
  3. The last step is a final diagnosis. Your final diagnosis reflects the decision you made, the diagnosis you feel most accurately accounts for the symptoms presented. The actual format for recording your final diagnosis will vary some depending upon the agency, insurance requirements, etc. However, at a minninum the final diagnosis should be reported with the correct code number, title (capitalized), and any necessary specifiers. Most disorders have coding notes and instructions for what specifiers are needed at the end of the Diagnostic Criteria section.

Suggestions from Morrison

Last week’s readings provided an overview of the process of diagnosis. The initial steps of this process include gathering information and identifying syndromes (Morrison, 2014). With this information in hand, therapists must construct a list of potential alternatives and determine an initial diagnosis (Morrison, 2014). A differential diagnosis “is a comprehensive list of conditions that could account for a patient’s symptoms” (Morrison, 2014, p14). Strategies that can aid in the construction of a differential diagnosis were discussed in this week’s readings (Morrison, 2014). These strategies are helpful in sorting through a complexity of symptoms as well as preventing therapists from diagnostic conclusions prematurely.

Safety Hierarchy

Morrison, (2014), suggests placing a list of potential diagnoses for consideration in a safety hierarchy. At the top of this hierarchy, are conditions that require urgent treatment and are likely to respond well (Morrison, 2014). Additionally, disorders due to physical disease or substance abuse should also be placed on top (Morrison, 2014). At the bottom of the list are conditions that are hard to treat with difficult outcomes.

An example from my own life experiences proves the utility of this strategy. As an infant, my son went into shock at home. This is a medical condition in which there is a lack of blood flow throughout the body. Causes of shock include: hypovolemic shock, cardiogenic shock, anaphylactic shock and septic shock. When I rushed him to the hospital, doctors recognized the condition immediately. They utilized a safety hierarchy similar to what is discussed in our textbook. Starting with the easiest to treat diagnoses, they assessed for dehydration and infection. After ruling out all possible alternatives it was finally determined my son had a congenital heart defect and required surgery. This process very much falls in line with the logic utilized in our textbook.

Decision Tree

Another strategy for differential diagnosis includes the decision tree. “A decision tree is a device that guides the user through a series of steps to arrive at some goal, such as diagnosis or treatment” (Morrison, 2014, p19). While not included in the DSM-5, the differential discussion sections under each diagnosis provide a similar logic. For example, the DSM-5 states the following regarding major neurocognitive disorder:

“[cognitive] difficulties must represent changes rather than lifelong patterns…[therapists must also] differentiate between [cognitive deficits] and motor or sensory limitations” (American Psychiatric Association, 2013, p608)

This insight suggests therapists must ask if observe deficits are the byproduct of recent events or symptoms of lifelong developmental patterns (American Psychiatric Association, 2013). Additionally, can cognitive deficits be explained by any sensory limitations, (American Psychiatric Association,

Diagnostic Uncertainty

The final bit of information I’d like to remember for future reference pertains to the issue of diagnostic uncertainty.   What follows are suggestions from our instructor in class:

First you have “Rule Out

There is not a code for this but you write out “Rule Out” followed by a specific disorder.  This means you have some evidence to suggest there could be a specific disorder, but not enough information to confirm or deny. For example, if parents suspect their son is using marijuana, you could record “Rule out Cannabis Use Disorder”.  This essentially says you should be on the look out for more information. I would list something as “rule out” in my final diagnosis if questions still remain after going through the differential process.

Then you have “Provisional Diagnosis”. 

This is given when you have a clear theory about a specific disorder, but need additional information to confirm.  This would be appropriate if you need results from a specific test (blood levels to see if it is medication induced) or a physician’s verification of a physical condition.  Perhaps you suspect substance use and the individual was not very cooperative, you may have a pretty good idea that they have a substance use disorder, but want this confirmed by another source such as a urine analysis.  With Rule Out I am not as confident about the disorder, but there is some evidence to suggest it should be explored.

Finally There is “Other/Unspecified”  

This is an actual diagnosis with the number determined by the class of disorders indicated.  These cases are tricky and rely heavily on clinical judgment.   “Other specified” is used when the presentation does not meet official criteria for a specific disorder within a specific a diagnostic class,  but the clinician communicates or “specifies” the specific reason why this is the case.  “Unspecified” also means the diagnosis does not meet the specific criteria but allows the clinician to choose not to explain the reason(s) why criteria are not met.  The unspecified/other diagnoses are given when you have enough information to be confident that the client has a disorder in a specific class.   This may occur because you do not have the complete picture of the symptoms or it may just be that this individual is experiencing the disorder in an atypical way so their pattern of symptoms does not quite match up.  The key is that the symptoms clearly indicate a class of disorders.   If you want to specify why they don’t quite match then use “Other specified”, if you don’t want to explain or cannot give a clear explanation then use “Unspecified”.  However, please understand that you are giving a diagnosis with a code when you do this.  You are saying they have a disorder.

References

Daniels, J. (2009). The perils of ‘adjustment disorder’ as a diagnostic category. Humanistic Counseling, Education and Development. 48(1). 77-90
Gorostiza, P.R. & Manes J.A. (2011). Misunderstanding psychopathology as medical semiology: An Epistemological inquiry. Psychopathology. 44, 205-215. doi: 10.1159/000322692.
Johnson, R. (2013) Forensic and Culturally Responsive Approach for the DSM-5: Just the FACTS. Journal of Theory Construction & Testing, 17(1), 18-22.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental healthclinicians, 2nd ed. New York, NY: The Guilford Press.
Maddux, J. & Winstead, B. (Eds.). (2008). Psychopathology: Foundations for a contemporary understanding (2nd ed.). New York, NY: Routledge. ISBN 978-0-8058-6169-3. (M&W)
Patrick, C (2012). Bellevue University – Defining Abnormality Video. Available from: https://cyberactive.bellevue.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_278013_1%26url%3D
Warren, J. (2012) Psychopathology defined in context. [Class handout, HS-513, Dr. Jane Warren, Bellevue, University]

 

 

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