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Ethical Issues in Multiculturally Competent
Mental Health Care Practice
Stephanie J. Cunningham, Ph.D., HSPPUniversity of Southern Indiana
Counseling Center
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Introduction and foundation
►A little bit about me
►Some ground rules and expectations
►Our plan for today What does it mean to be multiculturally
competent?
Why does multicultural competence matter?
How does multicultural competence intersect with ethical issues in clinical practice?
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Section One:
What does it mean to be multiculturally competent?
…and why does it matter?
►Learning objectives: Describe a conceptual framework for multiculturally
competent mental health care practice
Summarize the basis of the claim for a fundamental connection between multicultural competency and social justice
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Brief check-in with the room
► How much was multicultural competency an area of emphasis in your graduate training?
► How much do you think you recall of that training in multicultural competence?
► How much have you focused on maintaining state-of-the-art multicultural competence since you graduated?
► Do you remember learning anything about the connection between multicultural competency and ethical concerns?
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A moment of self-reflection
►Who are you?
►If you could create one rule that we all had to follow in life, what would it be?
►What activity brings you the most joy?
► Think of someone whom you admire. Describe them in one word. ~or~
► Think of a piece of art (e.g., book, film, music, etc.) that you find to be a masterpiece. Sum up in one sentence why it speaks to you.
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What does it mean to be multiculturally competent?
►The basic gist of it: "To become culturally competent,
psychotherapists are not required to change their theoretical orientation. Instead, they can adopt a cultural humility stance where they express a genuine desire to work with culturally diverse clients."
"To achieve this goal, clinicians acknowledge the central role that culture plays in people's lives as they embark on a lifelong journey to develop cultural competence." (Comas-Diaz, 2014, p. 419)
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Why does multicultural competency matter in clinical practice?
►First and foremost: avoiding harm Culture-blind care causes harm
"Counseling and psychotherapy have done great harm to culturally diverse groups by invalidating their life experiences, by defining their cultural values or differences as deviant and pathological, by denying them culturally appropriate care, and by imposing the values of a dominant culture upon them."
(Sue & Sue, 2008, p. 34)
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Why does multicultural competency matter in clinical practice?
►Our ethical guidelines emphasize beneficence and nonmaleficence as well as multicultural competency
NASW Code of Ethics
►Address social problems
►Challenge social injustice
►Affirm human dignity and worth
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How does social justice fit in with all that?
►What is “social justice”?
Social justice is: "full and equal participation of all
groups in a society that is mutually shaped to meet their needs. Social justice includes a vision of society in which the distribution of resources is equitable and all members are physically and psychologically safe and secure."
(Bell, 1997, p. 3)
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What does it mean to be multiculturally competent?
The fundamental idea =
I. Counselor Awareness of Own Cultural Values and Biases
II. Counselor Awareness of Client's Worldview
III. Culturally Appropriate Intervention Strategies
(Arredondo et al., 1996; Sue, Arredondo & McDavis, 1992)
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What does it mean to be multiculturally competent?
Source: Ratts, Singh, Nassar-McMillan, Butler, & McCollough, 2016, p. 35
The fundamental idea, made more comprehensive and specifically incorporating social justice =
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What does it mean to be multiculturally competent?
The practical application =
►NASW’s Standards and Indicators for Cultural Competence in Social Work Practice (2015)
Operationalization of a range of core concepts pertaining to multicultural competence
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Back to that self-reflection…
►Who are you? Information on social location, identity, and possibly values
►Your one rule Reflects core values for social dynamics
►What you enjoy Reflects core values of your own
experience
►Someone and/or art you admire Reflects core values for self or others
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Section Two:
How does multicultural competency intersect with
ethical issues in clinical practice?
►Learning objective:
Apply practical strategies for ethical practice and decision-making in working with diverse clientele
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Basics of the link between ethics and multicultural competency
►Culture is everywhere!
Comas-Diaz’s (2014) theoretical assumptions of multicultural psychotherapy:►Reality is constructed and embedded in a cultural context
►Every therapeutic encounter is multicultural
►Clinicians’ cultural competence is relevant to all clients
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Basics of the link between ethics and multicultural competency
►Ethics are everywhere!
Every choice we make is infused with our values and ethics – personal and professional
Ethics don’t just show up when there’s a dilemma: they are there all the time
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So what do we do with all that?
► Every discipline has its ethics codes, but we need some understanding of how to use it in the case of dilemma
► Without a clear process for weighing competing options, we’re likely to use our intuitive responses
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…And yet…
► Our intuition is going to be highly impacted by our social location and associated experiences and values
► Like all other aspects of multicultural competence, lack of critical awareness of those values can have a detrimental impact on our clients if their values are different
► A core part of multicultural competence is awareness of our own values and the values of others
► It is very easy to cause harm while still having the best of intentions
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Ethical decision-making in a multicultural context
► Advancing cultural and clinical responsiveness (Gallardo et
al., 2009)
Avoiding a dual “ethical lens” and “cultural lens” – these need to be integrated, with culture first
There can be no clinical competence without cultural competence – culture is for everyone
We need to rethink our ethical codes with this in mind►“the problem is not necessarily in the theoretical constructs [of
the current ethics code] but rather in the application of those constructs to populations they were not normed and standardized on.” (p. 432)
We can begin thinking about the therapeutic context as a living cell, not a box
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How to make that work
►That’s cool in theory… how does it work in practice, though?
►Hill, Glaser & Harden (1998)
► “All of the ethical principles… rest upon certain assumptions about those professionals making the decisions; one is that there is some common and agreed-upon sense of what constitutes harm and human welfare, and more significantly, that one’s judgment about these principles is unaffected by one’s personal and social context.” (p. 104)
► If we don’t attend to that personal and social context, the implicit values become invisible. They impact the process of decision-making without our realizing it.
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Bridging the ethical-cultural gap
► “…the inclusion of the person of the therapist in the description of the decision-making process [is] crucial to making a decision that is more fully informed and less likely to be based on unexamined biases.” (p. 111)
► So: we need a critical-rational component and an emotional-intuitive component
►In other words:
“How does who I am affect this process?”
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Ethical decision-making plus multicultural competency
►But… HOW do I do that?
► Ethical decision making from a multicultural perspective (Frame &
Williams, 2005)
Describes a multi-step process:
1. Identify and define ethical
dilemmas
2. Consider the context of power
and privilege
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Ethical decision-making plus multicultural competency
3. Assess the client’s identity development
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Ethical decision-making plus multicultural competency
3. Assess the client’s identity development
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Ethical decision-making plus multicultural competency
4. Seek consultation
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Ethical decision-making plus multicultural competency
5. Select a course of action
6. Evaluate the decision
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Time to practice!►Go through each of the
steps of the process:
Identify and define the ethical dilemma(s)
►What parts of the ethics code are in play?
Consider the context of power and privilege
►Who are you? What are your values?
Assess the client’s identity development
►Who are they? What are their values?
Seek consultation
►From whom would you seek feedback about how you are making sense of this dilemma?
Select a course of action
►Identify various options, define the relevant values that would be prioritized by each, consider the possible outcomes
Evaluate the decision
►What did I learn from this?
► Remember: “How does who I am affect this process?”
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Bringing it all together► Points to remember:
Multicultural competency must be regarded as a core part of general clinical competency
Multicultural competence is a PROCESS, not a GOAL
Multicultural competency is an ethical mandate
Multicultural competency and social justice are fundamentally linked
Multicultural competency and ethical decision-making are more connected than we might recognize at first glance
Ethical decision-making should incorporate both a critical-rational component and an emotional-intuitive component
Any final thoughts, questions or concerns?
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Coda: Understanding and naming our fundamental values
►When values of different cultures conflict (Knapp & VandeCreek, 2007)
Are ethics universal or relative?
►Absolutism/ethical universalism (what’s right is right no matter
the context or variables involved)
►Moral relativism (right is whatever is right in that context)
►Soft universalism (some principles are universally right, but
otherwise what is right depends on the context)
Responding to apparent conflicts in cultural beliefs
►Clarify values through respectful dialogue
►Use soft universalism: utilize principle-based ethics to balance conflicting moral obligations
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References
► Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., et al. (1996). Operationalization of the multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24, 42-78.
► Bell, L. A. (1997). Theoretical foundations for social justice education. In M. Adams, L. A. Bell, & P. Griffin (Eds.), Teaching for diversity and social justice: A sourcebook (pp. 3-15). New York: Routledge.
► Comas-Diaz, L. (2014). Multicultural psychotherapy. In F. T. L. Leong, L. Comas-Diaz, G. C. Nagayama Hall, V. C. McLoyd, & J. E. Trimble (Eds.), APA handbook of multicultural psychology: Vol. 2. Applications and training (pp. 419-441). Washington, DC: American Psychological Association.
► Frame, M. W. & Williams, C. B. (2005). A model of ethical decision making from a multicultural perspective. Counseling and Values, 49, 165-179.
► Gallardo, M. E., Johnson, J., Parham, T. A., & Carter, J. A. (2009). Ethics and multiculturalism: Advancing cultural and clinical responsiveness. Professional Psychology: Research and Practice, 40, 425-435.
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References
► Hill, M., Glaser, K., & Harden, J. (1998). A feminist model for ethical decision making. Women & Therapy, 21, 101-121.
► Knapp, S. & VandeCreek, L. (2007). When values of different cultures conflict: Ethical decision making in a multicultural context. Professional Psychology: Research and Practice, 38, 660-666.
► National Association of Social Workers. (2017). Code of ethics of the National Association of Social Workers. NASW.org. Retrieved February 2, 2018, from https://www.socialworkers.org/About/Ethics
► National Association of Social Workers. (2015). Standards and indicators for cultural competence in social work practice. NASW.org. Retrieved February 2, 2018, from https://www.socialworkers.org/practice/practice-standards-guidelines
► Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44, 28-48.
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References
► Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling and Development, 70, 477-486.
► Sue, D. W. & Sue, D. (2008). Counseling the culturally diverse: Theory and practice. (5th ed.). Hoboken, NJ: John Wiley & Sons, Inc.
► Wendt, D. C., Gone, J. P. & Nagata, D. K. (2015). Potentially harmful therapy and multicultural counseling: Bridging two disciplinary discourses. The Counseling Psychologist, 43, 334-358.
► Wronka, J. (2008). Human rights and social justice: Social action and services for the helping and health professions. Los Angeles, CA: Sage Publications.
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Presenter information
►For any questions or discussion, please feel free to reach out:
Stephanie Cunningham, Ph.D., HSPP
812-464-1867 (USI Counseling Center)
