Multicultural counseling and therapy does not utilize specific methods or techniques; instead, it aims to define treatment goals and use those therapeutic methods consistent with the life experiences and cultural values of clients. It strives to recognize that all client identities include individual, group, and universal dimensions, advocate the use of universal and culture-specific strategies and roles in the healing process and balances the importance of individualism and collectivism in the assessment, diagnosis, and treatment of the client and client systems (Sue, 2001). For example, all persons have aspects of their personality and biology that are unique to them from their genetic makeup, to personal life experiences and learning. Likewise, all persons have group memberships or relationships with culture that shape their identity, attitudes, emotions, and behaviors such as gender, family, age, religion, ethnicity, nationality, economic class, and more. All human beings also share some universal aspects such as basic emotions (happiness, sadness, anxiety, surprise, etc.), desire for acceptance, common life experiences (childhood, puberty, etc.), self-awareness, capacity for language and learning, etc. Some cultures are more individualistic, emphasizing one’s own personal perspective and achieving one’s own personal goals in life while other cultures are significantly more collectivist, emphasizing conforming behavior and actions that support one’s family, group, clan, or tribe.

The sociocultural perspective accepts and integrates the impact of cultural and social norms starting at the beginning of treatment. Therapists who use this perspective work with clients to obtain and integrate information about their cultural patterns into a unique treatment approach based on their particular situation (Stewart, Simmons, & Habibpour, 2012) and acknowledge cultural differences between client and therapist that could influence the therapeutic relationship and treatment. Sociocultural therapy can include individual, group, family, and couples treatment modalities.

As our society becomes increasingly multiethnic and multiracial, mental health professionals must develop cultural competence (Figure 1). This means they must understand; accept; and honestly and openly address issues of gender, race, culture, ethnicity, and other variables in terms of how these shape their own life and attitudes and how they shape the experiences of others. They must also develop strategies to effectively address the needs of various populations for which Eurocentric therapies, which tend to assume individualistic goals are most important (such as achieving one’s personal dreams or goals in life) have limited application (Sue, 2004). For example, a counselor whose treatment focuses on individual decision making may be ineffective at helping a Chinese-American client with a collectivist approach to problem solving (Sue, 2004) in which the needs and values of others may be more important than the client’s own goals.

Because of these concerns, most professional associations have adopted or incorporated cultural competence into their ethical standards or principles. For example, in 2017, the American Psychological Association adopted 10 basic principles of cultural competence that are “necessary for psychologists working in all domains: practice, research, consultation and education.”^[1] Among other points, these principles include

• psychologists need to understand that as “cultural beings” they hold personal beliefs and attitudes that shape how they view and interact with others;
• the need to be aware of how social and physical environments impact the lives of research participants, clients, students, and others;
• the need to understand and be aware of historical and ongoing issues of power and privilege, and histories of oppression and seek to address disparities and inequalities as they promote justice, human rights, and access; and
• the promotion of “culturally adaptive” interventions.

It is vital that all therapists understand and acknowledge the impact of social situations such as racial discrimination on mental health. For instance, a recent longitudinal study of almost 700 Black adolescents for a period of 18 years found that perceived racial discrimination predicted increases in anxiety and depression in adulthood among Black males.^[2].

Figure 1. How do your cultural and religious beliefs affect your attitude toward mental health treatment? (credit “top-left”: modification of work by Staffan Scherz; credit “top-left-middle”: modification of work by Alejandra Quintero Sinisterra; credit “top-right-middle”: modification of work by Pedro Ribeiro Simões; credit “top-right”: modification of work by Agustin Ruiz; credit “bottom-left”: modification of work by Czech Provincial Reconstruction Team; credit “bottom-left-middle”: modification of work by Arian Zwegers; credit “bottom-right-middle”: modification of work by “Wonderlane”/Flickr; credit “bottom-right”: modification of work by Shiraz Chanawala)

Link to Learning

This link takes you to a published case study of a Muslim-American “hijabi” woman (who follows traditional Muslim dress codes) struggling with an eating disorder and depression. It is a good illustration of the use of culturally competent practices. While the entire article is useful, especially review the initial mental status examination, diagnosis, case summary, course of treatment, and discussion. This will give you a good idea of how important cultural competence is and some of the major struggles that clients from different backgrounds face.

Understanding Barriers to Treatment

Statistically, people of color tend to utilize mental health services less frequently than White, middle-class Americans (Alegría et al., 2008; Richman, Kohn-Wood, & Williams, 2007). Why is this so? Perhaps the reason has to do with access and availability of mental health services. People from marginalized communities and individuals of low socioeconomic status (SES) report that barriers to services include lack of insurance, access to transportation, and time required to navigate these elements (Thomas & Snowden, 2002). However, researchers have found that even when income levels and insurance variables are taken into account, people of color are far less likely to seek out and utilize mental health services. And when access to mental health services is comparable across ethnic and racial groups, differences in service utilization remain (Richman et al., 2007).

In a study involving thousands of women, it was found that the prevalence rate of anorexia was similar across different races, but that bulimia nervosa was more prevalent among Hispanic and Black women when compared with non-Hispanic Whites (Marques et al., 2011). Although they have similar or higher rates of eating disorders, Hispanic and Black American women with these disorders tend to seek and engage in treatment far less than Caucasian women. These findings suggest ethnic disparities in access to care, as well as clinical and referral practices that may prevent Hispanic and African-American women from receiving care, which could include lack of bilingual treatment, stigma, fear of not being understood, family privacy, and lack of education about eating disorders.

Perceptions and attitudes toward mental health services may also contribute to this imbalance. A recent study at King’s College, London, found many complex reasons why people do not seek treatment: self-sufficiency and not seeing the need for help, not seeing therapy as effective, concerns about confidentiality, and the many effects of stigma and shame (Clement et al., 2014). And in another study, Black Americans exhibiting depression were less willing to seek treatment due to fear of possible psychiatric hospitalization as well as fear of the treatment itself (Sussman, Robins, & Earls, 1987). Instead of mental health treatment, many Black Americans prefer to be self-reliant or use spiritual practices (Snowden, 2001; Belgrave & Allison, 2010). For example, it has been found that the Black church plays a significant role as an alternative to mental health services by providing prevention and treatment-type programs designed to enhance the psychological and physical well-being of its members (Blank, Mahmood, Fox, & Guterbock, 2002).

Figure 2. Accessible mental health services for those who don’t speak English can be difficult to find.

Additionally, people belonging to ethnic groups that already report concerns about prejudice and discrimination are less likely to seek services for a mental illness because they view it as an additional stigma (Gary, 2005; Townes, Cunningham, & Chavez-Korell, 2009; Scott, McCoy, Munson, Snowden, & McMillen, 2011). For example, in one recent study of 462 older Korean Americans (over the age of 60) many participants reported suffering from depressive symptoms. However, 71% indicated they thought depression was a sign of personal weakness, and 14% reported that having a mentally ill family member would bring shame to the family (Jang, Chiriboga, & Okazaki, 2009).

Language differences are a further barrier to treatment. In the previous study on Korean Americans’ attitudes toward mental health services, it was found that there were no Korean-speaking mental health professionals where the study was conducted (Orlando and Tampa, Florida) (Jang et al., 2009). Because of the growing number of people from ethnically diverse backgrounds, there is a need for therapists and psychologists to develop knowledge and skills to become culturally competent (Ahmed, Wilson, Henriksen, & Jones, 2011). Those providing therapy must approach the process from the context of the unique culture of each client (Sue & Sue, 2007).

Dig Deeper: Treatment Perceptions

By the time a child is a senior in high school, 20% of their classmates—that is one in five—will have experienced a mental health problem (U.S. Department of Health and Human Services, 1999), and 8%—about one in 12—will have attempted suicide (Centers for Disease Control and Prevention, 2014). Of those classmates experiencing mental disorders, only 20% will receive professional help (U.S. Public Health Service, 2000). Why?

Apparently, the public has a negative perception of children and teens with mental health disorders. According to researchers from Indiana University, the University of Virginia, and Columbia University, interviews with over 1,300 U.S. adults show that they believe children with depression are prone to violence and that if a child receives treatment for a psychological disorder, then that child is more likely to be rejected by peers at school.

Bernice Pescosolido, author of the study, asserts that this is a misconception. However, stigmatization of psychological disorders is one of the main reasons why young people do not get the help they need when they are having difficulties. Pescosolido and her colleagues caution that this stigma surrounding mental illness, based on misconceptions rather than facts, can be devastating to the emotional and social well-being of our nation’s children.

This warning played out as a national tragedy in the 2012 shootings at Sandy Hook Elementary. In her blog, Suzy DeYoung (2013), co-founder of Sandy Hook Promise (the organization that parents and concerned others set up in the wake of the school massacre) speaks to treatment perceptions and what happens when children do not receive the mental health treatment they desperately need.

I’ve become accustomed to the reaction when I tell people where I’m from. Eleven months later, it’s as consistent as it was back in January. Just yesterday, inquiring as to the availability of a rental house this holiday season, the gentleman taking my information paused to ask, “Newtown, Connecticut? Isn’t that where that . . . that thing happened?”

A recent encounter in the Massachusetts Berkshires, however, took me by surprise.

It was in a small, charming art gallery. The proprietor, a woman who looked to be in her 60s, asked where we were from. My response usually depends on my present mood and readiness for the inevitable dialogue. Sometimes it’s simply, Connecticut. This time, I replied, “Newtown, Connecticut.” The woman’s demeanor abruptly shifted from one of amiable graciousness to one of visible agitation.

“Oh my God,” she said wide-eyed and open-mouthed. “Did you know her?”

. . . .

“Her?” I inquired

“That woman,” she replied with disdain, “that woman that raised that monster.”

“That woman’s” name was Nancy Lanza. Her son, Adam, killed her with a rifle blast to the head before heading out to kill 20 children and six educators at Sandy Hook Elementary School in Newtown, CT [December 14th, 2012].

When Nelba Marquez Greene, whose beautiful six-year-old daughter, Ana, was killed by Adam Lanza, was recently asked how she felt about “that woman,” this was her reply:

“She’s a victim herself. And it’s time in America that we start looking at mental illness with compassion, and helping people who need it. This was a family that needed help, an individual that needed help and didn’t get it. And what better can come of this, of this time in America, than if we can get help to people who really need it?” (pars. 1–7, 10–15)

Fortunately, we are starting to see campaigns related to the de-stigmatization of mental illness and an increase in public education and awareness. Join the effort by encouraging and supporting those around you to seek help if they need it. To learn more, visit the National Alliance on Mental Illness (NAMI) website (http://www.nami.org/). The nation’s largest nonprofit mental health advocacy and support organization is NAMI.

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