entering another's world--understanding client's cultures and contexts

8/7/2019 Entering another's world--Understanding Client's Cultures and Contexts

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E n t e r in g A n o t h e r 's W o r ldU n d e r s t a n d i n g C l i e n t s 'I d e n t i t i e s a n d C o n t e x t s

Laura is a 45-year-old woman of bicultural heritage whoseEuropean A merican father met her Japanese mother in Japanjust after the end of World War II. The couple decided to set-tle in Hawaii, where mixed marriages were more accepted.Laura and her yo unger sister attended public schools, and thefamily lived in a neighborhood where bicultural children wereso common as to be the norm . L ooking back on her childhood,Laura remembered being referred to as hapa, th e Hawaiianword for part, meaning part Japanese. However, as shereached her teenage years, she was m ore inclined to see her-self simply as "local," me aning bor n an d reared in Haw aii. Thisidentity gave her a feeling of com fort with friends of mixedethnicities.After high school, L aura l e f t Hawaii to attend a univer-sity on the mainland. Her school was located in a rural areawith few people of color. She was frequently asked where shewas from and was not sure if the person meant "what state"or "what country." Although she perceived herself to bevisibly bicul tural , everyone seemed to assume that she wasAsian. She began to think of herself more as Japanese Amer-ican and became interested in connecting with the few Jap a-nese Am erican and A sian Am erican students on cam pus.

After college, Laura moved to San Francisco, where sh eworked for a large bank. W hen she tu rned 30, she married a65


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6 6 C O N N E C T I N G W I T H Y O U R C L I E N T

Chinese American man named Dan. Her daily interactions w ith D an'slarge family contrasted with her predominantly Anglo work environ-ment, and heightened Laura's sense of herself as an Asian Americanwoman, although amon g h er in-law s, she was also strongly aw are ofher Japanese roots.In her late 30s, during the birth of her second child, Laura had astroke caused by a brain aneurysm. Because of moderate cognitive andphysical impairments and the paralysis of her right arm and leg, she hadto go on leave from her work. Her mother came to stay with her and carefor the children. Members of Dan's family came daily to bring meals andoffer support.

Laura regained her cognitive a bili ties within a month . However ,the right-side d paralysis persisted, and du ring this time La ura becam edepressed and anxious . She worried about whether she would everregain the m obility she had had before. She worried a bout her ability totake care of her children over th e long haul. And she worried about theirfinances, because although she was receiving disability insu ran ce income,it did not match her previous salary. H er husband was clearly stressedfrom coping with th e ordeal while m aintaining his usua l 55-hour-per-week job. It seemed that th e d isability dom inate d her entire e xistence,and only in negative ways.

Laura received both group and individual counseling through arehabilitation program th at lasted 6 mon ths. D uring this time, she gainedthe u se of her right arm, but her right leg remained weak. After 3 monthsin the program, her depression began to l if tnot solely becau se her pre-vious abili ties were returning, but also because she began to see newways of looking at her life. Through counseling, she realized that a bigmissing piece for her was a spiritual practice. She had been brought up ina Protestant church and, during college, was very interested in "thedeeper questions," but she had let go of this part of herself when sheentered the w orkforce . She could see now how she had been "caught upin the busy-ness" of working, rearing children, and maintaining a mar-riage and family relations and had had little time to think about th e mean-ing of these activities for her.

After 1 year, Laura continued to use a cane to walk. She returned towork part time, and she and her husband and children moved into asmaller house to decrease their expenses. L aur a became actively involvedin a cultura lly diverse church that one of Da n's siblings attende d. The newrelationships she made with church members provided an additionalsense of purpose and meaning in her life. Despite th e family's loweredincome and her difficulty walking, L aur a described herself as happy withher life.With regard to her identity, L aura continued to experience shifts inher sense of self, depending on her situation. At her core, she still felt


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Unde rstanding C lients' Identities and Contexts 67

"local" (i.e., born and reared in Hawaii). With Dan's family, she expe-rienced her Jap anese ethnicity as most salient beca use it contrasted withtheir Chinese culture. With friends who had disabilities (m ost of themEuropean Am erican), she was more aware of herself as an Asian Amer-ican woman , but in her cultu rally diverse church grou p, she thou ght ofherself more as a person with a disability. Permeating all of these iden-tities was a strong sense of herself as a spiritual person.

The Complexities of IdentityDuring the past 20 years, psychologists have given a great deal of atten-tion to describing the development of identity. Although this work ini-tially focused on racially based identities of "Blacks" an d "Whites" in theUnited States (W. E. Cross, f 991; Helms, 1995), attention soon shifted toinclude the development of identities related to ethnicity (D. W. Sue &Sue, 200 3), gender (Downing & Rou sh, 1985; Kimm el & Messner, 1992;Wade, 1998), sexual orientation (Cass, 1979; M cC arn & Fassinger, 1996;Troiden, 197 9), disability (Olkin, 1999), and minority status in general(Atkinson, Morten, & Sue, 1993).These ne w fields of study heightened awareness of individuals andgroups that had been marginalized from and by mainstream psychology.However, they also assumed a cultural homogeneity within the specificgroups that did not exist (e.g., gay and lesbian studies focused on peoplewho were European American, disability studies focused on EuropeanAmericans with disabilities, and mu lticultural counseling focused on eth-nic minorities who were h eterosexua l and did not hav e disabilities). Thisunidimensional conceptualization of identity no doubt reflected dom-inan t cu ltura l assumptions that a person is either a minority or not. Onlyin the past few years have researchers begun to address th e complexitiesof identity fo r most people.

With regard to people w ho hold more than one racial identity, Root(1996) described a framework for understanding self-identification.Drawing from Anz aldua's (198 7) ideas regarding "racial borders," shenoted that biracial people may identify in one of the following four ways:

( 1 ) An individual may solidly identify with both groups,simultaneously holding and merging m ultiple perspectives;(2) The individual may experience a shift in one identity, fromforeground to background, depending on the socioculturalcon text. That is, in one setting, one identity may be experiencedas primary, whereas in ano ther setting, the other identity m ay be;( 3 ) The individual may identify primarily as a biracial ormultiracial person, thus using th e "border between races"as a centra l reference point; or


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(4) The person may identify primarily with one group but, overan extend ed period of t ime, move in and out of identificationwith a number of other groups, (pp. xxi-xxii)Early s tudies (pre-1980s) of biracial and mu ltiracial people (here-

after referred to as "mu ltiracial") looked for and found negative effectsof a multiracial heritage. However, more recent research indicates thatmultiracial people's self-esteem is positive or similar to that of m o n o -racial individu als and tha t m ultirac ial people are increa singly likely toidentify themselves as biracial or multi racia l (Hall, 2003 ) . These shiftsprobably reflect changes in the numbers , power, and status of multi-racial people. A s interr acial relationships have increased, th e n um b er ofmultiracial children has grown. M ultiracial people ha ve form ed num er-ous support and social action group s, and they w ere su ccessful in lob-bying the U.S. government to allow individuals to choose more thanone racial category on the 2000 U.S. C ensus form (Hall, 2003) .

As L aura 's example illustrates, ethnic and rac ial identities can inter-act in complex ways with other self-identifications, too. Early on, Lauraidentified as biracial largely because of her social environment (i.e.,Hawaii), wh ere mu ltiracial identities are common. In contrast, th e pre-dominantly rural European American college environment pushed herto th ink of herself in more d ichotomou s terms (A sian Am erican vs.Eu ropea n A m erican ) . In ma rrying a man of C hinese heri tage, shebecame increas ingly aware of the dif ferences between her Japaneseheritage and th at of her in -law s. The stroke and disabili ty broug htanother layer of complexity, including identification with people withdisabilities and a religious community. In sum, the salience of eachidentity varied with her social si tuation and her personal and genera-tional experiences.

The Significance of Identityin Assessment

Why is it important to be aware of the varied identities clients experi-ence? Perhaps th e most obvious reason is that knowledge of clients'salient identities gives the therapist clues about how clients see theworld, what they value, how they may behave in certain situations, andhow others treat them. The more a therapist knows about a particularclient 's cultures and the variations within, the closer her or his infer-ences and hypotheses will be to the client's reality (Lopez et al., 1989).And the closer the therapist's hypotheses and questions are to a client'strue si tuation, th e greater his or her credibility, efficiency, and accuracy.


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Understanding Clients' Identities an d Contexts 69

Consider another example. An African American therapist was see-ing a married, m ale client in his 30s who had recently imm igrated to theUnited States with his family from Kenya. The assessment and two ther-apy sessions had gone well, and the therapist experienced a sense ofmu tual respect between them; because of their comm on African heritage,she also assumed that she held a deep understanding of his experiencesin the United States. However, the therapist found herself becomingincreasingly anno yed that the client called her a couple of times b etw eeneach session to confirm some agreem ent o r arrangem ent that the ther a-pist had considered firm from their in-session discussion. These behav -iors were not representative of any obsessive tendencies in the client; toth e therapist, it felt as though th e client did not consider her reliable andso was checking up on her.

Dur ing th e third session, th e therapist tactfully asked th e clientabou t his need to call. Th e client explained tha t in his coun try, he oftenhad to remind people to do things they said they would do, especiallypeople working in government or institutional settings. He added thatthings worked slowly and if you wanted something, you had to keepchecking on it. The therapist, who had never been outside the UnitedStates, recognized th e assumptions she held based on her own experi-ences with in stitutions a nd agencies in the U nite d States: People in suchsettings usually do what they're supposed to do, even if it 's slowly, andi f they don't , there are usually alternatives. Her annoyance subsided asshe and the client had a straightforward discussion of their differentexpectations.

In an initial assessm ent, the simplest way to learn about a client's self-identification is often to ask. However, at times, asking about a client'sidentity can be difficult. It is still considered imp olite an d even risky inmany North American settings to discuss race, social class, sexual orien-tation, age, or certain disabilities. In an initial session, clients may assumethat a therapist holds the dominant culture's biases. Hinrichsen (2006)described a poignant example of this ex pectation when, as a young psy-chologist born in ru ral Illinois and raised C atholic, he was g ently asked byan older Jewish woman, "Have you heard of the Holocaust?"In addition, the way in which th e therapist asks an identity-relatedquestion can subtly determine the client 's response. Depending on thecontext, the q uestion, "What is yo ur ethnicity?" ma y be perceived asridiculous or odd, because th e client believes th e answer to be obvious.O r, wh en the client's ethn ic identity is not self-evident, such a questionmay be offensive, because in the dominant cul ture , quest ions aboutidentity have historically been used to decide how people will be treated(Root, 1996 ). People of minority an d mixed identities may be especiallysensitive to such questions from a therapist who appea rs to belong to adom inant cu ltural group.


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A less direct form of th is quest ion, such as, "Would you tell m eabout your cultural heritage or background?" is more l ikely to el icithelpful informat ion withou t g iving offense. Sim ilarly, askin g clients todescribe their "religious upbringing" and then inquir ing about theirpractice today allows for a richer response than simply asking, "What isyo ur religion?" This sugg ested phras ing implies that heritage is not a uni-dimensional, static pheno m enon, and that one may have been broughtup in a pa r t icu la r cu l ture o r g roup but may cur ren t ly ident i fy withanother . In addit ion, unl ike more specific ques t ions (e.g., "How is it foryou as an African American in your school?"), such phrasing does notassume an identity for the client that the client does not hold for him-or herself .

In working with people who have disabil it ies, O lkin (1999) recom-mended avoiding questions such as, "What's wrong with you?" or "Whath a p p en ed ?" T h e first ques t ion assum es tha t on ly peop le wi thout d i s -abilities are normal, and the second suggests a search for something orsomeone to blam e. Similarly offensive is the q uestion, "How might youhave been different witho ut y our disability?" which is like asking some -one who they would be if they weren't a man, African American, Jewish,and so forth. M ore appropriate inqu iries are, "What is the na ture of yourdisability?" and, if the client has not b r o ug h t up the subject of disabilityfollowing a discussion of the presenting problem and curren t s i tuation,"Are there ways in which you r disability is part of this [presenting prob-lem]?" (Olkin , 1999, p. 167) .

With heterosexual and lesbian, gay, bisex ual, and transgender (LGBT)clients, therapists generally wan t to kn ow each individual 's sexual orien-tation and relationship history. However, the degree to which a therapistcan ask directly about these topics varies depending on the setting andclient population. For example, in rural community mental health set-tings, a therapist directly asking a person's sexual orientation may be per-ceived as embarrassing, offensive, or intrusive. Homophobic heterosexualmen may t ake the quest ion as implying that the therapist thinks theymight be gay, resulting in defensiveness; older clients may be put off bydirect questions about their sexuality; and LGBT individuals m ay feelthrea tene d abo ut disclosing such in fo rm atio n. In such settings, it can behelpful to obtain this inform ation indirectly for example, through qu es-tions about the client's relationship history. Through this process, it isalways important to avoid assum ing heterosexual i ty in one's questions(e.g., by using th e term p artner rather than husband or wife and avoidingsuch quest ions as "Are you marr ied?") .

With clients w ho openly identify as lesbian, gay, bisexual, or t rans-gender, the therapist may be able to ask direct qu estions regarding theindividual's attractions; how and when the person disclosed to others andimportant events in this process; how "out" the client is; how accepted


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Und erstand ing Clien ts' Identities and Contexts 71

th e client feels in his or her social environm ent and about th e individ-ual's experiences of discrimination, harassment, or victimization (Balsam,Martell, & Safren, 2 0 0 6 ) . A key aspect of these questions involves thetherapist makin g an assessment of the degree to which sexual o rientationplays a role in the client's presenting problem; in some cases, it may beth e focus, whereas in others, it may have little to do with th e problem(Balsam et al, 2006) .Therapists also need to be aware of the influence of European Amer-ican cultural assumptions on the psychological literature regarding sex-ual orientation and gender identity among LGBT people. For example,some of the work regarding the coming-out process fo r lesbian, gay, an dbisexual people assum es (a ) that it occurs in a linear progression of spe-cific stages, (b ) that it occurs only once in a person's l ifet ime (i.e., a per-son is either "out" or "still in the closet"), and (c) that the end result isusua lly positive (i.e., that there is an increased self-acceptance and inte-gration of one's sense of self; A. Smith, 1997). However, the coming-outprocess may be a very different experience for a person of color. Morespecifically, disclosure of one's sexu al orientation may involve the con-tradiction of cultural norms regarding personal and family privacy andthe potential loss of support from one's cultural group. It may also ad danother form of oppression that, for an individua l already affected byracism and possibly sexism, represents an u nbearable bu rden (G reene,1994). In such a context, a person's reluctance to disclose may be an adap-tive, self-protective response (A . Sm ith, 1 997). (See American Psycholog-ical Association, 2000a, fo r "Guidelines fo r Psychotherapy W ith Lesbian,Gay, and Bisexual Clients," and American Psychological Association,2006, for information regarding transgender individuals.)

Straightforward questions abou t a client's identity may also be inap-propriate when clients perceive the concept of identity to be an abstrac-t ion unre la ted to their present ing concerns . In fact, ident i ty is anabstraction one that m ay be useful to therapis ts but not necessarily ofinterest to clients. Recall the case of M rs. Sok (the Khm er wom an in chap.2 of this volum e), who would no doubt have found a discussion of heridentity to be even less relevant to her presenting complaint than th equestions she was asked.

In general, when a client does not wish to explore th e relationshipof perso nal and cu ltur al identities to his or her cur rent situation, it iswise to respect this wish, especially before a trusting relat ionship hasbeen built. How ever, this initial avoidance of the subject does not meanthat th e therapist should not consider identity issues and discuss theseissues la ter in therapy once a respectful relat ionship has been estab-l ished. Assessment and therapy wil l invar iably be faci li tated by anunders tanding of clients' identities (Comas-Diaz & Greene, 1994a) andby a consideration of the interaction between th e therapist 's own iden-tity and that of the client (Perez Foster, 1 996 ). Exhibit 4.1 lists quest ions


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EXHIBIT 4.1Understanding Clients' Identities: Questions for Clients1. How would you describe yourself?2. Would you tell meabout your cultural heritage or background? (Follow up with questions

about ethnicity, racial identification, national origin. Indigenous heritage, and primarylanguage, as relevant.)

3. What was your religious upbringing? Do you have a religiousor spiritual practice now?4. What was your family's economic situation growing up?5. Do you haveexper ience with disability, or have yo u been a caregiver fo r someonewho does?6 . Are there ways in which your disability is part of [the presenting problem]? (Olkin, 1999)7. What did it mean to grow up as a [girl or boy] in your culture and family? (L. S.Brown,1990)8. Do you currently have a partner? Couldyou tell meabout the significant intimate relation-

ships yo u have had?

therapists can use to inquire about cultural influences with clients, andExhibit 4.2 offers questions therapists m ay consider even if they cannotask them directly.

Turning Assumptions IntoHypotheses and QuestionsAt th e beginning of any assessment, information about a client's identityand situation is usually provided by the referral source (e.g., "Mrs. Chengis a 55-year-old, widowed, Asian American woman who presents with ...").Using this introductory information, th e therapist then engages in "a con-

EXHIBIT 4.2Understanding Clients' Identities: Questions for Therapists1. What are the ADDRESSING influenceson this client (i.e., age and generational influences,

developmental disabilities, disabilities acquired later in life, etc.)?2. What are this client's salient identities related to each influence? What are the possiblemeanings of these identities in the dominant culture, in the client'sminority culture(s),and from the personal perspective of the client?3 . How are my salient identities interacting with those of the client?a. How am I being perceivedby this client, on the basis of my visible identity?b. Am I knowledgeable about those groupswith which the client identifies?c. How might my identity and related experiences, values, and beliefs limit m y

understanding of this client?


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Und erstanding C lients' Identities and Contexts 73

tinuous cycle of hypothesis formulation and hypothesis testing about theparticular individual. Each item of information. . . suggests a hypothesisabout the person, which will be either confirmed or refuted as otherfacts are gathered" (Anastasi, 1992, p. 611).

For example, a therapist who has experience with Asian Am ericanpeople would immediate ly recognize that Mrs. Cheng's surname isChinese. This realization would then allow him to begin to form hypo-theses about the client's cul tura l context that a re more likely to be us e-ful (i.e., hypotheses that are relevant to a widow ed C hinese Am ericanwoman living in the area) . At the same time, th e therapist's experienceswould keep him aware of the diversity of possible influences in thisclient's life, including, for example, th e possibility that despite her name,the client is not C hinese Am erican.

Of course, once the therapist and client meet, a great deal moreinformation is usually available abou t a client's iden tity. The client's lan-guage f luency, national or regional accent, physical appearance, bodyposture, preferred physical distance during social interactions, manner-isms, clothes, grooming, and apparent age all serve as cues for the ther-apist's hypotheses about th e client's possible identities. H ere again, th eusefulness of such information depends on the knowledge base andexperience of the therapist.To illustrate this point, consider a less knowledgeable therapist'sinferences regarding Mrs. Ch eng's report that she was born in Vietnamand came to the United States with her husband and children at the ageof 30 . From the perspective of the second therapist, this piece of infor-ma tion would raise questions about th e client's experiences of immigra-tion and the Vietnam War and adju stm ent to life in a new country, andthese would be reasonable areas of inquiry. However, because the ther-apist is unfam iliar with Asian nam es and people, her observation thatMrs. C heng appears to be of Asian heritage, combined with M rs. C heng'sstatement that she was born in Vietnam, might lead th e therapist toassume that th e client is ethnically Vietnamese, when in fact she is not.In this situation, the therapist's lack of knowledge of the existence of aChinese minority culture within Vietnam (a s well as any informationabout this culture) could lead to questions, hypotheses, or interventionsthat are irrelevant or inappropriate (e.g., consultation w ith a Vietnameseindividual w ho holds negative att itudes toward people of C hinese her-itage). (See Rum baut, 1985, for information on Chinese Vietnameserefugees.)

There is no substitute for culture-specific knowledge and experi-ence in providing culturally responsive services. Moreover, what oneneeds to lea rn is therapist specific and dependent on the therapist 's owncultural identifications, experiences, and contexts. For example, to w orkeffectively with a gay African Am erican c lient , a the rapis t who is gayand European Amer ican would need to expand h is knowledge and


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experience in ways that are different f r om the ways in which a hetero-sexual African Am erican therapis t would need to expand hers .

H O W T H E A D D R E S S IN G F R AM E W O R KC AN H E L PFor therapists engaged in the cross-cultural learning process, the mostbasic level of atten tion in an initial assessm ent involves considering whatidentities may be relevant for a given client. The ADDRES S ING f rame-work can be helpful with this process, because it provides an easy-to-remember list of minori ty and m ajority identities that correspond to eachof th e ADDRESSING in f luences . T he following example describes th esystematic consideration of the ADDRE SSIN G in f luences and relatedidentities with one client.Jean (pronounced Zhahn) , a 35-year-old Haitian man, imm igratedto Q uebec at the age of 13 with his unc le and the uncle's wife, who hadno children of their own. Jean com pleted unive rsity in Mon treal but haddifficulty finding employment with his degree in political science. Afterm any m onths , he "sett led" on a position as assistant m anage r of a large,nationally franchised hotel. H e subsequently married a French C anadianwom an who also work ed in the hotel . They had a son, but after 2 yearsthey divorced becaus e, as Jean put it , "she looked down on my family."

Jean was referred to a counselor by his physician, who could findno medical reason for Jean 's recurr ing migraines . Six mo nths before th ereferral , Jean had ta ke n a new posit ion as m anag er of a midsized hotel ,a significant move up. The posi tion was so dem anding tha t he had nothad a weekend free in 3 mon ths , and m any t imes he s tayed overnightat the hotel . His form er wife was pressing to change th eir joint custod yarrangement , because she knew that Jean w as f requent ly leaving their8-year-old son with his a un t and uncle. Jean described his headachesas extremely painful and said that he had missed several days of workand was feeling anxiety and even som e panic that he might lose the job .

In the initial assessm ent, the therapist , Marie, a 40-year-old FrenchCanadian woman, spent the first few m inu tes talking socially with Jean.S he told him that she had vis i ted one of the F ren ch-s pea kin g is lands(St. M a r t i n ) , w h i ch p r o m p t ed J ea n to ta lk about the s imilar i t ies anddif ferences between i t and Haiti . Marie was aware o f the p re jud icetoward Hai t ians in Q uebec ( se e Menos , 2 0 0 5 ) and the need fo r her ,as a Q ueb eco i s e , to demons t ra te her respect for Jean fairly quick ly .Because she knew he had a univ ers i ty degree, she asked him w h a t hehad s tudied, thus ackn owledging his edu cat iona l s ta tus . His responseal lowed her to d r a w a connect ion be tween the i r exper iences , as herpartner also had a degree in political science with a focus on immigra-t ion issues. In sharing this info rm ation , she com m unicated her view ofJean as a peer .


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Understanding Clients' Identities and Contexts 75

Once a beginning rapport had been established, Marie explainedthe purpo se of the assessm ent and asked Jean if he agreed to procee d.He did, so she went on to ask if he would describe himself to her, includ -ing "any information that you think I might need to know in order tounderstand you and you r si tuation bet ter ." H e replied,

My father is a successful businessman in Port au Prince, and mymother was a teacher before she retired. I have one sister, who isalso a teacher, and two brothers, who work w ith my father in hisbusiness. M y brothers also attended u niversi ty in Montrea l , butthey re turn ed to live near our family. W e have a large family,and I have many aunts, uncles, and cousins, and my grandparentsare still living, too. I stayed here because my son is here .Reviewing the ADDRESSING influences in her head, Marie noted

those areas in which Jean provided inform ation regarding his identity.The most consistent aspect of his summ ary w as his emphasis on family.In addition, he provided information about his generational and socio-economic status throug h the details abou t his paren ts ' occupations, hissister being a teacher, and his brothers' university educations. From thisbrief description, as well as other o bserved cues (e.g., his physical app ear-ance, dress, language abilities, and social skills), th e therapist hypothe-sized that Jean's identity w as closely tied to his family relationships, thathe co nsidered himself middle class, and that his national origin was a cen-tral part of his identity. These hypotheses were accurate primarily becausethey reflected th e inform ation Jean provided (see Table 4.1).

T A B L E 4.1AD D R E S S IN G Clients' Cultural Influencesand Identities: The Case of JeanCultural influences Jean's influences, asnoted by MarieAge and gene rat ional inf luence sDevelopmental disabil ityDisabil ity acquired later in lifeReligion and spiritual

orientationEthnic and racia l identitySocioeconomic status

Sexual orientationIndigenous heritageNational originGender

35 years old;born in 1972 and grew up under theoppressive Duval ier governmen t (1957-1986) .None reported or appare ntNone reported or apparentSelf-identifies asCatholic; I did not askabout, and he did

not mention, any voodoo bel iefs orpractices.Haitian; reports he "does not feel Canadian," although hehas landed immigrant status (i.e., permanent residency) .Middle-class parents, has a university education, under-employed probably as a result of discrimination; speaksFrench fluently (a class-related ability).Probably heterosexualNoneHaitian; speaks Haitian Creole and French fluently;immigrated to Quebec, Montreal, Canada in1985.Male, sin gle (divorced), fathe r of one son; also a brotherand uncle.


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Marie also noticed that Jean did not m ention a religious or spiritualidentity, his sexual orientation, his gender, or the presence of any dis-ability. She hypothesized that he had not m entioned gender, sexual ori-entation, or disability becau se he assum ed that these were obvious. Shealso recognized that he might not conceptualize sexual orientation inth e same way as the dom inant cul ture (i.e., research suggests that forHaitians, sexual behavior between people of the same gender "i s oftennot correlated with a self-definition as gay or bisexual"; Bibb & Casimir,1996, p. 103). She asked if he ha d ha d a "partner" since his divorce, andhe said that he had gone out with a few women but that he had notdeveloped a serious relationship with anyone. M arie refra ined from fur-ther questions in this initial assessmen t but still cons idered th e possibil-ity that Jean could be gay or bisexual. Later, as she learned more abouthis life and relationships, she ru led out this hypothesis.Marie still needed to find out about religious influences in Jean'slife, becau se this could be a source of support and positive coping behav -iors. She asked, "What was y our religious upbringing?" Jean said thathe was Catholic but attended mass only when he was home (in Haiti),although he prayed "during hard times, like now." Marie was awarethat m any Haitians integrate voodoo ri tuals into C hristianity and thatsuch rituals might be helpful to him, providing some relief from th e bur-den he was feeling. However, she also kne w th at some people associatevoodoo w ith lower social class, and Jea n m ight interpret such q uestion sas stereotyping or as an indirect way of checking his class status (Bibb& Casimir, 1996) . So instead, she asked wha t he thought was contribut-in g to his migraines and what he had tried in order to change these con-tributing factors or to decrease th e pain. He did not mention any voodoobeliefs or practices, so she re f ra ined from asking specifics about this.(See N icolas, DeS ilva, G rey, & G onzales-Eastep, 2006, regarding expla-nations of illness and symptom presentations among Haitian people.)

U N D E R S T A N D I N G T H E M E A N I N G SO F IDENTITIESEven when a therapist has a clear description of a client's self-identification,this inform ation will not necessarily lead to a deeper understanding of theclient. What is important is knowledge of the meaning of these identities(L. S. Brown, 1990 ). Depending on one's reference point, there may bemore than one meaning for the same identity. That is, a particular iden-tity may have one meaning in the dominant c ulture, another in a minor-ity culture, and still another person-specific meaning for the individual.

Informat ion about th e person-specific meanings of identity usuallycomes from th e client, either ind irectly (throug h descriptive infor ma -tion and views shared by the client) or in response to direct questions(e.g., regarding Jean, "What does your identity as a Haitian man mean


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Und erstandin g C lients' Identities and Contexts 77

to you, in your present situation?"). However, to understand theseperson-specific meanings, it is imp ortant that therapists also understan dtheir culture-specific mean ings.

To understand the meaning of Jean's identity as a Haitian man livingin Canada , it is necessary to have at least a general knowledge of Haitianculture and history. Haiti became th e world's first independent Blackrepublic when slaves overthrew French colonizers in 1804. From 1915 to1934, Haiti was occupied by the U nited States, and the first group ofHaitians imm igrated to the U nited States. M any of them settled in Harlemand integrated into the African American comm unity (Menos, 2005 ).From 1957 to 1986, H aitians endured the oppressive regimes of Papa DocDuvalier and his son Baby Doc. The Tonton Macoutes, a secret militarypolice, routinely torture d and persecuted dissenting professionals, politi-cians, and students. The second wave of imm igration to the U nited Statesbegan during this period and consisted primarily of the well-educatedupper and upp er-m iddle classes, resulting in the loss of many profession-al s from Haiti. Later groups, from th e mid-1960s to 1971 and during th e1980s, consisted mainly of middle-class and poorer people. In the early1990s, anoth er 6 5,000 risked their lives to escape political persecutionand economic d evastation bu t w ere intercepted according to a U.S . pol-icy that ordered the Coast Guard to tur n aw ay all Haitian boats withoutscreening passengers (i.e., for refugee status; Menos, 2005). Between1980 and 2001, thousan ds of Haitians immigrated to Canada . As of 2001,approximately 82,000 Canadians identified as Haitian, the vast majorityresiding in Mo ntreal, Toronto, and Van couver (Internationa l Policy Coor-dination, Citizenship and Immigration, 2004).

More recently, Haiti has continued to experience armed uprisings(e.g., th e ousting of the democratically elected Jean-B ertrand Aristide in2004), foreign intervention (e.g., a U.S.-backed governm ent unt il 2006) ,natural disasters (e.g., Hu rrican e G eorge in 1998 killed 140 people anddisplaced 160,000; in 2004 flooding killed 1,000 people, with another2,400 missing or dead); and disease (approximately 4% of the popula-tion has AIDS; World Alm anac Education G roup, 200 7) . Today, Haitiremains th e poorest nation in the W estern Hem isphere. Class divisionsam ong H aitians both inside and o utside the coun try are strong. Fluenc yin French and lighter skin color (re lated to family histories of intermar-riage with th e French and thus a lignment with French colonial values)are associated with higher social status. In Quebec, Haitians who aref luent in French have the advantage of language (i.e., in contrast toHaitians in Vancouver, Toronto, or the United States, who must learnEnglish) . However, they are not accepted in the same way as Frenchspeakers of European or ig in ; co lor -based jo b discriminat ion is notuncommon (Bibb & C asimir, 1996; Glasgow & Adaskin, 1990).Jean was a l ighter-skinned Haitian man who was f luent in French,held a universi ty degree, and came f rom a middle -c lass family. In his


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culture of origin, he held privilege and status. In contrast, in a Canadiancontext, the same c ultura l identities held a different me aning. Being Hait-ian (or, from the dom inant c ultur al perspective, Black) meant that he wasseen primarily as an imm igrant and a foreign er. The most salient aspectsof his identity in Hait i gender an d social class were eclipsed by his eth-nic identity, which visibly set him apart from th e majority of Canadians.

Altho ugh it might at some point be app ropriate for the the rapist toask Jean about his personal experience as a Hait ian man l iving inQuebec , i t wo uld no t be appropriate fo r the thera pist to expect Jean toeduc ate her abo ut the ge neral cultur al mea nings of his identity (i .e. , thein format ion provided in the preceding pa ragra phs ) . N or would i t bewise, because in fo rmat ion about a whole cul ture from th e client's soleperspective is often quite l imited. Obtaining this kind of in fo rmat ion ispart of a therapist 's ow n personal learning, most of which should occuroutside the therapy sett ing.

As an analogy, consider a therapis t who has no direct experiencewith people who hav e dissociative disorder; she would not expect thefirst client she sees with this disorder to educate her a b o u t its commoncharacteristics. Rather, she would obtain this information herself out-side the therapeut ic rela tionship and then use the assessment t ime toexplore the cl ient 's personal experience of the disorder.

I f , with regard to Jean, th e therapist is unfam iliar with th e general his-tory and culture of Haiti, th e impact of political events on Jean's genera-tion, and the position of French -speaking "visible minority cultures" inCanada , she would be more likely to maintain her credibility by admittingthese gaps, at the least to herself, and, depending on the circumstances,possibly to Jean as well. She could then commit herself to expanding herknowledge for the benefit of her client. This commitment would lead herto seek information and experiences outside the therap y sett ing and toeducate herself abou t these general meanings. As her knowledge andexperience increase, her unders tanding of Jean's identity would still bef r a m e d as hypotheses , but these hypotheses and the ques t ions tha temanate from them would be much closer to the realities of his life.

Client-TherapistInteractions: BeyondTraditional TransferenceEarly psychoanalyt ic approaches emphasized the therapist 's role as ablank slate or m irror onto which the client's feelings about parental fig-ures could be projected. The client 's emotional reactions to the thera-


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Understanding Clients' Identities and Contexts 79

pist, known as transference, were seen as "projections by a client of expec-tations and distortions based on past experience" (C hin , 1994, p. 20 7) .However, when one introduces the concept of culture into an analysisof therapist-client interactions, it is clear that the emotional reactions ofclients to therapists, and vice versa, often reflect differences and powerimbalances in the real world.

As Perez Foster (1996) noted, "the fact is that analysts are neitherneutral screens nor simple clay for t ransferent ial t ransform ation. Theyare , in fact, formidable charac ters w ho often have robus t prejudices "(p . 15). Aclient's reaction to a therapist ofanother cultural identity maybe less related to the client's feelings about her parents than to the client'sdaily experiences with people of the therapist 's culture. Recognizingthis real i ty, psychodynamic theorists have broadened def ini t ions oft ransference and countert ransference in way s that open up a consider-ation of cultural influences (Chin, 1994; Muran, 2007) . For example,from th e perspective of self psychology, Hertzberg (1990) noted that th einternal representations people of mino rity identities hold include "boththe experience of self within a particular subculture, as well as the expe-rience of the self as an outsider of a larger, dominant culture" (p . 2 76) .

Co nsider the si tuat ion of a 60-year -o ld marr ied woman of G u a -temalan heritage who is referred to a much younger, Eu ropea n Am eri-can female therapist. Because the client's most intimate and long -lastingrelationships have been with her husband and children, and becauseshe is older than th e therapist , she may be more likely to see the thera-pist as a daughte r than as a pa re n t a l f igure . Similar ly, th e therapist ' sexperie nce of the client may invo lve feelings associated with her ownmother or grandm other . (S ee N ewton & Jacobowitz, 1999, for more ontransferential and countertransferential processes with older clients.)But the rea ctions of this client and therapist to one ano ther may be m orecomplex than those related solely to age. For example, w hat if the thera-pist is from a well-educated, upper-m iddle-class family and the client isfrom a poor, rural, Ma yan (Indig enou s) back grou nd? In this case, theclient may remind the therapis t more of the maid th at she has hired tohelp w ith househ old responsibilities and child care, and the thera pist mayremind th e client of the powerfu l Spanish-speaking landlords in G u a -temala or of a demanding emp loyer in her new coun try. C onceptualiz-ing the client's distrust as solely a projection of her feelings overlooksthe client 's history and da y-to -da y experiences of oppression by mem -bers of the therapist ' s cul ture (see G leave, C ham bers, & Manes, 2005,regarding the sociopolitical history of and U.S . role in suppressing democ-racy in G u a t e mal a ) .

Despite the negative emotions often associated with the topic, it isimportant that therapists be comfortable bringing up the topic of cul-ture (including race and other differences) if it appears to be re levant to


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the therapeut ic rela t ionship . For example, a European American ther-apist 's stra ightfor wa rd question to a Black family (e.g., "How do you feelabout working with a W hite therapis t?") makes avai lable for discussionwhat is probably a l ready on everyone's mind (Boyd -Frankl in , 1989). O fcourse, if the therapist does raise th e topic, it is essential that she has"seriously thou ght thro ug h its relevance" (p. 25 ); otherwise, the qu es-t ion may be perceived as patronizing (Greene, 1994). In addit ion,

White therapists need to be prepared for the possibility that thisquestion may elicit feelings of anger, an d some family membersm ay even verbalize their reluctance to work with a Whitetherapist . The m ore able a therapis t is to remain nondefens iveand nonapo loget ic while discussing this issue with th e family,the greater the likelihood of a therapeutic connection.(Boyd-Franklin, 1989, p. 102)Before raising these q uestions w ith cl ients, consu ltat ion an d super-

vision with people of diverse identit ies can be helpful . As C . B. Williams(1999) noted with regard to race,

th e task in t raining W hite counselors is to desensit ize them totalking about their feelings about race. For counselors and traineeso f color, on the other hand , this usually is not the problem. M uchof their exper ience . . . has been m arked by f requent , livelydiscussions abou t racial issues with other peop le of color. How ever,White people have typically been m issing from these discussions.The counse lor education classroom or professional workshop,thus, becomes a forum for an unfamil iar enterprise that is richwith oppor tun i ty fo r growth fo r everyone: discussing race acrossracial groups , (pp . 34-35)

At the same time, with some clients, it may not be appropriate to bringup the topic before a feeling of trust has been established. Many olderpeople, of both d om inant and m inority cultures, grew up in a time whenone was expected to hide or minimize differences related to race, socialclass, sexua l orientation, and disabilities (Sang, 1992). In addition, ma nyindividuals are uncomfortable with direct discussion abou t another per-son's abilities or limitations, fearing that such discussion might suggestthat the therap ist is not com petent. Finally, as m ention ed earlier in thecase of M rs. Sok, som e clients simply do not see the relevance of the ther-apist's identity or their own, and m aking it an issue before a relationshipis established may feel forced.

Jus t as clients' feelings abou t therapists may o riginate in their expe-r iences with members of the therapist 's culture, so too are therapistsinfluenced by their experiences w ith cl ients ' cultures. C hin (1 994) dis-cussed common mani fes ta tions of counter t ransference in therapists ofminority and dom inant ethnic identities. W hen the therapist is a personof color, countertransference may involve overidentifying with clients'experiences and thus underdiagnosing or minimizing psychopathology


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Und erstan ding C lients' Identities and Contexts 81

when it is present. A similar phenomenon can occur for any therapistwho shares a minority identity with her client (e.g., a lesbian therapistm ay assum e similarities betw een herself and her lesbian client that areunw arranted; M orrow, 200 0). C hin advised therapists of color to bewareof "interventions that promote an agenda for personal change regardingcultural and gender roles that is not the client's" (p. 212 ). However, thestrong identification of therapists of color with their clients frequentlyfacilitates the therapeutic relationship.

In contrast, countertransference in European American therapistsoften involves issues related to power and difference (Chin, 1994). O utof a desire to form an alliance with clients of color, European Americantherapists m ay minimize cultural differences (Quinones, 2007). A ndout of a lack of knowledge, they may assum e sim ilarit ies that do notexist. As a result, clients may feel misunderstood or alienated. How ever,countertransference m ay facilitate th e therapeutic relationship if thetherapist acknowledges the differences and her lack of knowledge regard-ing the client's cu lture but also holds a strong willingness to be helpfuland to learn (Chin, 1994, pp. 212-2 13).

Returning to the case of Jean, th e therapist 's assessment could befacilitated by an understanding of the interaction between her ownidentity and that ofJean. She could first use the ADDRESSING acronymto identify those aspects of her identity that are different from Jean'sand t hu s most salient in this particula r setting; these w ould include reli-gion, ethnicity, n ationa l origin, and gender. Recog nizing her o w n iden-tity as a Canadian-born feminist Q uebecoise, this therapist would w antto think critically about how her inexperience with Haitian peopleincreases her susceptibility to dom inant cultu ral assum ptions ab outHaitian men. She would want to consider th e possibility tha t her ownEuropean American feminist philosophy, which she considers relativelyunbiased, might contribute to any prejudice she holds (see Exhibit 4.2) .

Although the therapist might identify with Jean's experience as ame mbe r of a minority group because she holds minority status as awom an and as a French C anadian, she would w ant to be cautious aboutassuming similarities in this regard. When considered from a nationalperspective, her French C anadian ethnicity certainly constitutes a minor-it y status. French C anadians make up approximately 23% of the totalCanadian population of 33 million, and as a group they have tradition-ally been in a subordinate position relative to the Anglophone majority(World Almanac Education Group, 2007). However, within Quebec,French is the official language, and French C anadians constitute a power-ful ma jority. Thus, relative to Jean, and in the context of Quebec, th etherapist is a member of the dominant culture.Since the revision of discriminatory imm igration laws in 1962, th eproportion of European immigrants to Canada has decreased (Elliott &


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8 2 C O N N E C T I N G WITH Y O U R C L I E N T

Fleras, 1992). Between 1991 an d 2001, 3% of C anadian immigrants camefrom th e United States, 58% from Asia and the Middle East, 20% fromcentral and ea stern Europe, 11 % from Latin America and the C aribbean,and 8% from Africa (International Policy C oordination, C itizenship andImmigration, 2004 ). Mem bers of the non-U .S. and non -Eu ropea n groups,referred to as "visible mino rities" in C anada, commonly experience prob-lems related to language, employment, f inances, and the bureaucraciesof the social services, health care, and imm igration sy stems (W axie r-Morrison & Anderson, 20 05 ). Although U .S. and European immigrantsexperience these problems, too, th e barriers are often less formidable fortheir children, who physically resemble Anglo and French Canadians.

Along with this background information, Marie 's awareness of herperceived visible identity w ould help her understand Jean's behavior inth e therapeutic setting. If Jean initially appears defensive, Marie couldconsider the p ossibility that his self-protective behaviors m ay be in reac-tion to her visible identity as a Q uebecoise. Given the prejudice and dis-crimination he has experienced from mem bers of her culture, it wou ldnot be surprising that he feels defensive with her. How ever, Jean's reac-tion m ay have more to do with th e therapist 's identity as a woman .W hat ap pears to be defensiveness may be discomfort about sharing hisparticular problems with a woman or with a woman w ho belongs to thedominant cul ture . Whatever the case, th e more knowledgeable thetherapist is regarding her own and Jean's identities, th e more able shewill be to understand his reactions and then behave in ways that facili-tate their interactions. Facilitative behav iors a re discussed in mo re detailin chapter 5.

ConclusionIdentity is a complex phenomenon that includes both group-specif icand person-specific meanings. Although the concept of identity is notalways of interest to clients, it can be helpful to therapists who want adeeper understanding of their clients. Know ledge of a client's identityallows the therapist to more accurately infer what cul tural inf luenceshave been important in that person's life. In turn, such informationhelps the therapist to form hypotheses and a sk ques tions that are closerto the client's reality .Although information about a client's personal experience of cul-ture usua lly comes from th e client, it is generally not fair to expect clientsto educate the therapist about the broader cu l tu ra l meanings of theirident i ty. O btaining the lat ter inform ation is pr im ari ly the therapist ' sresponsibility and often involves work outside the therapeutic setting.


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Understanding Clients' Identitiesand Contexts

The more committed therapists are to this outside work, th e more ablethey will be to use this background information to unders tand theclient's personal experience and respond in ways that facilitate assess-m ent and the therapeutic process.

8 3

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Understanding Clients' Identities and ContextsIdentity is a multidimensionacultures, contexts, and time,

1. Identity is a multidimensional phenomenon that varies across2, Knowledge ofclients' salient identities gives the therapist clues

about how clients see the world, what they value, how theymay behave in certain situations, and how others treat them.

3 . In an initial assessment, the ADDRESSING framework can behelpful because itprovidesan easy-to-remernber list ofminor-ity and majority identities that may be salient in a client's life.

4. Even if a client does not wish to explore the relationship ofpersonal aad cultural identities to his or her current situation,it is important that the therapist considers identity issues,including the interaction between the therapist's own identi-ties and those of the client,5. Aparticular identity may have one meaning in the dominantculture, another in a minority culture, and still another per-son-specific meaning for the individual.

6. Information about the person-specific meanings of identityusually come from the client; however, obtaining knowledgeof culture-specific meanings of identity is a part of the thera-pist's own personal learning and ought to occur primarily out-side the therapeutic relationship.7. The reactionsof clientsand therapists to one another (transfer-ence and countertransference) often reflect cross-cultural rela-tionships, conflicts, and power imbalances in the real world,

8. Awareness regarding one's own cultural identity is essentialfor understanding cross-cultural transference and counter-transference in therapy.

9. The therapeutic relationship may be facilitated by an honestdiscussion of cultural differences between the therapist andclient, if the client is open to such a discussion.

10. Consultation, supervision, and ongoing self-assessment areimportant steps in building one's confidence and experiencein addressing cross-cultural differences with clients.

entering another's world--understanding client's cultures and contexts

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