Ethics in Psychotherapy and Counseling. Kenneth S. Pope
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worldviews. Pope, Chavez-Dueñas, and Adames (in press) report that:
members representing the four Ethnic Minority Psychological Associations (EMPAs) in the United States including the Asian American Psychological Association (AAPA), Association of Black Psychologists (ABPsi), the National Latinx Psychological Association (NLPA), and the Society of Indian Psychologists (SIP) met with the APA Ethics Committee at the 2011 annual APA convention. During this meeting the EMPAs and APA agreed to review whether the ethics code addresses issues of culture adequately, appropriately, and knowledgeably. Specifically, the EMPAs shared their thoughts on how the ethical code both “assists or hinders their work as Psychologists of Color” with the goal of broadening knowledge on “how culture intersects with ethical dilemmas” (APA, 2012a, para. 15). Several EMPAs have developed and published their own set of ethical commentaries. (see SIP, 2014), guidelines (see NLPA, 2018), or standards (see ABPsi, n.d.).
CULTURAL COMPETENCE AND PROFESSIONAL GUIDELINES
A focus on the role of culture in psychotherapy as practiced and regulated by state or provincial licensing laws is a relatively recent phenomenon. Historically, the field of mental health has been slow at recognizing the significance of culture in psychological science, practice, and ethics (see Hall, 1997; Guthrie, 2004; Pickren & Burchett, 2014; Sue et al., 2019; Vasquez, 2007, 2012). The first mention of culture as a factor in therapy took place at the Vail Conference of 1973 (Korman, 1974). Sixteen years later, in 1990, the APA published its first guidelines that addressed culture titled, The Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations (APA, 1990). That same decade, the CPA approved and published their Guidelines for Non-Discriminatory Practice. Since then, both APA and CPA guidelines have been revised. In 2003, the new APA guidelines were published with a new title, The Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change (see APA, 2003) and in 2017 they were revised once again (see APA, 2017b). The CPA guidelines were updated in 2001 and in 2017.
The 2017b version of the APA Multicultural Guidelines more broadly addresses the importance of attending to various identities and
encourage psychologists to consider how knowledge and understanding of identity develops from and is disseminated within professional psychological practice. Endemic to this understanding is an approach that incorporates developmental and contextual antecedents of identity and how they can be acknowledged, addressed and embraced to engender more effective models of professional engagement (APA, 2017b, p. 6).
Similarly, the 2017 CPA Guidelines for Non-Discriminatory Practice
promote non-discriminatory care in therapeutic work with clients, as well as to provide guidelines for evaluating the extent to which one’s work falls within the parameters of non-discriminatory practice. As our society and culture become more diverse, and as we become more aware of specific diversities, it is important that psychologists gain an awareness of the need for non-discriminatory practice. As the need arises, guidelines can be developed for use of specific diversities (CPA, 2017b, p. 1).
The APA Guidelines on Race and Ethnicity in Psychology (2019c) more specifically focus on race and ethnicity
and describe how clinicians, educators and researchers can develop racial and ethnocultural responsiveness and discuss the importance of understanding bias and recognizing the influence of race and ethnicity in society (APA, 2019c).
These guidelines encourage psychologists to understand and consider the role of culture in practice, research, consultation, and education. Unfortunately, we have a long way to go in the field of mental health to move beyond just highly encouraging people to consider the role of culture in assessment and interventions to requiring the integration of culture as a standard in practice.
BUILDING CULTURAL COMPETENCE
Building cultural competence in clinical practice often begins with effective training. Many programs in psychology and related fields historically have not provided adequate training on how to effectively integrate cultural knowledge into assessment and therapy. Adames et al. (2013) posit that
While psychology as a discipline maintains that diversity and multiculturalism training is important, some departments do not adequately address it as a central topic, emphasize its importance by making it a requisite, or provide a sound framework for effectively addressing diversity and multiculturalism (p. 3).
To what degree is culture and diversity respected, valued, welcomed, and its potential, approached in positive and creative ways? To what extent is it approached in ways that divide, isolate, set people against each other? For instance, several studies support how conversations about culture, ethnicity, and race provoke and exacerbate uncomfortable feelings including defensiveness, anxiety, anger, helplessness, blame, and invalidation (Bell, 2003; Helms & Cook, 1999; Sue et al., 2011; Utsey et al., 2005). Other scholars posit that when culture is addressed it is at the cost of Students of Color. Franklin (2009), for example, wrote:
Ethnic minority students often felt trapped between, if not victimized by, the roles of cultural educator and student. However, students as cultural brokers in class are often educators without a portfolio in the eyes of professors and fellow classmates. Challenging psychological information being presented that did not accurately represent our experiences could bring … a label as an impudent student. Parenthetically, it was not uncommon to have our personal insights as members of the community also challenged or dismissed by professors or researchers who had no experience with our communities other than their readings in psychology. This was infuriating to many colleagues and students, given their lived experiences … These in class and work experiences were frustrating, intimidating, humiliating, and discouraging to students and subsequently early career professionals in particular. This circumstance continues to contribute to the attrition of Students of Color in training programs and later becomes a deterrent to participation in organized psychology (p. 419; see also Kaduvettoor et al., 2009).
When we neglect how our own worldviews and cultural values influence the ways in which we navigate the world and interact with others—or when we fail to understand and appreciate the role of culture in our clients’ lives and in the work that we do as therapists—we end up straying from the appropriate and helpful to the useless or even oppressive. We cannot operate from a one-size-fits-all approach to training and psychotherapy by applying frameworks and interventions grounded solely in the experiences of the dominant group (Burkard & Knox, 2004; Gómez, 2015; Sue, 2015). The road toward cultural competence, or the ability to develop interventions that are culturally responsive begins by looking inward toward the self and outward toward others.
Looking Inward
We encounter people who practice different cultures and who differ from us in many ways as we go about our lives. We learn about cultural diversity in our studies, we work on developing ethical awareness in approaching it in our clinical work, but often we forget that we also carry our own private—and sometimes not so private—views and feelings about specific cultures, races, religions, and so on. Most readers would have no trouble naming areas in the world in which people are fighting each other in part because of religion, culture, ethnicity, and similar factors. Most could name groups in their own countries that view members of another group with suspicion, unease, resentment, disdain, or hate.
It is impossible for us as therapists to be completely free of the prejudices that afflict the rest of humanity; after all, we are socialized in societies that have long histories of racism, colorism, nativism, ethnocentrism, and many other forms of othering (Chavez-Dueñas et al., 2019). Life is remarkable in so many ways, but not that one. For any of us, various cultural, racial, ethnic, political, religious, and other groups—or topics related to these groups—may evoke an intense emotional response. The response may be subtle or powerful. We may be ashamed of it or embrace it as important. We may be reluctant to mention it to certain people. We may view it as not politically correct or—a more forbidding barrier for many of us—as not emotionally correct (Pope, Sonne et al.,