B Race and culture in mental health practices


This chapter considers the recognition of culture as an important variable in counselling psychology from an historical perspective. The earliest attention was focused on race and it’s positive and negative effects on the counselling process. Slowly, several other dimensions of diversity were included, to ultimately result in a focus on intersectionality, power, and privilege; a much more complex picture emerged that researchers and practitioners are still working on addressing in the counselling process.

Given the brief history of psychology', it is surprising that cultural issues were not incorporated from the beginning of the process, it was assumed that counselling was generic and it should work with everyone (Holliday and Holmes 2003; Sumari and Hanim 2008). People have always had biases, stereotypes, and assumptions about every culture in the world, probably based on the basic need for survival; however, these were based on speculation. Psychology set out to apply scientific methods to the study of human behavior, thoughts, and emotions. However, the pioneers were quite sure that they were the most advanced of the human species, therefore, they become the template for normal behavior, thoughts, and emotions (Holliday and Holmes 2003). Any variation indicated less evolved members of human species! Even writing this seems laughable, and impossible!

Research on cultural factors and their relationship to mental health, illness, and cure began in earnest after World War II. It has gained significant momentum due to globalization, advances in technology, especially communication and the media, and global migrations (American Psychiatric Association 2013).The relationship between mental health and cultural context was recognized by mental health professionals who worked in cultural contexts that were dissimilar from their own (Marsella 1978). They noticed that the presentation, and cure of psychological problems varied by context; this was not what they had learned or were exposed to in their training and education (Prince and Acosta 2006).This led to the development of transcultural psychiatry as an area of study spearheaded by Eric Wittkower and the creation of Montreal’s Transcultural Psychiatry Research Unit after World War II (Delille 2018). The Civil Rights Act (1964) in the United States prohibited discrimination on the basis of race, and gender in hiring, promotion, and firing, it helped in augmenting the age of ethnicity, race, and gender, in Psychology, and fueled the work of non-dominant cultural group psychologists, mostly African Americans initially, with help from several White psychologists committed to social justice and ethics (Holliday and Holmes 2003). Psychology in general was confronted with the missing piece of the puzzle, i.e., culture, which served as a wake-up call for American Psychology in 1976, with the publication of “Even the rat was White,” by Robert V. Guthrie (1976; 1998). Transcultural psychiatry had a nearly 35-year head start on studying how culture informed mental illness and mental health among the cultures of the world. Somehow, this research was not incorporated in mainstream psychology' and it remained blissfully ignorant of the emerging research in transcultural psychiatry (Holliday and Holmes 2003).

Today, there are many claimants to the title of “father” or “mother” of cross-cultural/multicultural counselling movement in counselling and clinical psychology, one scholar stands out as the parent of this movement in counselling psychology', namely Clemmont Vontress (Walcott 2010). He initiated the dialogue on the implication of White therapists working with African American clients (Vontress 1967). Vontress pioneered multicultural psychology' when he published “Counseling Negro Adolescents” in 1967, which brought attention to the White counsellor/Black client counselling relationship. His work has significantly influenced counselling and psychotherapy and has shaped and guided the application of Existential counselling and psychotherapy to cross-cultural encounters. Vontress focuses on the humanity of a client before race, nationality, etc. He emphasizes understanding client-specific variables, along with culture-specific, and culturally universal variables. This complex schema was also operationalized in the theory of cultural identity and worldview to understand the complexities of an individual’s world (Ibrahim 1991; 2010). In counselling psychology, research by Clemmont Vontress (1967; 1968; 1971) on counselling African Americans was the first instance of attention to non-dominant populations of the United States. His pioneering work brought the issue of counselling individuals with different cultural and sociopolitical contexts within the larger dominant cultural context, prior to his work, African philosophers and thinkers such as Frantz Fanón, W. E. B. DuBois, Angela Davis, and others, influenced thinking on the oppression and exclusion of Africans in the Caribbean and other colonized nations, including the United States.

Interest in understanding the influence of culture on the symptoms, and cure of mental illness was evident among scholars, however, even when culture was attended to, there were problems with methodology and interpretation. Anthony Marsella (1978) a prominent clinical psychologist who engaged in several epidemiological studies conducted in various countries on mental illness, studied how the symptoms, and the treatments varied by' cultural contexts. He noted that the research methods used to study' mental illness in various cultures were not providing adequate information from a research perspective, and were not rigorous.

Clinical and counselling psychology was forced to confront their training models and questioned what they had overlooked. It was determined that the goal of a psychology' training model was to educate applied psychology' students to be scientist-practitioners. Culture was not the focus and was not brought into the picture until much later due to the efforts of nondominant cultural group psychologists who kept agitating for change and asking for relevance of therapeutic interventions for the culturally different.This movement led to the emergence of multicultural psychology', which also relied on cross-cultural studies on culture, mental health, and cure in different geographical settings as evidence (Holiday' and Holmes 2003).Two major criticism of psychology and its lack of understanding and acceptance of cultural variables as critically' important in studying human behavior were that scientific racism (using science to discriminate against humans who were seen as less evolved based on Darwinian thinking); and the lack of attention to social justice issues, focusing on the psyche, without acknowledging the role of society, environmental variables, poverty', racism, and exclusion and so on (Holiday' and Holmes 2003; Ibrahim and Heuer 2016;Weikart 2004).

Holliday and Holmes (2003) note that evolutionary thinking gained momentum during the 20th century as colonialization of most non-European countries was the goal of Western Europe and contact with colonized nations increased. Further, they state that given that normal was the White European yardstick, cultures, values, beliefs and assumptions that were not similar to Western European assumptions were considered inferior. Similarly, ethnic and racial nondominant cultural groups in the United States when judged by European assumptions were found lacking. This thinking supported by “science” was used to enslave, exclude, oppress, conduct genocides, and other atrocities on people of color in the United States. Psychology maintained and continued with scientific racism into the 1940 and kept “inferior” humans out of positions of power in psychology, and from institutions of higher learning (Guthrie 1976, 1998; Holliday and Holmes 2003).

The latter part of the 20th century in the United States saw a resurgence in confronting issues of culture, a movement led primarily by non-dominant cultural group psychologists, with White allies who started to publish articles focusing on ethnic non-dominant cultural groups and their mental health needs. Professional organizations established task forces, and divisions to address the needs of ethnic non-dominant cultural groups. Ethnic non-dominant psychologists (from both clinical and counselling psychology) organized professional organizations to address the mental health needs of non-dominant cultural groups. Multicultural training during the civil rights movement was nonexistent when Black psychologists began to discuss the paucity of Black psychologists, lack of diversity of students in graduate programs, lack of publications on racism and its impact on people subjected to it, and diversity in the APA governing body. The following case example highlights the concerns regarding lack of understanding of culture, power, privilege, and social marginalization.

Elsa, a psychologist, has been practicing in her own private practice for 40 years in Hialeah, FL. She has upheld a great reputation in her community and has had a successful business. Elsa’s spouse recently acquired a new job in Oakland, CA. Consequently, Elsa relocated with her spouse and opened her private practice in Oakland, CA. Her client population had changed drastically in terms of diversity, but Elsa continues practicing as usual. She has recently been seeing a new client, Daniel who is a Black male in his early 40s. Daniel presented with symptoms of depression. Elsa has been treating clients with depression throughout her career and treats Daniel as she would most of her other clients. She utilizes a behavioral approach, as she has seen progress among her clients when they change their behavior related to their depression. After several sessions, it was evident that Daniel is not making any progress with his depressive symptoms. Elsa thinks she has tried everything she can to help Daniel and decides that he is too resistant to make a change in therapy.

What has Elsa overlooked in this case? Is her educational training (from the 1970s) and experience relevant to treat Daniel? What does Elsa need to know to work effectively with Daniel? Education and training in the 1970 s did not consider cultural or contextual factors, nor the effect of the sociopolitical history of African Americans in the United States, or the ongoing racism, the micro and macro aggressions that African Americans face on a daily basis. Neither was the status of African American males in US society, and the degree of hate and prejudice directed at them considered.

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