Appropriate Counseling Interventions With Diverse Clients
Providing socially and culturally appropriate interventions is the end result of counselor awareness and knowledge of self and diverse clients. Culturally appropriate interventions are interventions that take into account clients' communication styles, values and beliefs, and life experiences such that functional counseling relationships are formed and appropriate goals are attained. These interventions can range from the skills and strategies of traditional counseling approaches to indigenous or folk healing methods, or a synthesis of both. The form of the intervention may be conventional, delivered one-on-one in mental health setting, or may be delivered within the context of group, family, community, or other systems. Below is a list of recommendations adapted from Sue and Sue (2008) and Arredondo et al. (1996). Counselors who wish to use socially and culturally appropriate interventions skills should adopt the following recommendations:
• Become familiar with a variety of theoretical orientations and approaches, because a flexible counseling approach is necessary to meet the needs of diverse clients.
• Be open to interventions that are outside the scope of traditional counseling, such as systemic interventions and indigenous or folk healing methods.
• Become knowledgeable about the effects of all dimensions of diversity on communication style.
• Become aware of their own communication style. Feedback from varied sources that are knowledgeable about diversity is especially useful.
• Assess all counseling interventions for strengths and weaknesses with respect to clients' social, cultural, spiritual, and political dimensions.
• Focus on actual skill building.
• Be mindful of the goals of interventions. Successful adaptation of skills is more likely if client needs are clear and interventions are designed to meet those needs.
In the following sections we discuss adapting traditional counseling interventions, incorporating indigenous or folk healing methods, communication issues with diverse clients, empowering interventions, and advocacy interventions.
Adapting Traditional Interventions
Adapting traditional skills and interventions for diverse clients can range from using the skills as is, providing context to members about the purpose of the skill or intervention, to incorporating cultural variations. Working with diverse clients does not mean throwing out all traditional counseling skills (Sue & Sue, 2008); however, these skills will be much more useful if counselors orient clients to the counseling process and explain the purpose of specific skills and interventions (Arredondo et al., 1996). Diverse clients may become comfortable with skills and interventions upon understanding the purpose. Providing this type of context may also be helpful if the counselor and client decide to brainstorm alternative interventions and will also assist the counselor in finding appropriate cultural adaptations.
The range of adaptation can be demonstrated using as an example the common counseling skill, reflection of feeling. The counselor may choose to use reflection of feeling with a diverse client without much explanation or adaptation if the client is verbally expressive of feelings, seems comfortable with the counselor commenting on feelings, and responds to the reflection by agreeing, correcting, or expanding.
The counselor may also choose to explain the purpose of feeling reflections. The explanation may take a form similar to this:
I will say what I believe you are feeling because it is important for me to understand what you are feeling and for you to know that I understand. I would like to know if you feel differently or if my words make you uncomfortable.
Because some diverse clients may not be comfortable challenging the counselor, the counselor should monitor client verbal and nonverbal behavior for signs of shutting down or discomfort with feeling reflections. If the client does not respond well to reflection of feeling or if the counselor anticipates a poor response, the counselor may choose to adapt the skill to meet the client's needs. The counselor should consider, and possibly explore with the client, if verbal expression of feeling is discouraged by the client's cultural group or if the client is uncomfortable discussing feelings in an individualistic context versus a family or community context. In the first instance, the counselor and client can collaborate to find a suitable option, perhaps nonverbal techniques for expression (Arredondo et al., 1996). In the second instance, Cheatham et al. (2006) suggested rewording feeling reflections to include relationship and context, for example, "You feel anxious in relationships with your family." If use or adaptation of a customary skill or intervention does not seem to meet the diverse client's needs, then use of indigenous or culturally based interventions is another alternative.
Incorporating Indigenous or Folk Methods Many authors consider the incorporation of indigenous and folk healing into counseling to be a potentially effective treatment option for culturally diverse clients (Koss-Chioino, 2000; Sue & Sue, 2008; Yeh, Hunter, Madan-Bahel, Chiang, & Arora, 2004). Incorporating these methods may be particularly useful if clients are deeply involved in their culture and request or mention these methods (Koss-Chioino, 2000). Additionally, Sue and Sue (2008) contended that becoming familiar with indigenous healing practices may help counselors better understand the worldview of diverse clients and assist counselors in anticipating potential conflicts in belief systems that may affect the therapeutic process.
Every society and culture has its own versions of healing and healers that address physical and psychological disturbances (Sue & Sue, 2008). According to Koss-Chioino (2000), alternative healing methods are not only a part of communities of underrepresented groups but also a part of dominant groups. Examples of indigenous or folk healing include Asian culture practices such as Reiki, qigong, and pranic healing (Yeh et al., 2004); use by some Mexican Americans of a curandero or spiritual advisor; and Native American healing traditions such as those of the Native American church as well as more regional tribal traditions (Koss-Chioino, 2000).
The following is a summary of suggestions by Koss-Chioino (2000), Sue and Sue (2008), and Yeh et al. (2004) for counselors who are considering incorporating indigenous or folk methods or consulting with or referring to indigenous or folk healers:
• Become aware of your attitudes toward indigenous healing practices. Clients may hesitate to disclose interest in these methods if they sense negative attitudes.
• Become familiar with the beliefs and healing practices of different cultures.
• Extend knowledge of these practices by engaging in different communities and personalizing the information.
• Be willing to form respectful relationships with indigenous and folk healers. These relationships may provide useful information, build counselor credibility within the community, and facilitate future referral and consultation.
• Recognize the importance of spirituality in the lives of many diverse clients. Know your clients' views on indigenous healing.
• Be aware of the ethical and practical challenges of consulting with indigenous healers or incorporating their healing methods into treatment.
• Become aware of new practices that synthesize indigenous methods with traditional counseling.
Communication Issues With Diverse Clients
Therapy is a process of interpersonal interaction and social influence that relies on effective communication (Sue & Sue, 2008). Both counselor and client must communicate adequately, in both verbal and nonverbal realms, for effective therapy to take place. In particular, the counselor's communication should be both accurate and appropriate. Sue and Sue (2008) discussed several aspects of communication style that may affect counseling intervention. Differences between counselor and client proxemics, kinesics, and para- language may all contribute to miscommunication during counseling. Proxemics describe individuals' culturally influenced sense of personal space, whereas kinesics describe use of movement such as facial expressions, posture, gestures, and eye contact to communicate. Paralanguage describes use of voice loudness, pauses, silences, speech rate, and inflection to express differences in meaning. Counselors should also consider whether the client's cultural communication style is low context or high context. Low-context communication relies largely on the message relayed by verbal communication, whereas high-context communication relies less on the verbal communication and more on additional shared understanding, nonverbals, and paralanguage to convey the full meaning of the message. Counseling interventions for diverse clients should take into consideration all of these dimensions (Sue & Sue, 2008).
Skills and Interventions for Empowerment
Empowerment is a commonly mentioned goal of counseling, particularly with diverse clients who may have experienced oppression (Lee, 1999; McWhirter, 1991; Slattery, 2004). For empowerment to occur, counselors should use empowering interventions throughout the counseling process. According to McWhirter (1991), empowering interventions start with the attitudes, beliefs, and person of the counselor or therapist. To be empowering, counselors should believe in the client's ability to make positive changes. Thus, empowering interventions should give no more help than is required.
Empowering interventions may be used early in counseling. Slattery (2004) suggested that the counseling process will be most empowering if clients are offered the least restrictive effective treatment possible and are given choices about receiving treatment. Clients should be educated about the rationale for treatment and interventions during informed consent, and they should be aware that counseling is as much about learning to solve problems as it is about solving problems. Additionally, the therapeutic relationship should be egalitarian and collaborative within culturally appropriate boundaries.
Empowerment should also continue through the problem identification phase (McWhirter, 1991; Slattery, 2004). To maximize empowerment during this phase, counselors should listen to and respect clients' views of problems and desired outcomes (Slattery, 2004). Empowering conceptualizations take into account the social, political, and economic context; resist blaming the client for things beyond their control; and clearly differentiate between responsibility for the problem, which may be environmental, and responsibility for coping with the problem, which is the client's (McWhirter, 1991). Ineffective or problem behavior should be viewed as best attempts to cope with the situation (Slattery, 2004).
Helping clients become aware of personal resources is also critical to empowerment. Identification of problem-free times and areas of life is essential to empowerment. Counselors should recognize and validate client strengths, including support networks. Clients' attempts at solutions should be acknowledged and potentially used as building blocks for further problem solving (Slattery, 2004).
Education is one of the most empowering interventions and can be used throughout the counseling process. Educating clients to the power dynamics that surround them empowers them by making overt the external influences that have hindered them, helping clients see themselves as less damaged and encouraging more active and effective problem solving. Within the session, clients should be educated and encouraged to identify their own patterns and environmental barriers rather than relying on the counselor. Helping clients gain necessary skills, such as decision making, assertiveness, and social skills, is also empowering, although it is always important to consider the impact of these skills on other parts of the clients' system (Slattery, 2004).
Advocacy Skills and Interventions
Both the multicultural and social justice counseling literature have called on counselors to include advocacy within the scope of their practice (Sue & Sue, 2008; Vera & Speight, 2003). However, counselor education or training programs have not focused on advocacy as an intervention, which may explain why counselors are hesitant to implement advocacy strategies. In this section we define advocacy and its forms and identify advocacy skills and their use with diverse clients.
Ezell (2001) defined advocacy as "purposive efforts to change specific existing or proposed policies or practices on behalf of or with a specific clients or group of clients" (p. 23). Thus, advocacy is distinct from traditional counseling interventions in that its focus is ultimately the system and not the client. Ezell suggested that advocacy, in some form, is appropriate for clients who have little power and may not be able to advocate for themselves within the necessary systems without assistance.
Increasing acceptance of advocacy as a counseling intervention has increased discussion of its scope and targets. Ezell (2001) noted that advocacy may be undertaken for a specific client (case advocacy) or for a group of clients with similar issues or identity (class advocacy). Targets of advocacy may also vary. The ACA Advocacy Competencies describe advocacy as occurring at the microlevel, mesolevel, and macrolevels, which include the client/student level, school/community level, and the public information/social/political levels (Lewis, Arnold, House, & Toporek, 2002).
• At the client/student level, counselors identify and facilitate client understanding of social, political, economic, and cultural barriers to client well-being and advocate with or on behalf of clients to respond to these barriers.
• At the school/'community level, counselors advocate for clients within the clients' communities and relevant institutions using nontraditional interventions to change attitudes, policies, rules, and structures that are detrimental to client well-being.
• At the public arena level, counselors intervene on a larger scale to raise awareness of broad societal issues, change attitudes and beliefs of the general public, and change public policy and laws that are harmful to groups of clients.
To make the variety of advocacy targets and interventions more concrete, here are several examples adapted from Ezell (2001) that represent different advocacy types and targets:
• Teaching a client advocacy skills so she can advocate for fair work conditions for herself (client level, case advocacy)
• Representing a student/client at an administrative hearing to decide if he will be reinstated to school (school/community level, case advocacy)
• Presenting a rationale to the board of directors of a private, nonprofit counseling center for providing translators and bilingual counselors for non-English-speaking clients (school/community level, class advocacy)
• Gathering data about disparities in mental health services for immigrants to the United States (social/political level, class advocacy)
According to Kiselica and Robinson (2001), advocacy requires special skills and attributes, including verbal and nonverbal communication skills, understanding how systems work, possessing an awareness of group dynamics, technology and research skills, and a commitment to human rights issues. Ezell (2001) suggested that counselors who undertake advocacy must be persistent, persuasive, collaborative, assertive, and resourceful.
Because many counselors are relatively unfamiliar with advocacy, they should be vigilant of ethical issues (Ezell, 2001). Counselors should make every attempt to receive informed consent from clients or client groups before undertaking advocacy activities.
Similarly, clients should have the right to refuse advocacy. Counselors should also evaluate if advocacy for one client or client group will harm another client or client group. And because advocacy is often meant to help clients from diverse groups, the methods and outcomes of the advocacy should be carefully evaluated for consistency with clients' values and beliefs (Ezell, 2001).