Richard I. Ruth, PhD
Psychology has taken a multicultural turn. We understand the social context in which we work as a “salad bowl,” not a “melting pot” (D’Innocenzo & Sirefman, 1992; Sue, Bingham, Porche-Burke, & Vasquez, 1999). Since 2002, we have embodied our commitment in APA’s Guidelines on multicultural education, training, research, practice, and organizational change for psychologists (American Psychological Association, 2002). These guidelines define “multicultural” as follows: “The terms "multiculturalism" and "diversity" . . . in an absolute sense, [recognize] the broad scope of dimensions of race, ethnicity, language, sexual orientation, gender, age, disability, class status, education, religious/spiritual orientation, and other cultural dimensions. All of these are critical aspects of an individual's ethnic/racial and personal identity, and psychologists are encouraged to be cognizant of issues related to all of these dimensions of culture. . . . [W]e will use the term multicultural rather narrowly, to connote interactions between racial/ethnic groups in the US.” This article will touch on both broad and the narrow meanings of multiculturalism.
For health service psychologists, embracing multiculturalism entails formidable on-going learning tasks. Scientific, theoretical, interdisciplinary, and clinical discoveries about how to implement multicultural perspectives develop rapidly – reflecting this, APA’s multicultural guidelines are now undergoing revision. Even the most engaged and committed clinicians can struggle to keep up with and integrate the burgeoning relevant knowledge. It is not uncommon for a health service psychologist, novice or experienced, to be uncertain how to proceed in a multicultural clinical situation. Put differently, it is now common to be in unfamiliar multicultural clinical terrain.
Our ethics code (American Psychological Association, 2010) can help us think productively about how we can handle the struggle to make our work multiculturally attuned and responsive. Like DNA, clinical moments have a double helix structure – we think about what scientific evidence tells us is clinically effective, and simultaneously also think about what does or does not square with our shared ethical values. This double set of expectations is at the heart of the high standards our profession sets. At challenging clinical junctures, it can feel like a heavy burden, but it can also serve as a wellspring of possibilities.
This article explores ethical principles and standards that can help health service psychologists work to become more multiculturally effective. I will use fictionalized vignettes to invite readers to consider that sometimes, when clinical thinking does not offer a ready solution to a multicultural challenge, an ethical perspective might.
Principle E of our ethics code, Respect for People’s Rights and Dignity, states that psychologists proactively aspire to be “aware of and respect cultural, individual and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language and socioeconomic status and consider these factors when working with members of such groups” (American Psychological Association, 2010). The language is careful and instructive. It does not demand that we bring awareness of all facets of our patients’ identities and cultural values and their implications to each clinical moment, something our science tells us is generally beyond reach (Petty, Fazio, & Brinol, 2012). Rather, it asks our awareness of what we bring to the clinical encounter, and demands our respect for the perceptions and experience of those we serve – not just patients/clients, but colleagues too.
Dr. A, an experienced, male, European-American clinical psychologist, supervises psychotherapy performed by D. B, an early-career Latina clinical psychologist pursuing post-doctoral training. Dr. A works in an established solo practice; Dr. B works at a community mental health clinic in an impoverished community, and treats most of her patients in Spanish – a language Dr. A does not speak or understand.
Dr. B is excited to work with Dr. A, a well-respected senior clinician who has written influential papers. However, the first supervision sessions are awkward. Dr. A feels frustrated that Dr. B seems slow to feel comfortable speaking openly; Dr. B lacks confidence Dr. A understands her patients’ cultural and economic realities and is knowledgeable about psychotherapeutic approaches that can help them.
After a recent supervision session, Dr. A becomes aware of his growing sense that Dr. B is not as conversant with psychotherapy theories as he had thought she would be. Once this thought comes to his mind, he considers what meaning it might hold viewed through a multicultural lens. He realizes he has been more in touch with his similarities with Dr. B – both are committed to developing advanced psychotherapy competencies – than their differences. He sees he has made assumptions about their experiences and views of gender, social class, culture, ethnicity, and language, and their approaches to psychotherapy. He takes responsibility for his failing as an ethical lapse. In the next supervision hour with Dr. B, he speaks about the assumptions he now realizes he has held. Dr. A feels relieved Dr. B has begun to set their work together on a more multiculturally attuned footing. The sessions come to feel warmer and more productive.
Interestingly, Standard 1.04 of our ethics code, Informal Resolution of Ethical Violations, mandates bringing ethical concerns about the actions of other psychologists to their attention; it does not speak to our responsibility to work toward awareness of our own ethical lapses, which implicit bias theory (Petty, Fazio, & Brinol, 2012) suggests are inevitable for psychologists engaged in multicultural practice – as all psychologists are. Perhaps, in the future, it will. However, our ethics code addresses our proactive responsibility to consider whether we understand the boundaries of our professional competence and work to maintain them (2.01 and 2.03); the bases for our scientific and professional judgments (2.04), grounded in our collectively endorsed multicultural values and understandings; eschewing discrimination (3.01); and avoiding harm to those we serve (3. 04).
Under these standards, Dr. A may have contributed to the supervision launching with insufficient multicultural awareness and initial reluctance to explore multicultural issues present. Had this continued, Dr. B may have had to consider whether she had an obligation to bring these issues with ethical implications to his attention. Such a prospect can be daunting to trainees, at any level of training. This underscores the ethical importance of psychologists being aware of our power, privilege, influence, and vulnerabilities stemming from discrimination and prejudice – the responsibility Principle E commits us to undertake.
To Treat or Not to Treat?
Psychologists tend to be fair-minded people who want to help others; the great preponderance of us do not believe in intentional prejudice or discrimination (Bilgrave & Deluty, 2002; Inbar & Lammers, 2012). A parameter on our positive perception of our collective values, often difficult for us to acknowledge or discuss, however, is that most of us also aspire to make a good living from the services we provide (Power & Pilgrim, 1990). This built-in tension in our values motivations drives our commitment to Principle D, Justice, of our ethics code, which states: “Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence and the limitations of their expertise do not lead to or condone unjust practices.” Many psychologists, in private moments, recognize that this aspiration is among the most difficult to achieve in our professional lives (Power & Pilgrim, 1990).
We live in an economically stratified society (Lynch & Kaplan, 2000). Race, ethnicity, and other multicultural variables intersect with economic stratification (Adelman & Jaret, 1999). Economically underprivileged people, members of racial and ethnic minorities, and marginalized populations face damaging health disparities (Shi & Stevens, 2005; Williams & Collins, 1995). When we behave professionally in ways inconsistent with these realities, we expose ourselves to ethical concerns.
Dr. C, an Asian-American counseling psychologist, is the US-born son of refugee parents. He is the first person in his family to complete college. His parents are blue-collar workers.
Dr. C is in a peer consultation group for early career psychologists with Dr. D, a counseling psychologist who emigrated with her family to the US voluntarily from Western Europe. Dr. D is the only child of two fathers, an architect and a college professor.
Dr. C, Dr. D, and their consultation group colleagues are in the second year of their private practices. They find this stage of their careers professionally exciting but economically difficult. They did not realize marketing their practices would be so challenging.
Contemporary health service psychologists think and work in interdisciplinary climates and settings (Kessel, Rosenfield, & Anderson, 2008). Interdisciplinary perspectives define competencies to be acquired in our foundational training and maintained through lifelong learning (standards 2.01, 2.03, and 2.04).
Dr. C, bilingual and bicultural, receives many inquiries from persons from his ethnic/cultural background. He would be glad to serve them, but they typically lack insurance or financial resources to cover the costs of treatment. He has culturally expected financial obligations to his family of origin and a daunting student loan burden, so he treats primarily self-pay clients in his practice. Dr. D’s fathers paid for the cost of her undergraduate and graduate education, and subsidize her living expenses while she is establishing herself in practice. While striving to build her practice, she works at modest reimbursement 15 hours a week, providing assessments and psychotherapy in a homeless shelter.
Dr. C and Dr. D recognize their racial, ethnic, and socioeconomic realities, and personal preferences, shape their different approaches to practice development, but have not spoken together much about their differences. One day, Dr. D presents a patient she is seeing in the shelter to the group – a young adult with a chronic psychotic disorder and physical disabilities. Dr. C finds himself thinking she is wasting her talents treating someone untreatable. Dr. D, realizing his attention to her presentation has been drifting, asks what he is thinking and feeling. When he tells her, she becomes angry, and says without thinking that, if he devoted more time to work in his own community, he would not feel the way he does about her work.
Dr. C and Dr. D are commended ethically for devoting time and effort to a peer consultation group in efforts to develop (standard 2.01) and maintain (standard 2.03) their professional competencies. However, both are on more questionable ethical ground if they have not thoroughly considered how personal challenges may affect their work (standard 2.06, Personal Problems and Conflicts) and how their practice development strategies have considered contextualizing multicultural concerns (standard 2.04, Bases for Scientific and Professional Judgments). Such concerns include specifics of culture, ethnicity, and national origin, and broader issues of gender and socioeconomic status.
Dr. C and Dr. D can bring a multiculturally informed perspective to their intentions to behave more ethically. They can ask the group to think through what multicultural awareness, and consideration of its ethical dimensions, can bring to charged moments in the future. They can encourage the group to think together about gender, ethnicity, and other aspects of within-group diversity, and how the group’s diversity may be affecting its work on its peer-consultation task and its management of the ethical dimensions of its task – for example, to what extent the group members have considered what is entailed in their disclosure of confidential information to each other (standard 4.06, Consultations; standard 4.07, Use of Confidential Information for Didactic or Other Purposes) and whether they have given sufficient attention to their informed consent to group participation (7.05, Student Disclosure of Personal Information).
Dr. C can explore, in line with Principle D (Justice), how he can be of service to his ethnic community while also earning what he needs to support his extended family. Perhaps he might devote some time to supervising or teaching – activities that also have potential to expand his referral base. Dr. D might consider how the specialized skills she is building at the homeless shelter might import into her work in practice – opening the door to in-patient consultations, or forensic work, for instance. She could also consider whether her own bilingual skills could be a marketable asset as she builds her practice. Such measures could have practical value and would be in line with a multiculturally informed take on Principle D, helping her make psychology accessible to broader populations.
Together, Dr. C and Dr. D could also consider ways their diverse backgrounds have been allowed in or kept out of their conversations with each other in what has been and will likely continue to be a close, evolving professional relationship. Our multicultural guidelines urge us to consider such dynamics in every facet of our professional work; our ethical standards take this a step farther, and say that what our field knows about multiculturalism infusing all psychological work has to be part of the basis of our scientific and professional efforts (standard 2.05).
The Ethics of Intersectionality
Psychology’s turn toward multicultural awareness involves realizing our field itself is part of a professional and intellectual “salad bowl”. Contemporary health service psychologists think and work in interdisciplinary climates and settings (Kessel, Rosenfield, & Anderson, 2008). Interdisciplinary perspectives define competencies to be acquired in our foundational training and maintained through lifelong learning (standards 2.01, 2.03, and 2.04).
Intersectionality theory (Cho, Crenshaw, & McCall, 2013; Crenshaw, 1991; Crenshaw, Gotanda, Peller, & Thomas, 1995), originally developed in the field of critical legal theory, has had a powerful impact on contemporary developments in psychology (Cole, 2009; Warner, 2008). It offers a framework for thinking about the multifaceted, layered, complex identities and experiences our patients and clients bring to clinical encounters, especially when those we serve have multiple minority identities (Nettles & Balter, 2011).
Intersectionality theory orients us to consider the particularities of categories of identity and experience, such as the white privilege that nevertheless shapes the experience of European-Americans from oppressed groups (Neville, Worthington, & Spanieman, 2001), or ways the experience of African-American women differs from that of African-American men (Thomas, 2004).
Psychologists have an ethical obligation to accurately grasp of the tenets of intersectionality theory (potentially applicable standards include 2.04, Bases for Scientific and professional Judgments; 7.03, Accuracy in Teaching; 9.01, Bases for Assessments). Were a psychologist to employ intersectionality theory to argue that, because all persons have complex identities and encounter ways we feel mistreated or misunderstood, specific effects of categories of oppression are no longer relevant, this would potentially be ethically as well as scientifically problematic.
Ms. E, an undergraduate, came to her university counseling center for help when her coming out process brought up intense feelings of anxiety and depression, thoughts of self-harm, binge eating, and more existential concerns about who she was and how she could live her life. The clinical psychology extern who saw her for the brief therapy the counseling center allowed helped her reduce the intensity of her most pressing difficulties, but appraised that she could benefit from a more long-term therapeutic relationship. He referred her to Dr. F, a psychologist in local practice.
Ms. E was a dark-skinned, biracial Latina who identified as lesbian and outside a gender binary. She had been raised in a family that held to the strict values and detailed, demanding practices of their religion, a faith not accepting of homosexual or transgender identities and that advocated minimal contact with those outside the religion. The extern had chosen Dr. F because she was also Latina, out as a lesbian, and a person of faith who had written and spoken about her respectful, effective work with religious patients. Dr. F practiced from an evidence-based psychodynamic approach (Shedler, 2010), well suited to Ms. E’s needs.
Ms. E began therapy with Dr. F excited to feel understood and not judged. She asked, with some urgency, how to manage her still-impinging symptoms. She understood when Dr. F agreed these were serious concerns, but not the only useful focus for their work together, and would likely take some time to resolve. Dr. F appraised that Ms. E’s positive experience of her would likely lead to the emergence of a mix of feelings and reactions, which would be important to understand and manage effectively.
This proved correct. In the fourth month of therapy, Ms. E became very angry in a session. Reporting on a perceived snub by a peer at a dance the previous weekend, she burst out, “I can’t stand affluent white women!” Immediately, she realized the impact of what she had said – her therapist, Dr. F, was light-skinned, and made a good living from her work.
Dr. F’s response was guided by her appreciation of intersectionality theory. She invited Ms. E to explore with her how their racial differences intersected with their ethnic/cultural similarities, and how the differences in their economic realities affected Ms. E’s experience of Dr. F. This opened up a productive line in the therapy. Ms. E began to understand how much she had chafed, growing up, at her parents’ religion’s rejection of “worldliness,” and conflated feelings about her emerging awareness of being a sexual, gender, and racial minority with shame about having had less materially than many of her peers when she was younger.
Dr. F’s work with Ms. E used intersectionality theory to avoid oversimplifying Ms. E’s presenting concerns. Key facets of Ms. E’s identity and experience – race, ethnicity, culture, sexual orientation, gender identity and expression, socioeconomic status – had their own particular weight and dynamics. Dr. F’s thinking appreciated specific ways that psychologically organized issues, such as shame, intersected with family-system issues and sociocultural issues in shaping Ms. E’s experience.
In reflecting on her work with Ms. E, Dr. F’s appreciation deepened for the intersection between her clinical thinking, which had integrated the values of APA’s multicultural guidelines, and her ethical thinking, grounded in the principles of justice (Principle D) and respect for the rights and dignity of all people (Principle E), operationalized in a nuanced understandings of intersectionality theory and its research findings. Had Dr. F coasted on Ms. E’s initial feelings of being understood and not judged, and affirmed Ms. E’s identity without considering other aspects of her emotional experience, important lines of therapeutic work may have gone under-developed. Such a possibility would potentially have raised ethical concerns, such as those in standard 10.01, Informed Consent to Therapy, which requires psychologists to base therapeutic efforts on “generally recognized techniques and procedures” – including those recommended by our multicultural guidelines – and explain to patients, early in therapy, what the “nature and anticipated course” of therapy is likely to entail – in Ms. E’s case, exploring in a multiculturally attuned therapy the intersectional complexities of her development and experience.
Scientific Advances, Subjective Experiences, and Multicultural Competence
Psychology’s turn toward multiculturalism was initially driven by psychologists’ values and advocacy, but has long since been grounded in scientific evidence. The Census Bureau projects the US population will be “majority minority” by 2044, six years earlier than formerly thought (Colby & Ottman, 2015); if psychology is to serve the population as it is taking shape, health service psychologists must be equipped with the requisite conceptual bases and skills. Our science has established that findings about minority stress models (Clark, Anderson, Clark, & Williams, 1999; Meyer, 1995), implicit attitudes (Dovidio, Kawakami, & Beach, 2001; Greeenwald et al. 2002; Petty, Fazio, & Brinol, 2012; Rudman, 2004; Wittenbrink & Schwartz, 2007), stereotype threat (Schmader, Johns, & Forbes, 2008; Steele, 1997; , Steele & Aronson, 1995; Steele, Spencer, & Aronson, 2002), microaggressions (Sue, 2010), processes of ethnic identity development (Trimble, Helms, & Root, 2003), and biculturalism (LaFromboise, Coleman, & Gerton, 1993) are essential to effective health service provision to multicultural populations. Many relevant findings come from non-health-service areas of psychology, but this does not change health service psychologists’ obligation to meet ethical standards mandating development and maintenance of competencies (2.01, 2.03) and performing our work on solid scientific bases (2.04). The diversity of theory and findings we are asked to integrate highlights a task, our ethics code realizes, that is never completed, and involves lifelong learning.
A contemporary multicultural perspective recognizes that what is true about a specific cultural group may or may not apply to specific members of that group (American Psychological Association, 2002), as all identities are multiple and intersectional (Cho, Crenshaw, & McCall, 2013; Nettles & Balter, 2011). Health service specialties in psychology have long appreciated that knowing what tends to be true about a group is essential, but such knowledge serves clinical endeavors as hypotheses, to be proven or disproven in their applicability as clinicians get to know their patients/clients.
Multicultural health service psychology encounters this perspective when it considers cultural and multicultural competencies and how they are developed and sustained. On one hand, psychology insists that health service psychologists ground their work in cultural and multicultural knowledge and skills (American Psychological Association, 2002; Arredondo & Perez, 2003; Constantine & Sue, 2005; Hansen, Pepitone-Arreola-Rockwell, & Greene, 2000; D. Sue, 2001; S. Sue, 1998; Vera & Speight, 2003). On the other, the necessary practical application of cultural and multicultural competence is often difficult for teachers and supervisors to discern and clinicians to self-monitor (Cunningham, Foster, & Henggler, 2002; Dyche & Zayas, 2001; Ridley, Baker, & Hill, 2001; Wendt & Gone, 2012. Multicultural competence is an objective best understand as an aspirational moving target.
Holmes (2006, 2012), Leary (1995, 2012) and others suggest an elusive quality to multicultural competence has to do with its emotionally evocative unconscious dimensions. An appreciation of the ethical dimensions of multicultural competence can help psychologists appreciate this perspective.
Ms. G, a doctoral student in clinical health psychology, is Navaho. She aspires to work on her reservation, where many tribal members have multiple chronic health conditions and seek help from both traditional healers and Western-trained professionals. Her doctoral program has supported her desire to incorporate both Native and Western ways of knowing in her training (McCubbin & Marsella, 2009) unevenly. This is now causing tension between her and her dissertation chair, Dr. H., who is helping Ms. G frame research on interventions to improve diabetes control in tribal members living on her reservation.
Dr. H is European-American. She speaks often about how she values what she learned from growing up in a multicultural New York City neighborhood. Her record of distinguished publications includes several that address multicultural issues in health psychology. She has faced painful incidents of gender bias in her professional trajectory.
Ms. G is fond of and grateful to Dr. H, who has helped Ms. G emerge as a well-trained scientist-practitioner. However, when Ms. G speaks with Dr. H about the limited support the literature has found for the effectiveness of many evidence-based psychological practices in Native populations (Gone & Alcantara, 2007), Ms. G is startled by what she experiences as push-back. Dr. H tells Ms. G her concerns are valid “in the abstract,” but Ms. G “will not make it as a health psychologist” unless she emphasizes quantitative research methodologies, develops and implements evidence-based interventions with fidelity, and aligns her work with “mainstream” health psychology. Ms. G, feeling intimidated and unsure of herself, pushes through her feelings to tell Dr. H that she has rigorously searched the literature, and found almost no published health psychology interventions for diabetes management have investigated whether their findings apply to the population she is committed to serving. All Ms. G can recall of Dr. H’s response is that it felt dismissive.
After her meeting with Dr. H, Ms. G finds herself becoming more and more frustrated and upset, and stuck in the work on her dissertation. She wonders whether becoming and finding an accepted place as a psychologist is realistic. She speaks about her feelings with a trusted graduate student peer, who encourages Ms. G to seek guidance from Ms. G’s mentor outside her university – a Native psychologist who has worked on her reservation.
The mentor normalizes and validates Ms. G’s experience. Ms. G feels relieved, and her mentor helps her strategize what she might do.
Ms. G, understandably, found her reactions in the moment painful and overwhelming. She therefore did not consider that Dr. H’s comments to her may have been not just insensitive and personally hurtful, but scientifically misguided and ethically problematic. Had Ms. G been in touch in the moment with the ethical dimensions of what her dissertation advisor was bringing to their encounter (issues involving Principle D, Justice; Principle E, Respect for People’s Rights and Dignity; and standards 1.03, Conflicts Between Ethics and Organizational Demands, 3.01, Unfair Discrimination, 3.04, Avoiding Harm, 3.05, Exploitive Relationships, 7.03, Accuracy in Teaching, and 7.05, Assessing Student and Supervisee Performance), Ms. G , supported by psychology’s collectively endorsed values and standards, may have felt more empowered to seek redress.
Dr. H’s actions appear in serious tension with what our multicultural guidelines (American Psychological Association, 2002) advise about interactions with multicultural students in higher education and scientific findings identifying particular vulnerabilities and needs of Native American and other ethnic minority graduate students (Jackson, Smith, & Hill, 2003; Maton et al. 2006). Her intention – to facilitate what she perceived as Ms. G’s professional socialization – is not in question; but it was not tempered with the multicultural awareness and multiculturally informed actions Principles D and E demand we consider. Thus, she was on questionable ethical, as well as professional, grounds.
Perhaps neither Ms. G nor Dr. H was in sufficient touch with what their interchange triggered in them – outside their conscious awareness. It is likely Dr. H’s comments, stance, and tone evoked earlier experiences when Ms. G had felt her ways of knowing and her competence, strengths, and resilience were dismissed (Grande, 2004), and activated reactive striving for self-affirmation. Dr. H may have spoken to Ms. G based on Dr. H’s own suppressed painful experience trying to come of age in a still male-dominated psychological specialty, not realizing she was trying to inoculate a student she admired against similar difficulties.
A contemporary multicultural perspective recognizes that what is true about a specific cultural group may or may not apply to specific members of that group, as all identities are multiple and intersectional.
Had either Ms. G or Dr. H more proactively used psychology’s multicultural guidelines to consider what was unexpectedly activated in their encounter, with complex, charged, out-of-awareness dimensions, and taken time to consider the ethical implications of what they were trying to address together, they could have come to a better outcome. They had a history of respecting each other and working together productively. Stopping to consult our ethics code together could have reminded them psychologists always do well to hold both our aspirations and our responsibilities in mind, and to treat each other with collegial respect (standard 1.04, Informal Resolution of Ethical Conflicts).
Concluding Thoughts and Future Directions
I have tried to make the case that the challenges of multiculturally informed health service psychology practice have important ethical as well as scientific and professional dimensions. In doing so, I am aligned with and aim to contribute to a growing literature on multiculturalism and psychology ethics (Arredondo & Toporek, 2004; Gallardo, Johnson, Parham, & Carter, 2009).
The charge and complexity that accompany psychologists’ efforts to bring the best of our professional and ethical thinking to bear on practice in a rapidly evolving multicultural world imply that ethical practice, like multicultural practice, involves lifelong learning. I argue that, when we focus attention on the implications of our ethics code for multicultural practice, our creativity becomes engaged and effective possibilities, relevant to the diverse environments in which health service psychologists work, emerge. If, after reading this article, readers identity personal learning agendas, and realize there are no “cookbook” solutions to the ethical challenges of multicultural practice, my aim will have been achieved.
Richard Ruth, PhD, is associate professor of clinical psychology at The George Washington University in Washington, DC; core faculty member with his university’s LGBT Health Policy and Practice graduate certificate program; and on the faculty of the Washington School of Psychiatry. He has taught ethics classes to graduate students at George Washington since 2006, and teaches continuing education workshops to psychologists and other professionals at the Washington School and across the country. His research and clinical interests include cross-cultural assessment and treatment, disability, trauma, LGBT issues, and the intersection between psychology and religion/spirituality. He has been a registrant since 1988.
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