General Multicultural Issues

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1. Development of a Therapeutic Relationship

As noted by Hoffman (1996), persons with HIV/AIDS from the four culturally diverse groups discussed in this chapter often believe that they are oppressed, stigmatized, or discriminated because of their HIV/AIDS status. Because of this general belief, clients from these groups seeking mental health services to deal with the spectrum of medical and psychological difficulties resulting from HIV/ AIDS might be reluctant to discuss sensitive issues during therapy (e.g., how specifically the client believes he or she got the HIV virus; whether or not the client is engaged in preventive strategies to avoid infecting other members in his or her community). Thus, the development and maintenance (throughout the entire process of therapy) of a trusting client-therapist relationship is a critical issue to consider when assessing and treating clients with HIV/AIDS from the African American, American Indian, Asian, and Hispanic communities.

Paniagua (1998) proposed three levels (i.e., conceptual, behavioral, and cultural) to develop this therapeutic relationship with clients from such communities. The conceptual level includes, for example, the client's perception that the mental health professional is effective and trustworthy and the client's recognition that the therapist has provided something of value in the client-therapeutic relationship. These two elements of the conceptual level are known as credibility and giving (Sue & Sue, 1990). The behavioral level includes the client's perception of a mental health professional as competent in terms of his or her training in providing mental health services to persons with HIV/AIDS from culturally diverse groups.

The cultural level generally includes two approaches (Lonner & Ibrahim, 1996; Paniagua, 1996; Tharp, 1991). In the cultural compatibility approach, a client-clinician therapeutic relationship would be enhanced if racial differences between the client and the clinician were minimized. Thus, as these differences approach zero, the provision of both cultural and sensitive interventions are enhanced with a given racial group (Lopez, Lopez, & Fong, 1991). For example, this approach suggests that the assessment and treatment of Hispanic clients with HIV/AIDS would be enhanced if the therapist is also a member of the Hispanic community. Despite the apparent utility of this approach in the present context, clinicians are advised to use this approach with caution.

Among other problems with the compatibility approach (see Paniagua, 1998, pp. 6-7), the compatibility approach fails to distinguish between race and ethnicity concepts (Paniagua, 1998; Waytt, 1991; Wilkinson, 1993). In general, race "is a category of persons who are related by a common heredity or ancestry and who are perceived and responded to in terms of external features or traits" (Wilkinson, 1993, p. 19). Ethnicity, however, often refers to "a shared culture and lifestyles" (Wilkinson, 1993, p. 19). In terms of this distinction, the client and the therapist may share the same racial group (e.g., both Hispanics), but they may not share the same ethnicity (e.g., they have different values and lifestyles). Failure to appreciate this distinction when providing mental health services to culturally diverse groups may have a profound negative impact in such services. For example, highly acculturated Hispanic clinicians working with less acculturated Hispanic clients with HIV/AIDS may not agree with the cultural values of machismo (e.g., a sense of masculinity, respect from others, submission by others among Hispanic men) and marianismo (e.g., a sense of submission, obedience, dependence among Hispanic women) regardless of the fact that both therapists and client share the same racial group. This disagreement may lead to culturally inappropriate interventions with these clients. For example, a sense of marianismo in a Hispanic woman would prevent her from asking her Hispanic sexual partner to use a condom during sexual intercourse (Boyd-Franklin etal., 1995).

In the universalistic approach (Lonner & Ibrahim, 1996; Paniagua, 1998; Tharp, 1991) what appears relevant in the development of a trusting client-clinician therapeutic relationship is evidence that the clinician can display both cultural sensitivity (i.e., awareness of cultural variables that may affect assessment and treatment) and cultural competence (i.e., translation of this awareness into behaviors leading to effective assessment and treatment of the particular racial minority group). Thus, according to this approach a clinician's ability to provide mental health services to culturally diverse clients with HIV/AIDS in a culturally sensitive manner and to exhibit cultural competency during the assessment and treatment of these clients is more important than the similarity in the clinician's and client's racial membership (Tharp, 1991).

2. The Extended Family

Among culturally diverse clients described in this chapter, the extended family is a critical component of their community (Paniagua, 1998; Sue & Sue, 1990).

In this context, the extended family includes both biological (e.g., parents, uncles, aunts, sisters, brothers) and nonbiological (e.g., friends, the minister) individuals who could provide instrumental supports (e.g., money, clothing, housing) and emotional supports (e.g., counseling and advice). In the case of Hispanic clients, these nonbiological members often include the compadre (co-father) and the comadre (comother). Among the American Indian clients, the elders in the tribe (particularly the head of the tribe) and traditional medicine men and women have a special place in the family, and they are also seen as integral part of the extended family. In the case of African-Americans, church membership is an essential element in the family, and it is expected that church members (particularly the minister) would be involved in the solution of family issues. In this group, grandparents, sisters, and brothers often play a major role in the extended family (Boyd-Franklin, 1989). Among Asian American clients, the extended family does not generally include individuals (e.g., friends, minister, etc.) outside the core family structure (i.e., parents, children, grandparents, and relatives). This is because public admission of problems (including mental health problems) is generally not allowed in these groups (Sue & Sue, 1990). Finally, many Southeast Asian refugee clients (Vietnamese, Cambodians, and Laotians) may place more emphasis upon the availability of nonbiological persons (e.g., friends) or social agencies (e.g., welfare agencies, community supports) in their definition of the extended family, in comparison with an emphasis upon the nuclear family (e.g., parents). The reason for this is that many refugees either left their family behind in their country of origin when entering the United States or their family members were killed during war (Mollica & Lavelle, 1988).

Because of the historical and significant role the extended family had played among culturally diverse groups discussed in this chapter, the overall assumption is that the extended family should also be emphasized when working with HIV/AIDS infected clients from these groups (Boyd-Franklin et al., 1995). Clinicians, however, are advised to consider two points before deciding to include members of the extended family in the assessment and treatment of these clients. First, because of the stigma of HIV/AIDS and misconceptions regarding the transmission of HIV (Paniagua et al., 1997), some members of the client's extended family may not cooperate with the assessment and treatment of the case. For example, among many Hispanics, homosexuality is viewed as a sin against God (Jue & Kain, 1989). When this belief is combined with the misconception that the main risk for the transmission of HIV is homosexual relationships (Paniagua et al., 1997), a clinician working with a Hispanic client with HIV/AIDS should not be surprised to find out that this client is rejected by many members of the extended family. Similarly, among many Asians homosexuality is an unacceptable behavior. Therefore, Asian men engaged in homosexual relationships would maintain these relations secretly (Medrano & Klopner,

1992), which could prevent clinicians from including members of the extended family in the assessment and treatment of Asian clients with HIV/AIDS.

The second point to consider prior to a decision to include the extended family in the present context is not to assume that the client and the therapist share the same definition of an extended family. For example, it may be a mistake to assume that an aunt is viewed by an African American client as a member of the extended family (in the client's mind) simply because she is biologically related with the client. A guideline to understand the client's definition of "extension" in the interpretation of the client's extended family is to listen to the client's description of instrumental and emotional supports provided by any member of the community. Persons mentioned by the client with a fundamental role in the provision of such assistance should be considered in the client's extended family. These persons may include a brother (but not a sister), the priest (but not the grandfather), a friend (but not an uncle), the case manager assigned to the case by welfare agencies (but not the director of these agencies).

3. Acculturation

Acculturation is another crucial cultural variant in the assessment and treatment of culturally diverse clients with HIV/AIDS (Marin, 1991). In general, acculturation may be defined in terms of the degree of integration of new cultural patterns into the original cultural patterns. Paniagua (1998) proposed two processes of acculturation. In the internal process of acculturation, changes in cultural patterns may occur when an individual moves from a U.S. region to another region in the United States (e.g., from a city to another within the same state or across states). For example, when American Indians living in Arizona, New Mexico, or other states with a large number of reservations move from their reservations to cities, they experience the impact of a societal lifestyle quite different from their societal lifestyle they experienced in the reservations. For example, competition and individualism are two values with little relevance among American Indians who reside on reservations. These values, however, are extremely important for anyone who resides outside a reservation. In this example, the group simply moves from one area to another within the United States, and the assimilation of new values and lifestyles in the new area is a function of the process of internal acculturation.

The impact of the internal process of acculturation, however, would be minimal if an American Indian were to move from one reservation to another reservation in the United States. The internal process of acculturation is further illustrated by Hispanics residing in certain areas of New York City who move to certain areas in Florida (e.g., Miami). The impact of acculturation as an internal process would be minimal in comparison with a move from New York City to another city, such as Lawrence, Kansas, with few shared cultural patterns between the Hispanics and local residents. Another example is Mexican-Americans who reside on the U.S.-Mexican border (particularly in the lower Rio Grande Valley of Texas, including Edinburg, Brownsville, McAllen, and Harlingen). Mexican-Americans who move from this region of the United States to another region resembling little of Mexican-American cultural patterns (e.g., Washington, DC) would experience a difficult internal acculturation process. Mexican Americans who move from the U.S.-Mexican border into San Antonio, Texas, though, would not experience that internal process of acculturation (or its impact would be minimal) because many Mexican Americans residing in the U.S.Mexican border and Mexicans Americans residing in San Antonio share similar cultural patterns.

In the external process of acculturation, a person moves from his or her country of origin into another country. This is the process generally used in the acculturation literature (Dana, 1993) in the case of immigrants who move from their country of origin to the United States (e.g., Hispanics and Asians). The effects of the external acculturation process are less dramatic when immigrants move into the United States and reside in cities that resemble norms, cultural patterns, and values of their country of origin. This is the case of most Hispanics from Cuba, Dominican Republic, and Puerto Rico residing in New York City and Miami, as well as Mexicans who move to the U.S. cities located in the U.S.Mexican Border. Hispanics residing in such U.S. cities not only encounter people who can understand their language, but also find people from their countries of origin who share many of their cultural values (e.g., folk beliefs, customs, music, etc.). The effect of the external acculturation process is more dramatic in those cases when a person moves into the United States and resides in a city with little similarity to that person's original cultural patterns.

It is also important to determine the potential impact of different levels of acculturation upon the assessment and treatment of a client. These levels can be defined in terms of number of years in the internal or the external acculturation process, age at which the client enters such process, and country of origin. The general assumption is that younger clients are more easily acculturated than older clients, and that as the number of years in those process increases the level of acculturation also increases. In terms of the country of origin, the main assumption is that a racial group tends to show a higher level of acculturation depending on their country of origin. For example, a client from the Dominican Republic residing in New York City is more easily acculturated than a client from Vietnam residing in the same city because the Dominican client has already experienced (in his or her country of origin) a great deal of U.S. cultural values prior to entering the United States, including dressing style, music, language (many of them speak English prior to entering the United States), and a competitive approach.

As noted above, the assessment of acculturation could be a significant variable in the clinician's decision to implement a given treatment modality with culturally diverse clients with HIV/AIDS. For example, Marin and Marin (1990) found that less acculturated Hispanics tended to have less correct knowledge about HIV transmission than highly acculturated Hispanics. In the case of American Indians, Schinke (1996) suggested that the high prevalence of alcohol abuse among members of this racial group could be explained in terms of the effect of acculturation. (It should be noted that alcohol abuse is considered a risk factor for the transmission of HIV disease because alcohol is often associated with unprotected sexual activities, which is another risk for HIV transmission; Hoffman, 1996.) Schinke pointed out that many American Indians living in cities outside their reservations "may feel multiple pressures related to conflicts between their own culture and the dominant society. Such pressures demand a coping response ... [and American Indians may] adopt... alcohol use as a coping mechanism against acculturation stress" (p. 371). This is another example of the negative effect of the internal process of acculturation (i.e., American Indians moving from their reservations into U.S. cities representing the dominant culture).

Examples of acculturation scales recommended in the present context can be found in Paniagua (1998, see Table 8.1, p. 102). The Brief Acculturation Scale shown in Table V could assist busy clinicians to conduct a preliminary assessment of the level of acculturation clients with HIV/AIDS from the above culturally diverse groups, before using more extensive scales (e.g., Cuellar, Arnold, & Maldonado, 1995). In Table V, three variables are emphasized: generation, language preferred, and social activity. For example, family members in the fifth generation are considered highly acculturated, in comparison with members in the first generation. In terms of language preferred, the client should be asked a general question covering most situations in which a certain language is preferred (e.g., with children, with parents, with co-workers, etc.). In the case of social activity, a similar approach is recommended. For example, a Mexican American client may be asked, "When you listen to music and go to a restaurant to eat, would you do these things with Mexican Americans only, mostly with Mexican Americans, with Mexican Americans and other racial groups mostly (e.g., African Americans, whites, Asians, American Indians), with a different racial group of your own (e.g., whites), or only with a different racial group?"

The following acculturation scores are recommended in the Brief Acculturation Scale: 1 to 1.75 = low acculturation; 1.76 to 3.25 = medium acculturation; 3.26 to 5 = high acculturation. To obtain these scores, add all values checked across variables and divide them by the total number of items checked. For example, if the client checked 1 for the first item across each variable, the total score would be 1 (or 3/3 = 1, or low acculturation score). If the client checked 2, 2, and 3 for the generational, language, and social activity variables, the overall acculturation score would be 2.3 (medium acculturation score).

Results with this scale could assist clinicians in making culturally sensitive decisions. For example, Hispanic clients who scoring 1.0 in Table V would tend

TABLE V. Brief Acculturation Scale"

Instruction: Please check only one item from the group of Generation items, Language Preferred . items, and Social Activity items.1" My generation is

First Second Third Fourth Fifth

The language I prefer to use is:

Mine Mostly Both mine and Mostly Only only mine English English English

I prefer to engage in social activity with:

Only Mostly Within/ Mostly with Only with within within between a different a different racial racial racial racial racial group group groups group group

"Reprinted with permission from: Paniagua, F. A. (1998). Assessing and Treating culturally diverse clients: A practical guide. Thousand Oaks, CA: Sage Publications (Fig. 2.1). fcTo obtain the overall score, add all values checked across variables and divide them by the total number of items checked (e.g., checking No. 1 for the first item across each variable will result in a score = 1, or 3/3 = 1).

to speak Spanish and emphasize traditional cultural values in comparison to those Hispanics who are more acculturated (e.g., a score = 3.0, in Table V). In this example, an assessment of HIV/AIDS knowledge in Spanish would be culturally sensitive because language could be a barrier in the assessment of this knowledge among Hispanics (Marin & Marin, 1990). Similarly, lower scores on the Brief Acculturation Scale may also suggest strong belief in the cultural values of machismo and marianismo and, as noted above, these values could have a significant impact on the assessment and treatment of Hispanic clients with HIV/AIDS (Boyd-Franklin et al., 1995).

4. Religious Beliefs

In the study by Paniagua et al. (1998), 55.1% of participants agreed that a discussion regarding the role of the church should be a "recommended" topic in HIV/AIDS educational programs; but only 34.2% of respondents endorsed this topic in the "strongly recommended" scale. (The top four selected topics, i.e., 84% and above, included psychosocial issues = 84.1%; grief, loss, and death = 84.2%; ethical issues = 82.6%; and psychosocial crisis associated with learning that one is HIV-positive = 92.8%.) The results in the Paniagua et al.

(1998) study suggest that although mental health professionals interested in learning about strategies to deal with clients with HIV/AIDS might not perceive the role of the church as critical as other issues (e.g., learning how to counsel clients who just learned about their HIV positive status), the role of the church should not be minimized in the present context. Regardless of racial and/or ethnic membership, all major religious denominations in the United States have taken a leading role in helping their members to deal with emotional difficulties resulting from life-threatening diseases, including HIV disease (Landau-Stanton, Clements, Tartaglia, Nudd, & Spaillat-Pina, 1993). In the case of culturally diverse groups discussed in this chapter, the role of the church is considered the most important social support among many individuals with HIV infection. This is particularly true with African American and Hispanic clients with HIV/ AIDS (Boyd-Franklin et al., 1995).

Regardless of the client's race and/or ethnic status, mental health professionals are advised to explore three key areas before deciding to include the church in the assessment and treatment of clients with HIV/AIDS (Landau-Stanton et al., 1993). First, an extensive religious history with each client and his or her family should be conducted, with emphasis on how this history reveals the role of religion in facilitating healing (e.g., the role of the church in helping the family deal with other life-threatening disease or severe emotional difficulties such as a divorce or sudden death of a loved one). Second, an understanding of the importance of the blending of culture and religion from the client's and family's perspective would tell clinicians whether or not to emphasize the inclusion of the church in the assessment and treatment plan. For example, although for many African American families the church is a central aspect in their culture (Paniagua, 1998), this observation should not be generalized across all African Americans with HIV/AIDS seen in mental health services. Third, clinicians should conduct an evaluation of the client's and family's perception of emotional, physical, and social needs provided by the church in the past (i.e., it is crucial to determine that the client and the family perceive the church as part of the extended family).

5. Spiritual Issues

Regardless of racial and/or ethnic membership, the distinction between "spiritual" and the "religious" is a crucial point in the assessment and treatment of individuals with HIV/AIDS (Flaskerud & Miller, 1999). A universal agreement, however, is lacking regarding the parameters used to make that distinction. For example, Landau-Stanton et al. (1993) pointed out that the "spiritual" is a case for "finding meaning of existence" (p. 269) whereas the "religious" emphasizes "communal creeds and practice" (p. 269). A more detailed application of this distinction can be found in Hoffman (1996): "Spirituality [deals with] a basic value around which one's life is focused" (p. 123) including "being concerned with issues of meaning, hope, self-identity, self-worth, one's image of God, forgiveness, and reconciliation" (p. 123). The "religious" includes "a more formal framework for an institutionalized system of beliefs, values, and code of conduct" (Hoffman, 1996, p. 123). The applicability of this distinction in the present context can be appreciated in the following case vignette reported by Landau-Stanton et al. (1993). The case involved a homosexual diagnosed with AIDS who said to the chaplain (third author, in Landau-Stanton et al., 1993), "I have become spiritual, not in the traditional religious sense, but in a very personal way... the church [was, after all, one of the institutions that] condemned me and my (gay) lifestyle" (p. 268).

The difference between the "spiritual" and the "religious" is particularly significant in the case of culturally diverse clients with HIV/AIDS. For example, as noted in Table II, homosexual relationships (men who have sex with men) are a major the risk for the transmission of HIV infection among African American and Hispanic communities. Despite the fact that the church is a crucial social support among these communities, it is important to remember that an emphasis on the family and procreation among church denominations in such communities makes homosexual relationships unacceptable (Medrano & Klop-ner, 1992). Therefore, African American and Hispanic clients with knowledge of the acquisition of the AIDS virus (HIV) through homosexual contacts would not seek help from their church and, instead, would emphasize the "spiritual" in terms described above. Under this circumstance, mental health professionals working with HIV-infected individuals from these groups would not bring the church into the assessment and treatment of the case, but would rather emphasize the "existential questions" the client brings to the therapist (e.g., "Am I Safe?" "Am I Worthy?" "Am I valued?" "Am I Safe?"; see Landau-Stanton et al., 1993, pp. 269-270).

6. Modality of Therapy

In general, African Americans, American Indians, Hispanics, and Asians prefer a therapy process that encompasses an approach that is directive (i.e., what is the problem the therapist wants to solve), active (i.e., what role would the client play in solving that problem), and structured (i.e., what exactly is the therapist recommending to solve that problem; see Paniagua, 1998, pp. 17-18). This approach has been strongly recommended in the assessment and treatment of culturally diverse clients with HIV/AIDS (Jue & Kain, 1989). For example, the main problem might not be to help the HIV-infected client to deal with the anxiety resulting from knowing about his or her HIV status but fear that the client's revelation of this disease would lead to rejection from the extended family (including the church). In the absence of symptoms suggesting AIDS, however, the client might not agree to report that he or she has the AIDS virus (HIV) to anyone, minimizing the active role the client should play in making that report. Knowing that the client is heavily involved in church activities and that the client has already revealed to the therapist that he is homosexual, the practitioner might suggest that the client's perception of rejection could be "real" in the case of the church (for reasons explained above) but "imaginary" in the case of other members of the extended family and encouraged the client to play an active role in making that report at least in the case of family members he "trusts." In this case, the therapist would recommend a "reunion" (i.e., family therapy) including those individuals the client identified as examples of extended family members who have provided instrumental and emotional supports to the client in the past.

7. Language

A client's difficulty in expressing his or her feelings about HIV/AIDS using his or her primary language can be a critical barrier to assessment and treatment of the case. This is particularly true in the case of Asian American, Southeast Asian refugees, and Hispanic clients (Boyd-Franklin et al., 1995; Musser-Granski & Carrillo, 1997). Two significant findings resulting from a client's inability to speak and understand English include increased drop-out rates from therapy and noncompliance behavior with the treatment plan (see Paniagua, 1998, p. 12). In the specific case of clients with HIV/AIDS, these are two critical findings to consider in the effort to prevent the spread of HIV among clients unable to use their primary language in mental health services. For example, a fundamental difference between HIV disease and other life-threatening conditions (e.g., cancer) is that individuals with HIV can transmit this disease by engaging in specific behaviors (e.g., sexual contacts without the use of condoms). When a client with HIV infection drops out from therapy or does not follow the treatment plan because of limited English proficiency, HIV-prevention strategies would not be implemented with this client. The resulting negative outcome of this failure to implement such strategies would be an increase in the probability that this client might continue to engage in risky behaviors leading to the spread of the virus among healthy individuals in his or her community. The use of mental health professionals who speak the language of such clients is, of course, the best alternative to the problem of language barrier in this context. This alternative, however, is not cost-effective in many instances (e.g., not enough Hispanic clinicians to handle the number of Hispanic clients in a given mental health service for people with HIV/AIDS).

The use of translators is another alternative, but it may lead to three errors: omissions, additions, and substitutions during the process of translation from the primary language into English (Musser-Granski & Carrillo, 1997). Despite these errors, the use of translators may be unavoidable in clinical practices. For this reason, several guidelines have been proposed to minimize the effect of such errors and prevent clients from dropping out from therapy or refusing to follow the treatment plan (see Paniagua, 1998, pp. 12-13), including the use of translators who share the client's racial and ethnic background (e.g., Mexican-American clients-Mexican American translators) and assessment of the level of acculturation of the translator in relation to the client's level of acculturation. In general, bilingual children should also be avoided in the process of translation because children's bilingualism could reverse the hierarchical role of parents who are monolingual or who have a limited domain of English. In the context of HIV/AIDS, however, Boyd-Franklin et al. (1995) proposed another reason why children should not be used as translators: "One can only begin to imagine the burden and stress placed... on a young boy who has to translate for his mother that his newborn baby sister is HIV-infected" (p. 61).

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