A Workshop on Cultivating Culturally Sensitive Mental Health Practitioners

CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

CRITICAL CONSCIOUSNESS:

A WORKSHOP ON CULTIVATING CULTURALLY SENSITIVE

MENTAL HEALTH PRACTITIONERS

A graduate project submitted in partial fulfillment of the requirements for the degree of

Master of Science in Counseling, Marriage and Family Therapy

Kristina Cayton Garcia

December 2018

The graduate project of Kristina Garcia is approved:

______Bruce Burnam, Ph.D. Date

______Deborah Buttitta, Psy.D. Date

______Alberto Restori, Ph.D. Date

______Jennifer Pemberton, Ph.D. (Chair) Date

California State University, Northridge

DEDICATION

To my grandfather, Dominador E. Cayton.

Samantalang kami ay nagsisitingin hindi sa mga bagay na nangakikita, kundi sa mga bagay na hindi nangakikita: sapagka't ang mga bagay na nangakikita ay may katapusan;

datapuwa't ang mga bagay na hindi nangakikita ay walang hanggan.

2 Mga Taga-Corinto 4:18

[Translation] While we look not at the things which are seen, but at the things which are not seen: for the things which are seen are temporal; but the things which are not seen are eternal. 2 Corinthians 4:18

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ACKNOWLEDGMENTS

This project came to fruition with the help of the following individuals:

Deborah Buttitta For helping me flesh out my ideas to create an actual outline (that made sense) of how to tackle this endeavor. I was a bit overwhelmed until we talked.

Dana Stone For talking to me about my initial project idea and giving me something new to think about, which lead to the overhaul of the entire thing and prompted me to pursue a different angle. I’m glad I did.

Diana Losey For spending countless hours editing my project and giving me supportive, ample, and always timely feedback. Writing became less daunting with your input.

Bruce Burnam For taking time out of your Thanksgiving holiday to work your APA genius on my project. I’m grateful, and my appropriately cited sources are too.

Joyce Medley For being supportive and enthusiastic with whatever project idea I had brewing, and for giving me an outlet to which I could potentially make this project happen.

Jennifer Pemberton For saying yes to being my project chair and for accommodating my self-made deadlines with understanding and kindness. Thanks for believing me when I said I’d get it done.

When I was an undergrad at the University of California, San Diego, I thought I

knew exactly what I wanted to do “when I grew up,” and being an MFT was not on the

short list. I came in with a degree in Communication, read an extremely negative article

about Communication majors, and promptly switched my major to “Undeclared.”

Another year in, I switched back to being a Communication major, but this time I added an additional major – Ethnic Studies. That program, and really, that decision shaped my worldview. Never mind the fact that my entire Filipino family had no idea what I was

studying, I knew I had to pursue it. To what end? I wasn’t so sure. Because of that

program, I became part of a community dedicated to the study of race, ethnicity, gender, class, sexuality, dis/ability and indigeneity. I learned the concepts of power, privilege, inequality, and most of all, I learned the ability to critically examine systems.

More than a decade later, I find myself studying systems in a whole new light. As an MFT student, the degree I had no idea what to do with as an undergrad really came in handy. More importantly, it serves as the foundation on which I built this project. I acknowledge the significance of that particular decision as it helped shaped the kind of clinician I hope to be – critically conscious and culturally sensitive.

I also want to acknowledge my Mitchell Family Counseling Clinic family for quite possibly being the best classmates I have ever encountered in the history of my education. This program was made better because I was able to endure it with friends, and extremely talented clinicians in the making. Seriously, you’re all brilliant.

Lastly, I want to acknowledge my family. I doubt my parents ever thought they’d

raise a therapist, especially since no one I knew growing up ever went to therapy. I will

always be thankful they did not force me to study anything I was not interested in (ahem,

Nursing). I also could not have made it through this program without the patience and

support of my boyfriend, John. Thank you for keeping me grounded, and allowing me to

“therapize” you when I needed some “practice.” And finally, because I am forever

indebted to the sanity and serenity my dogs and cats bring me, I want to acknowledge my

four-legged animal friends for sitting with me as I furiously typed away on my keyboard

until the wee hours of the night. Their presence in my life has taught me the meaning of

compassion that no classroom, textbook, or theory could ever do.

TABLE OF CONTENTS

SIGNATURE PAGE ...... ii DEDICATION ...... iii ACKNOWLEDGEMENTS ...... iv ABSTRACT ...... vii CHAPTER I: INTRODUCTION ...... 1 STATEMENT OF PROBLEM ...... 1 PURPOSE OF GRADUATE PROJECT ...... 3 STATEMENT OF SIGNIFICANCE ...... 5 TERMINOLOGY ...... 6 SUMMARY ...... 9 CHAPTER II: REVIEW OF LITERATURE ...... 11 INTRODUCTION ...... 11 SELF-OF-THE-THERAPIST ...... 12 DIMENSIONS OF CULTURE ...... 24 IMPLEMENTATION OF A SOCIAL JUSTICE FRAMEWORK ...... 29 IMPLICATIONS FOR CLINICAL TREATMENT ...... 33 SUMMARY AND RELATION TO PROPOSED PROJECT ...... 41 CHAPTER III: PROJECT IMPLEMENTATION ...... 43 INTRODUCTION ...... 43 DEVELOPMENT OF PROJECT ...... 44 INTENDED AUDIENCE ...... 46 PERSONAL QUALIFICATIONS ...... 47 ENVIRONMENT AND EQUIPMENT ...... 48 FORMATIVE EVALUATION ...... 49 PROJECT OUTLINE ...... 50 CHAPTER IV: CONCLUSION ...... 55 SUMMARY ...... 55 RECOMMENDATIONS FOR PROJECT IMPLEMENTATION...... 56 RECOMMENDATIONS FOR FUTURE RESEARCH ...... 58 LIMITATIONS OF PROJECT ...... 60 CULMINATING THOUGHTS ...... 61 REFERENCES ...... 64 APPENDIX A: WORKSHOP GUIDELINES GUIDEBOOK FOR FACILITATORS ...... 75 APPENDIX B: WORKSHOP SLIDE PRESENTATION ...... 89 APPENDIX C: WORKSHOP HANDOUTS...... 115 APPENDIX D: WORKSHOP EVALUATION FORM ...... 118

ABSTRACT

CRITICAL CONSCIOUSNESS: A WORKSHOP ON CULTIVATING

CULTURALLY SENSITIVE MENTAL HEALTH PRACTITIONERS

Kristina Garcia

Master of Science in Counseling, Marriage and Family Therapy

It is essential for mental health practitioners to address the needs of a growing and

increasingly diverse population. While MFT trainees are required to undergo training on

how to address the needs of specific, diverse populations through a multicultural

counseling or diversity considerations course, one course may not be enough to cover a

broad range of topics relating to sociocultural and socioeconomic factors that can

adversely affect many communities. Additionally, it is significant to explore how people

from different backgrounds experience each other and what this implies for mental health

practitioners in delivering effective treatment. The purpose of this graduate project is to

address the needs of culturally diverse communities by strengthening cultural

competence, cultivating cultural sensitivity, and acknowledging cultural humility in MFT

trainees during their graduate program through an adaptable four-hour experiential

workshop. The workshop’s foundation rests on the concept of the self-of-the-therapist, and asks its participants to critically examine and address cultural issues from within themselves in order to confront their own responses to working with cultural “others.”

The goal of the workshop is to link the self-of-the-therapist and the development of cultural sensitivity in order to enhance therapeutic treatment of diverse populations.

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CHAPTER I

Introduction

“When we identify where our privilege intersects with somebody else's oppression, we'll find our opportunities to make real change.” - Ijeoma Oluo

Statement of Need

In addressing issues of diversity within the field of mental health, the Mental

Health America (MHA) organization advocates for all aspects of mental health systems to be reflective of the diversity of the communities they serve. MHA approaches culturally sensitive advocacy by incorporating skills, attitudes, and policies to ensure effective addressing of the needs of consumers and families with diverse values, beliefs, sexual orientations, and backgrounds that vary by race, ethnicity, religion, and language

(Mental Health America, 2018). According to the most recent United States census, the

U.S. population rose 5.9% since 2010. California ranked second in state population growth, adding over two million new residents (U.S. Census Bureau, 2018). California’s total population stands at 39.6 million, which is the largest in the nation (U.S. Census

Bureau, 2018). While 2017 data indicates that more people moved out of California than in, foreign immigration made up the difference in minority populations (World

Population Review, 2018). Nearly half of California’s population is made up of minority ethnic groups, and California has the largest minority population as well as the largest

Hispanic population in the country (World Population Review, 2018). In addition to race and ethnicity considerations, California also boasts a large LGBT population with nearly 1.5 million, or 4.9% of the population identifying as LGBT (California’s Equality

Profile, 2018).

The diversity spectrum extends beyond race, gender, and ethnic lines and also considers sociocultural and socioeconomic factors that affect individuals’ experiences in their communities. Addressing the needs of such a diverse population can prove to be a divisive issue when considering stark political disparities affecting communities across the nation. It is essential for mental health practitioners to address the needs of a growing and increasingly diverse population, and it is critical for them to keep up-to-date on issues that affect communities that are often marginalized or minimized by the dominant culture. Ethnic and minority population needs may differ from one another, and it is essential that mental health practitioners are qualified and trained to meet the needs of the communities they serve (Seponski, 2013).

The Board of Behavioral Sciences (BBS, 2018) in the state of California requires that marriage and family therapy (MFT) applicants for licensure meet a number of requirements through graduate school training before being eligible to take the licensing exam, including cultural competency (Business and Professions Code, 2018). Section

4980.36 of Article 1 of the Business and Professions Code of Licensed Marriage and

Family Therapists includes the following standards regarding diversity:

implications of socioeconomic position, and an understanding of how poverty and

social stress impact an individual’s mental health and recovery.

(D) Cultural competency and sensitivity, including a familiarity with the racial,

cultural, linguistic, and ethnic backgrounds of persons living in California.

(E) Multicultural development and cross-cultural interaction, including

experiences of race, ethnicity, class, spirituality, sexual orientation, gender, and

disability, and their incorporation into the psychotherapeutic process. (Business

and Professions Code, 2018, p.1 - 4)

BBS requirements indicate a strong understanding of the impact of various cultures and

applicable diversity considerations in servicing individuals, couples, children, and

families. As such, MFT graduate programs must meet requirements to ensure MFT

graduate trainees are equipped with the education and training necessary to work in

multicultural environments.

In addressing diverse communities, the National Alliance on Mental Illness

(NAMI, 2018) acknowledges that diverse communities face many barriers such as higher

levels of stigma and misinformation about mental health. Even when accessing

treatment, these communities often receive poorer quality of care due to lack of cultural

competence, bias, and inadequate resources. NAMI advocates for mental health professionals to account for cultural needs and differences to significantly improve treatment outcomes (NAMI, 2018). As evidenced by mental health advocacy organizations such as MHA and NAMI, the BBS’s Business and Professionals Code of

MFTs, and the increasing diversity of communities across the nation including

California, mental health practitioners must continuously refine their therapeutic skills to equip themselves with the knowledge, awareness, and necessary cultural sensitivities to respond to the needs of clients across a full range of cultural variables and diversity

factors.

Purpose of Graduate Project

While MFT trainees are required to undergo training on how to address the needs

of specific, diverse populations through a multicultural counseling or diversity

considerations course, one course may not be enough to cover a broad range of topics relating to sociocultural and socioeconomic factors that can adversely affect many communities.

The American Association of Marriage and Family Therapists (AAMFT) Code of

Ethics (2015) addresses Non-Discrimination as Standard 1.1 of MFTs’ responsibility to clients. It reads:

“Marriage and family therapists provide professional assistance to persons

without discrimination on the basis of race, age, ethnicity, socioeconomic status,

disability, gender, health status, religion, national origin, sexual orientation,

gender identity or relationship status.” (AAMFT, 2015, para. 13)

In keeping this in mind, it is vital that MFT trainees receive the necessary foundation to not just institute appropriate therapeutic interventions, but to also establish critical awareness and consciousness in their approach to their clients, in considering treatment paths, and in their overall practice of psychotherapy.

The purpose of this graduate project is to address the needs of culturally diverse communities by strengthening cultural competence, cultivating cultural sensitivity, and acknowledging cultural humility in MFT trainees during their graduate program. The project itself is the creation of a four -hour workshop, titled the Critical Consciousness

Workshop (Workshop), and designed to critically address the clinician’s responses to issues regarding race, ethnicity, gender, sexuality, class, and dis/ability. Through this four-hour workshop, MFT graduate trainees will receive supplemental training and education intended to enhance cultural sensitivity. By looking at existing structures of power, privilege, and inequality through a critical lens, trainees can expect to dissect and

understand their own cultural biases. While the Workshop will serve as a platform to share knowledge and specific skills, it will also operate on the basis that in order to work effectively in a multicultural world, it is not sufficient to just gain knowledge and skills.

The Workshop will emphasize the significance of recognizing how individual cultural backgrounds and identity influence beliefs, attitudes, and biases. Furthermore, it also examines how historical, political, and sociological factors have impacted culture and have manifested through the lived experiences of all individuals. The Workshop will work to incorporate how personal experiences and societal factors can affect the practice of psychotherapy for the development of culturally sensitive mental health practitioners.

Statement of Significance

As the composition of the United States continues to change, there arises a corresponding need to enhance cultural understanding and cultivate positive relations with individuals of diverse backgrounds. As future mental health practitioners, MFT graduate trainees must undergo appropriate training to learn how to respond to the needs of a diverse society. While MFT graduate programs require a course dedicated to addressing multicultural issues associated with various populations, many times those courses are not enough to engage students in critical dialogue about their own cultural frames of reference. Many things can affect an individual’s understanding of culture, and this Workshop is meant to address the development of different cultural frameworks that can influence how mental health practitioners respond to specific populations.

Whether or not people capitalize on learning more about other cultures and increasing their understanding of individual and cultural differences, it is significant to explore how

people from different backgrounds experience each other and what this implies for mental health practitioners in delivering effective treatment.

Terminology

• AAMFT: American Association for Marriage and Family Therapy

According to the AAMFT website:

The American Association for Marriage and Family Therapy is the

professional association for the field of marriage and family therapy. We

represent the professional interests of more than 50,000 marriage and

family therapists throughout the United States, Canada and abroad.

(AAMFT, 2018, para.2)

• Cultural competence: Cultural competence involves a level of cultural awareness

of self and others that enable effective treatment of clients from various cultural

groups. It combines interpersonal and intergroup problem-solving skills with the

unique cultural dynamics within a therapeutic environment. The definition of

cultural competence can vary depending on the models of the investigators’

“specific assumptions or focus for cultural competency” (Sue, S., Zane, N.,

Nagayama Hall, G.C., & Berger, L. K., 2009. p. 528).

• Cultural humility: Cultural humility involves “the ability to maintain an

interpersonal stance that is other-oriented (or open to the other) in relation to

aspects of cultural identity that are most important to the client” (Hook, Davis

Owen, Worthington Jr., & Utsey, 2013, p. 354). For the purposes of this project,

the expressions “cultural humility” and “cultural sensitivity” will be used

interchangeably.

• Cultural identity: Cultural identity combines elements of an individual’s social

identity, taking into consideration the ideals and values of the cultural group with

which the individual identifies. It encompasses ethnic identity and other social

identities such as gender, class, nationality, race, and sexual orientation.

Together, these elements contribute to one’s sense of self and belongingness

(Hook, Davis Owen, Worthington Jr., & Utsey, 2013).

• Cultural Sensitivity: Cultural sensitivity emphasizes the therapist’s understanding

of a client’s background, ethnicity, and belief system. It allows a therapist to first

“recognize and understand one’s own culture and how it influences one's

relationship with a client, then understand and respond to the culture that is

different from one’s own” (Psychology Today, 2018, para.1).

• LMFT: Licensed Marriage and Family Therapist

MFT graduate trainees are working toward eligibility for licensure, and their

initial introduction into the practice of psychotherapy is at their placement site

where they complete traineeship fieldwork hours. The definition provided by the

BBS outlines the scope of practice for licensees whom they regulate. The

California Board of Behavioral Sciences (2018) describes a LMFT:

“Section: 4980.02. PRACTICE OF MARRIAGE, FAMILY, AND CHILD

COUNSELING; APPLICATION OF PRINCIPLES AND METHODS

For the purposes of this chapter, the practice of marriage and family

therapy shall mean that service performed with individuals, couples, or

groups wherein interpersonal relationships are examined for the purpose

of achieving more adequate, satisfying, and productive marriage and

family adjustments. This practice includes relationship and premarriage

counseling. The application of marriage and family therapy principles and

methods includes, but is not limited to, the use of applied

psychotherapeutic techniques, to enable individuals to mature and grow

within marriage and the family, the provision of explanations and

interpretations of the psychosexual and psychosocial aspects of

relationships, and the use, application, and integration of the coursework

and training required by Sections 4980.37, 4980.40, and 4980.41.” (p. 12)

• Multiculturalism: Multiculturalism refers to diversity in backgrounds and

experiences as it relates to race, ethnicity, gender, sexual orientation, age,

religion, disability, education status, and socioeconomic status. For the purposes

of this project, the term multiculturalism will be used to describe the view that

cultural heritage and experiences of different groups are legitimate, unique, and

significant to consider within the context of clinical treatment (Constantine &

Sue, 2005).

• Power and privilege: The terms power and privilege will be used in conjunction

with one another from two perspectives. The first addresses the therapist-client

relationship and the impact of power differentials related to each person’s role in

the therapeutic setting, and therapist self-awareness and reflection of personal

privilege and its impact on the therapeutic relationship. The second addresses

social implications of power and privilege as it relates to oppression,

marginalization, and the creation of false narratives that can affect specific

populations that seek mental health treatment.

• Self-of-the-therapist: The term self-of-the-therapist refers to a therapist’s

emotional development, including emotional maturity, personality, and degree of

self-understanding. Researchers find that the interpersonal and intrapersonal

qualities of the therapist are tied to therapeutic outcome and the therapeutic

alliance is directly affected by a therapist’s ability to handle stress, to respond

constructively to anxiety, and to think and act autonomously while maintaining

meaningful connections with others (Regas, Kostick, Bakaly, & Donan, 2017).

The term will be referenced heavily throughout the next chapter as a foundation

for continued personal development as it relates to cultural sensitivity.

• Social justice: Defining social justice requires an understanding of the meaning of

justice. In a broad sense, justice entails “fairness” and implies behaving toward

others in an impartial manner and treating others fairly. However, treating others

fairly implies treating them differently in proportion to their relevant differences.

Broadly speaking, social justice means to promote human values of equality and

justice (Vasquez, 2012).

Summary

In an effort to identify the need for further cultural sensitivity training for mental

health practitioners, it is necessary to survey research pertaining to diverse and

marginalized populations. Chapter 2 examines a variety of topics concerning graduate clinical training, presents clinical research outcomes that have affected diverse groups, and will serve to substantiate the need for an increase in cultural sensitivity training in the field of mental health as a way to develop a more informed practice of psychotherapy.

Furthermore, research on the self-of-the-therapist will also be explored in greater detail as it relates to cultivating cultural sensitivity.

The goal of the proposed Workshop is to link the self-of-the-therapist and the development of cultural sensitivity in order to enhance therapeutic treatment of diverse populations. The Workshop is designed to illustrate the invaluable exploration of self, juxtaposed with the invaluable exploration of self within the context of critical awareness in clinical treatment. In the following chapter, the review of literature is broken into four main sections: Self-of-the-therapist, dimensions of culture, implementation of a social justice framework, and implications for clinical treatment. Each section will contain examples and ideas that will clarify concepts around the creation of the Workshop and support the need for its implementation.

CHAPTER II

Review of the Literature

The overall goals of this chapter are firstly to discuss the concept of self-of-the-

therapist and its significance in clinical treatment, then to identify the various dimensions

of culture that intersect within an individual’s life and operate within distinctive family

and social systems, including a look at how the clinical implementation of a social justice

framework can benefit cultural diversity training and its clinical implications for

developing and enhancing clinician cultural sensitivity. Lastly, the chapter will examine

the clinical implications for developing cultural sensitivity, specifically considering the

impact of psychotherapist training on client outcomes and will conclude with a look at

best practices that can be implemented by therapists and other mental health practitioners

in an effort to cultivate critical consciousness in themselves and others.

In this chapter, the concept of self-of-the-therapist is further examined through a critical lens wherein therapist self-awareness is put adjacent to cultural understanding and reflection of oneself amidst the sociocultural makeup of one’s history and current experiences. Concepts such as power and privilege and cultural fit are examined when identifying the varying dimensions of culture. The section will also include discussion on what those various dimensions could mean relative to individual and group identity formation and other factors that could affect, and have affected clients’ lived experiences.

As stated above, the final discussions will examine two aspects of implementing a social justice framework and will conclude with a discussion on clinical implications, graduate training, and best practices, specifically the development of a multicultural-orientation

(MCO) framework.

Self-of-the-therapist

According to Regas, et. al. (2017), interpersonal and intrapersonal qualities of the

therapist are significant in building a therapeutic alliance and in producing positive

therapeutic outcomes. In order to be more effective, therapists would need to build

stronger interpersonal skills and be genuinely engaged and responsive to their clients

(Regas, et. al., 2017). Winter and Aponte (2008) assert that therapists would need to be

aware of what aspect of themselves they bring to the therapeutic process, and confront

their own psychosocial issues. Bringing awareness to these aspects of self is integral to

shaping a healthy and effective therapeutic relationship between client and therapist.

Therefore, the concept of self-of-the-therapist serves as a foundational component of the proposed Critical Consciousness Workshop). The self-of-the-therapist will be utilized as a tool to continuously promote self-reflection and self-awareness as the workshop progresses through sensitive topics and issues that might trigger emotional responses among attendees.

Lum (2002) indicates that the Satir Model also facilitates the development of the self-of-the- therapist. Virginia Satir was a strong advocate for the self of the therapist, and the Satir Model was written to integrate her vision, philosophy, therapeutic beliefs, goals for therapy, tools, and techniques into an inclusive therapeutic method. One of the goals of the Satir model is responsibility. In the Satir model, therapists are encouraged to take responsibility to work through their unresolved issues because clients can be sensitive to the therapeutic relationship and may sense if there are any biases, resistance, discomfort, unresponsiveness, or disrespect coming from the therapist (Lum, 2002). The workshop’s focus on critically examining one’s own biases and unresolved issues is meant to elicit

therapist responsibility of factors that could potentially affect the way they respond to

cultural difference.

The following discussion considers tools and concepts as they relate to the

therapist’s use of self in their approach to clinical practice, and examines various

approaches to cultural considerations that play significant roles in the therapeutic

relationship and therapeutic outcomes.

Therapist Use-of-Self Orientations Questionnaire. According to Burdenski

(2017), few graduate training programs have emphasized training of the self, which

requires substantial time and experiential teaching methods, implying that clients are the

only ones who need to be open and vulnerable in the therapy process. While this may not

be the case for all MFT graduate training programs, the significance of training therapists

to develop the self reaches beyond self-awareness into the use-of-self orientation. The

Therapist Use-of-Self Orientations Questionnaire (TUSO-Q) helps with identifying varying self-orientations. Researchers found three orientation styles with distinctive therapist-client boundaries; these styles include the transpersonal orientation where the boundary becomes more permeable, the contextual orientation where social systems become the lens in which a client’s experiences become understood, and the instrumental orientation where clients are viewed as having deficits that need remediation through skills training (Burdenski, 2017). Looking at the contextual orientation, it appears that therapists can utilize this knowledge to critically address their own contextual history and to come to an understanding about the social systems and processes that have shaped their personal experiences. Essentially, learning more about oneself in context with one’s

own history and experiences allows for a greater understanding of others’ history and

experiences, which can ultimately lead to better therapeutic outcomes.

While not a significant focus of the proposed workshop, the TUSO-Q is discussed because of its reliability in providing useful information about therapists’ use-of-self when working with clients. Further study on the TUSO-Q revealed ways in which therapist self-orientation results illustrate what therapeutic practices they most value

(Anderson, Sanderson, & Košutić, 2011). For example, therapists that scored highest on instrumental self-orientation are likely to embrace the use of therapeutic contracts, clinical assessment, manualization, and development of therapist competencies (Rowan and Jacobs, 2002). The TUSO-Q questionnaire can be used in helping therapists in training identify areas they gravitate toward and areas they can improve upon in order to build upon their clinical competence.

Therapist cultural competence. Marsella (2006) asserts that “culture is shared learned behavior and meanings that are socially transmitted in various life-activity settings for purposes of individual and collective adjustment and adaptation” (p. 353).

Furthermore, culture has shared external and internal features that are modified according to specific situations making culture dynamic and subject to continuous change. Keeping this in mind, culture is not just a concept, but also an encompassing and ubiquitous part of being human. Applying culture to the practice of psychotherapy is imperative to the overall therapeutic process (Marsella, 2006). Trainees can come from a multitude of backgrounds and experiences, and their notion of culture may not always be what they expect to learn in the classroom, or what they encounter in the therapy room. In an effort to acknowledge culture as more than one-dimensional, whether a trainee exhibits a wider

or narrower lens when working with diverse clients, it is essential to develop culturally

sensitive practitioners (rather than the previous goal of cultural awareness) in order to

provide a safe and inclusive therapeutic environment for all clients.

Cultural awareness vs cultural sensitivity. Hardy and Laszloffy' (1995) argue

there is a difference between cultural awareness and cultural sensitivity. In their study of

training culturally competent family therapists, the researchers state,

The content-focused approach to multicultural education overemphasizes the

characteristics of various cultural groups while ignoring the importance of the

trainees’ perceptions of and feelings toward their respective cultural backgrounds.

As a result, trainees are rarely challenged to examine how their respective cultural

identities influence understanding and acceptance of those who are both culturally

similar and dissimilar. (p. 227)

In their study, the researchers distinguish between the concepts of cultural awareness and cultural sensitivity. This project proposal utilizes this premise to argue for more cultural sensitivity training for mental health practitioners since it is imperative that practitioners challenge their own notions of cultural difference by examining their own identities, thoughts, reactions, and past experiences with culturally diverse communities.

Teaching cultural awareness and sensitivity. Hardy and Laszloffy’s (1995) research supports the need for further training in cultural sensitivity beyond learning about characteristics of other groups. With this research in mind, self-of-the-therapist practice directly addresses the need to challenge and examine trainees’ cultural identities as it influences client treatment. Hardy and Laszloffy (1995) advocate for use of the cultural genogram as a way to promote cultural awareness and sensitivity, and to help

trainees gain insight into “ways in which culture impacts their role as therapists and

influences the lives of clients in treatment” (p. 228). The cultural genogram is designed

to illustrate and clarify the influence of culture on the family system, assist trainees in

identifying groups that contribute to the construction of their cultural identity, inspire

open discussions that reveal and challenge cultural assumptions, discover culturally based

emotional triggers, and help trainees explore how their own cultural identities influence and impact their own practice. The cultural genogram can be a beneficial and eye-

opening tool for many graduate trainees. Incorporating the use of the cultural genogram

into the workshop can help broaden trainees’ perspectives on sensitive cultural topics that are not always discussed in academic or social settings, or in therapy. Opening up dialogue regarding sensitive cultural topics could prove beneficial to trainees and the clients they serve as it can stimulate the process of cultural self-exploration and integration (Hardy & Laszloffy, 1995).

Laszoffy and Habekost (2010) address the Commission on Accreditation for

Marriage and Family Therapy Education (COAMFTE) standard of promoting cultural competence by considering issues of diversity, multiculturalism, power, and oppression and focus on programs offering a single course in diversity or multicultural counseling, which is an issue of debate. The authors find there is minimal guidance on how to design and teach diversity courses to maximize cultural competence in student clinicians, and propose a way to teach diversity courses to master’s-level MFT students which will enhance cultural competence. While the focus of their study is on how to teach a single diversity course, they also believe that the most effective way to ensure cultural competence is to infuse issues of diversity throughout the curriculum (Laszoffy &

Habekost, 2010). In infusing the curriculum with continuous discussion on diversity

issues, the training clinic can then serve as an appropriate setting to put cultural

awareness and sensitivity into practice in a way that holds trainees accountable for their

own professional and personal development. Incorporating curriculum or practices such

as the proposed Critical Consciousness Workshop into practicum classes could contribute

to infusing the curriculum with continuous discussion on diversity issues as well as to

cultivate continued self-awareness and self-reflection in MFT trainees.

Challenges to cultural competence. Researchers have studied why cultural

competency works with diverse clients and found that incorporating a contextual match

with clients’ external realities, an experiential match in the microsystem of the

relationship, and the client’s intrapersonal feeling of being understood and empowered all

bolstered therapeutic outcomes (Chu, Leino, Pflum, & Sue, 2016). Regarding the proven

benefits to practicing and enhancing cultural competency, several factors can affect its

implementation and practice within a therapeutic setting. For the purposes of this project,

challenges to cultural competence refer to challenges that can impede its practice as well

as challenges that offer newer ways of approaching client cultural diversity.

The beginning therapist. At the start of graduate clinical training, a beginning

therapist might not be well versed in addressing clinical aspects of cultural diversity.

According to Jones, Sander, and Booker, 2013, students of color in graduate training already have a sophisticated basic competence in cultural awareness, while their White student counterparts typically enter graduate training with less awareness of culture- specific considerations and with lower levels of cultural competence. Furthermore, a trainee first partaking in multicultural training is often faced with the challenge of

developing self-awareness, which is accomplished through self-reflection (Jones, et. al.,

2013).

Becoming a therapist is a process of continuous self-reflection, and engagement in self-reflective process is often cultivated early on in MFT student’s graduate program. In a study of first year MFT students engaged in a daily journaling project, Lee, Eppler,

Kendal and Latty (2001) found that confidence, boundaries between self and client, and boundaries between the personal and professional selves are central themes in student development. Study participants reflected one daily event showcasing a personal experience related to the student experience. Many critical incidents noted by students include life stressors such as balancing program expectations and the demands of family life (Lee et al., 2001). Meeting the challenges of balancing multiple obligations can feel even more stressful. Academic and clinical work can render many students to feel overwhelmed, which can ultimately pose a challenge to the continuous development of cultural competence in addition to other stressors.

According to Lee et al. (2001), developing peer relationships was a common theme found in the students’ journal entries. While there was a combination of joy and stress in these peer relationships, managing the concurrent roles of coworker, colleague, member of a treatment team, and classmate created a unique environment wherein students relied on peer support, but also experienced frustration working closely with another. Self-doubt also became a reoccurring theme when students found themselves dealing with challenging cases, but it was counterbalanced by feelings of success, wonder, competence, and excitement (Lee, et al., 2001). The proposed workshop attempts to address these initial challenges by highlighting the significance of the self-of-

the-therapist as way to build confidence and a sense of unique belonging. The focus on examining oneself within the context of the different systems by which each individual is a part is beneficial to personal growth, which can have a positive effect on professional growth, especially in further developing cultural competency and learning culture- specific considerations. While there are many challenges that can affect a beginning clinician, it is important to highlight the unique task of challenging one’s personal beliefs and confronting potential biases in order to promote growth, increase cultural competence, and foster awareness of cultural humility.

Therapist cultural humility. In their examination of the cultural humility approach, Mosher et al. (2017) find that it can facilitate stronger working alliances between therapists and diverse clients, In their study, Mosher, et al. (2017) address the concept of cultural competence by challenging its focus on developing knowledge and skills, and suggesting it be replaced with development of a multicultural orientation

“focused on ways of being with clients that prioritize and value diverse cultural identities” (Mosher et al., 2017, p. 222). Engaging clients in this type of culturally meaningful dialogue can enhance therapeutic connection.

The development of cultural competency guidelines promotes cultural awareness, cultural knowledge, and cultural skills, but can result in simplistic understanding regarding how to draw out culturally adapted interventions, and result in generalizations about specific groups of people. For this reason, the workshop will emphasize instead, the importance of a cultural humility stance in developing therapist comfort and confidence when working with clients from diverse backgrounds. Workshop attendees will learn how to integrate a cultural humility framework by first acknowledging their

own process of openness, self-awareness, by conscious self-reflection and honest impressions of their experiences within the various intersecting systems.

In a recent study on clients’ perceptions of therapists’ multicultural orientation,

Owen et al. (2016) found that clients who rated their therapist as being more culturally humble also reported better therapy outcomes. The study illustrates the importance of cultivating cultural humility in order to effectively deliver treatment to clients. While a course on cultural diversity or multicultural counseling can teach culturally adapted treatments and protocols, it can lead to generalizations about specific populations that can negatively affect the therapeutic relationship. The workshop intends to work beyond generalizations and help clinicians navigate aspects of their cultural identities that can affect the therapeutic relationship.

Microaggressions. Addressing microaggressions is important in understanding how therapists’ everyday verbal or non-verbal, intentional or unintentional communication can convey offensive or negative messages to their clients. In a 2017 research study, Owen et al. (2017) found that psychotherapy sessions are not necessarily free of microaggressions; a range of 53% to 81% of racial, ethnic minority clients report experiencing at least one microaggression during therapy sessions. Furthermore, their findings supported that therapists with high levels of cultural humility seldom assume ability to treat diverse clients, but rather express more openness to work collaboratively with the client’s cultural identities (Owen et al., 2017). Given this information, cultural humility appears to have meaningful impact on therapeutic treatment.

In a research study by Sue, Lin, Torino, Capodilupo, and Rivera (2009) addressing racial microaggressions in the classroom, researchers examined how graduate

students in the field of Psychology who were enrolled in a seminar on racism and antiracism dealt with difficult dialogues concerning race. The study revealed that dialogues on race proved uncomfortable for students of color, White students, and even the teacher especially within the presence of racial microaggressions. However, the study also revealed that the instructor’s comfort level in addressing race issues, validating feelings, legitimizing a different racial reality, and exhibiting good communication and facilitation skills can either hinder or facilitate difficult dialogue (Sue et al., 2009).

While the study focused on classroom interactions, its findings are significant in addressing how microaggressions exist and can affect sensitive topics even among students studying cultural diversity. Citing this particular research study is also meant to highlight how components of the workshop might challenge attendees’ notions on race or other culturally diverse topics that can elicit negative feelings. It also illustrates that training in cultural diversity must move beyond gaining knowledge and skills (cultural competence), and incorporate experiential components outside of the classroom that can foster cultural awareness and recognition of one’s cultural humility.

Cultural opportunities. Drawing upon these research findings, the workshop will also address clinicians’ aptitude in identifying cultural opportunities during session.

According to Owen (2013), “cultural opportunities are the moments within a session when there is an opening to directly attend to clients’ cultural identity” (p. 31). Research findings illustrate that engaging clients in further exploration of topics they bring up related to identity and culture is significant to positive treatment outcomes. Furthermore, researchers found a strong correlation between cultural humility and overall therapy outcomes (Owen et. al., 2013). Culturally humble therapists exhibit a “way of being”

with a client that is similar to Carl Rogers’ person-centered approach with an added cultural conceptualization component that informs presenting problems, diagnoses and interventions (Owen, et. al., 2013). The workshop, taught correctly, is meant to operate from this type of framework in order to serve as an example for attendees.

Therapist as an instrument. Psychotherapy can be very effective for most people

(Brownawell, A. & Kelley, K., 2011). While other models of health treatment utilize a

wide range of instruments such as stethoscopes and scalpels, therapists are the main

instruments of psychotherapeutic treatment. Like other licensed health professionals,

therapists are required to keep up to date with their clinical knowledge by attending

continuing education workshops as mandated by the Board of Behavioral Sciences (BBS,

2018). By requiring licensed professionals to have current training in various interventions, it is evident that the goal of enhancing therapists’ knowledge base and skillset is important to providing effective treatment. However, due to the nature of the therapist as the main treatment instrument in psychotherapy, it is also essential to address how therapists themselves, can be improved. The workshop attempts to make necessary instrument improvements by focusing on the instruments as a whole and necessitating that attendees be honest with themselves about the personal limitations, they would like to work on during the course of graduate training and as they grow in the field of mental health.

Therapist self-awareness. Studies have shown clinicians’ cognitive biases may limit awareness of their own clinical competence. Scott, Frankel, and Williston (2016) found biases such as the better-than-average bias (in which the average person perceives themselves as being better than the average) and confirmation bias, inattention to missing

data, and overconfidence may all contribute to clinicians’ perceptions of their own skills

as enhanced. Misconceptions about one’s skill level can negatively impact therapeutic

treatment outcomes and hamper the development of a sound therapeutic relationship with

clients. Researchers also found that reported burnout rates in mental health clinicians

resulted in poorer quality of care in which clinician’s own anxiety and distress

intolerance lead to suboptimal treatment and outcomes (Scott, et. al., 2016).

Increasing therapist self-awareness is tied to improved professional effectiveness.

According to Knapp, Gottlieb, and Handelsman (2017), self-awareness requires effort and is an essential element in living up to one’s professional obligations. Their article posits several questions that serve to help clinicians in their continuing efforts to self-

monitor. The following five questions were adapted from the article and will be posed to

the workshop attendees as instrument to facilitate self-awareness:

• “Do I recognize my immediate reactions?”

• “Do I judge my competencies accurately?”

• “Do I recognize that I might harbor implicit prejudices?”

• “Am I aware that I might succumb to cognitive biases or unhelpful heuristics

(approaches to a problem that employ trial and error or experimental methods

(merriam-webster.com)?”

• “Am I fully aware of my values?” (Knapp et. al., 2017, pp. 164-169).

The goal in asking the five questions is to help new clinicians assess their psychological

processes, and how those processes might affect their therapeutic practice. Honing in on

specific areas in which self-awareness might be lacking can help clinicians monitor their

quality of services and be conscious of their professional limitations (Knapp et.al., 2017).

Acknowledging personal biases and confronting professional limitations allows

practitioners to self-reflect and explore the impact of their own cultural upbringing on their engagement or disengagement with cultural others. Such reflection could effect change and allow for enhanced and connected communication with clients.

Dimensions of Culture

This section will discuss the various dimensions of culture within a framework that is inclusive of all differences and abilities. Gopalkrishnan and Babacan (2015) describe culture as, “the values the members of a given group hold, the norms they follow and the material goods they create. It is not a single static entity but is multi-layered and may be influenced by a number of aspects including national, regional, religious, gender, class and individual issues” (p.6). The reference to culture stems beyond racial and ethnic differences, encompassing a variety of other aspects that make up an individual’s identity. Additionally, taking into considering the intersectionality of cultural identities within the context of power and privilege can make it more challenging for therapists to address and recognize how significant aspects of clients’ culture can inherently affect their experience inside and outside the therapy room (Mosher et. al., 2017).

In an increasingly multicultural society, the ability of clinicians to develop effective therapeutic relationships with clients is very important. Organizations, businesses, and educational institutions are creating their own approaches to addressing diversity issues in a more meaningful and introspective fashion (Githens, 2011, Crary,

2017, Richards, Brown, & Forde, 2007). With changes being implemented to incorporate and address cultural diversity across a broad spectrum, it is important to understand what the word “culture” encompasses as it relates to mental health treatment. The Workshop’s

focus on cultivating cultural sensitivity and highlighting cultural humility by means of addressing therapist self-awareness through the self-of-the-therapist, is an effort to respond to individual and community needs that are often overlooked, generalized, and even stigmatized.

The following are common reactions when discussions of multiculturalism or diversity are brought up:

• “The United States is just one huge melting pot.”

• “People just need to be more tolerant.”

• “I don’t see race or color. I just see the person.”

While the comments are often well intentioned and not meant to dismiss another group or person, they are often drawn from individual experiences. Such comments can reflect the lens in which an individual sees and experiences the world. Sociocultural changes occur overtime, and can potentially affect the way individuals view diversity. In light of such changes in the sociocultural landscape, it is vital to the practice of psychotherapy that clinicians continue advanced training in developing contextual multicultural competence

(Esmiol, Knudson-Martin, & Delgado, 2012).

In a study by the U.S. Department of Health and Human Services (2001), the

National Institute of Mental Health (NIMH) looked at the influence of culture and society in mental health and discusses how the cultures of the clinician and the service system factor into the clinical picture and shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of services. According to the study, culture and social contexts shape the mental health of minorities and alter the types of mental health services they use, and it goes on to reason that

“Cultural misunderstandings between patient and clinician, clinician bias, and the

fragmentation of mental health services deter minorities from accessing and

utilizing care and prevent them from receiving appropriate care.” (U.S.

Department of Health and Human Services, 2001, p. 25)

Culture and social context are significant factors to consider in clinical treatment as their influences are evident in the clinical presentation of mental health consumers and in the clinical treatment provided by mental health practitioners. The following discussion examines specific factors of culture that can further affect clinical treatment and advocates for cultural sensitivity training for all mental health providers.

Considering sociocultural norms. According to researchers, norms can be defined as a collective awareness about the preferred, appropriate behaviors among a certain group of people (Chung and Rimal, 2016). The term sociocultural is used in the following discussion as a combination of social and cultural factors as it relates to norms.

In a pivotal study by Social Psychologist, Muzafer Sherif where he examined social influence on perception; he found that social norms are “social frames of reference” that are influenced by others (Muzafer, 1937). Further research on norms finds that self- categorization influences how a person is likely to act in accordance with the norms associated within the specific category of group membership (Haslam, Reicher, &

Platow, 2013). Drawing upon various research findings, it can be inferred that sociocultural norms are influential and can serve as both barriers and facilitators of personal development.

Understanding sociocultural norms is important in understanding how certain beliefs are formed and often perpetuated. While the concept is not limited to the field of

mental health, discussing it within the context of cultivating cultural sensitivity within

mental health practitioners is important because it can be easily overlooked and not

considered as a factor that can affect delivery of mental health treatment. As graduate

students undergo the process of seeing clients for the first time, it is vital that they have

an understanding on how implicit some norms can be, and how that may or may not

affect clinical considerations such as the therapeutic relationship, selecting appropriate

therapeutic interventions, and countertransference issues that might arise, influenced by

sociocultural norms and personal experiences.

In a study of adolescents who experience mental health difficulties and were stigmatized by their peers, Silke, Swords and Heary (2017) found that tackling the perception of negative descriptive norms may be an effective strategy for reducing explicit stigmatizing responses. In the study, researchers observed that individuals who

have a mental illness often partake in self-stigmatization and experience public

stigmatization due to their “membership” within a marginalized group. They found that

social norms played a pivotal factor in the expression of stigma. The results of the study

revealed that certain beliefs (norms) can have a negative effect (stigmatization) on a

marginalized group of people (adolescents with mental illness). While the study is not

encompassing of a wide population, it serves as an example of how pervasive sociocultural norms can be in influencing how people react and relate to others (Silke et

al, 2017).

Considering cultural fit and cultural constraints. Aside from considering

sociocultural norms, there is also the question of cultural fit and its implications,

particularly in addressing cultural constraints. Alegria, Atkins, Farmer, Slaton, and Stelk,

(2010), find that serious attention to diversity, culture, and context is largely missing, despite these factors being critical domains in improving care. Treating a diverse

population means there is diversity in beliefs and expectations, as well as diversity in

their assumptions about what clinicians can do for them. This can lead to a lack of

understanding of the shared problem between the client and the clinician, which would

then lead to misaligned treatment approaches (Alegia et.al., 2010). Misaligned treatment approaches can result in premature termination of services, superficial discussions about deeply rooted issues, or other detrimental effects on the client’s experience in therapy. In effect, these particular cultural constraints would not be an ideal cultural fit for the therapist and client.

In an example about treating racial minority youth living in neighborhoods of high environmental stress, evidence shows that these minorities are more likely to have interactions with the juvenile justice system (Freudenberg & Ruglis, 2007).

Corresponding these particular phenomena to the call for more culturally sensitive mental health practitioners means to acknowledge the individual’s persistent exposure to discrimination, racial profiling, and injustice within the system as a whole. While a clinician may consider particular cultural aspects such as low socioeconomic status or religion, it is imperative that clinicians’ approach particular aspects of cultural injustice with careful concern. The Critical Consciousness Workshop attempts to address issues such as racial injustice as a means to encourage dialogue about certain aspects of a client’s history that can all too often be discounted or not considered in the context of treatment.

Considering intersectionality. Intersectionality is a term that was initially used to describe ways in which race and gender interact to shape multiple dimensions of the realities of black women (Crenshaw, 1991). It has since been expanded to include all aspects of an individual’s multicultural identity such as individual ethnocultural identity, gender, sexual identity, spiritual identity, socioeconomic status, age, and primary language (Clark, 2015; Davis, 2008; Mackinnon, 2013). With its expanded definition, the concept of intersectionality allows clinicians to conceptualize client cases through consideration of unique individual differences and its relationship to larger social forces that can shape individual experience. According to Clark (2015), “all individual cultural factors interplay to create unique experiences, presenting concerns, and treatment options” (p.97).

Considering intersectionality also means considering oppression and marginalization as they relate to each individual’s intersecting identities. Clark’s (2015) study focuses on fostering critical consciousness creation in students by encouraging students to confront their own biases and privileges, and by reducing “memorization of group characteristics” (p. 98). The Critical Consciousness Workshop utilizes Clark’s study as a psychoeducational tool to incite trainees to explore and unpack internal biases rather than to reinforce them in generalized clinical treatment based on cultural group stereotyping (Clark 2015).

Implementation of a Social Justice Framework

The ensuing discussion first considers MFTs’ ethical responsibilities to their clients and the practice of psychotherapy. It is followed by a brief discussion on the concepts of power and privilege as it relates to the implementation of a social justice

framework in clinical treatment. Lastly, the discussion considers various avenues and

practices that can help orient mental health practitioners toward incorporating a social

justice framework within their clinical practice. The models are presented to illustrate

that a social justice framework can expand therapeutic interventions beyond just

symptom reduction, but toward impacting systemic change that can benefit marginalized

populations. Furthermore, it can facilitate clinician self-reflection and awareness via applicable techniques and practices, sometimes immersing the clinician into cultural dynamics that can further hone their cultural sensitivity training outside of the classroom and therapy room.

Considering ethical responsibilities. The AAMFT Code of Ethics (2015) state that therapists’ responsibility to clients that is firstly non-discriminatory on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity, or relationship status (AAMFT Code of Ethics Standard 1.1). In observing this standard, mental health practitioners have an ethical responsibility to respond to such changes in the cultural landscape by ensuring non-discriminatory treatment and assistance of their clients. Although recognition of diversity and multiculturalism is not a new phenomenon, research has shown that recognition and knowledge of difference is not enough. McGoldrick & Hardy (2008) find that learning how to address gender, societal power positions, and culture are significant components of clinical training. This project proposes various frameworks in addressing cultural difference in ways that sensitively considers unique, individual experiences.

Considering power and privilege. According to Johnson (2006), social justice issues are grounded in power, privilege, and oppression. Johnson’s research outlines

three characteristics of societies in which privilege and oppression exist – these societies

are dominated, identified, and centered on privileged groups (Johnson, 2006). Those in

the privileged groups dominate positions of power, cultural norms and modes of thought

are identified by members of the privileged group, and conventional practices and

policies are centered on and influenced by the privileged group (Lechuga, Clerc, &

Howell, 2009). These concepts are further discussed in the following models, and are

significant to consider when implementing a social justice framework. The Workshop

aims to work from this particular framework in an effort to challenge and confront

clinicians’ dominant narratives about cultural difference to further encourage self-of-the-

therapist work as it relates to systemic issues of oppression.

Scientist-practitioner-advocacy model. Clients can come to therapy for a variety of different reasons, but clients whose presenting problems are rooted in systemic oppression, discrimination, and marginalization can face further battles when seeking mental health treatment. Mental health practitioners are not only faced with the task of conceptualizing their clients’ cases through a clinical lens, but through one that also considers sociocultural forces at work. In a study on doctoral students in psychology,

Mallinckrodt, Miles, and Levy (2014) examined the domain of social justice advocacy and found that it strengthens their own scientist practitioner model by addressing contextual factors that are the cause of individual client’s distress. The scientist- practitioner advocate model intersects clinical practice with advocacy and calls for practitioners to advocate for clients’ needs beyond the treatment setting and calls for practitioners to empower clients to find their own voices to advocate for themselves, should that be something they choose to do (Mallinckrodt, et. al., 2014). While the

Workshop is not calling for trainees to immediately implement such practices, the goal of cultivating cultural sensitivity through heightened self-awareness requires that practitioners start thinking outside the box. As systemically trained clinicians, it is imperative to strongly consider the sociocultural contexts as it relates to individuals and to social systems in which clients are a part.

Relational-cultural theory model. According to Comstock et al. (2008), the

Relational-Cultural Theory (RCT) model advocates for creating and participating in growth-fostering relationships and is a comprehensive theory of counseling and development that provides an approach that involves “identifying and deconstructing obstacles to mutuality that individuals encounter in diverse relational contexts” (p. 285).

Its aim is rooted in a contextual approach to the helping process that assumes that the experiences of isolation, shame, humiliation, oppression, marginalization, and microaggressions are relational violations and that cultural oppression, social exclusion, and other social injustices underlie the pain and trauma that individuals in marginalized groups experience (Birrell & Freyd, 2006; Comstock et. al., 2008).

The RCT model expands traditional models of counseling and development to promote connection and challenge stereotypes, internalized dominance, and oppression by uniting with others in building communities of resistance in different environmental settings and working with advocacy groups to achieve shared goals (Comstock, et. al.,

2008). The RCT model also calls for students-in-training to explore some self-reflective questions. The following questions presented by Comstock et al. (2008) serve to illustrate RCT’s call for clinicians to self-reflect and asses their own experiences in

relationship-building in order to develop new relational and multicultural/social justice counseling competencies:

• What are your strategies for disconnection, and how are they exercised in

relationships with others who are culturally different from yourself?

• What do these strategies look like in your personal and counseling relationships?

• What are some of your relational and controlling images, and what experiences

have helped to shape these images?

• How have these images affected your capacity to create and maintain mutually

empathic, growth-fostering relationships with others who are culturally different

from yourself?

• What parts of your authentic experiences do you leave out of relationships?

• In terms of authentic relationships, how do you name and deconstruct obstacles to

mutuality in your personal and counseling relationships?

• What are some sociocultural influences that have affected your capacity/ability to

develop and maintain mutuality in your relationships? (p. 286).

Implications for Clinical Treatment

The following discussion will look at two main areas that can impact clinical treatment as it relates to the ideas explored in this chapter. The first discussion considers the impact of MFT training on client treatment outcomes and will look at a specific study done within a university-based training clinic. The discussion will also consider the cultural diversity aspect in regard to training MFTs. The second discussion outlines specific best practices that can be implemented by mental health practitioners in their clinical practice. The section also considers the use of an Implicit Bias Test from Project

Implicit, a non-profit organization and international collaboration between researchers

who are interested in implicit social cognition - thoughts and feelings outside of conscious awareness and control (Project Implicit, 2011).

Impact of psychotherapist training on client outcomes. Ward and McCollum

(2005) collected data from a university-based MFT training clinic to examine therapists’

rating of therapy effectiveness for clients seen for more than one session over five years.

The study looked at the impact of psychotherapist training on client treatment outcomes

and yielded a statistically significant relationship between treatment outcome and

treatment length, number of presenting problems, and attrition category on the

effectiveness of therapy for clients seen at the university-based MFT training clinic.

Such data implies that the onset of clinical training for MFT trainees can impact client outcomes, and adequate training on all aspects of therapy, from treatment modality to fee for services can have an impact on a client’s experience in therapy (Ward & McCollum,

2005). The proposed project aims to add to the training curriculum by focusing on cultural diversity as a whole, and to develop clinicians’ aptitude in not just addressing sensitive cultural issues, but in their implicit responses to specific cultural diversity

matters.

Regarding the importance of adequate clinical training, Peterson and Fagan

(2017) addressed the usefulness of monitoring client progress throughout psychotherapy

during graduate training. The authors surveyed graduate training clinic supervisors and

trainees on their practices of a process called routine outcome monitoring (ROM). They

concluded that training clinics have a unique opportunity to implement the use of ROM

for the next generation of clinicians, which could lead to better ROM implementation

rates, improve client outcomes, and lessen client drop-outs in training clinics. While training clinics do practice monitoring client outcomes, the argument that ongoing supervision and consultation after initial training is necessary to make lasting change in therapist behavior is a key part in the use of ROM (Peterson & Fagan, 2017).

This is significant given that an understanding of the effects of graduate training on client outcomes is substantial in creating an environment that supports graduate trainees’ work beyond the clinical environment, extending its efficacy into the clients’ personal lives. While ROM is concerned with routine outcome monitoring, as its name implies, it is also helpful to consider sociocultural concerns affecting the client’s progress and to consider this aspect when implementing ROM. In training MFT trainees early on about considering cultural diversity issues in conceptualizing and assessing clients, clinical supervisors are given the opportunity to facilitate the development of clinician self-awareness and cultural empathy, which would ultimately help trainees “identify and refute their naïve concepts and stereotypes about the experiences of clients from different cultures” (Suthakaran, 2011, p. 208).

The link between adequate graduate training and positive client outcomes is clear.

It is important to understand this link in the context of the complexity of the experience of graduate training. Mead (2013) makes recommendations to assist students in making the transition from the classroom to the consulting room and covered extensive literature on the components needed for competence within the field of marriage and family therapy. The researcher describes caution regarding new techniques as one of the components for competence:

You should be equally cautious about adapting a new technique presented at a

workshop or national meeting. Prudent therapists do not chase off after the latest

theoretical model no matter how charismatic the presenter. Hyperbole should not

be allowed to substitute for scientific evidence. (Mead, 2013, p. 104)

The author’s statement serves as a cautionary measure to students, urging them to be aware of the information they consume, and suggests that students might be influenced in their practice, not by evidence, but perhaps by a presenter’s level of sway. The author

also examines several therapeutic models of treatment and describes the chronological

stages of therapy from the initial phone call through to client outcomes and termination,

thereby, illustrating the extensive nature of psychotherapist training (Mead, 2013).

Relating Mead’s caution to the proposed workshop was done specifically to address any

potential reservations regarding the Workshop’s goals, methods, and/or curriculum. It

gives permission to the trainee to critically examine or even question the information they

receive.

Pica (1998), in writing as a graduate student in Clinical Psychology at the time of

his publication, states,

We struggle with ambiguous theories and concepts in our psychotherapy courses

and ambiguous scoring and interpretation systems in our assessment courses. We

eventually go into our first intake interviews, testing, and therapy sessions without

the experience or knowledge it takes to make confident decisions and feel good

about the way we handle moment-by-moment situations. (p. 362)

While the author was not an MFT student, his statement may hold true for other graduate students undergoing training in the mental health field. He finds that many students

undergoing clinical training cope with stress by talking to and receiving validation from fellow trainees. The connection with others as well as finding literature that supports his argument concerning graduate student experiences helped alleviate anxiety and provided hope amidst the uncertainty of clinical training. He believes that a certain level of ambiguity is necessary in order to facilitate and develop clinical training skills and decision-making, but there is an unnecessary amount of uncertainty and fear that also coincides with clinical training. Pica’s argument is valuable to the literature about clinical graduate training, and provides direct insight into the experiences felt by many graduate students who are seeing clients for the first time, and looking to apply barely- learned theoretical concepts to actual cases and people who come to them for help (Pica,

1998).

In another study, Cornille, McWey, Nelson and West (2003) examined student perceptions on the importance of specific MFT skills and perceptions of experienced therapists on the same skills. The authors found similarities and differences between the two groups’ perceptions. Of note, they suggest that MFT students value a crossover of theoretical foundations implying that “training and supervision may need to be first organized around the broad bases of therapists’ skills such as expertness and collaboration, rather than around specific traditional theories” (Cornille et al., 2003, p.

56). Furthermore, with students being able to formulate their preferred way of interacting with clients (whether expert or collaborative), the authors state “training and supervision could be developed upon that preference, which may result in students feeling more comfortable and competent with their skills and effectiveness” (2003, p. 56-57). The study adds to growing literature on graduate training experiences and approaches by

illustrating the importance of knowing more about the foundational skills of therapy and

the processes for “moving them into agencies that work with designated populations”

(Cornille et al., p. 58). It is in the work with designated populations that the proposed

Workshop’s curriculum hopes to address and potentially help clinicians early on in their

career to always consider the impact of sociocultural forces on their clients’ lives.

The development of a student clinician is a process that incorporates academic

learning with clinical practice. Often the two may not always seem to align, which

makes clinical graduate training and what students can expect from training to appear

ambiguous (Pica, 1998). The role of the training clinic in an MFT graduate trainee’s

experience can leave a lasting mark on their professional development, and therefore the

training clinic should be equipped to provide graduate students the basic tools needed to

thrive in their first foray into clinical practice. By incorporating training workshops such

as the proposed Critical Consciousness Workshop, graduate clinicians can begin critically

examining their implicit biases, which could inevitably result in ineffective clinical

interventions or impede the development of healthy therapeutic relationships.

Best practices for the mental health practitioner. Throughout this chapter,

there were intended discussions about a specific self-assessment, the TUS-Q, other tools

such as ROM to implement in clinical training, and various models of therapy that

support the goal of the proposed Workshop – to cultivate culturally sensitive mental

health practitioners. Two of the models discussed, RCT and Scientist-Practitioner-

Advocate supported the implementation of a social justice framework in clinical practice.

These models and assessments are brought up briefly in this section to involve them in the discussion, suggesting that the implementation of either models or assessment tools

are relevant to the discussion and should also be considered as best practices for the

mental health practitioner to undertake. In addition to the former, the following sections

will look at two other suggestions -- the multicultural orientation (MCO) framework and

then introduce a specific internet test on “implicit bias” to inform the discussion on best

practices.

Multicultural orientation (MCO) framework. The MCO framework is supposed

to complement other models of psychotherapy, such as cognitive-behavioral therapy or systems therapy, and is a framework that articulates “a way of being” in session for therapists (Davis et al., 2018). The MCO framework stems from research on multicultural competencies (MCC) and builds on it to “incorporate how cultural dynamics can influence the process of psychotherapy” (Davis et al., 2018, p. 90).

According to the authors,

MCO is concerned with how the cultural worldviews, values, and beliefs of the

client and the therapist interact and influence one another to co-create a relational

experience that is in the spirit of healing. (Davis et al., 2018, p. 90)

Adoption of the MCO framework helps bridge the self-of-the-therapist into the discussion about cultural dynamics that can help build a healthy therapeutic relationship between client and therapist.

Furthermore, Davis et al. (2018) state shifting language use from “competencies” to “orientation” in an effort to move beyond training and training standards

(competencies) and move into language that related to therapists’ orientation in conceptualizing cases, creating treatment plans, and applying interventions in psychotherapy (Davis et al., 2018). In essence, the MCO framework allows therapists to

understand and relate to the cultural identities of clients in which therapists can detect when cultural dynamics requires enhanced awareness, knowledge, and skills (Davis et al.,

2018). The MCO framework supports the goals of the proposed Workshop, particularly in developing therapists’ attentiveness and responsiveness to their clients’ needs and in supporting enhanced self-awareness.

Considering implicit bias. The non-profit organization, Project Implicit (2011), supplies internet consumers with a wide array of tests designed to measure implicit bias.

The website, implicit.harvard.edu is open for public consumption and allows the user to select from a list of different tests, each measuring a different implicit association with specific groups of people or even ways of being. Certain tests include measurement of implicit bias toward disabled people, Hispanic people, people battling alcoholism, and other populations. The website provides an expansive collection of self-assessments that can be taken at any time, and can readily supply results once the online test is over

(Project Implicit, 2011).

According to the Project Implicit’s (2011) website, the goal of the organization is to educate the public about hidden biases. The availability of the Project Implicit tests allows any individual to start considering his or her own hidden biases. While the tests are readily available, it is important that individuals taking the tests keep an open mind to the results received, and to take the tests responsibly and safely. This type of tool can also inform mental health practitioners about their own implicit bias, should it exist, toward specific populations of people (Project Implicit, 2011). In knowing this information, therapists can begin to reflect on their own biases and identify key areas in which they need to improve.

The website, along with its mission, and objectives will be discussed as an

instrument for trainees to utilize during their graduate training, and even into their

careers. The content of the website also provides a great way to introduce sensitive

discussion topics and can serve as a starting point for the proposed Workshop to achieve

its goal of cultivating cultural sensitivity.

Summary and Relation to Proposed Project

It is vital for mental health practitioners to address the needs of a growing and

increasingly diverse population, and it is critical for them to keep up-to-date on issues

that affect communities that are often marginalized or minimized by the dominant

culture. Ethnic and minority population needs may differ from one another, and it is

essential that mental health practitioners are qualified and trained to meet the needs of the

communities they serve (Seponski, 2013). The purpose of this graduate project is to

create a safe space in which graduate trainees can build on their clinical skills in order to

address the needs of culturally diverse communities by strengthening cultural

competence, cultivating cultural sensitivity, and acknowledging cultural humility.

The Critical Consciousness Workshop is designed to be a supplemental training

resource for graduate students entering the field of mental health. While MFT graduate training programs require a course on diversity or multicultural counseling, and accrediting bodies necessitate focus on cultural considerations when assessing and treating clients, there remains a need for further training of the therapists’ use of self when it comes to addressing cultural differences in clients. The Workshop aims to fill the gaps in which dialogue and critical reflection on concepts like power and privilege, personal bias, social justice are typically not the focus of classroom discussion. The

Workshop also aims to be a space in which dialogue and critical reflection on such sensitive topics take place.

The intentional focus on the self-of-the-therapist as a foundation for the

Workshop is meant to approach the topic of cultural sensitivity training from within. In undertaking such an approach, the Workshop’s objectives stand to challenge perpetuated stereotypes and over-generalizations of groups of people and promote clinicians’ self- efficacy through critical self-reflection. It is not enough to have a general understanding of specific cultural considerations when it comes to treating minority populations, but an understanding of one’s own responses to cultural diversity and how such responses might have come about.

It is the definitive goal of this project proposal to emphasize that one training, one class, one well-intentioned therapeutic intervention is not enough, and will perhaps never be enough to be fully “culturally sensitive” or even “culturally competent” as a mental health practitioner. It is the ultimate knowing and awareness of one’s limited understanding of the cultural “other” that is significant in the learning process. Through the proposed frameworks and best practices discussed throughout this chapter, proper training and guidance from clinical supervisors, and the mental health practitioner’s continued practice in the exploration of self, especially within the context of increasing critical awareness, can bring this project’s goals to fruition.

CHAPTER III

Project Audience and Implementation Factors

Chu, Leino, Pflum, and Sue (2016) found that a provider’s cultural competence and sensitivity enhances the therapeutic process and contributes to positive therapeutic outcomes. In order to meet the increasing diversification of the United States, culturally competent practice guidelines and mandates have been established across local, state, and national levels (Sue, Zane, Nagayama Hall, & Berger, 2009). Given these implementations and the significance of attending to cultural and diversity issues in psychotherapy, this project specifically focuses on addressing the importance of cultural attunement in the practice of psychotherapy. Chu et al., (2016) assert that cultural competency is effective, with research illustrating that therapist cultural empathy and humility, therapist cultural self-awareness, client perception of therapists’ cultural empathy and awareness, client engagement, culturally competent provider behavior

(including microaggressions), racial/ethnic match, and cultural adaptations of treatment are all factors that contribute to determining the most appropriate approach for clinicians to undertake with clients from various intersecting cultural identities (Chu et al., 2016).

The purpose of this project is to create a Workshop that addresses the complexities surrounding the concept of diversity as it relates to the practice of psychotherapy and treatment approaches. The project attempts to highlight the intersections of race with gender, class, sexuality, religion, and other systems of difference that underwrite individual client experiences. The mission driving this project is the hope for increased critical awareness of the embedded systems of oppression that affect the lives of individuals in marginalized communities, and to explicitly link the

clinician’s role in acknowledging and respecting cultural difference as way to provide

informed and relevant care into the practice of psychotherapy.

Development of Project

This project was inspired by individual experiences with psychotherapy and

conversations with graduate students who are seeking additional training in diversity

counseling. While speaking to a group of trainees, all mentioned a need to further explore

the concepts of counseling diverse populations. While courses in diversity and

multicultural counseling cover necessary topics on how to address certain cultural issues

as they arise in a therapeutic setting, there is not always enough time to flesh out the

clinician’s personal experience with diversity. Lectures and assigned textbook readings

can enhance knowledge on how to therapeutically approach cultural influences on

clients’ lived experiences. However, the development of cultural sensitivity is enhanced

with a deeper practice of self-reflection and self-awareness, specifically within a

multicultural orientation (MCO) framework (Davis et al., 2018). The MCO framework

“challenges therapists to fully examine their motivation to have an “orientation” that

guides their lived experiences around cultural dynamics” (Davis et. al., 2018, p. 90). The

Workshop curriculum was formulated with the MCO framework as a guide.

While the Workshop is psychoeducational in nature, it will also have a strong

process-oriented, experiential component that will allow attendees to reflect on their

personal experiences. The Workshop curriculum was created using information attained

from current research on topics that address the self-of-the-therapist, multicultural counseling, cultural competence, cultural sensitivity, cross-cultural training, and cultural identity formation. Online databases were used to obtain peer reviewed research articles

that underscore the self-reflective and cultural bases of the Workshop curriculum. The

review of literature was used to identify the significance of developing culturally

sensitive mental health practitioners, and to support the development of a workshop

specifically geared toward cultivating a multicultural orientation through experience and

continued personal and professional development.

In order to create the slide presentation, specific research ideas were identified

and fleshed out for a more thorough understanding of the concept. Concepts such as

multicultural counseling, diversity, cultural competence, cultural sensitivity, cross-

cultural training, and cultural identity formation are examined and presented alongside

the complexities of intersecting cultural differences. In addition to didactic instruction,

the Workshop curriculum strongly emphasizes self-reflection and self-awareness. A brief

video will be showcased regarding confronting our own shameful moments as a way to

bridge the Workshop with the group discussion. This particular portion is conducted as a

group process that is facilitated by a practicing clinician and/or associate MFT. The

discussion will look at cultural bias, individual perceptions surrounding cultural

difference, and thoughts concerning how these individual experiences inform one’s therapeutic practice and treatment outcomes.

The Workshop will be marketed to graduate programs specializing in mental

health, but can be adapted to fit other programs that would like to supplement student

training in cultural diversity. The Workshop will be advertised to universities and

graduate training clinics and agencies that hire MFT trainees and associates. The

Workshop should be capped at no more than 20 participants and can be facilitated by at

most two therapists. The Workshop costs will be determined accordingly, contingent on location and/or other unforeseen factors.

Intended Audience

The proposed project is intended for use with graduate students in the field of mental health, and/or other mental health practitioners seeking to enhance their cultural responsiveness to better meet the needs of their clients. The Workshop is intended to serve as a supplement to graduate student training in addressing multicultural issues and diversity factors. The BBS requires that educational programs in MFT address cultural competency and sensitivity, taking into consideration cultural, racial, linguistic, and ethnic backgrounds. In addition, instruction must be able to address multicultural development and cross-cultural interaction and incorporate these concepts and experiences in the psychotherapeutic process (BBS Code 4980.36). The Workshop will address the differences among the various terms associated with doing multicultural work in order to highlight how each have a specific purpose in meeting certain treatment needs.

While MFT programs require a course in diversity or multicultural counseling in order to meet educational licensing requirements, there is an expressed need for further professional development in that area (Constantine & Sue, 2005). This project intends to further enrich the instruction gained from graduate training and examine issues of culture and diversity through a critical lens. The Workshop curriculum aims to provide a supportive environment for therapists and therapist trainees to examine their own personal experiences surrounding issues of power, privilege, and other diversity factors that may have affected their views of others and themselves.

The activities embedded within the Workshop attempt to engage attendees to explore the complexities of the intersections of race with gender, class, sexuality, religion, and other systems of difference that influence and affect clinicians’ approach to therapeutic treatment of diverse clients. Workshop attendees will have the opportunity to

work in small groups and a short role-play during the Workshop will also be conducted.

During the role-plays, attendees will receive scenarios to perform in front of the group.

At the end of each role-play example, the group will be able to identify any cultural

opportunities that were missed or recognized by the therapist, and other potential cultural

identity pieces that could affect treatment. The Workshop will place strong emphasis on

developing self-awareness, and will ask all attendees to consider taking one of the many

Implicit Bias tests online as discussed during the Workshop. Attendees of the Workshop

are also encouraged to journal and reflect on their experiences and as a way to heighten

self-awareness to make positive changes in areas that need improvement.

Personal Qualifications

The Workshop curriculum is meant to serve as an opportunity for MFT trainees

and/or other clinicians to enhance their diversity training. The Workshop facilitator(s)

will be mental health clinicians working in the field either as associate MFTs or licensed

MFTs. It is vital to the success of the Workshop that facilitator(s) remain neutral when

engaging attendees about sensitive topics in order to provide a safe space for open

dialogue. The Workshop facilitator(s) should have a solid understanding of the concepts

of power and privilege as it relates to cultural differences, and are meant to relay research

information about the importance of cultural sensitivity to the practice of psychotherapy.

During the course of the Workshop, facilitator(s) will encourage attendees to share in

thoughtful discussion about the implications of cultural difference in their clients’ lived experiences, and its effects on therapeutic treatment.

As a matter of significance, the Workshop facilitator(s) should be ready to keep an open mind and relay a calm demeanor if any of the sensitive topics are met with hostility or defensiveness. While this might not arise as an issue during the Workshop, it is important to note that engaging in dialogue of a sensitive nature requires a level of emotional preparedness and unbiased feedback that can be challenging. Ideally,

Workshop facilitator(s) should appreciate discussions that provoke critical thought and responses in order to render effective content and share authentic experiences for the benefit of all involved.

Environment and Equipment

The Workshop is meant to provide a safe space for attendees to learn and process their personal experiences and understanding of power and privilege as it relates to cultural difference. Topics discussed during the Workshop may conjure feelings of discomfort and/or provide moments of deep processing and revelation. As such, the environment must be conducive to accommodate discussion and presentation of sensitive subjects. The Workshops will ideally be held in closed door classrooms or conference rooms where chairs can be moved around and provide a more open space to accommodate Workshop activities and discussions.

The equipment needed to run the Workshop includes the following audio/visual components: projector, projector screen, computer, and speakers. The room should be equipped with movable chairs and a large enough space for attendees to form circular discussion groups, and participate in a strategic icebreaker activity. Handouts and other

materials will be provided by the Workshop facilitator(s), either at the beginning of the

Workshop or during specific instances where the materials are relevant to the topic at hand. Props for the icebreakers will also be distributed during the beginning of the

Workshop.

Formative Evaluation

The Workshop serves as a training opportunity for individuals looking to enhance their knowledge on power and privilege as it relates to their clients’ experiences, and most importantly, their own experiences. Since this project will serve as a means to supplement the diversity course taught in graduate school, it is central to the success of the Workshop that thoughtful and honest feedback come from graduate project committee members and other professionals in the field of MFT, specifically CSUN faculty members, Dr. Dana Stone and Mitchell Family Counseling Clinic Director, Joyce

Medley. The committee chair, Dr. Jennifer Pemberton and committee readers, Drs.

Deborah Buttitta and Bruce Burnam will provide the necessary guidance and advice to ensure the effectiveness of running such a Workshop. The professionals in the field are given a copy of the Workshop presentation to review and comment on for constructive feedback.

Essential to the purpose of this graduate project, graduate students in the field of mental health with also be consulted. Colleagues and classmates who can benefit from this project will serve as integral sources of feedback. Consultation will be done in an informal, but thoughtful and professional manner. Their thoughts and opinions about attending this type of Workshop can illustrate how important it is to develop training opportunities that elicit personal reflection on topics that are often overlooked or glazed

over during classroom discussions. The goal in soliciting peer feedback is to gauge how willing graduate students in MFT are in sharing sensitive issues within a brief window of time.

Project Outline

The project is a four-hour experiential Workshop for MFT trainees and will consist of an icebreaker activity, a PowerPoint slide presentation, viewing short video clips, small and large group discussions, role-plays, and a reflection activity to conclude the Workshop. The Workshop is intended for a small audience in order to create a safe space for dialogue regarding sensitive topics and to ensure proper time and attention is given to Workshop activities. The maximum number of attendees should be capped at

20. There should be no more than two workshop facilitators in order to keep the discussion more focused and to decrease the likelihood of overwhelming the attendees.

The following is an outline and breakdown of content that will be included in the

Workshop. Further details and Workshop handouts are located in the appendix.

______

Critical Consciousness: A Workshop on Cultivating Culturally Sensitive

Mental Health Practitioners

• Introductions (15 minutes)

o Workshop presenter(s) (maximum of 2) will begin with a brief welcome

and personal introduction.

. Question will be posed to attendees: During your introduction,

please respond to the following question: “How do you identify?”

o Attendees will be asked to introduce themselves and to answer the

question in any manner they feel comfortable.

• Icebreaker Activity (45 minutes)

o Rules displayed and explained to each of the participants

o Props distributed by Workshop presenter(s)

o 30 minutes allotted for the activity itself

o 15 minutes allotted for discussion of the activity

• Establish Rules for Group Activities and Discussions (10 minutes)

o Discussion on language of hate, bias, discrimination

o Need to define boundaries for the process of discussion

o Must be inclusive of all attendees

o Extend discourse beyond polarizing issues

o Acknowledge that facts, interpretations, perceptions can change over time

o Introduce tools for conceptual understanding and dialogue

• PowerPoint Presentation + Activities (1-hour 50 minutes total)

o Psychoeducational slides

. Psychoeducation on the following concepts:

 Self-of-the-therapist

 Cultural Sensitivity vs. Cultural Humility vs. Cultural

Competence

 Power and Privilege

 Social Justice Framework

 Multicultural Orientation

 Implicit Bias

. Slides will provide prompts and context for planned discussions,

including videos and role play scenarios

. Objectives for Activities:

 Enhancing skills for dialogue that trainees and other

attendees can utilize to better understand clients’

experience.

 Promoting critical consciousness by helping trainees and

other attendees to understand complexities of cultural

difference.

. Objectives for post-activity discussion

 Reiterate that goals are to increase insight

 Handling of emotional responses – “triggers”

• Identify certain triggers to normalize the response

 Possible consequences or implications on client experience

in therapy

 Planning effective interventions to support vulnerable

populations o ACTIVITY: What do you know or what have you heard? (25 minutes)

. Participants will circulate around the room to read through posted

signs. They are asked to write down one thing they “know” or

what one thing they have heard about the specific group or people

identified on the signs. Once everyone has finished writing,

participants are asked to observe what they read and share their

thoughts.

o ACTIVITY: Think-pair-share (20 minutes) . Participants get a chance to respond to a question individually, in

writing. Divide participants into pairs or trios. Instruct attendees to

share their responses with group members. Have group reconvene

in order to debrief.

o ACTIVITY: Role-Play: Participants enact a scenario (20 minutes) . Divide participants into small groups (depending on the number of

participants). Assign each group a scenario to read over and

discuss. Have group pick two participants to enact the scenario for

the whole Workshop. Engage participants in discussion after each

group presentation.

• Video Screening: What can we do about the culture of hate? (20 minutes)

o After activities have ended, another video will be screened. The 17:46 minute video is from a TED Talk given by Sally Kohn in November 2017

in New Orleans, Louisiana titled “What can we do about the culture of

hate?”

o The TED Talk was chosen specifically for its discussion on internal feelings of hate. The word hate can be replaced by something less

offensive should the attendees feel the need to identify a different

descriptor for specific feelings.

o The clip is meant to elicit reflection among Workshop attendees about their own conscious and unconscious ways of exhibiting

hate/intolerance/prejudice/bias.

o Facilitator(s) are encouraged to reflect on these feelings along with the group and link the discussion to concepts discussed earlier on, such as:

self-of-the-therapist, social justice advocacy, cultural sensitivity, etc.

• Wrap-up – Conclusion (25 minutes)

o Bring group back together for any follow-up questions, thoughts, and concerns.

o Pass out Workshop evaluation for participants to fill out and submit before leaving the Workshop.

• There will also be a 15-minute break in between the first and second activity,

bringing the duration of the Workshop to exactly 4 hours.

CHAPTER IV

Conclusion

In order to bring more awareness to cultural issues by way of cultivating cultural

sensitivity in mental health practitioners, this project proposes the creation of a workshop

that will tackle subject matter that are both historical and current, and relevant to the

experiences of clients, therapists, and their communities. The strong emphasis on

exploring the clinicians’ personal cultural understanding and where they might lie on the

continuum of cultural competency through the exploration of the self-of-the-therapist is

aimed to foster curiosity and personal growth. As mental health professionals, therapists

might feel challenged to support culturally diverse clients as both therapist and client

bring their own expectations, experiences, and beliefs to the therapy setting. These distinct differences can positively or negatively affect therapeutic outcomes and hamper therapeutic goals (Culturally Connected, 2018.). The Workshop intends to enhance therapists’ cultural sensitivity training in order to increase their capacity to support diverse clients more effectively.

Based on the research presented, there is strong evidence that while having cultural competence is necessary; there needs to be more emphasis on cultural sensitivity and cultural humility (Hardy and Laszloffy, 1995; Mosher et. al., 2017). In an effort to supplement graduate courses in diversity and/or multicultural counseling, the proposed

Workshop’s focus will be less on the how to treat specific diverse populations approach, and instead focus on personal and individual responses to the cultural other. The proposed Workshop is geared to be experiential and process-oriented for those in attendance, but will also contain psycho-educational information as well as discussions

about relevant sociocultural issues and histories that can affect, complicate, and/or limit building strong therapeutic relationships with certain clients.

Recommendations for Project Implementation

To ensure proper implementation of the Critical Consciousness Workshop, facilitators must be willing to discuss sensitive issues related to race, ethnicity, gender, sexuality, religion, politics, ability, and other relevant cultural differences as it relates to power and privilege. Participants (trainees) should receive an overview of what to expect during the Workshop, should they choose to opt out of participating. It is the responsibility of the Workshop facilitator(s) to establish a safe environment for discussion and involvement in activities. Discussions about certain sensitive topics must be structured in a way with defined boundaries for the process and engagement of others.

It is imperative that Workshop guidelines regarding discussion on language of hate, bias, discrimination, and other sensitive topics are discussed by the facilitator(s) at the start of the Workshop.

The following bullet points were adapted from the University of Michigan (2016)

Center for Research on Teaching and Learning webpage. The points discussed are rules that need to be adhered to by Workshop facilitator(s), attendees, and other persons involved in the implementation of the Workshop.

• Boundaries for the process of discussion must be discussed and established at

the onset of the Workshop.

• Closure must be ensured at the end of the Workshop.

• The Workshop must be inclusive of everyone involved.

• The Workshop facilitator(s) and participants should strive to extend the

discourse beyond polarizing issues.

• The Workshop facilitator(s) should acknowledge that facts, interpretations,

and perceptions can change over time, and should relay that message to all

participants.

• The Workshop facilitator(s) should introduce tools for conceptual

understanding and dialogue in a clear and concise manner.

• The Workshop facilitator(s) must identify objectives for discussion to shape

the nature of the discussion and link it to overall workshop goals.

• NOTE: Should conflict arise or participants express feeling upset or triggered,

facilitator(s) should consider the following strategies:

o Acknowledge the participant(s) that raised the issue and reiterate that people can vary in their responses and concerns.

o Remind the group that the Workshop is meant to be reflective and exploratory, while also ensuring inclusivity of everyone present, which

includes being mindful of the kind of language used.

o Assess the group dynamic to see if participants would like to take a few minutes to share views about the issue that was brought up.

o If behavior or tensions escalate, pause the Workshop and ask if the participant(s) would like to take some time to gather their thoughts and

feelings outside of the Workshop. Should the participant(s) opt to step

out, ensure the person(s) that he/she/they can return to the Workshop.

o Make sure to acknowledge the conflict/issue during the closing discussion of the Workshop to ensure a sense of closure and invite

participants to share their thoughts on the Workshop evaluation form.

It is highly recommended that Workshop facilitator(s) work from a social justice

framework to guide good practice in working with marginalized populations. This

requires that Workshop facilitator(s) exhibit skills and knowledge related to reducing

prejudice, identifying bias, raising awareness, and continuing engagement in order to

encourage collective action. Furthermore, facilitator(s) must continuously touch upon the

main foundation of the Workshop, which is self-of-the-therapist work for all those in

participation. While these are listed as recommendations, the overall nature of the

Workshop requires that facilitator(s) and participants acknowledge their capacity to elicit

profound change in the lives of their clients when they engage in learning more about

themselves. Specific to the context of social justice, facilitator(s) and participants are

encouraged to reflect on their own reactions to systems of oppression (including

recognition of their own socialization into such systems) and their willingness to

challenge their own preconceived notions of marginalized populations.

Recommendations for Future Research

The Workshop addresses the issues related to the development of cultural

sensitivity, the limits of cultural competence, and the role that the self-of-the-therapist plays in recognizing aspects of the self that are often overlooked or unchecked. Foremost attention was given to research based in the United States, and does not particularly single out a specific cultural group to study. Research conducted for this project consisted of in-depth studies on cultural competence, and a growing number of studies on

cultural sensitivity and cultural humility. Research on self-of-the-therapist was also readily available through various scholarly journal databases. However, while doing research for this project, there appeared to be a lack of exploration in looking at the concepts of culture diversity as it relates to cultural sensitivity and self-of-the-therapist side by side.

This project seeks to intertwine the concepts above by creating an introductory experiential workshop to graduate trainees in the field of mental health. While it was written with a specific audience in mind, the Workshop is adaptable to incorporate work with wider audiences addressing the concepts with more depth and detail. Accordingly, the project can be expanded with the following recommendations:

• Further examination related to countertransference and cultural sensitivity.

• Further examination of specific cultural issues and phenomena, which can be

presented as case studies discussed during the Workshop and in the research.

• Further examination of the correlation between therapist background and

propensity to undertake a social justice approach.

• Expansion of the Workshop in its entirety by creation of a series of

experiential workshops that focus on specific cultural diversity topics during

each session.

• Creation of work groups that focus on bringing awareness to relevant and

pressing issues that affect marginalized populations.

• Expansion of the Workshop to encompass other fields of study that can

accommodate individuals in various disciplines.

Limitations of Project

The cornerstone of this project is self-of-the-therapist work, and requires that

Workshop facilitators be open and transparent with audience members and themselves.

Some individuals may feel ill-equipped in conducting the Workshop hinging on critical discussions regarding sensitive and divisive subject matters. Discomfort among audience members and Workshop facilitators can arise in light of discussions that elicit negative and personal feelings about cultural prejudice. There is a risk that subject matter might be glazed over, ignored, or devalued in an effort not to offend others in attendance. This could disrupt the necessary, subjective introspection during the Workshop’s activities.

There is also the possibility that anyone in attendance can take personal offense to words and/or actions delivered during the Workshop by a fellow participant or the facilitator(s) that is uttered without ill intent. In other instances, attendees may voluntarily refuse to engage in activities or discussions because of fear of judgment or chastisement by their peers. In these cases, it would behoove the facilitator(s) to call upon the guidelines and boundaries set forth in the beginning of the Workshop in order to bring the discussion back to doing self-of-the-therapist work, specifically acknowledging that one cannot expect to meaningfully conduct culturally sensitive therapy with diverse populations if one does not invest in personal investigation and awareness of self.

Certainly, the effect and outcome of the Workshop remains to be determined until it is conducted in its entirety. The potential outcomes listed here are hypothesized and operating solely on assumptions. There may be more limitations to consider once the

Workshop is eventually executed with formal and informal evaluations solicited from participants and facilitator(s).

Culminating Thoughts

The goal of the Critical Consciousness Workshop is to link the self-of-the- therapist and the development of cultural sensitivity in order to enhance therapeutic treatment of diverse populations. When I first conceptualized this project, I felt an overwhelming sense of dread at the thought of covering all the nuances that pertain to cultural diversity. I realized, however, that was not the direction I wanted to eventually take the project. I decided, with clear intention that I would make the primary focus of the proposed Workshop on the therapist.

I was particularly intrigued by the concept of the self-of-the-therapist when I initially heard the phrase uttered several years ago. I never fully understood it until I made it my mission to understand its impact in a therapeutic and educational setting.

While there were constant references to self-of-the-therapist, I noticed that most conversations around it were pretty safe and only mildly introspective, especially when it came to discussions during class. It dawned on me that perhaps people did not feel comfortable enough to confront or disclose their innermost thoughts and reactions. This could be due to several factors, some of which I attributed to 1) not feeling safe to disclose certain information, 2) fear of judgement by peers and supervisors/faculty, 3) not knowing what to say or how to say it, 4) fear of the repercussions, 5) simply not understanding their own personal thoughts and feelings, and 6) apathy. There could be a lot more reasons than the six I listed, but for each one, I try to understand and respect people’s reluctance to engage in sensitive topics. However, I often wondered how we could effect change if we were only more willing to take a look inwards and ask ourselves the tough questions. I wondered if we already knew the answer, or if we really

just had no idea what we were feeling inside, especially when it came to relating or not relating to our clients. I became concerned with how our preconceived notions and even our ways of being could affect our relationships and our treatment approaches to culturally diverse clients.

The idea for the Workshop was prompted by an encounter I had with another therapist. The individual was not a fellow student at CSUN or classmate of mine, nor even a professor or supervisor, but someone I encountered in passing that left an impression on me that soured my impression on the way certain clinicians conducted themselves among others. The encounter happened early on in my graduate program, and it never fully left me, or perhaps I just had not let it go. Either way, the behavior displayed by this particular individual impacted my view of certain clinicians and it caused me to wonder, just how much of ourselves are we aware of? Is there a time and place where we can stop being therapists, or do our judgments on others have an impact on how we conduct ourselves amongst our colleagues and clients, specifically those with whom we do not culturally align? After several project ideas later, the decision to tackle issues concerning cultural diversity finally took its course.

The proposed Workshop intends to work with mental health practitioners to cultivate cultural sensitivity by focusing on the internal and social mechanisms at play that inform our judgments and responses to the world around us. Clinicians have the responsibility to abide by the profession’s Code of Ethics, and to deliver treatment to clients without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity, or relationship status (AAMFT, 2015.). Despite knowing this, I wondered how

much of the “without discrimination” portion was sincerely put into practice and exactly

how clinicians consider implicit bias, if it was even considered.

While taking one course in diversity and considering cultural diversity issues may

teach trainees and those in the field about specific populations of people and “how to

treat” them, it often provides a blanket generalization about marginalized,

disenfranchised, minority groups. As clinicians practicing in an increasingly diverse

society, it is important to responsibly address cultural diversity issues that our clients

face, and that we might face ourselves. Taking a look inward is vital to personal and

professional growth within the field of mental health, and the role of the Critical

Consciousness Workshop is to begin the discussion about uncovering our hidden biases.

Through work focusing on self-of-the-therapist, juxtaposed with a critical awareness and social justice perspective, the Workshop purposes the development of cultural sensitivity in order to enhance therapeutic treatment of diverse populations.

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74 Appendix A

Critical Consciousness: A Workshop on Cultivating Culturally Sensitive Mental Health Practitioners

Workshop Facilitator Guidebook

KRISTINA GARCIA CALIFORNIA STATE UNIVERSITY, NORTHRIDGE MICHAEL D. EISNER COLLEGE OF EDUCATION DEPARTMENT OF EDUCATIONAL PSYCHOLOGY & COUNSELING

Guidelines for Facilitators

page 03 Beyond Diversity 04 Workshop Outline 05 Setting up the Space 06 Welcoming Attendees 07 Rules and Boundaries 08 Icebreaker Rules 09 Icebreaker Points of Discussion 10 Workshop Activities

11 Reflecting on the Workshop Videos Purpose 12 Handing Emotional To address the needs of culturally diverse Responses communities by strengthening cultural 13 Concluding the competence, cultivating Workshop cultural sensitivity, and acknowledging cultural 14 References humility by training mental health practitioners through an adaptable experiential workshop.

2 76 Beyond Diversity

The Critical Consciousness Workshop aims to extend the discussion of addressing cultural diversity issues beyond training that focuses on specific group characteristics and generalizations.

The Workshop you are leading is meant to be experiential and process-oriented. While there are definite psychoeducational components, the Workshop is geared toward addressing our own reactions, thoughts, and implicit biases when it comes to cultural differences.

In order to address the needs of our clients, we must first become aware of the conscious or unconscious ways we respond to people and groups who are marginalized based on their race, ethnic background, socioeconomic status, religion, gender, sexual orientation, and other social identities.

As you facilitate the Workshop, keep the following questions in mind:

• How do we understand our identities? • How do we demonstrate bias or implicit bias? • How do we feel about working with clients who do not share our similar values? • How do my personal experiences inform my judgment, clinically or otherwise? • How often do I impose my judgments to others, clients or others in general? • How can I move toward being a more critically aware mental health advocate?

The operational framework of the Workshop is based on the following practices:

• Self-of-the-therapist: Referring to the therapist’s emotional development and degree of self-understanding

• Multicultural Orientation Framework: Allows therapists to understand and relate to the cultural identities of clients in which therapists can detect when cultural dynamics requires enhanced awareness, knowledge, and skills

• Social Justice Advocacy: Expanding therapeutic interventions beyond just symptom reduction, but toward impacting systemic change that can benefit marginalized populations

3 77

Workshop Outline

• Introductions (15 minutes) o Workshop presenter(s) (maximum of 2) will begin with a brief welcome and personal introduction. o Video Screening – “Diversity Day” • Icebreaker Activity (45 minutes) • Establish Rules for Group Activities and Discussions (10 minutes) o Discussion on language of hate, bias, discrimination o Need to define boundaries for the process of discussion o Must be inclusive of all attendees o Extend discourse beyond polarizing issues o Acknowledge that facts, interpretations, perceptions can change over time o Introduce tools for conceptual understanding and dialogue • PowerPoint Presentation + Activities (1-hour 50 minutes total) o Psychoeducational slides . Psychoeducation on the following concepts: . Self-of-the-therapist . Cultural Sensitivity vs. Cultural Humility vs. Cultural Competence . Power and Privilege . Social Justice Framework . Multicultural Orientation . Implicit Bias . Slides will provide prompts and context for planned discussions, including videos and role play scenarios o ACTIVITY: What do you know or what have you heard? (25 minutes) o ACTIVITY: Think-pair-share (20 minutes) o ACTIVITY: Role-Play: Participants enact a scenario (20 minutes) • Video Screening: What can we do about the culture of hate? (20 minutes) • Wrap-up – Conclusion (25 minutes) o Bring group back together for any follow-up questions, thoughts, and concerns. o Pass out Workshop evaluation for participants to fill out and submit before leaving the Workshop.

There will also be a 15-minute break in between the first and second activity, bringing the duration of the Workshop to exactly 4 hours. ______NOTE: The Critical Consciousness Workshop can be adapted to fit other trainings, and can be lengthened or shortened depending on availability and/or training needs as organizers or facilitator(s) see fit.

78 4 Setting up the Space

Parameters • Workshop attendees should be capped at 20 • No more than two (2) Workshop facilitators at a time • Allot four (4) hours to complete the workshop (this does not include room or A/V equipment setup) • Ensure that every attendee fills out a Workshop Evaluation Form at the end Space Equipment • Computer • Projector • Screen • Speaker • Chairs to accommodate attendees and facilitators • The room should ensure safety and privacy concerns Materials • Starburst candy • Bags to hold candy • PowerPoint presentation slides (copies for attendees) • Workshop handouts • Paper and pens for activity • Evaluation forms

79 5 Welcoming Attendees

Welcome and Introduction

• Part I of the workshop comprises of a brief welcome by the facilitator(s) and an introduction of their background and interest in the subject of cultural diversity and awareness as it pertains to mental health treatment and approaches.

• As a way to model for the audience, the facilitator(s) should include the following information in their introduction: • Name and title • Educational background • Theoretical approach and/or preferred methods for conducting therapy • Personal anecdote about themselves and their investment in the topic of cultural diversity and awareness

• Facilitator(s) should also strive to create an open and safe space for sharing sensitive content by engaging attendees early on in the Workshop and by keeping a friendly and nonjudgmental demeanor.

80 6 Rules and Boundaries

Things to keep in mind

• Establish rules for group activities and discussions • Have an open conversation on language of hate, bias, discrimination • Define the boundaries for the process of discussion

• Must be inclusive of all attendees • Extend discourse beyond polarizing issues

• Acknowledge that facts, interpretations, perceptions can change over time • Introduce tools for conceptual understanding and dialogue Guidelines for Discussions

• Listen respectfully • Avoid inflammatory language • Respect each other’s views • Criticize ideas, not individuals • No blaming, no speculating

• Commit to learning

Dealing with Unanticipated Discussions • Acknowledge the comment, issue, opinion that was raised • Decide whether this is a topic you want to engage with at

that time • Assess the climate of the group and whether or not others

would like to have a dialogue about the issue that was raised

81 7 Icebreaker Rules

Starburst Icebreaker This activity is meant to address sociocultural issues that affect specific groups of people. It addresses issues such as power and privilege, unconscious language, bias, social stratification, and injustice. It is important that attendees remain unaware of the premise of the activity as way to elicit discussion once the activity has ended. During the activity the facilitator(s) must play a type of “character” that engages each of the three (3) groups utilizing specific language and a specific tone of voice that changes when addressing the different groups.

Groups are established using the candies as directed by the rules below.

• Group 1: Those with 40 or more points

• Group 2: Those with 20-39 points • Group 3: Those with less than 20 points There are two (2) rule changes during the activity, decided upon by members in Group 1. Rules

No talking allowed except by the facilitator(s) and when permitted by the facilitators. Directions

• Standup • Take 3 pieces of candy from the bag • Each color has a point value • Assign the points to the candies in your hand using the breakdown

below: • RED………….20 points • GREEN………10 points

• YELLOW…….5 points • PINK…………1point  BONUSES  3 of a kind……10 points  G, P, R………….5 points

82 8 Icebreaker Points of Discussion

Things to ask

The following are sample questions to ask after the Icebreaker has ended. Facilitator(s) should make every effort to engage all attendees in the discussion that follows. • How did the activity make you feel? • What do you think the activity was about? • What did you like or not like about the activity? • What were your thoughts while listening to the

facilitator(s)speak to your group or the other groups?

• How did it feel to not be able to talk? • Who was in what group? • Were you able to successfully move up to another group? • Did you wish you were part of another group? • How did you feel about the other groups?

• What do the other groups represent to you? • What do you think the rule changes were meant to do? • Why do you think there were rule changes allowed? • How can this tie into our work in mental health?

• Can you identify any clinical implications that would affect appropriate therapeutic treatment?

• What are your observations about how these topics play out in real life either by personal experience, heard on the news, or observed from friends/family? • Is there anything else you would like to add to the discussion?

83 9 Workshop Activities

Discussion on Implicit Bias

• Introduce concept of implicit bias and pull up website • Consider the following: Clinical implications of implicit bias o o Cultural diversity considerations in therapeutic treatment

What Do You Know or What Have You Heard?

• Participants will circulate around the room to read each posted sheet on the wall • With a marker, write ONE thing they you “know” or something you have heard about the people or group identified by the label on the poster boards • Once everyone is done, take some time to observe the completed lists Role Play

• Workshop attendees will have a chance to enact an assigned scenario/vignette • Divide participants into small groups (depending on the number of participants)

• Assign each group a scenario to read over and discuss. • Have group pick two participants to enact the scenario for the whole Workshop

• Engage participants in discussion after each group presentation. • Discuss identified cultural opportunities and other relevant concepts that were brought up during the role play Think-Pair-Share

• Workshop attendees get a chance to respond to a question individually, in writing • Workshop attendees will be broken up into dyads to discuss an assigned

topic and relate it back to their lives, experiences, or thoughts on the matter • Have participants reconvene with the larger group and debrief the activity • Inquire if anyone would like to personally share what they wrote

84 10 Reflecting on the Videos

“Diversity Day”

After Introductions, and as segue into part II of the Workshop, a brief video clip will be played from the popular television show, The Office. The 3:13 minute clip is from season 1, episode 2, titled “Diversity Day.”

• This clip was chosen specifically for its lighthearted, comedic take on addressing issues of diversity in a way that is subversive and thought- provoking. What might have started out as a noble cause with good intentions regarding “sensitivity training” quickly escalates into something unintentionally offensive.

• The clip is meant to set a specific tone for the workshop that will dive into sensitive issues concerning personal bias, power and privilege, and social justice.

“What can we do about the culture of hate?” After activities have ended, another video will be screened. The 17:46 minute video is from a TED Talk given by Sally Kohn in November 2017 in New Orleans, Louisiana titled “What can we do about the culture of hate?”

• The TED Talk was chosen specifically for its discussion on internal feelings

of hate. The word hate can be replaced by something less offensive should the attendees feel the need to identify a different descriptor for specific feelings.

• The clip is meant to elicit reflection among Workshop attendees about their own conscious and unconscious ways of exhibiting hate/intolerance/prejudice/bias. • Facilitator(s) are encouraged to reflect on these feelings along with the group and link the discussion to concepts discussed earlier on, such as: self-of-the-therapist, social justice advocacy, cultural sensitivity, etc.

85 11 Handling Emotional Responses

Identifying Triggers

Due to the nature of the Workshop, it is important for facilitator(s)to expect unplanned discussions and/or statements that cause emotional responses from other attendees or even themselves. Even well-intentioned comments can be taken personally. The following are common responses to triggers that facilitators should keep in mind:

• Avoidance: Avoiding future encounters and withdrawing emotionally from people or situations that can trigger unwanted feelings

• Silence: Not responding to the situation although upsetting • Misinterpreting: Feeling on guard and expecting to be triggered, we misinterpret something said and are triggered by our

misinterpretation • Attacking: Responding with the intent to lash back or hurt whoever has triggered us • Laughing: Being overcome by awkwardness or tension and bursting out in laughter, which can be misinterpreted • Launching asides or side conversations: Being unable to suppress commentary

• Internalizing: Taking in the trigger and believing it to be true • Being confused: Feeling angry, hurt, or offended, but not sure why we feel that way or what to do about it

• Naming: Identifying what is upsetting us to the triggering person or organization • Confronting: Naming what is upsetting us to the triggering person or organization and demanding that the behavior or policy be changed • Startling with surprise: Responding to the trigger in an unexpected way, such as reacting with constructive humor that names the

trigger and makes people laugh • Using discretion: Because of the dynamics of the situation (power imbalances, fear of physical retribution), deciding not to address the trigger at this time

86 12 Concluding the Workshop

Group Closure

• Acknowledge the experiential nature of the Workshop and reiterate

the importance of establishing healthy closure. • While the Workshop is not a “group,” the nature of the discussions

required processing and sharing of complex and personal stories. • To enable healthy group closure, facilitator(s) must allot enough

time at the end of the Workshop to bring the group together to recognize, console, celebrate, and thank the attendees for their

participation and openness. • Facilitator(s) can encourage attendees to briefly share what they

learned, their thoughts of appreciation to other attendees or facilitators, and/or acknowledgment of another participants’

willingness to share

Evaluations

• Introduce the evaluation form and encourage attendees to be candid and open about their experience in the Workshop.

• Note that the evaluation form is double-sided. • Let attendees know that the evaluation form is crucial to enhancing future workshops. • Workshop facilitators must allot enough time at the end of the

workshop to pass out workshop evaluation forms to all attendees. • The forms are to be filled out and returned to the facilitator(s) before attendees leave the workshop.

87 13 References

Center for Research on Learning and Teaching (2016). Guidelines for discussing incidents of hate, bias, and discrimination. Retrieved from http://crlt.umich.edu/publinks/respondingtobias

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., & ... Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100. doi:10.1037/pst0000160

Kohn, S. (2017 November). What can we do about the culture of hate? [Videofile]. Retrieved from https://www.ted.com/talks/ sally_kohn_what_we_can_do_about_the_culture_of_hate? language=en

Lum, W. (2002). The use of self of the therapist. Contemporary Family Therapy 24(1), 181 – 197. Kluwer Academic Publishers-Plenum Publishers. doi:10.1023/A:1014385908625 Mallinckrodt, B., Miles, J. R., & Levy, J. J. (2014). The scientist-practitioner- advocate model: Addressing contemporary training needs for social justice advocacy. 8(4). 303 – 311.

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Appendix B

A Workshop On Critical Cultivating Culturally Sensitive Mental Health Consciousness Practitioners By: Kristina Garcia Bellows College

Title Page – Introduce the Critical Consciousness Workshop. Refer to Guidebook to conduct brief introductions.

89 Agenda

• Introductions • Defining Terms Part II • Learning Objectives • Role-Play Activity • Guidelines for discussions • Discussion • Icebreaker activity • Think-Pair-Share Activity • Discussion • The Culture of Hate • Defining terms: Part I video • • What do you know or Discussion what have you hear? • Closing activity

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Briefly go over the agenda.

90 Objectives

➢ Exercise critical self- reflection ➢ Develop skilled dialogue ➢ Examine principles of cultural humility ➢ Practice creating safe spaces

https://youtu.be/PLp8pjqwlsc

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Review Workshop objectives and introduce the short video clip to start the workshop. Indicate that the clip is from the television show, The Office. Refer to the Guidebook for notes on the video clip.

91 Guidelines for Discussions

➢ Listen respectfully ➢ Avoid inflammatory language ➢ Respect each others views ➢ Criticize ideas, not individuals ➢ No blaming, no speculating ➢ Commit to learning

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Review workshop guidelines and reiterate the importance of adhering to the guidelines, give the sensitive nature of the Workshop. Refer to the Guidebook for more information.

92 Ground Rules Discussion Goals ➢ Listen respectfully ➢ Increase insight ➢ Avoid inflammatory ➢ Encourage critical self- language reflection ➢ Respect each others ➢ Practice safe dialogue views ➢ Identify emotional ➢ Criticize ideas, not triggers individuals ➢ Gain feedback ➢ No blaming, no speculating ➢ Commit to learning

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Review the ground rules and goals for discussions. Refer to the Guidebook for more information.

93 ICEBREAKER ACTIVITY NO CHEATING

NO TALKING

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Introduce the icebreaker activity and refer to the Guidebook for the rules.

94 Directions • Standup • Take 3 pieces of candy from the bag • Each color has a point value • Assign the points to the candies in your hand using the breakdown below:

• RED…………..20 points • GREEN………10 points • YELLOW…….5 points • PINK…………1 point ❖ BONUSES ❖ 3 of a kind……10 points ❖ G, P, R………….5 points

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Clearly explain the directions to the icebreaker activity.

95 Defining Terms

Cultural Competence Cultural Sensitivity Cultural Humility

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Introduce the next section’s focus on defining specific terms.

96 Self-of-the-therapist • Refers to a therapist’s emotional development, including emotional maturity, personality, and degree of self-understanding.

• Researchers find that the interpersonal and intrapersonal qualities of the therapist are tied to therapeutic outcome and the therapeutic alliance is directly affected by a therapist’s ability to handle stress, to respond constructively to anxiety, and to think and act autonomously while maintaining meaningful connections with others.

• Differentiation: Also known as emotional maturity. Entails the willingness to be accountable for your own emotional well being and destiny, while staying in meaningful contact with important people under stress.

(Regas, Kostick, Bakaly, & Donan, 2017).

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97 Cultural Competence

• Cultural competence involves a level of cultural awareness of self and others that enable effective treatment of clients from various cultural groups.

• It combines interpersonal and intergroup problem-solving skills with the unique cultural dynamics within a therapeutic environment.

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98 Cultural Sensitivity

• Culturally sensitive therapy emphasizes the therapist's understanding of a client’s background, ethnicity, and belief system.

• Cultural sensitivity also allows a therapist to gain and maintain cultural competence, which is the ability to first recognize and understand one’s own culture and how it influences one's relationship with a client, then understand and respond to the culture that is different from one’s own.

• A culturally sensitive therapist follows guidelines for working with diverse groups of people and understands that racial, cultural, religious, gender, and sexual identities interact with one’s beliefs and behavior. https://www.psychologytoday.com/us/therapy-types/culturally-sensitive-therapy

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99 Cultural Humility

• Cultural humility involves “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” (Hook, Davis Owen, Worthington Jr., & Utsey, 2013 p. 354).

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100 What Do You Activity Rules Know or What • Circulate around the Have You room to read each Heard? Activity posted sheet on the wall • With a marker, write ONE thing they you Goal “know” or something • Participants will you have heard about recognize the the people or group widespread use of identified by the label stereotypes • Once everyone is done, take some time to observe the completed lists

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Introduce the first activity. Refer to the Guidebook for more information. This activity should last no more than 25 minutes.

101 Multicultural Orientation Framework • The MCO framework is supposed to complement other models of psychotherapy, such as cognitive-behavioral therapy or systems therapy, and is a framework that articulates “a way of being” in session for therapists

• Stems from research on multicultural competencies (MCC) and builds on it to “incorporate how cultural dynamics can influence the process of psychotherapy

• MCO is concerned with how the cultural worldviews, values, and beliefs of the client and the therapist interact and influence one another to co-create a relational experience that is in the spirit of healing

(Davis et al., 2018, p. 90)

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102 Power and Privilege

• Social justice issues are grounded in power, privilege, and oppression

• Three characteristics of societies in which privilege and oppression exist – these societies are dominated, identified, and centered on privileged groups (Johnson, 2006).

• Those in the privileged groups dominate positions of power, cultural norms and modes of thought are identified by members of the privileged group, and conventional practices and policies are centered on and influenced by the privileged group (Lechuga, Clerc, & Howell, 2009).

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103 Social Justice Framework

Image obtained from https://ct.counseling.org/2016/01/multicultural-and-social-justice-counseling-competencies-practical-applications-in-counseling/ Bellows College 16

104 Social Justice Framework

Image obtained from https://familymedicine.queensu.ca/home/global_health/education Bellows College 17

105 Role Play Activity

• Break up into groups • Read over your assigned scenario • Discuss among yourselves how you would enact the scenario • Present the enactment in front of the group

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Introduce next activity and hand out scenario to each group. Group size depends on number of attendees. No more than 4 in a group. Refer to the Guidebook for more information.

106 Think-Pair- Share • Switch partners • Each person is given a prompt to briefly think and write about • Some prompts are the same, some are different • Once you’ve written your thoughts, share with your partner

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The next activity requires that attendees switch partners or break up into dyads with those not in their Role Play group. Pass out prompts to each pair. Refer to Guidebook for more information.

107 Implicit Bias

• https://implicit.harvard.edu/implicit/ • https://implicit.harvard.edu/implicit/takeatest.html

What is it? • “This tendency for stereotype-confirming thoughts to pass spontaneously through our minds is what psychologists call implicit bias. It sets people up to overgeneralize, sometimes leading to discrimination even when people feel they are being fair” (Payne, Niemi, & Doris, 2018).

Why does it matter? • Clinical implications • Cultural diversity considerations in therapeutic treatment

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Open up the website and show how to access the tests. If time permits, click on a test as an example.

108 TED Talk Video While watching, jot down: What we can do about the • Thoughts about her culture of hate presentation • What did you like or did not like about it? Sally Kohn • Can you relate? ~ • How might this affect • “In big and small ways, consciously and unconsciously, we constantly filter the treatment of others? world around us through the lens of our (Clinically or otherwise) explicit and implicit biases.”

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Introduce the next video clip and the accompanying book. Refer to the Guidebook for talking points.

109 ://What we can do about the culture of hate Bellows College

110 Closing

Reflect Discuss Evaluate

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111 Thank you

Kristina Garcia

[email protected] Bellows College 24

Bring the group back together to conclude the workshop. Debrief about the experience and ask if there are any questions.

Pass out the workshop evaluation forms to each attendee and indicate that it is 2 pages front and back. The forms should be collected before each attendee leaves the workshop.

112 References

Center for Research on Learning and Teaching (2016). Guidelines for discussing incidents of hate, bias, and discrimination. Retrieved from http://crlt.umich.edu/publinks/respondingtobias Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., & ... Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100. doi:10.1037/pst0000160 Johnson, A. (2006). Privilege, power, and difference. Boston: McGraw-Hill.37/a0032595 Kohn, S. (2017 November). What can we do about the culture of hate? [Videofile]. Retrieved from https://www.ted.com/talks/sally_kohn_what_we_can_do_about_the_culture_of_hate?language =en Lechuga, V.M., Clerc, L.N., Howel, A.K. (2009). Power, privilege, and learning: Facilitating encountered situations to promote social justice. Journal of College Student Development.50(2). 229-244. Lum, W. (2002). The use of self of the therapist. Contemporary Family Therapy 24(1), 181 – 197. Kluwer Academic Publishers-Plenum Publishers. doi:10.1023/A:1014385908625 Mallinckrodt, B., Miles, J. R., & Levy, J. J. (2014). The scientist-practitioner-advocate model: Addressing contemporary training needs for social justice advocacy. 8(4). 303 – 311.

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113 References

Payne, K., Niemi, L., Doris, J.M. (2018 March 27). How to think about implicit bias. Retrieved from https://www.scientificamerican.com/article/how-to-think-about-implicit-bias/ Penn State. (n.d.). Diversity activities for youth and adults. Retrieved from https://www.uh.edu/cdi/diversity_education/resources/activities/pdf/diversity-activities-for- youth-and-adults.pdf Project Implicit (2011). About us. Retrieved from https://implicit.harvard.edu/implicit/aboutus.html Regas, S. J., Kostick, K. M., Bakaly, J. W., & Doonan, R. L. (2017). Including the self-of-the-therapist in clinical training. Couple and Family Psychology: Research and Practice, 6(1), 18-31. doi:10.1037/cfp0000073 The Office US (2014 August 28). Michael Scott’s school of management – The Office US [Video File] Retrieved from https://www.youtube.com/watch?v=PLp8pjqwlsc&t=35s Winter, J. & Aponte, H.J. (2008). The person and practice of the therapist. Journal of Psychotherapy & the Family, 3(1), 85 – 111. doi: 10.1300/J287v03n01_10

*All images in this PowerPoint (unless otherwise cited in the slide) were obtained from www.unsplash.com, a website that hosts free to use photos

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114 Appendix C Workshop Handouts

Role Play Scenarios Everyone should form groups of 4. Each group will receive a scenario and will be given a chance to respond to it creatively, as a role play. Each group will decide to best illustrate what the prompt is asking for, and can add to the story in order to flesh out the characters and the enactment. The following scenarios will be passed out to workshop attendees on separate sheets of paper:

Scenario 1: Enact a brief role play that is culturally sensitive based off the following scenario/prompt: You are in your seventh session with an adult client who was a self-referral to the clinic where you work. The client discloses to you that his family hates his girlfriend who he plans on asking to marry him. He always spoke about his family in a positive light, so this strikes you as a surprise. He is very close to mother, who is adamant that her son not marry his girlfriend because she recently found out that she is transgender. Your client expresses that he initially had reservations, too, but knows “for sure” that he is “ready,” but does not want to upset his family. He feels torn and expresses that his girlfriend is very sad, but is understanding of his feelings. He is unsure how to handle the situation and it is causing him massive stress that is affecting his work and relationship.

Scenario 2: Enact a brief role play that is an example of power and privilege within a clinical or educational setting based off the following scenario/prompt: You are a first-year graduate student and you witness something in one of your graduate classes that was very upsetting to you and your classmates. When you speak up about it, you find yourself ostracized by the professor and believe that he is grading and treating you unfairly. When you try to speak to him about it, he intimidates you and threatens to fail you. You are too scared to bring this to anyone’s attention so you go on with the class, and accept the grade he gave you at the end of the semester. This causes you significant distress as you move along your graduate program, and you bring it to your therapist’s attention during one of your sessions.

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Scenario 3: Enact a brief role play that is an example of implementation of a multicultural orientation framework, based off the following scenario/prompt: You have been working with a client for three sessions that is culturally different from you. The client starts talking about her childhood and a particular memory she had of her grandmother talking about her experience with racism growing up. The client becomes subdued, but then starts talking rapidly and appears angry while telling the story, sometimes jumping back and forth between her grandmother’s story and her own experiences with racism. The client starts talking about an incident with a coworker that was blatantly racist and she asks for your input on what to do next.

Scenario 4: Enact a brief role play that illustrates the difference between cultural sensitivity and cultural competence based off the following scenario/prompt: You are in your third session with a bicultural couple that came in experiencing “intimacy issues.” The husband is Mexican, and the wife is Korean. During session, the couple begins arguing about each other’s family dynamics, and begins demeaning one another’s upbringing and cultural standards.

Scenario 5: Enact a brief role play that showcases a social justice framework in action based off the following scenario/prompt: You are in session with a client you have been working with for several months. She initially came in because was experiencing a lot of anxiety. She worries about finishing college in the United States because she is undocumented. She starts crying and talks about how her family lives in constant fear of deportation. She mentions wanting to protest and writing to her Congressman, but is too scared this might backfire against her. She indicates feeling weak and unable to do anything about the situation.

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Think-Pair-Share The following are questions to be used for the Think-Pair-Share Activity. Each question will be printed on a small piece of paper and distributed to the workshop attendees. Each pair will have a chance to respond to the question on their own and discuss their response with their partner. There will be a process discussion with the whole group after each pair has had their chance to respond to the question. Questions:

1. Have you faced or witnessed prejudice or discrimination in your work, school, or clinical setting? Describe what happened. 2. What thoughts do you have on the concept of white privilege? Discuss your feelings and initial impressions of the conversation around white privilege. 3. In your opinion, why are people sometimes hesitant in pursuing what they desire the most? Consider aspects of culture in formulating your response. 4. What are your thoughts on how money and social status affect the ways people interact (or don’t) across racial/ethnic boundaries? Does such status affect interaction across other boundaries as well? 5. In your opinion, what is the relationship between politics and diversity issues affecting society? How does your interest in and commitment to diversity issues relate to your own political identity? 6. In your opinion, what makes diversity issues so hard to talk about? 7. How and where do you see stereotypes reinforced in society? How and where do you see them challenged? 8. In what ways can stereotypes threaten or interfere with the therapeutic relationship? Give examples in your response. 9. What dimensions of your cultural background affect who you are, what you think, what you know, and what you want to learn? 10. How does your cultural background relate to what you notice about others and what is important to you?

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Appendix D Workshop Evaluation Form

Your feedback is critical to the success of the workshop. We would appreciate if you could take a few minutes to share your opinions with us so we can assess and evaluate the content of the workshop in order to identify areas that need to be re-evaluated, areas that participants enjoyed, and areas that you would like to see covered in future workshops. Please return this form to the facilitator or organizer at the end of the workshop. Thank you.

Workshop title: ______

Date: ______Location of workshop: ______

Name(s) of Workshop Facilitator(s): ______

Please rate the workshop content according to the following scale:

4 = Strongly Agree 3 = Agree 2 = Disagree 1 = Strongly Disagree 0 = No Opinion

Circle your response to each question

1. The workshop met my expectations. 4 3 2 1 0 2. The workshop content was helpful and informative. 4 3 2 1 0 3. The level of the workshop was appropriate. 4 3 2 1 0 4. The workshop format was enjoyable. 4 3 2 1 0 5. The facilitator(s) had a good grasp of the topics. 4 3 2 1 0 6. The workshop was worth my time. 4 3 2 1 0 7. The length of the workshop was appropriate. 4 3 2 1 0 8. I would highly recommend this workshop to others. 4 3 2 1 0 9. I learned something new about myself. 4 3 2 1 0 10. I learned something new that will benefit me. 4 3 2 1 0 11. I enjoyed the activities embedded in the workshop. 4 3 2 1 0 12. There was opportunity to ask questions. 4 3 2 1 0 13. I felt comfortable during the workshop. 4 3 2 1 0 14. The pace and style of the workshop was effective. 4 3 2 1 0 15. The facilitators made me feel comfortable. 4 3 2 1 0 16. The discussions were very helpful to my understanding. 4 3 2 1 0 17. My overall experience of the workshop was positive. 4 3 2 1 0

OVER, PLEASE

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18. Given the topic, was this workshop:  a. Too short  b. Right length  c. Too long

19. In your opinion, was this workshop:  a. Introductory  b. Intermediate  c. Advanced

20. Which topics or aspects of the workshop did you find MOST interesting or MOST useful? • ______• ______• ______• ______

21. Which topics or aspects of the workshop did you find LEAST interesting or LEAST relevant? • ______• ______• ______• ______

22. Did the workshop achieve its learning objectives? Yes No

If no, please state why: ______

23. Comments and suggestions for future workshops: ______

24. What would you have liked to have MORE of during the workshop?

 a. Discussion  b. Videos  c. Activities  d. OTHER ______

25. What would you have liked to have LEAST of during the workshop?  a. Discussion  b. Videos  c. Activities  d. OTHER ______

Thank you for your feedback!

Please feel free to contact the workshop organizers if you have any questions or concerns.

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