Integrating multiple multicultural identities into the conceptualization of a client is essential. Ridley and Hill (1998) explained culture is a shared learned behavior, passed from one generation to another, that includes internal (attitudes, values, beliefs) and external (artifacts, roles, and institutions) facets. Thus, culture plays a significant role in a person’s life. Culture determines what it means to be human depending on contextual factors. Individuals live within the context of multiple realities (Microtraining Associates, n.d.). For example, William Thompson is male, African American, non-disabled, heterosexual, catholic, and more. All people are multicultural (Cohen, 2009). However, it is essential to note individuals vary in their adherence to culture (Ridley and Hill, 1998). This paper will focus on three salient identities for William Thompson.
Overview of William
William Thompson is a 38-year-old African American male. He is a veteran of the Iraq War. He married Luli Kim, a 27-year-old Korean American female. He used to work in finance. However, he was recently laid off. He then lost his home in Hackensack, New Jersey and moved in with his stepbrother and sister-in-law in Pasadena, California. William started to abuse alcohol in Iraq to escape traumatic memories of the war. He experiences flashbacks, avoids reminders of the war and experiences sadness, insomnia, and anger. William and Luli have become estranged: Luli would like William to talk to her about what happened in Iraq and he believes he must protect her from those experiences. (Laureate Education, 2013)
One of William’s salient identities is that of being male. For example, William enjoys physically demanding activities like soccer that are historically male dominated. From a young age William was taught what it means to be a man in his culture. Young boys may be encouraged to be more rough and independent which may cause issues with empathy and bonding (Brown & Lent, 2008). The reason for concern is that boys may miss out on emotionally fulfilling connections with others. Furthermore, boys may be punished more severely when not following gender norms (Brown & Lent, 2008). For example, a boy’s father may be punitive toward crying. Brown and Lent (2008) explained that males may repress traumatic experiences because parents and society often normalize physical aggression while regarding the expression of emotion in boys as weakness. They further noted that men are more likely to abuse alcohol, engage in partner violence, exhibit road rage, and abandon children, potentially as a result of these social influences. In William’s case it does seem that he is repressing his emotions and often feels angry. He is also drinking daily which may have put his career in jeopardy. Male norms seem to have influenced William greatly.
Another salient identity for William is being African American. African Americans may experience insults to intelligence (microinsult) or be seen as overly sensitive (microinvalidation) (Laureate Education, 2012). Racial aggression can create a hostile environment (Microtraining Associates, 2003). William has likely dealt with these aggressions. These experiences tend to affect an individual’s identity. Individuals within minority groups often experience oppression, characterized by limited power and privilege. Furthermore, African Americans believe issues should be resolved within the family, if possible, and African Americans are expected to show strength (Thompson, Bazile, & Akbar, 2004). William may have trouble opening up, and seeking help, due to his African American cultural background which is likely exacerbated by being male as well.
Additionally, the influence of socioeconomic status [SES] and class on identity is salient. William received his Doctor of Jurisprudence degree and worked as a lawyer specializing in finance law. Social class can influence identity, stress, and worldview (Brown & Lent, 2008). His SES possibly influenced his interests like jazz music and art collecting. He was likely in an upper-middle class when working as a finance lawyer, however, he lost that status recently. Perceptions of social class define experiences more than objective income (Brown & Lent, 2008). It is possible that William still perceives himself as upper-middle class, since his current situation is only temporary. William and Luli may try to ‘keep up appearances.’ People of low SES backgrounds Poor are often regarded as subhuman or deficient; children, for example, have described those from low-income households as dirty, unintelligent, and unattractive, among other negative attributes (Lott, 2002). Thus, William and Luli may try to separate their identities from being poor. Internalized classism is when an individual experiences depression due to not being able to maintain perceived social class (Brown & Lent, 2008). William and Luli are at risk for depression. People from lower social classes face ongoing stressors stemming from limited control over their circumstances (Brown & Lent, 2008). William may be preoccupied with regaining some control in his life. He is likely very stressed due to adjusting to a different lifestyle and conflicting identity.
Social Context of Identity
Society heavily influences how identities are interpreted and what effect they have on the livelihoods of individuals. Brown and Lent (2008) explained the macrosystem influences identity: the macrosystem includes social identity structures and group level hierarchies like institutional racism. Race, for example, is a social construct and has historically been used to oppress groups of people (Microtraining Associates, 2008). Groups may internalize racial stereotypes integrating them into identity. Another example of social influence is how different sexes are socialized in gender defined cultures (Brown & Lent, 2008). People use culture to define the expectations of each gender. For example, society encourages men to be aggressive, preoccupied with sex, take risks, use power tactics, and dominate in relationships (Brown & Lent, 2008). It is evident that William’s identities (male, African American, etc.) were influenced by society.
Factors to Consider in Therapy
William’s identities can help predict cognitive, affective, and behavioral patterns that will present in therapy. The Microtraining Associates (2010) video explained, cultural factors may predict the course of treatment or provide markers for consideration. They stated, for example, the cultural importance of relationships and beliefs about relationship norms are factors to consider. As a male William may believe he must be the provider in a relationship. Men equate their masculinity to ability to provide, thus, the loss of the worker/provider role for men can lead to depression and suicidal ideation (Brown & Lent, 2008). The loss of the worker role may be a meaningful topic to consider in therapy. Brown and Lent (2008) stated helping men recognize that destructive behaviors may be due to socialized male norms increases self-control and decreases self-blame. It may be pertinent to address Williams inflexible beliefs about male expectations. When considering William’s African American identity the practitioner must be aware that trust may not come easily. Individuals from historically marginalized groups may not feel safe in therapy (Smith, 2008). Thompson, Bazile, and Akbar (2004) found that African Americans frequently perceived psychologists as insensitive; they feared misdiagnosis and brainwashing. They explained seeking psychotherapy was viewed by African Americans to show weakness which diminished pride. There could also be issues with conflicting SES status between the psychologist and client. Ballinger and Wright (2007) warned there is a potential for disempowerment when a middle class practitioner works with a working-class client. William is currently unhoused and maybe more likely to misinterpret the psychologist as judgmental. Furthermore, William is at risk of health issues due to his recent lower SES. He may need to find a lower status job that could be more physically demanding and stressful. Constant work stress can lead to depression, compromised immune, and cardiovascular disease (Brown & Lent, 2008). These factors must be considered in therapy to provide effective treatment.
How to Respond to Factors
It is essential to respond to the client in an affirmative and accepting way, challenging beliefs only when necessary. Brown and Lent (2008) stated psychologists must be able to address multicultural issues sensitively and in relation to the culture. They asserted cultural empathy is essential. When addressing SES, for example, it will benefit the client to understand his perception of class and not assume. Pedersen et al. (2008) stated that practitioners may need to focus on self-advocacy. For example, William may experience racism in the workforce and this should be addressed in therapy. Cardemil and Battle (2003) stated having an open discussion about race and recognizing differences can strengthen the therapeutic alliance. Brown and Lent (2008) suggested psychologists identify male’s false beliefs about pressure to reveal vulnerabilities prematurely or give up control in therapy. They recommended using humor, self-disclosure (only when helpful to the client), and psycho-educational groups with male clients. The psychologist must not force their cultural worldviews on the client.
Effect of Identities on Assessment and Diagnosis
The complex layers of William’s multiple identities could be misinterpreted and lead to under or over diagnosis. Brown and Lent (2008) stated that certain racial groups are more likely to receive a diagnosis, even when meeting the same criteria as individuals from other racial groups. They stated the client’s situation must be taken into account so bias is mitigated in diagnosis, however, culture should not be overemphasized either. For example, normal behavior, like anger due to prejudice, could be pathologized. Those that experience racism may be seen as overly aggressive and paranoid (Microtraining Associates, 2003). It is essential to learn dynamic sizing. Dynamic sizing is knowing when to generalize and when to focus on the individual (Bernal et al., 2009). Examiners must also be aware that there is diversity within groups (Laureate Education, 2011). Thus, the psychologist must be aware of how culture influences the way symptoms present in individuals.
Theoretical Approach
I would use psychodynamic therapy, integrating the interpersonal approach, when working with William to address the underlying feeling of guilt that is being externalized as interpersonal anger and drinking. I would also focus on the client’s strengths. Studies have shown the efficacy of positive psychotherapy which focuses on the client’s strengths (Microtraining Associates, 2010). A psychodynamic approach may be useful to delve deeper into cultural issues. Cardemil and Battle (2003) described how encouraging a Mexican American woman to look for another job might be useful, however, addressing how familismo is met through her current job is more revealing. Addressing causes of behavior, instead of only symptoms, can help prevent clients from making similar mistakes in the future. Psychodynamic therapy can be used to address a client’s inner conflict (which can lead to guilt or anxiety), coping, and relational characteristics (how an individual responds to others) (Yerushalmi, 2019). I believe psychodynamic therapy would benefit William since it addresses his primary concerns.
Multicultural Theories That Support Therapeutic Approach
Psychodynamic therapy aligns with multicultural theories. The ecological systems theory supports that some mental health problems are influenced by society, parents, and more (Brown & Lent, 2008). Psychodynamic therapy can address how systems have contributed to current symptoms by looking at childhood experiences and development. Multicultural theories support the concept of interpersonal defense mechanisms created in response to discriminatory and traumatic experiences which can be understood and addressed using psychoanalysis (Vazquez, 2014). The ecological validity argument is used to explain the need for psychotherapy to align with the client’s ethnocultural view (Bernal et al., 2009). Psychologists can integrate the client’s views and go in-depth into the meaning and implications of these cultural views with psychodynamic therapy. When interpersonal therapy was adapted using the ecological validity model which focused on familismo, respeto, and encouraged parent participation, 82% of teens were functional after treatment (Bernal et al., 2009). Using psychodynamic theory can facilitate exploration of complex cultural phenomena and how said experiences affect the individual in the present.
Additional Questions for William
To confirm assessment and diagnosis I would need to ask some clarifying questions. It will be essential to ask about culture. Cultural factors can vary in salience (Microtraining Associates, 2010). In relation to being male: do you feel it is your duty to be the provider, do you have trouble expressing emotion? Questions about being African American: how would you describe your experiences with racism, can you tell me about your culture? Finally, to know more about SES I would ask: do you feel people look down on your current situation, how did losing your job make you feel, what class do you consider yourself a part of?
How PTSD Influences Identities
There is an interaction between symptoms of posttraumatic stress and multicultural identities. First, posttraumatic stress disorder has put William’s identities at risk of being lost. William’s socioeconomic status was likely lost due to symptoms of PTSD and alcohol use. PTSD also hinders William’s ability to find employment and better his social class. He may question his manhood due to the stigma of being weak in relation to PTSD. As an African American male he may experience more severe hypervigilance or shame. Clients with the same diagnosis can present differently due to cultural background (Zalaquett et al., 2008). Coleman et al. (2008) found no evidence of more severe hypervigilance among African American veterans, however, higher reexperiencing was present. Mental health disorders and cultural identities have bidirectional influence on an individual.
Strategies for Processing Military Experiences
Identification of source of guilt would be an effective strategy for processing military experience. According to Hendin (2017), guilt is a major factor that increases suicide risk in veterans. He showed that psychodynamic psychotherapy successfully decreased guilt. He gave an example of processing emotions in a nightmare and connecting the nightmare to real events that had been buried: which helped the client accept what had happened. Hendin also stated for those with PTSD and abusing substances enrollment in a substance abuse program is beneficial. Thus, William should go to psychodynamic and substance abuse therapy. Levi et al. (2017) described psychodynamic group therapy [PGT] as another successful approach. He explained PGT helped veterans not feel isolated, to express emotion, trust others and work through grief, guilt, and suffering by confronting traumatic experience. Paintain and Cassidy (2018) described using the psychodynamic conceptualization that PTSD is a normal adaptive process. By using these approaches the individual can work through and move past traumatic experiences which will lessen problematic symptoms.
Explanation of Role of Religion on Identities
Religion and spirituality play a role in defining other cultural identities. For example, religion may define the role a man is supposed to take in the household. Religion(s) have shared rules, for example, people that follow the same religion may have similar prayers, holidays, and food restrictions (Cohen, 2009). African Americans often find a sense of community and celebration of culture at church. However, religion can be a source of resilience or can cause shame (Microtraining Associates, 2006). Religious individuals sometimes question if their misfortune is a punishment from God. William, for example, may believe that losing his job and house is his punishment for the actions he took in Iraq. Since religion defines what it means to be a good productive African American male going against religious doctrine will lead William to question his identity.
Impact of Religion on Diagnosis
Ignorance about religious norms could cause overdiagnosis of pathology. For example, those that are strict in their religion may experience more anxiety and guilt. They may also experience unreality and be seen as having symptoms of paranoia and schizophrenia. Some have posited that religion is a risk factor for psychosis or those with psychosis become religious (Rosmarin, 2018). It is essential to be aware of religious norms and work within that range.
Impact of Religion on Treatment
Religion may need to be addressed in treatment. William has a Catholic upbringing, however, after the war he stopped participating in church activities. It is possible that he is ashamed to go to church. He may believe that he no longer deserves forgiveness and he may be afraid to go to hell. Nonetheless, reconnecting with his religion has the potential to help William find forgiveness and meaning in his life. Spirituality can decrease depression and drug use; can increase marital satisfaction (Microtraining Associates, 2006a). Frankl argued discovering meaning was the primary motivating force in life and could help clients get better (Microtraining Associates, 2006b). The psychologist will have to collaborate with the client to see if returning to church is a good option or not.
Related APA Codes
There are more than a few American Psychological Association [APA] ethical codes that relate to interactions with William. According to the APA (2002), psychologists must be aware of their own perception as cultural beings; strive to move beyond categorical assumptions; promote culturally adaptive interventions; and be aware of cultural strengths. Clients must not be criticized for being different than the psychologist. Other pertinent principles are: A, competence with a variety of populations; D, respect the rights of others; E, mitigate harm; F, contribute to social justice (APA, 2003). It is imperative to be competent in multicultural psychology to ensure that bias and harm are mitigated in therapy.
Influence of Biases and Professional Development
Biases can lead to microaggressions. However, everyone has biases. Perceptions are difficult to control due to unconscious impressions (Johnson, 2018). Psychologists must examine their own cultural identities and interactions with different others (Laureate Education, 2011). One of the most prominent biases I may have when working with William concerns gender. For example, I must be careful to not assume that William is physically aggressive. According to Ballinger and Wright (2007), differing worldviews based on class can hamper development of empathy. I also lack an insider understanding of African American culture so it will always be challenging to truly put myself in William’s position. The first step in being ethical is having a sense of solidarity with other human beings (Gallardo, et al., 2009). Intimate contact with others is also essential for developing cultural empathy (Laureate Education, 2012). Thus, I can continue my professional development by taking advantage of opportunities to experience diversity
In conclusion, William is a multicultural being and it is essential to understand how his cultural identities shape his life. His three salient identities discussed here were male, African American, and upper-middle class. Society has played a significant role in defining key features of each identity. These features must be considered in therapy since they may play a role in how or why symptoms present. However, psychologists must be careful to not under or overemphasize culture. In William’s case, psychodynamic therapy would be a good fit since guilt and culture can be addressed with this approach.
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