Multicultural Counseling Meets Potentially Harmful Therapy

Abstract

This reaction includes an appraisal of contributions, limitations, and questions raised in Wendt, Gone, & Nagata’s major contribution regarding potentially harmful therapy (PHT) and multicultural counseling. The authors are commended for initiating a convergent dialogue between the PHT and multicultural counseling literatures, creating a strong argument for their integration, and contextualizing the prior division. Commentary is provided in response to the narrow emphasis on an ethnoracial domain of culture, and suggestions for broadening the PHT/multicultural counseling dialogue through inclusion of multiple identities and intersectionality are provided. Greater integration of specific ethics codes and guidelines is also encouraged. Finally, future directions for consideration and study are posited, including the practicalities of researching harm within an integrated PHT/multicultural counseling framework, the necessity of working toward a refined definition of harm, and the manner through which the multicultural counseling perspective on addressing culturally based injury could augment existing PHT efforts to mitigate harm.

Keywords

multicultural counseling potentially harmful therapy ethics

In beginning to bridge the separate discourses of multicultural counseling and potentially harmful therapy (PHT), the work of Wendt, Gone, and Nagata (2015, this issue) provides a thoughtful contribution. Given the indicators that these two areas of scholarship reside in the somewhat separate silos of counseling and clinical psychology, we are pleased to see this manuscript appearing in The Counseling Psychologist in an effort to start a vital dialogue in our field regarding PHT and multicultural counseling. We believe that this contribution raises important issues as well as critical questions regarding ethics, clinical practice, and research.

Wendt et al. (2015) are to be commended on conceptualizing the ways in which the literatures in multicultural counseling and PHT can and need to inform one another. Critically reviewing the work of Lilienfeld (2007); Barlow (2010); Castonguay, Boswell, Constantino, Goldfried, and Hill (2010); and Dimidjian and Hollon (2010) to recognize strengths and limitations, and in turn to start to examine the missing multicultural and contextual components, is laudable. In addition, the reflection on how our own field has neglected PHT in the framework of multicultural counseling is necessary if these two areas are to be bridged. Relatedly, noting the important differences between the two literature bases—and within the two respective disciplines of counseling and clinical psychology—with respect to (a) politics that have kept these literatures separate, (b) implicit assumptions, and (c) basic definitions, is a considerable strength of the contribution. Acknowledging and working to overcome these points of divergence is imperative to move forward.

The organization and contextualization of the manuscript are also points of strength regarding the contribution. First, the manuscript’s discussion of harm using the dimensions of sources, objects, and scope from Sharpe and Faden (1998) provides an accessible structure to understand the ways in which the respective discourses of PHT and multicultural counseling have considered harm in therapy. More specifically, the nuances between the literatures are highlighted in the discussion of (a) specific treatment approaches versus cultural and institutional factors that influence psychotherapy, (b) a focus on the individual client versus the group level, and (c) using a medical model framework of adverse effects versus potential alienation and oppression. In addition, situating the manuscript and the two disparate discourses of PHT and multicultural counseling within clear historical and societal contexts assists the reader in understanding why these literatures developed independent of one another, as well as the importance of alleviating this separation.

In light of these considerable strengths, two areas of omission stood out as we reviewed the contribution. First, Wendt et al. (2015) exclusively focus on the cultural domains of race and ethnicity to illustrate their view of the needed convergence of the PHT and multicultural counseling domains. They state that they narrowed the conceptualized breadth of multicultural counseling for pragmatic purposes, given the extensive range of cultural identities within the multicultural literature. Although it may be practical to limit the scope of cultural domains for the sake of manuscript length, we believe the authors could have broadened their discussion beyond the ethnoracial domain to include other facets of cultural identity (e.g., sexual orientation, gender, socioeconomic status, national origin, ability, religious affiliation). The explicit inclusion of the full range of cultural identities would present a more complete scope of the ways in which clients may be harmed by interventions or therapist effects that are culturally inappropriate. Furthermore, acknowledgment of the inherent intersectionality and respective salience of multiple identities (e.g., Ferguson, Carr, & Snitman, 2014; Seedall, Holtrop, & Parra-Cardona, 2014; Shields, 2008; Silverstein, 2006; Warner & Shields, 2013; Yakushko, Davidson, & Nutt Williams, 2009) is a critical component of incorporating multicultural issues within the PHT literature. To wit, Silverstein (2006) urged psychotherapists to consider that a “competent clinical practice requires a complexity paradigm that encompasses the intersectionalities of class, gender, race/ethnicity, and other aspects that define an individual’s subjective experience” (p. 21). Thus, reducing clients to a single identity is potentially harmful and culturally insensitive.

Second, ethics are at the core of this burgeoning discussion of joining the PHT and multicultural counseling literatures. However, the current contribution merely assumes the basic ethical mandate to “do no harm,” rather than providing more overt and specific connections to the American Psychological Association’s (APA; 2010) Ethical Principles of Psychologists and Code of Conduct. In addition, numerous guidelines that have been approved as APA policy (e.g., Guidelines for Psychological Practice With Lesbian, Gay, and Bisexual Clients [APA, 2012], Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists [APA, 2003]) are critically germane to this discussion. We believe the bridging of PHT and multicultural counseling must include explicit connections to particular APA Codes, Principles, and Guidelines. For example, APA (2010) Code 2.01(b) states,

Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies. (p. 5)

In addition, Guideline 1 of the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003) states, “Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves.” These two representative examples of our APA Code of Ethics and APA Multicultural Guidelines bear directly to the issues of PHT and multicultural counseling described in the current contribution. We suggest that the inclusion of the APA ethics codes and respective guidelines providing specific attention to ethical practice is a necessary component in furthering this important dialogue regarding PHT and multicultural counseling.

Questions and Future Directions

In response to the important contribution by Wendt et al. (2015), we offer the following questions for consideration and future study. First, we discuss two practicalities of researching harm using the integrative perspective of the PHT and multicultural counseling literatures, noting complicating practitioner and client factors. Second, we echo some concerns voiced within the PHT literature regarding the lack of a clear definition for PHT and caution against the over-extension of this label. Finally, we suggest that placing emphasis on the knowledge, awareness, and skills necessary for identifying harm and repairing ruptures across contexts and theoretical models may be a helpful extension of integrating PHT and multicultural counseling research.

As described by Wendt et al. (2015), it is well established that ethnocentric and oppressive therapeutic practices pose harm to clients, especially to those who are members of marginalized cultural groups. Fortunately, as the psychological field has shifted toward greater inclusion of multicultural perspectives (Pieterse, Evans, Risner-Butner, Collins, & Mason, 2009), APA-accredited graduate programs have been mandated to mirror this progress through developing coursework, research foci, and practice components for training culturally competent practitioners (APA, 2003). In addition, clear benchmarks for evaluating trainee competency have been established, including specific areas of ethics, clinical practice, and multicultural issues (Fouad et al., 2009). Despite these advances in developing multiculturally competent psychologists, there is still much progress to be made, and training programs would benefit from understanding whether current efforts are yielding improvements in multicultural competence (MCC) and ethical delivery of services among recently trained practitioners. Therefore, we suggest that future research within the integrated framework of PHT and multicultural counseling should account for psychotherapist cohort effects as the era in which practitioners were trained may be an important factor related to PHT and multicultural counseling. More specifically, the timing of graduate training may prove to be a confounding practitioner variable such that clinicians trained prior to, as opposed to during, the field’s current zeitgeist and commitment to multiculturalism may practice quite differently, and therefore, client experiences of culturally bound harm may vary accordingly. In addition, it is important to acknowledge the necessary ongoing development of MCC through continuing education and, therefore, account for knowledge, awareness, and skills acquired in these capacities when assessing differences among practitioners.

In a manner that echoes concerns noted by Dimidjian and Hollon (2010) and Lilienfeld (2007), when studying deterioration that occurs during the course of therapy, we wonder how to account for outside influences that impede progress or interact with treatment methods in a negative manner. Parsing the impact of treatment versus external stressors and events is difficult with respect to outcome research, and raises issues of client history and timing that are often outside a clinician’s control. For example, as part of a current clinical intervention study, we are implementing a manualized group counseling protocol for exploring shame and developing resilience to its deleterious effects. As a component of recruitment and screening to intervention, participants are informed that this treatment often results in a degree of emotional dysregulation as (often) suppressed experiences of shame become more overt as they learn about shame and shame triggers through the process of this group counseling protocol. This emotional discomfort is temporary as participants report that understanding and moving through the painful feelings associated with shame facilitates their development of self-compassion and self-worth. However, for some individuals, historical influences (e.g., trauma) and external factors (e.g., poverty, unemployment, substance use, intimate partner violence) have created crises during the course of treatment. Although these crises appear to be external to the group counseling intervention, they often result in increased symptom distress for participants and/or withdrawal from treatment. This example is provided to illustrate the methodological complexity of this line of PHT and multicultural counseling research regarding accurately accounting for treatment effects versus external and client-specific factors when evaluating the efficacy and safety of treatment.

Despite consensus regarding iatrogenic injury, it seems that the definition of harm within the PHT literature still needs to be refined. Of note, Wendt et al. (2015) indicated that in lowering the standards for harmful treatment in efforts to be more cautious, we should consider damage that does not directly impact the client but rather individuals who are secondarily affected by the client’s participation in therapy (e.g., romantic partner, friend, family member). Using facilitated communication as an example, it is clear that harmful therapies can have significant negative impacts on individuals closely connected to the client, and that distress within one’s mesosystem could reasonably impact the client in turn. Although it is certainly necessary to consider the wider ramifications of a client’s therapeutic work, we propose that scientist-practitioners evaluate and alter the standards for harmful therapy with caution. As we consider lowering the degree of “suitable evidence” for harm, we must be mindful to whom our primary ethical obligation is owed—the client. As basic systems theory informs us, an individual’s decision to create change will likely disrupt the systems within which one lives (Burnett, 2013). As practitioners, we can (and should) assist clients in trying to mitigate the potential negative interpersonal consequences of their therapeutic work, but we must be clear that our priority resides with the individual(s) who engage in therapy directly. That is, the person(s) in the room must be our central focus and to whom we hold our duty to do no harm.

Another concern regarding the definition of PHT includes the numerous, and at times unpredictable, ways in which clients are vulnerable to experiencing harm. PHTs have increased outcome variance, meaning that treatment will be beneficial for some clients and may cause deterioration for others. Therefore, developing a clear differentiation between normal discomfort and harm is a critical issue within this research agenda. Anecdotally, practitioners view clients’ discomfort and temporary worsening of symptoms while exploring vulnerabilities and developing insight regarding presenting concerns as a normal component of psychotherapy (Weinberg, 1996). Current empirical research supports these informal observations (Hayes et al., 2007; Keller, Feeny, & Zoellner, 2014). Drawing upon the aforementioned group intervention example, it is expected that clients will be triggered and experience some degree of shame when discussing its role in their lives, and subsequently must work through these feelings to develop greater emotional and social resilience. As scientist-practitioners, we must have patience for this element of the therapeutic process, while also learning to accurately monitor, assess, and intervene when true deterioration and harm occur.

Within the PHT literature, some treatments and therapist characteristics are clearly and definitively identified as likely causes of harm (e.g., critical incident stress debriefing, facilitated communication; Lilienfeld, 2007). However, at other times, treatments that have been effective and helpful for some clients are harmful to others. How can we anticipate which outcome will hold true for a specific client? Can we truly avoid any type of harm, even if we were able to definitively determine these treatment and therapist effects? Regarding this difficulty, the PHT literature could benefit from multicultural counseling perspectives that have resulted from the integration of cultural factors with the research in psychotherapy process and outcome.

Multicultural competence (MCC; Sue, Arredondo, & McDavis, 1992) and multicultural orientation (MCO; Owen, Leach, Tao, & Rodolfa, 2011) are used within the multicultural counseling literature as frameworks for understanding how counseling can be successfully implemented with diverse populations. Within these, multicultural sensitivity is conceptualized as acquiring sufficient knowledge, awareness, and skills (MCC) or as a “way of being” (Owen et al., 2011, p. 274) with clients that demonstrates counselors’ beliefs and values regarding the importance of recognizing culture (MCO). Within either framework, counselors’ cultural microaggressions are treated as inevitable, as they are most often committed in an unintentional and unconscious manner. Regardless of the degree of striving for cultural competence, clients are distinctive cultural beings, and therapists are humans who make mistakes.

Therefore, in addition to learning to avoid overtly culturally insensitive interventions, counselors’ abilities to perceive and address therapeutic ruptures are paramount. Therapists should be educated about known causes of culturally based harm, such as Eurocentric therapeutic practices, microaggressions, and personal biases held by the therapist. In addition, practitioners must be able to perceive ruptures in the therapeutic relationship and engage in “difficult dialogues” about culture, privilege, and power to address the often unintentional and unconscious ways in which societal oppression is recapitulated in therapy. In doing so, we can make gains toward repairing the therapeutic alliance and improving client outcomes (Owen, Tao, Imel, Wampold, & Rodolfa, 2014).

In a parallel manner, integrated training regarding PHT and multicultural counseling could prepare graduate students and professionals to identify markers of deterioration or harm within treatment and equip them for intervening appropriately. Future research should examine the utility of subjective and objective assessments of client outcomes to identify harm and deterioration as they are unfolding throughout the therapeutic process. This inquiry could be followed by studies of how practitioners can effectively intervene and change treatment course, if necessary. Such a paradigm shift would combine knowledge of iatrogenic harm from specific treatments with a flexible model of assessment and intervention that recognizes the idiosyncratic nature of harmful therapy.

Concluding Thoughts

We have learned a great deal from the contribution of Wendt, Gone, and Nagata (2015) and their challenge to the field to bridge the respective discourses in multicultural counseling and PHT. Yet this charge is not without complexity. Recognizing this dialogue is in its infancy, we aimed to describe a number of strengths and limitations to the current contribution, as well as pose critical questions and issues to consider as we move forward. The joining of the multicultural counseling and PHT literatures presents the broader mental health field with an opportunity to collaboratively move toward greater provision of safe and ethical services to our clients. Wendt et al. have provided an important first step in this progression, generating many more questions for the field.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

M. Meghan Davidson, PhD, is an associate professor of counseling psychology at the University of Nebraska–Lincoln, and a licensed psychologist. Her areas of interest include intimate partner violence, sexual violence, objectification, multicultural issues, and ethics. She was awarded the 2014 Fritz and Linn Kuder Early Career Scientist/Practitioner Award from the Society of Counseling Psychology of the American Psychological Association.

Claire T. Hauser, MA. is a doctoral candidate in counseling psychology at the University of Nebraska–Lincoln. Her primary interests include shame, self-worth, and counselor training.

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