W4-CH6

Issues in Multicultural Correctional Assessment and Treatment

By Corinne N. Ortega

Introduction Increasing diversity in the United States has widened the base populations to whom psychologists provide services. Various divisions of the American Psychological Association (APA) have recognized the importance of multicultural competencies for more than 25 years (notably, Division 17—Counseling Psychology and Division 45—The Society for the Psychological Study of Ethnic Minority Issues). In 2002, APA formally recognized the evolution of the science and practice of psychology in a diverse society by adopting as policy the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (APA, 2002b). Nowhere is the changing face of the United States reflected more clearly than in its correctional systems. Blacks and Hispanics make up 62% of the incarcerated population, although they comprise only 25% of the national population (Human Rights Watch, 2002). Hispanics represent 40% of all sentenced federal offenders, although they account for only 13% of the total U.S. population (López, 2000). According to the Bureau of Justice Statistics (2007), the lifetime chance of a person going to prison is higher for Blacks (18.6%) and Hispanics (10%) than for Whites (3.4%). Furthermore, Blacks represent approximately 40% of the death row population in the United States (Amnesty International, 2003). The sociopolitical and socioeconomic explanations for this phenomenon are complex and far beyond the scope of this chapter. It is clear, however, that given the disproportionate confinement of minorities in the United States, any meaningful discussion of correctional mental health must necessarily include a discussion of multicultural issues. This chapter will first focus on a general overview of multicultural counseling and its applications in correctional settings. Second, the use of psychological tests and assessments with multicultural correctional populations will be explored with an emphasis on forensic evaluations. Finally, the issue of cultural competence with religious minorities and religious extremists will be addressed.

Multicultural Counseling Jackson (1995) succinctly defines multicultural counseling as counseling that takes place between or among individuals from different cultural backgrounds. Although a simple enough definition, the implications of this in the mental health field are far-reaching. The increased racial, ethnic, and cultural diversity in the United States creates a demand for professional services, including mental health, that meet the needs of people from a wide variety of backgrounds (Barrett & George, 2005). The issues involved in providing culturally competent services are as complex and varied as clients themselves (Sue & Sue, 2007). Cookbook approaches to multicultural counseling cannot be utilized without contradicting the very concept. López (2000) discusses this in terms of culturally critical thinking. Multicultural awareness allows the counselor to think about diversity in nonjudgmental ways without polarizing issues into “right and wrong” and should take into consideration all of the complex dimensions of clients in a pluralistic society (Corey & Corey, 1998). Unidimensional concepts of race, ethnicity, and culture allow practitioners to conceptualize their clients as having more than just a singular notion of self. Most people have more than just one definition of who they are. People often define themselves by criteria such as gender, race, ethnicity, sexual orientation, socioeconomic status, citizenship, and religious affiliation. Multicultural counseling is the understanding that individuals exist and behave in a larger context that includes all of these notions of self. Indeed, cultural identity is fluid and often changes according to social context (Monk, Winslade, & Sinclair, 2008). A complex undertaking is made more challenging with the realization that cultures are not static and should be understood in terms of their own dynamic processes (López, 2000).

Multicultural counseling competency is the ability to understand and conceptualize a client through multiple worldviews, the ability to see the ways in which clients’ cultural experiences may or may not influence their presenting problems, the clients’ understanding of the source of their problems, and the understanding of what it will mean for the problems to be adequately addressed through the counseling process. The conceptualization of multicultural counseling competency understood in this light becomes, to coin a phrase, not a destination, but a journey. To make matters more confusing, there are many ways in which to define mental health. The Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) recognizes this by stating,

A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual’s culture. For example, certain religious practices or beliefs (e.g., hearing or seeing a deceased relative during bereavement) may be misdiagnosed as manifestations of a Psychotic Disorder. Applying Personality Disorder criteria across cultural settings may be especially difficult because of the wide cultural variations in concepts of self, styles of communications, and coping mechanism. (p. xxxiv) Likewise, the DMS-IV-TR recognizes the term culture-bound syndrome, which “denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category” (p. 898). The DSM-IV-TR goes on to suggest that culture-bound syndromes are generally limited to specific cultural areas. Thus, abnormal or psychopathological behaviors should be viewed in their cultural context (see Table 6.1 for examples of culture-bound syndromes).

Table 6.1 Culture-Bound Syndrome Source: Adapted from American Psychiatric Association (2000); see also Paniagua (2000). People from various cultures and backgrounds will also approach and respond to the therapeutic process differently. For example, Gonzalez (1997) notes that traditional Hispanic Americans are accustomed to being treated by physicians and may be unclear as to the role of a psychologist or other mental health provider, expecting medication and a quick solution to their problems. African Americans may be distrustful of the counseling process, based on historical hostility due to their prolonged inferior treatment by American society (Evans & George, 2008). They may prefer to use prayer, faith, spirituality, and religious figures to assist with personal problems (Toldson, 2008). Asian Americans tend not to seek psychological services and tend to terminate prematurely when they do (Kim & Park, 2008), as there is a cultural norm against sharing private matters with outsiders (Sue & Sue, 2007). Furthermore, in some Southeast Asian countries, a mental health problem is considered the same as being insane and is an admission of inferiority (Nguyen, 1985), thus reducing the likelihood of seeking treatment. Communication styles also vary widely across racial and ethnic groups. For example, African Americans may speak loudly and be more animated than their non–African American counterparts (Evans & George, 2008). Asian Americans may communicate through indirect means, use apology to maintain and build “face,” acknowledge and defer to hierarchy, be more modest and allow for more silence, and place a high value on emotional control and stoicism (Kim & Park, 2008). Native Americans may emphasize nonverbal communication and avoid direct eye contact out of respect for an elder or person in authority (Garrett, 2008). Multicultural Applications in Corrections Correctional mental health is practiced in a fast-paced environment and requires specialized training focused on the unique needs of the criminal population. This challenge is increased when it is also necessary to apply the principles of multicultural counseling to the offender population. Criminal offenders are as diverse as the racial, cultural, and socioeconomic backgrounds from which they come. The APA Ethical Principles of Psychologists and Code of Conduct (2002a) mandates that psychologists practice only in areas in which they maintain competence and, unless it is an emergency, refer clients with whom they do not have the necessary understanding of racial, socioeconomic, cultural, ethnic, and/or other issues essential to providing services. The ethical codes of the American Counseling Association and the National Association of Social Workers have similar expectations for providing services to diverse populations. Although this is a noble aspiration, it may be impractical at best and impossible at worst in a correctional setting. Imagine that a new inmate, who was recently arrested at an international airport, arrives at a facility. The inmate is from South Africa and speaks Bantu. He reports he is part of the Lemba tribe. After tackling the first challenge of finding a translator, cultural competence requires an understanding of this inmate’s background. Where does a clinician start—with his South African culture or with his tribal background? How many clinicians know anything about the Lemba tribe? In the absence of this cultural information, the APA ethical guidelines say that psychologists must refer the client to someone who does know about the tribe. How likely is it that there will be another clinician in the institution who is familiar with the Lemba tribe? (See Lerner & Lerner, 2006, for more information about the Lemba tribe). The pragmatic issues of referring are obvious. Just as unrealistic is trying to become educated and trained in every cultural group and all of their variations. To make matters more confusing, the issue of prison culture must also be considered. Brodsky (1975) describes the process of adapting to the prison culture as prisonization. The prison subculture has its own set of values and beliefs, which are different from the culture of the communities and families from which inmates come (Gordon, 1999). So, what is the solution? As with most aspects of correctional mental health, the key to successfully navigating the maze of cultural competence lies in flexibility. McAuliffe (2008) suggests three broad guidelines for flexibility in working with culture: recognizing the fluidity in culture; making measured, tentative generalizations; and adapting traditional counseling theories to cultures, but doing so flexibly. Individuals from the same racial, ethnic, and/or cultural background will have tremendous variability in the degree to which they adhere to those values. The culturally competent correctional mental health practitioner must balance an awareness of the variety of cultural influences prisoners bring with them to the correctional institution. They must also have an understanding of the impact of the prison culture and the ways in which prisonization modifies behavior as individuals adapt to their incarceration. Finally, they must attempt to provide meaningful interventions and services that are both culturally competent and appropriate to address underlying criminogenic tendencies such as antisocial and narcissistic beliefs and attitudes and criminal thinking errors (e.g., “I’m not hurting anyone” and “Everybody does it, they just don’t get caught”). As one can imagine, this is not an easy task, as the following sample case study illustrates.

Composite Case Study Reason for Referral “M” was referred to mental health services by another staff member. The staff member reported that during routine phone monitoring of inmate calls, M was overheard being informed of his mother’s unexpected death in an auto accident. The staff member requested that mental health staff offer services to M based on his recent loss. Background M is a 33-year-old Black male. He is currently serving a 10-year sentence for armed robbery. This is his second adult felony. His arms and neck are heavily covered in gang tattoos. He has a few institutional disciplinary infractions for gambling. Other than a routine intake screening, he has had no contact with mental health services during his incarceration. Findings Because it was unclear if M wanted or desired mental health services, he was seen briefly on his unit. He was called into a private office on the unit. The door to the office had a window that faced the common area. M came into the office and closed the door. Although his back faced the window of the door, he left one hand on the doorknob, as if preparing to leave. He initiated the conversation by stating, “What you need? I didn’t ask for no Psych.” He was informed that it was a routine visit to offer services in light of his mother’s passing. He stated, “I don’t need nuthin.’ I’m straight.” A final attempt was made to engage M by offering him condolences and expressing that it must be very hard for him to have lost his mother so unexpectedly, especially while he is incarcerated. At this point, M’s eyes began to tear up, and it appeared as though he might cry. Cognizant that the interview was still on the unit and in the presence of his peers, he was offered the opportunity to be taken to a private office off of the unit. M declined and continued to stand with one hand on the doorknob. However, M began to discuss the difficulty of his mother’s loss, and he was provided with supportive counseling. When offered the opportunity to come to the mental health department at a later date to talk further, he declined. However, when asked if it would be okay if a mental health clinician came back to the unit to check on him, he stated that would be “alright.” He was provided with an additional session that occurred in much the same manner as the first, with his hand never leaving the doorknob.

Discussion Understanding the dynamics of this encounter requires viewing the situation from multiple lenses. First, the presenting issue of bereavement takes many forms. People grieve differently, and talking is not necessarily helpful to everyone. So, M’s initial response that he was not interested in services is not indicative of anything in particular. However, as a Black male, multicultural awareness requires cognizance of the fact that M may have some inherent distrust of the mental health system. Therefore, it is possible that he may desire services but is apprehensive of availing himself of them. Finally, M’s affiliation with the prison culture must also be considered. As a second-time felon, he is a more experienced inmate. His tattoos indicate he has led an antisocial and criminal lifestyle. Thus, he is less likely to view services established by “the man” as something useful to him. Additionally, to “save face” with other inmates on the unit, he needs to minimize his emotions regarding his mother’s death and appear to remain “strong” by rejecting offers of help. By standing at the door with his hand on the doorknob, M gave the appearance to others on the unit that he did not want to be there and, in fact, was “trying” to leave the office. This shifted the responsibility onto the mental health staff for “keeping” him there, rather than his desire for services. Choosing to stay on the unit also sent a clear message to his peers that he was not voluntarily going anywhere with mental health staff. Because his back was to the unit, he was able to express himself, without being seen, while giving the impression that he did not want to be talking to the clinician.