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1. 1. CHAPTER 2: Culturally Effective Helping
   2. Multicultural Perspectives in Crisis Intervention

Laura Brown is the past president of Division 56, Trauma Psychology; she is a diplomate (recognized as knowing a lot and contributing a lot) in clinical psychology, has received numerous awards, and has authored what we believe is the best book on cultural competence when it comes to doing trauma therapy, Cultural Competence in Trauma Therapy: Beyond the Flashback (2008). So we can pretty much assume she knows what she’s talking about when she says, “After three decades of working intentionally with trauma I can say with utter certainty that I know that I have no idea of how any particular person will have experienced and made sense, or not, of her or his traumatic experiences” (p. 16). Therefore, as you read this chapter, understand that one of the best minds in this field is confessing to her ignorance when it comes to ferreting out all the ways that culture affects her clients. The message is that we’re a long way from knowing all we need to know to effectively weave multiculturalism into crisis intervention. However, we do know more than we did in the last edition of this book, and the way research is moving (Brown, 2008, 2009; D’Andrea & Heckman, 2008; Ponterotto & Mallinckrodt, 2007; Ridley & Shaw-Ridley, 2011; Worthington & Dillon, 2011; Worthington, Sott-McNett, & Moreno, 2007), we’re going to know more and more. So please understand that this chapter isn’t a GPS for multicultural competency in crisis intervention that will precisely target your destination, but more like a compass that will point you in the right general direction.

In the United States, whether we realize it or not, we live in a pluralistic culture (Sue & Sue, 2002), and the same could be said for practically every country in the world. So just what is this abstract and amorphous thing called “culture”? And how does it become “multi”? Furthermore, what makes it important in the crisis business?

Adler (1997) defines culture as “that complex whole which includes knowledge, beliefs, arts, laws, morals, customs and capabilities acquired by a person as a member of society. It is a way of life of a group of people, the configuration of all the more or less stereotyped patterns of learned behavior which are handed down from one generation to the next through the means of language and imitation” (p. 14). Members of a given culture hold all of the foregoing to be pretty much self-evident truths to live by, as a way of making order and sense out of their lives. Thus, they are generally able to live with one another in an overall peaceful, profitable way with some sense of control over their lives and the community within which they reside. The “multi” part comes into play when we start to mix up people from different cultural communities with different assumptions about all those variables Adler is talking about.

The role that culture plays in crisis intervention has to do with what Savicki (2002) has termed uncertainty avoidance—and, as you will see in this book, attempting to avoid uncertainty and get back in control of a situation gets a lot of playing time. Uncertainty avoidance has to do with the degree to which cultures feel threatened by uncertainty and ambiguous situations, so rules, procedures, rituals, and laws may be formulated to buffer uncertainties of individual judgment (Savicki, 2002, p. 27). What this means in crisis intervention is that 

Kiselica (1998, p. 6) identifies four attributes that are widely accepted as necessary for crisis workers and other mental health workers who intervene with clients in the multicultural world in which we work: (1) self-knowledge, particularly an awareness of one’s own cultural biases; (2) knowledge about the status and cultures of different groups; (3) skills to effect culturally appropriate interventions—including a readiness to use alternative strategies that better match the cultures of crisis clients than do traditional strategies; and (4) actual experience in counseling and crisis intervention with culturally different clients. Sue (1992, p. 12; 1999a, 1999b) reminds us that failure to understand clients’ worldviews may lead human services workers to make erroneous interpretations, judgments, and conclusions that result in doing serious harm to clients, especially those who are culturally different. A vast majority of the world’s population lives by non-Western perspectives, and a lot of those perspectives are making their way to the United States through immigration. Despite the fact that the world is culturally pluralistic, many of our books, professional teachings, research findings, and implicit theories and assumptions in the field of counseling and crisis intervention are specific to North American and European cultures. Such theories and assumptions are usually so ingrained in our thinking that they are taken for granted and seldom challenged even by our most broad-minded leaders and professionals (Pedersen, 1998; Ponterotto & Pedersen, 1993; Ridley, 1995).

As an example, critics of “culture-blind” crisis interventionists propose that their reductionistic and outmoded logical positivism (based solely on observable scientific facts and their relationship to each other and natural laws of nature) has no place in dealing with widespread violence and social upheaval in large, ethnically different populations caught in long-term wars, rebellions, or other social disasters. They further believe that Western traumatologists adopt a naive view that trauma leads in linear fashion to PTSD in all people in all cultures. Social constructivists in particular rail at this normative view of trauma. They believe it may be much more appropriate to look at trauma, and the crisis intervention that follows it, in much broader social terms, such as safety, grief, injustice, and faith, as opposed to distinct clinical categories of PTSD and depression (Silove, 2000).

There is also a great deal of debate on the validity of any measures that are used to assess the various aspects of crisis that are dealt with in this book, because cultural bias and cultural artifacts can skew results to make clients look very different from what they actually are and lead to erroneous treatment decisions (Brown, 2008; Cokley, 2007). Further, the biggest assessment measure of all, the Diagnostic and Statistical Manual, Fourth Edition Revised (DSM IV-R), of the American Psychiatric Association (2000), has come under fire (Brown, 2008; Zalaquett et al., 2008) for its limited inclusion of social and cultural factors in the diagnoses of mental disorders. These critics believe that the normative, disease-based, medical model of the DSM IV-R, which emphasizes client deficits, top-down expert-professional-to-client relationships, medication as a major form of treatment, and universal interpretation for persons from various cultures, flies in the face of a counseling view of idiosyncratic behavior and often leads to ethnocentric and grossly inaccurate diagnoses (Zalaquett et al., 2008).

Ivey (1987) and Arredondo (1999) emphasize that counseling and therapy should begin with counselors’ awareness of their own assumptions, values, and biases regarding racial, cultural, and group differences before considering individual variations on those themes. Ivey (1987) states that “only by placing multicultural counseling at the core of counseling curricula can we as counselors truly serve and be with those whom we would help” (p. 169). That statement is probably exponentially true for crisis workers. Specifically in regard to crisis, Brown (2009, p. 167) believes that more than any other form of distress, persons who have suffered complex trauma do so in relation to their psychosocial cultural context, and to deny the social identities they bring out of that culture is a pretty effective way to stop intervention before it starts.

1. 1. Culturally Biased Assumptions

Unintentional and unexamined cultural and racial assumptions can impair functioning of counselors (Arredondo, 1999; Ober et al., 2000; Ridley, 1995; Thompson & Neville, 1999). That statement holds doubly true for crisis workers given the cross-cultural circumstances within which they often operate—particularly in large-scale disaster relief. Pedersen (1987) discusses the following 10 culturally biased assumptions that crisis workers would do well to remember:

• 1. People all share a common measure of “normal” behavior (p. 17) (the presumption that problems, 

  
  emotional responses, behaviors, and perceptions of crises are more or less universal across social, cultural, economic, or political backgrounds).

• 2. Individuals are the basic building blocks of all societies (p. 18) (the presumption that crisis intervention and counseling are directed primarily toward the individual rather than units of individuals or groups such as the family, organizations, political groups, or society).

• 3. The definition of problems can be limited by academic discipline boundaries (p. 19) (the presumption that the identity of the crisis worker or counselor is separate from the identity of the theologian, medical doctor, sociologist, anthropologist, attorney, or representative from some other discipline).

• 4. Western culture depends on abstract words (pp. 19–20) (the presumption of crisis workers and counselors in the United States that others will understand these abstractions in the same way as workers intend them).

• 5. Independence is valuable and dependencies are undesirable (p. 20) (the presumption of Western individualism that people should not be dependent on others or allow others to be dependent on them).

• 6. Formal counseling is more important than natural support systems surrounding a client (pp. 20–21) (the presumption that clients prefer the support offered by counselors over the support of family, peers, and other support groups).

• 7. Everyone depends on linear thinking (pp. 21–22) (the presumption by counselors and crisis workers that each cause has an effect, and each effect is tied to a cause—to explain how the world works—and that everything can be measured and described in terms of good or bad, appropriate or inappropriate, and/or other common dichotomies).

• 8. Counselors need to change individuals to fit the system (p. 22) (the presumption that the system does not need to change to fit the individual).

• 9. The client’s past (history) has little relevance to contemporary events (pp. 22–23) (the presumption that crises are mostly related to here-and-now situations, and that crisis workers and counselors should pay little attention to the client’s background).

• 10. Counselors and crisis workers already know all their assumptions (p. 23) (the presumption that if counselors and crisis workers were prone toward reacting in closed, biased, and culturally encapsulated ways that promote domination by an elitist group, they would be aware of it).

All 10 assumptions are flawed and untenable in a pluralistic world. Cormier and Hackney (1987) warn that human services workers who do not understand their own cultural biases and the cultural differences and values of others may misinterpret the behaviors and attitudes of clients from other cultures. Such workers may incorrectly label some client behavior as resistant and uncooperative. They may expect to see certain client behaviors (such as self-disclosure) that are contrary to the basic values of some cultural groups. The culturally insensitive counselor or crisis worker may also stereotype, label, or use unimodal, inappropriate, or ineffective counseling approaches and concepts in an attempt to help clients from other cultures (pp. 256–258). Specifically in the field of crisis intervention, there has been criticism of the Western-based trauma model and particularly the elevation of PTSD as a pathological entity that has been coined in self-serving ways by victims’ groups, politicians, and profiteering lawyers and therapists when there is little empirical evidence to support such an assumption (Silove, 2000; Summerfield, 1999).

1. 1. Universal Versus Focused Views

There are both universal and focused views on multicultural counseling. A universal view considers not only racial and ethnic minorities, but other minority or special populations as well. A focused view looks at multicultural counseling in relation to “visible and racial ethnic minorities” (Sue, Arredondo, & McDavis, 1992). More encompassing parallel terms you may run into in a multicultural text for these views are the etic and emic models. An etic model views people one dimensionally—focusing, for example, on their race, sex, age, hair color, or preference for junk food. We agree with Brown (2008, p. 12) that using racial designation, ethnic label, or any one characteristic, trait, preference, or other category to identify people may have little or nothing to do with the crises they are encountering and is probably a pretty poor unimodal cultural lens through which to view a person who has been traumatized. To view culture from such a narrow perspective is, we believe, asking for a lot of trouble in crisis intervention.

1. 1. Working on the Individualist/Collectivist–High/Low Context Continuum

From a multicultural perspective, we may generally look at communication along an individualist/collectivist continuum. Individualism is a worldview that centralizes the personal—personal goals, personal 

In a meta-analysis of 170 studies on the individualist/collectivist worldview, Oyserman, Coon, and Kemmelmeier (2002) found that individualism centers on one’s self-concept rather than one’s family life, as opposed to collectivism, in which the opposite is true. In regard to “sense of well-being,” individualists see well-being as related to a sense of personal control; collectivists do not. Even more important in terms of crisis intervention, individualism proponents tend to see the event in terms of their own personal preferences, whereas collectivist proponents interpret the event in relation to what they believe the expectations of others might be. A rather startling discovery contradicts the accepted belief that people who are collectivist consider the group, and particularly the family, as taking precedence and obligation over individual well-being. They found essentially no difference between individualists and collectivists regarding “sense of family obligation.” When a dilemma was presented, collectivists responded by identifying themselves as part of a cooperative group, whereas individualists considered themselves to be individuals participating as part of a team effort. Finally, communication and conflict resolution styles were found to vary in relation to individualism and collectivism. Individualism consistently predicted goal-oriented, low-context, direct communication; collectivism opted for indirect, high-context communication. In confrontational situations, individualists adhered to a confrontational and arbitrational approach; collectivists preferred an accommodation and negotiation approach.

But how do people in a collective society operate under stress and traumatic conditions? The Heppners and their associates (2006) conducted research in establishing a collectivist coping styles inventory that attempts to discern how stressful and traumatic events are handled from an Asian perspective. Indeed, the 3,000 Taiwanese college students in the study endorsed coping strategies very different from those of their Western counterparts. Their acceptance, fatalism, efficacy, and interpersonal harmony strategies when faced with stressful events are unlike any other factors endorsed on traditional coping strategy inventories in the Western world. Family support and religious and spiritual resources are also different from their Western counterparts. Filial piety and elder support are important, and advice is generally sought within the sanctity of the family.

The Chinese kanji characters of crisis and opportunity that appear on the cover of this book are evident in the Taiwanese students’ approach to coping with crisis. The Confucian and Buddhist philosophies that one endures suffering, looks for positive meaning, and exercises control and restraint predominate in their responses. Finally, their avoidance and emotional detachment from the stressful event and private emotional outlets are also different. Whereas in the United States we might expect an outpouring of emotion and immediate public support and grief following a traumatic event (Halpern & Tramontin, 2007, p. 98), the results from this study suggest that these students seek outside help as a last resort, and when they do it is most often in a confidential and anonymous manner. Their coping strategies revolved around avoiding shame and seeking help in safe, anonymous ways. The Heppners and their associates (2006) suggest that these students might go to a mental health professional who was unknown to them or their families or go into a chat room on the Internet to discuss their problems. The point is that, at least for these Taiwanese students, when under stress or traumatized, they might seek mental health help very differently than would their American counterparts.

1. 1. High/Low Context Approaches.

To put the foregoing analysis in operational terms useful to the crisis worker, the individualist/collectivist continuum uses what Hall (1976) calls a high/low context approach. In low-context cultures, one’s self-image and worth are defined in personal, individual terms. In high-context cultures, one’s self-worth and esteem are tied to the group. In low-context cultures, information is generally transmitted explicitly and concretely through language; 

From the high-context client’s standpoint, the low-context worker’s attempt to gather specific information about the client’s personal and social status in relationship to the crisis may be seen as intrusive, rude, and offensive. A high-context culture uses stories, proverbs, fables, metaphors, similes, and analogies to make a point (Augsburger, 1992). Thus, a high-context crisis worker might be very delicate, ambiguous, sensitive, and somewhat circumlocutory in discussing personal and social issues related to the crisis. In trying to help a low-context client, a crisis worker using such a communication style might be viewed as not being remotely aware of what the frustrated client’s needs are.

As a result, one of the major problems in crisis intervention with culturally different people lies in both sending and receiving communications that are understandable, clearly communicating what we are attempting to do while not exacerbating an already potentially volatile situation. While it is impossible to know the nuances of every culture and the subtleties of the client’s native language, one of our rules of the road in crisis intervention in which cultural differences are an issue is that there are these two broad camps, and we need to find out which one the individual is operating in and act accordingly.

• Crisis worker: (speaking to an East African male, a recent immigrant, who has been injured in a train wreck and doesn’t know what has happened to his family) I understand you are from Somalia. I don’t know a lot about your country or customs, so please let me know if what I am saying doesn’t agree with what you think is right and I’ll do my best to explain why that is so here in the U.S. and how we might be able to still fit your cultural background as we try to find out about your family and get you the medical help you need.

We also need to clearly own that we may be culturally ignorant and thus appear to be insensitive to the crisis client’s needs. Such admissions early on go a long way in letting the client clarify what his or her needs are. Those owning statements are true whether we are dealing with survivors of an east Kentucky coal mine explosion, war refugees in Liberia, or survivors and their families from the 9/11 attacks.

1. 1. High/Low Uncertainty Avoidance Approaches.

High and low context cultures get a lot of space in professional human service publications. What doesn’t, and is particularly appropriate to crisis intervention, is understanding whether the culture one is entering is operating on high or low uncertainty avoidance principles (Savicki, 2002, p. 27). High uncertainty avoidance cultures develop a broad range of rules and regulations and procedures to cover a multitude of contingencies. In other words, if you are entering that high uncertainty avoidance culture, you had better understand they have a playbook of what is right and proper that will rival that of a playbook from the National Football League (if you are not a football fan, those books are huge and enormously complicated). If you don’t understand and operate within it, you’ll wind up butting your head against a very large cultural wall. On the other hand, if you are entering a low uncertainty avoidance culture you may well be frustrated by a “Relax! Be happy! We’re all alive! We have food and water! Hurricanes come and go! We’ll rebuild tomorrow!” view. That sort of a “chill out” worldview can sabotage the herculean efforts of highly motivated disaster workers who are operating on short time frames and deadlines, leaving them embittered and burned out from the experience.

1. 1. Emic Versus Etic Models of Multiculturalism

An emic model encompasses the smorgasbord of components that make up individuals, not just what their individual parts are, but more the total gestalt of how they come together. So please meet the emic model of Dr. Dick James, 60-something, father soon to be grandfather who is mostly happy about it, husband who thinks he’s been married longer than he’s been alive sometimes, hard of hearing from too many years in construction working his way through school and gets yelled at for not wearing his hearing aid enough, fisherman and hunter who pals around with one of his daughters doing those activities, white guy who grew up in a university town but had blue-collar parents, now has digestive trouble eating pizza and drinking beer, trains police officers to deal with the emotionally disturbed and severely agitated mentally ill, played 

These are what Laura Brown (2008, p. 24) calls social locations, and both she and we believe they are important from a multicultural standpoint when you are doing this work. So if you compare all that to just Dr. James old dude, or Dr. James professor, or Dr. James white guy, or any other unitary, focused view of Dr. James, you surely aren’t getting the view you got a couple of sentences ago and our guess would be you might not respond in quite the same way if you were doing crisis intervention with him. Thus, we take a universal/emic rather than a focused/etic view in crisis intervention. Therefore, when we speak of cultural diversity, we are speaking in the broadest possible terms in regard to all factors that somehow make clients “different” from the interventionist. Hopefully, the following analogies illuminate what is meant by a universal/emic view.

Your worldview, if you are a New York City social worker and you have spent your entire life in the city and are now trying to help a Midwestern farmer who has just lost everything in a flood, is going to be as different from his worldview as ours would be from Pakistani survivors of an earthquake we were attempting to help. Or how about your first encounter (assuming you are heterosexual) with a gay man who has just discovered he is HIV positive from his longtime, supposedly faithful partner? Or consider a staunchly devout Baptist woman who believes divorce is a sin but who is being severely beaten by her preacher husband. Does that mean you will be ineffective and should not go to Keokuk, Iowa, or we should not go to Karachi, Pakistan? Never work with gay men or Baptist women? Certainly not! What it does mean is that “multiculturalism” does not necessarily stand out in large neon lights saying “I am from Ethiopia or Nepal, and I am different from you” or “I have red, black, yellow, or green (there may be some of those aliens from Area 51 in Roswell, New Mexico, reading this, and we don’t want to leave them out) skin.” In a statement that absolutely captures the essence of what is meant by a universal view, Halpern and Tramontin (2007) quote New York regional mental health officials: “In the large and diverse state of New York, when you know one county in the state you know one county” (p. 316). So how in the world do you do this business if there is that much diversity, not just in the world, but in one state?

Laura Brown (2008, p. 12) has used Hays’s ADDRESSING model (2001, 2008) as one of the bases for her book on multiculturalism and trauma. The ADDRESSING acronym encompasses Age, acquired and Developmental Disabilities, Religion, Ethnicity, Social class, Sexual orientation, Indigenous heritage, National origin, and Gender. D’Andrea & Daniels (2005) have developed a comparable model called RESPECTFUL (Religious/spiritual, Economic class, Sexual identity, Psychological development, Ethnic/racial identity, Chronological age, Trauma and threats to well-being, Family, Unique physical issues, and Language and location of residence). From our own experience we would add geographic locale, living area (urban, suburban, rural), occupation, education, and marital or partner status. We believe these variables are the major components that capture the essence of how the crisis interventionist needs to think about clients and work with the multiple identities that intersect with the crisis.

Compounding the issue even more is the fact that you, the interventionist, are bringing all these social locations into the equation too. Consider Figure 2.1 and how the social locations of Dr. James fit (or not) with Leron, an individual you will meet in Chapter 3, who is having a really bad day. Dr. James will do a quick assessment of Leron’s affective, behavioral, and cognitive functioning and immediately start identifying his social locations, which he believes may affect his intervention with Leron. By owning who he is, he is attempting to engage the client, the first task of the crisis intervention model you will meet in Chapter 3. Besides dealing with the very obvious social locations that differ between crisis workers and their clients, you need to be aware of all the baggage you carry into this particular environment that may hinder your efforts. Thus, Dr. James’s social location of hearing impairment may not be visible, but on a noisy street it can be problematic to say the least if he misinterprets what he hears and is too proud not to mention this fact early on to a client who may see him as a whole lot of other things that are not helpful if he can’t 

1. 1. FIGURE 2.1