DOMINANT AND NON-DOMINANT
CULTURAL CHARACTERISTICS

Age > NEUTRAL

Disability > NEUTRAL

Religion/Spirituality > SOMEWHAT DOMINANT

Ethnic/Racial Identity > SOMEWHAT NON-DOMINANT

Social Class > NEUTRAL

Sexual/Affectional Orientation > DOMINANT

Indigenous Backgrounds > DOMINANT

National Origin > NEUTRAL

Gender Identity > NEUTRAL

Gender Expression > NEUTRAL

Size > SOMEWHAT NON-DOMINANT

Assigned Sex at Birth > NEUTRAL

SALIENT CULTURAL CHARACTERISTICS

Age > 6%

Disability > 7%

Religion/Spirituality > 6%

Ethnic/Racial Identity > 12%

Social Class > 12%

Sexual/Affectional Orientation > 3%

Indigenous Backgrounds > 2%

National Origin > 10%

Gender Identity > 8%

Gender Expression > 12%

Size > 6%

Assigned Sex at Birth > 12%

3

The New Reality
Diversity and Complexity 1

n her work at a community mental health center, a recently
graduated, young European American woman named Sarah1
received a referral from the Office of Children?s Services (OCS)
for a severely abused, biracial 4-year-old named Maya. Follow-
ing removal from her biological parents, Maya was brought to
the initial appointment by her new foster mom, Carmen, an
assertive, self-described Latina/African American Jehovah?s
Witness. Carmen agreed to meet with Sarah because OCS
required it. During sessions that alternated between individ-
ual and family meetings, Carmen interacted defensively with
Sarah but was warm and caring with Maya.

After 6 weeks, Maya appeared very comfortable with her
foster mom, and many of her posttraumatic stress disorder
symptoms had improved. However, in a subsequent meeting
alone with Sarah, Maya asked her if she believed in Jesus.
Sarah said that she wasn?t a Christian but that she believed in

I

1All cases are composites with pseudonyms and do not represent a
specific individual.

http://dx.doi.org/10.1037/14801-001
Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy,
Third Edition, by P. A. Hays
Copyright ? 2016 by the American Psychological Association. All rights
reserved.

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4 B E C O M i n g A C u L t u r A L L y r E S P O n S i v E t H E r A P i S t

god?a response that clearly distressed Maya, who brought up the topic
again in their next individual session, adding that she was afraid Sarah
would die and go to the ?bad place.? Sarah began to worry that Carmen
might be sharing religious beliefs that were reactivating Maya?s fears.
She also wondered whether Carmen knew that Sarah was gay and, if
so, whether this might be a factor, along with their cultural, age, and
religious differences, in Carmen?s defensiveness toward her. Considering
Carmen?s disinterest in Sarah?s help, Maya?s overall improvement while
in Carmen?s care, and the severe shortage of caring foster homes, Sarah
was unsure whether she should address her concerns with Carmen,
with OCS, or with both or neither.

When i began teaching a multicultural counseling class at Antioch
university in Seattle in 1989, the field of multicultural counseling was
just beginning, and like most new fields, its focus was relatively narrow.
relevant textbooks focused primarily on the ethnicity and race of the
client, with little attention to the therapist?s identity or to the interaction
of ethnicity and race with the client?s (or therapist?s) religion, class, age,
disability, gender, sexual orientation, or nationality. there were some
population-specific fields regarding women, older adults, and people
who identified as gay or as having a disability, but the available books
and articles in these fields also conceptualized identity in unidimen-
sional terms. Feminist therapy initially focused on women (presumably
White, Christian or secular, nondisabled, and middle class); the lesbian,
gay, and bisexual literature on lesbian, gay, and bisexual people (pre-
sumably White, Christian or secular, nondisabled, and middle class);
geropsychology on older men (presumably White, Christian or secular,
nondisabled, and middle class); and so on. A field known as transcultural
psychiatry overlapped with one called cross-cultural psychology, both of
which focused on work with populations outside north America and
Europe but were conducted primarily by European and u.S. (White)
researchers.

Since 1989, the world?s awareness of and approach to diversity have
changed significantly. increasing numbers of people have been displaced
both within and across national borders because of war, poverty, and
violence. Environmental degradation and extreme climate changes have
magnified the impact of natural disasters on human communities. With
economic globalization and technology accelerating the pace of change,
social connections have increased dramatically across borders, with a wide
range of effects including a growing number of people who marry across
cultural groups and who identify as multiracial and multicultural and
changing attitudes toward minority groups such as lesbian, gay, and trans-
gender people and people who have disabilities. And around the world,
as indigenous people become increasingly empowered and unified, the
value of indigenous traditions is being increasingly acknowledged.

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5The New Reality

in the face of such changes, therapists are now expected to work effec-
tively with people of diverse ages, ethnic cultures, religions, disabilities,
gender identities, sexual orientations, nationalities, and classes. At the
same time, the effects of violence, abuse, trauma, chemical dependency,
disability, chronic physical and mental illness?that is, poverty-correlated
problems?are now commonly encountered in clinical practice, even in
many wealthier countries. Counselors and clinicians are expected to ?fix?
the mental health problems stemming from these persistent social causes
even as economic pressures have resulted in higher caseloads, less super-
vision, and fewer mental health resources. Cases as complex as Maya?s
are now commonplace.

recognizing the need for clear guidance on what works, an American
Psychological Association (APA) task force took on the project of deter-
mining what constitutes practical, research-based, and highly relevant
psychotherapy practice. the result was their definition of evidence-based
practice in psychology (EBPP) as ?the integration of the best available
research with clinical expertise in the context of patient characteristics,
culture, and preferences? (APA Presidential task Force on EBPP, 2006).
this definition does not prioritize any one theoretical orientation but
rather tends to support a more integrative approach. in addition, by
emphasizing ?best available research,? the definition acknowledges the
reality that for many minority groups, controlled studies of psychotherapy
effectiveness do not exist. the definition also gives equal weight to clini-
cal expertise, with an emphasis on using one?s expertise to adapt therapy
to the particular individual and their cultural context.

Developing Multicultural
Competence

At a national psychology conference in the united States several years
ago, i started a conversation with a young European American psy-
chologist who had recently joined the faculty of a prestigious univer-
sity. in response to my questions about the diversity of the psychology
department, she told me that it consisted of 36 full-time members, one
of whom was a person of color. She stressed that they?d made signifi-
cant progress in the hiring of women, but all of the women were White
except the one person of color, and none were tenured. i asked her opin-
ion about why this was the case, and she replied, ?Well, i think the core
faculty put their priority on developing a high-quality research program
rather than on hiring for diversity.?

this psychologist?s statement reflects the commonly held belief that
quality and diversity involve competing agendas. However, i would argue,

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6 B E C O M i n g A C u L t u r A L L y r E S P O n S i v E t H E r A P i S t

as many others have, that the exact opposite is true. A high-quality pro-
gram by definition includes faculty of diverse perspectives who bring ideas
that move a department beyond those of the mainstream. it consists of
diverse teachers and supervisors who serve as role models for a culturally
diverse student body and clinical faculty who have firsthand knowledge
of the cultures of the clients being seen by their students. it includes fac-
ulty who speak more than one language, read the psychological literature
of more than one culture, and are connected to minority groups whom
they consider and consult in their development of research projects.

given the relatively monocultural origins of the field, this is a tall
order. However, significant strides have been made. throughout the fields
of psychology, counseling, mental health, and social work, professional
organizations have made a clear commitment to increasing the multi-
cultural competence of their members; in north America, this effort has
included the APA (2000a, 2000b), the American Counseling Association
(roysircar, Arredondo, Fuertes, Ponterotto, & toporek, 2003), and the
national Association of Social Workers (2007). As researchers, teachers,
supervisors, and practitioners in these professions become more diverse,
they are experiencing and demonstrating the advantages of a diverse
learning environment. And the idea that diversity can be addressed in
one multicultural counseling course has been replaced by the view that
cross-cultural information, experiences, and questions must be integrated
throughout the training curriculum, including practica and internships
(Magyar-Moe et al., 2005).

Addressing Both Diversity
and Complexity

When i teach multicultural awareness workshops, i start by asking partici-
pants to do the following: ?take a minute to share with a partner every-
thing you feel comfortable sharing about yourself that explains who you
are and your identity, including past and current cultural influences on
you.? if you?re reading this by yourself, try doing this in the box before
reading further.

List all of the cultural influences you can think of that explain
or describe your identity:

_____________________ ____________________
_____________________ ____________________
_____________________ ____________________
_____________________ ____________________

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7The New Reality

Once people have finished sharing, i ask how many mentioned
ethnicity or race in their self-description; depending on the makeup of
the group, a varying number of people raise their hand. i then ask how
many mentioned religion, and a different number raise their hand. i
also ask about age and generational influences, disability, sexual orien-
tation, social class, nationality, language, and gender. then i ask if any-
one thought of influences i did not mention, and participants often add
being from a particular geographic region, growing up in the military,
working in the business world, and others.

this exercise illustrates how, when we think of culture, so many
different influences come into play. All of these influences shape who
we are, but as i found when i began teaching, the dilemma is how,
whom, and what to focus on. For the purposes of psychological prac-
tice, i have chosen to focus on the influences and related minority
groups that the major helping professions target for special attention
because these influences and groups have been neglected in the field
and dominant culture. these influences can be organized in an easy-to-
remember acronym that spells the word ADDrESSing (see table 1.1).

As you read through the list of ADDrESSing influences and domi-
nant and minority groups, you will recognize that for many of the influ-
ences, the groups listed as minority groups are minorities only in the
united States (e.g., people of Asian heritage are not a minority in China
or, for that matter, in the world). So think of this list as only an exam-
ple: if you are practicing in a different region or country, the dominant
and minority groups will be specific to that particular context.

ADDRESSING Influences

A stands for Age and generational influences and includes not just chrono-
logical age, but also generational roles that are important in a person?s
culture. For example, the role of eldest son in many cultures carries
specific responsibilities, just as being a parent, grandparent, or auntie
brings with it culturally based meanings and purpose.

Age and generational influences also include experiences specific to
age cohorts, particularly experiences that occurred during the cohort?s
childhood and early adulthood (i.e., the formative years). For example,
for many elders, the great Depression, World War ii, and racial segrega-
tion were generation-related influences that profoundly affected their
lives. For baby boomers, important early influences were post-World
War ii economic prosperity, the civil rights movement, the women?s
movement, vietnam War protests, and the widespread use of drugs. For
people in their 20s, economic pressures, college debt, technology and
social media, and environmental degradation are common influences?

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8 B e c o m i n g a c u l t u r a l l y r e s p o n s i v e t h e r a p i s t

all of these also affect older people, but people in their 20s have never
lived without them.

obviously, age and generational influences vary across ethnic and
other cultural groups, just as dominant and minority groups vary in dif-
ferent countries and contexts. in north america, the minority groups
associated with age and generational influences are children and older
adults, because elders and children do not have the same privileges
that young and middle-aged adults have. however, in some countries,
elder status carries a great deal of privilege and power. i will provide
examples of contextual specifics of these definitions in chapter 2.

the next letters, DD, stand for Developmental or other Disability. the
broad category of disability includes disability that may occur at any

T A B L E 1 . 1

ADDRESSING Cultural Influences

Cultural influence Dominant group Nondominant or minority group

Age and generational
influences

Young and middle-aged
adults

Children, older adults

Developmental or other
Disabilitya

Nondisabled people People with cognitive, intellectual,
sensory, physical, and psychiatric
disabilities

Religion and spiritual
orientation

Christian and secular Muslims, Jews, Hindus, Buddhists,
and other religions

Ethnic and racial identity European Americans Asian, South Asian, Latino, Pacific
Islander, African, Arab, African
American, Middle Eastern, and
multiracial people

Socioeconomic status Upper and middle class People of lower status by occupa-
tion, education, income, or inner
city or rural habitat

Sexual orientation Heterosexuals People who identify as gay, lesbian,
or bisexual

Indigenous heritage European Americans American Indians, Inuit, Alaska
Natives, M?tis, Native Hawaiians,
New Zealand Ma

_
ori, Aboriginal

Australians
National origin U.S.-born Americans Immigrants, refugees, and inter-

national students
Gender Men Women and people who identify

as transgender

Note. Adapted from Addressing Cultural Complexities in Practice, Second Edition: Assessment, Diagnosis, and
Therapy (p. 18), by P. A. Hays, 2008, Washington, DC: American Psychological Association. Copyright 2008 by the
American Psychological Association.
aWith the increased use of the term intellectual disability, the term developmental disability is being used less often,
particularly within the Disability community; however, it is included in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM?5) and the International Classification of Diseases, Tenth Edition, Clinical Modification
(ICD?10?CM; see Chapter 4).

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9The New Reality

time during a person?s lifetime, for example, as a result of illness, acci-
dent, or stroke. Developmental disabilities are specifically those that affect
a person?s development from birth or childhood, such as fetal alcohol
spectrum disorder or Down syndrome. (note that the term intellectual
disability has replaced the pejorative term mental retardation; more on this
in Chapter 4.) related minority groups include people who have cogni-
tive, intellectual, sensory, physical, and psychiatric disabilities.

Some individuals with disabilities identify as members of a Disability
culture (signified by a capital D). However, many individuals who have
disabilities do not consider themselves members of a culture, particu-
larly people who acquire a disability later in life (e.g., an older woman
whose cognitive functioning is impaired following a stroke). Similarly,
many people who identify as members of Deaf culture do not identify as
disabled because they have no impairments when in the Deaf culture; it
is the hearing world?s inability to sign that is the problem.

the distinction between people who grow up with a disability and
those whose disability is acquired later in life has important implications
for therapeutic work. Many people who grow up with a disability learn
coping skills that enable them to function well in the dominant non-
disabled world; when these individuals come to counseling, it is often
for a problem that is unrelated to the disability. in contrast, individuals
who become impaired later in life (e.g., following an accident or physical
illness) often come to therapy for help with learning how to cope and
live with the disability.

the next letter, R, stands for Religion and spiritual orientation. in north
America, the largest religious minority groups are Muslim, Jewish, Hindu,
and Buddhist, and there are many smaller groups (e.g., Baha?i, Shinto,
Confucian, Zoroastrian). Although some members of particular Christian
religions (e.g., Mormon, Seventh-Day Adventist, Jehovah?s Witness, and
fundamentalist Christian) think of themselves as minority groups, they
are still Christian groups and as such have privileges that non-Christian
groups do not have. Similarly, some individuals with atheistic beliefs con-
sider themselves part of a minority group; however, atheists still benefit
from privileges related to the dominant secular culture.

E stands for Ethnic and racial identity. in the united States, the largest
groupings of ethnic and racial minority cultures are Asian, South Asian,
Pacific islander, Latino, and African American. Also included are people
who identify as biracial or multiracial and people of Middle Eastern her-
itage who are experiencing racism and other oppressive attitudes and
behaviors from the dominant culture. Within each of these large cul-
tural groupings, there are many specific groups. For example, South Asian
includes people whose heritage originates in Pakistan, india, Bangladesh,
Afghanistan, nepal, Sri Lanka, Bhutan, and the Maldives (and, depend-
ing on the definition, some additional countries such as tibet). Here
again, the definition of these cultures as minority groups is specific to

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10 B E C O M i n g A C u L t u r A L L y r E S P O n S i v E t H E r A P i S t

the united States; what constitutes a minority group depends on the
country and its dominant culture.

S stands for Socioeconomic status, which is usually defined by educa-
tion, occupation, and income. related minority groups include people
who have lower status because of limited formal education and the
occupations and lower income that usually go along with less educa-
tion. the focus is on people who are living in poverty, often in rural and
inner-city areas.

the second S stands for Sexual orientation, and the related minority
groups include people who ident