In their seminal work on counseling the culturally diverse, Derald Wing Sue and David Sue put forth an interesting proposition: the ideas and beliefs that form the foundation of the counseling professions are so fundamentally infused with Western thought that the counseling itself risks being just another mechanism for imposing the values of the dominant culture on those who are different.

They state, “…while mental health providers could be well intentioned in their desire to help clients of color, the goals and process of counseling and psychotherapy were often antagonistic to the life experience and cultural values of their clients. Without awareness and knowledge of race, culture, and ethnicity, counselors and other helping professionals could unwittingly engage in cultural oppression.” (pg 23)

No matter how deeply the clinician feels that his/her values are right in terms of cultural or religious beliefs, the client must be approached from the context of the client's values. Otherwise, the clinician becomes involved in proselytizing, not therapy. This departs from the primary mission of the mental health professions.

This issue of cultural diversity creates complex problems for the resolution of ethical dilemmas. Briefly, if ethics (and morals, from which ethics are generally derived) are dependent upon ideas of right and wrong behaviors, and right and wrong behaviors are culturally determined, is it appropriate to superimpose the clinician's ideas of right and wrong behaviors on clients who come from a different culture? Can a solution that is proper and ethical (and legal) in the culture of the clinician simultaneously be chauvinistic and culturally insensitive when viewed through the eyes of a client from a different culture?

To see the complexities of ethical decision making in situations of cultural diversity, please note the following scenario:

Jenny P. is a mental health clinician in private practice. She has a contract with a company that provides Employee Assistance Programs on the West Coast. One of the client companies that she serves has made a management referral of a key employee with work performance problems, Jula M. Jula is a mid-level executive who was recruited and moved from his home in the South Sea Islands to develop business in the Pacific Rim. His family is descended from royalty, and is very influential, with extensive business and personal connections in an area that provides certain raw materials vital to one of the company's most important products.

The company spent several years and an enormous amount of money recruiting and developing him as an executive, and has made very clear that he is a very unique and valuable commodity for the company. They are very concerned about his decline in performance and emotional disinvestment from the company. The Director of Human Resources for the company is personally supervising the referral, and has expressed concern about whether there might be a possible substance abuse or other serious personal issue that is causing his performance to slip.

The client is being referred to Jenny because she is one of the most skilled and experienced providers that the EAP company has available to them. When the referral was made, the President of the company called Jenny personally to tell her of the importance of this employee, and the care with which this case should be handled.

Not far into the interview with Jula, he reports to Jenny that is in the process of deciding whether to leave the company and return to his homeland. He is simply unhappy living in the United States, as there are many aspects of American culture that are disturbing and distressing to him as a father and husband. He expresses his concerns about the consumerism, the lack of community, and the American obsession with sex, including the unnatural ways in which Americans handle such an important and natural subject.

He goes on to tell Jenny that his two children, male and female fraternal twins, are almost 14 years old. He has been struggling to protect them from the portrayal of sex on television and the readily available flood of pornography around them, while simultaneously trying to protect them from other elements of American culture that are likely to make them feel guilty and ashamed of their bodies and their sexuality.

As the session proceeds forward, he goes on to say that this has made it difficult for them to remain grounded in their culture while they prepare for their initiation into their adult sexual life, which is to occur in the next several weeks. In accordance with the customs of his people, the grown-ups in the community will be initiating the two teenagers into the ways of sex at a ceremony to mark their fourteenth birthday, as they welcome them into adult life.

A trusted adult male from the community will be sexually initiating the daughter, and a trusted adult female from the community will be sexually initiating the son, providing a joyful and safe first sexual experience to be celebrated by the whole community. He only hopes that they have not already been too damaged by American culture to be able to enter into this key part of their adult life in a healthy manner - in accordance with the history and culture of his people.

With this last piece of information, Jenny realizes that she is in an ethical dilemma. Within the Western cultural framework that shapes laws concerning sexuality in minors, the initiation ceremony would probably be considered illegal and exploitative, in short – child abuse. Under the reporting guidelines for her state, she would probably need to make a report to the department of children and families.

However, she senses that within the culture of these people, the initiation ceremony would probably not be experienced as either exploitative or abusive. The consequences of a report to the department of family services could create a disastrous reaction on the part of her client and his whole community. In the clash of the two cultures in such an emotionally laden area, there is a conflict that does not seem to present any simple ethical solution.

What are the practical, legal and ethical considerations here, and how might you instruct Jenny to proceed? How well does your code of ethics help you to resolve this dilemma?

These complications are serious enough that we will now present some background material in preparation for the presentation of a model for addressing ethical decision making in situations of cultural diversity. We will begin with the manners in which the various codes of ethics attempt to lay the groundwork for dealing with matters of cultural diversity.

According to Social Work Speaks, (2006-2009), social workers have an ethical responsibility to be culturally competent practitioners as suggested by the NASW Code of Ethics. While the codes of ethics for counselors and marriage and family therapists do not cover cultural competence in as much detail as the NASW code, in their very first sections, both codes address the idea of cultural competence with the concept of non-discrimination:

ACA code: Standard of Practice One (SP-1): Nondiscrimination. Counselors respect diversity and must not discriminate against clients because of age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital status, or socioeconomic status. (See A.2.a.)

AAMFT code: 1.1. Marriage and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, or sexual orientation.

The first provisions of all three of the codes of ethics governing mental health clinicians speak of respect for the client and that the client’s interests are paramount, and for that reason, unless a mental health clinician is culturally competent in their practice, they will not be able to meet the expectations of these provisions in their codes of ethics.

Sue states that the definition of cultural competence is applied on two levels, the person/individual and the organizational/system. He defines cultural competence as:

“Cultural Competence is the ability to engage in actions or create conditions that maximize the optimal development of client and client systems. Multicultural counseling competence is defined as the counselor’s acquisition of awareness, knowledge and skills needed to function effectively in a pluralistic democratic society (ability to communicate, interact, negotiate, and intervene on behalf of clients from diverse backgrounds), and on a organizational/societal level, advocating effectively to develop new theories, practices, policies, and organizational structures that are more responsive to all groups.” (pg 46)

Sue states that a culturally competent therapist is working toward three competencies:
1. Awareness of one’s own assumptions, values and biases
2. Understanding the worldview of culturally diverse clients
3. Developing appropriate intervention strategies and techniques (pg 44 – 45)

He goes on to provide more detail about what each of these competencies entail:

“Multicultural Counseling Competencies
I. Cultural Competence: Awareness
1. Moved from being culturally unaware to being aware and sensitive to own cultural heritage and to valuing and respecting differences.
2. Aware of own values and biases and of how they may affect diverse clients.
3. Comfortable with differences that exist between themselves and their clients in terms of race, gender, sexual orientation, and other sociodemographic variables. Differences are not seen as deviant.
4. Sensitive to circumstances (personal biases; stage of racial, gender and sexual orientation identity; sociopolitical influences, etc.) that may dictate referral of clients to members of their own sociodemographic group or to different therapists in general.
5. Aware of their own racist, sexist, heterosexist, or other detrimental attitudes, beliefs and feelings.

II. Cultural Competence: Knowledge
1. Knowledgeable and informed on a number of culturally diverse groups, especially groups therapists work with.
2. Knowledgeable about the sociopolitical system’s operations in the United States with respect to its treatment of marginalized groups in society.
3. Possess specific knowledge and understanding of the generic characteristics of counseling and therapy.
4. Knowledgeable of institutional barriers that prevent some diverse clients from using mental health services.

III. Cultural Competence: Skills
1. Able to generate a wide variety of verbal and nonverbal helping responses.
2. Able to communicate (send and receive both verbal and nonverbal messages) accurately and appropriately.
3. Able to exercise institutional and intervention skills on behalf of their client when appropriate.
4. Able to anticipate impact of their helping styles, and limitations they possess on culturally diverse clients.
5. Able to play helping roles characterized by an active systemic focus, which leads to environmental interventions. Not restricted by the conventional counselor/therapist mode of operation.”

Sue goes on to state that skills should include alternatives to the traditional one-to-one therapy and could include such approaches as:
“- Having a more active helping style
- Working outside the office (home, institution, or community)
- Being focused on changing environmental conditions as opposed to changing the client
- Viewing the client as encountering problems rather than having a problem
- Being oriented toward prevention rather than remediation
- Shouldering increased responsibility for determining the course and outcome of the helping process.” (pgs. 47-48)

Sue, Derald Wing and Sue, David. (2008). Counseling the Culturally Diverse: Theory and Practice. John Wiley and Sons, Inc., Hoboken

Discussion of Values

To appropriately apply any ethical decision making model to an ethical dilemma, it is critical to have an understanding of the underlying values that may influence a professional’s ability to satisfactorily resolve the dilemma.

In The Ethical Decision-Making Manual for Helping Professionals, (Steinman, Richardson, McEnroe, 1998), the authors discuss what they refrer to as the “values trap,” which is a misunderstanding about personal, professional and religious beliefs and which of these values should guide a professional’s practice.

This manual offers definitions of these different values/codes/beliefs that should help practitioner’s distinguish between them and determine what values/codes should be guiding their professional practice:

- Religious beliefs – These can determine a person’s value system and moral standards and a sense of what is right and what is wrong. Because these religious convictions are handed down from a higher being for many they override any other authorities or values.

- Moral standards – These are codes of personal behavior that guide our everyday actions and how we relate to others and can be based on religious beliefs. If someone is seen as immoral it may be that they have different standards for moral behavior.

- Personal values – These are value systems that all peope have and which are used to determine what is and what is not important to them. Someone may be considered not to have any values just because their personal values may be different from our’s or society’s.

- Professional ethical code – These are the generally accepted standards of condut that guide the professional behavior of individuals in their working environment for how they relate to their clients, employer, co-workers, other professionals and within their own profession.

Being able to identify these values and understand the distinction between them will allow a mental health clinician to avoid situations in which their own personal or religious values might conflict with those of their profession, client or employer.

Diversity Model I: Ethical Self-Assessment

The following set of questions is adapted from questions posed in Abromson’s article and can be used as a tool to develop a level of self-awareness that can help guide ones application of any ethical decision making model.

Ethical Self-Assessment
1. What are the qualities of a good person?
2. What are the qualities of a competent therapist?
3. What are the qualities of a good employee?
4. What are the personal and professional standards to which I strive to meet or to hold myself accountable to?
5. When my roles as therapist, employee, moral person or upstanding member of society conflict, which role do I place first?
6. How important are the principles of autonomy (self-determination), beneficence (doing good), non-malfeasance (doing no harm) and justice to me, and which principle do I value most when they come into conflict?
7. When a client’s interests conflicts with the interests of society, how do I act and whose interests do I place first?
8. When faced with a shortage of resources, how would I decide to allocate them?

Values SCENARIO

Can Your Client Decide?
You are working with a family and your agency wants you to involve the client in deciding on the goals of care. You don’t believe that the client has the ability to make good decisions about what is best for her or her children. What do you do?

What is the ethical dilemma?
How do I fulfill my agency’s stated goal of involving clients in the decision making process around goals of care with a client who appears not to have the ability to make good decisions about what is best for her or her children?

What values or ethical perspectives should be considered (personal, societal, professional, client or agency)?
Part of the process the mental health clinician in this scenario should undertake is determining whether or not the client has the capacity to make decisions and to understand his or her own personal values. Do those values conflict with the client’s values? Are there cultural, class or religious differences between the client and worker?

Besides the clinician and the client, who else has a value or perspective on this situation that should be considered in resolving the ethical dilemma? Several examples are provided below of those people or entities that might have an interest in how this dilemma is resolved, and what some of their values might be.

Agency – The agency would value having employees sensitive to the values of the clients being served. The agency would value employees’ compliance with their professional codes and agency policies. The agency would value clients getting appropriate services. The agency would value the ability of employees to appropriately determine whether or not a client has the capacity to make decisions.

Professional organizations – Professional organizations would value members who abide by the professional code of ethics and who do not impose their personal values or beliefs on the people that they serve.

Client’s children – The children would value their relationship with their mother and family. The children would value receiving services that are appropriate to meeting their needs. The children would value clinicians who are sensitive to their cultural values.

Human Services – Human services would value a non-neglected and abusive environment for the children.

Courts – The courts would value appropriate determination of capacity.


Diversity Model II: Marvin T. Brown - Diversity Ethics Process Model

Marvin T. Brown, a leader in business ethics with more than 25 years of teaching, writing and consulting on organizational and business ethics states that: “Training in ethical decision making involves learning how to handle disagreement, engage in dialogue, prevent collusion, inquire about different views, explore assumptions, and to apply corporate values and principles.” (Working Ethics, Retrieved 12/26/07 at: http://workingethics.com/services.html).

Mr. Brown's lessons on making ethical decisions in situations of cultural diversity utilizes the language of dialogic or discursive processes. That is to say that ethical decision making is a shared process between the clinician and the client, where both parties enter into a dialogue about their different values. It is not a process where a clinician tells the client what to do, based upon a set of values that the clinician "knows" are "right" values. Parity is assumed between the clinician's values and the client's values, and both have a claim in shaping the final decision that is made. The clinician is just as likely to have their values changed by the cultural material of the client as is the client by the values of the clinician.

There are complications in this approach. Clinicians have obligations under federal and state laws. Those laws represent the complex efforts to define the shared or collective values of the larger culture, and there are biases written into the law, based upon who holds a dominant position in the political system that shapes law.

These complications are the reason that yourceus.com has constructed a five-hour course on ethical decision making in situations of ethical diversity: Cultural Diversity, Value Conflict and Ethical Decision Making: An Overview for Mental Clinicians. Clinicians who face complex ethical decision with diverse populations are encouraged to take this course.

For now, however, Brown’s Diversity Ethics Process Model is summarized below:

Brown’s Diversity Ethics Process Model

1. Make a proposal (What should we do?)
2. Identify observation (Why should we do it?)
3. State values (Why is this the right thing to do?)
4. Align personal, client, professional, societal values
5. Explore the alternative views (with the participation of the client)
6. Uncover the assumptions (for the client's values, the clinician’s values, the profession’s values and society's values)
7. Find the best option (in concert with the client)
8. Perform a consequence analysis (in concert with the client)

Brown, M., Concepts and Experience of the “Valuing Diversity and Ethics” Workshops at Levi Strauss and Company, www.workingethics.com

Brown's Diversity Ethics Process Model, performed correctly, seeks to create a process through which these thorny cultural collisions are led towards resolution to the satisfaction and adaptation of all the interacting parties. Please note the transformed role of the clinician in this process - from a role that places the clinician as the expert, towards a role as a participant in the process of uncovering the shape and direction of the decision or solution.

The key distinction in this way of operating as an expert is that the context and key definitions are not supplied exclusively by the dominant culture. This is a shared process of evaluating and responding to an ethical problem, and it is expected that the client’s cultural elements will be accorded enormous respect in terms of the power to shape the definitions - based upon the client’s systems of beliefs and values.

The advantages of this approach are important in terms of avoiding extreme (i.e., less adaptive) positions. The values and biases of the dominant culture are not automatically imposed on the client, with no room for discussion and interaction. The client's position is not labeled as deviant.

However, the extreme position on the other side is not taken, either. This is to say that the clinician is allowed to invite the client to examine his or her value orientations, beliefs, ideals and perceptions. The client is not given an automatic pass to avoid the dialogue through taking the position that any questioning or examination of his or her position is culturally disrespectful.

The responsibility for the clinician in terms of respecting the client's right to autonomy does not constitute permission for the client to refuse to engage in any process in which adaptation might be required. The client may still say, in essence, "this is my culture and I decline to change anything about it".

However, the clinician is not ethically required to respect cultural diversity and difference to the point of being unable to enter into dialogue about the intersection of the client's culture and the larger culture in which the counseling is taking place. At the very least, the client's autonomous decision to participate in the larger system that is the United States – and the fact that therapy is occurring - is an implicit and explicit acceptance of the reality of interaction and cultural interplay.

Dialogic work assumes one additional thing. It assumes that all the parties who enter into the dialogue will be willing to be changed or transformed through the interaction with the other parties. Said differently, instead of each party entering the interaction with the idea of dominating or convincing the other party to change their fundamental moral or value-based position, the transaction will be concerned with a joint effort at creating adaptive solutions to the conflict.

The solutions can utilize elements from either or any of the parties' original frameworks, or can create new and innovative positions wholly apart from what can be found in any of the original moral, value, or perceptual positions of the parties.

The nature of this kind of work has been explored by a number of authors in a number of arenas. Pearce and Littlejohn have developed a model of discourse designed specifically to address the kinds of intractable moral and value based conflicts that we are studying here. They call their model Transcendent Discourse. They describe the strengths and purposes of their model in the following ways:

1) Transcendent discourse goes beyond simplicity to explore the complexities of the lived experiences of the participants;
2) Transcendent discourse goes beyond obstruction to engage in genuine dialogue;
3) Transcendent discourse goes beyond blame to identify and critique the basic beliefs and assumptions of faith;
4) Transcendent discourse moves forward into new ways of understanding and acting.

Pearce and Littlejohn propose the following five-step process for resolving intractable moral conflicts:

1. Uncover the communities' basic assumptions
2. Develop categories to compare incommensurate differences
3. Seek to explore rather than convince
4. Assess the strengths and weaknesses of both worldviews
5. Seek to reframe the conflict into more productive terms (20)

Pearce, W and Littlejohn, S. Moral Conflict. Thousand Oaks, California: Sage, 1997

The leader's role in moving this process forward includes securing the willingness of the involved parties to engage in this sort of process, explaining and teaching the model sufficiently to allow the process to move forward, and facilitating the exchanges and interactions in accordance with the principles and tools of the model. This model is very compatible with the ideals of cultural competence in clinical practice.

A more detailed exploration of these models for managing diversity and ethical decision making is beyond the scope of this training. For clinicians who wish to engage in a fuller examination of this subject, once again we recommend yourceus.com’s course entitled, “Cultural Diversity, Value Conflict and Complex Ethical Decision Making for More Senior Clinicians”.

We will now turn to demonstrating the use of an ethical decision making model in addressing a defined clinical situation with ethical complications.

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