Abstract
The divergent discourses between scholars from the potentially harmful treatment and multicultural psychology camps are accurately observed by Wendt, Gone, and Nagata. I argue that the differences in perspectives between the two groups are more about a clash of therapeutic worldviews, that they are often antagonistic to one another, that conversations have been a one-way process (with one side “not wanting to hear”), and that sociopolitical forces play a significant role in preventing a true dialogue from occurring. I conclude that the ultimate harm to groups of color is cultural oppression.
“Potentially Harmful Therapy and Multicultural Counseling: Bridging Two Disciplinary Discourses” by Wendt, Gone, and Nagata (2015, this issue) is an outstanding contribution to the field of psychology and mental health treatments. Not only is it a major scholarly undertaking, but it is also beautifully written, clear, and concise. But what sets it apart are the substantive issues they tackle that have for too long remained unaddressed.
First, they reveal how major differences in perspectives and orientation between those who have advocated studying traditional therapeutic effectiveness (efficacious outcomes, evidence-based treatments [EBTs], and potentially harmful treatment [PHT]) and those studying multicultural counseling and therapy (MCP) have oftentimes moved in isolation from one another, seemingly oblivious to the contributions of each. As I will shortly indicate, however, it may be more accurate to characterize the lack of interaction as being one-sided rather than both sides contributing equally to the dearth of discourse.
Second, they argue persuasively that the divergence between traditional psychotherapy and multicultural counseling literatures is not simply due to the implied inclusion of sociodemographic concerns in PHT conceptualizations, or a failing of iatrogenic treatment studies on people of color (although they call for such studies from MCP advocates). Rather, they surmise that the lack of discourse and integration between the two camps is due primarily to differences in how harm is conceptualized in three dimensions: (a) sources of harm, (b) objects of harm, and (c) scope of harm. In this respect, they shine a light on how insular professional assumptions made in the PHT and MCP camps lead to different definitions of harm.
Third, their aim in this article is to begin a conversation between the two camps by making three recommendations. They propose that harm should be theorized as a social construct, that mental health interventions are cultural artifacts (thus potentially ethnocentric), and that collection of evidence of harm should be integrated within a social justice agenda. The authors are to be commended for taking the first steps toward such an important dialogue in their deconstruction of the reasons why such conversations are difficult to undertake. They attempt to present both sides of the “debate” in a balanced and fair manner, outlining the facts and issues.
Except for differences in perspective, however, I find little to disagree with in their presentation of the research literature on PHT and MCP, their deconstruction of worldviews that affect definitions of therapeutic harm, and their offering of possible solutions for new directions. Indeed, I am in agreement that moving toward a social justice perspective in conceptualizing harm is helpful and needed. How we do it is another matter. But, let me make an important point here and raise a question. Is the PHT movement really not the flipside of the therapeutic effectiveness forays (different sides of the same coin) that have resulted in evidence-based practice (EBP) initiatives to determine effectiveness, ineffectiveness, and possibly harm? If so, we would have to conclude that PHT and mainstream counseling practices considered “therapeutic” originate and share the same basic conceptualizations of mental health, definitions of what constitutes normality and abnormality, Western European assumptions of counseling and therapy, and standards that determine desirable therapeutic outcomes. In this respect, most criteria used to judge “well established” and “probably efficacious” treatments (Chambless & Hollon, 1998; Chambless & Ollendick, 2001) share basic assumptions with the PHT movement. Many of these have been identified by the authors and include (a) exploring effectiveness and harm for already existing and specific treatments (e.g., cognitive behavioral therapy, exposure/guided mastery, relapse prevention, brief dynamic therapy) and specific disorders (e.g., panic, phobias, bulimia, headaches), (b) calculation of harm for generic individuals as opposed to culturally diverse groups and systems, and (c) an individualistic or intrapsychic focus in determining harm. Thus, my comments are less about disagreements than perhaps more nuanced elaborations, complementary perspectives, and a stronger emphasis on sociopolitical relationships that impede a true conversation between the two camps.
The Sociopolitical Nature of Discourse
The authors refer to the harmful treatment literature from both camps as “divergent discourses,” but I would submit that the perspectives of PHT and MCP are (a) more about a clash of worldviews, (b) often antagonistic to one another, (c) conversations that have been a one-way process (with one side not wanting to hear), and (d) evidence of sociopolitical forces that play a significant role in preventing a true dialogue from occurring (Sue & Sue, 2013). The authors state that psychological interventions “may be ethnocentric,” but I would say with greater certainty that any system of therapy or “healing” is by its nature ethnocentric or more accurately culture-specific (Sue, Ivey, & Pedersen, 1996). An awareness of indigenous and non-Western modes of healing, for example, clearly suggests that what might be therapeutic (effective) to one group may be harmful to another (Gone, 2010; Moodley & West, 2005). Although PHT does acknowledge ethnocentrism and potential bias in the practice of counseling and therapy, its emphasis on individualism and the medical model ignores viewing harm from a larger cultural, systemic, and societal perspective. Thus, in essence, mental health professionals may view harm as residing in individuals, types of treatments, and specific disorders, and lose sight that harm from the MCP perspective results from cultural oppression, imposing the standards of one dominant group upon those who hold less power (Sue & Sue, 2013). Let me briefly elaborate on these observations as they relate to the authors’ major points.
PHT and MCP: Worldview Differences
To understand potentially harmful treatments from traditional therapeutic perspectives and MCP, it is important to note that these divergences represent differences in worldviews that the authors conceptualize as residing in three categories: sources, objects, and scope of harm. They point out that PHT focuses on specific treatments (I would also say specific disorders), individuals, and positive or negative changes in symptoms (medical model), whereas MCP concentrates on cultural and institutional aspects of bias and discrimination, uses a broader psychosocial framework that goes beyond the individual, and considers harm not only for individuals, but also for culturally diverse groups, families, communities, systems, and society. As such, I submit that what we have here is a clash of worldviews that is reflected not just in therapeutic domains but in nearly all aspects of life in the United States. Elsewhere, I have argued that traditional counseling and psychotherapy are derived from the components of White Western European culture (individualism vs. collectivism, universality vs. relativism, low context vs. high context communication, empiricism vs. experientialism, and so forth; Sue & Sue, 2013). These values and beliefs inundate the very nature of how we define normality and abnormality, and therapeutic effectiveness and harm; what constitutes therapeutic legitimacy; how we ask and answer questions about the human condition; and how research is conducted.
Thus, to view particular interventions in isolation from larger cultural and systemic values and assumptions (such as focusing simply on specific treatments and disorders) is to miss seeing the forest from the trees. In this respect, I believe that the primary responsibility for change must come from the PHT and EBT camps because they are so dominant in determining the direction of mental health practice and research. The EBT movement is a prime example. Underlying the research and clinical practice of EBT is a worldview that values empiricism: Empirical tests establish verifiable facts that represent the building blocks of knowledge and ultimately “truth.” Objectivism is valued over subjectivism and reason over emotion. Cause–effect formulations value reductionism and separation of variables rather than interrelatedness. In essence, these values and concepts ultimately have their roots in the Protestant work ethic of individualism, separation, and personal responsibility (Sue, in press). Although empiricism and individualism have positive components, is it possible that their extreme form may result in narrow views of the human condition and by inference therapeutic practice, and that they risk becoming meaningless, inappropriate, restrictive, and oppressive? Let me provide two examples of this concern.
First, the authors call for MCP scholars to begin conducting iatrogenic studies that identify potential harm for clients of color and note that rarely have they focused on specific treatments. In many respects this is true, but it may be due to a disinclination to view treatment in isolation from the larger context of values and assumptions that are embedded in how specific interventions are developed. One of my greatest fears is that such a focus will lead to inappropriate and meaningless conclusions and implications unless seen from a broader perspective. The authors indicate that the work linking racial microaggressions to therapeutic alliance and supervision (Sue, 2010), for example, represents an exception. I would submit that viewing the work on microaggressions in this manner misses the wider clinical picture and relationship issues involved. Studies reveal the harmful impact of specific microaggressive behaviors (e.g., color-blindness, denial of individual racism, ascription of intelligence) on interpersonal relations, which are reenacted in therapy (Sue, 2010). The findings have often resulted in training and practice aimed at avoiding specific behaviors/statements (considered harmful), so as not to put down, insult, or invalidate culturally diverse clients. These training techniques and guidance about avoiding microaggressions are superficial and cosmetic in nature because microaggressions are reflections of a worldview of inclusion–exclusion, superiority–inferiority, desirability–undesirability, and normality–abnormality. Racial microaggressions are deeply embedded implicit racial biases, and it is this element that is harmful to clients of color, not just the specific behaviors. What is dangerous here is that implicit biases are outside the level of conscious awareness and cannot be separated from their behavioral expressions. Thus, avoiding harm does not occur through simply eliminating behavioral or non-verbal manifestations of microaggressions but requires major personal change and self-reckoning by clinicians.
Second, EBTs are traditionally based upon the values of empiricism, in that “not all evidence is created equal” (Hunsley, 2007). As a result, the degree of psychological “truth” resides in an evidence hierarchy that considers randomized controlled studies more valid than observational studies, and these, in turn, are more valid than case studies and clinical judgments (Ghaemi, 2010). This hierarchy was clearly evident when certain groups within the American Psychological Association (APA) began promoting the use of validated or research-supported treatments effective for a specific disorder (Chambless & Ollendick, 2001). This original narrow approach to determining therapeutic effectiveness has given ground to strong criticisms as to its mechanistic character and failure to consider the holistic nature of human existence. Interestingly, the change to a more liberated understanding of individual and cultural influences in the assessment, treatment plans, and therapeutic outcomes has seen an evolution in clinical intervention terminology: empirically validated treatments (EVTs) to empirically supported treatments (ESTs) to evidence-based practice (APA, Presidential Task Force on Evidence-Based Practice, 2006). In other words, there is now recognition that the narrow and restrictive nature of early formulations associated with EVT has given way to acceptance of practices based upon a broader recognition of what constitutes evidence. If the PHT movement is the flipside of EBTs, little wonder that it, too, may be bound to the values of empiricism, objectivity, control, and separation; the result is that harm is defined solely in individuals and in isolation from the larger meaning of harm that involves cultural differences and larger systemic considerations.
One-Way Conversations: A Tale of Two Stories
Wendt, Gone, and Nagata (2015) rightly note that “ethnoracial minority concerns have been simply off the radar within the PHT literature.” But that is not surprising as the concerns of people of color have also historically been off the radar in the profession of psychology, in general. Arnett (2008) in a hard-hitting article took the profession to task for focusing narrowly on U.S. Americans who comprise only 5% of the world’s population. This begs the question, “Can the principles and findings be applicable to what he calls ‘the neglected 95%’ of the rest of the world?” Are human beings similar enough that studying them in one part of the world allows us to generalize them to people residing in different countries? Furthermore, when most of the research done on PHT and EBT consists primarily of White Euro-Americans and when race, culture, and ethnicity are ignored, how relevant are they to people of color? Most of the PHT and EBT literatures have been insular and fallacious in assuming that findings on non-Latino White Americans are universally applicable across all populations, situations, and disorders. It is not that multicultural scholars have not attempted to raise these issues and concerns with the profession, but it has been largely ignored despite APA’s (2003) endorsement of multicultural competencies.
A true discourse between the MCP and PHT camps can only come about when both sides are willing to engage in dialogues and not just monologues. Much like songs that no one wants to hear, the voices and concerns of MCP scholars represent counternarratives to the master narrative of traditional White Western European psychological thought. In my work on racial dialogues (Sue, in press), for example, I have likened “race talk” between Whites and people of color as storytelling. The master narrative is “White talk,” and the counternarrative is “back talk.” The former can be likened to a public transcript (master narrative) that legitimizes the position of the majority group and implies that it is the natural order of things. Back talk, however, voices a hidden transcript that challenges the racial realities of Whites. In many respects, I find this analogy very appropriate in the conversations between PHT and MCP as it applies to mental health, and the determination of clinical effectiveness and harm. I am often struck by listening to conversations between White mental health professionals and those of color. I liken it to storytelling in which the stories represent a master narrative and a counternarrative. Traditional White Western European “therapy talk” operates from hidden assumptions that (a) define disorders as residing in individuals, (b) disorders are departures from conventional (statistical) norms, (c) psychological principles derived from the dominant group are universally applicable, and (d) therapy consists of a series of strategies and techniques detached from the cultural context. These have resulted in traditional mental health therapeutic taboos: A counselor does not give advice or suggestions, does not self-disclose his or her thoughts and feelings, does not serve in dual role relationships, does not accept gifts from clients, and does not bargain (Sue & Sue, 2013). These behaviors are considered to be non-therapeutic and potentially harmful to clients. Interestingly, Parham (1997) has argued persuasively that it is these counselor qualities that make a therapist credible to many African American clients.
The themes of “back talk” from MCP scholars tell a different story: (a) mental disorders are often sociopolitical constructions, (b) all treatments and behaviors cannot be isolated from their cultural contexts, (c) the individual is not necessarily the psychosocial unit of operation, (d) cultural universality must be balanced with cultural specificity, and (e) the most important element of harm in therapy is cultural oppression. Conversations between PHT and MCP scholars represent a tale of two stories that echo the common historical and cultural themes from dual perspectives, often at odds with one another. Back talk threatens established assumptions and beliefs of traditional mental health practice and questions their validity as they apply to other groups of color. As a result, the history of the profession reveals disinclination from well-intentioned mental health professionals to hear the voices of those most oppressed and silenced, or to even engage in meaningful discourse with MCP scholars and practitioners (Guthrie, 1997; Thomas & Sillen, 1972). Accepting the master narrative from the mental health profession maintains the status quo, minimizes the concerns of multicultural psychologists, and absolves responsibility for changing the system of assessment, diagnosis, and treatments. Thus, what we really have here is a broader clash of therapeutic realities, and it begs the question, “Which reality is the true reality?” Unfortunately, the answer seems to reside in a group’s sociopolitical power to impose its definitions upon less empowered groups.
Cultural Oppression as Harm in Therapy
In my view, the most dangerous and insidious form of harm for persons of color and others in therapy is cultural oppression (Sue, 1978). If counseling and psychotherapy originate from a specific White Western European cultural context, they must reflect the values, assumptions, biases, and proclivities of the larger society. In this respect, counseling and psychotherapy may serve as handmaidens of the status quo and be potential instruments of oppression rather than liberation. PHT and EBT scholars, for example, focus their research primarily on specific treatments for specific disorders. As we have emphasized, specific treatments are culture-bound, and the focus on specific disorders assumes cultural universality, assumptions that there exists a fixed set of disorders whose obvious manifestations cut across all cultures and societies. Western concepts of normality and abnormality are considered universal and equally applicable across racial, cultural, and ethnic groups. MCP proponents, however, stress the importance of cultural relativism, and the idea that lifestyles, cultural values, and worldviews affect the manifestation and determination of disorders. Were these two positions given equal consideration and had they shared an equal status relationship, perhaps the mental health profession would conclude that both views have validity; some disorders manifest similarly across cultures, and cultural values and characteristics of a society affect how disorders present themselves. Indeed, this seems to be one of the goals advocated by the authors.
In practice, however, although lip service is paid to recognizing multiculturalism in mental health, the profession continues to operate (perhaps unknowingly) on a predominantly monocultural basis. Our educational, economic, legal, political, and social systems inundate our lives with monocultural values, beliefs, and practices. Little wonder that our mental health system also reflects these values and biases. Thus, it should not be surprising that therapeutic reality and its derivation to practice whether effective, ineffective, or harmful in nature come primarily from a White Western European framework. Discourse from MCP to PHT/EBT or the profession in general is difficult to hear or consider legitimate because of several major obstacles.
First, the power to define reality (in this case, therapeutic reality) resides in the history of the mental health movement, beliefs about minority inferiority and White superiority, and reflections of healthy and unhealthy (pathological) characteristics derived from Western cultural values (Guthrie, 1997; Thomas & Sillen, 1972). According to one of my colleagues, the group that owns history is the group that has the power to determine reality. Thus, therapy is defined as individual-centered (stressing the I–Thou relationship), changing individual cognitions, emotions, and/or behaviors, and attacking specific disorders through the use of specific scientifically derived therapeutic strategies. Second, and perhaps most damaging, is the power to impose this definition of therapeutic reality upon culturally diverse groups who may not share the worldviews of their well-intentioned helping professionals. This is accomplished through individuals (significant others in our lives—friends, family, neighbors, etc.), institutions (educational, social, and political), and society (cultural values and ideals) who socialize and culturally condition us. Forced compliance to such a therapeutic worldview occurs through both overt and covert enforcement. Professional standards of practice and codes of ethics in our associations are one means by which such enforcement occurs. In addition, when issues of cultural diversity arise, the profession simply advocates modifying current practices “to meet the needs of clients of color.” There is almost an assumption that historical human groups never had anything like “psychotherapy” until Western Europeans invented it. Little thought is given, even by therapists of color, that this may represent an insidious form of cultural oppression itself. Let me provide an example to illustrate what I mean.
Ever since the beginning of human existence, all societies have developed their own explanations of abnormality and culture-specific ways of dealing with human distress and problems. Africa, Asia, Latin America, and even the indigenous peoples (Native Americans) of the United States have utilized ritualized healing practices and intrinsic help-giving networks to aid their communities. Basic to the principles of non-Western indigenous healing is a holistic outlook in life (minimal distinction between mental and physical functioning), interconnectedness of the human condition (with all things living and nonliving), and balance and harmony (with the group). Illness, distress, and problematic behavior are seen as an imbalance in people relationships, and a lack of synchrony within and outside of the person. In addition, spirituality and belief in metaphysical levels of existence are common in non-Western beliefs and practices (Sue & Sue, 2013). As we have seen earlier, these principles of illness and healing are in marked contrast to Western mental health beliefs and principles. The concepts of reductionism, separation, objectivity, isolation, and individualism are hallmarks of Western concepts of mental health, mental disorders, and treatment. Western healing traditionally operates from several assumptions: Reality consists of distinct and separate units or objects (therapist–client and observer–observed), reality is whatever can be observed and measured through the five senses, space and time are fixed and absolute, and science operates from universal laws and is culture free. Interestingly, these characteristics and imperatives are oftentimes seen by indigenous groups as the causes of disorders.
Conclusion
In closing, I believe the authors are on the right track in proposing that harm should be conceptualized as a social construct, that therapy (I prefer the term healing) is a cultural artifact, and that evidence of harm must be informed by a social justice agenda. They offer some specific recommendations that, if implemented, could potentially start the process of integrating divergences in worldviews. But how we get cooperation from both camps to dialogue is a major challenge. Such a movement becomes sociopolitical in nature because, in many respects, it means altering power relationships. The power to impose Western European worldviews of mental health and disorder and consequent treatments on diverse groups is, I believe, the ultimate exercise of cultural oppression and harm in counseling and psychotherapy. Perhaps our profession would profit from attempting to understand principles of indigenous healing, entertain the possibility of their legitimacy, and build therapeutic interventions from the ground up rather than always attempting to adapt current Western models to fit the diverse populations that reside in this country. I submit that a system of healing balanced from the ground up rather than solely from the top–down will reveal more effective forms of treatments while minimizing harm to multiple client populations.
But, as the authors point out, this is not an either/or issue but potentially valuable if the discourse can lead to defining harm from a social justice perspective and both sides can begin a conversation, and truly listen to one another. There appears to be some hope on the horizon that such a dialogue can prove productive. In an article titled “Evidence-Based Practices With Ethnic Minorities: Strange Bedfellows No More,” Morales and Norcross (2010) argued that EBP and multiculturalism are converging and how they must complement one another rather than stand in isolation and opposition. They stated, “Multiculturalism without strong research risks becoming an empty political value, and EBT without cultural sensitivity risks irrelevancy” (p. 823). This very same conclusion may be said to apply equally to the work of PHT and MCP scholars.
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.