Even when a therapist has a clear description of a client's self-identification, this information will not necessarily lead to a deeper understanding of the client. What is important is knowledge of the meaning of these identities (L. S. Brown, 1990). Depending on one's reference point, there may be more than one meaning for the same identity. That is, a particular iden- tity may have one meaning in the dominant culture, another in a minor- ity culture, and still another person-specific meaning for the individual.
Information about the person-specific meanings of identity usually comes from the client, either indirectly (through descriptive informa- tion and views shared by the client) or in response to direct questions (e.g., regarding Jean, "What does your identity as a Haitian man mean
to you, in your present situation?"). However, to understand these person-specific meanings, it is important that therapists also understand their culture-specific meanings.
To understand the meaning of Jean's identity as a Haitian man living in Canada, it is necessary to have at least a general knowledge of Haitian culture and history. Haiti became the world's first independent Black republic when slaves overthrew French colonizers in 1804. From 1915 to 1934, Haiti was occupied by the United States, and the first group of Haitians immigrated to the United States. Many of them settled in Harlem and integrated into the African American community (Menos, 2005).
From 1957 to 1986, Haitians endured the oppressive regimes of Papa Doc Duvalier and his son Baby Doc. The Tonton Macoutes, a secret military police, routinely tortured and persecuted dissenting professionals, politi- cians, and students. The second wave of immigration to the United States began during this period and consisted primarily of the well-educated upper and upper-middle classes, resulting in the loss of many profession- als from Haiti. Later groups, from the mid-1960s to 1971 and during the 1980s, consisted mainly of middle-class and poorer people. In the early 1990s, another 65,000 risked their lives to escape political persecution and economic devastation but were intercepted according to a U.S. pol- icy that ordered the Coast Guard to turn away all Haitian boats without screening passengers (i.e., for refugee status; Menos, 2005). Between 1980 and 2001, thousands of Haitians immigrated to Canada. As of 2001, approximately 82,000 Canadians identified as Haitian, the vast majority residing in Montreal, Toronto, and Vancouver (International Policy Coor- dination, Citizenship and Immigration, 2004).
More recently, Haiti has continued to experience armed uprisings (e.g., the ousting of the democratically elected Jean-Bertrand Aristide in 2004), foreign intervention (e.g., a U.S.-backed government until 2006), natural disasters (e.g., Hurricane George in 1998 killed 140 people and displaced 160,000; in 2004 flooding killed 1,000 people, with another 2,400 missing or dead); and disease (approximately 4% of the popula- tion has AIDS; World Almanac Education Group, 2007). Today, Haiti remains the poorest nation in the Western Hemisphere. Class divisions among Haitians both inside and outside the country are strong. Fluency in French and lighter skin color (related to family histories of intermar- riage with the French and thus alignment with French colonial values) are associated with higher social status. In Quebec, Haitians who are fluent in French have the advantage of language (i.e., in contrast to Haitians in Vancouver, Toronto, or the United States, who must learn English). However, they are not accepted in the same way as French speakers of European origin; color-based job discrimination is not uncommon (Bibb & Casimir, 1996; Glasgow & Adaskin, 1990).
Jean was a lighter-skinned Haitian man who was fluent in French, held a university degree, and came from a middle-class family. In his
7 8 C O N N E C T I N G W I T H Y O U R C L I E N T
culture of origin, he held privilege and status. In contrast, in a Canadian context, the same cultural identities held a different meaning. Being Hait- ian (or, from the dominant cultural perspective, Black) meant that he was seen primarily as an immigrant and a foreigner. The most salient aspects of his identity in Haiti—gender and social class—were eclipsed by his eth- nic identity, which visibly set him apart from the majority of Canadians.
Although it might at some point be appropriate for the therapist to ask Jean about his personal experience as a Haitian man living in Quebec, it would not be appropriate for the therapist to expect Jean to educate her about the general cultural meanings of his identity (i.e., the information provided in the preceding paragraphs). Nor would it be wise, because information about a whole culture from the client's sole perspective is often quite limited. Obtaining this kind of information is part of a therapist's own personal learning, most of which should occur outside the therapy setting.
As an analogy, consider a therapist who has no direct experience with people who have dissociative disorder; she would not expect the first client she sees with this disorder to educate her about its common characteristics. Rather, she would obtain this information herself out- side the therapeutic relationship and then use the assessment time to explore the client's personal experience of the disorder.
If, with regard to Jean, the therapist is unfamiliar with the general his- tory and culture of Haiti, the impact of political events on Jean's genera- tion, and the position of French-speaking "visible minority cultures" in Canada, she would be more likely to maintain her credibility by admitting these gaps, at the least to herself, and, depending on the circumstances, possibly to Jean as well. She could then commit herself to expanding her knowledge for the benefit of her client. This commitment would lead her to seek information and experiences outside the therapy setting and to educate herself about these general meanings. As her knowledge and experience increase, her understanding of Jean's identity would still be framed as hypotheses, but these hypotheses and the questions that emanate from them would be much closer to the realities of his life.
Client-Therapist Interactions: Beyond Traditional Transference
Early psychoanalytic approaches emphasized the therapist's role as a blank slate or mirror onto which the client's feelings about parental fig- ures could be projected. The client's emotional reactions to the thera-
pist, known as transference, were seen as "projections by a client of expec- tations and distortions based on past experience" (Chin, 1994, p. 207).
However, when one introduces the concept of culture into an analysis of therapist-client interactions, it is clear that the emotional reactions of clients to therapists, and vice versa, often reflect differences and power imbalances in the real world.
As Perez Foster (1996) noted, "the fact is that analysts are neither neutral screens nor simple clay for transferential transformation. They are, in fact, formidable characters who often have robust prejudices"
(p. 15). A client's reaction to a therapist of another cultural identity may be less related to the client's feelings about her parents than to the client's daily experiences with people of the therapist's culture. Recognizing this reality, psychodynamic theorists have broadened definitions of transference and countertransference in ways that open up a consider- ation of cultural influences (Chin, 1994; Muran, 2007). For example, from the perspective of self psychology, Hertzberg (1990) noted that the internal representations people of minority identities hold include "both the experience of self within a particular subculture, as well as the expe- rience of the self as an outsider of a larger, dominant culture" (p. 276).
Consider the situation of a 60-year-old married woman of Gua- temalan heritage who is referred to a much younger, European Ameri- can female therapist. Because the client's most intimate and long-lasting relationships have been with her husband and children, and because she is older than the therapist, she may be more likely to see the thera- pist as a daughter than as a parental figure. Similarly, the therapist's experience of the client may involve feelings associated with her own mother or grandmother. (See Newton & Jacobowitz, 1999, for more on transferential and countertransferential processes with older clients.) But the reactions of this client and therapist to one another may be more complex than those related solely to age. For example, what if the thera- pist is from a well-educated, upper-middle-class family and the client is from a poor, rural, Mayan (Indigenous) background? In this case, the client may remind the therapist more of the maid that she has hired to help with household responsibilities and child care, and the therapist may remind the client of the powerful Spanish-speaking landlords in Gua- temala or of a demanding employer in her new country. Conceptualiz- ing the client's distrust as solely a projection of her feelings overlooks the client's history and day-to-day experiences of oppression by mem- bers of the therapist's culture (see Gleave, Chambers, & Manes, 2005, regarding the sociopolitical history of and U.S. role in suppressing democ- racy in Guatemala).
Despite the negative emotions often associated with the topic, it is important that therapists be comfortable bringing up the topic of cul- ture (including race and other differences) if it appears to be relevant to
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the therapeutic relationship. For example, a European American ther- apist's straightforward question to a Black family (e.g., "How do you feel about working with a White therapist?") makes available for discussion what is probably already on everyone's mind (Boyd-Franklin, 1989). Of course, if the therapist does raise the topic, it is essential that she has
"seriously thought through its relevance" (p. 25); otherwise, the ques- tion may be perceived as patronizing (Greene, 1994). In addition,
White therapists need to be prepared for the possibility that this question may elicit feelings of anger, and some family members may even verbalize their reluctance to work with a White therapist. The more able a therapist is to remain nondefensive and nonapologetic while discussing this issue with the family, the greater the likelihood of a therapeutic connection.
(Boyd-Franklin, 1989, p. 102)
Before raising these questions with clients, consultation and super- vision with people of diverse identities can be helpful. As C. B. Williams
(1999) noted with regard to race,
the task in training White counselors is to desensitize them to talking about their feelings about race. For counselors and trainees of color, on the other hand, this usually is not the problem. Much of their experience . . . has been marked by frequent, lively discussions about racial issues with other people of color. However, White people have typically been missing from these discussions.
The counselor education classroom or professional workshop, thus, becomes a forum for an unfamiliar enterprise that is rich with opportunity for growth for everyone: discussing race across racial groups, (pp. 34-35)
At the same time, with some clients, it may not be appropriate to bring up the topic before a feeling of trust has been established. Many older people, of both dominant and minority cultures, grew up in a time when one was expected to hide or minimize differences related to race, social class, sexual orientation, and disabilities (Sang, 1992). In addition, many individuals are uncomfortable with direct discussion about another per- son's abilities or limitations, fearing that such discussion might suggest that the therapist is not competent. Finally, as mentioned earlier in the case of Mrs. Sok, some clients simply do not see the relevance of the ther- apist's identity or their own, and making it an issue before a relationship is established may feel forced.
Just as clients' feelings about therapists may originate in their expe- riences with members of the therapist's culture, so too are therapists influenced by their experiences with clients' cultures. Chin (1994) dis- cussed common manifestations of countertransference in therapists of minority and dominant ethnic identities. When the therapist is a person of color, countertransference may involve overidentifying with clients' experiences and thus underdiagnosing or minimizing psychopathology
when it is present. A similar phenomenon can occur for any therapist who shares a minority identity with her client (e.g., a lesbian therapist may assume similarities between herself and her lesbian client that are unwarranted; Morrow, 2000). Chin advised therapists of color to beware of "interventions that promote an agenda for personal change regarding cultural and gender roles that is not the client's" (p. 212). However, the strong identification of therapists of color with their clients frequently facilitates the therapeutic relationship.
In contrast, countertransference in European American therapists often involves issues related to power and difference (Chin, 1994). Out of a desire to form an alliance with clients of color, European American therapists may minimize cultural differences (Quinones, 2007). And out of a lack of knowledge, they may assume similarities that do not exist. As a result, clients may feel misunderstood or alienated. However, countertransference may facilitate the therapeutic relationship if the therapist acknowledges the differences and her lack of knowledge regard- ing the client's culture but also holds a strong willingness to be helpful and to learn (Chin, 1994, pp. 212-213).
Returning to the case of Jean, the therapist's assessment could be facilitated by an understanding of the interaction between her own identity and that of Jean. She could first use the ADDRESSING acronym to identify those aspects of her identity that are different from Jean's and thus most salient in this particular setting; these would include reli- gion, ethnicity, national origin, and gender. Recognizing her own iden- tity as a Canadian-born feminist Quebecoise, this therapist would want to think critically about how her inexperience with Haitian people increases her susceptibility to dominant cultural assumptions about Haitian men. She would want to consider the possibility that her own European American feminist philosophy, which she considers relatively unbiased, might contribute to any prejudice she holds (see Exhibit 4.2).
Although the therapist might identify with Jean's experience as a member of a minority group because she holds minority status as a woman and as a French Canadian, she would want to be cautious about assuming similarities in this regard. When considered from a national perspective, her French Canadian ethnicity certainly constitutes a minor- ity status. French Canadians make up approximately 23% of the total Canadian population of 33 million, and as a group they have tradition- ally been in a subordinate position relative to the Anglophone majority (World Almanac Education Group, 2007). However, within Quebec, French is the official language, and French Canadians constitute a power- ful majority. Thus, relative to Jean, and in the context of Quebec, the therapist is a member of the dominant culture.
Since the revision of discriminatory immigration laws in 1962, the proportion of European immigrants to Canada has decreased (Elliott &
8 2 C O N N E C T I N G W I T H Y O U R C L I E N T
Fleras, 1992). Between 1991 and 2001, 3% of Canadian immigrants came from the United States, 58% from Asia and the Middle East, 20% from central and eastern Europe, 11 % from Latin America and the Caribbean, and 8% from Africa (International Policy Coordination, Citizenship and Immigration, 2004). Members of the non-U.S. and non-European groups, referred to as "visible minorities" in Canada, commonly experience prob- lems related to language, employment, finances, and the bureaucracies of the social services, health care, and immigration systems (Waxier- Morrison & Anderson, 2005). Although U.S. and European immigrants experience these problems, too, the barriers are often less formidable for their children, who physically resemble Anglo and French Canadians.
Along with this background information, Marie's awareness of her perceived visible identity would help her understand Jean's behavior in the therapeutic setting. If Jean initially appears defensive, Marie could consider the possibility that his self-protective behaviors may be in reac- tion to her visible identity as a Quebecoise. Given the prejudice and dis- crimination he has experienced from members of her culture, it would not be surprising that he feels defensive with her. However, Jean's reac- tion may have more to do with the therapist's identity as a woman.
What appears to be defensiveness may be discomfort about sharing his particular problems with a woman or with a woman who belongs to the dominant culture. Whatever the case, the more knowledgeable the therapist is regarding her own and Jean's identities, the more able she will be to understand his reactions and then behave in ways that facili- tate their interactions. Facilitative behaviors are discussed in more detail in chapter 5.
Conclusion
Identity is a complex phenomenon that includes both group-specific and person-specific meanings. Although the concept of identity is not always of interest to clients, it can be helpful to therapists who want a deeper understanding of their clients. Knowledge of a client's identity allows the therapist to more accurately infer what cultural influences have been important in that person's life. In turn, such information helps the therapist to form hypotheses and ask questions that are closer to the client's reality.
Although information about a client's personal experience of cul- ture usually comes from the client, it is generally not fair to expect clients to educate the therapist about the broader cultural meanings of their identity. Obtaining the latter information is primarily the therapist's responsibility and often involves work outside the therapeutic setting.
The more committed therapists are to this outside work, the more able they will be to use this background information to understand the client's personal experience and respond in ways that facilitate assess- ment and the therapeutic process.
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I
Understanding Clients' Identities and Contexts Identity is a multidimensiona
cultures, contexts, and time,
1. Identity is a multidimensional phenomenon that varies across 2, Knowledge of clients' salient identities gives the therapist clues about how clients see the world, what they value, how they may behave in certain situations, and how others treat them.
3 . In an initial assessment, the ADDRESSING framework can be helpful because it provides an easy-to-remernber list of minor- ity and majority identities that may be salient in a client's life.
4. Even if a client does not wish to explore the relationship of personal aad cultural identities to his or her current situation, it is important that the therapist considers identity issues, including the interaction between the therapist's own identi- ties and those of the client,
5. A particular identity may have one meaning in the dominant culture, another in a minority culture, and still another per- son-specific meaning for the individual.
6. Information about the person-specific meanings of identity usually come from the client; however, obtaining knowledge of culture-specific meanings of identity is a part of the thera- pist's own personal learning and ought to occur primarily out- side the therapeutic relationship.
7. The reactions of clients and therapists to one another (transfer- ence and countertransference) often reflect cross-cultural rela- tionships, conflicts, and power imbalances in the real world, 8. Awareness regarding one's own cultural identity is essential
for understanding cross-cultural transference and counter- transference in therapy.
9. The therapeutic relationship may be facilitated by an honest discussion of cultural differences between the therapist and client, if the client is open to such a discussion.
10. Consultation, supervision, and ongoing self-assessment are important steps in building one's confidence and experience in addressing cross-cultural differences with clients.
Making Meaningful Connections
Establishing Respect and Rapport
r. Ortega, age 32 and of Costa Rican heritage, arrived for an appointment with the physician in his company's outpatient clinic. In fluent English with a Costa Rican accent, he explained that during the past 5 months he had had pains in his stomach, had not eaten well, and had lost about 20 pounds. The physi- cian, a European American man in his 60s, did a thorough medical examination and then asked Mr. Ortega if he was experiencing some stress in his life. Mr. Ortega said yes, that he and his wife had not been getting along, that she had gone back to Costa Rica with their daughter to visit her family, and that he was afraid she might not come back. The physician responded that this sounded like a very stressful situation. He went on to explain that Mr. Ortega's problem appeared to be heartburn, which can be aggravated by stress. While writing a prescription for a medication, the physician asked Mr. Ortega if he would be willing to see the "nurse practitioner therapist"
for a few minutes "to talk about stress and diet in relation to your stomach problems and get some suggestions regarding your health and what you can do to feel better." Mr. Ortega agreed, so the physician found the nurse practitioner, Sharon, introduced her to Mr. Ortega, and left the two to talk.
Sharon, age 38 and of Italian American heritage, greeted Mr. Ortega with a firm handshake and some informal con- versation about how difficult traffic had become in the two
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