Ethics in Psychotherapy and Counseling. Kenneth S. Pope

      Psychotherapists are like all people. We too are shaped and influenced by many factors including our cultural heritage and our multiple social group memberships (e.g., race, ethnicity, gender, sexual orientation, religion, ability status). Subsequently, we navigate the world with a set of attitudes and ideologies that shape how we see ourselves and others. Indeed, you and I are “cultural beings,” all of our interactions are cross-cultural, and all of our life experiences are perceived and shaped from within our own cultural stance—the mantra and bedrock of cross-cultural and multicultural practice. As psychotherapists, our culture provides a rich context for becoming more aware of how our mores, values, customs, and traditions influence our own professional practice, ethical views, and reasoning. Ronald Francis (2009) wrote:

One of the singular merits of ethical considerations in a cross-cultural context is the way in which it forces us to confront our own values, to develop them, and to defend them. Cross-cultural comparisons afford a marvelous opportunity to examine the bases of our ethical codes in a manner which does not invite the heat more commonly attending intercultural value debates. Ethics is essentially about human values. Since not all values are shared, we are compelled to consider the issues we have in common; and those on which we divide. For instance, what may seem self-evident in one culture may be ethically repugnant to another. Ethics affords an opportunity to discuss and resolve these human values in a non-threatening frame of reference (pp. 182–193).

Ethical assessment and intervention also depend on our ability to understand culture beyond the surface level and popular culture (see Chapter 20). When considering the role of culture in psychotherapy, scholars have discussed and illustrated ways to examine and understand culture at the deep structural level, address how it impacts the psychotherapeutic process, and plan how to best integrate it into our practice (see Adames & Chavez-Dueñas, 2017; Gallardo et al., 2012; Parham et al., 1999; Vasquez, 2007). Five domains of culture at the deep structural level introduced and described by Ani (1994) include: ontology (nature of reality); axiology (value system); cosmology (relationship to the divine); epistemology (system of knowing and believing what is the truth); and praxis (systems of human interaction). Conversely, examples of surface level culture include food, holidays, celebrations, clothing, visual and performing arts, sports, dancing, language, and the like. The model in Figure 7.1 illustrates culture at both the deep and surface levels, with questions to guide us to explore, unpack, and understand culture in nuanced ways.

      Figure 7.1. The Deep and Surface Levels of Culture Model.

      Note: The model aims to assist you in thinking about you own assumptions of how you conceptualize culture in your life and in your practice. The model includes two layers: (a) outer layer depicting culture at the surface; and (b) inner layer illustrating the five domains of deep culture. The domains of deep culture influence each other in non-linear but dynamic ways. Each domain includes question(s) for individuals and groups to consider when exploring their culture, which is continuously shaped by context and history. The model can also be used with clients to explicitly introduce and explore culture in therapy—therapists can compare their responses to that of their clients and assess areas where their deep cultures overlap and diverge, which can help inform the therapeutic process.

      Source: Pope, Vasquez, Chavez-Dueñas, & Adames (2021).

Our professional responsibility to consider and integrate our clients’ culture in therapy begins with a realistic appraisal of our own multicultural training and competence. When we hear of the word “competence” we often envision an individual who is a content expert, or perhaps someone who has reached the pinnacle in their career—we may also think of a group of people who know what to do in any situation—this is not competence. Instead, we invite you to think of competence as a process through which someone gains sufficient knowledge, judgment, and skills to carry out a task without doing harm. According to scholar practitioners, cultural competence involves three aspects: (a) developing awareness of one’s own cultural values, traditions, and biases; (b) learning about the cultural values, traditions and worldviews of others; and (c) developing a set of culturally informed interpersonal skills (Mio et al., 2012; Sue et al., 2019; Vasquez, 2007). Accordingly, cultural competence is a continuing, life-long process of learning and relearning about ourselves and others as complex and layered cultural beings. In turn, this process strengthens our therapeutic alliance, increases the effectiveness of treatment, and deepens our ethical awareness and sense of personal ethical responsibility (see Arredondo et al., 1996; Casas et al., 2016; Fouad & Arredondo, 2007; Vasquez, 2007, 2009).

      The Impact of Cultural Competence on Treatment

      Our cultural competence influences the experience that clients have in therapy. For instance, Smith and Trimble (2016) conducted a meta-analysis focused on therapists’ cultural competence and its connection to clients’ experiences in treatment. They concluded that

Diverse clients tend to see therapist multicultural competence as highly related to, yet distinct from, other positive counselor attributes. In addition, culturally diverse clients are moderately more likely to prematurely discontinue treatment when their therapists do not demonstrate multicultural competence. Client outcomes improve when their therapists are able to competently attend to and value the varying experiences of culturally diverse clients (p. 64).

      More recent decades have seen an increase in scholarship describing and centering the role of culture in treatment outcomes. For instance, the evidence-based practice movement in psychology frames evidence as the “best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA, Presidential Task Force on Evidence-Based Practice, 2006, p. 273). This expansive description of evidence underscores the pivotal role of culture in psychotherapy outcomes. To illustrate, meta-analyses provide support for the effectiveness of culturally adapting psychotherapies for different groups (see Benish et al., 2011; Bernal & Domenech Rodríguez, 2012; Griner & Smith, 2006; Smith & Trimble, 2016; Zane et al., 2016).

      The abundance of evidence supports the need to consider the client’s culture and our own cultural competence in the therapeutic process—not doing so can result in unintentional harm to clients (Vasquez, 2009, 2012; Sue, 2019). Thus, the inclusion of cultural factors in psychotherapy is not just a desirable practice, it is a fundamental ethical responsibility outlined in standards.

      The CPA Code of Ethics Standard II.10 encourages psychologists to:

      “evaluate how their own experiences, attitudes, culture, beliefs, values, individual differences, specific training, external pressures, personal needs, and historical, economic, and political context might influence their interactions with and perceptions of others, and integrate this awareness into their efforts to benefit and not harm others” (2017b, p. 19). Standard IV.15 requires that psychologists “acquire an adequate knowledge of the culture, social structure, history, customs, and laws or policies of organizations, communities, and peoples before beginning any major work there, obtaining guidance from appropriate members of the organization, community, or people as needed” (p. 33).

      APA Ethics Code Standard 2.01b, Boundaries of Competence, states:

Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies (2017b, p. 5).

      Several psychological associations in the US have published documents that articulate and augment our ethical responsibilities