12.3 Ethical Issues in Multicultural Counseling
Cultural Tunnel Vision
Counselors enter the profession with unique cultural backgrounds shaped by personal experiences, values, and beliefs. While these experiences can serve as a valuable starting point for developing cultural competence, they may also unintentionally limit a counselor’s openness to unfamiliar cultural perspectives. This can result in biases, even if unintentional, that may affect the therapeutic relationship. For instance, a counselor might inadvertently project their worldview onto a client, potentially invalidating their lived experiences.
Consider the example of a person of color who expresses frustration about being repeatedly subjected to full-body searches at airports. If the counselor dismisses their concern with a statement like, “Oh, it is just a security measure,” they risk ignoring the more profound significance of the client’s experience—such as feeling targeted or stereotyped based on their racial identity. This dismissal can damage trust and reinforce the very marginalization the client is grappling with. A culturally competent counselor, however, would take the opportunity to explore the client’s feelings, acknowledging the possibility of systemic bias and validating their perspective.
Even when the counselor and client share similar identities, challenges can arise. Shared cultural backgrounds or experiences may lead to assumptions of mutual understanding that cloud clinical judgment. For example, a counselor may over-identify with a client’s emotions or struggles, resulting in diminished objectivity. This dynamic, often called countertransference, can lead to therapy being guided more by the counselor’s emotions than the client’s needs.
To counter these challenges, counselors must intentionally develop cultural self-awareness, recognizing their biases and blind spots. They should strive to understand the diverse worldviews of their clients and remain curious about the complexities of each individual’s cultural identity. This requires active listening, empathy, and a willingness to ask thoughtful questions without making assumptions. By doing so, counselors can create an inclusive therapeutic environment, affirming and attuning to each client’s unique cultural experiences.
NAADAC (2021) discusses the importance of counselors understanding their own cultural values and beliefs:
“Addiction professionals shall develop an understanding of their own personal, professional, and cultural values and beliefs. Providers shall recognize which personal and professional values may be in alignment with or in conflict with the values and needs of the client. Providers shall not use cultural or values differences as a reason to engage in discrimination. Providers shall obtain supervision and/or consultation to address areas of difference and to decrease bias, judgment, and microaggressions, and shall document the recommendations (Standard IV-4).
Case Study: Cultural Tunnel Vision
Ronnie approached a client seeking mental health and substance use treatment to conduct a diagnostic assessment. During the assessment, the client disclosed that their partner had engaged in black magic, putting a spell on them, causing them to hear voices and experience their body as an outside observer. The client became emotional when speaking about the experience that happened five years ago and denied any active hallucinations or delusions. After the assessment, Ronnie was conflicted about the client’s diagnosis. Ronnie belonged to the same culture as the client and believed in the existence of black magic and that it was culturally relevant not to warrant a diagnosis around psychosis. Ronnie also thought about how the client did not currently meet the criteria for a psychosis diagnosis. However, he did think about how his cultural identity may be causing biased opinions about the client.
In this case, Ronnie identified the same identity as the client, making it difficult to choose between having to give a psychosis diagnosis or to note cultural relevance. This is when it is essential to consult with co-workers to see a different perspective on the case and then make a decision.
Discussion Questions
- How can counselors differentiate between culturally specific beliefs or experiences and symptoms of a mental health disorder, such as psychosis, when conducting a diagnostic assessment?
- What steps can Ronnie take to ensure that his cultural identity and beliefs do not unduly influence his professional judgment in this case?
- What role does consultation with colleagues or supervisors play in addressing potential biases or cultural considerations in diagnostic decisions, and how can it be effectively utilized in this scenario?
- How can counselors balance cultural sensitivity with adhering to diagnostic criteria when a client’s reported experiences may align with culturally specific beliefs rather than symptoms of a mental health disorder?
Implicit Bias
Implicit bias refers to the unconscious, negative evaluation of individuals based on irrelevant characteristics such as race or gender (FitzGerald, 2017). Unlike explicit bias, which is conscious and intentional, implicit bias operates outside one’s awareness, often influenced by early experiences and environmental factors. This subtle nature makes it challenging to identify or acknowledge, even for counselors who strive to act ethically and equitably. Greenwald and Banaji (1995, as cited in Boysen, 2009) differentiate between explicit and implicit bias. Explicit bias involves consciously held negative beliefs, judgments, and stereotypes, often measured through self-reporting. Implicit bias, by contrast, is unintentional and occurs without conscious awareness, making it difficult to self-report or consciously address.
Even counselors who self-report high levels of multicultural competence are not immune to implicit bias. Boysen (2009) highlights that implicit bias is pervasive among counselors and contributes to disparities in mental health outcomes for marginalized populations. Counselors’ unconscious biases can hinder their ability to provide equitable and client-centered care, as these biases may influence their decisions about offering specialized treatment, following evidence-based practices, or allocating resources.
Marginalized groups, including homeless individuals, veterans, people of color, and those who are incarcerated, are particularly vulnerable to the effects of implicit bias. For example, a counselor’s unconscious assumptions about a client’s worthiness or behavior might lead to suboptimal care or reinforce systemic inequities. This bias not only undermines the therapeutic relationship but also perpetuates barriers to accessing high-quality mental health services. Counselors must actively engage in self-reflection and seek ongoing education to combat implicit bias. Tools such as bias awareness training, peer consultation, and consistent use of culturally competent practices can help counselors mitigate the effects of implicit bias, fostering a more inclusive and equitable therapeutic environment for all clients.
Case Study: Implicit Bias
Monica, a licensed professional counselor, has been working with Alex, a 22-year-old college student, for three months. Alex sought therapy to address anxiety and difficulties adjusting to college life. During their sessions, Alex mentioned feeling unwelcome in group activities on campus, attributing some of the discomfort to being one of the few Latino students in their program. Monica offered reassurance, encouraging Alex to focus on building resilience and self-confidence.
One day, Alex shared an experience at a recent campus event where they overheard a group of peers making derogatory comments about immigrants. Alex expressed frustration and hopelessness, saying, “I feel like no matter how hard I try, people just see me as different and don’t take me seriously.”
Without realizing it, Monica responded dismissively, saying, “I’m sure they didn’t mean it personally. Maybe it’s more about miscommunication.” Alex nodded politely but grew quiet, avoiding eye contact for the rest of the session. Over the next few sessions, Alex became increasingly distant, offering short answers and eventually missing an appointment.
Reflecting on the change in Alex’s engagement, Monica reviewed her notes and realized she had overlooked the significance of Alex’s concerns about cultural exclusion. She also recalled a training on implicit bias, where she learned that minimizing a client’s experiences of discrimination can stem from unconscious biases. Monica scheduled supervision to explore her response to Alex’s disclosure and began revisiting resources on culturally responsive counseling practices.
When Alex returned for their next session, Monica acknowledged the previous conversation. She said, “I’ve been reflecting on our last sessions and realize I may not have fully understood how painful that experience was for you. I want to make sure this space feels safe for us to talk about anything that impacts you.”
Alex hesitated but eventually opened up, explaining how often they felt invalidated when sharing experiences of discrimination. This acknowledgment marked a turning point in their therapeutic relationship, allowing deeper discussions about Alex’s experiences and coping strategies.
Discussion Questions
- What role did Monica’s implicit bias play in her initial response to Alex’s concerns?
- How might Monica have handled Alex’s disclosure differently to provide a more validating and supportive response?
- What strategies can counselors use to identify and address their implicit biases in their work with clients?
- How does cultural humility factor into ethical counseling practices?
Immigrant Population
The current political climate has significantly impacted the mental health of the immigrant population, particularly undocumented immigrants. Financial barriers often prevent them from accessing treatment, compounded by the fear of deportation, which deters many from seeking help. For example, during the COVID-19 pandemic, many immigrants avoided healthcare services out of fear of immigration enforcement. Extended visa overstays due to lockdowns left many with depleted financial resources and separated from family and support systems. Some undocumented immigrants lost their jobs, resorted to homelessness, and refrained from seeking treatment. Similar disparities were observed during the H1N1 pandemic, where disadvantaged groups, including immigrants, faced inequalities in preparedness, response, and clinical outcomes (Clark et al., 2020). Additionally, mixed-status families—where U.S.-born children have citizen status while their parents may be undocumented—add complexity to the challenges faced by immigrant communities.
Immigration itself presents a significant barrier to accessing mental health care. Despite clear evidence of the negative mental health impacts of immigration-related stressors, stigma and mistrust remain prevalent among immigrant populations. Undocumented individuals often experience discrimination, marginalization, isolation, fear of deportation, and socioeconomic hardships, all of which contribute to poor mental health outcomes (Garcini et al., 2017).
Counselors working with immigrant clients must approach these challenges with cultural competence and ethical sensitivity. Peer consultation with colleagues who are knowledgeable about immigration issues is essential to provide the best care. Counselors should also prioritize confidentiality and careful record-keeping to ensure that client progress notes cannot be misused. By consulting peers and adopting best practices, counselors can navigate unfamiliar situations and offer effective, culturally informed support to immigrant clients.
Ethical codes offer guidance on maintaining confidentiality in the counseling relationship.
The ACA (2014) Code of Ethics states:
“Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process” (Standard B.1.b.).
The NAADAC (2021) Code of Ethics highlights:
“Addiction professionals and the organizations they work for shall ensure that confidentiality and privacy of clients shall be protected by providers, employees, supervisees, students, office personnel, other staff and volunteers” (Standard II-6).
Case Study: Immigrant Population
Anita, working as a school counselor, asked an eighth grade student to meet with her to discuss recent complaints from the student’s teachers. Anita was informed by the teachers that they have concerns regarding the student, appearing to be distracted during class lectures and was at times found to be sleeping. The teachers also brought up concerns regarding student’s eating habits and negative mood presentation as they noticed the student had been isolated from peers and not eating during lunch or recess. Moreover the student’s grades were slipping that were not reflective of the student’s potential to perform well. After building rapport with the student, Anita asks the student about her family and enquires about any stressful situation the student may be facing. The student disclosed she had two younger siblings in elementary school and had been busy preparing food everyday for the siblings and managing the household. When asked about taking on such responsibilities, the student said both her parents are working double shifts to provide food and at times they have fallen short of money to purchase food. The student admitted to not eating food so her siblings could have something to eat. The student spoke about her parents being undocumented immigrants and working for less than minimum wage. The student shared her parents are working double shift to make ends meet. The student had been experiencing a lot of anxiety around fear of her parents being deported as there have been incidents where other students in similar situations found out about their parents being deported. Anita suggested the student fill out a form to apply for a free lunch program at school, but after looking at the questions on the form the student panicked and showed mistrust toward Anita and abruptly left the room. Anita feels conflicted between her growing concerns about student’s mental and physical health and her helplessness to be an effective advocate around complicated legal issues with which she is unfamiliar with (Gonzalez, 2015).
Discussion Questions
- How can school counselors effectively support students facing significant family responsibilities and financial hardships, especially when those responsibilities impact their academic performance and well-being?
- What steps can counselors take to build trust with students who may be reluctant to seek help due to fears related to their family’s immigration status or other legal concerns?
- How can school counselors advocate for undocumented students and their families while navigating complex legal and systemic barriers, and what resources or training might help them in these situations?
LGBTQ+ Community
As our society progresses toward inclusivity and diversity, we acknowledge that there are communities that still face significant barriers to accessing treatment, especially for fear of judgment and retribution. The acronym LGBTQ+ includes affectional orientation, sexuality, and gender identity and expression (Goodrich & Luke, 2015). Goodrich and Luke (2015) highlighted that people within this community often face marginalization because of approaches that do not account for the unique needs of different groups. They also noted that mental health counselors historically receive very little training in this area, even though research shows that LGBTQ+ individuals experience higher levels of mental health challenges and need more resources. Many in the LGBTQ+ community report facing issues such as discrimination, microaggressions, rejection, violence, and systemic oppression (Bostwick et al., 2014; Goodrich & Luke, 2015; Peters, 2018).
There is evidence that the LGBT communities generally experience poorer mental health outcomes because of social stress, experience of discrimination, and living in a heterosexist or homophobic environment. Individuals who are exposed to discrimination of a personal nature are often at greater risk of developing depression, experiencing psychological distress, or even suicide (Rees et al., 2021).
The Society for Sexual, Affectional, Intersex, and Gender Expansive Identities (SAIGE), previously called the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, created guidelines to help counselors work with individuals in the LGBTQ+ community, including those who identify as lesbian, gay, bisexual, queer, questioning, intersex, and allies (ALGBTIC LGBQQIA Competencies Taskforce, 2013). They also developed separate guidelines for working with transgender and gender-diverse clients (SAIGE, 2010). Both sets of guidelines encourage counselors to take an affirmative approach that supports and uplifts clients and to focus on building resilience and promoting wellness. These competencies also highlight the knowledge, skills, and self-awareness counselors need when working with LGBTQ+ individuals.
Killian et al. (2019) explored how healthy counselors are prepared to work with LGBTQ+ clients and found that many do not feel confident in their ability to do so. Their study focused on how experiential learning—hands-on training—can help counseling students become more prepared. The findings showed that this type of learning boosted students’ confidence and helped them expand their knowledge and skills for working with LGBTQ+ clients. One strength of Killian et al.’s research is that it outlined specific ways to help students improve their cultural competence when working with LGBTQ+ clients. However, the study did not address the unique needs of different subgroups within the community, like how the experiences of a transgender person may differ from those of a lesbian. This highlights the importance of tailoring training to address the diverse experiences within the LGBTQ+ population. You will have the opportunity to explore these strategies further in your social and cultural diversity course.
Case Study: LGBTQ+ Population
Kavya has been providing mental health services to an adolescent client who has been going through a period of anxiety. Kavya concluded in her diagnostic assessment of the client that they have gender dysphoria, and the client expressed a desire to explore what transitioning might entail. The client, however, revealed that their parents are unaware of their desire to transition and are afraid of being shunned and pushed for conversion therapy. Kavya thinks about how to progress with note writing as the client’s parents can access their notes, which may cause a significant rift between them and their parents. Kavya also thinks about the client’s mental health taking a toll as they have expressed fleeting thoughts of suicide for not having social support and feeling isolated. Kavya is conflicted with deciding between concealing the information on the progress note and having to mention the diagnosis so the client can access gender-affirming care with regard to physical and mental health.
Discussion Questions
- How can counselors ethically navigate the tension between maintaining client confidentiality and documenting necessary information in progress notes when those notes may be accessed by third parties, such as parents?
- What strategies can Kavya employ to support the client’s mental health and well-being while respecting their concerns about family dynamics and fear of rejection?
- How can counselors advocate for clients seeking gender-affirming care while ensuring their safety and mental health are prioritized, particularly when clients face significant barriers such as family opposition or lack of social support?
The examples offered in this chapter include a very small example of cultural identities and backgrounds. Students will explore these identities, along with many others, in greater depth and detail in their social and cultural diversity course.
Key Takeaways