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Some mental health professionals identify their religious affiliations or beliefs in their advertising, on their cards, or in their informed consent paperwork. Others develop specific specialties in areas dealing with religious concerns . Although a generic clinical interview includes religion as an aspect of the whole person, the interviewer must gently bring the dialogue back to problem areas and sources of distress. Also, treatment planning may certainly include consultation with religious leaders or authorities .

390 Interviewing Special PopulationsTHE IMPORTANCE OF CONTEXT Interviewing in a multicultural setting involves a delicate balance between awareness and understanding of broad cultural group characteristics and the individual internalization and expression of those characteristics. As unique cultural beings, people must interact with an environment that exhibits its own cultural qualities and requires certain qualities of individuals. For example, a Mexican American student quickly learns that mastery of the English language is required to be successful in public schools. This is a contextual requirement that requires adaptation for success. In the process of adapting, the student makes many decisions about other aspects of his or her cultural background that either ?t, don’t ?t, are useful or not useful, in this new context. The essential task of the interview becomes understanding the uniqueness of ethnocultural individuals within their various contexts. As Swartz Kulstad and Martin state, “. . . the ?eld is in need of a functional method to assess the interactive in?uences of all three levels-universal, group and individual-and to determine how these in?uences have an impact on the individual’s successful adaptation to his or her psychosocial environment” .

Their personal or family con?icts have become too great; and the answers, cures, or solutions within their religious framework have failed.

Because religion represents both culture and personal choice, differences between counselor and client, though not visible, can still be pronounced and unsettling . You might be directly asked about your religious beliefs in an initial interview. We recommend a balanced response:

• First, as a professional, it is your job to explore both the cause for concern and the

concerns themselves as they relate to the client’s problems and needs.

a brief summary of your own religious or spiritual orientation only exacerbates the concerns in most situations. After your summary, return the topic to how it feels for the client to work with you. Do not debate matters of faith.

One of our colleagues, a psychologist who is also an ordained minister, often provides religious clients with the following commentary about the relationship between religious and psychological well being: I understand it can be hard for a person with strong religious beliefs to consult a professional about personal problems. One way I look at it is like this: I know some people who are doing very well psychologically and very poorly when it comes to their religious adjustment. On the other hand, I know some people who are doing ?ne with their religious life, but they have some psychological or emotional work to do. Although many times religious and psychological well being are highly connected, being well in one area doesn’t necessarily mean you are feeling well in the other. I guess what I’m saying is that, if you want, I think we can work on the emotional and psychological concerns here, without violating issues of faith.

-Henri J. M. Nouwen, The Living Reminder For a deeply religious person, seeking help from a secular mental health professional may feel like a contradiction of faith-or at least a very risky thing to do. Therefore, the interviewer needs to be particularly sensitive to behaviors suggesting a challenge to religious authority. Mental health issues and problems are obviously very connected to religious concerns. Finding a comfortable middle ground that denies neither perspective can be challenging. As Samuel M. Natale says in the article Psychotherapy and the Religiously Committed Patient: Multicultural and Diversity Issues 389There are few problems more demanding in psychotherapy than dealing with a client’s religious beliefs. This is so for a number of reasons, which include not only a lack of sensitivity and understanding on the part of the therapist but also a hesitation, avoidance, and even downright fear on the part of the therapist to explore distinctly religious values with a client.

In keeping with the trend to look at the whole picture when working with individuals, families, or couples, religion and/or spirituality can often be integrated into the counseling process . However, although this may be true with regard to more liberal thinking religious clients, fundamentalists and deeply committed people from most organized religions generally prefer not to seek secular help for their problems . Therefore, similar in some ways to working with Asian American families, the ?rst visit may be because of a family or personal crisis. Their entry into the professional mental health world generally is not a casual inquiry into the potential use of psychotherapy to expand and grow. More likely, it is an expression of desperation.

Sometimes, when interviewing a person with an obvious disability, professionals assume it is more polite to ignore crutches, missing limbs, wheelchairs, or even canes indicating blindness. However, as stated earlier with regard to race and culture, asking directly about the “difference” is usually welcomed. Such questions as “Have you used a wheelchair all your life, or is it a more recent addition?” can open the door to a candid discussion of the disability.

Facing and managing a disability affect all areas of an individual’s life. However, too often, mental health professionals without rehabilitation training do not know how to calibrate the presence of the disability. The disability is either treated as the de?ning feature of the individual, overshadowing all else, or it is ignored; ignoring a disability implies that it really should not have any direct impact on the emotional and interpersonal functioning of the individual.

Men who have accepted their disabilities or chronic conditions often have adopted a new set of values that replace the dominant male values in society. This process may take a good deal of time, depending upon the man’s special circumstances, personality, and social situation.

-A Man’s Guide to Coping with Disability

The Religiously Committed

The challenge of ministry is to help people in very concrete situations-people with illnesses or in grief, people with physical or mental handicaps, people suffering from poverty and oppression, people caught in the complex networks of secular or religious institutions-to see and experience their story as part of God’s ongoing redemptive work in the world.

Interviewers need to be sensitive to relationship and family issues among homosexual, bisexual, and transgendered clients. Gay and lesbian couples come with all the varieties of needs and problems that trouble heterosexual couples, and more. In particular, they are often without societal and familial supports and sanctions that help and nurture heterosexual couples. In times of illness or loss, a gay or lesbian lifepartner may not be recognized or accorded the same privileges of a heterosexual partner. Additionally, many such individuals experienced harsh rejection from one or more family members. These experiences may lead them to be either reluctant to admit their sexual orientation or to express their sexual orientation loudly and aggressively.

The day I saw a poster declaring the existence of an organization of Gay American Indians, I put my face into my hands and sobbed with relief…. What Americans call Gayness not only has distinct cultural characteristics, its participants have long held positions of social power in history and ritual among people all over the globe.

-Judy Grahn, Another Mother Tongue 388 Interviewing Special PopulationsPersons with Disabilities But as Kit squeezed my hand, I knew that as far as she was concerned, none of these things made any difference. I was simply the man with whom she was in love. We were a man and a woman, eagerly looking forward to spending a lifetime together. Nothing else mattered, least of all my blindness . . . The waiter arrived with our drinks.

“Here you are mademoiselle,” he said, putting Kit’s bourbon and water in front of her. Then he whispered, “Where would he like his drink?” -Harold Krents, To Race the Wind An extensive literature exists for interviewers wishing to work with clients who have physical, developmental, or emotional disabilities. In fact, there are master’s and doctoral level training programs in special education and rehabilitation counseling and psychology. Although there are many technical aspects to various medical conditions and disabilities, in general, as with all groups of people, an open and accepting attitude is the most important prerequisite to working with people who have disabilities.

Sexual identity and sexual orientation are intensely personal and central matters to Multicultural and Diversity Issues 387most people. Sexual attraction is a powerful motivator of human behavior and is foundational to most people’s sense of self. The longing for a soul mate is probably as old as life itself. To date, there has been no de?nitive explanation as to why, across time and culture, a consistent minority of humans are attracted to members of the same sex.

Many theories have been offered, but, at present, it seems best to consider homosexuality, like left or right handedness, simply a fact of nature. Some people are attracted to opposite sex partners for sexual intimacy, and some people are attracted to members of the same sex.

Many homosexual people report knowing they were homosexual even before kindergarten, and others report becoming aware much later in life . Because of stigma and lack of cultural role models, many homosexual people have, at times, struggled with their sexual orientation and tried to ignore or change it .

People with gender identity or sexual orientations other than heterosexual go to counselors for all the reasons heterosexual people go, and they do not necessarily identify their sexual orientations as part of the problem. However, many have endured verbal abuse, violence, vicious labeling, loneliness, and harsh judgments; sometimes, these experiences occurred during childhood or adolescence, while some clients report that these experiences are more recent or current. These cruelties exact a great developmental and psychological price.

Many people who are homosexual, bisexual, or transgendered do not share that information during an initial interview. In fact, many share this component of their identity with very few people. Interviewers need to listen for themes suggesting struggles with sexual identity, dating, attraction, and so on. Because many nonheterosexual people anticipate harsh judgment and rejection, some gay friendly therapists suggest leaving homosexual friendly pamphlets or literature in the waiting room to communicate an open attitude toward these issues . It is also important that care is taken to avoid using gender speci?c words indicating the assumption of heterosexuality. For example, when inquiring about intimate relationships, the word partner rather than boyfriend or girlfriend should be used. This allows clients to reveal the partner’s gender when ready. For younger clients, or clients who are dating, it is helpful to ask general questions about romantic relationships or romance.

The professor watched the over?ow until he no longer could restrain himself. “It is overfull. No more will go in!” “Like this cup,” Nan in said, “you are full of your own opinions and speculations. How can I show you Zen unless you ?rst empty your cup?” A case example of working with an Asian American client is provided in Putting It in Practice 13.5.

OTHER DIVERSE CLIENT POPULATIONS The groups with which we identify-the ones we claim and the ones that claim us- profoundly in?uence us. Our families of origin; our ethnic, cultural, and/or racial identities; and our sexual identities affect our lives continuously, both consciously and unconsciously. Further, our chosen beliefs and the experiences life brings shape our identities and the quality of our lives. The following groups of individuals are included as illustrations of this truth.

Gay, Lesbian, Bisexual, and Transgendered People Mel [White, gay pastor] had no choice about being a homosexual. Believe me, if he had a choice, I know he would have chosen his marriage, his family, and his unique ministry; for Mel’s values, like most gay and lesbians I know, are the same as mine and my heterosexual friends: love, respect, commitment, nurture, responsibility, honesty, and integrity…. We are all on this journey together and we must ensure that the road is safe for everyone, including our homosexual brothers and sisters who for far too long have been unfairly condemned and rejected. Isn’t it past time that we opened our hearts and our arms to welcome them home instead of seeing them as strangers still waiting at the gate? -Lyla White, Stranger at the Gates Sexual orientation is, of course, a very controversial topic. Many dominant world religions declare homosexuality to be sinful, although there are certainly substantial numbers of religions, and denominations within the religions, that do not take this stand . For many years, homosexuality was considered a mental disorder, and to this day, there exist treatments designed to “cure” homosexuals .

However, as described by Christopher , Simon’s presenting problem stimulated deeper personal re?ection: I confess that initially this case placed me in a dif?cult position with respect to my own values. Having spent a number of years critiquing Western culture and learning about the moral visions of non Western traditions, my tendency was to focus on the limitations of assertiveness and the individualism it manifests and supports. Moreover, I was troubled to see someone from a cultural tradition as rich as Simon’s almost eager to forsake this heritage to become Western …. I … felt a sense of reservation about helping Simon with his stated goals.

This case illustrates an interesting potential contextual dilemma associated with cross cultural counseling. That is, how does the therapist handle a situation in which he or she values a client’s culture to a greater degree than the client? Take some time to re?ect on John Christopher’s dilemma. How would you be affected by a similar situation? Are there any particular ethnocultural perspectives, philosophies, or behavior patterns that you ?nd more desirable than your own? Putting It in Practice 13.5ing and decision making. Religious orientations are as varied as the countries from which Asian Americans have come, including such diverse belief systems as Buddhism, Islam, Hinduism, Christianity, Janism, and many branches in each.

Much has been written about the Western mind or worldview and the Eastern mind or worldview in religious and philosophical literature. Although the following quote may not help the interviewer with any particular Asian American client, it may serve as a guide in our quest to be more authentically multicultural:

A Cup of Tea

Nan in, a Japanese master during the Meiji era , received a university professor who came to inquire about Zen. Nan in served tea. He poured his visitor’s cup full, and then kept on pouring.

It is important to be respectful to all clients, but Asian American clients may respond especially well to being treated with formal respect. Using Mr., Mrs., and Ms.

and a last name is a signal of respect and should not be discontinued until the client directly invites a ?rst name address. However, be aware that traditionally, in most Asian countries, women keep their own family surnames and may wish to be called by that surname even if, because of customs in the United States, she has begun to use her husband’s surname. A simple inquiry along these lines indicates respect.

Spiritual and Religious Matters

A common practice among many Asian cultures has been the keeping of an ancestor altar. A reverence toward ancestors and various beliefs regarding ancestral spirits, wishes, or presence in family matters can be central to individual and family function386 Interviewing Special Populations

Working with an Asian American Client

In a recent issue of Psychotherapy, John Chambers Christopher, a colleague of ours, reports on the following case: Simon, an East Asian international student, referred himself to the university counseling center after about one year of studying in the United States. Simon reported low self esteem, dif?culty concentrating, and problems with socializing. His stated goal for therapy was to become “more assertive in his interactions with others” . In particular, Simon expressed a desire to become more similar to his American roommates and less like other international students from his homeland.

Presented by a different therapist and/or a different client, this case might simply be cast into the rather straightforward mold of assertiveness training.

Further complicating the ?rst visit is the fact that such a visit and the problems that made the visit necessary might be experienced as shameful. The client may not be forthcoming but may, instead, minimize problem areas or attempt to describe them in vague, impersonal ways.

Asian families living in the United States are almost all in some phase of acculturation. The children often become bilingual, therefore assuming a power in the family that upsets traditional roles. Further, some families have members living in the home country and some members living here, which adds more relational and role strain .

Orientation toward Authority

Many Asian cultures are rigid and hierarchical in structure . This is directly related to a concept called ?lial piety, which refers to the honor, reverence, obedience, and loyalty owed to those who are hierarchically above you . The deference toward authority manifests in a number of ways. Asian American clients expect a counselor to be an expert and to act with authority.

In the same vein, verbal communication with a mental health professional may not be direct and certainly is not confrontive. It is likely that an Asian American client, when faced with uncertainty, simply offers the most polite, af?rmative response available. Among Asians, as among many American Indian tribes, silence is a sign of respect. Also similar is the pattern of eye contact. Direct eye contact is invasive and disrespectful, especially when interacting with persons of higher status or authority .

Even during a ?rst interview, many Asian American people expect concrete and tangible advice. This runs contrary to most training models for beginning interviewers; therefore, you need to practice how to give quick advice. This practice is necessary, too, Multicultural and Diversity Issues 385because the advice being offered will likely be coming from a non