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
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Dating back to African practices, African American family roles tend to be more egalitarian than those in the White patriarchy, where women’s roles were limited to childbearing and homemaking . African American women are likely to work for the family’s sustenance as well as function in an equal or dominant parenting role.
Couples counseling often occurs because of child focused concerns . Also, African American women have been noted to stay in a dysfunctional relationship because of a reluctance to add further distress to the burdened lives of African American men . This reluctance to take care of themselves out of deference to “their men” can be very frustrating for counselors working with African American women.
Language
For an interviewer unaccustomed to street talk, or Black English, a client using such can be a challenge to understand. However, we do not see this issue as qualitatively different from any other bilingual challenge. Some African Americans speak perfect Standard American English and can switch to nearly indecipherable Black English at will. Some White Americans can do the same. However, it is unlikely that most White counselors easily understand street talk or Black English. You simply need to acknowledge your inability to understand and ask for help. The important 380 Interviewing Special Populationsthing to remember is that it is the interviewer’s language de?cit, not the languagespeaker’s problem. A polite attitude with a bit of a sense of humor goes a long way toward bridging language barriers that might exist.
Issues of Assumptions
There are approximately 30.8 million Americans of African descent . They make up the largest non White cultural group in the United States.
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Eye contact in many Indian cultures is different from the dominant American culture. Respect is communicated to others by listening quietly and avoiding direct eye contact. This is especially true when the Indian person is wishing to communicate respect to an elder or someone of perceived higher status.
For some Indian clients, note taking during the initial interview may not be experienced as a listening behavior . It is wise to watch for nonverbal signals that taking notes is seen as rude , and stop taking notes if possible. If you must take a few notes, simply explain the function of your notes and try to compensate for the distraction they represent.
A case example of an initial interview and case formulation with an American Indian is provided in Putting It in Practice 13.2.
African American Cultures
I am Kikuyu. My people believe if you are close to the Earth, you are close to people.
What an African woman nurtures in the soil will eventually feed her family. Likewise, what she nurtures in her relations will ultimately nurture her community. It is a matter of living the circle.
-Wangari Waigwa Stone in Refuge: An Unnatural History of Family and Place, by Terry Tempest Williams 378 Interviewing Special PopulationsSimilar to the experience of American Indians, the relationship between African Americans and European settlers did not begin as a mutual, voluntary relationship.
Both American Indian and African American cultures experienced the decimation of family structure, severe illness, loss of property and custom, and loss of liberty because of their involuntary contact with Whites. Between the years 1518 and 1870, approximately 15 million Africans were captured and brought by force to serve as slaves in the New World . The resulting intergenerational trauma, role confusion, grief, and loss reverberate in the African American culture as it rebuilds itself. There are spectacular success stories and examples of healing, depth, and wisdom throughout African American culture, but the costs of these traumas are still evident.
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American Indian Cultures
Oona was only ?ve years old but she was already trained in many of the ways of a good Ojibway. She knew almost all that she could not do and all that she must learn to do.
She went to her grandparents and stood before them with eyes cast down, knowing she could not speak the many questions she wished to ask, for they who are wise must speak ?rst. Always, the ?rst words spoken should be from the older people.
-Ignatia Broker, Ojibway elder and storyteller, Growing up Native American, ed. by Pat Riley According to the 2000 census, there are approximately 500 tribes represented in the United States; not surprisingly, each tribe has distinct values, customs, and histories.
Historically, Berkhoffer points out, more than 2,000 cultures were represented on the North American continent when Europeans ?rst arrived in the late ?fteenth century. These cultures had diverse languages, practices, and friendly or warlike interrelationships. They did not think of themselves as a single people. It is a mistake to assume more commonality among American Indians than exists. On the other hand, there are aspects of past and current Indian life that allow American Indians from different tribes to ?nd much common ground.
One such area of common ground is that American Indians experienced genocidal practices at the hands of European settlers for more than two centuries . The trauma and intergenerational grief and despair associated with these experiences are still readily in evidence in most tribal cultures and still take a toll in many tragic ways. Although American Indians come to counseling for all the reasons anyone in the dominant culture might come to counseling, we must remember that, as a people, their cultures were systematically decimated.
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Sometimes clients from nondominant cultural backgrounds have dif?culty responding quickly and smoothly to mental status examination questions. For example, as noted by Paniagua , “Clients who are not ?uent in English would show thought blocking” . This particular phenomenon, characterized by a sudden cessation of thought or speech, may signal symptoms of anxiety, schizophrenia, or depression.
However, “African American clients who use Black English in most conversational contexts would . . . spend a great deal of time looking for the construction of phrases or sentences in Standard American English when they feel that Standard American English is expected” .
Thought Content
Thought content refers to speci?c meaning expressed in client communication. Whereas thought process constitutes the how of client thinking, thought content constitutes the The Mental Status Examination 223224 Structuring and Assessment Table 8.2. Thought Process Descriptors Blocking: Sudden cessation of speech in the midst of a stream of talk. There is no clear external reason for the client to stop talking and the client cannot explain why he or she stopped talking. Blocking may indicate that the client was about to associate to an extremely anxiety laden topic. It also can indicate intrusion of delusional thoughts or disturbed perceptual experiences.
Circumstantiality: Excessive and unnecessary detail provided by the client. Sometimes, very intellectual people can become circumstantial; they eventually make their point, but they do not do so directly and ef?ciently. Circumstantiality or overelaboration also may be a sign of defensiveness and can be associated with paranoid thinking styles.
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Overall, the key point is to politely prompt clients to only discuss essential and highly relevant information about themselves. Either before or after practicing this activity with your partner, see how many gentle prompts you can develop to facilitate managed care intake interviewing procedures.
Putting It in Practice 7.2Psychologists appropriately document their professional and scienti?c work in order to facilitate provision of services later by them or by other professionals, to ensure accountability, and to meet other requirements of institutions or the law.
The American Counseling Association includes an almost identical statement in its ethical code: Counselors maintain records necessary for rendering professional services to their clients and as required by laws, regulations, or agency or institution procedures.
The guidelines as written by the American Counseling Association and American Psychological Association imply a balancing act; they suggest, but do not directly state, that written documents must meet standards set by more than one entity. This leads us to a discussion of the ?rst challenge of report writing: Determining your audience.
Determining Your Audience
Consider this question: When you write an intake report, are you writing it for yourself, for another professional, for your client, for your supervisor, or for your client’s insurance company? In other words, as you write, who might be looking over your shoulder? Having a diverse audience may be the hardest part of report writing. For example, imagine giving your report to a supervisor. Depending on your supervisor, you might emphasize your diagnostic skills through a sophisticated discussion of your client’s psychopathology or you might try using behavioral jargon such as “consequential thinking, response cost, and behavioral rehearsal.” On the other hand, if you imagine your client reading your report, you may choose to avoid the behavioral jargon-and certainly you will deemphasize complex discussions of psychopathology.
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SUMMARY The leadership characteristics and roles of the exercise leader and assistants have been described for the ?rst time focusing on a UK context. Safety in the delivery of the exercise session and in the use of different equipment is the responsibility of the exercise leader. Protocols for care and use of equipment are also required to be developed by the CR team. Should any medical incident occur, this chapter provides a template for actions to be taken.
REFERENCES American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for Cardiac Rehabilitation and Secondary Prevention Programmes, 4th edn, Human Kinetics, Champaign, IL.
American College of Sports Medicine ACSM’s Guidelines for Exercise Testing and Prescription, 6th edn, Williams and Wilkins, Baltimore, MD.
American College of Sports Medicine ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 4th edn, Williams and Wilkins, Baltimore, MD.
American Heart Association Operation Heartbeat Implementation Guide,American Heart Association, Dallas, TX.
American Physical Therapy Association Minimum eligibility criteria for cardiovascular and pulmonary physical therapy. specialist/ABPTSCert/minimum_eligibility/cert_cardio [accessed 19 Nov 2004].
Armstrong, G., Dunn, M., Bredin, Y., McCuskey, F., Brown, C. Patients’ views on community cardiac rehabilitation. Proceedings of the British Association for Cardiac Rehabilitation Conference.
Association of the Chartered Physiotherapists Interested in Cardiac Rehabilitation Standards for the Exercise Component of the Phase III Cardiac Rehabilitation, The Chartered Society of Physiotherapy, London.
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REFERENCES American College of Sports Medicine Position Stand: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular strength and ?exibility in healthy adults.Medicine and Science in Sports and Exercise, 30, 975
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Time
The overload period should last between 20 and 30 minutes.Exercise Prescription SUMMARY This chapter has addressed the components and prescription for exercise and activity for CR across all four phases. Within a cardiac rehabilitation class there will be a wide range of participants, all with varied ability, psychological outlook and preconceptions.The challenge facing the exercise leader and prescriber is complex: to identify co pathologies and adapt the exercise programme to allow patients to participate safely, yet effectively.
REFERENCES American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 3rd edn, Human Kinetics, Champaign, IL.
American College of Sports Medicine Guidelines for Exercise Testing and Prescription, 5th edn,Williams and Wilkins, London.
American College of Sports Medicine The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular ?tness, and ?exibility in healthy adults. Medicine Science in Sports and Exercise, 30, 975
