Because it is a ?uid, value laden, and con?icted process for many people, directly asking about ethnocultural orientation is not generally advisable. There are many formal instruments to measure acculturation ; and should this issue be central, it can be gradually addressed directly.

However, in the initial interview, it is best to simply explore how strong the connections to the various cultures are and what emotions are attached to those connections.

Multicultural and Diversity Issues 391An informal assessment of ethnocultural orientation can be obtained by listening as information emerges during the session or by asking for speci?c information. For example: Listen for the sense of connection to the culture historically. Ask: “Did you grow up on the reservation ?” or “I know everyone’s different, so I’m wondering for you personally, do you feel much connection with your culture?” Listen for the relationship between the client and other members of the culture.

Does the client go to cultural events? Are original cultural practices a regular part of life? Does he or she speak the original language? Ask: “What kinds of things do you celebrate?” or “Do you attend very often?” and “What language do you prefer to speak at home? with friends? at work?” Listen for methods or style of coping with environmental demands Ask: “Is there anything about your work that challenges you? How do you handle the challenges?” Listen for how the person envisions life in the future. Will he or she play a role in traditional cultural ceremonies or practices? Will he or she seek a bicultural stance in life? Ask: “What things about your culture do you appreciate or not appreciate? What things about the Western culture do you appreciate, or not appreciate? How would you like your life to be in the future in terms of your culture?” The client’s cultural orientation to the past, present, and future can be very informative with regard to engagement with the dominant culture . The more culturally oriented and embedded the client is, the more important it is for the professional to seek appropriate cultural input and education to be of assistance in a culturally sensitive manner.

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.

Needless to say, this behavior is not ordinary father daughter behavior in an initial counseling session. It alerted the student counselor that there was more going on here than was apparent on the surface. Although it would have been a mistake to draw attention to the foot stroking until she had built more of a relationship with the family and knew more about the dynamics, her observations led her to investigate a number of potential problem areas more thoroughly. Consistent with her supervisor’s theoretical orientation, she also determined that she would need to meet with members individually and perhaps in dyads to fully understand the coalitions in the family and the reasons for these coalitions.

The Body

The body of the family or couple interview, like the opening, is strongly in?uenced by the interviewer’s theoretical orientation. After hearing about the chief complaint, inquiry is directed toward central feelings, behaviors, and thoughts related to the problem areas. However, before going more deeply into these areas, it is appropriate to explain the theoretical orientation that guides your work, including the use of certain techniques, such as having everyone speak, assigning homework, listening skill practice, questionnaires, and so on. It is important, on an ongoing basis, to assess each person’s willingness to participate and/or cooperate with your strategies and plans.

Theoretical Orientations with Couples

There are many ways to approach working with couples. Some are based in the traditional theories of psychotherapy and some are more skill or value based, such as therapy speci?cally oriented toward improved sexual functioning or, in contrast, toward compliance with religious beliefs about how couples should relate to each other. Some examples follow.

A detailed review of your client’s current situation includes an evaluation of his or her social support network, coping skills, physical health , and personal strengths. Each of these areas may provide information crucial to the diagnostic process.

290 Structuring and Assessment

Case Conceptualization and Theoretical Orientation

One of the guiding forces determining what information is valued by interviewers and counselors is theoretical orientation. Although it may be too soon for you to identify your theoretical orientation, you may ?nd yourself having particular leanings. The following questions are designed to help you explore your theoretical perspective, and at the same time, develop greater focus during your interviewing assessments and treatment planning. While answering the questions, keep in mind a few cases with which you have worked or cases that have been discussed in class.

How would you de?ne your theory of therapy? In other words, what processes do you believe must occur for people to change? As you think of a particular case, how would your theory of therapy in?uence the information you want to obtain from your client? Given your response to question 1, what is your theory of etiology? In other words, what causes or contributes to individuals’ personal problems? Again, what information does this make you to want to obtain from your client? What factors do you believe play a strong role in symptom maintenance? What client information do you need to have to understand symptom maintenance? Given your theoretical perspective, what are your usual treatment goals and plans for your individual client? What intuitive reactions do you have when imagining yourself working with this particular case? How would you let your intuition guide or in?uence your assessment and treatment plan? Putting It in Practice 10.1Client Social Support Network Sometimes, it is critical to obtain diagnostic information from people other than the client, especially when interviewing children and adolescents. In such cases, parents are often interviewed as part of the diagnostic work up . However, even when interviewing adults, it may be necessary to obtain outside information to substantiate diagnostic impressions. To rely exclusively on a single clinical interview to establish a diagnosis may be inappropriate and unprofessional. As Morrison has stated: Adults can also be unaware of their family histories or details about their own development. Patients with psychosis or personality disorder may not have enough perspective to judge accurately many of their own symptoms. In any of these situations, the history you obtain from people who know your patient well may strongly in?uence your diagnosis.

Just do the best you can in answering them. Tell me, what day is it today?” Client: “They told me I was riding my bike and that I didn’t have my helmet on.” Interviewer: “That’s right. I’m still curious, though. What day is it today?” Client: “Could I get a glass of water?” After several minutes of this client’s interview, it became apparent that he was evading the question about orientation to time. Note also that the examiner began with a simple orientation to time question . When clients are resistant to answering orientation questions, you may tentatively conclude they are disoriented, especially if additional evidence suggests disorientation.

Orientation levels can be pursued in greater or lesser depth. For example, clients can be asked what county they are in, who the governor of the state is, and the name of the mayor or local newspaper. They also can be asked if they recognize hospital personnel, visitors, and family. However, these additional questions may be confounded by factors such as the client’s level of intelligence, social awareness, or cultural background, and, therefore, they are not always accurate indicators of orientation.

Clients can become disoriented for a number of reasons. Common causes include drug intoxication, recent brain trauma, and dementia . It is not the mental status examiner’s task to determine the cause of a client’s disorientation, but to accurately and brie?y document presence or absence of disorientation.

In cases of delirium, acutely disoriented clients may experience a gradual clearing of The Mental Status Examination 229consciousness. When clients become disoriented, they usually lose their sense of time ?rst, then of place, and ?nally of person. Orientation is recovered in reverse order .

Visual or tactile hallucinations are often linked to organic conditions. These conditions may include drug intoxication or withdrawal, brain trauma, or brain disease.

Clients in acute delirious states may pick at their clothes or skin in an effort to remove 228 Structuring and Assessmentobjects or organisms they believe are producing their sensory experiences.

Similarly, clients may reach out or call out for people or objects that do not exist. Obviously, when clients report such experiences or you observe clients as they experience such perceptual disturbances, the disorder is usually of a very serious nature. Immediate medical evaluation and intervention is warranted.

Orientation and Consciousness

Mental status examiners routinely evaluate whether clients are oriented to their current situation. The question of whether a client is oriented involves evaluating basic cognitive functions. The examiner asks a client three simple questions: What is your name? Where are you ? What is today’s date? When a client answers these queries correctly, the examiner might write in the progress notes that the client was “OX3″ , referring to the fact that the client is aware of who and where he or she is, and what day it is. Evaluating a client’s orientation is a direct way to assess level of confusion or disorientation. Extremely disturbed clients may not be able to respond accurately to one or more of these simple questions. Resisting questions about orientation may indicate disorientation. In the following example, a hospital patient with a recent head trauma was interviewed regarding orientation: Interviewer: “I’m going to ask you a few questions that may seem a bit strange.