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Using functional analytic psychotherapy to improve awareness and connection in racially diverse client-therapist dyads

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Using functional analytic psychotherapy to improve awareness and connection in racially diverse client-therapist dyads

Abstract

As the diversity of clients seeking mental health care services across the United States continues to grow, the need for culturally sensitive interventions is increasingly urgent. Discrimination associated with stigmatized minority status is associated with negative mental health outcomes and thus may require clinical attention. Unfortunately, many therapists are unprepared to address cultural issues due to social taboos surrounding racism, discrimination, and White privilege. Using a behavioral perspective, this paper reviews the role of Functional Analytic Psychotherapy (FAP) principles and clinical strategies for integrative treatment with underserved and marginalized populations. The critical ingredients of vulnerability and honesty when approaching uncomfortable topics, such as shame or out-group discrimination, are discussed. We explore how FAP also enables the clinician to gain awareness of their own cultural assumptions and biases as they register their clients' responses to their culturally-influenced perspective. This presents clinicians with the opportunity for an improved therapeutic relationship and ongoing expansion of the clinicians' multicultural competence. Taken together, these techniques may help clinicians to evoke and explore the functional drivers of client behavior while promoting therapeutic change in a culturally-sensitive manner.
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...
Correspondence to Todd E. Brown, M.A.,
University of California, Los Angeles,
Department of Psychology, 1285 Franz
Hall, Box 951563, Los Angeles, CA 90095
toddbrown@ucla.edu
AS OF 2010, NON-HISPANIC WHITES com-
prised 63% of the U.S. population, yet the
number of minority psychologists lingers
under 25% (American Psychological Asso-
ciation [APA], 2010; U.S. Census Bureau,
2011). The limited data available on psy-
chologist demographics is encouraging
insofar as APA membership is shifting to
include greater numbers of ethnic and
racial minorities in its various membership
categories. Even so, the rate at which eth-
noracially diverse populations seek mental
health services is outpacing the availability
of minority psychologists. Ethnic and racial
minorities are projected to exceed 57% of
the population by 2060 as non-Hispanic
White Americans become aminority over
the next three decades (U.S. Census
Bureau, 2012). As a result, ethnoracially
diverse therapy dyads are increasingly
common. This growth in diversity acceler-
ates the need for ongoing scholarship,
informed attitudes, and clinician compe-
tency for multicultural clinical training at
parity with other important therapeutic
skills.
Discrimination resulting from stigma-
tized minority status is associated with neg-
ative mental health outcomes, such as
depression, anxiety, substance use, post-
traumatic stress disorder, and overall psy-
chological distress (Banks &Kohn-Wood,
2007; Blume, Lovato, Thyken, & Denny,
2012; Chae, Lincoln, & Jackson, 2011;
Pieterse, Todd, Neville, &Carter, 2012). As
a result, such experiences and the related
psychological sequelae may require
focused clinical attention (e.g., Williams,
Gooden, & Davis, 2014). Additionally,
research indicates that the adaptation of
cognitive-behavioral therapies (CBT) for
cultural competency may be superior to
nonadapted CBT (Kohn, Oden, Munoz,
Robinson, &Leavitt, 2002; Miranda et al.,
2003). Thus, the mental health community
is ethicallyboundto cultivatemulticultural
competency and continue investigating
empirically supported treatments for
diverse populations (Constantine, Miville,
&Kindaichi, 2008; Ridley, 1985; Sue, Zane,
Hall, &Berger, 2009).
This need is met with a host of chal-
lenges as many therapists are unprepared
to address cultural issues due to inadequate
multicultural education and/or social
taboos surrounding racism, discrimina-
tion, and White privilege (Neville, Wor-
thington, &Spanierman, 2001; Terwilliger,
ACCESS&EQUITY
Using Functional Analytic Psychotherapy to
Improve Awareness and Connection in Racially
Diverse Client-Therapist Dyads
Annette Miller and Monnica T. Williams, University of Louisville
Chad T. Wetterneck, Rogers Memorial Hospital
Jonathan Kanter and Mavis Tsai, University of Washington, Seattle
September 2015 151
Celebrating Its 43rd Anniversary
Steven T. Fishman, Ph.D., ABPP |Barry S. Lubetkin, Ph.D., ABPP
Directors and Founders
Since 1971, our professional staff has treated over 30,000 patients with compassionate, empirically-based CBT.
Our specialty programs include: OCD, Social Anxiety Disorder, Panic Disorder, Depression, Phobias, Personality
Disorders, and ADHD-Linked Disorders, and Child/Adolescent/Parenting Problems.
Our externs, interns, post-doctoral fellows and staff are from many of the area’s most prestigious universities
specializing in CBT, including: Columbia, Fordham, Hofstra, Rutgers, Stony Brook, St. John’s, and Yeshiva
Universities.
Conveniently located in the heart of Manhattan just one block from Rockefeller Center. Fees are affordable,
and a range of fees are offered.
New York City
INSTITUTE for BEHAVIOR THERAPY
Forreferrals and/orinformation,pleasecall: (212)692-9288
20 East 49thSt., SecondFloor, New York, NY 10017
e-mail: info@ifbt.com | web: www.ifbt.com
Bach, Bryan, & Williams, 2013). There is
currently no standardized training model
for multicultural competency. Although a
handful of scholars have devoted signifi-
cant energy to measuring multicultural
competency, training for therapists to
engage clients of diverse racial, ethnic, and
cultural backgrounds may remain inade-
quate (Worthington, Soth-McNett, &
Moreno, 2007). One systematic review
found that although multicultural training
made clinicians feel more knowledgeable,
there was poor evidence that patient out-
comes were improved; furthermore, the
vast majority of programs omitted the con-
cepts of racism, bias, or discrimination
from their content (Price et al., 2005).
Matching by racial group has been one
approach used to serveethnoracialminori-
ties seeking mental health services. Propo-
nents of matching point to an elevated per-
ception of multicultural awareness,
treatment retention, and client preference
(Lee, Sutton, France, & Uhlemann, 1983;
Meyer &Zane, 2013). However, matching
may oversimplify both the client’s and clin-
ician’s experience as it assumes a high
degree of similarity in backgrounds, values,
level of assimilation, religion, and language
(Williams, Chasson, &Davis, 2015). It may
also remove acritical opportunity for client
and clinician to grow and connect as they
learn to appreciate differences in cultural
values and experiences. Although match-
ing is preferred by most clients, alliance,
skill, knowledge of client culture, ethnicity,
and race appear to have agreater impact on
positive therapeutic outcomes (Cabral &
Smith, 2011). Most recently, Ibaraki and
Hall (2014) examined ethnic matching,
finding it functions as a proxy for shared
culture, where common values and closely
held beliefs influence the content minority
clients discuss in therapy. This suggests
therapeutic outcomes are linked to the clin-
ician’s ability to understand the client’s
perspective and cultural background
(Flicker, Waldron, Turner, Brody, &Hops,
2008).
One risk in diverse dyads is uninten-
tionally stigmatizing the client. Lack of
insight about the client’s cultural, racial, or
ethnic identity might result in inadvertent
microaggressions or other expressions of
bias; this may alienate the client, threaten
the therapeutic relationship, impede treat-
ment progress, and increase risk of early
dropout (Constantine, 2007; Sue,
Capodilupo, Torino, & Bucceri, 2007).
Additionally, when culturally normative
behaviors are not considered in treatment,
therapists risk misdiagnosing minority
clients (Chapman, DeLapp, & Williams,
2014). Rather than adopting acolor blind
approach, which discourages the client
from expressing their experiences as a
racialized minority and exploring protec-
tive factors (Terwilliger et al., 2013), thera-
pists can benefit the relationship by bring-
ing this part of the client’s experience into
therapy. To do this effectively, therapists
must first understand their own relation-
ship to diverse groups and acknowledge
race as asocial power construct (Cardemill
&Battle, 2003). By building on this attune-
ment to social power and privilege, thera-
pists can benefit from experiential learning
to explore their own feelings, beliefs, and
attitudes about race, ethnicity, and culture,
to gain greater cross-racial understanding
(Devereaux, 1991; Okech & Champe,
2008). In describing the experiential
process of growth and change, McKinney
(2006) found that “most of the turning
152 the Behavior Therapist
point experiences involved aWhite person
first coming into sustained contact with
persons of color.” Similarly, cross-racial
friendships have been found to enhance
cross-racial therapeutic relationships
(Okech & Champe). Taken together, this
suggests experiential contact and closeness
with diverse populations may expand clin-
ical awareness.
Functional Analytic Psychotherapy
Functional analytic psychotherapy
(FAP), an approach rooted in the contex-
tual behavioral tradition (Hayes et al.,
2012), focuses on the therapeutic relation-
ship as the agent of change to improve the
client’s outside relationships (Tsai et al.,
2009). It is similar to many CBT interven-
tions because it focuses on concrete behav-
ioral change and includes homework
assignments, but it differs with respect to
the amount of time and attention given to
building astrong therapeutic relationship
that serves as the primary vehicle for client
change. Abasic position of FAP is that the
therapeutic relationship is a genuine
human relationship. This relationship is
powerful in promoting learning and
change, fostering motivation, and keeping
clients engaged in treatment and adherent
to treatment plans.
FAP promotes increased awareness
both in the client and the therapist. FAP
therapists take interpersonal risks by expe-
riencing, processing, and disclosing reac-
tions to the client immediately as they
occur in-session in the service of client
growth and, in turn, encourage their clients
to do the same. When the client engages in
courageous self-expression in session, the
therapist responds withgenuinefeedback
to increase theconnection throughthe
exchange. This vulnerability and immedi-
acy serves as a model to help the client
improve connections with others, which is
an important transdiagnostic outcome
(Wetterneck & Hart, 2012). In this way,
FAP provides a complement to peer sys-
tems’ techniques such as psychoeducation,
cognitive restructuring, behavioral experi-
ments, and exposure.
FAP leverages five core principles, or
rules, to conceptualize client behaviors,
evaluate their functions, and conditionally
change or reinforce behaviors through the
interpersonal dynamics in the dyadic rela-
tionship (Tsai, Callaghan, & Kohlenberg,
2013; Tsai, McKelvie, Kohlenberg, &
Kanter, 2014). These client behaviors are
identified as clinically relevant behaviors,
or CRBs (see Figure 1). Maladaptive CRBs
(CRB1s) and adaptive CRBs (CRB2s) are
identified collaboratively by both the ther-
apist and client and analyzed for function
at both the micro and macro level to
broadly understand and effect change in
the client (Tsai, Kohlenberg, Kanter,
Holman, &Plummer Loudon, 2012). Sim-
ilarly, therapist-relevant behaviors (TRBs)
have a clinically relevant impact in treat-
ment as well.
Recent FAP writings have discussed
how the implementation of FAP’s five
behavioral rules may be supplemented
with an understanding of awareness,
courage, and therapeutic love towards
clients (Tsai et al., 2009; Tsai et al., 2012).
The first rule of FAP centers on awareness
of how a client’s CRBs appear in session
and promotes self-awareness as well,
including awareness of one’s attitudes,
biases, and assumptions about the client.
The second rule is that clinicians evoke
CRBs in therapy, and this may at times
involve being courageous and vulnerable
with clients. The third rule centers on being
therapeutically loving to reinforce positive
CRBs while challenging maladaptive CRBs.
As behaviors are exhibited in-session, the
fourth rule calls for the therapist to be
aware of their impact on clients, both as a
clinician and as aperson. Finally, the fifth
rule calls on the therapist to facilitate gen-
eralization of in-session client behavior
changes to promote sustainable change in
the client’s life. FAP is particularly well-
suited for culturally sensitive CBT and clin-
ician growth because of its focus on the
relationship as a primary change mecha-
nism, and FAP is flexible enough to be used
for analyzing the functions of behaviors in
client-specific content across cultures and
ethnicities (Vanderburghe, 2008).
Common TherapistProblem
Behaviors
All therapists stand to gain increased
competency across treatment approaches,
settings, goals, and client backgrounds
using an authentic and culturally sensitive
approach. Below we describe examples of
common challenges therapists experience
when working in racially and ethnically
diverse therapist-client dyads and how they
might be addressed using FAP interven-
tions.
Discomfort AddressingRacial
Differences With Clients
Race is one of the first features per-
ceived when encountering a new person,
yet despite the obvious differences in an
unmatched dyad, many therapists are
uncomfortable discussing race (Knox,
2007). FAP emphasizes the unique history
of each client, and, for minority clients,
ethnic and racial identity are an important
part of this history that should be addressed
early in treatment. Therapeutic awareness,
acceptance, and exploration of discomfort
related to racial differences in the service of
client growth can be an important shift
toward therapist growth that ultimately
bolsters trust and connection with the
client. Although it may be anxiety-provok-
ing for therapists who have previously
avoided such discussions to address racial
differences, acknowledging diversity in the
therapeutic relationship is likely to result in
greater satisfaction and connection with
minority clients, as it demonstrates cultural
sensitivity (Neville, Tynes, &Utsey, 2009).
Working to understand aclient’s potential
struggles with identity, self-concept, and
intersectionality may mediate feelings of
Figure 1. Clinically relevant behaviors
September 2015 153
invisibility often reported by racial and
ethnic minorities, and correspondingly,
acknowledging cultural strengths, such as
collectivism and racial pride, can promote
resilience in the face of challenge (Franklin,
1999; Hays, 2009).
Failure to UnderstandWhite Privilege
As a culture, we are socialized not to
acknowledge Whiteness and the power and
unearned privilege it affords (Neville et al.,
2001). As aresult, therapists are often con-
fused and uncomfortable with related
topics, such as discrimination, racism, and
stigmatized minority status. Acknowledg-
ing unearned privilege may provoke guilt,
shame, and defensiveness. FAP, because it
locates the source of this problem in our
social context and not in the individual,
allows therapists to increase awareness and
exploration of White privilege and differ-
ential access to important reinforcers (e.g.,
money, education, promotions) as aresult
of differences in power and privilege.
Deliberate self-disclosure of this status,
when used in the service of client growth,
may be linked to higher levels of trust and
perceived sensitivity in ethnic minority
clients and improvements in the quality of
the therapeutic relationship (Constantine
& Kwan, 2003; Tsai et al., 2009). Indeed,
privilege and social group membership are
inseparable components of the emergent
therapeutic context (Terry, Bolling, Ruiz, &
Brown, 2010). For a White therapist,
admitting to astigmatized minority client
that the therapist has benefited from race in
away that the client has not, and to exhibit
a willingness to change behaviors that
maintain power and privilege (e.g., have a
sliding fee scale, being open to learning
more about indigenous therapies such as
soul retrieval for Native Americans) exem-
plify a commitment to genuineness that
can promote authenticity, growth, and
connection.
Endorsing StereotypicalBeliefs About
Clients
Because of pervasive negative social
messages about ethnic and racial minori-
ties, we tend to make automatic and inac-
curate judgments about others based on
pathological stereotypes, which in turn lead
to microaggressions (Blair, Judd, & Fall-
man, 2004; Williams et al., 2012). Microag-
gressions committed by therapists have
been demonstrated to be asignificant pre-
dictor of dissatisfaction with the therapeu-
tic experience (Constantine, 2007) and pre-
sent significant barriers to FAP’s
fundamental and necessary intimate, trust-
ing, andsafe transactions that celebratethe
client’s expression of his/herfull self as an
ethnic and cultural being. It is helpful for
therapists to acknowledge their own ten-
dency to make unfair judgments and
demonstrate awillingness to reject stereo-
types. By being courageous enough to
admit alack of accurate knowledge about
important cultural, racial, or ethnic topics,
therapists can exhibit vulnerability and
seek understanding with clients in a
manner that will facilitate an open
exchange of information. FAP’s behavioral
and interpersonal techniques allow thera-
pists to admit they are not the authority on
all topics, such as the minority experience.
In this way, clinicians can begin to under-
stand the client’s daily life without relying
on stereotypes and subsequently reducing
the likelihood of committing harmful
microaggressions.
It is not enough, however, just to admit
alack of cultural knowledge. It is important
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to remediate these deficits by seeking infor-
mation from sources other than clients, as
ethnic minorities often report feeling weary
of bearing the burden of educating others.
Furthermore, in order to minimize stereo-
typing clients, it is important to maintain
relentless emphasis on understanding the
cultural context of CRBs and the adaptive
functions of “problem” behaviors. For
example, what may be seen as “depen-
dence” and “enmeshment” by young Asian
clients with their families can be under-
stood within acultural context of emphasis
on interdependence and prioritizing family
needs over individual needs (Sue & Sue,
2008).
Failure of Therapistto Continually
Develop as an Instrumentof Change
FAP emphasizes that a therapist’s
potency as achange agent can be increased
by continually cultivating awareness of the
impact of one’s own history on potential
biases. It may be helpful to explore individ-
ually or in consultation group questions
such as the following:
What were your first experiences with
feeling different?
What were you told about others who
were ethnoracially different?
What were your earliest memories of
race or color?
What stereotypes do you hold of
pluralistic populations?
What are your experiences as aperson
having or not having power in relation
to race or class?
What steps can you take to learn more
about your clients’ cultural back-
grounds?
What are your preferred therapeutic
methods that may not be culturally
attuned or adequate?
How might you be inadvertently repeat-
ing negative or oppressive interactions
representing the dominant culture with
clients?
How can you make use of therapeutic
“mistakes” or microaggressions in ways
that increase therapeutic alliance?
What is difficult for you to address
regarding race, culture, or other differ-
ences you have with your clients?
Table 1lists afew examples of common
therapist issues surrounding race, ethnic-
ity, and culture (Daily Life Problems), how
the problem might look in a therapeutic
relationship (TRB1), and one way that a
therapist might overcome the problem
from aFAP perspective (TRB2).
Conclusion
As the scholar-clinician community
seeks to improve quality of care for every-
one, it is imperative that we acknowledge
the importance of multicultural knowledge
and skills. This includes an appreciation of
other psychological perspectives, such as
Afrocentric research, which is often viewed
critically rather than with respect (Delapp
& Williams, 2015). Future scholarship
should build on preliminary work to
enhance and measure therapist compe-
tence in diverse dyads (Constantine, 2008;
Daily Life Therapist Problem
Table 1. Therapist-Relevant Behaviors
Problem Behavior (TRB1) Goal Behavior (TRB2)
White therapist experiences
anxiety, agitation, and confu-
sion in response to racially
provocative material.
Referring a minority client
to another therapist of their
same ethnic background.
Expressing the feelings open-
ly with client and also recog-
nizing own potential bias or
lack of understanding.
Belief that discussing racial
issues beyond a superficial
level is a taboo.
Avoiding topics about race
or culture and redirecting
to a different topic when it
is culturally sensitive.
Asking the client if the dif-
ference in race is something
they would like to discuss,
while recognizing that it
might be uncomfortable.
White therapist denying
benefits experienced from
Whiteness because therapist
has not previously consid-
ered this.
Denying or invalidating
client when this topic or
problem arises.
Acknowledging the unfair
and unearned benefits of
being White and validating
client if the topic arises.
White therapist ashamed of
his/her own ignorance on
cultural topics.
Avoiding topics related to
race in order to hide own
shame.
Expressing feelings openly
and asking the client if/how
they would like to address
the topic.
Taking steps to learn more
about applicable cultural
topics.
Therapist generalizing norms
of racial minorities based
upon assumptions and
research/statistics.
Making assumptions in
session about problems
and not allowing client to
explain problems in his
or her own words.
Exploring problems with an
open mind and allowing
client to express how he or
she faces problems associated
with race.
Latino male therapist feeling
shame about his cultural
heritage.
Being too deferential to
White clients due to
feelings of inferiority.
Acknowledging therapist
may have biases due to
learning history and being
aware and appropriately
assertive in session.
Black female therapist with
dark skin believes that fairer
skinned Black women are
arrogant and want to be
White.
Hostility toward fair-
skinned Black female
clients.
Asking client about her expe-
riences as a fair-skinned
Black woman, and recogniz-
ing her own biases.
154 the Behavior Therapist
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Drinane, Owen, Adelson, & Rodolfa,
2014). Such investigations may reveal
where cultural competency constructs
diverge from general clinician compe-
tency, allowing training to better prepare
clinicians to work with diverse popula-
tions.
Furthermore, many training programs
may benefit from aformat that is curricu-
lum-integrated and experiential. To
answer the need for culturally adapted
CBT, we propose FAP for its integrative
principles of awareness, courage, and love.
Future research should investigate the use
of such skills, including clinician self-
awareness, immediacy, and connection
relative to therapeutic outcomes within
mismatched racial dyads. Remembering
that training is alifelong exercise for ther-
apists, FAP provides the additional benefit
of ongoing therapist self-discovery and
growth (Tsai et al., 2009). In anation built
on fused genealogies and cultures, it is
imperative that we advance an under-
standing and application of skills to
enhance treatment utilization, reduce pre-
mature dropout, and promote culturally
informed change. Every client is amicro-
culture, carrying deeply rooted cultural,
social, generational, and reinforcement
histories. The building blocks of inclusion,
racial equity, social justice and prosocial
change can begin within the therapeutic
alliance (Vandenberghe et al., 2010).
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...
Correspondence to Monnica Williams,
Ph.D., Center for Mental Health Dispari-
ties, University of Louisville, Department
of Psychological &Brain Sciences, 2301
South Third St., Louisville, KY 40292;
m.williams@louisville.edu
www.abct.org
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... A good understanding of microaggressions and racism The ability to identify/diagnose racial trauma (Williams, Printz, et al., 2018) The ability to initiate a nondefensive repair of any microaggressions or cultural insensitivities committed in session Have done their own personal antiracism and allyship work (e.g., Williams, Sharif, et al., 2021) Willingness to discuss racism and cultural issues, even when it evokes discomfort (Calloway & Creed, 2021;DeLapp & DeLapp, 2021;Malott & Schaefle, 2015) The ability to learn about a client's culture from the client and other sources Appreciation of individualistic versus collectivistic cultural worldviews An understanding of their own cultural development (bias, blind spots, areas for growth) and how that can affect the therapeutic relationship (Miller et al., 2015) An understanding of models of racial identity development and how this might impact the therapeutic alliance (Graham-LoPresti et al., 2019) Koch et al. (2020) examined affirming experiences reported by culturally diverse graduate students. Those who were deemed to be affirming were described as validating, nonjudgmental, interested, genuine, receptive, mindful, and self-aware, with an affirmative communication style. ...
... For example, they may have struggles related to not adhering to their cultural group's norms, and so may worry about judgment from someone from their same community. Additionally, unmatched dyads provide an opportunity to grow surrounding awareness, connection, and cross-cultural understanding in both the client and therapist (Miller et al., 2015). ...
Article
Racism can be stressful or even traumatizing. Psychological unwellness emerges out of the confluence of historical, cultural, and individual experiences, and resulting syndromes may or may not fit into a DSM-5 PTSD diagnostic framework. Although racial stress and trauma are common presentations in therapy, few therapists have the resources or training to treat these issues. Based on the empirical evidence to date, this article describes the essential components of treatment for racial stress and trauma from a cognitive-behavioral perspective, called the Healing Racial Trauma protocol. Each technique is described with reference to the literature supporting its use for racial stress and trauma, along with guidance for how therapists might implement the method with clients. Also provided is information about sequencing techniques for optimal outcomes. Critical therapist prerequisites for engaging in this work are also discussed, with an emphasis on an anti-racist, empathy-centered approach throughout.
... A terapeuta passa a ter papel crucial para o desenvolvimento desse processo, e não pode se eximir de iniciar um letramento racial (Tavares & Kuratani, 2019), caso não tenha conhecimentos que precisem ser mobilizados no atendimento a pessoas negras. Inclusive, acredita-se que uma terapeuta FAP poderá usar da autorrevelação (Miller, Williams, Wetterneck, Kanter & Tsai, 2015), vulnerabilizando-se e assumindo o seu pouco ou nenhum conhecimento sobre racismo estrutural ou relações étnico-raciais. Mas não somente, a tera-peuta deve se implicar no processo de aprendizagem sobre tais relações junto ao consulente. ...
... Para Miller et al. (2015), é necessário ter uma competência para atendimento clínico multicultural. Os autores sugerem o modelo ACL como uma possibilidade de reunir técnica e experiência na ampliação de competências interpessoais que são relevantes para o atendimento de pessoas com origens étnicas e raciais não dominantes. ...
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Resumo: O artigo é um ensaio teórico, que propõe articular os conceitos da FAP (Functional Analytic Psychotherapy-Psicoterapia Analítica Funcional) com a obra de bell hooks, espe-cialmente o que a autora afro-americana teoriza como ética amorosa. O objetivo é apontar que esta literatura feminista negra pode ser um recurso teórico e terapêutico para auxiliar o desenvolvimento de habilidades interpessoais orientadas pela FAP. Para tal, discutimos como a subjetividade da população negra é conformada no Brasil e discorremos sobre o alto nível de sofrimento psíquico que se manifesta nessa população, em decorrência das violências sofridas. Por fim, apontamos caminhos que a clínica comportamental pode trilhar para cons-truir uma prática competente ao atendimento de queixas relacionadas ao racismo e aprimo-rar habilidades terapêuticas que atendam às necessidades de grupos raciais não dominantes. Ressaltamos também que tais conhecimentos devem ser mobilizados para além da clínica, buscando generalizar os comportamentos que definem essa ética amorosa. Palavras-chave: psicoterapia analítica funcional; bell hooks; análise do comportamento; amor; racismo.
... Third wave CBT approaches may be well-suited for psychedelic psychotherapy, particularly for people of color (Miller et al., 2015;Sloshower et al., 2020;Walsh & Thiessen, 2018). Functional Analytic Psychotherapy (FAP) is a therapeutic approach rooted in the contextual behavioral tradition that focuses on the therapeutic relationship as the agent of change to improve the client's relationships (Tsai et al., 2009). ...
... Robyn's therapists honored these parts of herself that developed out of necessity and wanted to expose her to other possibilities of engaging with White people. With Robyn's trauma history in mind, clinicians enlisted a White therapist at the clinic to have a discussion with Robyn about the therapist's experiences with White privilege and to provide Robyn with the space the share her personal experiences with White people in an empathetic and supportive manner (e.g., Miller et al., 2015). After the exposure with the other therapist, Robyn described shock and disbelief that a White person was willing to openly discuss privilege and did not minimize or try to change her perception of her lived experiences. ...
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Current research suggests that ketamine-assisted psychotherapy has benefit for the treatment of mental disorders. We report on the results of ketamine-assisted intensive outpatient psychotherapeutic treatment of a client with treatment-resistant, posttraumatic stress disorder (PTSD) as a result of experiences of racism and childhood sexual abuse. The client's presenting symptoms included hypervigilance, social avoidance, feelings of hopelessness, and intense recollections. These symptoms impacted all areas of daily functioning. Psychoeducation was provided on how untreated intergenerational trauma, compounded by additional traumatic experiences, potentiated the client's experience of PTSD and subsequent maladaptive coping mechanisms. Ketamine was administered four times over a 13-day span as an off-label, adjunct to psychotherapy. Therapeutic interventions and orientations utilized were mindfulness-based cognitive therapy (MBCT) and functional analytic psychotherapy (FAP). New skills were obtained in helping the client respond effectively to negative self-talk, catastrophic thinking, and feelings of helplessness. Treatment led to a significant reduction in symptoms after completion of the program, with gains maintained 4 months post-treatment. This case study demonstrates the effective use of ketamine as an adjunct to psychotherapy in treatment-resistant PTSD.
... For many clinicians, it is the general lack of awareness and knowledge of the deleterious physical and psychological impacts of discrimination on POC, leading them to incorrectly attribute observed traumatization to other causes (Carter, 2007;Gaertner & Dovidio, 2005;Parham, 2002). For others, assessing discriminatory distress in patients from different ethnoracial groups may prove uncomfortable, resulting in awkward, potentially harmful clinician-client interactions or avoidance of the topic by the clinician altogether (Miller at al., 2015;Sue et al., 2010). This lack of skill and uneasiness in discussing discrimination could be more fruitfully addressed if clinicians had access to appropriate tools. ...
Article
Racism has been linked to the development or worsening of mental health disorders. When posttraumatic stress disorder symptoms occur due to experiences of racism, it may be referred to as race-based traumatic stress or racial trauma. More work is needed to quantify the distress experienced by those affected. The present study aimed to assess the validity of the Racial Trauma Scale (RTS), a new clinical tool for the measurement of trauma-related symptoms arising from race-based maltreatment of people of color (POC). Using CloudResearch (formerly Amazon Mechanical TurkPrime), 941 diverse participants across the United States were included in the study—POC (n = 665) and non-Hispanic White participants (n = 276). The results validated a three-factor structure, with 10 items on each component, for a total of 30 items. The three components can be described as Lack of Safety, Negative Cognitions, and Difficulty Coping. Reliability of the RTS and the three subscales were excellent, and the RTS scale was positively correlated with other measures of mental health and trauma. Furthermore, there was a significant difference in RTS scores between POC and non-Hispanic White participants. Based on these findings, the RTS appears to be a valid means of quantifying racial trauma symptoms in POC. The ultimate goal of the RTS is to identify racial trauma to improve the mental health of marginalized racial/ethnic groups. The RTS can be used in clinical or research settings to ascertain racial trauma in clients and inform treatment.
... We are paralysed by anxiety and avoidance that prevents change. At an individual level, we are afraid to address our own issues (Miller et al., 2015). Many therapists are unprepared to address cultural issues due to inadequate cultural education and social taboos surrounding racism, discrimination and White privilege (Neville et al., 2001;Smith et al., 2021;Terwilliger et al., 2013). ...
Article
Full-text available
Racism is a pervasive problem in Western society, leading to mental and physical unwellness in people from racialized groups. Psychology began as a racist discipline and still is. As such, most clinical training and curricula do not operate from an anti-racist framework. Although most therapists have seen clients with stress and trauma due to racialization, very few were taught how to assess or treat it. Furthermore, clinicians and researchers can cause harm when they rely on White-dominant cultural norms that do not serve people of colour well. This paper discusses how clinicians can recognize and embrace an anti-racism approach in practice, research, and life in general. Included is a discussion of recent research on racial microaggressions, the difference between being a racial justice ally and racial justice saviour, and new research on what racial allyship entails. Ultimately, the anti-racist clinician will achieve a level of competency that promotes safety and prevents harm coming to those they desire to help, and they will be an active force in bringing change to those systems that propagate emotional harm in the form of racism. Key learning aims (1) Knowledge of how racism manifests in therapy, psychology and society. (2) Understanding the difference between racial justice allyship versus saviourship. (3) Increased awareness of microaggressions in therapy. (4) Appreciation of the importance of combatting systemic racism.
... Evidence: TG: Miller et al. 2015 • CSS: Williams et al. 2015 • ThP: Sue et al. 2007 2. The greater stigma surrounding mental health care and OCD, and differences in mental health literacy in various ethnic communities Evidence: OR: Turner et al. 2016, Williams et al. 2017a • CSS: Chong et al. 2016 • PS: Williams et al. 2012a ...
Article
Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.
... As clinical psychologists, we are trained to attune to issues of vulnerability and trust in our interactions, and the importance of responding with empathy and caring is key to our work, especially when a client of color is discussing racially sensitive material (Miller, Williams, Wetterneck, Kanter, & Tsai, 2015;Williams et al., 2014). However, we recognize that an administrator or faculty member outside of mental health may not naturally attune to the importance of these responses in this moment. ...
Chapter
Racial conflict at universities across the nation has become the focus of academic concern and media attention, yet too often administrators and faculty do not understand the problems and have little insight as to how to approach solutions. Victims of racially hostile environments may experience diagnosable psychiatric symptoms including traumatization, anxiety, depression, extended periods of disability, and even suicidal ideation. Improving harmful race relations on campuses is not easy but necessary. Using the available evidence and real-life examples, we discuss actions that departments and universities can employ to improve the racial climate and thereby promote ethnic and racial diversity. Actions discussed include recruitment and retention of minority faculty and academic advisors, adequate academic diversity course offerings, better integration of diversity issues into existing courses, forums to facilitate conversations about inequity, diversity trainings for faculty, removal of environmental microaggressions, and the responsible use of student course evaluations. Additional actions include willingness to listen to the experiences of those suffering as a result of the adverse climate, responding to perpetrators as needed, and taking action.
... Research indicates that prejudice dissipates as individuals gain knowledge of diverse cultures and recognize individuals for having multiple intersecting identities and group memberships (i.e., the ADDRESSING framework; Hays, 2008). It is of crucial importance that clinicians examine their own biases related to racial and ethnic groups, and that they engage in a continuous and persistent process of disallowing these to impact their behavior in assessment, diagnosis, and access to quality care for clients of color (for helpful thought and growth questions, see Miller, Williams, Wetterneck, Kanter, & Tsai, 2015). ...
Chapter
This chapter describes empirically informed best practices for the assessment and diagnostic process with clients of color, including the intake process and culturally informed diagnostic considerations. The multicultural counseling competencies comprise a widely used model for training that consists of three developmental areas: attitudes and beliefs (awareness of one's assumptions, values, and biases); knowledge (understanding the world views and values of diverse clients); and skills (developing relevant and appropriate assessment, diagnostic, prevention, and intervention strategies and techniques). The chapter focuses on these skills as they relate to assessment and diagnosis and how this can contribute to the development of effective therapeutic relationships and mental health treatment retention. Clinicians should introduce issues of marginalization early in the assessment process, and they should assess for the experience, frequency, and perceived impact of experiences of race-based discrimination and marginalization based on the clients' intersecting identities. Clinicians must also be aware of the role of stereotype threat in maintaining disparities in seeking and engaging in mental health treatment. Clinicians should determine the impact of mental health stigma for clients of color to aid in case conceptualization. Sources of this stigma are widespread, including media and societal messages as well as cultural and familial influence.
... where student behavior is shaped through the use of interpersonal reinforcers such as empathy, statements of caring, and self-disclosure. FAP has been described as a modality that can help improve therapeutic relationships across racial differences (Miller, Williams, Wetterneck, Kanter, & Tsai, 2015) and also as a technique for teaching therapists (e.g., Schoendorff & Steinwachs, 2012). The training approach described here is for educators who are looking for guidance in navigating this challenging terrain. ...
Chapter
Classroom discussion is an important component to training, but it takes practice and skill to successfully engage potentially resistant students, with White students typically more resistant to the realities of racism than students of color. This chapter provides a step-by-step description of the techniques that were used to effectively engage participants and will be particularly beneficial to readers who are interested in conducting diversity trainings. Presentation slides are provided as supplemental material, and it may be helpful to reference these while reading this chapter. The chapter is intended as a roadmap for interactive classroom discussions that teach students about race and racism, the first leg on their journey toward cultural competence. These are challenging concepts to teach, so do not attempt this training without having done your own personal anti-racism work first. It is useful to have data handy to help respond to common racial misconceptions. Those who have not conducted diversity trainings before are encouraged to read the references provided to learn more about the information. Finally, keep in mind that maintaining an atmosphere of safety, mutual respect, and caring in the room is critical for success.
Article
Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illnessfor as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed tobe essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.
Chapter
Full-text available
The present article presents and reviews the contextual behavioral treatment Functional Analytic Psychotherapy (FAP). FAP is unique in its focus on the genuine relationship that forms during therapy as a mechanism for changing problematic behaviors. Using the therapeutic relationship as a tool for change allows FAP to be used as a standalone treatment or as an additive component to other treatments. Evidence from case studies and progressively larger scale designs have indicated the potential of FAP as an intervention, but the empirical support of FAP is still young and many questions have not been investigated. More well controlled-studies are needed to fully understand the scope in which FAP is effective, but so far the data are promising, especially in the domain of social functioning.
Chapter
Full-text available
Ethnic matching has shown a positive impact on the establishment of the therapeutic relationships for African Americans. However, limited research exists examining racially different dyads, and the impact of a racial mismatch on anxiety and affect. This study compares anxiety and affect between ethnoracially mismatched dyads in an evaluative assessment situation. Participants (N = 489) were paired with European American or African American interviewers then administered measures of depression, anxiety, and situational affect. According to multivariate analysis of variance, the interaction between interviewer and participant race was not statistically significant, nor was the effect for interviewer race, but there was a statistically significant effect for participant race. African American participants reported higher severity across all indices of distress compared to European American participants, regardless of interviewer race. Exploratory analyses also indicated that age, gender, student status, and occupational status may be associated with distress in the African American group. Future research should continue to examine the impact of race and racial match/mismatch within the treatment dyads in assessment situations, and examine methods for ameliorating distress in assessments situations for African Americans.
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Full-text available
Problems with intimacy and interpersonal issues are exhibited across most psychiatric disorders. However, most of the targets in Cognitive Behavioral Therapy are primarily intrapersonal in nature, with few directly involved in interpersonal functioning and effective intimacy. Functional Analytic Psychotherapy (FAP) provides a behavioral basis for working on intimacy and interpersonal functioning. The current paper describes how intimacy concerns are addressed by FAP and provides evidence for the need to assess and understand the role of intimacy across a number of disorders. There are several justifications for support for including attempts to measure intimacy and design treatments to increase clients’ effectiveness in intimacy. In conclusion, there appears to be a need to empirically determine the extent to which intimacy should be a therapeutic target of interest across many psychiatric disorders and FAP may be an important part of therapeutic change in these areas.
Article
Full-text available
African Americans are underrepresented in psychology and may face discrimination in a variety of professional settings, such as the academy. Black professors experience more problems in the classroom and disrespect from students at institutions of higher learning, and Black therapists may face increased negative affect and aversive racism from clients and clinical supervisors. Additionally, Black psychologists may feel isolated in their professional environments. This paper reviews research documenting these issues and discusses how such problems may operate and be maintained via subtle forms of racism known as microaggressions. Microaggressions are often based on stereotypical notions of African Americans, which are largely negative. The impact and implications for psychologists are discussed along with coping strategies for those experiencing these issues.
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This chapter provides an overview and framework for understanding race, ethnicity, and culture as factors that affect adult psychopathology. Of primary interest are the assessment and treatment of psychopathology that integrates culturally- salient values, ideologies, and behaviors into the mental health care of ethnic minorities. Moreover, the chapter is organized into two sections. In the first section, we present a model that highlights relevant multicultural factors that should be considered when working with ethnic minorities. The second section provides a discussion of how to effectively apply the knowledge of these multicultural factors when assessing or treating individuals with diverse ethnic backgrounds. Ultimately, the main objective of this chapter is to encourage mental health professionals to acknowledge the impact of race, ethnicity, and culture on adult psychopathology in order to optimize the efficaciousness of mental health services provided to ethnic minority individuals.
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