Cultural Bias in Alcoholism Counseling

Robert J. Chapman, Ph.D.
Copyright 1988 ©

Counseling literature has been dominated by articles concerning theory and the application of technique in the intervention with and treatment of clients addictions. Such have been primarily postulated by a white middle class counseling establishment, as is the case with most literature on psychotherapy (Pedersen, 1981, 1987). To this end, culturally different clients have not fared well with such approaches to counseling in general (Sue, 1981) and addictions counseling specifically. From the early 1960's come the beginning reports of the counseling profession's failure to adequately serve the culturally different.
This lack of cultural sensitivity in counseling has included the mistaken belief that counseling is the preferred mode of intervention to assist individuals in all cases of maladaptive behavior. Recently, the Western counselor has begun to realize that counseling and psychotherapy are merely representative of the many approaches to providing mental health services world wide (Das, 1987; Pedersen, 1981, 1987).

In light of these facts, counselor perceptions of client progress in treatment are often influenced by that counselor's personal cultural perspective or bias. When addressing addictions problems, with their high incidence of denial and low levels of committment to abstinance, the issue of cultural bias becomes significant when evaluating the treatment needs and progress of the culturally different client.

When the counselor encounters the distinct values and beliefs of the culturally different client with an addiction, cultural bias may well result in the counselor's perception of denial. Unfortunately, such bias invites misperception and a resulting misdiagnosis which contributes to an ineffective approach to treatment.

An example can be illustrated by considering a frequently used therapeutic response to denial; the counselor directed model of intervention (Johnson, 1980). The Johnson model is a typical technique employed by chemical dependency counselors in order to impact perceived denial. This approach has the counselor coordinate a specific and intentional intervention with the family of an addicted client. The expressed purpose is to guide the family in its caring but firm confrontation of the person with alcoholism. The resulting effect is to offer the family an appropriate way to respond to the dependency and its impact on them specifically and the family in general (Johnson, 1980).

When used to confront a culturally biased perception of denial, such an approach leads to frustrated clinical relationships as exemplified by failed appointments and prematurely terminated treatment and to disappointing therapeutic results as well. This clinical problem is further exacerbated by the counselor's attempt to direct the culturally different family to intervene in the addictive process. A counselor initiated attempt to orchestrate a family intervention (Johnson, 1980) may only serve to suggest that the family abandon its traditional values regarding familial roles. An example can be seen in the Latino family with a father with alcoholism.

In an intervention, the family is placed in a position of choosing between the traditional cultural value of "respecto" or familial respect shown towards elders and the counselor directed intervention. (The following specific examples illustrate the existence of cultural bias in alcoholism counseling).

1. Monocultural assumptions with resulting stereotypical views are held by the addiction counselor. The counselors' dogmatic acceptance of the stereotypical beliefs of the dominant culture promotes a view that the resolution of problems in treatment for the culturally different is the responsibility of the client.

An example may occur when the culturally different counselor expects the alcoholic client to be prompt for each session. Because of a culturally based difference in the value placed on promtness, a client with alcoholism may be consistently late for scheduled appointments. Such behavior may be interpreted by the culturally different counselor as a disinterest in counseling and contribute to the counselor's perception of patient denial and affect the evaluation of the client's progress in therapy. In actuality, such tardiness results from the client's interest in other events in the present, which are perceived as more important than the scheduled appointment. This is frequently experienced when treating Native Americans who hold strong beliefs regarding the importance of the temporal present and a commitment to such values (Richardson, 1981). The counselor unfamiliar with the culturally different perceptions of time often misinterprets consistent tardiness. This tardiness is then seen as indicative of the client's limited commitment to therapy or characteristic of active denial and indicative of the need for direct and specific confrontation.

2. An insensitivity to the cultural variations among individuals and the assumption that the counselor's perception of life corresponds with reality. This bias not only adds to the counselor's difficulty in establishing a relationship with a culturally different alcoholic client, but also significantly increases the likelihood that a misperception of denial and/or lack of commitment to treatment will result in an ineffective or unnecessary intervention. To expand upon the example cited in number 1, being consistently late or missing scheduled appointments may not only influence the counselor's evaluation of the client's progress in therapy, but also influence the counselor's diagnostic impressions of that client. Such an evaluation of client tardiness finds the clinician weighing the benefits of intervention against termination of the client for lack of commitment to therapy.

3. Counselor perceived resistance to treatment. The acceptance of stereotypical assumptions about counseling, its outcome, and appropriate client responses increase the likelihood that the counselor will perceive a resistance to treatment when therapeutic suggestions are resisted by the client.

This is illustrated when the counselor believes that passive verbal acceptance of treatment goals and objectives without active follow through is indicative of denial and must be confronted promptly. When such a belief is accepted without confirmation, the counselor may implement a traditional therapeutic response of intervention (Johnson, 1980), before exploring the possible cultural bases for the perceived client behavior.

A classic example can be seen when the culturally insensitive counselor encounters a Native American client. Being unfamiliar with the traditional Native American value of maintaining a posture of noninvolvement and avoiding behavior that could be construed as attention seeking, finds the counselor perceiving resistance to treatment in the behavior of the client who refrains from active participation in group or individual counseling (Richardson, 1981; Trimble, 1981).

4. Cultural bias and a counselor's dogmatic adherence to a specific treatment modality. Cultural bias in this example reduces counselor sensitivity to specific client issues and increases the likelihood of treatment being dictated by a diagnosis based upon the misperception of cultural difference as pathology. As noted frequently in this article, the counselor will perceive denial and a low commitment to treatment when encountering the personal values of the culturally different client. This perception invites a standard response to such client behavior, confrontation. However, clinical focus isthen placed on treating the alcoholism rather than the client who happens to have alcoholism.

A case in point; a forty-five year-old Native American male who, on being questioned in group therapy about the consequences of his drinking, assumes a nonassertive posture of no eye contact, silence, and apparent emotional withdrawal. Such is perceived by the counselor unfamiliar with the traditional Native American values noted above as denial and fatalism and therefore in need of direct confrontation by the group.

The confrontation results in no measurable change in the client's disclosures. As a result, the counselor recommends to staff that the client in question be discharged from treatment for reasons of noncompliance with treatment.
A discharge does not take place. The counselor is presented with the salient cultural issues influencing this case along with the recommendation that issues of individual concern for the counselor in this client's treatment be addressed in individual counseling. When the recommended changes in treatment are implemented, the client is able to successfully complete treatment. These four examples give rise to a fifth, which is the most pervasive of all examples of cultural bias in alcoholism counseling.

5. Clinical arrogance. This bias is exemplified by a tendency to attribute the difficulties in counseling the culturally different client with alcoholism to the client. The problems encountered in counseling the culturally different alcoholic client are exacerbated by the counselor's cultural bias and apparent unwillingness to address salient cultural issues. The client often ends treatment prematurely, frequently after the first interview. Such behavior serves to confirm a perception of denial and resistance to treatment. Clinical arrogance attributes all problems in therapy to the client. As a result, recommendations are made for direct and confrontational measures to impact the perceived denial. Examples of such measures may include the termination of social service benefits, a recommendation of incarceration, termination of employment, or the placement of the client's children in foster care.

Confrontation is an effective tool in addressing genuine resistance to treatment. However, if a client's behavior is culturally motivated rather than genuine denial, the confrontation only serves to reinforce the client's perception of institutional racism.
Practical alcoholism treatment experience with culturally different clients together with a review of the cross cultural counseling literature leads to eight suggestions for the culturally alcoholism counselor in order to avoid what Wrenn (1962) referred to as cultural encapsulation.

1. To note that the client with alcoholism may hold stereotypical views which are applied to the counselor from the dominant culture. Such a realization will enable the alcoholism counselor to prepare for the issue of distrust held by many patients for their culturally different counselor (Deloria, 1983; Dings, Trimble, Lockart, 1981). The counselor can avoid the hasty perception that client hesitation, steeped in distrust, is indicative of denial and/or resistance to treatment.

2. To acknowledge a lack of familiarity with the cultural different values one's alcoholic client. The client likely assumes that the culturally different counselor is unfamiliar with the client's culture (Deloria, 1983). Many professionals fail to learn about the various cultural values of their client not to mention the importance of counselor sensitivity to the issues of counseling across cultures. This results in one or more of the following:
· A general lack of understanding of the client's native culture;
· Counselor retention of stereotypical cultural views of the client;
· The use of standardized techniques and approaches to treatment with all clients, regardless of their cultural background.

On those occasions where a clinician works and/or lives close to the environment from which the culturally different client comes, it can be both helpful and enlightening to familiarize one's self with the culture of the client. The author, when working on a Native American reservation frequently attended the festivals or "doins," as they were referred to locally. These exposures to the values and customs of the reservation resulted in a better appreciation for and sensitivity to the issues affecting the lives of clients being treated.

3. To recognize that all barriers to treatment are not indicative of client resistance and/or denial of alcoholism. Although direct and confrontational, an intervention is an effective method of addressing genuine denial (Johnson, 1980), the counselor is well advised to confirm the denial, in part by ruling out cultural bias, before proceeding with plans to confront.

4. To become aware of the need to determine treatment based upon client issues. It is inappropriate to hastily assign treatment strategy to observed client behaviors and the culturally biased clinical evaluation of such (Pedersen, 1987). To treat the alcoholism rather than to treat the person who has the alcoholism renders the clinician prone to a display of cultural insensitivity and bias. Consequently, this focus on the illness results in the clinician's greater interest in technique than the real issues and needs of the client. To provide treatment in such a way will only serve to confirm a suspicious client's expectation of institutional racism.

5. To speak and share openly with the culturally different patient displaying an attitude of respect (Youngman and Sodongei, 1974). Lewis and Ho (1983) in referring to Native Americans, state that a worker who shows respect for the system, values, and norms of the client eventually places him or herself in a position of trust and credibility.

6. To avoid giving advice. Most alcoholic patients tend to see their culturally different counselor as interested in quick answers and easy solutions. To pursue such answers and solutions serves to confirm the client's cultural biases around the counselor's tendency to dominate, with little respect for the cultural values of the client (Lewis and Ho, 1983; Lockart, 1981).

7. To avoid that hasty expectation of results in therapy. Counseling which has as its primary intent to quickly assess the client, formulate a diagnostic impression, articulate a treatment strategy and proceed according to that strategy, often serves to confirm if not exacerbate the culturally biased opinions held by many clients for their culturally different counselor (Lockart, 1981).

8. To recognize that an alcoholism counselor should not be preoccupied with seeing through a client's denial, but rather seeing the client through treatment. The anticipation of being taken advantage of by one's client may lead the counselor to see the culturally different values, beliefs, and behaviors of the client as denial. A defensive posture by a counselor plus a lack of sensitivity to the important cultural issues of one's client almost certainly results in difficulty in counseling the culturally different client with alcoholism.

CONCLUDING REMARKS
An initial review of these suggestions may appear to support the belief that a culturally different client may best be served by arranging for the client to work with a culturally similar counselor. This is not this author's recommendation. Rather, the interests of therapy with culturally different alcoholic patients are best served when counselor sensitivity to the relevant cultural issues concerning the client is coupled with professional skill, proficiency, technique (Acosta, and Sheehan, 1976; Atkinson, Marayama and Matusi, 1978) and a thorough understanding of alcoholism as an illness.
As issues of cultural bias are addressed and the alcoholism counselor is successful in avoiding cultural encapsulation, the results of therapy with culturally different clients with alcoholism are significantly improved.
An awareness of the importance of cultural sensitivity in the counseling relationship will enhance the outcome of therapy. Approaching treatment in such a way may well work better than to attempt to match a client with a culturally similar counselor who has been trained in techniques of the white middle class counseling establishment (Pedersen, 1981) and assimilate into the dominant culture.

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