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APA Psychotherapy Training Videos are intended solely for educational purposes for mental health professionals. Viewers are expected to treat confidential material found herein according to strict professional guidelines. Unauthorized viewing is prohibited.
In Working With Immigrants, Dr. Rita Chi-Ying Chung demonstrates a multicultural approach to counseling clients who are immigrants or come from families that have immigrated to the United States. The approach Dr. Chung uses, called the multilevel model of psychotherapy, social justice, and human rights, provides a culturally sensitive framework for applying cognitive, affective, and behavioral interventions. Because immigrants often come from cultures in which psychotherapists are not commonly consulted, the first step of this approach is to educate the client about mental health practices. Immigrant clients may often feel out of control in a new culture, so therapists may focus on issues of environmental mastery—helping clients understand how systems work, where to get assistance, and how to access resources—in addition to more typical therapeutic concerns. In this session, Dr. Chung works with a young woman whose parents emigrated from the Philippines. Dr. Chung helps the client deal with acculturation issues, particularly how to balance her parents' cultural expectations with the American culture within which she has grown up.
The approach Dr. Chung uses for counseling immigrants and refugees is based on a model that she developed with her colleague, Dr. Fred Bemak. The model or intervention is called the Multilevel Model (MLM) of Psychotherapy, Social Justice, and Human Rights. The MLM model is based on their work and the literature and research on immigrants and refugees, and uses the Multicultural Competencies as the foundation for the model. The MLM model is developed so that psychologists and counselors can address the complex and multiple issues with which immigrants present in psychotherapy. There are several prerequisites to effectively use of the MLM model. It is essential that psychologists are multiculturally competent and therefore are aware of, understand, acknowledge, appreciate, respect, and are sensitive to the historical background, sociopolitical experiences, and psychosocial challenges in adjustment and adaptation. The psychologist must be aware of issues of acculturation and the psychosocial dimensions related to adaptation to a new culture as well as the psychological realities and deeply rooted trauma and loss associated with migration. In addition, psychologists must be knowledgeable about cultural influences on the conceptualization of mental illness and cultural belief systems and worldviews. Within the MLM context, psychologists should be able to culturally adapt individual, family, and group counseling skills and techniques to immigrant clients. These culturally adapted interventions are based on a comprehensive understanding, awareness, and acceptance of cultural, sociopolitical, and historical backgrounds of immigrant clients, as well as the ability to experience and communicate empathy across cultures. Fundamental in employing the MLM is personal awareness and understanding of the ethnic or racial identity process for immigrant clients, as well as insight into their own identity and the interaction of that identity with the immigrant client. In addition, psychologists must be acutely aware of their own transference and political countertransference issues as they relate to the immigrant's cultural background and heritage. The MLM provides a model that includes cognitive, affective, and behavioral interventions inclusive of cultural foundations and their relation to community and social processes. The MLM includes the following five phases:
The five levels in MLM are interrelated and may be implemented concurrently. Although each level can be viewed as separate, their interrelationship is essential for attaining the goals of psychotherapy. It is important to note that there is no fixed sequence to implementing the MLM levels so that they may be used simultaneously or independently. Emphasis and utilization of any one level or a combination of levels is based upon the assessment by the psychologist. Furthermore, it is not a model that requires additional resources or funding; rather, it represents a reconceptualization and diversification of the role of the psychologist as a helper. A brief description of the MLM levels is as follows: Level I, mental health education, focuses on educating clients about mainstream mental health practices and interventions. Immigrants may not be aware of the types of services available or the expected normative behavior for psychologists or clients. Basic procedures such as intake assessments, professional and interpersonal dynamics in the counseling process, the interpreter's role, and time boundaries, and any use of medication may be strange concepts for migrants. They may feel awkward and uncomfortable participating in the therapeutic relationship, especially in the absence of prior knowledge or information. Thus, Level I informs the individual, family, or group about the process of psychotherapy and the mental health encounter. The role expectations for professional and client are discussed. Although Level I is always introduced at the beginning of any mental health intervention, it may be reintroduced at any point in the psychotherapeutic process if clarification is needed and expectations should be redefined. Level II is based on traditional Western individual, group, and family psychotherapy interventions. These techniques and interventions are applied in a culturally sensitive manner. An example of this is the need to be more directive and active during psychotherapy with some immigrant groups. The interventions that are effective with immigrants and that can be incorporated in Level II include cognitive–behavioral therapy, existential counseling, gestalt interventions, relaxation, role playing, psychodrama, and the use of metaphor, imagery, myth, ritual, and storytelling. MLM's Level III, cultural empowerment, helps the immigrant gain a better sense of environmental mastery. Psychologists may find themselves faced with immigrant clients who are initially more motivated to understand and effectively adapt to the world around them, rather than delving into intrapsychic and interpersonal problems. The frustrations and anger of not understanding how systems work, how to access services, or where to go for assistance with problems related to education, finances, health, or employment may be a predominant concern that must first be resolved before other issues can be explored. Thus, psychologists must be attuned and sensitive to the challenges of adapting to a new culture and provide case-management-type assistance and guidance that will empower the immigrant. In MLM the psychologist is not expected to actually become the client's case manager. Rather, the psychologist becomes a "cultural systems information guide," assisting the immigrant with relevant information about how the cultural system works and what the client can do to resolve associated problems. Level IV of the MLM, indigenous healing, combines Western and nontraditional healing methodologies. It is vital that the psychologist is knowledgeable and accepting of traditional cultural practices and open to establishing "treatment partnerships." This would optimally provide the immigrant client with the rich combination of healing sources from their culture of origin and culture of resettlement. Level V, social justice and human rights, addresses social injustices and potential human rights violations encountered by immigrant populations in resettlement countries. Similar to the other MLM levels, Level V is not a discrete level, but is infused throughout the various MLM levels. Therefore, this Level requires the psychologist to assume a social advocacy role emphasizing basic human rights that contribute to psychological problems for clients. In Level V, psychologists are proactive and active rather than only reactive to social injustices and human rights violations that clients encounter. The premise of MLM Level V is that immigrant clients' (similar to all human beings) mental health is not solely an intrapsychic issue, but that environmental variables impact an individual's mental health. Therefore, by not addressing outside variables, the psychologist is merely "band-aiding" the situation. Examples of types of appropriate social justice interventions by psychologists include educating clients about their rights; assisting clients, their families, and communities to stand up for equal treatment and access to resources and opportunities; and changing policy and legislation by writing to legislators.
Rita Chi-Ying Chung, PhD, is a professor in the Counseling and Development Program at the College of Education and Human Development at George Mason University in Fairfax, Virginia. Her research focuses on cross-cultural psychology and counseling, social justice, immigrant and refugee psychosocial adjustment and adaptation, the trafficking of Asian children, interethnic group relations, and racial stereotypes. She has lived in five different countries and has worked in the Asia Pacific Rim region, Asia, and South America. Prior to being at George Mason University, Dr. Chung was an assistant professor at the Ohio State University in Columbus, a consultant for the World Bank, and an adjunct professor at Johns Hopkins University in Baltimore and George Washington University. She arrived in the U.S. in 1990 as a postdoctoral fellow at the National Research Center for Asian American Mental Health at the University of California Los Angeles, and during that time was the project director of the first Chinese American Psychiatric Epidemiological Study and conducted the first U.S. conference on Southeast Asian Refugee Re-Education Camp Detainees and Vietnamese Amerasians. Dr. Chung has published more than 70 journal articles and book chapters and a book on counseling refugees and has made more than 100 national and international presentations. As a result of her work on Asian immigrant children, she was invited by Save the Children, UK, to be a consultant on their human trafficking program in Myanmar. She is a member of the executive committee of the International Association for Counseling, which was the first international association of counseling. She has been the cochair of the American Counseling Association's Human Rights committee and was the former chair of the American Counseling Association International committee. She received the Counselors for Social Justice (a division of the American Counseling Association) O'Hana Award for her work in social justice.
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