Healthcare Training Institute - Quality Education since 1979
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Description of the Transcultural Integrative Model
Step 1 depicted in the model is awareness and fact finding, which under the original model meant the following: enhancing sensitivity and awareness about the potential dilemma, reflecting on whether there is actually a dilemma, determining the parties or stakeholders involved, and engaging in a thorough process of fact finding. Step I is particularly relevant in the practice of multicultural counseling. Enhancing sensitivity and awareness means not only being aware of the ethical component of a dilemma but also how a dilemma may affect the different stakeholders involved who may have different or even opposing worldviews. Various stakeholders may give different meanings to a situation involving a dilemma, and it is the responsibility of the counselor to understand those different meanings during this awareness and fact-finding step.
Counselors' awareness about their own cultural identity, acculturation, and role socialization may affect their view of the dilemma and the extent to which they perceive a situation as a dilemma. For example, a counselor with strong affiliation to family interdependence values can perceive the situation of a client with HIV who recently immigrated to this country and who is seeking vocational services as one that requires advising the client to return to his original country, where he would find family support. For this counselor, there would not be a dilemma. However, for another counselor, this situation may pose a conflict in which the client's freedom of choice (autonomy) could be in opposition to what the counselor believes would be best for the client. In the latter case, the counselor contemplates both conflicting courses of action, which constitutes the dilemma.
Similarly, if the client was a woman, a feminist counselor and a nonfeminist counselor may view the dilemma differently, depending on the extent to which they consider the client's gender role socialization. The client's culture may elicit particular emotional reactions in the counselor, depending on how much the client's values or behaviors contradict those of the counselor. Again, this emotional reaction may affect the perception of a particular situation.
Sensitivity to intragroup differences is another important consideration. Counselors need to ascertain the extent to which a client is actually representative of the cultural patterns of the referent group (Sciarra, 1999). Sciarra described a process whereby individuals can change their referent group during an interaction based on age, socioeconomic class, religion, gender, national origin, or disability. In fact, the concept of cultural identity formation applies not only to race but also to gender, sexual orientation, or disability (Julia, 2000; W M. L. Lee, 1999; Sue & Sue, 1999). A simple example is the following: A counselor responds to the principle of beneficence by helping the client obtain a job at a grocery store against the client's wish to stay at home (supported by the principle of autonomy), ignoring the upper socioeconomic status of the client. Class-bound values (Sue & Sue, 1999) may explain the preference expressed by the client. Finally, the theoretical orientation of the counselor may affect the perception of a dilemma as well. For example, a counselor working under a family system approach would be more likely to define the dilemma as one affecting others and not only the individual client.
Step 2 involves the formulation of an ethical decision. This is primarily a rational process, similar to the rational model outlined by Forester-Miller and Davis (1995). However, the integrated Transcultural Integrative Model incorporates specific cultural elements under each one of the strategies to complete this step. This means that counselors need to (a) review all cultural information gathered in Step 1, (b) review potential discriminatory laws or institutional regulations, (c) make sure that the potential courses of action reflect the different worldviews involved, (d) consider the positive and negative consequences of opposing courses of action from the perspective of the parties involved, (e) consult with cultural experts if necessary, and (f) select a course of action that best represents an agreement of the parties involved. In the case presented previously that involves a client living with HIV, laws that apply to immigrants who have this diagnosis are particularly relevant because they may be discriminatory and present the counselors with a conflict between the law and the ethical standards of the profession.
Considering that agreement among all parties is not always attainable, Cottone (2001) offered a three-step interpersonal process that included negotiating, consensualizing, and arbitrating. Negotiating means the discussion and debate of an issue about-which two or more individuals disagree. Consensualizing describes a process of agreement and coordination between two or more individuals on a specific issue. This is an ongoing verbal and nonverbal interactive process rather than a final outcome. The parties involved may seek arbitration if the disagreement persists; Cottone suggested seeking a negotiator, a consensually accepted arbitrator, who then can make the final judgment. Consensualizing is the primary means of preventing disagreement because consensualizing implies the process of "(socially constructing a reality [i.e., between counselors and clients]" (p. 42).
The use of relational methods (Davis, 1997) and social constructivism techniques (Cottone, 2001), as described earlier in this article, is a key element of the Transcultural Integrative Model because these are particularly applicable to situations that require reaching an agreement among parties who may hold potentially conflicting cultural worldviews. Step 3 in Table 2 refers to weighing potentially competing, nonmoral values that may interfere with the execution of the course of action selected. Cultural values are particularly relevant here; again, the counselors' cultural identity, acculturation level, and gender role socialization may be crucial in uncovering these values. For example, the execution of a particular course of action may imply a level of client competence in dealing with the health care system that is not consistent with his or her acculturation level, or the course of action selected may contradict the female client's learned gender role.
Another task under this step is to identify contextual influences that may constitute a barrier for the implementation of the course of action selected. The original integrative model includes collegial, professional, institutional, and societal levels. The Transcultural Integrative Model adds a specific cultural level. Again, this is critical in dilemmas found in multicultural counseling because the counselors' values may contradict the clients' values or the contextual values. For example, in the case of the client with HIV depicted in this section, counselors need to be aware of potential prejudice against persons with HIV/AIDS as well as against immigrants from particular ethnic groups. In recommending a course of action that involves a vocational goal, counselors should consider the client's disposition to face such attitudes as well as anticipate possible reactions from employers and even vocational service providers.
Last, Step 4, is to carry out that plan, document, and carefully evaluate the consequences of the ethical decision. From a cultural standpoint, this involves securing resources that are culturally relevant for the client and involves developing countermeasures for the potential contextual barriers identified earlier. For example, in the case of the client with HIV, it could mean securing future employers and service providers who match the client's cultural identity, level of acculturation, and gender role socialization, among other factors. In addition, the counselor should consider preparing the client and other stakeholders to deal with potential biases, discrimination, stereotypes, and prejudices. Because this step involves the development and implementation of a plan involving different stakeholders, the counselor should be familiar with the relational and social constructivism methods cited earlier in this article because these strategies can facilitate the achievement of common goals.
It must be reiterated that Tarvydas's (1998) Integrative Model is inclusive of a virtue-ethics approach as well. Tarvydas recommended that counselors adhere to the virtues of reflection, attention to context, balance, and collaboration. Under our proposed Transcultural Integrative Model, this list of virtues or personal characteristics of counselors should be extended to include tolerance, sensitivity, and openness as suggested earlier in this article. These virtues are essential for implementing the steps we outlined within this model that require understanding and listening to people from cultures that differ from that of the counselor.
Reflection Exercise #6