GSJP Volume 16 final Graduate Student Journal of Psychology 2015, Vol. 16 Copyright 2015 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University 71 Ethical Research With People Of Color: Implications For Clinical And Community Applications Alicia San Miguel, B.S. Jennifer Moniz, M.S. Washington State University Department of Educational Leadership and Counseling Psychology Mental health counseling and research with ethnic minorities and indigenous communities within the United States has evolved; yet cultural consideration should be evaluated in evidence-based research. Some of the common errors in research include generalizing cultural groups and using White norms for comparison. The outcome of marginal- ization of these communities has developed mistrust with healthcare providers. This conceptual paper establishes WKH�UHOHYDQFH�RI �FXOWXUDO�GLIIHUHQFHV�DFURVV�PDQ\�GRPDLQV�DQG�LGHQWLÀHV�D�FRPPRQ�FRUROODU\�LQ�RUGHU�WR�KHOS�DOOH- viate past injustices of the ethnic minority population and indigenous communities. Given these past injustices, it is vital to discuss avenues that will minimize detrimental effects. and examine possibilities for improving cultural and ethical standards in two regards: in client and therapist relationship and within social psychology research. Developing a culturally sensitive environment in psychotherapy research is a growing need, eco- nomically and empirically. The current number of ethnic minority individuals in the United States is rising quickly (Mindt, Byrd, Saez, & Manly, 2010). According to the U.S. Census Bureau (2014), it is es- timated that ethnic minorities (all diverse populations other than non-Hispanic Whites) compromise 37% the general population and that number is projected to increase to 57% of the population in 2060. Of those ethnic minorities, a percentage are of indige- nous origin (Cunningham & Stanley, 2003). With this increasing diversity, we as social scientists and prac- titioners are compelled to humbly adapt in therapeu- tic application and in psychological research. This paper will comprehensively examine cultur- ally appropriate ways to collect data from ethnic mi- nority and/or indigenous communities and culturally HIÀFLHQW� ZD\V� WR� DSSO\� HYLGHQFH�EDVHG� WUHDWPHQWV�� Perspectives on the issue will incorporate culturally competent care from multitudes of frameworks in- cluding those from biomedical research, sociopolit- ical research, healthcare research, and psychological research. In order to reach the expectations of valu- ing clinical applications with ethnic minorities, we will examine the distinct characteristics that differentiate cultures (interdependence, spirituality, discrimination; Hall, 2001), critically assess the common errors found in research, and offer culturally sound practices for therapeutic application and/or research data collection in ethnic minority and/or indigenous communities. There are dissimilar characteristics among cul- tural groups of ethnic minorities and indigenous communities; these include a group’s sociopolitical context and the historical relationship to their par- ticular geographical region. As authors we chose to VSHFLÀFDOO\�LGHQWLI\�WKHVH�WZR�PDMRU�FKDUDFWHULVWLFV�LQ� evaluating cultural considerations. Although indige- nous communities such as Aboriginals of Australia, American Indians (First Nations), Native Hawaiians, and the Maori of New Zealand fall under the um- brella term indigenous owing to political coloniza- tion, we will not discuss sociopolitical implications. Rather we favor using the term indigenous (specif- ically in the United States) through “an attractive GHÀQLWLRQµ��6WDQOH\��������S��������,QGLJHQRXV�FRP- PXQLWLHV�SODFH�VLJQLÀFDQW�HPSKDVLV�RQ�KRZ�WKH\�UH- late to the natural world, which is strikingly different from other worldviews. Three main worldviews in- clude (a) the Judeo-Christian (Western) view in which God is external and heaven is above, (2) the Eastern view in which concentration is inward (e.g., in med- itation), and (3) the Indigenous view in which peo- ple have essential relationships with nature including WKH� ODQGVFDSHV� RI � WKHLU� FRPPXQLW\³WKHLU� ULYHUV�� mountains, seas, and land (Royal, 2003). Respectful- ly, we regard the label of indigenous according to WKLV� GHÀQLWLRQ� UDWKHU� WKDQ� WKH� GHÀQLWLRQ� DVVRFLDWHG� Keywords: Indigenous research, Indigenous, counseling diversity, Culturally diverse, counseling psychology, counseling research, diversity research, counseling competencies. Corresponding author: alicia.sanmiguel@wsu.edu 72 SAN MIGUEL, MONIZ with the sociopolitical restraints of people affect- ed by colonization (Blaser, Harvey, & McRae, 2004). Although there are distinctions in experienc- es among ethnic minorities (e.g., Asian Americans, Mexican Americans/Latinos(as), African Ameri- cans) and those in indigenous communities, a com- PRQDOLW\� RI � H[SHULHQFH� H[LVWV� LQ� LPSURSHU� LGHQWLÀ- cation, compared with a White norm or standard, issues of microaggression, and mistrust of health- care providers. We will discuss these themes as well as attempt to offer alternatives for alleviating these issues through culturally appropriate means of col- lecting research data in these communities and cultur- ally sound ways of applying therapeutic techniques. Common Errors Found in Research Grouping-Mislabeling Ethnicity and race are two of the most distin- guishable terms used in ethnic minority research, yet they have been used interchangeably. Ethnicity de- notes shared values, culture, traditions, and sense of identity and group; it is a socially created construct WKDW� LV� XWLOL]HG� IRU� LGHQWLÀFDWLRQ� �%KRSDO� � 6HQLRU�� 1994). Race is more biologically driven and sociopo- litical in context. In the realm of research, the terms ethnicity and race are utilized interchangeably and further complicate the cultural divisions that exist in each origin of race and/or ethnicity. For example, an individual is of one race but can identify from various HWKQLF�DIÀOLDWLRQV��H�J��(WKQLF�LGHQWLÀFDWLRQ�DV�3ROLVK� DQG�,ULVK�EXW�HVVHQWLDOO\�FODVVLÀHG�DV�RQH�UDFH��ZKLWH������� � ,Q� JHQHUDO�� HWKQLFLW\� LV� GLIÀFXOW� WR� LGHQWLI\� LQ� and out of research. Grouping large cultures with- RXW� GHÀQLQJ� WKH� GLVWLQFWLRQV� EHWZHHQ� WKHP� DQG� then comparing them may create confounding fac- tors and/or common errors. For example, group- ing commonly occurs through the collection of Federal data (e.g., U.S. Census; Miranda, Lawson, & (VFREDU�� ������� WHUPLQRORJ\� LQFOXGHV� WKH� FODVVLÀ- cation of four categories: Hispanic, non-Hispanic, Asian, and Caucasian. This terminology is ambigu- RXV� DQG� ODFNV� DQ\� VSHFLÀF�PHDQLQJ� �%KRSDO�� ������� Let us evaluate the term Hispanic for a moment. 7KH�WHUP�+LVSDQLF�ZDV�ÀUVW�FRLQHG�RQ�WKH������8QLW- HG�6WDWHV�&HQVXV�IRU�GHPRJUDSKLF�FODVVLÀFDWLRQ�SXU- SRVHV��$OWKRXJK� WKLV� LQVWDQFH�ZDV� WKH�ÀUVW� WLPH� WKH� 8�6�� JRYHUQPHQW� RIÀFLDOO\� UHFRJQL]HG� WKLV� FXOWXUH�� use of the term aggregated many cultures with Span- LVK�RULJLQV�ZLWKLQ� WKLV� VLQJOH� FODVVLÀFDWLRQ� �5HLPHUV�� 2005). Individuals of Spanish origin but from differ- ent regions including Mexico, Cuba, Puerto Rico, and Central and South America were all categorized into one label, one umbrella term, Hispanic. However, this term does not differentiate the many cultural differ- ences among geographic regions. The Mexican-her- itage population alone varies in legal status, time in the United States, race/phenotype, generation status, DQG� ODQJXDJH�ÁXHQF\� �*DUFtD�� ������/ySH]� �6WDQ- ton-Salazar, 2001). The use of the one category of +LVSDQLF�ZLWKRXW�GHÀQLQJ�WKH�XQLTXH�FKDUDFWHULVWLFV� of any discrete cultures (e.g., Mexican American vs. Cuban) creates a misrepresentation, and simply speak- ing, is too broad of a label. There is a very distinctive difference between a Mexican American (e.g., Chi- cano(a), Latino(a)) who was born in the United States and a Puerto Rican, who was born and raised in Puer- to Rico but recently immigrated to the United States. In terms of labeling with the term Hispan- LF�� QRW� DOO� LQGLYLGXDOV� DJUHH� ZLWK� WKLV� LGHQWLÀFDWLRQ�� Some individuals in the Hispanic/Latino(a) com- munity associate the term with the negative conno- WDWLRQV� RI � JDQJ� DIÀOLDWLRQ�� XQHPSOR\PHQW�� DQG� ORZ� degrees of education (Austin & Johnson, 2012). In some areas of the United States (e.g., Los Angeles), WKLV� VHOI�LGHQWLÀFDWLRQ� LQ� WKH� +LVSDQLF�/DWLQR�D�� community has been noted as a development of an “emerging ethnic consciousness” (Reimers, 2005, p. 32). So depending on the geographic region of the United States and the relationship one has with his or her identity, an individual of the Hispanic/Latino community may self-identify differently. Hispanic/ Latino(a) individuals may identify according to their geographic region (e.g., Cuban, Chicano(a), Lati- QR�D���RU�HYHQ�0HVWL]R�� VHOI�LGHQWLÀFDWLRQ� LQ� UHVSHFW� of Spanish and Amerindian roots; Schaefer, 2000). Similarly, this transition into more acknowledge- DEOH�� UHVSHFWIXO�� DQG� HPSRZHULQJ� VHOI�LGHQWLÀFDWLRQ� has occurred for African Americans, Asian Ameri- cans, and American Indians. The standard terms have transitioned from “colored” to “Negro” to “Black” to “African American” and “oriental” to “Asian” (Dajani, 2001). The common goal in the evolutionary 73 ETHICAL RESEARCH WITH PEOPLE OF COLOR changes with labeling is an attempt to socially rede- ÀQH�RQH·V�RZQ�JURXS��LQVWLOO�JURXS�SULGH��DQG�LPSDUW� greater self-esteem (Smith & Tom, 1992). It is vital in discussion, research, or in the therapeutic realm WR� LQYHVWLJDWH� WKH� FXOWXUDO� YDOXHV� DQG� LGHQWLÀFDWLRQ� of the subgroups rather than focus on an umbrella term that aggregates cultural/ethnic populations into one massive assembly. This descriptive distinction is EHQHÀFLDO�RXW�RI � UHVSHFW� IRU� WKH�XQLTXH�GLIIHUHQFHV� each ethnic community or indigenous communi- ty has in conjunction with their experiential history. The White Standard The comparative approach of using the White population as the norm or standard is concerning to say the least. With the growing interest in health disparities with ethnic minorities and indigenous communities, the normalizing population that was used for comparison shifted to the White (Cauca- sian) population. Although this shift was necessary to understand some of the variables that contributed to health disparities in that population, we as social researchers and mental health professionals are now ORRNLQJ�DW�YDULRXV�RWKHU�GLIIHUHQFHV��VXFK�DV�HIÀFDF\� of treatments (e.g., cognitive-behavioral therapy with American Indians). Researchers should evaluate the XQGHUO\LQJ� KLVWRULFDO� DQG� VRFLRSROLWLFDO� MXVWLÀFDWLRQ� regarding how and why the White population should be appropriate as the standard control. In the same regards, the outcome of evaluating such health dis- parities has been translated in the media to be a nega- tive perspective of health in diverse communities. Al- WKRXJK�LW�LV�GLIÀFXOW�WR�FRQWDLQ�WKH�SHUVSHFWLYH�RXWVLGH� the construct of research, it is pertinent that those conducting research with culturally rich communi- ties be aware of the high impact that may result from implications found in studies. Furthermore, another possible avenue of alleviating this negative perception of ethnic minority health disparities is through ana- lytical discussion of its social and cultural relevance in peer reviewed journal articles to clarify distinctions (Bhopal, 1997). For example, may of the factors that contribute to health disparities (e.g. Hispanics and African-American’s are twice as likely as whites to have diabetes mellitus) are due to structural bases of racism such as lack of access, stigma surrounding ill- ness, and lower income rather than direct biological correlations (Neville, Spanierman & Lewis, 2012). Mistrust of Healthcare Providers Another barrier that prevents adequate repre- sentation of ethnic minorities and indigenous pop- ulations includes a prominent mistrust of healthcare providers (Miranda et al., 2002). According to the Commonwealth Fund Minority Health Survey, 43% of African Americans, 28% of Latinos, and 5% of Whites felt mistreated by healthcare providers be- cause of their cultural background (Boulware, Coo- per, Ratner, Laveist, & Powe, 2003). This mistrust may originate from direct experience of the indi- vidual due to social cues (e.g., media) or from sec- ondhand experiences (Boulware et al., 2003). This FRQFHUQ� OHDGV� WR� GLIÀFXOWLHV� LQ� FRQGXFWLQJ� VWXGLHV� WKDW� DGHTXDWHO\� UHÁHFW� WRGD\·V� GLYHUVH� FRPPXQLWLHV�� If there is fear, hesitation, and mistrust on behalf of the participant with a healthcare profession- DO��PRUH� VSHFLÀFDOO\� D� UHVHDUFKHU�� LW� ZRXOG� EH� GLIÀ- cult to ascertain the validity of the data collected. Historically, mistrust has arisen due to the ill ZLOO� WKDW� KDV� EHHQ� LQÁLFWHG� XSRQ� HWKQLF� PLQRULW\� and indigenous populations. One major instance of major ethical racial bias is known as the Tuske- gee Syphilis Study (Reverby, 2009). In 1932, United States public health doctors observed the course of syphilis in hundreds of African American men, offering little to no treatment even after the discov- ery of penicillin in a study called the United States Public Health Service Study of Untreated Syphilis in the Male Negro at Tuskegee. This tainted study LV�LPSULQWHG�RQ�RXU�VRFLHW\�DQG�UHÁHFWV�XQHWKLFDO�DE- errances in medical research. At a later date, it was discovered that the same doctor involved with the syphilis studies had also done a similar unethical study regarding syphilis being introduced into Gua- temala prison populations with no consent (Reverby, 2011). In response to an article published by Reverby (2011) on the occurrences of this maltreatment on individuals in Guatemala without informed consent, Hillary Rodham Clinton, then Secretary of State, and Kathleen Sebelius, then Secretary of the De- partment of Health and Human Services (DHHS), offered a formal apology to the people of Guatema- la; President Barack Obama expressed his distress as 74 well to the President of Guatemala (Reverby, 2011). Another such misappropriate handling was the negative perception of African Americans during certain political eras in the United States. In the 1850s, psychiatrists labeled African American slaves who were compelled to run away from their White masters with a mental illness called drapetomania; lat- er accounts were also noted in medical journals of a form of madness called dysaesthesia aethiopis when African American slaves disrespected their master’s property (Metzl, 2010). Although we have progressed into a more culturally sensitive environment, some of the most recent experiences of this negative per- ception of African Americans is as recent as the civil rights movement. In the 1960s, as the political movement of the civil rights uproared, the medical community translated their political reactions into a new diagnosis. In Bromberg and Simon’s (1968) article “The ‘Protest’ Psychosis: A Special Type of Reactive Psychosis,” they denote a form of schizo- phrenia that African American men develop with hostility, rage, and delusional anti-Whiteness after listening to Malcolm X or aligning with any politi- cal militant resistance to the social order of Whites. The negative perception of African American men and hostility due to the political resistance was DOVR�GHÁHFWHG�LQ�DQWLSV\FKRWLF�PHGLFDWLRQ�DGYHUWLVH- ments such as those for Haldol (haloperidol). These advertisements in the 1970s depicted a photo of an $IULFDQ� $PHULFDQ� PDQ� ZLWK� D� FOHQFKHG� ÀVW� �RIWHQ� seen in militant groups during the civil rights era), XQGHU� D� FDSWLRQ� $́VVDXOWLYH� DQG� EHOOLJHUHQW"� &RRS- eration often begins with Haldol or Haloperidol” (Metzl, 2012). Although it has been more than four decades since the publication of these campaign DGV�DQG�EODWDQWO\� UHÁHFWHG� UDFLVW� VWHUHRW\SHV�RI �$I- rican American men, this skewed perception is still an open wound and continues to lay a foundation of mistrust between patient and medical professional. Although not discussed here, other indigenous communities have been subjected to ill care by the PHGLFDO� ÀHOG�� )RU� H[DPSOH��$PHULFDQ� ,QGLDQ�ZRP- en underwent unethical sterilizations in the 1970s by the Indian Health Services without consent or just medical cause (Carpio, 2004). The indescribable shame and fear that arose out of this experience has silenced an already oppressed culture. The ster- ilization process was due to the belief that Native American women were a substantial threat to the colonial structure since they could reproduce anoth- er generation of colonial resistance (Smith, 2003). The cultivation of many of these negative ex- periences from various ethnic/cultural backgrounds and indigenous communities still impact everyday in- WHUDFWLRQV��VSHFLÀFDOO\�ZLWK�PHGLFDO�FRPPXQLWLHV��,Q� order for the medical community to rebuild a foun- dation with ethnic minority and indigenous commu- nities, we must ethically approach individuals and be sensitive to cultural values in research data collection and in the clinical and therapeutic realm. Clinical interaction themes that are more relevant to ethnic minority and indigenous populations include interde- pendence, spirituality, and discrimination (Hall, 2001). Implications for Therapeutic Environment � ,W� LV� GLIÀFXOW� WR� XQGHUVWDQG� ZKLFK� WUHDWPHQWV� work with which populations if previous research has not carefully considered the cultural nuances among the various ethnic minority communities and/ or indigenous communities. The American Psycho- logical Association (APA) has developed objectives to consider this sociocultural framework in psycho- logical assessment, case formulation, therapeutic relationship, and intervention through an integrat- ed approach called the Evidence-Based Practice in Psychology (EBPP; La Roche & Christopher, 2009). The EBPP denotes a more comprehensive approach to evidence-based practices that is more culturally sound and sets the tone for future evidence-based psychotherapy research (APA, 2006). However, al- though APA has acknowledged the need to be cul- turally sensitive to the needs of our diverse patients, there still has not been adequate evidence that eth- QLF� PLQRULW\� SRSXODWLRQV� DUH� SURSHUO\� UHÁHFWHG� LQ� UHVHDUFK� �0LUDQGD� HW� DO��� ������� ,Q� RUGHU� WR� ÀOO� WKLV� gap, we will discuss the common themes that are relevant across various ethnic, cultural and/or in- digenous communities. These themes include issues of interdependence, spirituality, and discrimination. Common Ground: Interdependence, Spirituali- ty, and Microaggressions SAN MIGUEL, MONIZ 75 � 9DULRXV� WUHDWPHQWV� KDYH� EHHQ� LGHQWLÀHG� DV� HYL- dence-based treatments for certain groups but have QRW� EHHQ� DGHTXDWHO\�PRGLÀHG� IRU� FXOWXUDOO\� GLYHUVH� populations. For example, one of the most widely used manualized treatments is cognitive-behavior- al therapy (Beck, Rush, Shaw, & Emery, 1979). One ZD\� WR� DGHTXDWHO\� UHÁHFW� D� FXOWXUDOO\� ULFK� SDWLHQW� LV� to utilize culturally sensitive treatments, which mod- ify clinical interventions to be unique to the indi- YLGXDO� DQG� WKHLU� FRPPXQLW\�� 6RPH� PRGLÀFDWLRQV� include incorporating cultural components into clin- ical applications, for example, using racial identity development for African Americans (Carter, 1995), evaluating empowerment and indigenous problem solving for American Indians (LaFromboise, Trim- ble & Mohatt, 1998), identifying healing and value systems with Asian Americans (Root, 1998), and discussing the family unit with Latino Americans (Szapocznik, Kurtines, Santisteban, & Pantin, 1997). One such example of a culturally sensitive mod- LÀFDWLRQ�LQFOXGHV�&XHQWR�WKHUDS\�IRU�/DWLQR�D���+LV- panic populations. Cuento therapy is based on Ban- dura’s social learning theory; it utilizes cuentos (Spanish language folk stories) in a cognitive and emotional framework to improve outcomes related to role-play- LQJ�� VRFLDO� LQWHUDFWLRQ�� UHÁHFWLRQ�� DQG� GLVFXVVLRQ� (Ramirez, Jain, Flores-Torrez, Perez, Carlson, 2009). 7KH�IRON�VWRULHV�DUH�LGHQWLÀHG�WR�EH�FXOWXUDOO\�UHVSRQ- sive on the various differences between Latino(a)/ Hispanic cultures. However, this form of culturally adapted therapy is limited such that not many stud- ies have applied this approach across various Lati- no(a)/Hispanic populations. Otherwise, these forms RI � PRGLÀHG� WKHUDSLHV� DUH� YDOXDEOH� LQ� WKH� HIIRUWV� of a culturally sound application in psychotherapy. Apart from culturally sound treatments, we can evaluate common themes across various eth- nic minority and/or indigenous communities. The themes that run through various multicultural ap- plications include interdependence, spirituality, and discrimination as they relate to family and commu- nity. These constructs vary across different ethnic minorities but remain focal points of discussion. European Americans are less likely to value inter- dependence and value internal attributes more than other groups such as Latino Americans and Afri- can Americans (Suro & Wesman de Mamani, 2013). Furthermore, interdependence is emphasized more in collectivist cultures than in individualist cultures. Interdependence. Although the individual- ism-collectivism construct varies on a spectrum, VRPH�VWXGLHV�KDYH�LGHQWLÀHG�DWWULEXWHV�RI �LQGLYLGXDO- ism as being higher in the United States, Britain, and Australia and collectivism attributes as being higher in samples from Africa, Asia, and Latin America (Tri- andis, McCusker, & Hui, 1990). Culturally sensitive therapy incorporates common values at the commu- nity level (e.g. using family therapy for a culture that values the family unit) in order to approach cultur- al groups with more interpersonal emphasis (Hall, 2001). A common mistake in application of family therapy is using the European American middle class model with an individual from a culturally rich fam- ily with a dynamically different outlook, one parallel to collectivist values, such as those of Asian Ameri- cans, Latinos(as), and the like. Similarly, interdepen- dence plays a large role in the matter of intrapsychic forces in the human experience for ethnic minorities and indigenous cultures (Yeh, Hunter, Madan-Bahel, Chiang, & Arora, 2004). In other words, if a men- tal health professional personally views the distinc- tion of mind and body as separate, that lens of bias will cause a disconnect between the client and mental health professional. According to Western psycholo- gy, there is a line of separation between spirituality, mental health, physical health, and overall well-being (Grills & Ajei, 2002; Sue & Sue, 1999). To clinically treat patients in a culturally and ethically appropri- ate manner, we should be attentive to such biases. Spirituality. The view of approaching spiritual values has evolved within the application of diverse populations. The attention on this issue has grown GXH�WR�WKH�VLJQLÀFDQFH�RI �LWV�LQWHUZRYHQ�IHDWXUHV�ZLWK� various multicultural dimensions including spiritu- al traditions, values, and worldview practices (Pow- er, 2005). In providing care for an ethnic minority or indigenous patient, spirituality may be an avenue for discussion. Such application that is pertinent to therapy through prayer or evaluating spiritual heal- ing experiences may be applicable in some cases where spiritual support is warranted in their family and/or community. The European American per- ETHICAL RESEARCH WITH PEOPLE OF COLOR 76 spective of religiosity is different that other ethnic minority groups; in other various cultures spirituality LV� KLJKO\� LQÁXHQWLDO� RQ� WKH� VRFLDO� DQG� SROLWLFDO� FRQ- struct of the community (Hall, 2001). For example, spirituality for Chicano/Latino individuals shapes the way in which they raise their children in a social environment; the family is viewed as a “protective sanctuary” that honors their ancestors and engrains generational wisdom to the younger generations through prayers of God, angels and saints (Koss-Chi- onio & Vargas, 1999; Cervantes & Ramirez, 1992). Microaggressions. A pertinent theme that should be acknowledged with a culturally diverse cli- ent is the experience of discrimination and/or racial microaggression. These issues could be perceived as a hypervigilant response to the environment; howev- er, it is evident that ethnic minorities experience dis- crimination much more than European Americans (Hall, 2001). Although discriminatory practices are less common currently than in the period before the Civil Rights movement and the Chicano Movement, discrimination still persists (Thomson & Neville, 1999). Discrimination has manifested into what is termed racial microaggression. Racial micro-aggres- sions are “brief and commonplace daily verbal, be- havioral, and environmental indignities, whether in- tentional or unintentional, that communicate hostile, derogatory, or negative, racial slights and insults to the target person or group (Sue et al., 2007, p. 273).” In order to competently address ethnic minorities and/or indigenous communities, mental health pro- fessionals should develop cultural competency, via cultural humility, to alleviate bias or microaggressions. This also contributes as noted earlier in the paper to issues of mistrust between healthcare providers and ethnic minorities, which leads to discrepancies in care. For example, European Americans are more likely than ethnic minorities to obtain mental health care and are less likely to be misdiagnosed with psy- chotic disorders or depression (Alvidrez & Areán, 2002). In research alone, mistrust has evolved by ear- O\�H[SORLWLYH�VRFLDO�MXVWLÀFDWLRQ�RI �HGXFDWLRQDO�VHJUH- gation and slavery that is too vast a topic to discuss in this article (e.g., Drapetomania: irrational desire of slaves to run away; Bhopal, 1997). Attitudes and per- spectives towards mental health are valid issues worth discussing with an ethnic minority client. This discus- sion brings to light the generalizing of ethnic minori- ties through research errors and bias that emphasize health disparities rather than the underlying contri- bution factors that cause these health disparities. How do we alleviate these errors in the ther- DSHXWLF� HQYLURQPHQW"� +RZ� GR� ZH� DFNQRZOHGJH� WKH� LQMXVWLFHV� RI � WKH� SDVW� DQG� UHEXLOG"� :H� FDQ� begin to heal the open wounds that the medi- cal community has indirectly caused through the application of cultural competence, cultural hu- PLOLW\�� DQG� IRFXVLQJ� RQ� FXOWXUH�VSHFLÀF� QHHGV� Culturally Relevant Applications in Client-Therapist Interactions Cultural Competence Multicultural Counseling Competency. One RI � WKH� SULPDU\� FRQFHSWXDO� IUDPHZRUNV� WKDW� ÀUVW� made headway in the multicultural world of coun- VHOLQJ� SV\FKRORJ\� VSHFLÀFDOO\� ZDV� WKH�0XOWLFXOWXUDO� Counseling Competencies (MCC) model by Sue et al. (1982). This framework had initiated a call to pro- gram accreditation standards (American Counseling Association, 2005), licensing regulations (Council for Accreditation of Counseling and Related Edu- cational Programs, 2001), and mental health provid- er standards (APA, 2003). The model can be widely adapted for many cultural, ethnic, and/or indigenous populations. It consists of three areas of emphasis: (a) attitudes and beliefs: being aware of own attitudes, beliefs, biases, assumptions, and values of another culture; (b) knowledge: learning and understanding the worldview of other cultural backgrounds; and (c) skills: learning adequate intervention techniques DQG� VWUDWHJLHV� WR�ÀW� WKH�XQLTXH�QHHGV�RI � WKH� FOLHQW�� In order to have a high quality experience in train- ing, students should seek cultural information and experiences (of self and other cultures), commu- nicate and collaborate with other cultural groups, attend cultural events, and be open to learning about other cultural values/practices (Ridley, 2005). Cultural Humility Although cultural humility is minimally discussed within counseling psychology research, we should take into consideration that it is utilized across bio- SAN MIGUEL, MONIZ 77 medical research and nursing research. Cultural hu- mility differs from cultural competency; cultural KXPLOLW\�GRHV�QRW�IRFXV�RQ�D�ÀQLWH�HQGSRLQW�RI �VDW- isfying cultural competencies but rather on openness to the other (Hook, Owen, Davis, Worthington, & Utsey, 2013, p. 354). In other words, whereas MCC is viewed as a way of applying and doing, cultural humility is approaching openness and a way of being with culturally diverse clients (Hook et al., 2013). Cul- tural humility is an evolving and dynamic process that LQYROYHV�WKH�FOLHQW·V�FXOWXUDO�QHHGV�� WKH�UHÁHFWLRQ�RI � the therapist’s worldview, and appreciates that there is no end goal, rather a pursuit for development. Encompassing a much deeper process of re- ÁHFWLRQ��FXOWXUDO�KXPLOLW\�GRHV�QRW�IRFXV�RQ�FRPSH- tence but rather on the recognition that daily expo- sure to various cultures affects the therapist’s views and brings about the realization of how much is not known about other cultural groups (Yeager & Bau- er-Wu, 2013). In a meta-analysis, perceived cultural humility of the therapist (from the client) over- lapped with the client ratings of the therapeutic al- liance in positive outcomes (Owen, Imel, Adelson, & Rodolfa, 2012). So it is believed that with more salient cultural humility on behalf of the therapist, the client may experience positive outcomes through a sense of self, increasing motivation and instilling hope (Wampold, 2007). On a smaller scale, counsel- ing psychologists should cater to the unique needs RI �WKHLU�FOLHQWV��DQG�WKHVH�FXOWXUH�VSHFLÀF�QHHGV�FDQ� EH� LGHQWLÀHG�ZLWKLQ�$3$·V�DSSURDFK�WKURXJK�(%33�� &XOWXUH�6SHFLÀF�1HHGV�7KURXJK�(%33� EBPP has demonstrated the suggestions needed to identify FXOWXUH��VSHFLÀF�QHHGV�LQ�WKH�WKHUDSHXWLF�HQYLURQ- PHQW��$OWKRXJK�(%33�KDV�EHHQ�EULHÁ\�UHYLHZHG�LQ� this paper, we should demonstrate the emphasis of this framework with culturally diverse populations. One of the objectives clearly emphasized through- out the EBPP guidelines is culturally sensitive psychotherapy. The EBPP guidelines also carefully FRQVLGHU�WKH�LQÁXHQFH�RI �HFRQRPLF�IDFWRUV��VR- ciocultural factors, and situational factors on the mental/physical health of a client (APA, 2006). Although the APA Task force of 2006 is a complex and comprehensive approach to evidence-based treatments and considerations for culturally diverse clients, the limitation of this approach consists of the lack of research that encompasses culturally PRGLÀHG�LQWHUYHQWLRQV�DQG�FXOWXUDO�VHQVLWLYLW\�WR� ethnic minority and indigenous communities. Healing With Indigenous people. In work- ing with individuals who have various worldviews, such as indigenous populations, we need to acknowl- edge healing from a different perspective. Indige- nous healing takes a holistic outlook on well-being (Singh, 1999; Sue & Sue, 2002). Certain cultures at- tribute mental illness, deviant behavior, or chronic ailments to spiritual or cultural origins (Harner, 1990; Sue & Sue, 1999; Lee & Armstrong, 1995). For ex- ample, although alternative medicine is viewed as an alternative to natural science and medicine, it is not uncommon for certain cultural groups to view it as primary line of treatment. Mestizo communities (indigenous Latino(a) origins) utilize plants, herbs, and medicinal teas for the treatment of mental/ physical conditions through a curanderismo (spir- itual healer) in their communities (Lara, 2008). In this regard, alternative medicinal treatments are not alternative at all to the healers and/or curanderos of a mestizo community (Hernandez-Wolfe, 2011). Some indigenous considerations have been cul- tivated from work by Lee & Armstrong (1995), Sue & Sue (1999) and Helms and Cook (1999) in Yeh et al.’s (2004) review of indigenous perspectives of healing. Although the review accounts for various counseling and research considerations, the most per- tinent to counseling are as follows: (a) be open and aware to indigenous healers and forms of healing, (b) reach out and connect with healers and incorpo- rate their spiritual/healing beliefs into the therapeu- tic alliance, (c) understand that indigenous healing is not goal oriented and does not focus on technique RU�TXDQWLÀFDWLRQ��$OWKRXJK� WKHVH�DUH�RQO\�D� IHZ�RI � the listed considerations, they are not exclusive to the therapeutic alliance with indigenous populations. In order to fully encapsulate working with indigenous populations in research we will discuss research sug- gestions that can be applicable to ethnic minority populations as well, in the research and clinical realm (e.g., Latino(a), indigenous populations, Mestizo). Culturally Relevant Applications in Research ETHICAL RESEARCH WITH PEOPLE OF COLOR 78 Many of the recommendations that will be pro- vided are similar to community-based participato- ry research (CBPR); however, CBPR can mostly be found in public health research rather than social sci- ence research (Flicker, Travers, Guta, Mcdonald, & Meagher, 2007). This is not to say that this research method cannot make the transition to a more social science–based practice; however, it is vital to the au- thors to make a clear distinction of the themes more relevant to indigenous and ethnic minority commu- nities in evidence-based practice research. CBPR “. . . is an orientation to research that focuses on re- lationships between academic and community part- QHUV��ZLWK�SULQFLSOHV�RI �FR�OHDUQLQJ��PXWXDO�EHQHÀW�� and long-term commitment and incorporates com- munity theories, participation, and practices into the research efforts” (Wallerstein & Duran, 2006, p. 312). Some of the major challenges with CBPR include the participation of the community members and the control behind the initiatives of the researchers, and who has the primary control over the research process, data-collection, and data-dissemination. An- other challenge is based on the community consent and who provides the approval in each community (Wallerstein & Duran, 2006). CBPR is well estab- lished in literature for empowering and improving communities. However, it is important to note that the goals and outcomes of the research should not be solely determined by the researchers and should be a collaborative process with the community. Eth- nocentric perspectives should not be forced upon the individuals of ethnic minority backgrounds; rather researchers ought to work with the community to ensure that research is meeting the goals of the com- munity and are relative to their worldviews. Practice goals should be comparable to the goals of the com- munity. One interesting recommendation provided in the CBPR research is that university-community partnerships should be developed (Wallerstein & Duran, 2006). However, it is important to mention that this may be a challenge, with the lack of high- er educational institutions located in all communities of ethnic minorities. For example, in Hawai’i, it is GLIÀFXOW� IRU� FRPPXQLWLHV� WR� GHYHORS� UHODWLRQVKLSV� with the university system as the main universities are located on the main island and many of the in- digenous communities are located on the outer is- ODQGV���5HODWLRQVKLSV�FDQ�EH�GLIÀFXOW�WR�GHYHORS�EDVHG� on travel time and costs, and cultural differences. Another limitation is that the literature on CBPR does not show the effect of interventions in commu- nities once researchers/clinicians have left the com- munities. Much of the literature found on CBPR is based on urban health care research (Minkler, 2005). With our focus being more on ethnic minorities and indigenous populations; the goals differ. In an ur- ban setting, it is a bit easier to access populations of ethnic minorities, develop university-communi- ty relations, and have research meetings. In a more rural and culturally sensitive setting, more challeng- es arise with the key components of CBPR. Rela- tionships take time and effort to develop, with travel time and costs; urban-based research would be more HIÀFLHQW� WKDQ� UXUDO�EDVHG� UHVHDUFK�� 2XU� GLVFXVVLRQ� will focus on more humble collaborative approach- es that are stronger and longer, withstanding the limitations of CBPR in order to establish longer and more salient relationships in the community. Research Implications for Indigenous and/or Ethnic Minorities Developing Community Relationships. Due to previous injustices experienced by ethnic minori- ties (e.g., discrimination) and previous mistrust of healthcare providers, it is vital that when services are provided they meet the needs of the communities, families, and/or clients. Most researchers and prac- titioners are operating from a Western framework; thus, relationship development with ethnic minority patients and the indigenous community is the foun- dation of ethically sound research and practice. Fur- thermore, building strong communal relationships that are more holistic, universal, and culturally sensi- tive will ensure more successful implications of clin- ically competent research (Vicary & Bishop, 2005). Extra care should be taken to be involved in the community in which research and practice is execut- ed. Cultivating social relations is vital in building re- spect within the community (Darou, Hum, & Kurt- QHVV�� ������� � 0RUH� VSHFLÀFDOO\�� EXLOGLQJ� VWURQJ� WLHV� between community members and leaders in the re- search process helps unite researcher and community SAN MIGUEL, MONIZ 79 through at a common framework. Since researchers and practitioners can be viewed as outsiders that do not fully understand the culture, this can create a barrier to accurate cultural insight. Without a deep XQGHUVWDQGLQJ�RI �WKH�FXOWXUH��UHVHDUFK�ÀQGLQJV�PD\� QRW� EH� SUHVHQWHG� LQ� D�PDQQHU� WKDW� LV� � UHÁHFWLYH� RI � the true nature of minority ethnic or indigenous life. Uniting researcher with the community may also alle- viate mistrust and help lessen fear associated with the experience of discriminatory and exclusionary his- tory. Understanding and respecting these hesitations is necessary in softening the negative perceptions of research in these communities. Researchers and prac- titioners must gain a deeper understanding of the his- tories of a community and its culture to ensure stron- ger relationship development (Darou et al., 1993). Developing Advisory Boards. Developing ad- visory boards among ethnic minority and indigenous communities to assist oversight of research from initiation to completion can foster trusting working relationships. The objective of these advisory boards would be to protect community values and its mem- bers through meaningful culturally relevant research (Quinn, 2004). Advisory boards would consist of SURPLQHQW�FRPPXQLW\�PHPEHUV�ZKR�SOD\�VLJQLÀFDQW� roles in the community, educational leaders, research- ers with similar cultural backgrounds, and other rele- vant advocates. By establishing a community council board, researchers are opening community conversa- tion and considering the input directly from those who DUH�LPSDFWHG�E\�WKH�UHVHDUFK�SURMHFW�DQG�LWV�ÀQGLQJV��� Community advisory boards allow for a collaborative research relationship to develop between community members and researchers and continuous community engagement throughout the research process (Cana- dian Institutes of Health Research, 2010). The com- munity board would play an active role in establishing project completion and assist in contributing their perspective on the cultural issues being evaluated. Most importantly, the ethical responsibility would rely solely on the researcher regardless of the prominent role the community advisory board plays (Darou et al., 1993). So we must keep in mind that research- ers must establish this relationship while continuous- ly maintaining ethically sound research in line with ethical review boards (e.g., Internal Review Board). Identifying Community Leaders/Advocates. Although the strategy of utilizing community lead- HUV�LQ�WKH�UHVHDUFK�SURFHVV�LV�EHQHÀFLDO�IRU�DGHTXDWH� representation, we must also emphasize the chal- lenges associated with choosing the most appropri- ate advocate for the community. For example, there is no direct leader or groups of leaders in Hawai’i representing Native Hawaiians. So how would a re- VHDUFKHU� VHHN� RXW� D� FRPPXQLW\� OHDGHU� WKDW� UHÁHFWV� +DZDL·L� LQ�WKHLU�UHVHDUFK"�$�SRVVLEOH�SURSRVLWLRQ�WR� this challenge is opening discussion with local his- WRULFDO� DJHQFLHV�� VSHDNLQJ� ZLWK� SXEOLF� RIÀFLDOV�� DQG� speaking to individuals in the community. Although this pursuit is more time consuming and takes a great quality of effort, it contributes to an open and trust- ing relationship with the people (Ball & Janyst, 2008; Schnarch, 2004). The relationship built between the researchers and community should not be brushed over, as strong bonds are necessary to ensure cultur- ally responsive research that may pave more oppor- tunities for research to be conducted in the commu- nity. Creating this new trusting relationship may aid some ethnic minority and indigenous communities to combat the injustices faced in history (Johnstone, ������� � )XUWKHUPRUH�� UHVHDUFKHUV� FRXOG� ÀQG� ZD\V� to show appreciation and gratitude to that commu- nity for allowing them to enter their cultural space and not impinging on their values in order to con- duct research (Ball & Janyst, 2008). Understanding and showing an appreciation of political structures in their communities is important to identify early in the relationship (Darou et al., 1993). This may pre- vent any type of power struggle that may arise. Ad- ditionally, navigating through this understanding will help minimize the potential for exploitation or the appearance of exploitation (Alvidrez & Areán, 2002). Focusing on Trust and Communication. Ac- cording to a core principle of the Tri-Council Policy Statement on ethical conduct for research involv- ing humans, it is imperative for researchers to take time to establish relationships with the community in order to promote mutual trust and communica- tion. Developing relationships with the community FDQ�WDNH�D�VLJQLÀFDQW�DPRXQW�RI � WLPH��DQ�HVWLPDWHG� timeframe for relationship development should be factored into a prospective research plan. This al- ETHICAL RESEARCH WITH PEOPLE OF COLOR 80 lows the researcher and community to work com- SDVVLRQDWHO\� LQ� WKH� LGHQWLÀFDWLRQ� RI �PXWXDOO\� EHQH- ÀFLDO� UHVHDUFK� JRDOV� �&DQDGLDQ� ,QVWLWXWHV� RI �+HDOWK� Research, 2010). Once relationships have been es- tablished within the community, it is critical for a new researcher to slowly build a similar trusting re- lationship and not attempt to acclimate too quickly. This process is necessary in order to maintain re- lationships with the community (Schnarch, 2004). Sharing Data Results With the Community. Throughout the research process and at the end of the project, data-sharing sessions are important for participants, community members, and the advisory boards (Darou et al., 1993). These data sharing ses- sions allow for the community to gain a better under- VWDQGLQJ�RI �ÀQGLQJV�UHODWHG�WR�WKH�SURMHFW�DQG�UHODWHG� EHQHÀFLDO� RXWFRPHV�� � ,Q� FRQGXFWLQJ� D� VHVVLRQ�� WKH� data should be presented in a general and simplistic procedure. The community should be aware of the systematic approach to research in general and how WKH�ÀQGLQJV�ZLOO�EH� LQWHUSUHWHG��$�FKDOOHQJH� WR� WKLV� approach includes the authority of who owns the in- formation (Schnarch, 2004). During initial establish- PHQW�RI �WKH�SURMHFW��UHVHDUFKHUV�VKRXOG�FOHDUO\�GHÀQH� WKH�DXWKRUVKLS�RI �WKH�ÀQGLQJV�DV�ZHOO�FRPPXQLFDWH�� genuine appreciation for the sharing of information by the community. Although it is probable that some may suggest ownership belongs to the people and the community and others may believe the researchers and academic institutions hold the rights to the infor- mation, the common bond is the sharing of accurate information. Another piece of information should be discussed during the initial phases of the research. The community should have an understanding of WKH�SRWHQWLDO�ÀQGLQJV�DQG�LPSOLFDWLRQV�IRU�WKH�FRP- PXQLW\��$Q�H[DPSOH�RI �WKLV�ZRXOG�EH�LI �WKH�ÀQGLQJV� show the community in a negative light by bringing shame to their identity or damaging cultural history. Enriching Indigenous/Ethnic Minority Cultures. One component of culturally sensitive research is not conducting research for the sake of conducting research but rather it is encompassing the well-being of the participants and their community (Darou et al., 1993). Research conducted in ethnic minority and indigenous communities should be with aspirations to revitalize and enrich the culture rather than to impose on the culture. Revitalization of the culture includes identifying, promoting, and enhancing the strengths of the community rath- er than emphasizing weaknesses or shortcomings. Cultural comparisons and other biases should be carefully considered before initial publications or should be forthcoming in discussion. In other words, including issues in research that are not culturally relevant or congruent for them should be careful- ly assessed and evaluated. One worldview, such as that of a Western perspective, should not be held higher than another worldview (Darou et al., 1993). Addressing Language Barriers. In addition to, creating a community advisory board and including members from the community, researchers need to adequately address language barriers, if there are any. Individuals from multiple language backgrounds may not understand the research material, test measure- ments, or even the basic instructions needed to com- plete a consent form if these materials are not trans- lated accurately in their native language. To ensure maintenance of recruitment and retention, research PHPEHUV�VKRXOG�EH�HLWKHU�SURÀFLHQW�LQ�WKH�ODQJXDJH� PRVW� FRPPRQ� LQ� WKH� FRPPXQLW\� RU� ÀQG� VRPHRQH�� ZKR� KDV� SURÀFLHQF\� LQ� WKH� FRPPXQLW\·V� ODQJXDJH� and comfortable with working in the community. This critical point is also relevant for clinical practice (Lau, Chang, & Okazaki, 2010). In the ef- fort of translating measures and content used in the research project, researchers should be attentive to cultural differences that may occur in direct language WUDQVODWLRQV��)RU�H[DPSOH��VRPH�FXOWXUHV�PD\�GHÀQH� abstract concepts differently from those of a West- ern perspective or an ethnocentric concept, especially in regards to highly technical academic vocabulary. 7KHVH�GLIÀFXOWLHV�DUH�HVSHFLDOO\�SUHYDOHQW�ZKHQ�WU\LQJ� to translate research instruments and measures (Lau HW�DO�����������/DQJXDJH�PRGLÀFDWLRQV�VKRXOG�DOVR�EH� aligned with treatment protocols. In general, cultural- O\�ULFK�FOLHQWV�PD\�KDYH�GLIÀFXOW\�ZLWK�KLJK�ODQJXDJH� (therapeutic jargon), and this language may be prob- lematic if not translated into laypersons vocabulary (Vicary & Bishop, 2005). Being cognizant of these possible limitations and language barriers is vital. 0RUH� VSHFLÀFDOO\�� XVLQJ� DQ� DFFHVVLEOH� XVHU�IULHQGO\� written consent form that only includes relevant in- SAN MIGUEL, MONIZ 81 formation in conjunction with an oral consent com- ponent may lessen possible language barriers (Mead- ows et al., 2003). Although these considerations are minuscule in scale, the effect is immeasurable for the ethnic minority and indigenous communities. Conclusion Although the tasks to approach culturally sound and ethical practices in the application of psycho- therapy and in counseling research can be consid- ered a large feat, the discussion of the common threads is fundamental to the practices of research- ers and psychologists alike. In looking for answers on ethnic minority clinical treatment, we found a commonality of values within indigenous popula- WLRQV� WKDW� FRXOG� EHQHÀW� IURP� VLPLODU� DSSOLFDWLRQV�� Certain considerations should be evaluated for the XQLTXHQHVV� RI � WKH� FOLHQW� LQ� SV\FKRWKHUDS\�� VSHFLÀ- cally evaluating indigenous practices and traditions as a source for mental and physical health. Although there is limited support for some conceptual frame- works such as the MCC, it is not a sole framework with which to focus. Rather, in order to be cultur- ally sound psychologists, we should have a dynamic framework that encompasses MCC, EBPP, and cul- tural humility. Research is limited in cultural humility within counseling psychology practices, but it would be an interesting focus of research for the future. In regards to working with indigenous commu- nities and ethnic minorities for data collection, it is imperative to focus on long-standing humble rela- tionships. Although some frameworks are similar, such as CBPR, which originates in public health, are based primarily on the medical model, as social sci- ence researchers, our initiative is based on a more holistic and humanistic approach, commonly named the biopsychosocial model. So it would be interesting to see the applicability of CBPR in the domain of a biopsychosocial framework in social science research on indigenous and/or ethnic minority communities. In appreciation of cultural differences with ethnic minorities and/or indigenous communi- ties, we recognize that as patients or as subjects in UHVHDUFK� WKH\� DUH� KXPDQ� ÀUVW� DQG� IRUHPRVW�� $OVR�� building cultural humility is vital in patient/ther- apist interactions as well as being socially humble with these communities in research. If we keep this in mind, we can further develop and progress as a counseling profession towards ethically sound and culturally relevant clinical and research practices. 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