Cancer is a nondiscriminatory disease. It impacts persons from all cultural, ethnic and racial groups and backgrounds. The American Cancer Society reports that, as the second leading cause of death in the United States, cancer is projected to affect more than 1.4 million Americans by the end of 2006. Of those individuals who are diagnosed with one or more forms of cancer, 564,830 will die as the result of their illness by the end of this year.
Counselors routinely come in contact with persons who either suffer from cancer themselves or are psychologically impacted by a family member or friend with cancer. Because this illness affects so many people in our nation, it is important for counselors to understand some of the central psychological and multicultural issues that are linked to the complex problem of cancer in our society.
From a multicultural perspective, counselors are encouraged to keep four particular points in mind when working with persons who either have cancer themselves or are adversely affected by someone close to them who does.
- Become aware of your attitudes and biases regarding cancer
- Recognize the disproportionate numbers of persons from different cultural-racial-ethnic groups who are diagnosed with cancer in the United States
- Develop an understanding of the cultural-racial disparities that impede many persons from accessing the quality health care services designed to address cancer
- Make a commitment to implement a broad range of helping services that are both culturally responsive and respectful when working with persons directly or indirectly affected by cancer
We hope the information presented here will help you become more aware of the counselor’s role in dealing with persons affected by cancer. We also hope to stimulate your thinking about the types of multicultural counseling competencies that you either already possess or need to develop to work more effectively, respectfully and ethically with culturally different persons who are affected by cancer.
Developing a greater awareness
The multicultural counseling competencies developed by the Association for Multicultural Counseling and Development in 1992 and formally endorsed by the American Counseling Association in 2003 fall within three main domains: multicultural counseling awareness, knowledge and skills. A number of these competencies are particularly relevant because they relate to counselors’ work with persons affected by the high incidence of cancer in our society.
Multicultural Counseling Competency #2: Culturally competent counselors are aware of how their own cultural background and experiences, attitudes, values and biases influence psychological processes. An expansive definition of the term “cultural background and experiences” includes individuals from diverse religious/spiritual and socioeconomic backgrounds as well as persons in vulnerable at-risk groups.
Mary and Allen Ivey, leading proponents of the multicultural counseling movement, have commented on the need for counselors to embrace a broad definition of culturally different groups. That definition is inclusive of the millions of persons whose unique physical, ethnic, racial, sexual, socioeconomic and residential characteristics and identities not only distinguish them from persons in other groups but often place them at high risk for future psychological problems.
Commenting further, the Iveys state that “Counselors and psychologists are frequently called upon to work with persons in various vulnerable at-risk cultural groups, including poor, homeless and unemployed people, adults and children in families undergoing divorce, pregnant teenagers, individuals with HIV or AIDS and persons with cancer.”
It is indeed important to embrace a broad definition of the terms “culture” and “cultural groups” that includes persons with cancer. It is also important for counselors to be aware of the attitudes and biases they may have developed as a result of not having any direct or indirect experience with cancer themselves. When left unexamined, such attitudes and biases may be subconsciously or unconsciously generalized to clients who are encountering psychological and emotional distress because of their own experience with cancer.
Multicultural Counseling Competency #3: Culturally competent counselors are able to recognize the limits of their competencies and expertise. This competency complements the previously mentioned points in a couple of ways. First, culturally competent counselors are aware that their attitudes and biases about cancer may be affected by their lack of experiences with persons who have cancer, their lack of personal experience as a cancer patient or the types of experiences they have had with a family member or friend who developed the disease. By reflecting on these issues, counselors can become aware of how their experience or inexperience with cancer may limit their effectiveness in professional practice. In doing so, counselors are better able to seek consultation and training to increase their level of competence and expertise when working with clients whose presenting problems are linked to cancer in some way.
Culturally competent counselors also demonstrate a willingness to acquire new knowledge about this problem from a multicultural perspective. Multicultural Counseling Competency #12 captures this point: Culturally competent counselors possess specific knowledge and information about the particular group that they are working with. They are aware of the life experiences, cultural heritage and historical background of their culturally different clients.
The following section provides information about cancer from a multicultural perspective. Despite the fact that death rates for all cancer types have declined during the last several years and the incidence rates of various cancers have been stable since the mid-1990s, various cancer research groups have consistently reported cultural disparities in the incidence of cancer. In a recent report generated by the National SEER Cancer Statistics Review group, researchers reported that cultural-racial-ethnic group cancer incidence and death rates, from highest to lowest, were as follows: African-American, White, Hispanic, Asian/Pacific Islander and American Indian/Alaska Native. It is also noteworthy that there were consistently greater rates of cancer incidence for males in each subgroup.
The American Cancer Society further informs us that significant disparities in the incidence of cancer continue to exist among persons in specific racial-cultural-ethnic populations. African-Americans (males in particular) and people in low socioeconomic groups continue to have the highest rates of new cancer cases and cancer deaths. A more detailed report by the American Cancer Society indicates that African-American men show the highest incidence and death rates for all cancers, followed by White males, African-American females and White females, respectively.
Furthermore, the U.S. Department of Health and Human Services confirms that African-Americans in the United States are 19 percent more likely to die from all types of cancer than Whites. African-American men are 50 percent more likely to die from prostate cancer than their White counterparts. And although breast cancer is diagnosed 24.5 percent less frequently among African-American women than White women, women of African descent are 33 percent more likely to die from this disease.
Other minority groups are also afflicted with severe cancer rates nationwide. The Department of Health and Human Services published a report in 2005 stating that women of Latina descent are 2.2 times more likely to be diagnosed with cervical cancer than non-Hispanic White women. In addition, Asian/Pacific Islander women were found to be 2.4 times more likely to be diagnosed with stomach cancer than non-Hispanic White women. American Indian women are 1.9 times more likely to die from cervical cancer than White women. And Asian/Pacific Islander men and women are both found to have higher incidence and mortality rates for liver cancer than White persons in the United States.
Gaining up-to-date knowledge on the rates of cancer among various cultural-ethnic-racial groups may lead mental health professionals to think of the types of culturally sensitive approaches they can use to help persons cope with this disease’s unique challenges. In considering the types of specific interventions counselors can use, it is important to remember that individuals from disadvantaged cultural-racial groups who have received a cancer diagnosis often believe they have little control over the disease or the types of medical, psychological and social support services they can secure.
When faced with the prospect of cancer, people’s coping abilities are often undermined by feeling a lack of control over their medical problems or experiencing difficulties in accessing quality health care services for themselves, family members or friends. Knowledge of these issues can help counselors to better understand their clients’ thought processes and unique coping perspectives. With this knowledge in mind, culturally competent counselors will assess the degree of control that persons in diverse cultural-ethnic-racial groups experience in their lives and work to build on their current coping skills and strengths. When considering issues related to external and internal locus of control, it is also important to assess the role that religion and spirituality play in clients’ belief systems in terms of illness and healing.
Culturally competent counselors also understand the need to extend their professional impact in other ways. This includes advocating for the development and implementation of consistently high-quality health care services for all persons in the United States, especially those from culturally diverse groups, who are affected by cancer. In accepting an advocacy role, culturally competent counselors demonstrate their understanding of the need to move beyond simply providing direct counseling services. We need to implement other types of organizational, community, social and political change strategies that assist culturally different persons affected by cancer to experience a greater sense of control over the types of medical services that complement their cultural worldviews and values.
These efforts represent more comprehensive and respectful ways of promoting the health and well-being of culturally diverse clients who are affected by cancer. By implementing a more comprehensive approach to promoting the empowerment, health and well-being of these individuals, culturally competent counselors demonstrate their understanding of the multiple factors that affect persons impacted by this disease. In so doing, they exhibit a willingness to address the injustices that exist in the availability and delivery of quality health-care services that complement clients’ life experiences, historical backgrounds and cultural-racial-ethnic heritage.
Multicultural Counseling Competency #13: Culturally competent counselors understand how race, culture and ethnicity may affect help-seeking behaviors and the appropriateness or inappropriateness of various counseling approaches.
Race, culture and ethnicity play significant roles in the way a cancer patient views the appropriateness of help-seeking behaviors. Edward Sarafino of the College of New Jersey notes that many African-Americans and individuals with low annual family incomes are less likely than White persons and individuals in higher socioeconomic groups to access outpatient clinics for their health care needs. This is unfortunate because outpatient health care service providers can often detect and treat cancer during its early stages. Early detection and treatment often results in the amelioration of many forms of cancer that would otherwise result in more serious and even fatal outcomes.
Counselors need to be particularly sensitive to the differences that exist among people in diverse socioeconomic classes in terms of their utilization of health services. The underutilization of health care services among poor and working-class persons, specifically as it relates to early detection and treatment of cancer, is a major barrier in promoting the health and well-being of people in these cultural groups. In combination with socioeconomic status, other demographic factors such as age are closely related to how willing or successful a person will be in accessing needed mental health counseling services when experiencing cancer. It is useful for counselors to familiarize themselves with research findings that discuss why many poor and working-class individuals tend to perceive that they are less likely to develop cancer than are people from higher socioeconomic classes.
It is also important to be sensitive to the reasons many of these individuals may feel less welcome or less trusting of counselors, particularly if the professional is of another race, not fluent in the client’s native language or communicates in ways that reflect culture-bound biases in his/her helping approaches. Derald Wing Sue, a pioneer in the multicultural counseling movement, stresses that eye contact, vocal tone, hand gestures, body language and other verbal and nonverbal communication gestures are culture-bound. These culture-bound dimensions of communication style can either facilitate or hinder development of a positive relationship in counseling.
Culturally competent counselors implement intervention strategies that foster a trusting relationship and positive counseling outcomes with persons from diverse socioeconomic and racial-ethnic groups who are affected by cancer.
Acquiring a wider range of multicultural counseling skills
Considering that many persons in lower socioeconomic and non-White ethnic-racial groups view counseling as a White, middle-class profession, it is important for counselors to address these negative views and suspicions. Counselor education programs would do well to direct increased attention to these issues by implementing new training initiatives that foster a greater level of cultural sensitivity, knowledge and skills among students.
We believe it is particularly important for counselor education programs to provide training that enables students to develop and integrate an expanded skill set. This approach will assist future counselors in fostering mental, physical, spiritual and cultural wellness among persons in minority communities where cancer rates are known to be high. One of the fundamental ways counselor education programs can increase students’ multicultural counseling skill sets is to address the issue of linguistic differences. Many multicultural counseling situations involve clients who speak a language different from that of the counselor.
Multicultural Counseling Competency #29: Culturally competent counselors take responsibility for interacting in the language requested by the client. This may necessitate securing translation services when working with persons from linguistically diverse populations.
Linguistic differences and language barriers can pose an enormous challenge in counseling in general and when counseling individuals impacted by cancer in particular. Many cancer clients who are in need of mental health counseling services come from backgrounds in which English is the second language. It is obvious that positive counseling outcomes depend largely on the degree to which both the counselor and the client understand the verbal interactions that occur in the helping process. Yet the language bias that exists in the United States results in most counselors being limited in their multicultural communication abilities. Consequently, individuals who have limited ability communicating in English may suffer from the imposition of monolingualism in many counseling situations.
The dramatic increase in the number of persons of Latino/Latina descent living in the United States has resulted in counselors more frequently encountering clients whose primary or preferred language is Spanish. Commenting on this issue, Sue notes that the need for bilingual counselors and health care practitioners has never been greater. Thus, becoming competent in a second language is another important multicultural counseling skill that professional training programs are being challenged to address in our pluralistic society.
While this issue should be addressed as part of the counseling profession’s ongoing commitment to greater multicultural competence in professional training programs, counselors need to implement strategies to effectively confront the challenges associated with language differences now. Consequently, counselors are strongly encouraged to utilize the services of translators when they are not thoroughly fluent in the client’s preferred language.
Caution must be taken, however, to ensure accurate translation of the verbal interactions that occur between the counselor and client. Be constantly vigilant of this issue because the words to connote various issues in different cultural-ethnic groups often have different meanings. In addition, it is also important to point out the confusion that often emerges when counselors and clients use slang terms that make it difficult for professionals to accurately translate in multilingual counseling settings.
We hope the various issues presented in this month’s column will stimulate new thinking about the role counselors can play in addressing the needs of persons who are affected by cancer in our pluralistic society. We particularly hope our readers will consider both the strengths they currently possess as well as those areas they need to improve upon to work effectively and respectfully with persons from diverse cultural groups. By using the multicultural counseling competencies as described above, we can promote the dignity, development and well-being of persons from diverse groups and backgrounds who are struggling with cancer in our country.