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ETH5556 - Cultural Diversity, Value Conflict and Ethical Decision Making for Mental Health Clinicians presents:

Cultural Diversity, Value Conflict and Ethical Decision Making for Mental Health Clinicians

by Charles D. Safford, LCSW
with guidance and input from other senior, Inc.
course developers and from NASW GA

Charles D. Safford, LCSW is President of, Inc. Mr. Safford has over 20 years of post-master’s experience as a clinician, and has over fifteen years of experience as a training developer and trainer in business and clinical settings. A live version of this course was presented at the 2001 annual conference of NASW GA.

This course is the copyrighted property of and may not be copied in part or in entirety without the express written permission of For information on how to secure permission to use this course or any part of this course, contact us at:




The objective of this course is to help the mental health clinician address the complex ethical problems that arise in working with clients from different cultural backgrounds and value systems, and to explore how one begins to find solutions and compromises to complicated ethical dilemmas while simultaneously operating within the clinician's professional framework and honoring and respecting cultural diversity and difference. This training will use a number of scenarios to highlight some of the complex ethical dilemmas that counselors are likely to face. When the trainee completes this course, he or she will:

1) Learn the elements, purposes and dynamics of cultural material, such as values, beliefs, and rituals;
2) Understand where and why tensions exist between the values of the dominant ethos and the values of non-majority groups within the larger culture;
3) Know the overall principles of ethical decision making, and where those principles must be modified when operating with non-majority cultures;
4) Comprehend the dialogic processes that will allow the ethical decision making process to proceed in situations of value conflict.

This course is designed for mental health clinicians in the intermediate to advanced stage of their career.

Course length: 5 contact hours

Easy Navigation Instructions

You may move through this course by simply scrolling down, using the scroll bar on the right side of the page. You may also move quickly to any specific page in the course by clicking on the Pages tab on the left side of the course. This will open thumbnail pages. Using the scroll bar on the left, simply scroll down to the thumbnail of the page you wish to move to, and click on that thumbnail. The page you have chosen will immediately open.

On the first page of each section, you will also find a navigation button that will allow you to move easily to the next section. To move to the next section in the course, click on this Next Section button.
Prior to beginning this course, you must read the following agreement related to each mental health clinician's ethical obligations towards fulfilling continuing education requirements.


- to complete this course in its entirety
- to complete all exercises contained in this course
- to complete the course post-test
- to complete the evaluation form after taking this course

Your decision to continue at this time constitutes acceptance of this agreement.

Section I: Introduction
Section II: Presentation of Scenarios
Section III: Cultural Diversity, Value Conflict, and Ethical Decision Making: Setting the Stage
Section IV: Understanding Culture
Section Five: Models of Cultural Value Orientations
Section Six: Processes for Examining the Competing Interests and Principles
Section Seven: Advanced Ethical Decision Making Tools
Section Eight: Analysis of the Scenarios
References and Test



Section I: Introduction

As an introduction to the dilemmas of ethical decision making when diversity is present, please take 5 -10 minutes to read and analyze the following scenario:

Scenario One: Introductory Scenario

Jenny P. is a mental health clinician in private practice who is contracted with a company that provides Employee Assistance Programs on the West Coast. One of the client companies that she serves has made a management referral of a key employee with work performance problems, Jula M. Jula is a mid-level executive who was recruited and moved from his home in the South Sea Islands to develop business in the Pacific Rim. His family is descended from royalty, and is very influential, with extensive business and personal connections in an area that provides certain raw materials vital to one of the company's most important products. The company spent several years and an enormous amount of money recruiting and developing him as an executive, and has made very clear that he is a very unique and valuable commodity for the company. They are very concerned about his decline in performance and emotional disinvestment from the company. The Director of Human Resources for the company is personally supervising the referral, and has expressed concern about whether there might be a possible substance abuse or other serious personal issue that is causing his performance to slip. The client is being referred to Jenny because she is one of the most skilled and experienced providers that the EAP company has under contract. When the referral was made, the President of the company called Jenny personally to tell her of the importance of this employee, and the care with which this case should be handled. Not far into the interview with Jula, he reports to Jenny that is in the process of deciding whether to leave the company and return to his homeland. He is simply unhappy living in the United States, as there are many aspects of American culture that are disturbing and distressing to him as a father and husband. He expresses his concerns about the consumerism, the lack of community, and the American obsession with sex, including the unnatural ways in which Americans handle such an important and natural subject. He goes on to tell Jenny that his two children, male and female fraternal twins, are almost 14 years old. He has been struggling to protect them from the portrayal of sex on television and the readily available flood of pornography around them, while also trying to protect them from other elements of American culture that are trying to make them feel guilty and ashamed of their bodies and their sexuality. As the session proceeds forward, he goes on to say that this has made it difficult for them to remain grounded in their culture while they prepare for their initiation into their adult sexual life, which is to occur in the next several weeks. In accordance with the customs of his people, the grown-ups in the community will be initiating the two teenagers into the ways of sex at a ceremony to mark their fourteenth birthday, as they welcome them into adult life. A trusted adult male from the community will be initiating the daughter, and a trusted adult female from the community will be initiating the son, providing a joyful and safe first sexual experience to be celebrated by the whole community. He only hopes that they have not already been too damaged by American culture to be able to enter into this key part of their adult life in a healthy manner - in accordance with the history and culture of his people.
What are the practical, legal and ethical considerations here, and how might you instruct Jenny to proceed?

In their seminal work on counseling the culturally diverse, Derald Wing Sue and David Sue put forth an interesting proposition: the ideas and beliefs that form the foundation of the counseling professions are so fundamentally infused with Western thought that the counseling itself risks being just another mechanism for imposing the values of the dominant culture on those who are different. (28)

To quote,

"Mental health practice has been characterized as primarily a White middle-class activity that values rugged individualism, individual responsibility, and autonomy." (28)

Some of the more radical apologists for this kind of thinking have gone so far as to propose that counseling is actually just another tool of Euro-American cultural hegemony, with its practitioners serving as members of a kind of a cult of self-propagating and culturally biased thought. When different values come into the cultural stew, according to this viewpoint, the typical mental health clinician's first inclination might be to nudge the client back towards the values of the dominant culture in response.

Welcome to the world of ethical decision making in culturally diverse times.
While these ideas – at first glance – may appear to be somewhat esoteric or philosophical in nature, they are in fact tremendously relevant to the changing face of ethical practice as performed by real clinicians in the current era. The idea of what constitutes ethical practice in a more or less homogeneous culture – with clearly defined and mutually shared concepts of what is right and what is wrong – begins to seem less certain when the parties from multiple cultural orientations enter the interaction with fundamentally different ideas of what is right and what is wrong.

Hopefully our introductory scenario was successful in raising the level of awareness on that point. Now also consider just the following two statistics of our changing demographics:

- By the year 2020, nine states - including the three most populous states in the country - will have minority populations of over 42%.
- Two of the three most populous states (California and Texas) will have minority populations of over 50%. California's minority population will be over 60%. (28)

We are rapidly moving from a relatively mono-cultural orientation to a multi-cultural reality. The changes will affect virtually everything, including the landscape of the mental health sector, and our definitions of what is a problem and what is merely cultural difference. The difficulties that the mental health clinician will face in managing ethical dilemmas with increased cultural diversity will be a reflection of the difficulties of the culture as a whole in integrating and assimilating a diversity of cultural opinions and ideals.

When our clients' actions and behaviors are ego-dystonic and cause them discomfort and problems, it is relatively easy to label the problems as dysfunctional, and work with them to create something more adaptive in their lives. As clinicians, this makes our practice simpler.

On the other hand, when certain of our clients' actions and behaviors are not ego-dystonic, but are rather an intrinsic part of - and hold a rightful place in - their own cultural landscape, the journey of deciding whether we can ethically agree with their choices becomes much more uncertain and problematic.

If, as Frederick Reamer says, ethical decision making is concerned with the resolution of conflicts of professional obligation (23), then there are some very hard questions that will need to be raised about how to resolve these conflicts when working with diverse populations. This is the difficult terrain into which we are going to wade in the course of this training program.

This will require the presentation of material in a number of areas. Clinicians who work with clients from diverse backgrounds will need to have some detailed understanding about the nature of culture: how it works, what it is made of, how it interacts with other, conflicting cultures. Towards this end, we will present a brief, but substantial, foundation of information on culture.

This presentation of material will work at three levels that have been described in the literature. First, clinicians who work with clients from different cultural backgrounds are supposed to be culturally aware. (28) This is to say that – at the very least – clinicians should be aware of their own cultural background - and aware of how the socialization from that background has created certain assumptions and biases that shape how they see and interact with the world.

These assumptions and biases – left unattended – can create blinders on the eyes of the clinician when working with clients from different cultures. This is because these items are often embedded in value systems that are so familiar and comfortable for the clinician that they are almost invisible. These biases can cause the clinician to shape the therapeutic experience in ways that affirm and make comfortable the values of the clinician, while denying and discounting the experience and cultural material of the client.

Cultural awareness requires that the clinician remove his or her blinders and strive to become comfortable working with the cultural differences that exist between the client and clinician. (28) The cognitive parts of this involve keeping one's thinking and perception flexible, to remain open to seeing and understanding different world views.

The emotional parts of this may at times be even more difficult than the cognitive part. The emotional part requires the laying aside of any hidden or buried cultural chauvinism and tolerating the discomfort of having one's own deeply held personal – and/or professional - values challenged by someone who may partially or wholly disagree with and reject those values.

The human and personal components of being a clinician can be sorely tested by this. The clinician's core defining values may be the central reason why he or she entered the mental health field in the first place. It may be for religious or spiritual reasons, or it may be for deeply held personal values and beliefs. However it is based, this set of core defining values often serves a very important centering function in the emotional life of the clinician, in addition to bringing comfort, certainty, and meaning to the work that he or she does.

For this reason, having one's most important values questioned or rejected can be a very disturbing or unsettling emotional experience. It can provoke powerful countertransference feelings and inclinations to translate those feelings into actions. This is a real risk or danger in cross-cultural work.

However, one of the ethical sacrifices that is required of those who choose this profession is the willingness to engage in these difficult questions - without running away too easily and too quickly towards that which is more personally comfortable. One cannot practice ethically without being able and willing to tolerate a certain amount of the discomfort that comes with sitting with cultural differences.

The final piece of being culturally aware is to know one's limitations when working with clients from different backgrounds. (28) This falls under the category of operating within one's area of competence. When clinicians are not able to remove their own blinders or handle the emotional challenges of working with clients with different world views, the culturally aware clinician is at least able to know this about himself or herself, and know when to refer the client to another clinician who may be better able to respond to the cultural needs of the client.

The second level of cultural competence involves being culturally knowledgeable. (28) This requires that the clinician possess a significant degree of understanding concerning the cultural elements of the client that are relevant to the definition of problems and solutions. This includes knowing the role - in relation to the dominant culture - of the minority group of which the client is a member.

(Not to state the obvious, but this also requires that the clinician has a quite clear picture of the landscape of the dominant culture, what its biases are, what its assumptions are, what the weaknesses, flaws, and internal contradictions in its perceptions and values are, etc.)

The culturally knowledgeable clinician should also have a solid background in the relevant practice literature concerning practice with non-dominant cultural groups, and also understand the institutional and cultural barriers that impede minority groups from using mental health services. (28)

Finally, the third and highest level of cultural competence is being culturally skilled. (28) This requires that the clinician possess a wide range of skills to use in interventions with clients from different cultural backgrounds, including fluency with verbal and non-verbal modes of communication that are well-received and understood by the clients within their own cultural experience. (28)

This level of cultural competence also requires that the clinician be able – and willing – to intercede on the behalf of the client when the client's cultural components are "right" and the dominant culture's cultural components are "wrong". (28) When the dominant culture's values are "dysfunctional" for the client from a different cultural background, the clinician must not be blinded by his or her own biases, and unwilling or unable to grasp this.

The trouble, of course, is how do we determine in this process – with clear eyes – what is functional and what is dysfunctional? Often, definitions of functional and dysfunctional ideas and actions are culturally determined and culturally bound. So therefore what principles will be used to determine if we are right?

These last two questions – which in some ways create the most complex aspect of ethical decision making in situations of diversity – will bring us to an important area of knowledge whose concepts will be included in this training: dialogic processes. These processes, while sounding complicated, will actually seem very familiar to mental health clinicians, since they are used in practice almost every day.

Dialogic processes are concerned with the ways that people interact and communicate to bring resolution to difficult conflicts. These are also sometimes called discursive processes, from the word, "discourse". One of the more frequently cited iterations of this sort of process is something called Transcendent Discourse. (20) Some concepts from this area will also be helpful as we proceed in looking for solutions to the conflicts of professional obligations.

Because trainees are – one would hope - taking this course to improve their ethical decision making and become better clinicians, we will try to prevent this course from becoming simply a philosophical exercise. Instead, we will at all times be searching for ways to bring something practical and useful to the table. For this reason, the training will include a number of practical tools for ethical decision making that may be kept by the trainee for use in their practice.

One of the other ways that we will try to bring some practical knowledge to the training is through the use of ethical scenarios to study and analyze. Clearly, we have already started this part of the process with our introductory scenario. As the course moves forward, we will refer back to this scenario as a point of reference, since it highlights some of the substantial problems in the subject area.

We will continue this by presenting a couple of additional scenarios for you to read – before we have presented the course material. You will be asked to write down your thoughts and impressions on how to resolve the scenarios, as you have with the introductory scenario to start the course.

This will serve two purposes. First, it will allow you to see very quickly the divides and conflicts being caused by diverse cultural ideas being brought into the real work of the clinician. This will highlight the importance of examining the topic area and the need for adequate thought and preparation in this area.

Later in the training, we will come back to all of the scenarios – including our introductory scenario - and offer expert analysis based upon feedback received from live training audiences who have wrestled with the same scenarios over the past several years.

This brings us to the second purpose of presenting the scenarios. This will help the trainee to ascertain what he/she has learned from the training program. You will have an opportunity to see if your level of understanding – and your responses – have been changed by the material you have learned and the lessons drawn from responses of other clinicians who tackled the scenarios in a live training format.