Keywords

Introduction

Grounded in three decades of progress, from soul-searching to maturation, the multicultural counselling competency movement has now arrived at a critical juncture in its development. The push towards engaging in critical introspection, examination, and refinement within the field of multicultural counselling is well-reflected in the tenets and the principles of culture-infused counselling (CIC; Collins & Arthur, 2010a, 2010b). Specifically, the revised CIC framework introduced in Chap. 2 highlights the need to expand and transform existing multicultural counselling practices and training to incorporate changes in the broader societal systems and community spheres and to promote social justice and advocacy. The revised CIC framework urges counsellors to attend to the underutilization of counselling services; to address barriers for individuals, families, or communities; and to develop relationships within the community to support consultation and referral for culturally diverse clients. Similarly, counsellors are compelled to apply a systems-level lens to case conceptualization and intervention planning and to consider shifting target of change from internal elements to external factors that influence clients’ well-being. Finally, adopting the revised CIC framework is intended to address transformative changes that need to occur at the micro-, meso- , and macrolevels to enable counsellors to promote multiculturalism and social change, either with or on behalf of clients.

However, concrete examples or models of multicultural counselling and social justice interventions that encompass more comprehensive changes for clients and counsellor, or therapist trainees, at these multiple levels are currently rare. Exemplars of multicultural counselling training that are grounded in experiential, service-based learning models and that incorporate the learning of multicultural counselling skills through working directly with actual, diverse clients are rarer still (Kuo & Arcuri, 2014; Kuo & Boucher, submitted). For this reason, I will describe, as an example, a multicultural therapy practicum that offers a new direction and approach to experiential diversity counselling and social justice education for therapists. It is a refugee-serving therapy practicum course I developed and have taught regularly since 2007, at the University of Windsor (UW) in Ontario, Canada. This therapy practicum course is designed to train advanced clinical psychology Ph.D. students to provide direct, free counselling and therapy services to community-referred refugee newcomers in the Windsor-Essex area. As a culture-infused model of clinical training, grounded in a university-community collaboration, the practicum incorporates the theories and principles of multiculturalism, social justice and advocacy, community outreach and service, experiential learning, and traumatology into its training and therapy provision.

In recent years, within the field of multicultural counselling training, there have been increasing calls for the discipline to develop critical teaching and learning strategies to enable therapists to translate multicultural knowledge and awareness into demonstrable culture-infused counselling/therapy skills and to engage in social change and advocacy. Working under close supervision with multinational refugee survivors, who have a history of torture, trauma, and a complexity of needs, provides a unique learning opportunity for therapists to develop and exercise multicultural counselling and social advocacy competencies. I will argue that this refugee-serving multicultural therapy practicum, which is grounded in an experiential learning framework and a university-community collaboration, represents a distinct, culture-infused, service-based training model that promotes trainees’ learning of therapy, helping skills, and personal growth through attending to refugee clients’ diverse needs at the micro-, meso-, and macrolevels.

In presenting this service-based model of multicultural therapy training, I speak from the position of an academic faculty member, a clinical/therapy training instructor, a researcher, a practicing psychologist, and an immigrant to Canada, who was born and raised in Taiwan and educated in both Canada and the USA. This positioning provides me with the analytical lens through which I view the state of multicultural and social justice counselling and training, the needs of immigrant and refugee newcomers, and this multicultural therapy practicum. I will first describe the service-training framework of the multicultural practicum by depicting the contextual, conceptual, and structural characteristics of the training model, highlighting its culture-infused nature. Then, in the second half of the chapter, I will present a client-therapist case dyad to further illustrate the inner working processes, the therapy interactions, and the impacts of this practicum from the vantage points of the refugee client as well as the student therapist. This case dyad makes explicit the system and community-wide mesolevel of interventions and learnings being adopted by the therapist throughout her work with this particular client.

Background Characteristics of the Multicultural Therapy Practicum

Before entering academia, I began my career in the community, first as an immigrant settlement worker in a social services community centre and then as a counsellor in a family services agency in Toronto, Ontario. In those capacities, I had the opportunity to provide counselling and various social services to English-speaking clients as well as non-English speaking Chinese immigrant adults, adolescents, couples, and families residing in the Greater Toronto area. These front-line experiences gave me a unique understanding of the divergence between the needs and perspectives of the community and those of academia, the gulf between practice and theory, and the gap between the reality faced by practitioners out in the field and their academic training/education. This is an example of higher-order critical thinking that is required of counsellor educators, committed to multicultural counselling and social justice, if we want to ensure that our training is relevant and responsive to both student and community needs. Although I have had the good fortune of designing and teaching a multicultural course for clinical psychology graduate students at UW for the last 15 years, I often wondered how well a stand-alone, one-semester course could enable my students to incorporate and translate their learning of multicultural principles into actual counselling practices and clinical interventions. I was not satisfied with the single-course, didactic model of multicultural counselling training, even though it typifies the most common approach of cultural training for counsellors in the field today. I wanted to take multicultural counselling to the next level, so to speak, to allow student trainees to integrate multicultural theories, concepts, and principles with actual practice experiences through more creative, challenging, and hands-on modes of learning. Hence, the multicultural therapy practicum described below was borne out of an initial dissatisfaction and a later aspiration on my part.

Contextual Backgrounds of the Practicum

In 2006, I formally established the course, Multicultural Counselling and Psychotherapy with Refugees Practicum, with the support of my home department, the Department of Psychology at UW. The objectives of developing this multicultural practicum were twofold. First, the practicum course was designed to meet the training needs of clinical psychology graduate students, because the majority of the students in the UW programs had very limited exposure to working with clients who are members of nondominant cultural groups within Canada (specifically, non-Caucasian/European Canadians). The practicum was intended to offer therapist trainees a culture-infused training environment in which they could implement and translate their acquired, cognitive-based, multicultural knowledge and awareness from previous course work into actual, behavioural intervention skills and working relationships with clients of diverse language, religious, and cultural backgrounds. Secondly, the practicum was initiated as a creative response to the seriously underserviced psychological and mental health needs of a growing refugee population in the local Windsor-Essex area, so the practicum represents a community-oriented and social action-driven response initiated by the university department in an attempt to help address an existing mental health service gap in the community. Both practicum objectives, to advance an experientially and skill-focused multicultural training strategy and to improve the psychosocial conditions of a disadvantaged multicultural population, correspond directly to emergent critical issues in the multicultural counselling literature (Priester et al., 2008; Smith, Constantine, Dunn, Dinehart, & Montoya, 2006) and the propositions of the revised CIC framework.

Responding to Underserviced Populations

The origin of this multicultural therapy practicum began with a letter from the community. In the spring of 2006, I received an appeal letter from the emotion-support worker of the government-assisted refugee program at the Multicultural Council of Windsor and Essex. The letter described the seriously underserviced needs of refugee clients who were being settled in the Windsor area in significant numbers. Most of these refugees were survivors of torture and trauma in their countries of origin. Consequently, they came with enormous psychological, emotional, social, and physical needs. The letter was an urgent appeal to registered psychologists in the area to consider offering pro bono mental health services to this growing population. The letter went on to describe the circumstances of five refugee survivors who were desperately in need of counselling intervention and emotional support. The letter moved and affected me deeply – the image of these refugees, and many others, and the injustice of their not being able to access the much-needed psychological help lodged in my head! I felt that doing nothing was not an option and that I ought to help somehow, but I was not sure how. Amid this emotional turmoil, an idea came! I asked myself: “Is there a way, as a clinical psychology faculty member, I can utilize my current resources to facilitate a mechanism to meet the psychological needs of refugees and, at the same time, develop the clinical and multicultural training needs of my students?” In the end, I found the answer to this question in the creation of this university-community, multicultural therapy practicum that serves refugee clients.

The multicultural therapy practicum itself is part of a larger in-house clinical training practicum for senior doctoral students in the Adult Clinical Psychology track. Each year, four or five student therapists are enrolled in this training. It is a required 8-month practicum that extends over two academic semesters, September to April (Kuo & Arcuri, 2014; Kuo & Boucher, submitted). All students enrolled in the practicum have previously completed a course in multicultural counselling/therapy (i.e., Multicultural Issues in Clinical Practice) as a prerequisite. Distinctively, this multicultural practicum is founded on a university-community collaboration involving UW’s Department of Psychology and the Multicultural Council of Windsor and Essex, a local agency, as the community partner. The Multicultural Council is a large-scale immigrant- and refugee-serving social service organization in the greater Windsor-Essex area. The collaboration was established on the basis of sharing mutual resources and expertise. The Department of Psychology offers free therapy and mental health services to refugee clients referred by the Multicultural Council; the agency provides the vital practical and logistic support that makes it possible for refugee clients to attend the therapy sessions on a regular basis, including transportation (e.g., taxi service), language interpretation services, and ongoing case management. The Multicultural Council assigns each client a designated case manager, who functions as the facilitator and liaison between the client and the therapist. This model of university-community partnership is distinctive in its inclusion of these supports for refugee clients’ psychosocial and practical needs at the mesolevel.

Target Clients

The client recipients of this practicum service are government-assisted refugees (GARs), who are serviced and referred by the Multicultural Council. Many GARs arrive in Canada from war-torn and conflict-ridden countries (e.g., Iraq, Syria, Bhutan, Somalia, Kenya, Congo, Nepal) and have witnessed and experienced extreme forms of social injustice, such as torture or trauma, in their countries of origin. In our practice, we see that these GARs or refugee survivors of torture and trauma (hereafter referred to as refugee survivors for brevity) face yet additional forms of social injustices upon arriving in Canada, including the experience of discrimination and a serious lack of psychological treatment and mental health services to support their acculturation and resettlement (Vasilevska, Madan, & Simich, 2010). At the same time, refugee survivors represent highly heterogeneous individuals and groups, with diverse backgrounds, demographics, and identity characteristics across nationality, ethnicity, language, religion, regionalism, education, socioeconomic status, migration status, and history domains. For example, over the last few years, in our practicum, we have seen refugee clients originating from Iraq, Somalia, Myanmar, and Bhutan with a mixture of Muslim, Christian, and Buddhist religious backgrounds. Most recently we have been witnessing a large wave of Syrian refugees being resettled in the City of Windsor and across Canada and, hence, being referred to our therapy practicum for counselling and psychotherapy. In fact, according to a recent, official government recent report (Government of Canada, 2017), between the fall of 2015 and mid-2017, Canada had received and resettled 400,000 refugees originating from Syria. To put Syrian refugees’ situation in perspective locally, in Windsor alone, over a short span of 14 months between November 4, 2015, and December 31, 2016, the city had received 1389 Syrian refugees (City of Windsor, 2018).

The critical issues they face in adapting to Canada are as diverse as their demographics, including language, financial, legal, medical, social, cultural, and psychological/emotional concerns (Kuo, Huang, Keshavarzi, & Taylor, In revisions; Rousseau, 2017). In fact, most of these refugee clients attend therapy with multiple needs. For instance, we have seen a middle-aged Iraqi woman with symptoms of PTSD and chronic back pain from previous injuries; an older Somalian man with a disability who was tortured and imprisoned back home and was dealing with extreme social isolation, poverty, and conflicts with his neighbours; and young Nigerian man in his 20s struggling with a diagnosis of HIV and with conflict between his sexuality and his devoted Christian faith.

Effective CIC with refugee survivors calls for creative, flexible, and community-based interventions, as well as problem-solving that goes beyond the typical microlevel, client-therapist-only, conventional counselling or therapy (Gorman, 2001). Due to GARs’ unique backgrounds, needs, and the significant cultural distances between them and clinical psychology graduate students (i.e., predominantly English-speaking, Canadian-born individuals), working with GARs offers student therapists an unparalleled learning opportunity to engage and refine their competencies and skills in multicultural therapy and social justice advocacy.

Conceptual and Philosophical Bases of the Practicum

Refugees’ experiences of torture and trauma are complex, involving social, moral, and ethical injustices and injuries (Kuo et al., In revisions). Therefore, I grounded the training practicum in a number of principles for the intervention and healing processes for refugee survivors. These include (a) incorporation of a social-ecological transactional framework, established on the basis of multiculturalism and traumatology, (b) utilization of a multilevel and multifaceted intervention and helping approach, and (c) involvement of interprofessional collaboration or collaborative client-centred practice (American Psychological Association [APA], 2010; Gorman, 2001). Culture-infused counselling and mental health services for culturally diverse clients, such as refugees, can be most effectively accomplished through incorporating and integrating the support of various professional and community sectors, with the therapist being the central advocate (Kuo et al., In revisions). These concepts represent supportive and relevant operating elements in a client’s mesosystem and exosystem, according to Bronfenbrenner’s (1979) social-ecological theory. According to Bronfenbrenner’s social-ecological theory, the mesosystem represents the connection, interplay, and interaction among an individual’s most immediate microsystems, such as family, school, and peers. On the other hand, Bronfenbrenner confers to the exosystem to denote the various resources available to an individual at the community-level, including supportive networks, social services, school resources, health/welfare services, and legal services (Bronfenbrenner, 1979). Hence, this social-ecological framework forms the foundational underpinnings and the governing principles of this service-based multicultural practicum.

In terms of training philosophy, I attempted to establish the practicum on the basis of (a) experiential learning for multicultural counselling education, especially through cultural immersion programs and/or supervised multicultural practice and (b) development of therapist trainees’ skills in advocacy, outreach, and interprofessional-community collaboration at the mesolevel, incorporating critical elements of the clients’ mesosystem and exosystem in the helping process (Barden & Greene, 2015; Smith et al., 2006; Vera & Speight, 2007). Ultimately, this practicum-based training aims to afford students a direct, hands-on opportunity to implement and hone their multicultural competencies across the CIC domains of cultural awareness, reflection on social location, and culturally responsive and socially just working alliance and change processes, with the support of multicultural supervision. In the context of this practicum, multicultural supervision refers to a supervision approach and process that is grounded in the principles of multicultural counselling competency and views culture and its influence as a core aspect of person’s personhood, identity, and helping relationship.

Structure, Content, and Learning Conditions of the Practicum

Owing to the specific objectives of this service- and community-based practicum and the unique refugee survivor client population it serves, I resorted to multiple experiential teaching and learning modalities to help create a supportive and stimulating learning environment for the trainees. Prevailing multicultural and diversity education for counsellors in the USA and Canada has been criticized as very much limited to the in-class didactic course model and as being narrowly focused on increasing trainee’s cognitive knowledge (Cates & Schaefle, 2009; Pieterse, 2009). For this reason, I wanted to offer my students a more challenging and more comprehensive learning experience through this practicum. Thus, the methods of training and instruction used in the practicum include both didactic and experiential elements, which address training topics and issues that cut across the CIC levels of intervention.

Cultural Competency Development: Supervised Predoctoral Internship Training on Multicultural Therapy

One of the most rewarding clinical training experiences in my career stems from my full-year predoctoral internship training at the Student Counselling Services at Iowa State University in 2000–2001. Of particular significance to my own cultural competency development was the opportunity I received to undertake a multicultural and diversity-focused rotation during that internship. Although I had already accumulated some counselling and clinical experiences with immigrant, ethnic, and racial minority client populations by that time, it was this training rotation that opened me up to an even broader scope of diversity issues, including sexual orientation, first-generation college students, native/aboriginal cultures, and religiosity. Not only was I assigned to work with clients from diverse cultural backgrounds with varied cultural-clinical issues of which I had no previous experience, but I was also given support and guidance by several supervisors who had expertise and experience in multicultural counselling services and training. It was within this training and supervisory learning environment that I began to process and integrate what I had previously learned about the concepts, principles, and ideals of multicultural counselling and to implement them in a real and hands-on manner. The affective and relational components of my learning, through interacting, connecting with, and sometimes being challenged by my diverse clients, were tremendous, and they could not be replaced by any amount of reading or studying multicultural principles or case examples. The experience was so profound that I still use many case anecdotes from my internship days to help illustrate concepts in my teaching of multicultural counselling and clinical supervision today. Because of this training experience, I have become a strong believer that only through experiential learning, working directly with clients, will a counsellor come to fully appreciate the many nuances and intricacies of the counselling relationship and become an effective counsellor. The development of multicultural counselling competence is no exception to that rule. This conviction is reflected in the present multicultural therapy practicum.

Didactic Training Component

The student therapists begin the practicum with the basic knowledge they gained from the multicultural counselling and psychotherapy course. The initial 6–7 weeks of the practicum uses a small group seminar format devoted to orienting student trainees to the overall structure and operation of the practicum course. Students are given a list of assigned readings that deal with literature pertaining to critical cultural, clinical, ethical, procedural, and logistic issues relevant to working with refugee survivors. Students facilitate and present the various topics to their peers in the class setting under the instructor’s guidance. In terms of macro as well as micro topics related to refugee survivors, the didactic component of the practicum reviews issues of social, psychological, and political nature: consequences of torture and trauma, PTSD symptoms, recovery, acculturation and cultural adjustment, multiplicity of cultural identities, cultural/language barriers, and psychotherapy models associated with working with this population. Additionally, other micro- and mesolevel topics concerning how to conduct therapy with language interpreters, manage therapists’ vicarious traumatization, and handle ethical and procedural concerns unique to this university-community partnership, which has an interprofessional team of service providers and stakeholders (e.g., student therapist, case manager, language interpreters, faculty supervisor), are carefully reviewed and discussed in this segment of the training. Of note, training and discussion around the subject of vicarious traumatization is of particular importance for counsellors and therapists working with refugee survivors of trauma and torture because of the unique characteristics and histories of this client population. Vicarious traumatization (also known as secondary traumatization) refers to the phenomenon by which a therapist is significantly affected by his/her client’s life events expressed through the therapy work, such as the client’s experiences of trauma, injury, or serious harm. Vicarious traumatization can lead to changes in the therapist’s view of self, others, and the world.

Experiential Training Component

Beyond this didactic learning component lies the hands-on, skill/behaviour-oriented, experiential training component that constitutes the mainstay of this multicultural therapy practicum. Domains III and IV of the revised CIC framework highlight the importance of counsellors’ ability to assess and remove current systemic or organizational barriers that are impinging on the health and well-being of culturally diverse clients. Accordingly, this component of the practicum is designed to prepare student therapists not only to work proficiently with their refugee clients at the micro process therapy level but also to expose them to working within an interprofessional collaborative framework involving the partner community agency and other potential service providers and stakeholders within the refugee clients’ mesosystem and exosystem.

For example, to enable student therapists to work with a language interpreter effectively in therapy, a 2-hour training workshop titled Therapeutic Use of Interpreters is delivered to the trainees. The workshop is instructed by an invited, outside instructor who teaches professional language interpreters at the local college. Through lecture, discussion, and role-play, the seminar is intended to orient trainees to the intricacies of communicating with clients who use a different language; the involvement of the language interpreter in the therapy process; and the procedural and ethical implications of this trio-therapy arrangement. As well, a community visit and outreach component is built into the early part of the practicum. The course instructor brings the students on an outreach visit to the off-campus partner agency, the Multicultural Council. At this event, the student therapists are formally introduced to the agency and its services for refugees and meet directly with the coordinator and the case managers of the refugee resettlement program so as to begin building a working relationship. The respective roles and responsibilities of the therapist, the supervisor, the case manager, and the agency coordinator on this interprofessional team are clearly defined and specified at this outreach meeting, prior to receiving client referrals. Moreover, to evaluate the effectiveness of the services provided through the practicum, a meeting between the case managers, the coordinator of the Multicultural Council, the student trainees, and the practicum course supervisor is held at the conclusion of the practicum. In this meeting, partners in this university-community project share and discuss ideas and successes, as well as issues that arose over the past year, to seek ways to strengthen and improve the partnership in providing support for future refugee clients.

These and other training activities expose students to knowledge, skills, and resources above and beyond in-class multicultural learning for helping refugees. They allow students to counsel and to help their clients from a more comprehensive, community-grounded, meso-framework. This training and intervention approach transcends the narrowly prescribed one-to-one client-therapist interaction that is typical of Western counselling and psychotherapy practices. As a result, this multicultural training model aligns with the American Psychological Association (APA, 2010) recommended social-ecological model of interventions in addressing refugees’ distinctive cultural and psychosocial needs.

In the following section, I present a therapy case example to further demonstrate and highlight several principal features of the refugee-serving multicultural therapy practicum. Although the case example involves counselling interventions at the micro-, meso-, and, to a lesser degree, macrolevels, I will focus more on the changes and interactions between the client and the therapist at the mesolevel, incorporating and involving elements of the mesosystem and the exosystem of the client. In particular, I hope to highlight aspects of community-based intervention, outreach, advocacy, and interprofessional collaboration. To ensure anonymity for the client, the demographic backgrounds of the client and the therapist, and certain details related to the therapy process, have been modified in the case description below.

Case Example of Luah and Crystal

An Overview of the Case and Its Therapeutic Processes

The present case is based on a dyadic therapy between Luah, a 45-year-old Karen-speaking female refugee client from Burma, and her therapist Crystal, a 29-year-old, Caucasian Canadian female clinical psychology student – a therapeutic working relationship established over 10 therapy sessions within the multicultural therapy practicum. At the start of the therapy, Luah had been married to her husband for 12 years and was a mother of three children, aged 5, 9, and 11 years old. Luah, her husband, and her extended family identified themselves as Christians of the Karen ethnic minority in Burma. Luah and her family had been in Canada for 2 years as GARs. Back in Burma, Luah was raised in a large family with 11 younger siblings. She had very limited education and grew up facing considerable poverty, hardship, and persecution in Burma as a consequence of being a member of a religious and ethnic minority group in that country. Prior to coming to Canada, Luah spent 15 years living in a refugee camp in Thailand, where she met and married her husband. Consequently, Luah’s personhood is characterized by a complex intersection of multiple identities, including being a woman, a mother, a wife, an eldest daughter, a refugee newcomer, a devout Christian, a Karen, and a person of low socioeconomic and education backgrounds, both back home and in Canada.

Luah was referred to Crystal by her case manager at the Multicultural Council, and the therapy was conducted with the assistance of a Karen-speaking interpreter. Initially, Luah reported having chronic health problems (ulcer and stress-related migraines) as well as being highly distressed, easily distracted, and having concentration difficulty, frequent nightmares, and insomnia. Luah reported that her difficulties were worsened, and she was grief-stricken, after she learned about the unexpected death of one of her beloved younger sisters, who resided in another city, shortly her first appointment with Crystal. Additionally, during the first few sessions with Crystal, Luah hinted at some marital tensions with her husband and “emotional pains,” about which she was unwilling to elaborate at the time. It was not until the midpoint of their therapy work, after Luah had developed sufficient confidence and a close therapeutic relationship with Crystal, that Luah disclosed more about her lived experience related to the marital discord between her and her husband. Subsequently, in the 7th session, Luah confided to Crystal that her husband physically abused her and that, the night before, he had made a verbal threat to hurt the children. Luah reported the abuse as having continued on and often for several years. From that point onwards, Crystal’s therapy with Luah immediately switched into a crisis counselling mode. With the support of Crystal, Luah decided to leave the abusive relationship, taking her three children with her, and subsequently pressed charges against her husband.

The subsequent counselling and support for Luah compelled Crystal to utilize and implement diverse helping, problem-solving, and intervention approaches and skills in a focused yet culturally-sensitive and flexible manner. With the support of her practicum supervisor, Crystal gradually expanded her role and the therapy to include outreach visits with Luah and her children at the shelter, psychoeducation and consultation for Luah, social advocacy for practical and logistic needs on behalf of Luah, and negotiation and facilitation of various social, community, and religious resources and organizations in support of Luah across the micro-, meso-, and macrolevels.

Highlights of the Key Processes of the Case

In the section below, five unique elements of this live, training-service multicultural practicum are highlighted, elaborated, and illustrated through a close analysis of Crystal’s therapy with Luah.

Development of Cultural Knowledge in Preparation for Working with the Client

During the initial didactic, seminar portion of the training, Crystal was both nervous and excited about the prospective of working with, and providing therapy to, refugee survivors. Through the class readings, topical presentations, and guided discussions in the weekly practicum class, the clinical perspectives of Crystal and her peers, as novice therapists, were challenged and expanded. They came to learn and appreciate the complex therapeutic, cultural, and social issues faced by refugee survivors on a day-to-day basis. The on-site outreach visit at the Multicultural Council and the workshop training on working with language interpreters opened Crystal’s eyes to additional dimensions of helping beyond what she had already learned in the coursework of her clinical psychology program. Within this learning context, Crystal gained macro- and mesolevel knowledge about Canadian immigration policy regarding refugees, specific settlement programs, services tailored to refugees and immigrants, and locally available social and health resources for refugees. This information was both informative and, at the same time, overwhelming for Crystal. However, she realized that her perspectives on therapy and helping with culturally diverse community clients were being stretched and broadened effectively.

Participating in a role-play exercise in a mock therapy situation involving a language interpreter, during the Therapeutic Use of Language Interpreter training workshop, helped ease some of Crystal’s initial anxiety about working with language interpreters in therapy. The workshop provided her with some concrete in-session skills to tune into multiple channels of communication within the client-interpreter-therapist triad. In addition, upon receiving the case assignment to work with Luah, Crystal immediately searched the Internet, and the available literature, to learn about the country of Burma, its cultures, and the sociopolitical history related to the Karen-speaking, Christian ethnic group of which Luah was a member. Through this process, Crystal was further exposed to, and learned about, the macrolevel historical and sociopolitical conditions associated with her client. Not only did this newly acquired cultural knowledge equip Crystal with some basic, culture-specific information about Luah’s background, but also the information challenged some of Crystal’s previously held preconceptions and stereotypes. For instance, prior to this research Crystal thought that Burmese people belonged homogenously to the Buddhist religion. Crystal’s efforts to increase her cultural knowledge and awareness about the client’s background characteristics underscore Domains I and II of the revised CIC framework, which focus on awareness of both client and counsellor cultural identities and social locations; specifically, counsellors are cautioned against misusing general cultural knowledge in ways that stereotype clients, and it encourages therapists to continually readjust their cultural lens to include new knowledge.

Removal of Service Barriers and Bridging of Service Gaps

One of the major contributing factors for the underutilization of mental health services among racial and ethnic populations in North America is logistic and/or involves institutional service barriers (Sue & Sue, 2016), which include service availability and accessibility. Consequently, to better serve refugee newcomers, the multicultural therapy practicum sets a priority on overcoming or minimizing potential logistic barriers that might hinder refugee clients from attending therapy through the university clinic. Even before meeting Luah, and being able to work with her, Crystal had to proactively advocate and problem-solve around three immediate, pragmatic obstacles that might have directly and indirectly impacted Luah’s ability to attend therapy: language, transportation, and childcare. Compelled by these necessities, Crystal first contacted Luah’s case manager at the agency. With the case manager’s assistance, a Karen-speaking language interpreter was identified and secured through the agency’s Translation and Interpretation Services. Further, extra care was taken to acquire a female interpreter, because of the sensitive nature of Luah’s presenting concerns and the need to respect Karen culture’s code surrounding communication restrictions between women and men. Crystal, secondly, requested and arranged a regular taxi (reimbursed by the agency) to transport Luah from her home to the clinic for the scheduled appointment and then to drive her home after the session, which resolved the transportation concern.

Thirdly, Crystal sought a childcare arrangement for Luah’s youngest child to free Luah’s time up to come to the therapy sessions. The solution did not come easily, due to Luah’s time and financial constraints. Fortunately, after creative and persistent negotiations among Luah, the case manager, and Crystal, a low-cost community program for children at another local social service agency was obtained for Luah’s 5-year-old son during the weekly therapy time. While these pragmatic needs might seem somewhat trivial and involve services that are taken for granted by more affluent, well-supported, non-refugee/immigrant clients, advocating for these concrete auxiliary support services were vital in bridging the structural gaps in accessing mental health services for refugee clients like Luah (APA, 2010). These case management and advocacy efforts characterize culturally responsive, good therapy practices in working with refugee newcomers; they went a long way in ensuring a stable and lasting therapy working relationship between Luah and Crystal.

Attention to the Client’s and the Therapist’s Multiple Identities and the Intersections Among Them

Domains I and II of the revised CIC framework stipulate that therapists’ ability to discern the most salient cultural identity and awareness of the intersection of multiple identities of their diverse clients constitutes a critical aspect of their multicultural counselling competency. At first glance, there existed a conspicuous cultural distance between Luah and Crystal, given their respective distinct backgrounds and personal characteristics. Unquestionably, Luah, being a mother in her mid-40s and a Karen-speaking refugee newcomer from Burma, who did not speak English and held a Christian faith, stood in a stark contrast to Crystal, a highly educated professional and graduate student, a married woman without children, in her late 20s, who is a native English speaker and a Canadian-born citizen with no strong affiliation to any religious faith. However, as the thesis of this chapter argues, this cultural distance provides an exceptional opportunity and learning condition for therapists to develop, exercise, and strengthen their multicultural counselling and social advocacy competencies.

As a case in point, when Crystal began to work with Luah, she was made keenly aware of their cultural distance and the need to carefully attend to Luah’s multilayered identities and to how the identities and cultural forces faced by Luah interfaced with her own identities. Based on the previous multicultural knowledge Crystal had gained through reading about racial and ethnic identity and the ongoing multicultural supervision she was receiving in this practicum, Crystal was made aware of Luah’s cultural identities, the intersections of various identities, and how these influences might impinge on Luah’s worldviews, well-being, and decisions, as well as on Crystal’s approaches to interventions and case conceptualization. As an example, Luah’s initial reluctance to disclose her domestic abuse experience in therapy was more accurately understood and construed as a consequence of combined multilayered identity forces and cultural influences. Her avoidance of disclosing the domestic violence to Crystal could be attributed to her unique social locations and multiple identities: her culturally prescribed gender role identity as a woman, who should tolerate her husband’s misconduct; her ethnocultural norm and taboo against sharing family dirty laundry with outsiders; her entrenched Christian belief that she must forgive her husband’s wrongdoing (turn the other cheek) and hope and pray for his repentance; and her conditioning as a mother to want to keep the family intact for her children’s sake. In addition, Crystal was aware that Luah’s lack of resources, information, and familiarity with Canadian systems made it difficult for her, as a refugee, to seek out the external help that was available. Seeing Luah’s dilemma in this cultural and contextual light, Crystal was more able to approach Luah with a greater sense of cultural empathy and to work with more accurate conceptualizations.

In regard to the specific issue of domestic violence, with the support of the group supervision, Crystal worked out a multipronged approach to help Luah explore and negotiate through diverse cultural expectations and external forces. Crystal opted to tactfully and gently probe Luah’s concern, while providing Luah with timely psychoeducation – information about domestic violence, child abuse, and their effects on and resources for victims. She also clarified with Luah the Karen culture’s prescribed norm about family violence and its means of resolution, appealed to Luah’s Christian beliefs and teachings against violence, encouraged her to confide her “emotional pains” to trusted clergy in her church community, and affirmed her strong will and determination to protect her three children from harm in her role of mother.

Moreover, Crystal’s first-hand contact through therapy with Luah, a refugee woman, in this experiential training environment, forced Crystal to reflect upon her own identities and social locations. In terms of gender identity, the issue of domestic violence triggered strong emotional reactions for Crystal, because she considered herself to be a feminist and a vigorous proponent of gender equality. She was strongly opposed to violence against women and children. In exploring the suspected domestic conflicts with Luah, Crystal came to realize the challenge of keeping her own cultural and professional values and assumptions in check and refraining from reacting or making judgments based on her instincts and reflexes. These included Crystal’s own beliefs about marital relationships, spousal rights, and the use of corporeal punishment for disciplining children, all of which are rooted in the dominant European Canadian culture and differed substantially from Luah’s Karen cultural norms and standards.

The therapy work with Luah further prompted Crystal to reflect upon her own identity as a Canadian-born, second-generation immigrant, born of first-generation immigrant parents from central Europe. Even though Crystal was a native-born Canadian citizen, she recalled the migration experiences and hardships her grandparents and parents had undergone as foreign-born immigrants in Canada. Crystal recounted her own struggles while trying to fit in with other non-immigrant kids in school and the need to negotiate the intergenerational cultural differences between herself and her parents and between Canadian mainstream values and her parents’ more “traditional” beliefs. At the same time, through witnessing Luah’s many disadvantages as a refugee, Crystal came to reevaluate and acknowledge the many privileges associated with her own social location. This first-hand, reflective process of learning not only deepened Crystal’s own sense of personal and cultural identity but also helped foster her clinical and cultural empathy towards Luah and her family’s struggles as refugees.

Engagement in Community Collaborations and Social Advocacy Interventions

The opportunity to integrate community-based resources and advocacy interventions into the process of counselling and psychotherapy with refugee survivors marks a distinctive feature of this model of multicultural therapy training. The high degree of basic subsistence needs among refugee newcomers in the areas of language, finance, housing, health care, employment, legal, and immigration concerns significantly affects their overall physical and psychological well-being (APA, 2010). Consequently, culture-infused and responsive therapy interventions for refugee newcomers invariably entail advocating for additional logistic and subsistence supports by the therapist with, or on behalf of, their clients. As stated in the thesis of this chapter, this service-based and community-partnered multicultural therapy practicum offers an ideal learning ground for therapist trainees to engage in advocacy services as they work to support refugee newcomers.

Incidentally, throughout the process of providing therapy to Luah, Crystal was compelled to assume the role of a change agent both with and on behalf of Luah on many occasions. This began with negotiating interpretation, transportation, and childcare services for Luah. On the day of reporting the domestic abuse, Crystal accompanied Luah and acted as her emotional support, guide, advisor, negotiator, and, of course, therapist and mental health-care provider throughout the process. Crystal’s helping roles were clearly expanded as she advocated for, and helped Luah navigate through, the complex and overwhelming processes involved in reporting the abuse and pressing charges against her husband. Crystal had to step in and act as Luah’s advisor and spokesperson as they met and dealt with a steady stream of helpers: police officers, nurses, and medical staff at the hospital; social workers from Children’s Aid Society; and Luah’s case manager, interpreter, and shelter staff.

Crystal’s advocacy role continued even after the day of reporting the domestic violence. To ensure that Luah’s therapy was not interrupted while Luah and her children were living in the women’s shelter, Crystal requested the approval of the practicum supervisor and permission from the shelter director to allow her to see Luah on-site at the shelter to continue their therapy work. As a result, adjustments were made to the protocol of the practicum to include community outreach to accommodate the need of clients, such as Luah – an adjustment that was deeply appreciated by Luah. In addition, with Luah’s consent, Crystal further advocated with the Children’s Aid Society on behalf of Luah to acquire counselling and emotional support services for her three children. Through these efforts a social worker was secured and assigned to work with Luah’s children to help address their adjustment difficulties and their emotional, social, and education needs.

Also, during a meeting between Luah and Crystal, Luah privately expressed to Crystal the difficulty she and her children were having with the unfamiliar Western food being served at the shelter. Realizing that this issue was significantly affecting the quality of their lived experiences in the shelter, Crystal brought the concern to the attention of the shelter coordinator. Through communicating with the shelter staff, Luah was given permission to prepare her own food in the shelter. Interestingly, this exchange unexpectedly prompted the shelter to reexamine their operational and governing policies around cultural sensitivity and accommodation for their clients, which led to some policy changes on the part of the women shelter, particularly around their clients’ culture-specific or religious needs and accommodations. This stands as a good example of organizational changes that can be brought about through a therapist’s activism and social advocacy on behalf of clients and the disadvantaged. Crystal came away from these learning experiences with a new perspective on, and appreciation of, the helping role and the helping process. Participation in changes at the institutional, mesolevel again broadened Crystal’s previously held view as to what constitutes useful, culture-infused counselling and psychotherapy for clients with diverse backgrounds.

Learning Through Group Supervision and Experiential Reflection

As an experientially based multicultural training, another key feature of the practicum is its emphasis on culture-infused supervision and trainees’ personal reflective learning. Within the structure of this practicum model, ongoing support for the therapist trainees and monitoring of their therapy work with refugee clients are provided through a 2-hour, weekly group supervision class that includes all the practicum students. The philosophical foundations of this multicultural supervision approach are grounded in multicultural and traumatology principles and community and social justice services. During these weekly supervision classes, Crystal and her peers took turns reporting on the progress of their therapy work with their respective refugee clients, as well as presenting and discussing selective clips from their videotaped therapy sessions. While the supervision is coordinated and guided by the course instructor/supervisor, an additional focus of the group supervision is to allow trainees to develop and hone their competence and skills in providing peer consultation for each other and to further their peer supervisory skills. The supervisor also offered additional individual supervision to Crystal and other trainees, on an as needed basis, at the initiation of either the trainee or the supervisor.

In her reflection, Crystal identified the intimate small group supervision approach in this practicum as invaluable. Crystal noted that, given the complex nature of her therapy work with Luah, she appreciated the ability to brainstorm and to garner many different perspectives, opinions, and suggestions for tackling difficult situations with Luah from her peers and the supervisor. Furthermore, having the opportunity to share her own struggles with Luah with her peers and, in return, hearing her peers share similar struggles with their refugee clients was very reassuring and validating for her, as a novice therapist learning about a new-to-her cultural situation. For example, during the group supervision, students talked about and processed their anxiety over having to manage the therapy process with the additional involvement of a language interpreter in the session; their struggles with trying to connect with refugee clients across language differences; and the emotional reactions they felt from listening to refugee clients’ account of their traumas. Their shared experiences and the support they received from each other during this group supervision helped them normalize challenges they faced working with refugees and reinforced the learning they gained through the practicum.

Moreover, as part of the course assignments, Crystal and the other trainees undertook the writing of critical incident journals following each therapy session. This activity enabled trainees to reflect on, assess, and document their own learning processes and personal development through treating refugee survivors, with a special focus on the changes in their cognition, affect, and behaviours. The written content of these reflective journals also became the source of discussion and processing for trainees during the weekly supervision class. The combination of the small-group supervision and the therapists’ own guided and reflective learning experience served to make this multicultural therapy training model deeply experiential and acutely meaningful for the students.

Conclusion

There have been increasing calls for the multicultural counselling and training movement to respond to rising social justice issues (Arthur & Collins, 2016; Ginsberg & Sinacore, 2015), as well as to find best practices in advancing new methods of promoting culture-infused counselling practice and education (Kuo & Arcuri, 2014). In this chapter, I describe a novel, experiential approach to multicultural counselling and psychotherapy training for clinical psychology Ph.D. students: a live, training-service-based therapy practicum that incorporates into its training of students services for refugee survivors through social advocacy, community collaboration, and multilayered interventions. This hands-on, culture-infused practicum attempts to challenge and expand the scope, the methods, and the mandates of conventional multicultural counselling coursework, which is dominated by didactic, cognitive-based teaching. Through the case example of Luah and Crystal, the therapeutic benefits and the training potentials and challenges associated with this new multicultural therapy practicum were highlighted. This training model allows therapist trainees to participate directly in their clients’ changes, both within, and outside, of the therapy room. It facilitates trainees’ reflection on their development of clinical and multicultural competencies in relation to their own learning and through their service contribution to community-based clients at the micro-, meso-, and macrolevels of the revised CIC framework. As such, the multicultural therapy practicum stands as a promising, innovative model for training, preparing, and facilitating multicultural counselling and social advocacy competencies for future therapists and counsellors.

Questions for Reflection or Discussion

  1. 1.

    The multicultural therapy practicum described in this chapter challenges counsellors to bring about changes at the micro-, meso- , and macrolevels and to engage in social advocacy, particularly when helping clients from nondominant populations. Think of an encounter or experience (personal or with your client) in which you had to act or respond to the situation at two or more of these levels (e.g., having to advocate for, or speak on behalf of, yourself or a peer/client in the face of a higher authority). Describe what that experience was like for you and the implications for you as a counsellor.

  2. 2.

    In reading the case example of Luah and Crystal, what struck you most about this particular case? If you were Luah’s counsellor, what would you have found most challenging about working with Luah? What does this suggest about your current level of awareness of your own cultural identity and the cultural characteristics and identities of refugees?

  3. 3.

    In what ways were the counselling processes and relationship between Luah and Crystal different from, or similar to, most client-counsellor interactions? Which aspects were key to developing an effective and respectful working alliance with Luah?

  4. 4.

    I have argued that hands-on, experiential learning involving direct contact with culturally diverse clients is a helpful, perhaps even necessary, element in developing a counsellor’s true multicultural counselling competence, particularly in terms of acquiring multicultural skills and building a culturally responsive and socially just relationship. Take a few minutes to consider what opportunities or avenues you might undertake in your current training or practice setting to increase your opportunity or exposure to working with clients of diverse backgrounds.

Learning Activities

  1. 1.

    Find someone you know who is a relatively recent refugee or immigrant (migrated to the host culture within the last 10 years). Request an interview with this individual to learn about this person’s experience as a newcomer, including both positive and negative aspects of the person’s migration both prior to and after their arrival. Then, place yourself in this person’s shoes and think about what kind of help you would need from a counsellor.

  2. 2.

    In helping refugee and immigrant clients, counsellors who use the revised CIC framework outlined in Chap. 2 should be familiar with local social services and resources available to newcomers to support their counselling work with these populations. Research the services or programs in your neighbourhood or community that are designed to serve and support newcomer populations. Collect this information for your own resources.

    If permissible, make an appointment and plan a trip to visit your local immigrant-refugee serving centres/organizations and other social services agencies, such as shelters. Orient yourself to these support services and, better yet, establish a working relationship with the staff in these organizations.

  3. 3.

    It is beneficial and eye-opening for counsellors to experience what it is like to conduct counselling and therapy with the aid of a language interpreter. If you never have such an opportunity, try doing the following exercise. Conduct a mock interview or counselling session with someone (i.e., a classmate or colleague), the client, who speaks a different language from you, and another bilingual person, who speaks both the language of your client and your language, as the language interpreter. Process your experience and reactions after the exercise with your client and interpreter.