Therapeutic engagement and refugees: analyzing the impact of demographic variables
Access and proper utilization of services in general and health care services in particular is a very challenging process for refugees and immigrants who arrive in a multi cultural and diverse setting such as Canada. Apart from the cultural shock refugees and immigrants face in these settings, many demographic variables put further stress on their ability to cope with their new environment and get proper care. Of these factors, gender, race and cultural background play a crucial role to determine whether they receive proper care.
Tsang, Bogo, and Lee (2011) analyze therapeutic engagement as a process through which client and practitioner negotiate a shared pattern of interaction that can facilitate future collaboration on therapeutic tasks. Tetley, Jinks, Huband, and Howells (2011) see it as the extent to which the client actively participates in the treatment on offer. Whether one chooses to see therapeutic engagement as a shared process or one that comes from the side of clients, how we engage with clients remains a fundamental and key factor in successful clinical practice (Brimhall and Butler, 2011); especially during the initial phase of contact and relationship development (Tsang et al., 2011).
In this paper, I will provide a discussion on strategies of engagement when building a relationship with clients from different demographic backgrounds by focusing on gender, race and cultural background as some of the factors that could influence the level of therapeutic engagement while providing services to diverse population such as refugees and immigrants.
The psychological and cognitive differences between males and females have been documented (Halpern, 2004). In line with this, various studies have been conducted to determine the impact of Gender on engagement. Some of these studies indicate that females have more tendency to have therapeutic engagement than males. For example, Staton et al (2007) examined differences between male and female programs in treatment engagement, psychosocial functioning, and criminal thinking using gender as a moderator of the relationship between offenders’ engagement in treatment and ratings of psychosocial functioning while controlling for age, race, and length of time in treatment.
Their analysis indicates that, on each of the treatment engagement measures, including counsellor rapport and treatment participation, female programs reported significantly higher scores which supported their hypothesis that the relationship between treatment engagement and psychosocial functioning was moderated by gender.
Another similar study by Czuchry et al. (2006), examined the effectiveness of motivational activities designed to improve early treatment engagement for probationers receiving substance abuse treatment and differential effects on males and females. They used gender as the independent variable and treatment engagement and post treatment success as the multiple dependent variables. Their finding indicates that females reported greater treatment readiness at intake and 3 months into treatment and further reported higher levels of treatment readiness over time compared to males. Other studies show similar findings (Rowan-Szal et al., 2000; Sacks, 2004).
However, a great caution must be exercised when one interprets and uses the findings of such studies. This is mainly because their significance becomes less important when/if one looks gender from a social construction theory perspective. In addition to such limitations related to theoretical framework, the methodologies used in these types of studies mostly involve analysis of categorical, binary variables and cross sectional study designs.
Such study designs, unfortunately, have their own limitations and might not provide a result that can significantly inform direct and daily practice. These limitations range from inadequate and non probability sample size that limit generalizablity of findings vis-à-vis a wider population to limitations that arise from the fact that such study designs lack analysis with respect to time. (Perry and Pauletti, 2011).
As a result, designing our engagement strategies based solely on our client's categorical variables such as gender and not considering other confounding variables might carry a risk of blanket generalizations that may be based on wrong assumptions. To further elaborate this point, let's take a hypothetical example where a black female client who came to a white male social worker seeking help regarding her husband.
If we only consider her gender on how easily and well she can be engaged in the first session, the social worker (considering such studies as above) might assume that she will do so easier than her husband or other male clients. Subsequently, he may not put as much effort to engage her as he would do while dealing with his male clients.
If a due consideration is not given to other factors that might contribute to a low level of engagement, this might further hinder the process of establishing rapport between her and the social worker, which may further lead to a possible drop out. The women, say for example, might not want to have any conversation with a white male social worker as a result of racial discrimination that she recently faced in her work place; in which case, her race was a contributing factor to her disengagement rather than gender.
In addition to impacts on the therapeutic process, recognizing how specific races adapt to various stressors is essential to develop an effective therapeutic engagement strategy. For instance, Miller et al. (2011) examined the impact of racial and cultural factors on the mental health of Asian Americans. They assessed how racism-related stress, acculturative stress, and bicultural self-efficacy predict mental health. Their finding provides a compelling evidence for the plausibility of the racial and cultural factors model, which accounted for approximately 12% of the variance in mental health.
Their result also indicates that both acculturative stress and racism-related stress were positively related to mental health difficulties. Miller et al. (2011) appropriately address limitations to their findings such as variability that may be due to acculturation, personality factors, immigration status, ethnic sub groups and cultures. Despite their limitations, however, such studies remain very important especially when social workers adopt anti oppressive practices and work in a multicultural society such as Canada.
Moreover, it is reported that having open conversations about race and ethnicity can serve as an effective strategy to establish therapeutic engagement with clients. Cardemil and Battle (2003) indicate this by stating the importance of how therapists can incorporate diversity issues into their work and demonstrating a willingness to engage clients in these dialogues can promote an environment of trust and understanding. This, they argue, will ultimately help the treatment process.
Thus, failure to recognize such racial components of the therapeutic process and not recognizing the race specific elements of clients results in failure to establish engagement and rapport with the client which, in turn, contributes to high drop-out rate of clients (Tsui and Schultz, 1985).
Worthington, Soth-McNett, and Moreno (2007) did a comprehensive analysis of studies that were conducted in areas of multicultural counseling competencies over a 20 years period. Their analysis indicates how the number of such studies have evolved over this period, signalling the significance that practitioners and researchers associate with the role of having a multicultural competency in managing and engaging with clients.
Stressing on the importance of such multicultural competency in counselling, Feinberg et al (1982) indicated that misunderstandings in the counselling process can often times arise from cultural variations in communications that may lead to alienation and or inability to develop trust and rapport which may lead to early termination of therapy. As a result of this, the multicultural aspect of counselling has been given a due attention over the past years.
Further exploring this cultural aspect and using a process-outcome study design on cross-cultural clinical practice, Tsang et al (2011) made analysis of the client-practitioner engagement process during the first session in cross-cultural therapy by making an in depth assessment of clients that represented a wide variety of client-practitioner ethno-cultural differences. Their findings show that positive engagement is associated with effectively communicated cognitive understanding of the client’s needs and concerns, emotional attunement, and appropriate handling of specific cultural experiences.
Such findings are especially important as the methods and study designs that they used can inform daily practice and addresses a wide variety of variables that may affect how clients can be engaged in the first therapy session. This is mainly so because their analysis focused more on the process and outcome variables, rather than a set of categorical ones, which gives an insight into how specific cultural experiences play a role in the level of client engagement while considering an intersection of several and often times overlapping variables.
From the literatures reviewed above, it is clear that several demographic variables such as gender, race and cultural background contribute to how clients from diverse background can be engaged. However, it is also equally clear that there is no silver bullet approach to how clients can effectively be engaged by a simple consideration of such categorical variables only. It seems that various factors affect the level of client engagement independently and in combination.
Although studies that explore the independent impact of such categorical variables as gender still remain informative, it was shown that they might fell short when it comes to informing daily practice. On the other hand, studies that focus on the process and outcome variables while giving a due consideration to a combination of these categorical variables seem to provide results that can inform daily practice and a better approach to client engagement.
A simple consideration of binary categorical variables may lead to wrong assumptions and conclusions about client engagement. Recognizing individual differences and establishing a dialogue on some key aspects of the client's background such as race can be used to help the engagement process. Involving multiple dimensions of the client and considering the multicultural aspects of client's backgrounds within a context of other intersecting diversities serve as a good strategy in order to establish a successful client engagement, especially when dealing with vulnerable segments of our population such as refugees and immigrants who face barriers to access services even before reaching service providers.
Brimhall, A. S., & Butler, M. H. (2011). A primer on the evolution of therapeutic engagement in MFT: Understanding and resolving the dialectic tension of alliance and neutrality. Part 1 retrospective: The evolution of neutrality. American Journal of Family Therapy, 39(1), 28-47.
Cardemil, E., & Battle, C. (2003). Guess who’s coming to therapy? Getting comfortable with conversations about race and ethnicity in psychotherapy. Professional Psychology: Research & Practice, 34(3), 278–286
Czuchry, M., Sia, T., & Dansereau, D. (2006). Improving early engagement and treatment readiness of probationers. The Prison Journal, 86(1), 56-74. doi:10.1177/0032885505283877
Feinberg, L., Vasquez-Nuttall, E., Smith, E. J., Pedersen, P., Sue, D. W., Bernier, J. E., & Durran, A. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10(2), 45-52.
Halpern, D. F. (2004). A cognitive-process taxonomy for sex differences in cognitive abilities. Current Directions in Psychological Science, 13(4), 135-139.
Miller, M. J., Yang, M., Farrell, J. A., & Lin, L. (2011). Racial and cultural factors affecting the mental health of Asian Americans. American Journal of Orthopsychiatry, 81(4), 489-497.
Perry, D. G., & Pauletti, R. E. (2011). Gender and adolescent development. Journal of Research on Adolescence, 21(1), 61-74.
Rowan-Szal, G. A., Chatham, L. R., Joe, G. W., & Simpson, D. D. (2000). Services provided during methadone treatment: A gender comparison. Journal of Substance Abuse Treatment, 19, 7-14.
Sacks, J. Y. (2004). Women with co-occurring substance use and mental disorders (COD) in the criminal justice system: A research review. Behavioural Sciences & the Law, 22, 449- 466.
Staton-Tindall, M., Garner, B., Morey, J., Leukefeld, C., Krietemeyer, J., Saum, C., & Oser, C. (2007). Gender differences in treatment engagement among a sample of incarcerated substance abusers. Criminal Justice and Behavior, 34(9), 1143-1156. doi:10.1177/0093854807304347
Tetley, A., Jinks, M., Huband, N., & Howells, K. (2011). A systematic review of measures of therapeutic engagement in psychosocial and psychological treatment. Journal of Clinical Psychology, 67(9), 927-941.
Tsang, A. K., Bogo, M., & Lee, E. (2011). Engagement in cross-cultural clinical practice: Narrative analysis of first sessions. Clinical Social Work Journal, 39(1), 79-90.
Tsui, P., & Schultz, G. L. (1985). Failure of rapport: Why psychotherapeutic engagement fails in the treatment of Asian clients. American Journal of Orthopsychiatry, 55, 561–569.
Worthington, R. L., Soth-McNett, A., & Moreno, M. V. (2007). Multicultural counseling competencies research: A 20-year content analysis. Journal of Counseling Psychology, 54(4), 351-351-361. doi:10.1037/0022-0126.96.36.1991