The Ethical Practice of Psychology: Ethnic, Racial and Cultural Issues

Leonardo M Marmol. Handbook of Racial & Ethnic Minority Psychology. Editor: Guillermo Bernai. Sage Publications. 2003.

Concerns about the role of culture and ethnicity on the theory and practice of psychology have had a checkered history in American psychology. Some may say the same about psychology’s concern about ethics in general. The American Psychological Association (APA) was founded in 1892 and incorporated legally in 1925. It functioned for 13 years without an Ethics Committee. This was established in 1938 but without written codes or guidelines to govern its activities.

But today we have come to the realization that ethnicity, race, and culture are ethical issues. The future of psychology as a force in human affairs may well hang on how it addresses the multicultural milieu of 21st-century America in a way that is relevant to all the people and not just a privileged few.

In 1947, Carl Rogers, as president of the APA, appointed a committee to define psychotherapy and suggested the idea of writing a code of ethics for the practice of psychotherapy. In 1948, a letter went out to 7,500 psychologists requesting reports of ethical dilemmas they had encountered in practice. One thousand reports came back.

The Boulder Conference of 1949, which promulgated the scientist-practitioner model for clinical psychology, actually left psychotherapy purposely vague and “undefined.” The conference did not explicitly make any pronouncements about ethical practice. It was assumed that all practitioners would adhere to high standards. The impetus for writing a code was, however, strong, and such an effort continued.

Despite the opposition of such well-known psychologists as Calvin Hall, who in 1952 stated that an ethics code would “play into the hands of the crooked operator [who] reads the code to see how much he can get away with” (Hall, 1952), the first Ethical Standards of Psychologists was adopted in 1953 (APA, 1953). This is a national association of professionals that essentially practiced for 61 years without a written code of ethics.

This first code was revised in 1958, 1963, 1968, 1977, 1979, and 1981. The 1990 revision changed the name to Ethical Principles of Psychologists (APA, 1990). Finally, the current version of 1992 changed the title again to Ethical Principles of Psychologists and Code of Conduct (APA, 1992).

Historical Background

Perhaps the earliest call in the literature for attention to the role of race and ethnicity for psychotherapy was sounded by I. S. Lindsay (1947), writing in the Journal of Social Casework. In 1962, G. G. Wren, writing in the Harvard Educational Review, warned psychology of its cultural encapsulation (Wren, 1962) and again revisited the issue in 1985 in his chapter in Pedersen’s edited volume, Handbook of Cross-Cultural Counseling and Therapy. The civil rights and feminist movements within the general society were beginning to sensitize many in psychology about the etic quality of most theories and practices of the profession, especially its assessment practices with its terrible history of racism and bias (e.g., Eysenck, 1971; Jensen, 1973; Putnam, 1961).

Etic and emic are concepts that have come into psychology from anthropology research. Etic refers to those theories, values, and practices that are considered to be not only universal but also normative for all people. Usually these came from the Eurocentric background of the researchers. Emic, on the other hand, refers to those values, mores, and practices that are specific to a given community, tribe, or nation. Traditionally, psychology has considered its theories to be etic—that is, universal—applicable to all people. The multicultural movement has tried to sensitize psychology to the validity of emic forms of practice. In fact, all psychology should be considered emic because traditional psychology is always emic to White, Anglo-Saxon populations. It needs to be reinterpreted and retranslated for each and every racial, ethnic, and cultural group.

Not surprisingly, then, the Vail Conference of 1973 (reported by Korman, 1974) was permeated by a new awareness of the importance of incorporating emic concerns into the theory and practice of psychology, especially clinical and professional practices. For the first time in its history, “official” psychology promulgated as a principle that “counseling persons of culturally different backgrounds by persons not trained or competent to work with them should be regarded as unethical” (Pedersen & Marsella, 1982, p. 492).

To this day, this remains the strongest statement on the subject ever pronounced by an APA entity. The 1992 Ethical Principles of Psychologists and Code of Conduct refrains from such a strong position. Only Ethical Standards 1.08, 2.04, and 2.05 can obliquely be interpreted to address the issue.

After Vail, many things began to happen. In 1982, Division 17 (Counseling Psychology) adopted a position paper recommending that APA consider cross-cultural counseling competencies to become a criterion for the accreditation of training programs in counseling psychology (Ponterotto & Casas, 1991). APA also created committees and boards, such as the Committee for Equality of Opportunity in Psychology, the Board of Social and Ethical Responsibilities in Psychology, the Office of Minority Affairs, and the Board of Ethnic and Minority Affairs (BEMA).

In 1984, BEMA established a task force for “conversation” with minority constituents. Also, in 1986, Division 45, the Society for the Psychological Studies of Ethnic Minority Issues, was chartered. Eventually, 9 years later, the APA adopted the “Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations” (APA, 1993). It is interesting to note that the “Guidelines” were adopted 1 year after the 1992 code. Had this code addressed the issues adequately, the BEMA guidelines might not have been necessary.

In summary, we have 46 years from Lindsey, 31 years from Wren, and 20 years from Vail for the APA to officially go on record recognizing the importance of emic factors in counseling and psychotherapy. Psychology’s concern for ethnic and cultural issues moved as slowly as its general concern for ethics as such.

Ethnicity as an Ethical Issue

Before moving on to the present, we need to raise some questions. Is a professional standard for ethical cross-cultural practice a feasibly attainable goal, given the diversity of the nation (and world) we practice in? Are there minimal competency standards for culturally sensitive therapy that can be compared to the minimal standards for licensure used by the state boards? Are there standards for excellence in the field comparable to American Board of Professional Psychology (ABPP) standards? In the field of medicine, there are “universal precautions” taken with every patient (gloves, masks, disposable sterile instruments). Can we develop “universal precautions” to guard against biases that might misconstrue diagnoses and interventions with culturally different clients?

Any attempt to answer those questions has to keep in mind the history of colonialism that lies behind all interactions between European White peoples and people of color in the rest of the world. The historical facts of how the great empires—be they British, German, Dutch, or Spanish—imposed their cultures on the weaker, less developed cultures of Africa and America permeate all interactions between these peoples to this day.

It must be acknowledged that the conquerors deceived themselves in thinking that their mission was to bring civilization and Christianity to the underdeveloped nations (Venditti & Venditti, 1996). Nevertheless, the objective accounts of the conquest demonstrate that colonialism was nothing less than aggression and exploitation (Neil, 1964; Rivera Pagan, 1991).

In psychology, many have lamented the damage done on ethnic persons by the thoughtless application of White, Anglo-American values and behavioral expectations to persons of color. Some of these are documented in the articles in the volume edited by Janet Helms (1990), Black and White Racial Identity: Theory, Research and Practice. Perhaps the strongest indictment of this practice was voiced by T. Gordon (1973): “White psychology stands accused of unethical conduct in its relation with the black community. … Instead of service to black people, white psychology has been flagrantly self-serving and opportunistic” (p. 88).

The 1992 code tried very hard to steer away from a deontic approach of categorical imperatives toward a more utilitarian philosophy. There are only two categorical prohibitions in the entire code. One is about sexual relations with current patients, students, supervisees, and research subjects, and the other is against abandoning patients. Everything else is couched in what Bersoff (1999) has called “weasel words” (p. 112)—wording such as “whenever feasible,” “as soon as possible,” and so on. The legalistic protection of the psychologists seems to often overrule the optimal concern for the recipients of psychological services.

Others have related the issue to a philosophy of ethics embodied in the APA codes that is at odds with the basic values of minority communities. Underlying the 1992 (and all other versions) of the APA code is a ground floor of individually oriented values, such as autonomy, individualism, independence, and self-centeredness, that ignore values of community and interdependence important to other cultures (LaFromboise, Foster, & James, 1996).

There are more subtle implications in the code such as concepts of consumerism (e.g., more is better, strive for acceptance through success and competition). These differences in value orientation may lead psychologists to negatively evaluate those who are different from themselves, even stereotyping them as “inferior.”

Some writers have even identified gender biases in the code by reflecting concepts of “rights” and “independence,” which are judged to be “male,” while ignoring concepts of caring and relationships that are judged to be “female,” which are prevalent in cultures with a more altruistic outlook (Harding, 1987, cited by Ponterotto & Casas, 1991).

Despite other world cultures being more collectivistic, the APA code has had a strong influence on the ethics codes of many countries. The work of Triandis (1995) and others clearly establishes how it is that the ethnic cultures represented in the minority populations of the United States tend to be less individualistic than the dominant Anglo-American culture. Mark Leach and J. Judd Harbin (1997) surveyed and compared the APA code with those of psychological associations of 24 countries. They found the Canadian code to be most similar to the U.S. code and, not surprisingly, China’s to be the most dissimilar. Most European and even several South American codes reflect major values of the U.S. code.

Training programs on cultural awareness and attitude change have proliferated since the 1980s, but how effective they are remains to be seen. A survey by Katz (1997) does not present a very optimistic picture of their effectiveness. Jane Guishard (1992) from the United Kingdom considers these as “seance-type group work … [which has] rightly received a cool response from a wide range of professionals” (p. 43). LaFromboise and her colleagues (1996) felt that most training models assume that increased knowledge translates into improved skills, so that after some modest training, European American counselors overestimate their multicultural skills.

Professional clinical psychology training programs are not much better. Most ethics classes in clinical programs boil down to rote learning of the APA code and are divorced from the practicum experiences. Abeles (1980) proposed teaching ethics through empirical analysis from clinical practice—that is, a grappling with ethical dilemmas that arise from the conflicts between the codes and the day-to-day struggles of clients. Confronting conflicting cultural values would enhance this process significantly. The courage to risk disagreeing with the codes from specific cultural and ethnic practices is lacking in the field. Casas, Ponterotto, and Gutierrez (1986) proposed a scathing indictment of the current training in both research and counseling from an ethical point of view.

LaFromboise et al. (1996) surveyed 10 popular casebooks used in ethics classes and found only 5 pages of cases related to ethnic minority issues. Even the most respected book, considered by many the classic “bible” in ethics—Koocher and Keith-Spiegel’s (1998) Ethics in Psychology, now in its second edition—devotes only 2Vi pages to the subheading “Ethics and Cultural Diversity,” with only five cases cited. And only half a page is given to the heading “Subgroup Norming,” without citing any cases.

The issue of assessment instruments with ethnic minority persons raises multiple ethical issues. The racism espoused by the works of Jensen (1969, 1973), Eysenck (1971), and Putnam (1961) is well known in the field—not to mention the recently published onerous volume, The Bell Curve (Herrnstein & Murray, 1994) (see Andrews & Nelkin’s 1996 comments on The Bell Curve in Science). The cultural biases in test construction manifested in content, internal structure, and item selection are dealt with in more detail in the “Diagnoses and Assessment” section of this volume. The works of Richard Dana (1993, 1996) in this area are also well known in the field.

But the history of the misuse of assessment instruments with ethnic and minority populations goes back to early attempts to import the Binet test into America. Such a history, so expertly documented by Stephen Jay Gould (1981) in his seminal work, The Mismeasure of Man, is a shameful beginning for American psychology. The conclusions reached by such luminaries of psychology as H. H. Goddard, L. M. Terman, and R. M. Yeakes from their early use of intelligence tests are appalling. Statements to the effect that Negroes (as African Americans were called then), Mexicans, and American Indians as a group were “feebleminded” due to their low scores on these tests give the modern reader conniptions. The offensive language was not spared for Caucasians of foreign birth. Tests performed at Ellis Island led Goddard to astounding results:

83 percent of the Jews, 80 percent of the Hungarians, 79 percent of the Italians, and 87 percent of the Russians were feebleminded; that is below age 12 on the Binet scale. Goddard himself was flabbergasted: could anyone be made to believe that four-fifths of any nation were morons? (Gould, 1981, p. 166)

In the 1980s, the U.S. Employment Service (USES) tried to reduce the impact of standardized testing on ethnic minority groups by using within-group scoring, also known as subgroup norming. But the Civil Rights Act of 1991 banned its use in the name of avoiding reverse discrimination. Brown (1994) questioned this practice, considering it a case of reverse discrimination. But Gottfredson (1994) and Sackett and Wilk (1994) provided a more objective view of the practice of race or subgroup norming.

Ethics and Ethnicity in Multicultural Practice

On the question of whether the therapist and client should be racially or ethnically matched, the literature provides more heat than light. Gender and sexual orientation matching between therapist and client has also entered the discussion. A complete summary of the literature on these issues is beyond the scope of this chapter. Suffice it here to say that Sanchez and Atkinson (1983) investigated the subject among Mexican Americans; Atkinson, Furlung, and Poston (1986) among African Americans; and Atkinson, Maruyama, and Matsui (1978) among Asian Americans. Stanley Sue (1988) reviewed the research findings on ethnic matches in general and found no significant differences in therapeutic outcomes, provided the White therapists were culturally sensitive.

The question of whether multiple relationships that often happen in ethnic communities are considered unethical by APA codes is a more complicated subject. Ethical Standard 1.17 acknowledges that “in many communities and situations, it may not be feasible or reasonable for psychologists to avoid social or other nonprofessional contacts with persons such as patients, clients, students, supervisees, or research participants” (APA, 1992, p. 1601). Stockman (1990) illustrated this dilemma in rural communities.

In Hispanic communities, for example, a therapist who is well known in the community for his or her involvement in social groups, churches, political organizations, and so on, is a more respected and desirable person to be accepted as a therapist than someone from outside the community. Even someone who is an outright relative or the relative of a friend is preferable as a therapist. In Native American communities and especially in the reservations, all persons are considered part of the extended family. Tribal kinship “requires” familial designations. Anyone who is older than you should be addressed as “uncle” or “aunt” (LaFromboise et al., 1996). The culturally sensitive therapist must blend with the community values and, in a sense, ignore the codes.

The first of the four questions raised earlier as to whether a professional standard for ethical cross-cultural practice is an attainable goal can now be answered. The answer is in the affirmative if we agree to espouse two emphases.

The first is to acknowledge what Pedersen proposed in 1990 and later expanded on in the volume he edited in 1999, titled Multiculturalism as a Fourth Force. He suggested that multiculturalism has become a “fourth force” in psychology, with the other three being psychoanalysis, behaviorism, and humanism. Accepting multiculturalism on an equal standing with these other forces puts all research and developments in multiculturalism in the midst of “mainstream” psychology and not a “side issue” of interest only to a small cadre of devotees or rebels.

The work of Division 45 would no longer be that of consciousness raising for the profession but of promoting the newly acknowledged fourth force. It would include seeing that multiculturalism takes its rightful place in the pantheon of psychology, alongside the theories of psychoanalysis, behaviorism, and humanistic psychology. There should be at least two representatives of Division 45 on the APA’s Committee on Accreditation to make sure that all training programs are teaching multiculturalism at the same level of importance and depth as they teach cognitive-behavioral, psychodynamic, and systemic psychotherapy. State licensing boards should be lobbied to begin requiring a minimum number of hours of supervised experience with ethnic and cultural clients for admission to licensure.

A further purpose for Division 45 would be to promote that “ethical relativism” is an appropriate and legitimate approach to practice. This concept, first proposed by Casas and Thompson (1991) and endorsed by LaFromboise et al. (1996), allows for an interpretation of the ethics codes of APA and others (e.g., American Association for Counseling and Development’s 1988 Ethical Standards), taking into account the value differences underlying the codes and how they are relevant to the lives of ethnic cultures and communities. This principle allows for the reinterpretation or “translation” of concepts of altruism, responsibility, justice, and caring (Casas & Thompson, 1991). Ethical relativism allows us to look at “ethnic life,” avoiding the ethical lapse on the part of researchers whose fascination with pathology does not allow them to see the positive aspects of ethnic life.

Ethical relativism should not be confused with cultural relativity. Because we have come to accept that certain things that were thought to be absolute are actually relative to culture, and because mores are relative to culture and enforced by social pressure, some have argued that as long as a practice is acceptable in a subculture, it should be allowed by the larger U.S. society. An example of this problem is the old custom of polygamy among Mormon settlers of the territory of Utah, which had to be abolished so that Utah could be recognized as a state. Cultural practices that impinge on moral judgments have to live in harmony with the host cultures of which they are a part. So, then, moral judgments are only valid for the culture in which they arise. Wellman (1985) made the point that “generically similar acts may be right and good in one society and wrong or bad in another. Any comparison between the ethical views of the members of different societies can only be partial” (p. 45).

Recommendations for Training and Research

The second question we raised had to do with standards of minimal competency for a multiculturally sensitive practice. Teaching of ethics is required in all accredited programs, and classes in ethics are expected to show on the transcripts of applicants for licensure in most states. A separate class on multicultural issues in therapy is also expected by APA’s accreditation standards. But the two are kept distant and separate in most training programs. By separating ethical training from cultural sensitivity training, knowledge, and skills, clinical practitioners run the risk of perpetuating oppression and racism without being aware of doing it. As Lakin (1991) has pointed out,

Some contemporary critics of the mental health establishment claim that the values represented in most psychotherapies in our society are in fact sexist and racist. They argue that much treatment is actually disguised social control and functions, perhaps inadvertently, to ensure a perpetuation of the traditional subordinacy of women by males and to justify the racist attitudes of the society, (p. 62)

Standard textbooks for the teaching of ethics in graduate clinical programs all contain chapters on individual differences, and many specifically address issues of culture and ethnicity (Bersoff, 1999; Bowie, 1985; Ibrahim & Arredondo, 1990; Koocher & Keith-Spiegel, 1998; Lakin, 1991; Pope & Vasquez, 1991). They all have illustrative case vignettes, but as we noted before, cases dealing specifically with the ethical implications of factors of ethnicity and culture are few in number. On the other side, texts used in multicultural classes tend to be heavy on techniques of how to address, diagnose, and treat in therapy persons of different ethnicities (Paniagua, 1994; Pedersen, 1985; Ponterotto, Casas, Suzuki, & Alexander, 1995; Sue & Sue, 1990; Vargas & Koss-Chioino, 1992). However, the ethical implications of misdiagnosis, mistreatment, lack of treatment, or outright malpractice perpetuated on ethnic minority persons due to lack of sensitivity and poor education of practitioners do not get addressed directly. Only by implication do these issues become ethical issues. That is why many commit what Iijima Hall (1997) calls “cultural malpractice.” Gil and Bob (1999) made a similar point about research that is not culturally informed.

The third question we have raised regarding standards of excellence in the diagnosis and treatment of ethnic persons is still being debated. The ABPP has clear standards for diplomate status in clinical psychology and several other specialties. The ABPP should be encouraged to develop a diplomate in multiculturalism with clearly defined standards of excellence in the field. Some training programs have developed multicultural “tracks” or specialties. One example is the California School of Professional Psychology at its Alameda campus. But this is training for minimal competency, similar to the competency standards required for the independent practice of psychology by state boards. We need clear standards for excellence in the field.

The last question of “universal precautions,” such as the ones in medicine that are used to operationalize the Hippocratic principle of primo non nocere (first do no harm), can be expressed as follows. The culturally competent and sensitive psychotherapist must be able to articulate certain knowledge, beliefs, attitudes, and skills:

  • Knowledge: They understand the impact of racist concepts on psychological theory and on their own professional lives. They understand the role of oppression in the etiology of mental illness. They are aware of institutional barriers that prevent minorities from using mental health services. They acquire specific knowledge about the historical traditions and values of the group they are working with, as well as the history of oppression and colonization that group has suffered.
  • Beliefs and attitudes: They are aware of their own values, attitudes, and biases and how these are likely to affect minority clients. They are able to monitor their own functioning and obtain consultation, supervision, and continuing education. They believe that it is possible to integrate different value systems in the interest of health and growth. They are willing to refer a client because of their own limitations.
  • Skills: They are able to use styles and techniques that are congruent with the value system of their clients. They are not threatened by having to adapt conventional approaches to accommodate cultural differences. They are able to receive and send both verbal and nonverbal messages that are appropriate to the clients. They are willing to engage in institutional interventions on behalf of their clients, sometimes out of the office.

As cultural sensitivity becomes more and more an expected ethical “requirement” of all psychologists, the beliefs, attitudes, knowledge, and skills needed to become a culturally sensitive therapist will be required subjects in all clinical training programs. Accreditation standards will become more explicit in making sure that issues of race, ethnicity, and cultural diversity are in the forefront of psychological research and practice. As Sue and Sue (1990) have so cogently stated,

Becoming culturally skilled is an active process, that is ongoing, and never reaches an end point. Implicit is recognition of the complexity and diversity of the client populations, and acknowledgement of our personal limitations and the need to always improve, (p. 146)