Journal of Genetic Counseling, Vol. 3, No. 4, 1994
Cultural Competency in Genetic Counseling Vivian Ota Wang t,2
Incorporating a cross-cultural curriculum into genetic' counseling training programs demonstrates a professional conviction of genetic counselors that cultural issues are important in genetic counseling. Funded by the Special Projects Fund in 1993 from the National Society of Genetic Counselors and the Kitson Fund from the Department of Social, Organizational, and Counseling Psychology, Teachers College, Columbia University, the Handbook of Cross-Cultural Genetic Counseling was developed to provide genetic counseling programs a curriculum to teach cross-cultural genetic counseling. The theoretical rationale for the development of a cultural curriculum is presented. By expanding cultural knowledge, developing an awareness of oneself and others, and increasing the repertoire of culturally relevant counseling skills within a socio-political context, genetic counselors will be able to better serve all clients seeking genetic counseling. KEY WORDS: cultural competency; genetic counseling training programs; cross-cultural; education.
INTRODUCTION As genetic services expand because of available medical technology and are thus increasingly utilized by the presently underserved racially and ethnically visible population, the importance of cross-cultural competency becomes more crucial. The most recent census data (1990) shows a significant increase in the number of Blacks, American Indians, Asian/Pacific Islanders, and Latinos in the United States (U.S. Census, 1991). In particular, emigration patterns from Asian and Latin American countries have changed 1Department of Counseling Psychology, Teachers College, Columbia University, New York, New York. 2Correspondence should be directed to Vivian Ota Wang, Department of Counseling Psychology, Box 102, Teachers College, Columbia University, New York, New York 10027. 267 1059-7700/94/1200-0267507.00/1© 1994NationalSocietyof GeneticCounselors,Inc.
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(Lin-Fu, 1988). Between 1970 to 1990 the Latino population in the United States increased 145% and the Asian/Pacific population by 375%. About 22.3 million Latinos and 7.2 million Asian/Pacific Islanders now live in the United States (U.S. Census, 1990). Almost one in three Americans are either foreign born or members of racially-ethnically visible groups. Given the present rate of emigration as well as fertility rates, the researchers at the Bureau of Immigration have predicted that by the year 2040, Whites will comprise only 62% of the total population (Bouvier and Gardner, 1986; Lamm and Imhoff, 1985). These shifts in the United States population have led genetic counselors to acknowledge the importance of culturally appropriate interventions (National Conference, 1990; Paul and Kavanagh, 1990). Genetic professionals often cite cultural barriers as a major obstacle for those seeking genetic counseling (Lin-Fu, 1988, 1990a; Mittman, 1990; Thorngren, 1990). When counseling has been available, clients have often been misunderstood by genetic counselors because of disparate health beliefs and social customs (Barker, 1990; Hartog and Hartog, 1983; Lew, 1990; Perez-Stable, 1987; Wang and Marsh, 1992). Unfortunately, the cultural issues in genetic counseling have predominantly been limited to categorized ideas about service delivery and knowledge of racially and ethnically visible people (Dixson, Dang, Cleveland, and Peterson, 1992; Paul and Kavanagh, 1990). Thus, the "cultural" client has been analyzed and studied with little focus on the culturally latent values, beliefs, and stereotypes of the counselor (McRae and Johnson, 1991). Since the primary focus has been on the client, the counselor's values, beliefs, and ideas about power and authority within a given socio-political reality have been overlooked. Thus, it has been suggested that genetic counseling training programs include a cross-cultural genetic counseling curriculum (Weil and Mittman, 1993). In general, cross cultural researchers have begun to address the complexity of culture not only to understand "exotic groups" but also to understand practitioners (Pedersen, 1991; Segall, Dasan, Berry, and Poortinga, 1990). By understanding cultural encounters both within a client's world view and of their own, counselors might develop more accurate perceptions and engage in more relevant interventions (Leighton, 1982; Pedersen, 1985). Like other counseling programs, genetic counseling has traditionally reflected the majority world view of the dominant White, Anglo-Saxon, Protestant culture (Benkendorf, Callanan, Grobstein, Schmerler, and FitzGerald, 1992; Katz, 1985; Marks, 1993; Pedersen, 1991; Sue and Sue, 1990; Takaki, 1979; Wrenn, 1962, 1985). Consequently people who have this perspective often fail to include the alternative world views of others who might not share this viewpoint (Takaki, 1979). By broadening the existing
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paradigms to include other cultural worldviews, thinking and decision-making processes might be better understood and applied in both academic and clinical settings (Ibrahim, 1985; Ibrahim and Schroeder, 1990; Lynch and Hanson, 1992; Pedersen, 1991; Sue, 1978; Sue and Sue, 1990).
WORLDVIEW
Worldviews are conceptual frameworks of values, beliefs, feelings, and attitudes that affect thoughts, decisions, and behaviors (Ibrahim, 1985; Ivey, Ivey, and Simek-Downing, 1987; Kluckhohn and Strodtbeck, 1961; Leighton, 1982; Pedersen, 1985; Sue and Sue, 1990). A person's worldview is a personal cultural reality from which he or she views and finds meaning of the world (Ibrahim, 1991). When feelings, thoughts, assumptions, and biases have not been examined, a person may presume his or her worldview as universal and just (Pedersen, 1985; Pedersen, 1987; Sue and Sue, 1990; Tyler, Sussewell, and Williams-McCoy, 1985). Genetic counselors may be operating from this universalist perspective by primarily focusing on other worldviews rather than examining their own (Wang and Punales-Morejon, 1992). Thus, genetic counselors need to develop their capacity to become aware of their worldviews while understanding the worldviews of their clients as a way to more competently practice genetic counseling. The concepts of culture and worldview are complex (Papajohn and Speigel, 1976; Pinderhughes, 1989). Kluckhohn and Murray (1953) have discussed cultural complexity as universal (every person is like all persons), culture specific (like some persons), and individualistic (like no other persons). Their model of human universality, culture specificity, and individual uniquenesses for understanding worldview has been expanded in the Integrative Model of Cross-Cultural Counseling-Complex Dynamic Formulation (Leong, 1994). Leong has proposed that the universal assumptions of traditional Western counseling, the cultural group orientation of the racial identity models, and the focus of individual uniquenesses in existential and social learning models should be integrated when understanding worldviews. He has suggested that exploring the simultaneous influences of human universality, cultural specificity, and individual uniqueness is necessary to gain a clearer cultural understanding of people. Leong has submitted that people are a complex adaptive system. Their thoughts, feelings, and behavior styles are constantly adjusting to the continuous shifts between these three perspectives. The consequence for neglecting any one of these influences may be a misunderstanding of a person's worldview.
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Cross-cultural genetic counseling is complex. Therefore, competency should be more than gathering knowledge and facts about racially and ethnically visible individuals. Cultural complexity involves accounting for the individualistic, culture specific, and universal aspects of the client's and counselor's worldviews and translating this information into appropriate counseling interventions (Pinderhughes, 1989). Unfortunately, a study examining cultural competency of practicing genetic counselors has shown cultural genetic counseling to mean knowing only specific cultural knowledge without understanding and awareness of its' broader socio-political implications (Wang and Punales-Morejon, 1992).
CULTURAL COMPETENCY IN GENETIC COUNSELING Approximately 100 genetic counseling students graduate from genetic counseling programs annually (Smith, 1993). Minimum curriculum guidelines have been previously suggested by certification stipulations of the subspeciality of Genetic Counseling within the American Board of Medical Genetics (ABMG) and is currently being re-evaluated by the American Board of Genetic Counseling. Training has involved a two year academic curriculum of seven specific didactic content areas and supervised clinical fieldwork in at least 50 cases representing a broad spectrum of counseling situations (Dumars, Burns, Kessler, Marks, and Walker, 1979; Scott, Walker, Eunpu, and Djurdinovic, 1987; Walker, Scott, Biesecker, Conover, Blake, and Djurdinovic, 1990). Genetic counselors' competencies have been based on didactic knowledge (i.e., biochemical, molecular, and clinical genetics) and abilities to provide support and guidance compatible with community attitudes and practices (Cohen, 1984; Emery and Pullen, 1984; Kessler, 1979; Witmer, Wedl, and Black, 1984). Researchers have documented the need for cross-cultural effectiveness in genetic counseling education (Goldstein and Bowles-Biesecker, 1993; Walker et aL, 1990; Wang and Punales-Morejon, 1992; Weil and Mittman, 1993). The National Society of Genetic Counselor's Code of Ethics has addressed professional practices around cultural issues stating that genetic counselors should "strive to respect their client's beliefs, cultural traditions, inclinations, circumstances, and feelings" (National Society of Genetic Counselors, 1992, p. 42). Nevertheless, standards of cross-cultural competency for genetic counselors have not been established. Researchers in other counseling fields have developed criteria for cross-cultural counseling competency. Cross-cultural competency of counselors has been based on the acquisition of knowledge, awareness of beliefs and attitudes, and skills of: (1) social, cultural, and institutional
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barriers that restrict utilization of services; (2) the socio-political context of worldviews; (3) the counselor's own worldview and how his or her values and biases may influence clients; (4) valuing and acknowledging cultural differences; (5) particular knowledge of a group membership(s) he or she may be working within the context of within group variation; (6) general knowledge and understanding of counseling; (7) sending and receiving verbal and nonverbal communications accurately and appropriately (American Psychological Association, 1991; Carney and Kahn, 1984; Casas, Ponterotto, and Gutierrez, 1986; Ibrahim and Arredondo, 1986; Ponterotto and Casas, 1991; Sue, Arrendondo, and McDavis, 1992; Sue, Bernier, Durran, Feinberg, Pedersen, Smith, and Vasquez-Nuttal, 1982; and (8) understanding racial- cultural identity models (Ponterotto and Casas, 1991). Since no formal training of cross-cultural genetic counseling exists, genetic counseling programs and counselors have based their cultural competency upon culture specific information provided by speakers from all of the different cultural groups, clinical practica, second language training, recruitment of students from "diverse" backgrounds (Smith, SteinbergWarren, and Misra, 1993; Weil and Mittman, 1993), training members of target communities as case mangers or genetic assistants (Dixson et al., 1992); working with "culturally diverse colleagues" (Dixson et aL, 1992, p. 273), and educational programs and meetings focusing on cultural specific information and self-awareness/sensitivity (Barker, 1992; Paul and Kavanagh, 1990; Weil and Mittman, 1993). Genetic counselors have taken the approach of collecting culture specific information of people who are different from the White dominant culture of the United States to understand cultural complexity (Paul and Kavanagh, 1990; Ponterotto and Casas, 1987). Sue and Zane (1987) have suggested that this strategy of limiting counseling interventions to culturespecific notions and techniques is a form of cultural oppression (Sue and Zane, 1987). Funded by the Special Projects Fund in 1993 from the National Society of Genetic Counselors and the Kitson Fund from the Department of Social, Organizational, and Counseling, Teachers College, Columbia University, The Handbook of Genetic Counseling was developed to provide genetic counseling programs a curriculum to teach cross-cultural genetic counseling. The theoretical underpinning and organization of the Handbook of Cross-Cultural Genetic Counseling is based on the conventional cultural competencies outlined by the Education and Training Committee of the Division of Counseling Psychology of the American Psychological Association (Sue et al., 1982) and others (Ibrahim and Arredondo, 1986; Ponterotto and Casas, 1991). (Reader note: The Division of Counseling
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Psychology is currently sponsoring a national committee [Sue, Carter, Casas, Fouad, Ivey, LaFromboise, Manese, Ponterotto, and VasquezNuttal, 1992] to re-examine and update the competency report published in 1982). The cultural competencies are organized into didactic presentations and experiential group learning along three general areas: cultural knowledge, cultural awareness and beliefs, and counseling skills. Cultural Knowledge refers to the counselor's knowledge of the client's culture and worldview in the genetic counseling relationship. Cultural awareness and beliefs is the genetic counselor's sensitivity to her or his personal values and biases and how they may influence perceptions of the clients, the client's problem, and the counseling relationship. A culturally aware genetic counselor understands that different worldviews may be operating in a cross-cultural counseling session (Sue and Sue, 1990). Cultural skills of the genetic counselor is his or her ability to intervene in a manner that is culturally sensitive and relevant. The objective of the curriculum is to provide knowledge of cultural concepts and issues, examine issues of self-awareness and transference/countertransference, awareness within the context of group dynamics, and the acquisition of genetic counseling skills within a cultural context. The format of the curriculum is designed to accommodate the prevailing medical and genetic requirements in genetic counseling programs. The curriculum is divided into a series of five components each lasting approximately 2 hours in duration. A series of audiovisual slides, group exercises, and/or audiovisual tapes accompany each component. Each component has a corresponding set of recommended readings. An extensive bibliography of additional readings was developed and can be used at the discretion of the genetic counseling training program. The Handbook of Cross-Cultural Genetic Counseling is developed to function independently within a genetic counseling curriculum and be supplemented with additional speakers. The cultural curriculum is organized into a series of five sections: Component 1: General Cultural Knowledge. The first component introduces the rationale and theoretical underpinnings of cross-cultural counseling theory. Worldview is examined within the context of health care systems. Component 2: Cultural Awareness. Part 1: Self in Relation to Self explores the self-awareness of the student's own cultural self-understanding through racial and cultural identity development and how accepted norms and institutional prejudices are manifested and affect self perceptions. Assumption and behaviors are explored through didactic lectures, group exercises, and a videotape presentation.
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Component 3: Guidelines for Counseling Clients familiarizes the genetic counseling student with the efficacy and issues of verbal and nonverbal c o m m u n i c a t i o n . The dynamics and impact of third party interpreters are be examined. Cultural knowledge of various cultural groups is addressed within the value orientations model of Kluckhohn and Strodtbeck (1961). This information is placed within the context of cross-cultural competency. Component 4: Cultural Awareness. Part 2: Self in Relations to Others examines cultural assumptions by increasing awareness of societal influences and expectations of genetic counselors and clients. Issues of power and authority within groups and between domains of difference are examined through a videotape and group exercise examining the dynamics of difference. Component 5: Cultural Counseling Skills. Role play analysis through prescribed vignettes provides experience and practice of cultural interventions in genetic counseling sessions. The skills component is based upon Pedersen's Triad model but uses four roles, the client, the anti-counselor, the genetic counselor, and the anti-client. This self-talk model heightens the awareness of the internal and covert processes that occur and affect genetic counseling sessions. The efficacy of the Handbook of Cross-Cultural Genetic Counseling and its' influence on cultural competency is currently being evaluated. The affirmation of the Handbook of Cross-Cultural Genetic Counseling by genetic counseling training program directors has been encouraging. The curriculum was initially piloted at three board certified genetic counseling training programs: Sarah Lawrence College (New York); Northwestern University (Illinois), and; the University of Colorado (Colorado). Additional training workshops of the Handbook of Cross-Cultural Genetic Counseling have been completed at other genetic counseling programs including: the Medical College of Virginia (Virginia), Indiana University (Indiana), the University of California Berkeley (California), and the University of Minnesota (Minnesota). These programs as well as the University of Pittsburgh's program have incorporated the Handbook of Cross-Cultural Genetic Counseling into their curriculum. Directors at two other training programs, the University of Cincinnati (Ohio) and the University of South Carolina (South Carolina) have made inquiries into using the Handbook of Cross-Cultural Genetic Counseling. Incorporating cultural competency issues into genetic counseling curricula provides students an important learning opportunity to develop a sophisticated understanding of how culture and worldviews affect genetic counseling. Genetic counselors and clients do not function in a vacuum isolated from a socio-political reality. Cultural competency of genetic counselors
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necessitates combining an understanding of culturally learned perspectives that are unique to a particular culture, qualities specific to an individual, and common universals that are shared across cultures. Cross-cultural genetic counseling is more than gathering knowledge and facts of visible racial-ethnic groups and cultural sensitivity training. Genetic counselors need to develop cultural competency by applying counseling interventions within a socio-political context of cultural knowledge, self-awareness, and awareness of others. Cultural competency in genetic counseling has suffered because a systematic approach to teaching cultural genetic counseling has not existed within training programs or taught to practicing genetic counselors. Thus, the major purpose of the Handbook o f Cross-Cultural Genetic Counseling has been to furnish genetic counseling training programs and professionals with the necessary theory, awareness, and counseling skills to provide culturally meaningful genetic counseling.
ACKNOWLEDGMENTS T h e d e v e l o p m e n t of the H a n d b o o k o f Cross-Cultural Genetic Counseling was funded by the Special Projects Fund in 1993 from the National Society of Genetic Counselors and the Kitson Fund from the Department of Social, Organizational, and Counseling, Teachers College, Columbia University. The author gratefully thanks Patricia M. Raskin, Ph.D. and Roger A. Myers, Ph,D. who both reviewed portions of this manuscript and have p r o v i d e d s u p p o r t and guidance t h r o u g h o u t the d e v e l o p m e n t and implementation of the handbook and Robert T. Carter, Ph.D. for his inspiration and encouragement. The author also thanks the two manuscript reviewers for their thoughtful comments.
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McRae MB, Johnson SD (1991) Toward training for competence in multicultural counselor" education. J Counsel Dev 70(1): 131-135. Mittman I (1990) Immigration and the provision of genetic services. In: Paul N, Kavanagh L (eds) Genet& Services for Underserved Populations. Birth Defects Original Article Series (vol 26, no 2). Washington, D.C.: National Center for Education in Maternal and Child Health, pp. 139-146. National Conference (1990) Overcoming Cultural Barriers to Genetic Counseling. Tucson, AZ, April 18-20. National Society of Genetic Counselors (1992) National Society of Genetic Counselors Code of Ethics. J Genet Counsel 1(1):41-43. Papajohn J, Spiegel J (1976) Transactions in Families. San Francisco: Jossey-Bass. Paul N, Kavanagh L (eds) (1990) Genetic Services for Underserved Populations. Birth Defects Original Article Series (vol 26, no 2). Washington, D.C.: National Center for Education in Maternal and Child Health. Pedersen, PB (1985) Handbook of Cross-Cultural Counseling and Therapy. Westport, CT: Greenwood Press. Pedersen PB (1991) Multiculturalism as a generic approach to counseling. J Counsel Dev 70: 6-12. Perez-Stable E (1987) Issues in Latino health care. Western J Med 146:213-218. Pinderhughes E (1989) Understanding, Race, Ethnicity, & Power New York: The Free Press. Ponterotto JG, Casas M (1991) Handbook of Racial~Ethnic Minority Counseling Research. Springfield, IL: Charles C. Thomas Publisher. Ponterotto JG, Casas M (1987) In search of multicultural competence within counseling education. J Counsel Dev 64:430-434. Scott JA, Walker AP, Eunpu DL, Djurdinovic L (1987) Genetic counselor training: A review and considerations for the future. A m J Hum Genet 46:191-199. Segall MH, Dasan PR, Berry JW, Poortinga YH (1990) Human Behavior in Global Perspective: An Introduction to Cross-Cultural Psychology. New York: Pergamon. Smith ACM (1993) Update on Master's Genetic Counseling training programs: Survey of curriculum content and graduate analysis summary. J Genet Counsel 2(3):197-212. Smith SC, Steinberg-Warren N, Misra L (1993) Minority recruitment into the genetic counseling profession. J Genet Counsel 2(3):171-182. Sue DW (1978) World view and counseling. Personnel Guidance J 56:458-462. Sue DW, Sue D (1990) Counseling the Culturally Different: Theory and Practice (2nd Ed.). New York: John Wiley & Sons. Sue DW, Arredondo P, McDavis RJ (1992) Multicultural counseling competencies and standards: A call to the profession. J Multicult Counsel Dev 20:64-88. Sue DW, Bernier JE, Durran A, Feinberg L, Pedersen P, Smith EJ, Vasquez-Nuttal E (1982) Position paper: Cross-cultural counseling competencies. Counsel Psychol 10:45-52. Sue DW, Carter RT, Casas JM, Fouad N, lvey AE, LaFromboise TD, Manese J, Ponterotto JG, Vasquez-Nuttal E (1992). Cross-cultural competency (II) group (manuscript in progress). Sue S, Zane N (1987) The role of culture and cultural techniques in psychotherapy: A critique and reformulation. A m Psychol 10:45-52. Takaki R. (1979) Iron Cages. New York: Oxford University Press. Thorngren M (1990) Health care concerns of Hispanic populations. In Paul N, Kavanagh L (eds) Genetic Services for Underserved Populations. Birth Defects Original Article Series (vol 26, no 2). Washington, D.C.: National Center for Education in Maternal and Child Health, pp. 39-45. Tyler FB, Sussewell DR, Williams-McCoy J (1985) Ethnic validity in psychotherapy. P~ychotherapy, 22:311-320. U.S. Census (1990) 1990 Census of Population and Housing. Summary Tape file 1A. U.S. Census (1990) U.S. Census of Population and Housing. Summary Tape 3A. Walker AP, Scott JA, Biesecker BB, Conover B, Blake W, Djurdjinovic L (1990) Report of the 1989 Asilomar Meeting on Education in Genetic Counseling. A m J Hum Genet 46:1223-1230.
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Wang V, Marsh FH (1992) Ethical principles and cultural integrity in health care delivery: Asian ethnocultural perspectives in genetic services. J Genet Counsel I(1):81-92. Wang V, Punales-Morejon D (1992) Evaluating cultural awareness, knowledge, and skills: A prototype for the development of multiculturalism in genetic counseling [Abstract]. J Genet Counsel 1(4):340-341. Weil J, Mittman I (1993) A teaching framework for cross-cultural genetic counseling. J Genet Counsel 2(3):159-169. Witmer JM, Wedl L, Black B (1986) Genetic counseling: Ethical and professional role implications. J Counsel Dev 64:337-340.
Cultural Competency in Genetic Counseling Vivian Ota Wang t,2
Incorporating a cross-cultural curriculum into genetic' counseling training programs demonstrates a professional conviction of genetic counselors that cultural issues are important in genetic counseling. Funded by the Special Projects Fund in 1993 from the National Society of Genetic Counselors and the Kitson Fund from the Department of Social, Organizational, and Counseling Psychology, Teachers College, Columbia University, the Handbook of Cross-Cultural Genetic Counseling was developed to provide genetic counseling programs a curriculum to teach cross-cultural genetic counseling. The theoretical rationale for the development of a cultural curriculum is presented. By expanding cultural knowledge, developing an awareness of oneself and others, and increasing the repertoire of culturally relevant counseling skills within a socio-political context, genetic counselors will be able to better serve all clients seeking genetic counseling. KEY WORDS: cultural competency; genetic counseling training programs; cross-cultural; education.
INTRODUCTION As genetic services expand because of available medical technology and are thus increasingly utilized by the presently underserved racially and ethnically visible population, the importance of cross-cultural competency becomes more crucial. The most recent census data (1990) shows a significant increase in the number of Blacks, American Indians, Asian/Pacific Islanders, and Latinos in the United States (U.S. Census, 1991). In particular, emigration patterns from Asian and Latin American countries have changed 1Department of Counseling Psychology, Teachers College, Columbia University, New York, New York. 2Correspondence should be directed to Vivian Ota Wang, Department of Counseling Psychology, Box 102, Teachers College, Columbia University, New York, New York 10027. 267 1059-7700/94/1200-0267507.00/1© 1994NationalSocietyof GeneticCounselors,Inc.
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(Lin-Fu, 1988). Between 1970 to 1990 the Latino population in the United States increased 145% and the Asian/Pacific population by 375%. About 22.3 million Latinos and 7.2 million Asian/Pacific Islanders now live in the United States (U.S. Census, 1990). Almost one in three Americans are either foreign born or members of racially-ethnically visible groups. Given the present rate of emigration as well as fertility rates, the researchers at the Bureau of Immigration have predicted that by the year 2040, Whites will comprise only 62% of the total population (Bouvier and Gardner, 1986; Lamm and Imhoff, 1985). These shifts in the United States population have led genetic counselors to acknowledge the importance of culturally appropriate interventions (National Conference, 1990; Paul and Kavanagh, 1990). Genetic professionals often cite cultural barriers as a major obstacle for those seeking genetic counseling (Lin-Fu, 1988, 1990a; Mittman, 1990; Thorngren, 1990). When counseling has been available, clients have often been misunderstood by genetic counselors because of disparate health beliefs and social customs (Barker, 1990; Hartog and Hartog, 1983; Lew, 1990; Perez-Stable, 1987; Wang and Marsh, 1992). Unfortunately, the cultural issues in genetic counseling have predominantly been limited to categorized ideas about service delivery and knowledge of racially and ethnically visible people (Dixson, Dang, Cleveland, and Peterson, 1992; Paul and Kavanagh, 1990). Thus, the "cultural" client has been analyzed and studied with little focus on the culturally latent values, beliefs, and stereotypes of the counselor (McRae and Johnson, 1991). Since the primary focus has been on the client, the counselor's values, beliefs, and ideas about power and authority within a given socio-political reality have been overlooked. Thus, it has been suggested that genetic counseling training programs include a cross-cultural genetic counseling curriculum (Weil and Mittman, 1993). In general, cross cultural researchers have begun to address the complexity of culture not only to understand "exotic groups" but also to understand practitioners (Pedersen, 1991; Segall, Dasan, Berry, and Poortinga, 1990). By understanding cultural encounters both within a client's world view and of their own, counselors might develop more accurate perceptions and engage in more relevant interventions (Leighton, 1982; Pedersen, 1985). Like other counseling programs, genetic counseling has traditionally reflected the majority world view of the dominant White, Anglo-Saxon, Protestant culture (Benkendorf, Callanan, Grobstein, Schmerler, and FitzGerald, 1992; Katz, 1985; Marks, 1993; Pedersen, 1991; Sue and Sue, 1990; Takaki, 1979; Wrenn, 1962, 1985). Consequently people who have this perspective often fail to include the alternative world views of others who might not share this viewpoint (Takaki, 1979). By broadening the existing
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paradigms to include other cultural worldviews, thinking and decision-making processes might be better understood and applied in both academic and clinical settings (Ibrahim, 1985; Ibrahim and Schroeder, 1990; Lynch and Hanson, 1992; Pedersen, 1991; Sue, 1978; Sue and Sue, 1990).
WORLDVIEW
Worldviews are conceptual frameworks of values, beliefs, feelings, and attitudes that affect thoughts, decisions, and behaviors (Ibrahim, 1985; Ivey, Ivey, and Simek-Downing, 1987; Kluckhohn and Strodtbeck, 1961; Leighton, 1982; Pedersen, 1985; Sue and Sue, 1990). A person's worldview is a personal cultural reality from which he or she views and finds meaning of the world (Ibrahim, 1991). When feelings, thoughts, assumptions, and biases have not been examined, a person may presume his or her worldview as universal and just (Pedersen, 1985; Pedersen, 1987; Sue and Sue, 1990; Tyler, Sussewell, and Williams-McCoy, 1985). Genetic counselors may be operating from this universalist perspective by primarily focusing on other worldviews rather than examining their own (Wang and Punales-Morejon, 1992). Thus, genetic counselors need to develop their capacity to become aware of their worldviews while understanding the worldviews of their clients as a way to more competently practice genetic counseling. The concepts of culture and worldview are complex (Papajohn and Speigel, 1976; Pinderhughes, 1989). Kluckhohn and Murray (1953) have discussed cultural complexity as universal (every person is like all persons), culture specific (like some persons), and individualistic (like no other persons). Their model of human universality, culture specificity, and individual uniquenesses for understanding worldview has been expanded in the Integrative Model of Cross-Cultural Counseling-Complex Dynamic Formulation (Leong, 1994). Leong has proposed that the universal assumptions of traditional Western counseling, the cultural group orientation of the racial identity models, and the focus of individual uniquenesses in existential and social learning models should be integrated when understanding worldviews. He has suggested that exploring the simultaneous influences of human universality, cultural specificity, and individual uniqueness is necessary to gain a clearer cultural understanding of people. Leong has submitted that people are a complex adaptive system. Their thoughts, feelings, and behavior styles are constantly adjusting to the continuous shifts between these three perspectives. The consequence for neglecting any one of these influences may be a misunderstanding of a person's worldview.
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Cross-cultural genetic counseling is complex. Therefore, competency should be more than gathering knowledge and facts about racially and ethnically visible individuals. Cultural complexity involves accounting for the individualistic, culture specific, and universal aspects of the client's and counselor's worldviews and translating this information into appropriate counseling interventions (Pinderhughes, 1989). Unfortunately, a study examining cultural competency of practicing genetic counselors has shown cultural genetic counseling to mean knowing only specific cultural knowledge without understanding and awareness of its' broader socio-political implications (Wang and Punales-Morejon, 1992).
CULTURAL COMPETENCY IN GENETIC COUNSELING Approximately 100 genetic counseling students graduate from genetic counseling programs annually (Smith, 1993). Minimum curriculum guidelines have been previously suggested by certification stipulations of the subspeciality of Genetic Counseling within the American Board of Medical Genetics (ABMG) and is currently being re-evaluated by the American Board of Genetic Counseling. Training has involved a two year academic curriculum of seven specific didactic content areas and supervised clinical fieldwork in at least 50 cases representing a broad spectrum of counseling situations (Dumars, Burns, Kessler, Marks, and Walker, 1979; Scott, Walker, Eunpu, and Djurdinovic, 1987; Walker, Scott, Biesecker, Conover, Blake, and Djurdinovic, 1990). Genetic counselors' competencies have been based on didactic knowledge (i.e., biochemical, molecular, and clinical genetics) and abilities to provide support and guidance compatible with community attitudes and practices (Cohen, 1984; Emery and Pullen, 1984; Kessler, 1979; Witmer, Wedl, and Black, 1984). Researchers have documented the need for cross-cultural effectiveness in genetic counseling education (Goldstein and Bowles-Biesecker, 1993; Walker et aL, 1990; Wang and Punales-Morejon, 1992; Weil and Mittman, 1993). The National Society of Genetic Counselor's Code of Ethics has addressed professional practices around cultural issues stating that genetic counselors should "strive to respect their client's beliefs, cultural traditions, inclinations, circumstances, and feelings" (National Society of Genetic Counselors, 1992, p. 42). Nevertheless, standards of cross-cultural competency for genetic counselors have not been established. Researchers in other counseling fields have developed criteria for cross-cultural counseling competency. Cross-cultural competency of counselors has been based on the acquisition of knowledge, awareness of beliefs and attitudes, and skills of: (1) social, cultural, and institutional
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barriers that restrict utilization of services; (2) the socio-political context of worldviews; (3) the counselor's own worldview and how his or her values and biases may influence clients; (4) valuing and acknowledging cultural differences; (5) particular knowledge of a group membership(s) he or she may be working within the context of within group variation; (6) general knowledge and understanding of counseling; (7) sending and receiving verbal and nonverbal communications accurately and appropriately (American Psychological Association, 1991; Carney and Kahn, 1984; Casas, Ponterotto, and Gutierrez, 1986; Ibrahim and Arredondo, 1986; Ponterotto and Casas, 1991; Sue, Arrendondo, and McDavis, 1992; Sue, Bernier, Durran, Feinberg, Pedersen, Smith, and Vasquez-Nuttal, 1982; and (8) understanding racial- cultural identity models (Ponterotto and Casas, 1991). Since no formal training of cross-cultural genetic counseling exists, genetic counseling programs and counselors have based their cultural competency upon culture specific information provided by speakers from all of the different cultural groups, clinical practica, second language training, recruitment of students from "diverse" backgrounds (Smith, SteinbergWarren, and Misra, 1993; Weil and Mittman, 1993), training members of target communities as case mangers or genetic assistants (Dixson et al., 1992); working with "culturally diverse colleagues" (Dixson et aL, 1992, p. 273), and educational programs and meetings focusing on cultural specific information and self-awareness/sensitivity (Barker, 1992; Paul and Kavanagh, 1990; Weil and Mittman, 1993). Genetic counselors have taken the approach of collecting culture specific information of people who are different from the White dominant culture of the United States to understand cultural complexity (Paul and Kavanagh, 1990; Ponterotto and Casas, 1987). Sue and Zane (1987) have suggested that this strategy of limiting counseling interventions to culturespecific notions and techniques is a form of cultural oppression (Sue and Zane, 1987). Funded by the Special Projects Fund in 1993 from the National Society of Genetic Counselors and the Kitson Fund from the Department of Social, Organizational, and Counseling, Teachers College, Columbia University, The Handbook of Genetic Counseling was developed to provide genetic counseling programs a curriculum to teach cross-cultural genetic counseling. The theoretical underpinning and organization of the Handbook of Cross-Cultural Genetic Counseling is based on the conventional cultural competencies outlined by the Education and Training Committee of the Division of Counseling Psychology of the American Psychological Association (Sue et al., 1982) and others (Ibrahim and Arredondo, 1986; Ponterotto and Casas, 1991). (Reader note: The Division of Counseling
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Psychology is currently sponsoring a national committee [Sue, Carter, Casas, Fouad, Ivey, LaFromboise, Manese, Ponterotto, and VasquezNuttal, 1992] to re-examine and update the competency report published in 1982). The cultural competencies are organized into didactic presentations and experiential group learning along three general areas: cultural knowledge, cultural awareness and beliefs, and counseling skills. Cultural Knowledge refers to the counselor's knowledge of the client's culture and worldview in the genetic counseling relationship. Cultural awareness and beliefs is the genetic counselor's sensitivity to her or his personal values and biases and how they may influence perceptions of the clients, the client's problem, and the counseling relationship. A culturally aware genetic counselor understands that different worldviews may be operating in a cross-cultural counseling session (Sue and Sue, 1990). Cultural skills of the genetic counselor is his or her ability to intervene in a manner that is culturally sensitive and relevant. The objective of the curriculum is to provide knowledge of cultural concepts and issues, examine issues of self-awareness and transference/countertransference, awareness within the context of group dynamics, and the acquisition of genetic counseling skills within a cultural context. The format of the curriculum is designed to accommodate the prevailing medical and genetic requirements in genetic counseling programs. The curriculum is divided into a series of five components each lasting approximately 2 hours in duration. A series of audiovisual slides, group exercises, and/or audiovisual tapes accompany each component. Each component has a corresponding set of recommended readings. An extensive bibliography of additional readings was developed and can be used at the discretion of the genetic counseling training program. The Handbook of Cross-Cultural Genetic Counseling is developed to function independently within a genetic counseling curriculum and be supplemented with additional speakers. The cultural curriculum is organized into a series of five sections: Component 1: General Cultural Knowledge. The first component introduces the rationale and theoretical underpinnings of cross-cultural counseling theory. Worldview is examined within the context of health care systems. Component 2: Cultural Awareness. Part 1: Self in Relation to Self explores the self-awareness of the student's own cultural self-understanding through racial and cultural identity development and how accepted norms and institutional prejudices are manifested and affect self perceptions. Assumption and behaviors are explored through didactic lectures, group exercises, and a videotape presentation.
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Component 3: Guidelines for Counseling Clients familiarizes the genetic counseling student with the efficacy and issues of verbal and nonverbal c o m m u n i c a t i o n . The dynamics and impact of third party interpreters are be examined. Cultural knowledge of various cultural groups is addressed within the value orientations model of Kluckhohn and Strodtbeck (1961). This information is placed within the context of cross-cultural competency. Component 4: Cultural Awareness. Part 2: Self in Relations to Others examines cultural assumptions by increasing awareness of societal influences and expectations of genetic counselors and clients. Issues of power and authority within groups and between domains of difference are examined through a videotape and group exercise examining the dynamics of difference. Component 5: Cultural Counseling Skills. Role play analysis through prescribed vignettes provides experience and practice of cultural interventions in genetic counseling sessions. The skills component is based upon Pedersen's Triad model but uses four roles, the client, the anti-counselor, the genetic counselor, and the anti-client. This self-talk model heightens the awareness of the internal and covert processes that occur and affect genetic counseling sessions. The efficacy of the Handbook of Cross-Cultural Genetic Counseling and its' influence on cultural competency is currently being evaluated. The affirmation of the Handbook of Cross-Cultural Genetic Counseling by genetic counseling training program directors has been encouraging. The curriculum was initially piloted at three board certified genetic counseling training programs: Sarah Lawrence College (New York); Northwestern University (Illinois), and; the University of Colorado (Colorado). Additional training workshops of the Handbook of Cross-Cultural Genetic Counseling have been completed at other genetic counseling programs including: the Medical College of Virginia (Virginia), Indiana University (Indiana), the University of California Berkeley (California), and the University of Minnesota (Minnesota). These programs as well as the University of Pittsburgh's program have incorporated the Handbook of Cross-Cultural Genetic Counseling into their curriculum. Directors at two other training programs, the University of Cincinnati (Ohio) and the University of South Carolina (South Carolina) have made inquiries into using the Handbook of Cross-Cultural Genetic Counseling. Incorporating cultural competency issues into genetic counseling curricula provides students an important learning opportunity to develop a sophisticated understanding of how culture and worldviews affect genetic counseling. Genetic counselors and clients do not function in a vacuum isolated from a socio-political reality. Cultural competency of genetic counselors
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necessitates combining an understanding of culturally learned perspectives that are unique to a particular culture, qualities specific to an individual, and common universals that are shared across cultures. Cross-cultural genetic counseling is more than gathering knowledge and facts of visible racial-ethnic groups and cultural sensitivity training. Genetic counselors need to develop cultural competency by applying counseling interventions within a socio-political context of cultural knowledge, self-awareness, and awareness of others. Cultural competency in genetic counseling has suffered because a systematic approach to teaching cultural genetic counseling has not existed within training programs or taught to practicing genetic counselors. Thus, the major purpose of the Handbook o f Cross-Cultural Genetic Counseling has been to furnish genetic counseling training programs and professionals with the necessary theory, awareness, and counseling skills to provide culturally meaningful genetic counseling.
ACKNOWLEDGMENTS T h e d e v e l o p m e n t of the H a n d b o o k o f Cross-Cultural Genetic Counseling was funded by the Special Projects Fund in 1993 from the National Society of Genetic Counselors and the Kitson Fund from the Department of Social, Organizational, and Counseling, Teachers College, Columbia University. The author gratefully thanks Patricia M. Raskin, Ph.D. and Roger A. Myers, Ph,D. who both reviewed portions of this manuscript and have p r o v i d e d s u p p o r t and guidance t h r o u g h o u t the d e v e l o p m e n t and implementation of the handbook and Robert T. Carter, Ph.D. for his inspiration and encouragement. The author also thanks the two manuscript reviewers for their thoughtful comments.
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