Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy

Monday, October 31, 2011

Ethics, Diversity, and Multiculturalism

Samuel Knapp, Ed.D., ABPP
Director of Professional Affairs

Recent years have seen an emphasis on multiculturalism and diversity issues within psychology* both by addressing the ability of professional psychologists to serve the health care needs of cultural minorities, and by increasing the number of psychologists from ethnically diverse backgrounds. The two strategies may be synergistic. For example, graduate programs with a critical mass of diverse students may find that the minority students will teach (even if informally) the European American students to become more culturally competent.

This movement has a foundation in the underlying ethical foundations of our profession. Sometimes psychologists use the word ethics to refer to the minimal standards of conduct that apply to all psychologists and that could be the basis of a disciplinary action by a licensing board or malpractice suit. The enforceable Standards of the APA Ethics Code specifically state that psychologists should not discriminate unfairly (Standard 3.01, Unfair Discrimination) nor harass (Standard 3.03, Harassment) based on age, gender, gender identity, sexual orientation, race, culture, national origin, language, religion, disability, or socioeconomic status. In addition, psychologists should ensure that they are competent when working with diverse populations (Standard 2.01b, Competence); ensure that they use tests Awhose validity and reliability have been established for use with members of the population tested@ (9.02b, Assessments); interpret tests with consideration of linguistic and cultural differences (Standard 9.06); and ensure that consent is obtained when using interpreters (9.03c).

Ethics also refers to the General or Aspirational Principles that follow the Preamble in the APA Ethics Code. Unlike the enforceable Standards, which can be the basis for a disciplinary complaint against a psychologist, the General Principles are guides for psychologists on how to excel in their professional roles. They can also inform the ethical decision making process. The General Principles state, among other things, that psychologists Aare aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origins, religion, sexual orientation, language, and socioeconomic status.@ (Principle E, Respect for People=s Rights and Dignity).

Finally, ethics refers to personal overarching moral perspectives derived from philosophical or religious instruction or study which inform our day-to-day behavior. The enforceable Standards, General (Aspirational) Principles, and personal sense of morality can overlap considerably. For example, a psychologist who has a personal moral perspective, perhaps based on religious instruction, who believes in the universality of human rights and dignity, would easily see that reflected in General Principle E, and operationalized in the directive to avoid unfair discrimination or harassment of individuals based on incidental demographic factors.

Few psychologists end up being disciplined specifically for violating enforceable ethical standards related to diversity or multiculturalism. In that sense, diversity and multiculturalism have only a small overlap with ethics. However, many psychologists struggle over how to implement the General (Aspirational) principles and their personal sense of morality when providing professional services to diverse populations. In that sense, diversity and multiculturalism are deeply intertwined with ethics.

The emphasis on a diverse or multicultural perspective appears to rest primarily on two overarching ethical principles. First, diversity or multiculturalism is justified on the basis of justice, in that it helps ensure a more equal access to quality psychological services to persons from traditionally marginalized groups who otherwise would not find them available.

Also, diversity and multiculturalism are justified on the basis of beneficence and nonmaleficence in that psychologists with a diverse or multicultural perspective will do better at treating patients and will reduce the likelihood that they will harm patients. Although many authors have argued that a diverse or multicultural perspective will improve outcomes, this relationship was verified by the meta-analysis of Griner and Smith (2006) who found that interventions targeted to specific cultural groups were more effective than generic interventions provided to heterogeneous groups. AOverall, culturally adapted interventions resulted in significant client improvement across a variety of conditions and outcome measures@ (p. 541). In other words, psychologists should be able to upgrade the quality of their services to multicultural patients by accommodating multicultural perspectives into their treatment.

Striving for excellence requires more than just good intentions; it requires a conscientious effort at self-reflection and training. For example, consider the experience of one psychologist supervisor who was trying very conscientiously to develop a supervisory relationship based on her deeply held moral values of trust and empowerment. This supervisor was very committed to feminist ideas of equality and power sharing. She told her internship students that they should feel free to challenge her during supervision. For some students this was very empowering and helped them to become more comfortable in sharing their thoughts openly. For another student, the comment created anxiety because it is normative in her Asian culture to show great respect for hierarchy and not to challenge authority directly. Fortunately, the student was able to receive advice on how to approach her supervisor about this issue.

Here is another example from my personal experience. About 30 years ago I temporarily worked in an urban mental health clinic after working in very rural mental health centers for several years where I commonly introduced myself to my adult patients by my first name and used their first names as well. However, when I took a job in an urban inner city mental health clinic, in my effort to be egalitarian, I continued to introduce myself to my adult patients, who were mostly African American, by my first name and used their first names as well. However, an African American social worker explained to me that African American males are used to being called by their first names by all Whites, regardless of their age or status. It would be more respectful, she explained, if I called them by their surname and later asked permission to use their first name. Therefore, I became aware of a personal blind spot. I learned that my greeting style, which appeared appropriate and egalitarian in rural Pennsylvania, came across quite differently with inner city African American patients.

Or consider this last example: A psychologist sometimes worked with Spanish-surnamed patients and was always careful to ensure that they were comfortable using English (or getting an interpreter if they were not). One patient with a Spanish surname reported that she felt comfortable conducting psychotherapy in English. She related a background of substantial trauma and strife, but did so in a detached manner. However, research shows that the affect associated with a traumatic event can be captured more intensely through the use of the patient's primary language at the time that the trauma occurred. Relating the trauma in a language that was learned subsequently does not evoke the intensity of feeling or vividness of imagery as it would if the patient had used the original language. A psychologist who was not aware of this fact might miss the emotional significance of certain past events.

These are just a sample of the issues that can arise and where a knowledge of cultural or diversity factors can improve relationships and outcomes. Many questions arise, such as how can psychologists evaluate the functioning in a diverse family without unfairly pathologizing culturally normative relationships (e.g., averting eyes in some cultures is not a sign of shyness, but a normative sign of respect)? What teaching technique can help psychologists become more alert to their blind spots (e.g., well meaning people may have implicit prejudices outside of their conscious awareness; Knapp, 2007)? How should psychologists respond when patients make racist, homophobic, or sexist remarks? How, or can, English speakers supervise trainees who treat patients where English is not a primary language? How does diversity inform effective practice? When or how to incorporate folk healing remedies or strategies into therapy? How to accurately evaluate refugees in light of stressful or traumatic experiences that they may have encountered? How to respond when patients’ religious beliefs appear to harm their functioning or adjustment? Continued reflection, dialogue, and training will help conscientious psychologists address these issues, and help them to fulfill their aspirations to be just and helpful health care professionals.


Griner, D., & Smith, T. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, 43, 531-548.

Knapp, S. (2007, January). Implicit prejudice: The bad news and the good news. Pennsylvania Psychologist, 6-7.

*The words diversity and multiculturalism are sometimes used synonymously. However, many use the term multiculturalism to refer to ethnic or racial groups, whereas diversity is a broader term that includes multiculturalism and other aspects of identity such as religion, gender, sexual orientation, disability, or socioeconomic status.