Dorothy E. Holmes, PhD
Literature on the psychotherapist’s multicultural competence has burgeoned over the past 35 years. It has delivered increasingly nuanced conceptual and clinical papers on what constitutes multicultural competence. At the same time, research studies to date have failed to link clinically demonstrated multicultural competencies to therapeutic outcomes, leaving the field with two questions to address: Is there a gap between multicultural knowledge and skill in the average clinician, and/or are there conceptual and/or methodological challenges to demonstrating the therapeutic impact of multicultural competencies? This paper suggests that both are true and that the current dilemma is determined by insufficient understanding and/or acceptance of the psychologically deep and abiding ways in which patients, therapists, teachers, and supervisors are affected by multicultural factors. That is, the existing conceptual tools, training models, and research methods do not capture the complexity of attaining and maintaining multicultural competencies. Some suggestions are offered to improve the situation.
THE COMPLEX AND VARIED NATURE OF MULTICULTURAL COMPETENCE
We know now that to achieve multicultural competence the clinician must have a multi-faceted and flexible view of multiculturalism. There are abundant papers in support of this fact, based on clinical cases and theory (Nettles, R. & Balter, 2012; Moodley & Palmer, 2006), and based on empirical research (Berg-Cross & So, 2011). Such writings note that just knowing facts about the styles, values, religion, travail, triumphs, etc. of various cultural groups does not carry over into effective therapeutic action in the consultation room. It is also clear today that any given individual may come for help with numerous co-cultural attributes, and that these attributes are likely to be an important aspect of the person’s total psychological make-up.
There is a wide array of published clinical cases showing the ways in which various cultural factors (e.g., race, ethnicity, gender, sexual orientation, religion) are manifested in the treatment situation (Leong et al, 2006; Holmes, 2002, 2006), how the diversity status of the therapist impacts the treatment (Kaslow et al, 2010; Holmes, 2012b), and on how the therapist struggles to work therapeutically with important cultural factors, as they impact the alliance, and are played out in transference-countertransference manifestations (Haldeman, 2010; Holmes, 2001, 2012a). All of these papers show that how cultural factors work in the consultation room is more than the sum of one’s conscious knowledge, values, and cultural identifications, identities and conflicts. The multicultural competence of the therapist depends on recognition of these facts. How do existing conceptual frameworks, training models and organizational expectations help us to respond to the complexities just summarized?
Specific training models to achieve multicultural competence have been developed and refined over the past several decades. Thy focus on development of three dimensions: multicultural knowledge, the therapists’ awareness of their cultural attitudes, values and biases, and multicultural skills (e.g., Sue & Sue, 1999; Sue, 2001). At the organizational level, the American Psychological Association has promulgated important “Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists” (2003). The established accrediting body for professional psychology education and training in this country, the Commission on Accreditation, requires that training programs articulate multicultural program objectives and curricula and outcomes measures of multicultural competence. They also expect that programs develop systematic an intentional recruitment and retention policies and procedures for inclusion of multicultural faculty and students.
EMPIRICAL V. CLINICAL SUPPORT FOR MULTICULTURAL COMPETENCE
So, there has been advancement in our knowledge base of multicultural psychology; there have been decades of effort to develop models of, and to provide specific training in, various components of multicultural competence, and there is national organizational expectation and monitoring of multicultural competence. Have these efforts enabled us to identify and measure multicultural competence? Unfortunately, the direct answer so far is, “no”. This circumstance has persisted from the mid-1990’s when it was found that while there have been sharp increases in multicultural curricula in graduate psychology programs (Bernal & Castro, 1994), there has not been a corresponding increase in the field’s capacity to demonstrate multicultural competence empirically (Cancio et al, 1995). Berg-Cross and So (2011, p. 9), in reporting on a study by Owen et al (2011), pointed out, “…there is only one [empirical] study…that compares outcome effectiveness based on multicultural competencies. The referenced study employed a client and therapist survey of multicultural knowledge, attitudes, and skills. Overall, they found that multicultural competency was unrelated to differential therapeutic outcomes among therapists”. Correctly, Berg-Cross and So suggested that subtle differences within and among therapist-patient dyads in how and how much they worked with multicultural factors accounted for the lack of findings for the aggregated data.
Limitations of Empirical Studies and Training Models of Multicultural Competence.
The Owen et al finding (2011) relates to the major point of this paper, based on the author’s several decades of teaching and supervising multicultural competencies, and her own journey as a therapist to achieve multicultural competence. Specifically, the current training models, while necessary and useful, are insufficient in that they do not acknowledge the complex and often irrational and unconscious nature of cultural factors that unfold in psychological treatment. Our emphasis to date has been on conscious, rational, and manifest factors that are easily grasped intellectually, but are not deeply integrated emotionally. To the extent that our training models work only at the surface of cultural factors that may emerge in treatment, therapists may sometimes be ill-prepared. Consistent with this point of view, Pope-Davis et al (2003), noted, “Sue’s 2001 model is descriptive but not prescriptive…It really does not illustrate how these dimensions interact or operate as an aggregate construct. Hence, it is difficult to execute the model to reflect cultural competence in everyday professional activities” (p. 27). Also, to the extent that our measurement instruments only relate to the surface of multicultural factors and treatment process, they will not be effective in capturing the therapist’s multicultural competence when it is in evidence.
Why do we stay at the surface of what constitutes the vast array of therapeutically-relevant cultural factors? In this author’s experience, what is in the cauldron of multicultural factors in the consultation room is sometimes quite scary to patients and therapists. Specifically, when cultural factors do come to the fore in therapy, they are often manifest in the form of a prejudice – that the patient has experienced and by which he or she has been deeply affected, and which may play itself out in being directed towards the therapist. Additionally, therapists, too, may become aware of their own prejudices when we work beyond the surface manifestations of cultural factors. There is considerable literature acknowledging the large role of prejudice and discrimination in our society, and their impact on our patients (Berg-Cross & So, 2011; Bartoli & Pyati, 2009). Even the recent APA Presidential Task Force Report on Immigration warns that the current influx of immigrants, which is made up largely of people of color from Latin America, the Caribbean, and Asia, will be subject to discrimination as African-Americans, Hispanics and Asian-Americans continue to be. As Deaux (2006) points out, we live in an anti-immigrant, xenophobic society. The Multicultural Guidelines document referenced above (2003) also notes that cognitive schemas, value systems and social practices powerfully shape human experience. There are also numerous articles noting that while therapists tend to be egalitarian in terms of sincerely held conscious beliefs and values, they also may demonstrate prejudice when confronted with cultural trends (e.g., gay adoption) that buck conventional cultural practices (Eubanks-Carter et al, 2005). Some of our literature hints that psychologists find it difficult to work with cultural factors in a deeper way, as in fully acknowledging to ourselves and with our patients the personal problems that are caused or aggravated by prejudice and discrimination, for example, that poverty and race operate as stressors and that racism leads to depression and anxiety (Aklin et al, 2006).
THE DEEPER PSYCHOLOGY OF MULTICULTURAL COMPETENCE
In this author’s view, the profession of psychology needs to build on its current base of policy and training advances by an acknowledgement of the deeper and more complex levels of prejudice and discrimination that are embodied in our work on multicultural factors in the consultation room. Further, we need to acknowledge that the deeper roots, early origins, and conflicted nature of our subjectivities concerning multicultural factors make them difficult to access and difficult to work with consistently and effectively. As to their early origins, the building blocks of prejudice are established in us from very early in life, some say as early as age two (Vanderbroeck, et al, 2010), and certainly within the preschool years (Raabe, T. & Beelmann, 2011). Thus, some of the roots of prejudicial tendencies are established on the basis of implicit memory, and may require attention to non-verbal factors in treatment (Ivey et al, 1997). It is these kind of considerations that needs to be added to our existing training models and measurement approaches to multicultural competence. Of utmost importance is that those who develop prejudices often will use them to discriminate against members of various out groups, that is, do them harm, either by exclusion or by negative behaviors directed against them (Fiske, S. et al, 2002). It is also important to note that prejudices are held in place by complex unconscious defenses, particularly projection (Moss, 2001) and projective identification (Holmes, 2006). In the former, that which would find disfavor in ourselves if we would acknowledge it, we ascribe to another whom we then avoid. In the latter, we also attribute to another that which we cannot abide in ourselves, but unlike with projection, in projective identification, we seek to punish or otherwise discomfit the other. When such factors arise in the treatment situation, all parties will necessarily be uncomfortable as part of the treatment. Our current training models and measuring instruments do not focus and concentrate on multicultural factors at this level.
Going Deeper: The Need for Enhanced Teaching, Learning, and Supervision of Multicultural Competence.
I think our current training models, policies and case examples are good starting points, but as just reviewed, stay too much on the surface with respect to the complex psychology of multicultural competence. Bartoli & Pyati (2009) may have been alluding to this missing element when they wrote (p. 146), “The scarcity of clear guidelines on how to address racist or (other) prejudicial comments in psychotherapy is striking, given the prevalence of racially charged interactions in psychotherapy…In addition, the messages psychologists receive regarding these issues from different areas of the field are at times contradictory…” What is at the base of the contradictions? In general psychologists tend to be egalitarian. To acknowledge that we, too, can be prejudiced, or even discriminate on the basis of cultural factors is anathema to our conscious values and beliefs. This fact is hinted at when in commenting on how to respond to a patient making a racist comment, Bartoli & Pyati (2009) note (p. 145-146), “As their psychotherapist, your anxiety is likely to rise as you attempt to find appropriate ways to respond. Unfortunately, the same theories you so easily accessed before to assist your clients seem inadequate to help you decide whether, how, and when to therapeutically address their racist or prejudicial comments.” Why are the theories we use for other aspects of our day to day work inadequate when confronted with multicultural factors in the consultation room? In part it is because we pitch our training and education to our conscious, egalitarian values and beliefs, but in the consultation room, and in supervision, other aspects of ourselves and our patients come to the fore, and we find ourselves doing things contradictory to what we have been taught.
So, while in our training, it is urged that we address cultural factors in our work with patients, the literature remains scant on just how to do so in the nitty-gritty of the therapeutic process, especially given that the work may put the patient and/or therapist in touch with their own prejudices and possibilities for discrimination. This gap between what is taught and what is actually accomplished persists despite multiple published resources, including a special issue of Psychotherapy, Theory, Research, Practice, Training on culture, race, and ethnicity in psychotherapy (Leong & Lopez, 2006). In that issue there were numerous rich “conceptual articles…authored by psychotherapists who wrote experience-near pieces including an abundance of case material” (Gelso, 2010, p. 143). Furthermore, there is a recent special section of Psychotherapy, Theory, Research, Practice, Training on the diversity status of the psychotherapist (Kaslow & Kelly, 2010).
Guidelines for Achieving Multicultural Competence in the Classroom.
In addition to lack of in-depth training and overly simplistic measuring tools that cannot capture the vicissitudes of achieving multicultural competence, what else contributes to unpredictable fluctuations or gaps in actual and measured multicultural competence? Perhaps because of the difficult acknowledgments we must make to do the harder therapy work on cultural factors, those beneath the surface, we in various ways tend to let ourselves off the hook. For example, otherwise richly informative scholarship on multicultural competence will include statements such as, “Multicultural factors are not relevant in every psychotherapy case” (Berg-Cross & So, 2011, p. 15). This assertion seems contradictory with the same author’s recommendation in the same paper that all therapists become competent in making multicultural case conceptualizations. They stated, “We believe (making) multicultural case conceptualizations is a core skill…(Berg-Cross & So, p. 11). So, would it be best to leave the matter of the relevancy of multicultural factors an open question in all cases?
Staying Open to the Potential Importance of Multicultural Competence in All Cases.
In this author’s experience, to exempt cultural factors from consideration before the fact of the full unfolding of each case, supports therapists and supervisors in bypassing such factors not because they are irrelevant, but because they are uncomfortable. This can be the case even in the classroom when one seeks to “go deep” on the issues pertaining to multicultural competence, including looking at the psychological ramifications of how cultural factors have played out between dominant and co-cultural groups in our society, affecting all of us – patients and therapists, in both dominant and co-cultural groups. Specifically, we know that discrimination negatively impacts those exposed to it (e.g., damaged self esteem, conflict over one’s strivings and passions based on internalization of nay-saying cultural proscriptions, development of symptoms such as anxiety and depression). Clinicians (Aklin et al, 2006) and educational researchers have documented the ill effects. Early education intervention programs have been developed to prevent or limit the negative effects (Raabe & Beelmann, 2011; Vandenbroeck, et al, 2010). There are negative effects for those who perpetrate and perpetuate stereotypes and prejudices as well. For example, Levy et al (2009) found that those who had used age stereotypes in their youth suffered negative physical health consequences later in life, more than those who had not relied on such stereotypes. There are harmful psychological effects, too, of using the primitive defenses involved in perpetrating and perpetuating discrimination (e.g., devaluation, splitting, projection, projective identification). Certainly, we know that patients who use such defenses are relying on maladaptive defenses and may suffer other psychological problems as well. For example, in the case of Tina reported by Bartoli & Pyati (2009), devaluation of a Latino during one of her sessions was based on Tina’s “inadequacy, insecurity, and powerlessness” (p. 149) which she projected onto a Latino.. Is there any reason to believe that therapists are free of such dynamics? The special issue of Psychotherapy: Theory, Research, Practice, Training referenced above (Kaslow & Kelly) offers insight into therapist dynamics for therapists who have a diverse identity. We need published clinical papers by White therapists as well who have grappled with their struggles to attain multicultural competence, with the emphasis being placed not only on the patient, but on the therapist’s subjectivities and how they played out in the treatment, and how they were then reflected upon as a guide to their own continuing efforts to achieve multicultural competent, and as a teaching guide to others.
The Necessary Discomforts of Achieving Multicultural Competence.
Anxiety in the learning and therapy situations is inevitable when we address multi-cultural competency training at a deeper level. As already noted, our training models to date do an invaluable but incomplete job to the extent that they tend to address the surface aspects of complex factors. However, when we attempt to go below the surface, the anxiety experienced contributes to push backs at various levels. Let us consider the classroom first. Case in point, when this author was teaching a multicultural competence module in a core psychotherapy course, at the beginning when the more descriptive aspects were being presented (e.g., instructing students to ask patients about themselves culturally and about any immediate culturally relevant experiences such as being the only person of color in their work environment), the student pleaded and somewhat protested, “why can’t we just treat a patient’s problem, not their race!!??. This author’s point of view, shared with the student and in a recent paper (Holmes, 2012a), is that there is no such meaningful dichotomy, though we may all seek it at times. He seemed to think that whatever ailed patients could be meaningfully addressed without addressing cultural factors, as if they were trivial surface aspects of a more important clinical reality. It was only when specific clinical examples were offered, showing the inextricable link between cultural factors and clinical issues, did the dubious and protesting student and others come to understand the importance of studying cultural factors and achieving multicultural competence.
As Berg-Cross & So point out there are two important culturally-relevant questions each therapist needs to ask (2011, p. 10), “Do I understand my own cultural baggage in relation to this case? Do I understand my client’s cultural baggage”? They suggest that through such understanding, the therapist will be able to establish a culturally sensitive therapeutic alliance. Here, too, this author thinks such an achievement is a necessary beginning. However, given the extent to which cultural factors have the characteristics already presented – they have developmentally early roots, are easily implicated in proneness to prejudicial use and discrimination; they stir anxiety signaling the possible eruption of dissonant attitudes, thoughts and feelings; the anxiety leads to avoidance – their important meanings and expressions often will need exploration after an effective alliance is established. A positive working alliance is vulnerable to being disrupted or ruptured by the emergence of cultural factors. This is likely to happen not because of a deficiency in the working alliance, but because strong affects, biased attitudes, and tendencies towards prejudice and discrimination associated with cultural factors, when they come into the treatment process, can momentarily disrupt the alliance. Such developments, with explicit attention to the dynamics of the cultural factors involved and repair of any ruptures that occur are not to be avoided, but accepted as a necessary part of the work. The case of Tina presented above (Bartoli and Pyati, 2009) is a case in point. Anti-Latino sentiments erupted in the context of a good alliance when the patient was about to experience her own “inadequacy, insecurity and powerlessness” (p. 149). In other words, her speaking derogatorily about a Latino and devaluing him represented a displacement away from attributes in herself which she devalued. The authors stated that the therapist working with Tina, “chose to base her further interventions on such a conceptualization” (p. 149). However, the specifics of the intervention were not mentioned in the paper. Even so, the authors’ illustration makes clear that the patient’s psychopathology was importantly linked to a propensity in the patient to use race in a prejudicial way. Some patients who in society have been on the receiving end of such prejudice will look to the therapist to acknowledge that they have been affected by such prejudice. Leong & Lee (2006) note that it is important for therapists to acknowledge the racial dynamic and experience to which a client attributes his current difficulties (p. 412).
Clinical Cases Illustrating Multicultural Techniques and Therapists’ Reflections.
Beyond what can be taught to students, as in the kind of case illustrations and discussion noted above, students also need exposure to actual clinical interventions and discussion of therapists’ reflections on why interventions were or were not made. The following two excerpts from reported cases (Moskowitz, 2001; Holmes, 2012) are presented as illustrations of how cultural factors are revealed in the treatment process and specifically how they are addressed, and with what results and reflections on the part of the therapist.
Case 1: Jewish Patient; Jewish Therapist
In reference to his own therapy with a therapist who, like himself, was white and Jewish, Moskowitz (2001) noted that nothing about race came up in his treatment for a very long time. Although Moskowitz had not grown up in close association or physical proximity to Blacks, he dreamed of a Black doorman when he was in a competitive struggle with his therapist. The therapist recognized the doorman as himself since his last name meant “black”, and his therapist explicitly interpreted to Moskowitz that he was making use of the Black doorman to express his wish to gain a competitive advantage over his therapist. Moskowitz stated that he found the interpretation meaningful in his therapy. However, it is of note that Moskowitz thought that there was more work to be done on how he felt about Blacks, including how he had appropriated them into his neurosis, and that he was left to do that work as self-analysis after the conclusion of his treatment. His case illustrates that there is variation in the way therapists treat multicultural factors – whether they do so at all or deeply or long enough. Furthermore, the case illustrates a point made earlier in this paper – that even when there is nothing about cultural factors on the surface of a case, or in its beginning, cultural factors still may emerge over the course of the case. Further, the emerging cultural factors may be importantly linked to the person’s presenting problem, even if not directly or in the early sessions of a treatment. This vignette also illustrates that sameness in the dyad (in this case, same religion and same Whiteness) is not predictive of any particular process, ease in it, or outcome with respect to cultural factors.
Case 2: White Patient, Black Therapist
In a case presented at a national symposium on psychotherapy manifestations of the “Black Nanny-White Mother Dyad” (Holmes, 2012b), a married White male patient was presented for whom his Black nanny was the transference object for his Black therapist, on two multicultural dimensions, race and class. The therapist worked easily and thoroughly on the patient’s racial uses of her that were linked to his Black nanny. For example, after several months of treatment, the patient revealed that his brother-in-law was Black, and that he had not mentioned it because he was uncomfortable about how he felt, knowing that there was no (objective) basis for his feelings, since his brother-in-law was, in personal integrity, education and profession his equal. Nevertheless, he did not feel comfortable that his sister was married to a Black man, and he wondered how his therapist would respond to knowing how he felt. When the patient was explicitly invited by the therapist to look for the missing pieces that would help him and the therapist to understand the discrepancy between his thoughts and his feelings, he shed what seemed to be tears of relief and sadness. In that period of work, several months into treatment, he mentioned for the first time his Black nanny, Mary, who had taken care of him from kindergarten through most of elementary school. She was warmly remembered, a feeling then extended to the therapist. He had loved Mary because she had “spine” and could talk about feelings, qualities he found sorely missing in his parents. Somewhat inconsistent with her having “spine”, Mary responded to the patient’s stated hatred of girls (an aspect of his rivalry with his younger sister), that he could hate girls in general, but that he had to love his sister because she was family. The therapist wondered if he had taken that advice so much to heart that it had become part of his ongoing difficulty acknowledging and managing his anger. He began to understand that his tendency to view himself as weak, discombobulated and inefficacious was a defense against awareness of his anger. Over time, he began to qualify his feelings for Mary, and for the therapist in the transference, and was able to face and work through his anger which required a phase in which he protected himself from fear of retaliation by belittling Mary and the therapist on the grounds that given that both were Black, they had no power or authority over him. So, by openly confronting the defensive aspect of the patient’s idealization of his Black nanny, and explicitly inviting him to explore his racial feelings, race became salient, was directly and emotionally expressed towards the therapist, and became part of the resolution of his problems with anger, which resulted in a less idealized view of the nanny and his therapist, though ultimately, he still identified positively with both.
On reflection, the therapist realized that fuller work could have been done on the multicultural aspects of this case, particularly on the patient’s identification with the poverty of his Black nanny. He saw himself as “poor” like her in that there was a shameful and secreted aspect of his family life (his mother had had an out of wedlock pregnancy) which he linked to Blacks living in poverty. Less work was done on this theme in part because the therapist was hesitant to allow the patient to work out his feelings about his identification with the poverty of his nanny through transferring impoverished social class onto the therapist. On reflection, the therapist realized that she resisted such uses of herself on the concrete grounds that she had not grown up poor. In other words her countertransference reaction to her patient contributed to less effectiveness in working on one of this patient’s multicultural issues. Thereby, the deeper issue of social class serving as a surface manifestation of the ways in which the patient felt psychologically impoverished was not probed as thoroughly as it could have been. Hopefully, had the patient not left therapy due to a mandatory work relocation, this aspect of the patient’s complex multicultural issues would have been more thoroughly worked through, given the therapist’s dawning awareness of its importance as just outlined. This case is offered as an example of the specific techniques used to work with multicultural factors, although again, they were not manifest immediately or in the patient’s presenting problems. It is also offered as an example of how the therapist’s subjectivities contribute to the waxing and waning and fluctuations in effectiveness when working with cultural factors. Another important aspect of this case is its revelation that White patients may have important positive identifications with Blacks - a fact not readily discussed in our culture that puts so much emphasis on a cultural hierarchy that idealizes that which is White and devalues Blackness, a fact that may lead to multicultural blinds spots in therapists.
Haldeman (2010) also clarifies the importance of the therapist speaking to cultural factors in the work as it unfolds, including acknowledgement of the therapist’s known misgivings about how to approach a cultural factor. In his paper, he, a White gay male therapist discussed how he worked with Black gay males. His candor about how his own conflicts might affect the work, and how he dealt with the issue in the treatment is especially refreshing and noteworthy. He stated, “with some clients of color, if I challenge their internalized religiously mediated proscriptions against homosexuality, I fear being perceived as disrespectful of their cultural experience, and I say so (italics added)” (p. 180). “Saying” so is perhaps the hardest part of achieving multicultural competence.
Multicultural Competence in Supervision.
Thus far, this paper has outlined how training models for multicultural competence need to be enriched to address the complexity and d anxiety-making nature of cultural factors as they emerge in the treatment situation. Illustrations of the challenges in promoting multicultural competence in the classroom and consultation room have been offered. Last, it is important to mention the role of supervision and to point out that in that context, too, there is challenge and more to be accomplished. This author’s impressions of how multicultural issues are addressed in supervision are informed by her experience as an internship training director (1980-1992), a Director of Clinical Training (2003-2011) and Program Director (2005-2011) in a Psy. D. Program, a doctoral training clinic team leader (1980-2011), and a teacher of graduate core courses in psychotherapy that included multicultural competency modules (1980-2011). Her predominant experience is that regarding cultural factors supervisions often do not effectively extend and consolidate what is learned in the classroom. Rather, students have often stated that supervisors are silent about, ignore, minimize, or refute the relevance of cultural factors. It is not clear how much the students’ accounts are a function of students not raising culturally relevant questions about their cases in supervision, or how much the supervisors do not raise questions with the students, do not help students identify or work with clinical manifestations of cultural factors, and/or do not address the students’ questions. Nevertheless, this author’s experience is of much more than a chance number of instances in which cultural factors are not addressed, or are mishandled in supervision. Apropos the latter, students have reported being “deskilled”, meaning that their understandings or hypotheses about how cultural factors may be playing out in the treatment process are scuttled or revamped to consider the case material only from another, “culture-free” perspective. In some cases, supervisors have expressed disinterest or disdain, or have become rattled by cultural factors. An example of the latter is published in the Ethics Casebook of the American Psychoanalytic Association (2001, pp. 68-69). In that supervision, a supervisor lost focus and lectured his supervisee on the total dissimilarity between the fate of African slaves and the Holocaust when the supervisee reported that his Black patient had likened the fate of the Jews in the Holocaust to the fate of millions of African slaves killed in transit from Africa to America. When the supervisee confided in another supervisor how rattled the supervisor had become and sought advice on what to do, the supervisee was advised not to pursue the matter further with the initial supervisor. Consequently, the supervisee did not raise the matter again, nor did the supervisor, and the supervisee elected to end the supervision as soon as he had reached the minimum number of required hours. Supervisor and supervisee did not learn im-portant lessons about how cultural factors affected them. Thus, they could not use those lessons to help the patient work with her pain and suffering related to cultural factors.
This paper has attempted to account for why validation of multicultural competence has remained elusive despite several decades of advances. The advances include understanding of a wider array of cultures, understanding that individuals may need to be understood and worked with in terms of multiple cultural identifications and identities, and the impact of cultural factors on their symptoms and defenses. We have made some gains, too, in understanding the biases that may impede psychologists from achieving multicultural competence. Organizationally, there have also been some gains in terms of published guidelines and accreditation criteria to achieve multicultural competencies. Still, published accounts make clear that a significant gap remains between valuing multicultural competence, espousing, teaching and attempting to practice it, and being able to validate it empirically. This paper has proffered that one limitation in demonstrating empirical support for multicultural competence is that the training models we use focus too much on the surface of what is to be learned in terms of knowledge, attitudes and skills. There is not enough focus on the conflicts and sometimes biases students, teachers, therapists and supervisors experience in relation to important cultural factors in their own lives and their psychological work. Given the intrinsically complex nature of working with multicultural factors, including the teachers’, supervisors’ and therapist’s sometimes resistant subjectivities, the identifed limitations in training models compound the problems of being able to consistently achieve multicultural competence in the consultation room and in research studies.
Limitations to the Measurement of Multicultural Competence and the Need for Additional Organizational Guidelines and Practices.
Some question whether multicultural competence can be measured by conventional measures (Ridley & Shaw-Ridley, 2011; Worthington & Dillon, 2011). In this author’s view, the current methods put the cart before the horse, in that we first need to acknowledge that the training models have not kept up with the difficulty and complexity of the subject matter. It is recommended that training models put more emphasis on experiential, interactive learning that focuses on the complex subjectivities and conflicts of students, teachers, therapists and supervisors in relation to multicultural competence. Case examples have been offered to show the unfolding of relevant cultural factors and the corresponding conflicts in the therapist or supervisor that either facilitated or partially limited the work. More such examples need to be published to reduce the underlying anxiety, guilt and shame around these issues that have led to undue silence rather than the speaking out that is neededby the student, the student therapist, the established therapist, and the supervisor. Once the field is truly more open to this aspect of our work, training models can be enriched and appropriate measures will follow, as noted below.
Organizationally, more is needed as well. For example, Birbilis (2009) raises an interesting question about the applicability of Implementing Regulation “C-24: Empirically Supported Procedures/Treatments of the APA Commission on Accreditation” to the achievement of multicultural competence. That implementing regulation calls for students and interns to collect quantitative outcome data on psychological services provided. Bibris’s question is whether such an approach will be, “…to the exclusion of qualitative data, which…may be more appropriate to the cultural norms and values of some populations..” (p. 31). Similarly, this author thinks that the relevant data for multicultural competence occurs at various points in a treatment, often not early, and often played out in its impact on the alliance and/or in the transference-countertransference manifestations between therapist and patient. This fact calls for more complex ways of measuring the effects we are looking for, as with time-series analyses that can study complex occurrences such as the emergence of cultural factors over time in a single case between a therapist and patient (Jones, 2003).
In addition to organizational support of more advanced and more appropriate measurement approaches, what additional organizational responsibility could improve the achievement of multicultural competence? At present the Commission on Accreditation requires that doctoral programs have a systematic and intentional minority recruitment and retention plan, and multicultural content in their curricula. It would be helpful if it also required measures of congruence between multicultural content in the curriculum and its utilization in supervision, since it is in the latter process and setting that these important matters get “disappeared”.
The last several decades have seen significant progress in the amount and quality of scholarly work on multicultural competence. This author salutes those advances, but notes that psychology has lagged in matching training models, organizational supports, and adequate methodology to the rich array of clinical demonstrations of the importance and reality of multicultural competence. In order to enhance multicultural competence, refinements are recommended in what is taught in the classroom and supervision, as well as how it is taught and how it is measured and monitored.
Dorothy E. Holmes, Ph. D., ABPP (Clinical Psychology) is Professor Emeritus of The George Washington University where she was Program Director and Director of Clinical Training of the Professional Psy. D. Program through June, 2011. She is also Training and Supervising Psychoanalyst, Baltimore-Washington Institute for Psychoanalysis. She is in private practice in Bluffton, SC.
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