Linda Berg-Cross, PhD, and Dominicus So, PhD
We define multicultural therapies as therapeutic practices that are founded on a worldview that accepts and appreciates diversity within and between groups of individuals and embraces a) transcultural interactions and learning, b) respect for the cohesive function of cultural traditions and rituals, c) freedom to be critical of cultural dictates, behaviors, and attitudes detrimental to individuals and institutions, and d) a human homogeny that assumes human beings have diverse and often conflicting identities and allegiances.
The cultural context of psychotherapy practice in the United States
Over the past 15 years, most graduate clinical psychology programs have been redesigned to train students in evidence-based practices (EBPs) and to supplement that core training with a coursework in multicultural competencies (MCCs). With few exceptions, the initial multicultural (MC) efforts were clumsy: stereotypes were perpetuated, with each person being pigeonholed into one ethnic identity (Caucasian, Black, Asian or Latino). Such macro racial classifications are often unreliable and unstable over time. For example, two individuals from different races are just as likely to share the same amount of genetic information as two individuals from the same race (Bamshad & Olson, 2002). Or consider that 37% of infants who died between 1983 and 1985 and labeled Native American on their birth certificate had a different racial label on their death certificate (Hahn, Mulinare, & Teutsh., 1992). While genetic variation has been driven by population geographics and accounts for many of the physical differences between people, there is ample evidence that the common racial categories are not genetically linked to any specific behaviors, cognitive potentials, or emotional patterns. Rather, race is a psychosocial construction tied to personal identification, geography, affiliation patterns, and culture. Although the findings reported in this paper use racial categories, it is important to realize that minority races are actually culture groups created to impose and sustain, in varying degrees and across varying domains, social inequality.
To complicate matters more, individuals are no longer conceptualized as monocultural or bicultural - but multicultural. We each belong to multiple culture groups as defined by ethnicity/race, gender, age, socioeconomic status, disability, spiritual and sexual orientations, religion, and so on.
Instruments that evaluate the multicultural competencies of therapists began to be developed in the 1980s and The Handbook of Multicultural Measures (Gamst, Liang, & Der-Karabetian, 2011) provides a cutting edge compendium. Widely used instruments include the Cross-Cultural Counseling Inventory-Revised (LaFramboise, Coleman, & Hernandez, 1991), the California Brief Multicultural Competence Scale (Gamst, Dana, Der-Karabetian, et al., 2004), the Multicultural Mental Health Awareness Scale (Khawaja, Gomez, & Turner, 2009) and the Multicultural Counseling Inventory (Sodowsky, 1996).
We are currently starting to document which MCCs matter to clients and what MC techniques lead to better outcomes. The future is clear. MC approaches will become part of being an evidence-based therapist. This article focuses on the evidence for multicultural competencies (MCCs) and multicultural treatments based primarily on ethnicity and race., Increasing diversity begs for therapy models that incorporate culture sensitive assessments and treatments. According to the U.S. Census Bureau, more than one-third of the population self-reports as a minority race or ethnicity (Humes, Jones, & Ramirez, 2011). The number of minorities has risen from 86.9 million in 2000 to 111.9 millions in 2010, representing a growth of almost 30 percent over the decade. Many high-diversity states along the coast or on the Mexican border have counties where more than 60% of the population is from various non-Caucasian racial/ethnic groups. State-wise, California has the largest minority population in the country, but Washington D.C., Hawaii, New Mexico and Texas all reported more than half of their population from minority groups in 2010. According to the U.S. Census Bureau’s American Community Survey Report (Grieco, 2010), from 1960 to 2007, the percentage distribution of the immigrants has shown a dramatic change, from a 75% European majority (and 9.8% North American, 9.4% Latin American, 5.1% Asian) in 1960 to a 53.6% Latin American majority (and 26.8% Asian, 13.1% European, and 2.2% North American) in 2007. Note that within these ethnic groups, there are myriad cultural sub groups, with the differences in each ethnic group often as large as the differences between.
Yet, the growing minority populations share a disproportionate health burden compared to the majority culture. Overall, 20 percent of the U.S population is affected by mental illness during any given year, but the Surgeon General’s Office reports that minorities are over-represented on myriad mental health metrics, including rates of living in poverty, mental illnesses, homelessness, incarceration, substance abuse, exposure to violence-related trauma, foster care and child welfare. Minorities are also more like to delay seeking help from professional psychologists and to drop out of treatment prematurely. They are less likely to comply with medical directives. The Surgeon General’s report on cultural issues in mental health set a priority for reducing these disparities in mental health (U.S. Department of Health and Human Services, 2001).
In order to reduce health disparities and treat everyone with the dignity and respect they deserve, psychologists have put their faith in MC therapies as a way to help redress these problems. Many public and private institutions, including academic agencies and their professional and accrediting agencies have joined in to systematically organize their constituents to master MCCs for an increasingly MC population. The American Psychological Association (APA), for instance, has issued its Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (American Psychological Association [APA], 2003), to foster MC competence among psychologists. In 2003, the APA stance was that even though there was a lack of extensive research supporting increased outcome effectiveness among MC therapists, there was an ethical mandate to be culture-centered. But what are MC competencies and techniques?
Defining MC competencies and MC techniques
In the 80s and 90s, D.W. Sue and others (e.g. D.W. Sue, Arredondo, & McDavis, 1992; D.W. Sue et al., 1982) presented a triadic meta-therapeutic model, where the client’s cultural values and worldview act as a screen for selecting and modifying assessment procedures and interventions. The triadic model stresses attitudes (awareness of own biases and cultural assumptions), knowledge (understanding of clients’ culture-specific worldview), and skills (techniques to accommodate culturally diverse clients). The data supporting the effectiveness of each component in achieving better client outcomes is somewhat uneven although there are findings that can be translated into practice.
Unfortunately, there is only one study, so far, that compares outcome effectiveness based on MCCs. This study employed a client and therapist survey of MC knowledge, attitudes, and skills. Overall they found that MCCs were unrelated to differential therapeutic outcomes among therapists (Owen, Leach, Wampold, & Rodolfa, 2011). However, within any one therapist, clients who perceived their therapist as high in MCCs reported better outcomes. This suggests that therapist’s skill in using MCCs varies across clients and/or that clients who improve are more likely to perceive the MCCs in their therapist. There is some limited evidence that when the client perceives a therapist with strong MCCs, it is because cultural issues are an important aspect of their presenting problem and they appreciate the way the therapist’s sensitivity has allowed the process of therapy to unfold (Owen et al., 2011).
MCCs have been found to significantly reduce minorities attrition in therapy.. Wade and Bernstein (1991) found that clients assigned to counselors with cultural-sensitivity training returned for more sessions than did clients in a control condition. Worthington, Soth-McNett, and Moreno (2007) in conducting a content analysis of 20 years of empirical research, lists five therapy outcomes related to MCCs, including therapist credibility, therapist effectiveness, client self disclosure, client satisfaction, and attrition.
The field is just giving birth to the generation of researchers who will discover the complex relationships between MCCs and therapeutic outcomes. Chances are the connection between MCCs and therapy outcome is not a direct one. More than likely, MCCs act as powerful moderators between the client’s problems and response to therapeutic interventions (much like warmth, empathy and congruence). It is also likely that the lack of MCCs is contributing to the small but ever present deterioration effect found in every psychotherapy study. Thus, MCCs may be a necessary but not sufficient ingredient for positive therapeutic outcomes.
Examining each of the MCC components separately gives us much more insight into what is working. Some studies show between group differences larger than what is generally found in evidence-based practices (EBPs) (Level I evidence), some demonstrate Level II evidence (good to moderate support) and there are many Level III, promising practice reports.
Evidence on the importance of MC attitudes
MC attitudes encompass values as openness to other cultures, openness to challenging one’s own attitudes, empathy for multiple life narratives, flexible problem solving, and the desire to work in collaboration with client. A therapist trained to have MC attitudes appreciates the importance of culture in shaping our lives and treats problems within relevant cultural contexts.
Research utilizing self-assessment surveys provide consistent evidence that therapists with MC training do report significantly higher MC competencies than those without training. Meta-analyses using only studies that compared MC trained vs. untrained therapists show a moderate effect size. The effect size is similar to what is achieved when comparing an efficacious treatment to a placebo (d=.49). Another way of understanding the size of this effect is to assume that on a 60 item survey, the average trained therapist reports they had good competencies to 8 questions where the untrained therapist reported average competencies. Meta-analyses that used studies with a more rigorous pre-post design (How much does a therapist change their MC competencies as a function of training?) reveal a large effect size (d=.95), similar to that achieved when comparing an efficacious treatment to no treatment. Some studies in this meta-analysis included the client’s ratings of therapists as well as therapist ratings of themselves, providing data that MC training may lead to clients perceiving differences in therapist attitudes and behavior (Smith, Constantine, Dunn, Dinehart, & Montoya, 2006).
MC attitudes are measured by relying on client or therapist ratings of perceived cultural competency. However, therapist self perceptions are not a valid predictor of either client perceived MC competencies in the therapist or therapy outcome (Constantine & Ladany, 2000). Therapists may be very confident of their MC skills but clients find many of these confident therapists terribly lacking in MC C. Most importantly, client perceptions of MCCs have consistently been found not to vary based on client or therapist race or ethnicity (Constantine & Ladany, 2000; Lee & Tracey, 2008; Li & Kim, 2004). What radar do clients use to judge their therapists? Perhaps client perceived MCCs involve subtle verbal or non verbal behaviors of the therapist or perhaps it is the process of the therapy and nothing to do with the content. Likely, when acknowledged by the client and used to their benefit, MCCs help to create a strong therapeutic alliance. The client says, “This person gets me.”
Therapist attitudes towards clients have consistently been shown to be related to the therapeutic alliance (Orlinsky, Ronnestad, & Willutzki, 2004; Ackerman and Hilsenroth, 2003). The therapist attitudes that predict a strong alliance include flexibility, honesty, respect, trust, interest, and warmth – the very attitudes that form the core of MC attitudes. Techniques, such as accurate interpretations, facilitating the expression of affect, and attending to the client’s experience are rooted in MC attitudes and impact the therapeutic alliance. Also, therapists with low MCCs are far more likely to have unconscious prejudices and biases towards clients that show up in very subtle ways, like not empathizing with a client’s loss or threat. Likewise, clients who don’t trust the therapist are far more likely to defer and conceal any negative emotions and attitudes (Hill, Cogar, & Denman, 1993). They don’t want to risk rejection from the therapist and out of deference to the therapist’s authority may hide the shame and conflicts fueling their despair. In all, we can conclude that while high MCCs strengthen the therapeutic alliance, low MCCs weaken the alliance.
The take home message is that therapists cannot trust their self ratings of MCCs to indicate if clients trust them or value their cultural openness or are poised for better therapeutic outcomes because of their self proclaimed MCCs. MC therapists should focus on how the clients perceive the therapist instead of relying on their own perceived MC sensitivities. Best practices suggest therapists ask themselves after the initial session: Do I understand my own cultural baggage in relation to this case? Do I understand my client’s cultural baggage? Do I understand how to create a transcultural partnership and strong therapeutic alliance?
We believe research will continue to validate the utility of MCCs and that the canon of evidence-based MC therapies will be built upon a foundation of MC attitudes and sensitivities.
Evidence supporting impact of MC knowledge
In the beginning, MC knowledge was a laundry list of facts about broad culture groups. It included descriptive information about ethnic food choices, clothing, recreation, language, religion, child rearing preferences, and arts. Now, MC knowledge focuses on the unique risk and protective factors within specific culture groups, the barriers to seeking treatment, rituals, social structures, and most importantly, the wide range of individual differences within any culture group. MC knowledge involves how race, religion, gender, disability, age, geography, ethnicity, acculturation, racial identity, and SES impact different culture groups. However, there is a strong consensus that MC knowledge should not focus on cultural facts that are often outdated, incorrect, or stereotypes. With stereotyping as great a threat to therapeutic success as cultural blindness, the new MC knowledge stresses the processes and dynamics within various subcultures to expand and deepen one’s ability to be warm, empathic, and genuine to clients whose lives are very different.
MC knowledge is related to sophisticated case conceptualization skills. It is well established that case conceptualization skills are a core competency for effective psychotherapy practice (Morran, Kurpius, Brack, & Rozecki, 1994). Case conceptualization refers to the ability to perceive which types of information are important to assess and to interpret patterns of information based on cognitive, behavioral, emotional, and interpersonal data. MC case conceptualization also requires the therapist to integrate contextual and sociopolitical factors into the assessment and treatment plans.
MC case conceptualization requires training and practice. When therapists of various levels of MCC are given case descriptions with various degrees of cultural information, primarily the more experienced MC therapists see how cultural factors impact all individuals (Lee, 2008). Once a therapist decides to use a MC approach, they can usually focus on obvious factors such as the race or religion of the client. However, among therapists with extensive MC practice, context and sociopolitical factors are examined in every case. For example, the novice may not see a need for a MC conceptualization of a Caucasian woman presenting with a problem of depression. However, the seasoned MC therapist knows effective treatment may require assessment and empowerment of factors such as social class, ethnic background, religion, neighborhood, work environment, age, cultural background of spouse, and/or gender roles. Note that therapist self report of MCCs, or what is referred to as MC self efficacy, has failed to show an empirical link with case conceptualization skills in two separate studies (Constantine & Ladany, 2000; Ladany, Inman, Constantine, & Hofheinz, 1997). Yet, it has been demonstrated that trainees whose mastery of MCCs is based on objective criteria develop more complex MC case conceptualizations that take into account the role of gender, social class, ability status, ethnicity, sexual orientation, race and other personal, contextual and sociopolitical factors (Ladany et al., 1997). It takes knowledge about subcultures to differentially conceptualize treatment plans: a drug abusing Asian teen from a gang in the inner city needs a different treatment plan than a middle class Latino teenager spending weekends alone getting high. But again, we can’t trust our own ratings of MC competency to insure we have this skill, since self ratings appear to be influenced by social desirability factors more than objective competencies. We believe MC case conceptualizations is a core skill in evidence based MCCs.
Importance of MC therapeutic skills and techniques
Evidence-based MC therapeutic skills and techniques research is focused on three domains of inquiry:
A. What cultural competencies are related to building a strong therapeutic alliance as measured by client satisfaction, client self disclosure, and reduced attrition? As discussed above, the relevant competencies appear to be those related to the attitude and knowledge domains of MC competency.
B. What techniques should we develop when MC issues are central to the client’s problems or identity?
MC skills and techniques are the growth industry of MCCs. A paucity of efficacy research exists on the impact and use of MC therapy skills using real-life clients. Nonetheless, the following evidence-based techniques and best practices form an incubator from which more sophisticated interventions will emerge. While the first two techniques (case conceptualization based on MC knowledge and a therapeutic alliance based on MC attitudes) were discussed above, the following 10 techniques are also likely to become part of the canon. The research cited throughout this section is just a sampling of the literature and is far from an inclusive review.
MCT #1: Linguistic competence. Linguistic hindrances are the biggest hurdle for MC therapists. A shared preferred language facilitates treatment and when the client has to speak in a non preferred language they are less likely to seek treatment or stay in treatment (Fortier & Bishop,2008).
MC therapists should strive to be bilingual or multilingual and able to communicate easily in the preferred language of the client. However, this is most often not the case. However, it is possible to learn a few of the emotionally charged words or sayings clients use to describe their life stressors as well as their intense feelings and attitudes. Also, it is critical to teach clients the conceptual words that the therapist is using so they understand the proposed treatment. This will help create a shared vocabulary and common purpose.
Indeed, therapists need to develop culture sensitive vocabularies focused not only on issues of race, but on oppression, helplessness, stigma, and coping. How do these psychological concepts translate into words that capture the client’s experience and ways of understanding? Consider how different culture groups in the U.S. talk about feelings of helplessness. In Latino culture, the situation is desesperado or one feels sin esperanza, and in Jewish culture, someone fears feeling like a nebbish. Using culture relevant terms to describe emotional states gives the client permission to self disclose in a trusting environment.
How does this translate into technique? When a client speaks through the scripture, the therapist creates metaphors or questions based on biblical tales. When a client’s speech is filled with emotional words and gestures, the therapist matches the intensity and emotional vocabulary of the client. But most importantly, the therapist asks relevant questions, in that first session. To the scripture bound client, the therapist may say “It sounds as if religion is helping you cope. Can you tell me how you are using your faith in this situation”? For the emotionally expressive client, the therapist might state, “It sounds like you have so many different feelings about this issue. Describe what is most emotionally frustrating and most emotionally confusing about your situation?”
MCT #2: First session dialogues. Best practices would dictate that a MC therapist address the importance of cultural issues in the first session. First session dialogues include asking the client about their cultural identities as well as opening a conversation about client concerns or questions surrounding working with a therapist who is of a different gender, generation, ethnicity, etc. It involves subtle permission giving to discuss the social cues that put a person at ease and makes them feel safe.
MC therapists can also ask clients to describe culture-specific terms or idioms. This not only helps the MC therapist understand the client better, but helps clients to reflect on their situation. Therapists who prompt clients about their cultural experiences can increase self-disclosure. Thompson, Worthington, and Atkinson (1994) conducted an experiment to investigate the impact of counselors’ culturally relevant verbalizations on client behaviors in therapy. They instructed the counselors to make three cultural content statements throughout treatment, (e.g. “Tell me how your feelings of loneliness reflect on your experiences as a Black student on this campus”). Some of the content statements were completed with the prompt “as a Black woman” or “Black student” (in the cultural content/experimental condition), or “as a student,” “roommate,” “sorority sister,” or “student activist” in the universal /control condition. The clients presented with cultural content statements made more self- disclosures of private issues, had more references to self, and displayed more vulnerability and introspection than the control group. In a related study, Thompson and Jenal (1994) reported that when therapists used the term race, many African American clients felt free to disclose their thoughts and concerns. When the therapist was race avoidant in their verbalizations, some African Americans clearly were alienated from the therapist and the therapeutic process while others appeared to concede to the boundaries imposed by the therapist.
MCT 3: Culture consultations. MC therapists seek out consultation with clients who present as members of culture groups unfamiliar to the therapists, especially if those referent groups are central to the presenting problem. Whether it is your first blind client, your first Cambodian client or your first octogenarian, culture consultations will help you develop a more effective treatment plan and a stronger therapeutic alliance. Culture consultations insure that one is practicing within one’s areas of competency. State psychological associations, immigrant services, and religious organizations can assist in locating an appropriate colleague. Alternatively, APA electronic mailing lists (e.g. Division 44 for lesbian, gay, bisexual issues or Division 52 for international issues) can be a helpful resource. Most culture consultants are honored to provide consultation as a peer courtesy. The consultations usually have three phases: a) the therapist describes the presenting problem and cultural subgroups creating the client’s identity; b) consultant asks relevant questions and places the problem in a salient cultural context; c) together therapist and consultant create an intervention plan that incorporates cultural values and needs.
MCT #4: Client-therapist matching when needed. Despite the minority gains in the percentage in the U.S. population, racial and ethnic minority students and doctoral level professionals continue to be underrepresented in the profession of psychology. A disproportionate number of minority students drop out in the training process. Minority psychologists are underrepresented in the practice and governance of psychology (APA, 2003). But is it important for someone to be seen by a therapist of the same ethnicity?
It no longer makes sense to ask how important is it to match clients with therapists who are similar to them because the number of cultural traits, attitudes and behaviors on which matching can take place is too large. In a transcultural model, there are multiple ways to share cultural traits with any one person (sic: we are both women) and multiple ways to highlight the differences in culture (sic: client is Chinese and I am Korean). The more relevant question to ask is: Does this particular client, with this particular problem, at this particular time, need a therapist similar to them on any particular traits or characteristics?” The best way to find the answer is to ask the client three questions: “What type of characteristics or qualities are you looking for in a therapist?” “What type of therapist would help you be open?” “Do you think that your therapist needs to be similar to you on some dimensions, like race, or sexual orientation, or age?”
Research in the past five years demonstrates that the US is maturing into a pluralistic society and for most adults ethnic matching is no longer a necessary prerequisite for forming a strong therapeutic alliance. Partly this is because a White client with Swedish roots matched with a White therapist with Australian roots may not share any ethnic identity with one another. Nor may an Afro American Black client share any ethnic identity with a Black therapist whose parents are from Cameroon. It is how the therapist uses his/her third ear during the session to talk about and explore relevant cultural issues that matters most (Chang & Berk, 2009). Indeed, Takeuchi, Sue, and Yeh (1995) demonstrated that therapists’ cultural competence can reduce treatment attrition, and enhance treatment outcomes significantly more than therapist-client ethnic paring.
The one area where culture matching often pays big dividends is when working with adolescents. Recent studies have found that drug abusing Latino and Caucasian adolescents matched for gender showed greater retention and a stronger therapeutic alliance than those that had a cross gender therapist (Wintersteen, Mensinger, & Diamond et al., 1991). Ethnic matching for drug abusing adolescents also leads to greater retention (Wintersteen et al., 1991; Flicker, Waldron, Turner, Brody, & Hops., 2008). Studies of racial matching among substance using adolescents treated by Caucasian therapists found only 48% of clients stayed through two thirds of treatment, compared to 79% of Caucasian clients treated by Caucasian therapists (Worthington, Soth-McNett, & Moreno, 2007). Thus, sometimes for therapy to succeed there must be matching on gender, ethnicity, values, age, or other dimensions vital to the client. Many young clients still want to see a familiar face when they come to therapy. Their initial impressions serve as a filter for judgments about the therapist. If the therapist is perceived as similar to the client, a significant minority will immediately project positive traits onto the therapist, including strong MCCs. Research with adults indicates that up to twenty six percent of the variance in African American ratings of their therapist’s MCCs can be accounted for by the race of the therapist (Smith, Constantine, Dunn, Dinehart, & Montoya, 2006). So while more and more clients come seeking the expertise reflected in the training and title of the therapist, there are still many who come believing therapeutic expertise is most likely when one is talking into the mirror.
MCT#5: Pre-therapy interventions. When working with clients who are not familiar with Western approaches to psychotherapy, it is very helpful to give them a preview of what to expect, including protocol, and the purpose and limitations of psychotherapy. The policies governing confidentiality are important. Clients need an opportunity to ask their own questions. Whether it is supplying them with written materials, a videotape, an introductory bridge meeting that includes an indigenous healer (e.g. shaman, guru, herbalist) or a pre-meeting telephone greeter, pre-therapy interventions are an integral part of implementing a MCC therapy practice (S. Sue, 2006). Studies have demonstrated that the no show rate can be cut in half by supplying clients with a reminder notice, delivered the day before the appointment, that describes appropriate expectations when entering the mental health service culture (what will happen and how one may benefit from services) (Swenson & Pekarik, 1988). Western-trained psychologists may also reveal their willingness to learn from clients and encourage explanations of culture-specific idioms that express intense interpersonal dynamics and/or personal problems.
MCT #6: Culture based interventions. Whenever possible, MC therapists should use contextual and sociopolitical factors as a positive force in change. A religious person going through a severe depression might be encouraged to look to their church or synagogue for social and spiritual support. If the client comes from a cultural background that values inhibiting displays of emotion, and they are being bullied in their marriage, modify the assertiveness training so that the victim need not rely on verbal dueling but rather can employ humor, letter writing, or contractual agreements. If the client is a lesbian, involved in activist politics in the GLBT community, reframe their personal solutions as a form of social activism, employing the same successful skill sets they use in the community. A commonly used culture based intervention is to create metaphors based on cultural stories, myths, and belief systems (Dwairy, 2009).
MCT#7: Cultural genograms. Genograms help conceptualize a case and allow the client to achieve insight about family patterns. MC therapists use genograms to track the critical cultural and sociopolitical factors influencing each client over three generations. Genograms are a supreme integrative tool, allowing one to explore one’s own attitudes and behaviors in the context of multigenerational socialization practices. Cultural genograms start out by having the client define their historical countries of origin, prior to settling in the U.S. (all but Native Americans have cultural roots in other countries that may still affect family dynamics). Then the client describes the core beliefs that were handed down from each culture group as well as the attitudes and behaviors that provoke shame and pride from those family members. The traditional genogram legend symbols are used in cultural genograms, but there are additional markers, so that one can easily see cultural patterns. Usually each culture group is a different color. Individuals with multiple cultural backgrounds have their symbols multi-colored to show what proportion of their background is from each group. There are symbols for ethnic and national behaviors that elicit strong pride and shame reactions, and a sign that denotes intermarriages. Finally, the client interprets which aspects of the culture are dear to them, which have been neglected but could serve as resources, and which aspects, if any, may be contributing to their problems (Hardy & Laszloffy, 1995). Cultural genograms were developed to facilitate training therapists to understand their own cultural processes but the technique is essential to have in the clinical toolbox for use with clients.
MCT #8: Feedback from client. Discussion of perceived MCCs can improve outcomes, particularly if the therapeutic alliance is weak or the treatment program is not reaping results. Having clients rate the therapist after the first session can help client and therapist, explore together, how to build a stronger therapeutic alliance. A simple four item True or False survey might include such items as:
- I think this therapist understands my problem and respects me. (Relationship)
- I believe this therapist’s approach can help me. (Approach or Method)
- I was open with my therapist and able to work on difficult issues today. (Goals and Topics)
- The therapist created a useful session today that will help resolve my problems. (Overall)
These questions cover the same content domains as the four item Session Rating Scale that has been shown to improve the therapeutic alliance and client outcomes, but they explicitly focus on the perceived effectiveness of the therapist. Use of Session Rating Scales have been shown to increase client retention and to increase the effect size of services by 60% (Duncan et. al., 2003; Johnson, Miller, & Duncan, 2000; Lambert, Whipple, Hawkins, Vermeersch, Nielsen, & Smart, 2004). Presented as a method to help maximize treatment effectiveness and collaboration, the scale can be given at the end of the session by the therapist or clinic administrator or even emailed to the client the following day.
Besides getting client feedback, the therapist needs to explore any negative impressions of the client. For example, did they speak a street dialect that was offensive? Were they obese and objectionable on those grounds? Was their lack of religion a problem? Therapists need to explore, hopefully in a peer supervision context, the cultural biases and prejudices they project onto the client.
MCT #9: Gifting. Working with Chinese families in the San Francisco area, Sue et al. (1987) drew on the important role of gifts as a way of honoring the relationship between individuals and/or families. They postulated that the connectedness forged by a symbolic gift, such as a clinical handout or an old postcard that may have relevance for the client, is much the same as a material gift. The gift serves as a way to focus on the relationship and the shared experience brings both relief and hope. Gift giving as a MC technique refers to the immediate benefits the client receives from any one session. Perhaps the client has been able to get things off their chest and blow some steam; perhaps they felt that someone valued their lives. Different clients seek different types of gifts, and the MC therapist tries to make sure each client leaves each session with a meaningful gift. Gifting is a universal technique but the type of gift that is appreciated varies with the cultural values of the client.
MCT #10: Explore short term and long term goals. Often times, important cultural factors are outside the awareness of the client, so they cannot report on them when asked. Time perspective is one such factor – time perspectives are mostly shaped by culture. To an immigrant from Haiti, it is not odd to assume that they expect a solution they can implement that very evening, while a New York movie producer may be willing to wait years to achieve insight. Kim, Li, and Liang (2002) focused on the outcome expectations of Asian American clients. They found that clients working with therapists who emphasized the culturally congruent Asian expectation for immediate resolution of problems rated the working alliance higher than clients whose therapists had adapted insight oriented goals. Agreeing on how time will be related to treatment goals is an essential MCT.
C. How can EBPs be adapted to include MC components that will improve therapeutic outcomes?
The ecological validity model delineates 8 elements in every EBP that should be evaluated to assess whether cultural adaptations are needed: language, personnel, metaphors, content, concepts, goals, methods and context (Bernal, Bonilla, & Bellido, 1995). More broadly, the three most common strategies for creating culturally sensitive EBPs include a) modifying existing EBPs, b) supplementing existing EBPs with new modules and techniques, and c) creating new culture specific EBPs. Note that the following discussion is not meant to be a scholarly review of the area but rather to let the reader sample the type of work being done in each area.
1. Modify existing EBPs.
Many therapists routinely modify the manualized programs to fit their clients, but research is just catching up to clinical practice and documenting how therapeutic effectiveness is enhanced by replacing generic information and formats with culturally inviting information and formats. A recent empirical test of the efficacy of cultural modifications was reported by Pan, Huey, and Hernandez (2011) in their customization of a phobia treatment for Asian American college students. They tweeked a manualized one session treatment that involved in vivo exposure for phobia clients by including cultural components relevant to many Asian Americans. The seven modifications included (a) focusing on clients’ acculturation by evaluating and discussing clients’ acculturation status, (b) accepting the client’s explanation of the problem, (c) normalizing the problem, (d) reiterating treatment confidentiality, (e) enhancing clients’ emotional control by reframing phobia treatment as a self-control, and by describing anxiety reporting as a cognitive activity, (f) optimizing clients’ respect for therapist’s authority (vertical relationship) by stating procedures in a definitive manner and taking a directive role in the session by making directive statements to clients such as, “Let’s have you try that step now”, and (g) emphasizing psycho-education. One group of clients got the culturally adapted one-session treatment, another standard treatment, and a control group received self-help instructions. They found that both treatment conditions were effective and reduced symptoms more than the self-help control condition. Significantly, the culturally adapted treatment was better than the standard treatment in both reducing catastrophic thinking and general fears in the short term (at 1 week follow up). The modifications that were most predictive of positive outcomes were enhancing the client’s emotional control, using the authority of the therapist as a positive force in change and psycho-education.
CBT program adaptations for depressed Latinos have emphasized the behavioral activation component over the cognitive component (Aguilera, Garza, & Munoz, 2010; Kanter, Santiago-Rivera, Rusch, Busch, & West, 2010; Santiago-Rivera, Kanter, Benson, Derose, Illes, & Reyes, 2008). The program stressed pertinent psychosocial and environmental factors likely to alter behavior, rather than verbally debating the stiffer and less accessible beliefs and attitudes. The study concluded that the modified program was effective in enhancing the Latina clients’ treatment adherence, retention, and outcomes. Other CBT programs have been successfully adapted for depressed low-income African American clients (Kohn et. al., 2002).
2. Supplementing the original EBPs with additional, culturally appropriate modules, activities, and techniques.
Some programs include additional units or cultural extensions to the manualized program. For example, the Parent Management Training from the Oregon Social Learning Center (OSLC) added units to enhance treatment effectiveness for Latino families (Martinez & Eddy, 2005). The original OSLC program involved didactic instruction, modeling, role plays, and in vivo practice to enhance parents’ skills in encouraging, monitoring, disciplining, and problem solving to control the externalizing behavior of children. The control group received no treatment while an experimental group received a culturally expanded program called Nuestras Familias. Nuestras Familias utilized a team of Latino, family service experts and community focus groups to evaluate each treatment component and assess its fit with the local population. The team then piloted, refined, and added 5 new treatment components, including (a) cultural roots, (b) bridging between cultures, (c) systemic hurdles to success, (d) calling the facilitators coaches instead of therapistsand (e) including a meal and time for socializing and networking. Using multiple pre- and post-treatment assessments, the study found significantly more positive outcomes among the Nuestras Familias parents than the control group parents in the areas of parenting, encouragement, and overall effectiveness. Nuestras Familias youth were significantly more likely to reduce their aggression and to report no substance use. US born Latino youth showed greater gains than the immigrant Latino youth, highlighting that the cultural add-ons were less successful in responding to the needs of immigrant Latino youth.
Another group of MC psychologists (Tucker & Herman, 2002) adopted a cultural lens of self empowerment to capitalize on the need of inner city, disenfranchised African American students to achieve. Operating in an African American church community, the program randomly selected and assigned children into the experimental group, a tutoring only (control) group, and a control group. The experimental group was treated with a standard CBT intervention, but the treatment team added (a) individualized academic tutoring, (b) teaching adaptive skills for emotional regulation, creating positive attitudes and prosocial behaviors, (c) daily reports of positive feeling , (d) parent training, and (e) teacher training. Results found gradual but significant changes only among the culturally modified program in GPAs, skills, and adaptive behaviors.
3. Create new EBPs, independent of the Western canon of psychological knowledge.
Some ethnic minority mental health practitioners have developed psychotherapeutic models based on their traditional beliefs. Some instances include the Chinese Taoist cognitive psychotherapy (Zhang, Young, Lee, Li, Zhang, Xiao, et al., 2002), the Japanese model of Morita therapy and Naikan therapy (Morita, 1998; Reynolds, 1980), the Puerto Rican model of folktale therapy (Costantino, Malgady, & Rogler, 1994) and African NTU psychotherapy (Phillips, 1988). For example, NTU psychotherapy is based on Afro-centric philosophy, and is spiritually-oriented (emphasizing authenticity, interconnectedness, oneness, sacred relationship, and awareness), family-focused (using genograms and other intergenerational reviews), group-oriented (unity with others), competency-based (instead of looking at symptom-reduction), holistic (attending to systemic issues), and value drawn (from African traditions). While it does not have an explicit treatment manual or work sheets, the therapist’s role is clearly defined, working with the traditions of harmony, life energy, and community resources to help clients cope with stress and resolve problems.
Among the various ethnic minorities, Native American programs are the least visible in the literature. One short but comprehensive survey on best practices among 68 mental health practitioners found three oft repeated successful techniques. First, it is important to welcome clients warmly, offer refreshments, display Native American artifacts, use self-disclosure, reduce intake paperwork, and discuss confidentiality and therapy expectations. In other words, the process needs to appear warm and informal. Second, it is fruitful to enlist the help of Native American community members and elders. And third, there are times when referral to the Native American healer was most appropriate (Thomason, 2011).
One problem in researching MCTs is that governmental agencies, such as NIH, are much more likely to fund efficacy studies that employ randomized control trials over studies that demonstrate improved treatment effectiveness from modifications to EBPs. Another problem is that many culture communities do not embrace the quantitative and statistical methodologies preferred by funding agencies; rather they put more value on qualitative data. Coupled with pressing everyday operational problems, they are far less likely to submit grants for program development or effectiveness, even where there are strong public-academic liaisons.
Multicultural factors are not relevant in every psychotherapy case. However, when cultural factors precipitate or perpetuate a problem, or when specific cultural identities are salient for the client and affect his/her willingness to form a therapeutic alliance, MC competencies greatly facilitate successful outcomes. The therapist lacking in MCCs is far more likely to have the client drop out of treatment. The therapist with MCCs is much more likely to conceptualize the case in a manner that leads to an effective treatment program that will minimize resistance and maximize motivation to achieve the desired changes.
For readers interested in developing MC modifications or additions, an excellent
resource will be Bernal & Rodríguez’s forthcoming Cultural Adaptations: Tools for Evidence-Based Practice with Diverse Populations, to be published by APA.
Linda Berg-Cross received her PhD from Teachers College/Columbia University and is a Professor of Psychology at Howard University. Dr. Berg-Cross was a member of the National Register Board of Directors from 2002-2009.
Dominicus W. So, PhD, is a native of Hong Kong and received his doctorate in clinical/community psychology in 1997 from the University of Maryland, College Park. He is Director of an award-winning Clinical Psychology PhD program and Associate Professor of Psychology at Howard University in Washington, DC. He publishes in the areas of help-seeking, HIV-related risky sexual and substance use behaviors among diverse populations, spirituality, alternative and holistic treatments, and other immigrants', cross-cultural and minority mental health issues.
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