Culture in Psychotherapy Practice and Research

Introduction

As the people of the United States become even more culturally diverse, psychotherapists are required to develop their cultural competence.  Health disparities persist with regard to many cultural identities including race, class, sexual orientation, and ability (Gehlert, Mininger, Sohmer & Berg, 2008; Smeldy, Stith, & Nelson, 2003; Sue & Dhindsa, 2006).  Furthermore, treatment offered within marginalized communities is often less than ideal. For example, psychotherapy can be difficult to access, underutilized, or prematurely terminated and the treatments offered are less likely to be state of the art (Sue, 1998).  Cultural competence is a relatively new construct to help psychotherapists improve service delivery by increasing their understanding of cultural factors.  However, what it means to be culturally competent and how to acquire this competence is unclear and often elicits conflicting perspectives.

The following review outlines trends in cultural competence theory and research, with a focus on ethnicity. The analysis is the level of the provider and the treatment applies both to cultural similarities and differences between psychotherapists and patients. At the provider level, three main areas are highlighted across the theoretical and empirical literature: self-awareness, knowledge, and skills (Sue, Hall, Nagayama Hall, & Berger, 2009; Ponterotto & Grieger, 2008). While beyond the scope of the present paper, there is also a body of literature that conceives of cultural competence at the level of the agency, institution, neighborhood, and the local socio-political climate (Adams, 2007; Sue, 2006; Mistry, Jacobs, & Jacobs, 2009).

Awareness

According to cultural competence models, psychotherapists must cultivate an awareness of their cultural identities and beliefs to better understand how their perspective impacts their perceptions of their patient (Ponterotto Gretchen, Utsey, Rieger, & Austin, 2002; Sue, 2005; Gelso & Mohr, 2001). Although general awareness of one’s values and attitudes is positively associated with how psychotherapists think about and behave with their patients (Gelso & Hayes, 2007), as well the strength of the psychotherapy relationship (Dadlani, 2009), there are few empirical investigations about the relationship between cultural self-awareness and psychotherapy processes.

Towards defining and facilitating cultural self-awareness, Hays (2008) offers the ADDRESSING framework.  This model provides psychotherapists a way to organize and explore influences of Age and generation, Developmental or acquired Disability, Religion and spirituality, Ethnicity, Socio-economic status, Sexual orientation, Indigenous heritage, National origin, and Gender.

Hays suggests that psychotherapists first use this framework to examine socio-cultural aspects of their own identity and identify how these perspectives impact the therapist’s values and biases.  Next, psychotherapists can use the framework to explore patients’ socio-cultural identities and identify the ways that their perspectives interact with their patients’ self-perceptions.

Although tools such as these encourage psychotherapists to examine how their own contexts could influence their clinical perspectives, the effects of self-assessments have not been studied.  Instead, the thrust of the empirical work on culturally competent self-awareness assesses therapists’ understanding of diversity issues generally (Sodowsky, Taffe, Gutkin, & Wise, 1994), psychotherapists’ perceived comfort when working with diverse cultures (e.g., Ponterotto et al., 2002), and self-awareness as a function of multicultural training and racial identity (Fuertes et al., 2006).

Furthermore, the scale developers emphasize that tools such as these should only be used for group-based research (Ponterotto et al., 2002). As such, further research is needed to provide greater definitional clarity, construct validity and clinical applicability of culturally competent self-awareness and to examine how culturally competent self-awareness relates to patient engagement and treatment outcomes.

Tools such as these also help prevent a common misperception of the role of expertise in cultural competence. Vargas (2008) highlights the ways in which psychologists have inadvertently implied that cultural competence is comprised of a static skill set and specific knowledge base that is mastered by a small group of individuals. Instead, Vargas argues that competence means that all individuals develop a critical mindset that questions frames of reference and expressions of behavior, cognition, and emotion in contexts. This reflective process is ongoing, ever-changing, and a life-long commitment.

Knowledge

Psychotherapists are also urged to acquire specific knowledge about diverse populations, and to choose appropriate interventions. A substantial body of research highlights the importance of learning culture-specific knowledge and suggests that therapists learn from multiple sources including literature, cultural immersion, and peer and supervisor consultation (Ponterotto & Potere, 2003; Sue & Sue, 2008).  Psychotherapists are also encouraged to ask patients directly about their experience of their culture while being careful consider the balance between the individual and group-based experiences.

In addition to culture-specific knowledge, psychotherapists must also develop their culturally competent intervention knowledge. Culturally competent interventions include translated interventions, culturally adapted interventions, and culturally specific interventions (Gorman and Balter, 1997).

Translated interventions are those in which the provider and/or agency translate treatment and treatment frame into the language of the target group. Linguistically appropriate services are being offered with increasing frequency in community settings (e.g., Semansky et al. 2009), and guidelines for using translators in psychotherapy are being developed (Searight, 2009).  However, given the complexity of the relationship between language and emotions, the use of translators in psychotherapy must proceed with caution.

Culturally adapted interventions refer to those that aim to incorporate the values of a target group into treatment (see Giner & Smith 2006 for a meta-analytic review).  Psychologists first attempted to do this by providing patients with a therapist of the same or similar ethnic background.  It was assumed that providing an ethnic match would help patients feel understood and safe with their therapist, and as a result, engage fully in treatment. However, empirical efforts examining the impact of ethnic and racial matching on treatment engagement and outcome have yielded contradictory findings (Maramba & Nagayama Hall, 2002; Sue, Fujino, Hu, Takeuchi, & Zane, 1991; Wintersteen, Mensinger, & Diamond, 2005).  Reviews of this literature suggest that other factors such as cognitive match, racial identity, acculturation, perceptions of the presenting problem, and expectations about treatment goals may be of greater importance (Chang & Berk, 2009; Helms & Cook, 1999; Zane et al., 2005).

After initial attempts to address cultural factors through provider characteristics (i.e., by matching particular therapists and clients), cultural adaptations began to identify culturally specific values and integrate them into existing treatments. For example, in their work with substance abusing Latinas, Kail and Elberth (2003) identified the cultural values of confianza (trust), dignidad (dignity), personalismo (personalism), respecto (respect), familismo (family), and simpatia (compassion). Kali and Elberth highlight how understanding the meaning of these values affect treatment engagement, interpersonal communication intake procedures, and attitudes towards noncompliance and confrontation.

Bernal (2009) argues that cultural adaptations must be examined as systematic modifications to evidence-based treatments. For example, Markowitz et al. (2009) highlight adaptations to Interpersonal Therapy for depression for use with low income, monolingual Spanish-speaking adults; these adaptations specifically focus on themes of family, migration and acculturation, gender roles, avoidance of social confrontation, and responses to unpredictable environments. Similarly, Hays (2009) presents a model of Cognitive Behavioral Therapy with guidelines for adaptations to problem identification, responses to experiences of oppression, use of collaboration and confrontation, emphasis within cognitive restructuring, homework assignments, and the assessment of needs, strengths, and support systems.

Finally, culturally specific interventions refer to those designed for a specific cultural group. For example, Costantino (1986) developed Cuento Therapy, a treatment for Hispanic adolescents that utilizes culturally relevant folktales to address issues related to educational and psychological difficulties.  The use of cuentos is thought to increase treatment engagement, to convey cultural beliefs, values and behaviors, and to model functional relationships. Cuentos are adapted to incorporate themes relevant to the group at hand; for example, cuentos targeting Puerto Rican youth may focus on issues related to immigration, racial identity, bicultural competence, and adaptive coping in American culture. After cuentos are read aloud, children react to them and discuss the meaning and personal relevance of the cuentos.

Cuento therapy is associated with reduced anxiety and greater levels of self-esteem and reading performance (Ramirez, 2009) and has been found to be a superior treatment for Hispanic youth over the use of traditional folk tales and art and play therapy (Costantino, 1986). Other culturally specific interventions that are associated with improved outcomes for the target group include The Grady Nia Project, a 10-session group treatment targeting low-income, abused, and suicidal African American women (Davis et al., 2009) and the I Mau Mau Ohana program, a long-term residential treatment program for Hawaiian, Asian, and Pacific Islander adolescents with substance abuse and mental health concerns (Kim & Jackson, 2009).

Skills

Finally, psychotherapists are encouraged to examine cultural influences on the interpersonal skill between the therapist and patient. Evidence suggests that there are culture-general relational processes such as empathy, affective involvement, rupture-repair, credibility, giving, and appropriate disclosure that are associated with positive outcomes (Chang, 2009; Sue & Zane, 2009).  However, the content and manifestations of these universal relational processes may vary across cultural groups.  Thus, cultural competence models also examine therapists’ ability (skill) to integrate self-awareness, culture-specific knowledge, and knowledge about the patient.

Sue (2006) offers the constructs of dynamic sizing and scientific mindedness to highlight ways to integrate awareness, knowledge and skills. Dynamic sizing refers to the ability to “flexibly generalize” culture-specific knowledge and to discern when to focus on individual and/or group-based experiences. Scientific mindedness refers to the tendency to develop, test, and refine hypothesis with regard to knowledge of the self, a patient, a culture, and effective interventions.

Several similar but distinct measures have been developed to examine therapists’ culturally competent skills.  The Cross-Cultural Therapy Inventory–Revised (CCCI–R; LaFromboise, Coleman, & Hernandez, 1991) examines therapist multicultural competence as a unitary construct characterized by interaction of the three components: awareness, knowledge, and skills.

The Multi-Cultural Knowledge and Awareness scale (MCKAS; Ponterotto et al., 2002) only emphasizes the level of therapists’ knowledge and awareness while the Multicultural Awareness Knowledge and Skills Survey-Clinician Edition-Revised (MAKSS-CE-R; Kim, Cartwright, Asay, & D’Andrea, 2003) identifies culturally competent skills as an additional and separate factor.  Finally, the Multicultural Therapy Inventory (MCI; Sodowsky et al., 1994) highlights awareness of cultural issues separate from the therapy process as an additional element of self-awareness, in a four-factor model.

Although measures such as these have been used primarily to examine the effect of multicultural training on cultural competence, they have recently been used to explore the associations between multicultural competencies, the strength of the therapeutic alliance, treatment satisfaction, and patients’ perceptions of therapist empathy (Fuertes et al., 2006). Furthermore, relationship between cultural incompetence and treatment dissatisfaction is emerging (Chang et al., 2009) and must be understood. Thus, empirical efforts must identify possible moderators, such as the therapeutic alliance, of the relationship between cultural competence and treatment outcomes.

Developing Cultural Competence

As psychotherapists pay greater attention to cultural diversity, we are beginning to find that cultural identity and cultural context are key features of a patient’s psychology, alongside cognitions, behaviors, and emotions.  If this is the case, then cultural competence is as important for a therapist to develop as competence in other areas of psychology, even when cultural issues may not appear to play a role in a patient’s presenting issues.

The literature reviewed herein highlights the need for more research on therapists’ awareness of cultural identities and beliefs, and the potential impact of therapist self-assessment on improved treatment engagement and outcomes.  Furthermore, the research on therapist skills needs to examine therapists’ ability to think flexibility and question knowledge in interpersonal exchanges with patients. Although the research on therapist awareness and skills is just beginning, there is strong and growing body of evidence that highlights the importance of culturally-specific and intervention-based knowledge. Moving forward, psychotherapists must also examine cultural competence at the level of the agency, institution, and neighborhood and must explore the influence of larger socio-political systems on individual functioning and therapy processes.