2010 45(2)

Psychotherapy Bulletin 45(2): Online Version

National Health Service Corps Announces a New Loan Repayment Program

The National Health Service Corps (NHSC) Announces a New Loan Repayment Pilot Program for Part-Time Clinicians. This program joins the Full-Time Program in recruiting “fully-trained health professionals to provide culturally competent, interdisciplinary primary health services to underserved populations located in selected Health Professional Shortage Area (HPSAs) identified by the Secretary of the Department of Health and Human Services. HPSAs can be found in rural, frontier, and urban communities across the Nation.” In return, the Projects provide loan repayment assistance to clinicians for their qualifying educational debt.

For additional information on these loan repayment opportunities, visit http://nhsc.hrsa.gov/loanrepayment/.

2010 45(1)

Psychotherapy Bulletin 2010, 45(1)

Important Changes Approved by the APA Council

Linda Campbell

Linda Campbell

The APA Council In Action!  By Linda Campbell and Norine Johnson.

We are quite used to stalemates, filibusters, and partisanship these days, aren’t we? I wish you could all have attended this Council meeting to see actual decision-making, compromise, and respectful disagreement. There were items on this Council agenda that truly spoke to who we are, what our values are, and what is important to us. You would have been very proud to see how differing members conducted themselves and how the decisions were made.  We are going to plunge into the top items of importance to Div. 29 here and hope that if you want more detail or want to discuss any of these subjects that you will contact us at lcampbel@uga.edu or NorineJ@aol.com.

Recognition of Psychotherapy Effectiveness

Before your blood pressure goes up, yes, all of us who are members of Div. 29 know and have known for many years that psychotherapy is effective. What we recently realized, however, is that never has there been a resolution, declaration, or any official statement adopted by APA to acknowledge this fact. Melba Vasquez, Nadine Kaslow, and Linda Campbell authored a new business item to be presented in August for a vote of Council acknowledging this important fact. Linda Campbell or Nadine Kaslow can send you a copy of the statement if you would like to read it. Several of our Div. 29 members contributed to the supporting seminal references and citations. It’s a great read!

Amendment to The APA Ethics Code

For the first time ever, the APA Ethics Code has been amending between official revisions. You are aware of the concerns that many APA members have had regarding the potential use of the Standards 1.02 and 1.03 and the ambiguity of the meaning of the standards in serving as guidance for psychologists. A primary concern about the potential interpretation of the standards as they stood was the possibility that following the law could be used to coerce psychologists into inhuman treatment of others. The APA Ethics Committee drafted the proposed change that is meant to better define this uncertainty. The draft change went through without a hitch. The revised standards are written as follows. The underlining represents added text and the strike through represents deleted text:

Standard 1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority

If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologist clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority. Under no circumstances may this standard be used to justify or defined violating human rights.

Standard 1.03 Conflicts Between Ethics and Organizational Demands

If the demands of an organization with which psychologist are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and to the extent feasible, resolve the conflict in a way that permits adherences to the Ethics Code. Take reasonable steps to resolve the conflict consistent with the General Principles and Ethics Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

These amendments represent hard work by many people and very difficult and challenging conversations. Those whose efforts were greatly invested in this matter rose to the occasion most admirably and respectfully.

The APA Model Licensure Act Has Been Approved!

The primary purpose of the Model Licensing Act is to provide a model to state, provincial, and territorial legislatures of language that would be consistent with APA’s policies in the event that legislatures enact a change in their law or regulations that affect the practice of psychology. Several areas were reviewed and updated; however, the major discussion centered around the use of the term “psychologist” in school settings and licensure requirements for I/O psychologists. The challenge for consensus came from the policy of APA enacted several years ago and the stance of professional psychology in that psychology is a doctoral level profession. Although, some state and provincial licensing boards have variations in masters level practices, the policy of APA is that psychology remains a doctoral level profession.

For many years, prior to licensure in some states, State Departments of Education have authorized and certified individuals who have masters and educational specialist degrees to practice in the schools and be termed “school psychologists.” Individuals who work in public school settings in these roles are typically not doctoral level. The question at hand was whether or not to extend the exemption that school psychologists have had for some years. In other words, could school psychologists be an exception to the requirement for doctoral level status of those calling themselves psychologists?

In hearing out all sides and all opinions on this very difficult matter, the Council voted to adopt the following: “The act recognizes the authority of appropriate state education bodies to issue titles to those who provide psychological services in schools as long as those titles incorporate the word “school.” The act continues to restrict the practice of such individuals and their use of their title to employment within school settings.” In other words, the adopted wording recognizes Departments of Education to be able to authorize professional positions under their aegis. The second amendment to the Model Act exempted I/O psychologists from the requirement of licensure (except as required in their jurisdictions) unless they provide mental health services to individuals.

Council Moves Out Of The Manchester

Contracts for APA Convention sites are made several years ahead of the event. After contracting with the Manchester Hyatt, it was discovered that the owner, Doug Manchester is a major contributor to the California Proposition 8, an effort to overturn the California Supreme Court ruling providing marriage equity for same-sex couples. This development resulted in much deliberation between values and money. On the one hand, many members felt that they could not in good conscience attend the Council meeting if held in the Manchester. The other meetings and where members’ hotel reservations are would, of course, be individual or divisional decisions. The Council meeting location represents a decision by APA that is logistical, financial, symbolic, and value-driven. The Treasurer, Paul Craig determined that a move would cost no more than $100,000. President Goodheart established a context for Council members’ remarks that was respectful, inclusive, and encouraging of all to speak. After the discourse, Council voted overwhelmingly to move the August Council meeting to another location. Dr. Goodheart summarized the discussion by saying, “Members of our Council will now not be faced with having to choose between their responsibilities as members of Council and their wish to express their opposition to Mr. Manchester’s action by not entering his hotel.”

Consensus and Endorsement of the APA Core Values

Our APA CEO Norm Anderson has initiated the development of our first ever Strategic Plan. Along with the plan was needed a mission statement, vision statement, and set of core values. As we have reported from earlier Council meetings, all had been decided except the core values. The task force charged with developing the core values for acceptance by Council was chaired most ably by Rodney Lowman and one of our representatives, Linda Campbell, was a member of this group. Over a period of months, the task force worked on finalizing the values with the sticking points being around (1) how to word the diversity value and (2) how to word the science value. Even on the floor of Council during the discussion, editing and compromise were still going on. Almost miraculously, we now have a set of core values overwhelmingly supported by Council and they are:

The American Psychological Association commits to its vision through a mission based upon the following values:

Continual Pursuit of Excellence

Knowledge and its Application Based Upon Methods of Science

Outstanding Service to its Members and to Society

Social Justices, Diversity and Inclusion

Ethical Action in All that We Do

Approval of APA 2010 Budget

Good news, sort of. As you know, APA like the rest of us was hard hit by the economic downturn of 2008 and 2009. Many cuts were made in meetings, personnel, and services, and benefits in order to right the ship. The cash flow from the buildings, however, yielded $3.5 million which contributed greatly. As a result, APA can report a forecast of $114,400. with expenditures of $113,500 resulting in a forecasted operating margin of $900.000.

Transparency In Advertising

APA has become aware that students and potential students who are reading APA materials see paid advertisements which sometimes appear to be endorsed by APA and therefore can be misleading for students who are looking for graduate programs and other educational services. As a result, the Council voted soundly to develop criteria and transparency for educational advertising:

  1. Advertising of educational programs in APA publications and  web sites must be programs that are fully accredited by regional or other institutional accrediting associations recognized by the Department of Education.
  2. Programs representing areas of professional psychology that are eligible for APA Accreditation (e.g., clinical, counseling, school, I/O, combined) must be accredited by APA to quality as advertisers.

To our loyal and faithful members, if you made it this far in the report, you not only get the t-shirt but a sweatshirt to boot!. It is our pleasure to serve as your Council representatives and we would very  much like to talk with you individually about your thoughts regarding Council and our Division 29.

Respectfully submitted,

Linda Campbell, Ph.D.

lcampbel@uga.edu
phone: 678-234-1444

Norine Johnson, Ph.D.

NorineJ@aol.com
phone: 617-471-2268

Culture in Psychotherapy Practice and Research: Awareness, Knowledge, and Skills

Mamta Dadlani

By Mamta Dadlani, M.S.

David Scherer

and David Scherer, Ph.D.

University of Massachusetts Amherst

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.

References

Adams, M. (2009). Pedagogical frameworks for social justice education. In M. Adams, L. Bell, & P. Griffin (Eds.) Teaching for diversity and social justice. New York: Routledge/Taylor & Francis Group.

Bernal, G., Jiménez-Chafey, M., & Domenech Rodríguez, M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40, 361-368.

Chang, D. F., & Berk, A. (2009). Making cross-racial therapy work: A phenomenological study of clients’ experiences of cross-racial therapy. Journal of Counseling Psychology, 56(4), 521-536.

Costantino, G., Malgady, R., & Rogler, L. (1986). Cuento therapy: A culturally sensitive modality for Puerto Rican children. Journal of Consulting and Clinical Psychology, 54(5), 639-645.

Dadlani, M. B. (2009). Countertransference behavior and alliance quality as a function of therapist self-insight.  Paper presented at the Northeast regional meeting of the North American Society for Psychotherapy Research.

Davis, S. P., Arnette, N. C., Bethea, K. S., Graves, K. N., Rhodes, M. N., Harp, S. E., et al. (2009). The Grady Nia project: A culturally competent intervention for low-income, abused, and suicidal African-American women. Professional Psychology: Research and Practice, 40(2), 141-147.

Fuertes, J. N., Stracuzzi, T. I., Bennett, J., Scheinholtz, J., Mislowack, A., Hersh, M., et al. (2006). Therapist multicultural competency: A study of therapy dyads. Psychotherapy: Theory, Research, Practice, Training, 43(4), 480-490.

Gehlert, S., Mininger, C., Sohmer, D., & Berg, K. (2008). (Not so) gently down the stream: Choosing targets to ameliorate health disparities. Health & Social Work, 33(3), 163-167.

Gelso, C. J., & Mohr, J. J. (2001). The working alliance and the transference/countertransference relationship: Their manifestation with racial/ethnic and sexual orientation minority clients and therapists. Applied & Preventive Psychology, 10(1), 51-68.

Gelso, C., & Hayes, J. (2007). Countertransference and the therapist’s inner experience: Perils and possibilities. Mahwah, NJ: Lawrence Erlbaum Associates Publishers.

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

Gorman, J. C., & Balter, L. (1997). Culturally sensitive parent education: A critical  review of quantitative research. Review of Educational Research, 67(3), 339-369.

Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed.). Washington, DC: American Psychological Association.

Hays, P. A. (2009). Integrating evidence-based practice, cognitive–behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40(4), 354-360.

Helms, J., & Cook, D. (1999). Using race and culture in counseling and psychotherapy: Theory and process. Needham Heights, MA: Allyn & Bacon.

Hernandez, M., Nesman, T., Mowery, D., Acevedo-Polakovich, I., & Callejas, L. M. (2009). Cultural competence: A literature review and conceptual model for mental health services. Psychiatric Services, 60(8), 1046-1050.

Kail, B., & Elberth, M. (2003) Engaging and treating the substance abusing Latina. Journal of Ethnicity in Substance Abuse, 2, 19-30.

Kim, R., & Jackson, D. (2009). Outcome evaluation findings of a Hawaiian culture-based adolescent substance abuse treatment program. Psychological Services, 6(1), 43-55.

Kim, B. S. K., Cartwright, B. Y., Asay, P. A., & D’andrea, M. J. (2003). A revision of the multicultural awareness, knowledge, and skills survey-counselor ed. Measurement and Evaluation in Counseling and Development, 36, 161–180.

Lafromboise, T. D., Coleman, H. L. K., & Hernandez, A. (1991). Development and factor structure of the Cross-Cultural Counseling Inventory-Revised. Professional Psychology: Research and Practice, 22, 380–388.

Maramba, G., & Nagayama Hall, G. (2002). Meta-analyses of ethnic match as a predictor of dropout, utilization, and level of functioning. Cultural Diversity and Ethnic Minority Psychology, 8(3), 290-297.

Markowitz, J. C., Patel, S. R., Balan, I. C., Bell, M. A., Blanco, C., Heart, M. Y. H. B., et al. (2009). Toward an adaptation of interpersonal psychotherapy for hispanic patients with DSM-IV major depressive disorder. Journal of Clinical Psychiatry, 70(2), 214-222.

McCurdy, K., Gannon, R., & Daro, D. (2003). Participation patterns in home-based family support programs: Ethnic variations. Family Relations, 52(1), 3-11.

Mistry, J., Jacobs, F., & Jacobs, L. (2009). Cultural relevance as program-to-community alignment. Journal of Community Psychology, 37(4), 487-504.

Ponterotto, J. G., Gretchen, D., Utsey, S. O., Rieger, B. P., & Austin, R. (2002). A revision of the Multicultural Counseling Awareness Scale. Journal of

Multicultural Counseling and Development, 30, 153–180.

Ponterotto, J.G., & Grieger, I. (2008). Guidelines and competencies for cross-cultural counseling research. In: P. Pedersen, J. Draguns, W.J. Lonner, &J. Trimble (Eds.), Counseling across cultures (6th ed.). Thousand Oaks: Sage Publications, Inc.

Ponterotto, J., & Potere, J. (2003). The Multicultural Counseling Knowledge and Awareness Scale (MCKAS): Validity, Reliability, and User Guidelines. In: D. Pope-Davis (Ed.), Handbook of multicultural competencies: In counseling & psychology (pp. 137-153). Thousand Oaks, CA US: Sage Publications, Inc.

Ramirez, S., Jain, S., Flores-Torres, L., Perez, R., & Carlson, R. (2009). The effects of Cuento therapy on reading achievement and psychological outcomes of Mexican-American students. Professional School Counseling, 12(3), 253-262.

Searight, H. R., & Searight, B. K. (2009). Working with foreign language interpreters: Recommendations for psychological practice. Professional Psychology: Research and Practice, 40(5), 444-451.

Semansky, R., Altschul, D., Sommerfeld, D., Hough, R., & Willging, C. (2009). Capacity for delivering culturally competent mental health services in New Mexico: Results of a statewide agency survey. Administration and Policy in Mental Health, 36(5), 289-307.

Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

Sodowsky, G. R., Taffe, R. C., Gutkin, T. B., & Wise, S. L. (1994). Development of the multicultural counseling inventory: A self-report measure of multicultural competencies. Journal of Counseling Psychology, 41(2), 137-148.

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural competencies / standards: A call to the profession. Journal of Counseling & Development, 70, 477–486.

Sue, D. W., Carter, R. T., Casas, J. M., Fouad, N. A., Ivey, A. E., Jensen, M., et al. (1998). Multicultural counseling competencies: Individual and organizational development. Thousand Oaks: Sage Publications, Inc.

Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5th ed.). Hoboken, NJ: John Wiley & Sons Inc.

Sue, D. W., & Torino, G. C. (2005). Racial-cultural competence: Awareness, knowledge, and skills. In R. T. Carter, & R. T. Carter (Eds.), Handbook of racial-cultural psychology and counseling: Training and practice. (pp. 3-18). Hoboken: John Wiley & Sons Inc.

Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440-448.

Sue, S. (2006). Cultural competency: From philosophy to research and practice. Journal of Community Psychology, 34(2), 237-245.

Sue, S., & Dhindsa, M. (2006). Ethnic and Racial Health Disparities Research: Issues and Problems. Health Education & Behavior, 33(4), 459-469.

Sue, S., Fujino, D., Hu, L., Takeuchi, D., & Zane, N. (1991). Community mental health services for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal of Consulting and Clinical Psychology, 59(4), 533-540.

Sue, S., & Zane, N. (2009). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. Asian American Journal of Psychology, , 3-14.

Torralba-Romero, J. (1998). Recruitment, retention, training, and supervision of mental health services staff. In M. Hernandez (Ed.), Promoting cultural competence in children’s mental health services (pp. 81-93). Baltimore: Paul H Brookes Publishing.

Vargas, L. (2008). Epistemology, individual diversity, and cultural competence. Presentation at The University of Massachusetts Psychology Diversity Roundtable.

Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based practice in mental health services: A complementary perspective. American Psychologist, 62(6), 563-574.

Wintersteen, M., Mensinger, J., & Diamond, G. (2005). Do Gender and Racial Differences Between Patient and Therapist Affect Therapeutic Alliance and Treatment Retention in Adolescents? Professional Psychology: Research and Practice, 36(4), 400-408.

Zane, N., Sue, S., Chang, J., Huang, L., Huang, J., Lowe, S., et al. (2005). Beyond Ethnic Match: Effects of Client-Therapist Cognitive Match in Problem Perception, Coping Orientation, and Therapy Goals on Treatment Outcomes. Journal of Community Psychology, 33(5), 569-585.

Mental Health Resources for Military Troops and Veterans, Families, and Providers

Ken Pope has done a wonderful job of summarizing a number of resources for Military Troops, Veterans, their families and mental health providers.   The resources, which he has given us permission to summarize here include articles, publications, and links to service and military organizations.  The full list of resources can be found at Dr. Pope’s website.

Cultivating Cultural Competence: Understanding and Integrating Cultural Diversity in Psychotherapy

Saunia Ahmad

Saunia Ahmad

and David Reid

David Reid

York University
Toronto, Canada

In today’s rapidly growing multicultural society, psychotherapists are faced with the complex task of working effectively with clientele whose psychosocial dynamics include increasingly diverse cultural values, beliefs and attitudes that the psychotherapist is either not aware of or not prepared to engage as part of the therapy.  In response to such diversity, much been written on cross-cultural therapy (e.g. Sue & Sue, 1999). However, the clinical literature tends to provide static and stereotypical descriptions of ethnic group members’ psychological characteristics, whilst ignoring the dynamic and evolving nature of culture; understanding culture as a dynamic process is particularly important when working with people that identify with and integrate values and attitudes of their homeland as well as their host culture. Moreover, most of the literature on working with culturally diverse clients in psychotherapy lacks an empirical basis. What is needed is a more theoretically guided and empirically informed approach to incorporating culture into the process of psychotherapy. To this end, systemic-constructivist theory of human change processes (Fergus & Reid 2001, 2002; Mahoney, 1991; Neimeyer & Winter, 2006) is proposed as a model for conducting culturally inclusive psychotherapy.

From a systemic-constructivist perspective, culture is intrinsic to every individual’s core meaning making processes. Both psychotherapist and client are immersed within their culturally shaped meaning systems. The culturally sensitive psychotherapist’s job is to develop an appreciation of his or her own culturally circumscribed constructs and learn to engage the client in a therapeutic discourse that allows the client’s culturally nuanced ways of construing to be drawn out and be the focus of psychotherapy. We demonstrate by presenting preliminary results of our research with South Asian Canadian couples receiving a culturally grounded application of Systemic-Constructivist Couple Therapy (SCCT; Reid, Dalton, Laderoute, Doell, & Nguyen, 2006; Reid, Doell, Dalton, & Ahmad, 2008).

A Systemic-Constructivist Understanding of Culture

Systemic-constructivist theory is a postmodern epistemology that integrates classical systems theory of interpersonal dynamics with more recent social constructivist ideas about how individuals make meaning (Fergus & Reid, 2001, 2002; Mahoney, 1991). This view proposes that individuals actively construct their knowledge — what they know and experience as their ‘reality’ – as they interact with their environment. An objective and true account of reality as it exists is considered impossible. The knower and what is known are indistinguishable. Individuals are engaged in a process of reflexively making sense of their ongoing flow of experience in order to adapt (Wittezaele, 2004). What a person knows is derived and maintained to the extent that it is ‘functional’ for one’s existence, rather than a ‘verifiable’ universal given (Fergus & Reid, 2002; Neimeyer & Winter, 2006). In other words, constructs give order and meaning to the otherwise chaos of human experience and allow one to navigate their internal and external experiences and coexist with others in predictable and intelligible ways.

Each individual’s ways of construing are highly idiosyncratic and complex yet they are not randomly determined. People’s ways of knowing are a product of a consensual validation process within the various social systems they engage in such as their family, community, and country. This is not just an interpersonal validation process, but also an interpersonal process with internalized symbolic others. Such collective systems provide members with a view of morality and purpose, and these views are reflected in, as well as perpetuated by, the ways in which people think, feel, behave, interact, experience, etc. The mutually validated construing systems of social groups represent equally legitimate ‘realities’ to that of other groups (Christopher, 2001; Markus, 2008).  It is important to note that every person within a specific community does not necessarily maintain the same construct system. People engage in many different collectives, and this is particularly salient for ethnic minorities such as South Asians who simultaneously participate in their heritage culture as well as their host culture.

An implicit and insidious assumption pervading the clinical literature and discussion of cultural sensitivity in psychotherapy is that culture is a thing people ‘have’; culture is an attribute or trait added on to a client’s authentic individual experience. Furthermore, culture is viewed as something ethnic minorities from traditional and Eastern societies have that people of a more individualistic and Western society have progressed beyond. The tendency to view culture as another layer on top of presumed universal core psychological processes is reflective of a Western individualistic way of thinking — which itself is cultural — that sees people as self-contained autonomous entities (Christopher, 2001; Markus, 2008; Wittezaele, 2004). This cultural bias explains the field’s inherent interest in studying and attempting to understand the phenomena of culture as distinct ‘groups of people’ differing on bipolar categories, where people belong to an Eastern or Western society; tend to be more individualistic or collectivist; are either high on independence or interdependence. This desire to analyze people in reductionist ways in order to identify internal basic, essential characteristics stripped of their social context is reflective of a Western idealistic view of people as self-reliant, behaving independent of their social milieu.

In order to develop cultural competence in clinical work, it is important to be conscious of such assumptions and start to cultivate an appreciation that culture is not a ‘thing’ that a person has, nor a type or category they fall into, but an integral part of every person’s ways of processing. In fact, culture is better understood as something people ‘do’ rather than ‘have’ (Markus, 2008). Individuals reify culture by their socially patterned ways of behaving, thinking, feeling, sensing themselves, etc.  A therapist’s sensitivity to their client’s culture involves sensitivity to their clients’ construct systems, while at the same time being astutely aware of their own construing processes.

Therapists’ Attunement to Cultural Construing Processes

In attempting to be more ‘culturally sensitive’ in psychotherapy, psychotherapists’ face the paradox of trying to understand their clients’ worlds using the clients’ constructs when inevitably psychotherapists use their own constructs. It helps greatly for psychotherapists to cultivate an awareness of how engulfed they are in their own cultural assumptions. A good example of making one’s cultural self awareness conscious is to visit another culture. Consider, for example, what happens to an American upon starting to live in India. One’s sense of self, preferences, priorities, habits, food tastes, social norms, ways of understanding and so forth become very apparent because of the contrast of one’s own culture with that of others. Similarly, the client from a different cultural background is likely to sense the self in ways that reflect the cultural diversity and this sensitivity is highly dialectical in the relationship with the psychotherapist.

The systemic constructivist approach attempts to address this paradox by developing a deeper understanding of the clients’ constructions that accompany their observable behaviours (Fergus & Reid, 2002; Reid, et al., 2006; 2008). The psychotherapist, through their own ways of talking and understanding, draw out their clients’ sense of their difference in a myriad of ways, some of which clients may not necessarily be open to or aware of until participating in the therapy. The psychotherapist guides clients to become more aware of their constructs; then this client awareness is combined with experimentation to make changes in clients’ ways of understanding and behaving that work for them interpersonally and intra-personally (examples of how this may be done is provided in the next section). Theoretically, this is what we mean about working from within the client’s framework and reality; we spend a lot of time engaging the client to openly convey how they see, act and feel about their lives. The process of drawing out the client’s ways of seeing things is in itself therapeutic for the client who starts to have an increasing understanding of themselves which can be empowering.

Some of that increasing awareness of cultural difference may impede the therapy process not because of the client alone, but because culturally naïve therapists are not aware of their own difference in an interpersonally empathic way.  That naivety creates a glass wall that one cannot penetrate especially if the client and psychotherapist are not fluent in the nuances of the language used in the therapy sessions. This interpersonally dynamic cultural difference can become particularly poignant as the psychotherapist tries to instill a close and more intimate alliance commensurate with the therapist’s automatic goal to instill a therapeutic alliance that is itself, culturally defined.

Furthermore, the psychotherapist may be at risk of misinterpreting the client’s difficulties in the psychotherapy as being a form of therapeutic resistance on the part of the client rather than the psychotherapist’s culturally based difficulties in engaging the client in a therapeutic discourse. The antidote to such experiences is for psychotherapists to cultivate a deep awareness of the cultural diversity in meaning making that they and their clients have, respectively.

The psychotherapist develops a great deal of self sensitivity so as to not inadvertently impose culturally based ways of construing. To counter that risk, the psychotherapist normally takes an agnostic attitude that puts the client as the expert and constantly draws out the client’s ways of understanding so that the psychotherapist is learning from the client. The dialectical qualities of psychotherapist learning from the client helps greatly for the therapeutic alliance to move forward and in tune with the cultural nuances so critical to the client’s therapeutic progress.

The Systemic-Constructivist Approach to Working with South Asian Couples

To demonstrate what has been proposed in this paper thus far, we introduce our program of research which focuses on developing an empirically based approach to couple therapy that accommodates to the cultural nuances of the South Asian marriage (Ahmad, 2006; Ahmad & Reid, in process; Ahmad & Reid, 2008). This work is pioneering in that the psychotherapy combines both qualitative and quantitative methods in order to carefully assess the dynamics of each South Asian couple and subsequently provide interventions that are coherent with culturally based ways partner’s understand, experience and respond to each other. This program was designed so that the referred couples feel comfortable with the therapy model because it is consistent with their values and ideals.

This research is an extension of an empirically derived couple intervention called Systemic Constructivist Couple Therapy (SCCT; Reid, et.al, 2006: 2008). The SCCT itself was developed in a manner similar to the work with South Asians in that rather than using extant models of couple therapy that were themselves initially derived from a theory of therapy for the individual, Reid and his colleagues developed SCCT through experimental clinical interventions guided by systems and constructivist principles. This included careful qualitative analysis of in vivo change processes couple therapy sessions. Interventions were designed to draw out each partner’s ways of knowing, their intuitions, their experiencing, etc., to enhance their understanding of themselves, particularly of themselves in the context of their relationship. The techniques were focused on working within each partner’s system of values, beliefs, experiences, etc. What emerged as a key component to the effectiveness of SCCT therapy was the enhancement of each partner’s couple identity or ‘we-ness’. We-ness is the degree to which partner’s identify themselves with their marital relationship. It is simultaneously an intra and intersubjective experience of partners who through the process of SCCT come to intuitively know their partner, as well as themselves in relation to their partner, in a deeper way. This identity was found to be central to how well the couple functions and the resulting satisfaction that partners have with their marriage at post therapy and gains made post therapy were significantly related to outcome at 2 year follow up (Reid et al., 2006). Details of the therapy and explanation of we-ness are published elsewhere (Reid et al, 2006; 2008).

The underlying principles of SCCT are accommodating of cultural differences, yet we continued to maintain an agnostic attitude towards South Asians and were rigorous in our calibration of SCCT to this population. In our first phase of this research program we recruited South Asian couples in distress that were looking to enhance their relationship. There were 30 partners comprising 15 couples. Couples were referred for couple therapy at an urban university clinic in Toronto, Canada. Partners identified themselves of South Asian ancestry that included 19 Asian Indians, 8 Pakistanis, and 2 Bengalis. The average length of marriage was 5.19 years (SD = 5.93) and ranged from 5 months to 19 years. Average age of wives was 30.27 years (SD = 5.44) and husbands was 33.06 yrs (SD = 6.42). There were 5 couples whose marriage was arranged by parents, 9 couples who indicated having personally selected each other and 1 common-law couple. Couples received seven weekly sessions of 2-hr SCCT couple therapy. They were self-referred, hearing about us from various sources that included physician, community services, the media, internet, and family/friends. Couples were not screened and were seen as long as both partners were interested in improving the relationship. Examples of presenting complaints: constant arguing, verbal/physical violence, problems with sexual intimacy, affair, extended family interference, unfulfilled expectations, etc.

Within the session the psychotherapist takes a participant-observer role (Fergus & Reid, 2001; 2002) of empathic sensitivity to the partners’ constructions, and of stepping back and observing the therapist-couple system. The psychotherapist takes an agnostic position with respect to the partners, being aware that they are not neutral observers, and exploring with the client the meaning of their words and descriptions of presenting issues. For example, a common presenting complaint for South Asian partners has been ‘in-law interference’. One spouse feels their partner’s loyalties are towards their parents rather than the spouse. An initial reaction of the Western therapist may be that the partner has not successfully individuated from their family of origin. Other therapists who are becoming increasingly aware of the great degree of value placed on connectedness with extended family for South Asians may be sympathetic to this dilemma and attempt to help the couple negotiate a healthy balance between their parents and spouse. Both positions could be true, yet there still remains a need to draw out a richer understanding of how each partner in the relationship idiosyncratically construes this issue.

When partners express this issue of extended family interference to the therapist, open ended questions that facilitate emergence of the partners ways of knowing and feeling can draw out the partner’s constructs and the therapist may realize their initial formulation was based on their own constructs. For instance, asking the couple to draw on examples from how their parents may have dealt with in-law conflict can explicate each partner’s values and ways thinking. While on the one hand it may appear that they are merely describing how their parents did things, there is a lot of meaning in their choice of words and reasoning that can be further explored with the clients to draw out the nuances of their understanding of family relationships, values and beliefs which they themselves had never fully thought through. It is not necessary that the psychotherapist be silent and not provide any suggestions for fear of tainting the therapy with their own cultural constructions. Indeed, the psychotherapist can provide a construction of the issue which is close to the client’s way of seeing things after immersing themselves in the client’s ways of thinking. Reid and colleagues (2006, 2008) have described other more focused interventions available in the approach. The overall spirit of the 7 session intervention is to drawing out partners’ deepened understanding of themselves and of the spouse that leads to a mutual discovery of their couple system and collaboratively identify alternative ways they may do things in their relationship that fit within their internal values and ideals.

A preliminary analysis of the 15 couples that completed the 7-session therapy found significant improvement on the main outcome variables at post therapy. On the widely used Dyadic Adjustment Survey (DAS; Spanier, 1976), which measures relationship satisfaction, at pre-therapy (session 1) 70% of the partners were in the clinically significant range and at post therapy (session 7) 43% of partners were in clinically significant range. On the Revised ENRICH Relationship Adjustment Survey (Fowlers & Olson, 1993) which in our program includes an additional 10 culturally relevant items (e.g. issues regarding extended family, social status, religion) validated on a large sample (n = 114) of South Asian Canadians (Ahmad & Reid, in press), couples demonstrated significant pre-post therapy change (p < .001). The results were comparable to our previous sample of non-South Asian couples (Reid et al., 2006). Several process variables are currently being explored and a 2-year follow up will be done to ascertain the long-term maintenance of post-therapy gains and how these are connected with therapeutically induced changes in the therapy 2 years earlier.

Concluding Remarks

Research to date on developing evidence-based therapy for cross-cultural clients is lacking. Cultural competence in clinical work requires ongoing disciplined awareness of one’s own ways of knowing in order to cultivate an appreciation of clients’ culturally based constructs. Our program of research demonstrates a viable attempt to develop an intervention with South Asian couples that is grounded in an understanding of psychological processes that are indigenous to this group. While our work is focused specifically on one cultural group, the systematic observation of psychological processes with this community we believe can broaden the basis of systemic-constructivist theory of psychotherapy and the science underlying clinical intervention in general.

References

Ahmad, S. (2006).  Contextualizing selves of South Asian Canadian couples: A grounded theory analysis. Unpublished Masters Thesis

Ahmad, S. & Reid, D.(in process). Relationship Satisfaction among South Asian Canadians: The Role of ‘Complementary-Equality’ and Listening to Understand. Interpersona.

Ahmad, S. & Reid, D. (2008, September) Cultural Adaptation of Systemic-Constructivist Couples Therapy for South Asians: Exploring the Mechanisms of Change. Poster session presented at the 2008 North American Society for Psychotherapy Research (NASPR) conference, New Haven, Connecticut, United States.

Christopher, C. (2001). Culture and psychotherapy: Toward a hermeneutic approach. Psychotherapy, 38(2), 115-128.

Fergus, K.D., & Reid, D.W. (2001). The couple’s mutual identity and reflexivity: A systemic-constructivist approach to the integration of persons and systems. Journal of Psychotherapy Integration. 11(3), 385-410.

Fergus, K.D., & Reid, D.W. (2002). Integrating constructivist and systemic metatheory in family therapy. Journal of Constructivist Psychology, 15, 41-63.Herman, H.J.M. (2001). The dialogical self: Toward a theory of personal and cultural positioning. Culture & Psychology, 7(3), 243-281.

Fowlers, B. & Olson, D. (1993). ENRICH marital satisfaction scale: A brief research and clinical tool. Journal of Family Psychology. 7, 176-185.

Mahoney, M.J. (1991). Human change processes: The scientific foundations of psychotherapy. New York: Basic Books.

Markus, H. (2008). Pride, prejudice, and ambivalence: Toward a unified theory of race and ethnicity. American Psychologist, 63(8), 651-670.

Neimeyer, R. A. & Winter, D. A. (2006).  Personal construct therapy.  In N. Kazantzis & L. L’Abate (Eds.),  Handbook of homework assignments in psychotherapy.  New York:  Kluwer.

Reid, D. W., Dalton, E. J., Laderoute, K., Doell, F. K., & Nguyen, T. (2006). Therapeutically induced changes in couple identity: The role of we-ness and interpersonal processing in relationship satisfaction. Genetic, social and general psychological monographs, 132, 241-283.

Reid, D., Doell, F., Dalton, J, & Ahmad, S. (2008). Systemic-Constructivist Couple Therapy (SCCT):  Description of approach, theoretical advances, and published longitudinal evidence. Psychotherapy Theory, Research, Practice, Training, 45(4),477-490.

Spanier, G. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15-28.

Sue, D.W. & Sue, D. (1999). Counseling the culturally different: Theory and practice. New York: J. Wiley & Sons.

Wittezaele, J. (2004). A systemic and constructivist epistemology for a relational vision of a man. Brief Strategic and Systemic Therapy European Review, 1,11-18

Excellent Resources for Clients Seeking Therapy

Psychotherapists are always looking for good places to send clients to get simple, quick information about seeking treatment for a wide range of symptoms. The Canadian Psychology Association maintains a nice resource of Psychology Works Fact Sheets which may be of use.