Cross-Cultural Assessment in Therapeutic Recreation

Therapeutic Recreation Journal Vol. XlVIII, No. 1 • pp. 1–14 • 2014

Cross-Cultural Assessment in Therapeutic Recreation

Rodney B. Dieser

Abstract

The cross-cultural assessment model presented in this paper draws heavily on the academic literature in cross-cultural mental health counseling, and in particular, the academic labor of McAuliffe and Erickson (1999) and McAuliffe, Erickson, and Kress (2005). The primary purpose of the manuscript is to adapt the context-phase-stage-style (CPSS) model into the field of therapeutic recreation. The CPSS model is an in-teractive assessment framework to gain information about clients related to how their cultural identity and social contexts are related to their presenting problem and leisure behaviors. Beyond presenting the CPSS assessment model this paper will also outline broad factors to consider when assessing clients from ethnic minority backgrounds.

Keywords

context-phase-stage-style model of ethical assessment; cross-cultural assessment tests/inventories; cross-cultural therapeutic recreation assessment; cultural identity; minority identity development; white racial identity

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Rodney B. Dieser is an associate professor in the School of Health, Physical Education, and Leisure Services at the University of Northern Iowa. Please send correspondence to [email protected]

ASSESSMENT PAPER

2 Cross-Cultural Assessment in Therapeutic Recreation

In a recently published book related to multicultural counseling, Jun (2010) outlined that as the new millennium was entered with the sociocultural con-text and voice of increasingly diversified populations in the United States, vari-ous helping professional associations re-sponded by updating their ethical codes and multicultural competencies to em-phasize practitioners’ cultural sensitiv-ity to human diversity. Jun underscored how, for example, the American Coun-seling Association (ACA), the American Psychological Association (APA), and the National Association of Social Work-ers (NASW) made curriculum changes to help professionals become competent in working with clients from differing cultures, such as in cross-cultural as-sessment (see, for example, section E of the ACA [2005] code of ethics regarding assessment). In regard to cross-cultural mental health assessment and treatment, Paniague (2004 p. ix) identified the fol-lowing relevant questions:

• What should a practitioner do dur-ing the first meeting or session with an African American client versus an Asian client?

• Should a practitioner treat an Ameri-can Indian client with the same ther-apeutic approach used with a His-panic client?

• What exactly should a practitioner do differently in assessing and treat-ing members of different cultural groups?

• What are some examples of cross-cultural skills a practitioner should display to minimize bias in the as-sessment of clients from different cultural groups?

In regard to standardized measure-ment and inventory/test interpretation (e.g., Beck Depression Inventory, Minne-

sota Multiphasic Personality Inventory-2, Wechsler Adult Intelligence Scale), Hood and Johnson (2007) outlined in mental health assessment it is paramount that therapists understand cross-cultural in-formation:

In using standardized tests in counseling with a person from another culture, a general rule is that the less the counselor knows of the client’s culture, the more errors the counselor is likely to make. It is important for the counselor to be knowl-edgeable about the culture of the person being assessed and to develop skills for dealing with culture-related behavior pat-terns (p. 212-213).

Rarely are any such cross-cultural thoughts expressed in therapeutic recre-ation assessment. For example, in some of the most used textbooks and readings related to therapeutic recreation assess-ment (e.g., burlingame & Blaschko, 2010; Howe, 1989; Stumbo 1997, 2003, 2009), the dimension of cross-cultural sensitiv-ity is either nonexistent or covered briefly. Pertaining to cross-cultural competen-cies of therapeutic recreation assessment, Stumbo’s (2009) words are wise: “. . . much still remains to be done” (p. 279).

The cross-cultural assessment model presented in this manuscript draws heav-ily on the academic literature in cross-cultural mental health counseling, and in particular, the academic labor of McAu-liffe and Erickson (1999) and McAuliffe, Erickson, and Kress (2005). As such, the primary purpose of this piece is to adapt the context-phase-stage-style (CPSS) model into the field of therapeutic recre-ation. The CPSS model is an interactive assessment framework to gain informa-tion about clients related to how their

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cultural identity and social contexts af-fect their presenting problem, personal strengths, and leisure behaviors. To this end, the first part of the manuscript will provide broad information regarding cross-cultural assessment and factors to consider when assessing clients from ethnic minority backgrounds. This will be followed by an overview of the CPSS model of ethical assessment.

Factors to Consider When Assessing Clients from Ethnic

Minority Backgrounds

In therapeutic recreation, assessment is concerned with data collection and analysis in order to determine the status of the client and identify his or her prob-lems and strengths in order to develop a treatment plan to help the client with his or her presenting problems (Carter & Van Andel, 2011). Therapeutic recre-ation assessment includes the concept of leisure and its connection to the clients presenting problem. As Kinney and Wit-man (1997) state, therapeutic recreation specialists “. . . assess physical, cognitive, social, emotional, and behavioral func-tioning, as it relates to leisure behavior, leisure knowledge and skill, and func-tional independence in life activities” (p. 9). Assessment is the foundational aspect of the therapeutic recreation process and can rest on the methods of interviewing, observation, standardized testing, and the use of secondary data sources (Aus-tin, 2009).

According to Cormier, Nurius, and Osborn (2012) all human services work-ers, which would include therapeutic rec-reation specialists, should be aware of the following five areas when assessing cli-ents from diverse cultural backgrounds:• Awareness of the participant’s world-

view: How the participant sees the

world and through what perspec-tives and lenses.

• Awareness of the participant’s cul-tural and ethnic identity: How the participant makes sense of himself/herself culturally.

• Awareness of the participant’s level of acculturation: How the partici-pant identifies with both former and current cultures and how a partici-pant moves through these cultures in regard to resources and barriers.

• Awareness of cultural information sources: What information the par-ticipant reports or shares about areas of his/her cultural life.

• Awareness of any stigmas associated with the participant: What is the cul-tural meaning of various life events, such as leisure.

In regard to these five cross-cultural assessment domains, there are different assessment procedures to help human service providers gain cross-cultural in-formation. For example, Vernon and Cle-mente (2005) provide a listing of scales that can be used from a multicultural perspective, such as the Short Accultura-tion Scale for Hispanic Youth (see Bar-ona & Miller, 1994) and the Asian Values Scale (see Kim, Atkinson & Yang, 1999). Likewise, Vernon and Clemente also pro-vide a sixteen question Self-Assessment of Cultural Awareness Scale (p. 58-60), which can be used by different types of human service professionals, includ-ing therapeutic recreation specialists, in order to assess their own knowledge of cross-cultural awareness.

Beyond these five areas of cross-cultural assessment, Hood and Johnson (2007) highlight many assessment tests/inventories do not choose normative samples that include members of di-verse groups when measurements are


being constructed. In regard to the de-velopment of assessment instruments, Hood and Johnson propose that separate norming groups related to ethnicity and socioeconomic backgrounds should be part of assessment construction. Many of the assessment tools used in the pro-fession of therapeutic recreation, such as the Leisure Diagnostic Battery or the Lei-sure Competence Measure, provide no or scant attention to ethnic norming groups that were used when these measures were being constructed.

Context-Phase-Stage-Style Model of Ethical Assessment

The CPSS model, also known as the Developmental Constructivist Model for Ethical Assessment (McAuliffe & Erick-son, 1999; McAuliffe, Erickson, & Kress, 2005), is based on four strands of con-structionist and developmental thinking: context, life phase, life stage, and person-ality style. The constructivist perspec-tive posits that meaning in life is made, or constructed, within cultural contexts (e.g., gender, race/ethnicity, religion, abil-ity, age, class, and sexuality) along with the contexts of community, friendship, family, situation, and individual. The developmental perspective maintains humans evolve in regular ways through differing psychosocial phases. Drawing heavily on McAuliffe & Erickson (1999) and McAuliffe, Erickson, and Kress (2005) the following section explains these four assessment components in re-lation to therapeutic recreation.

ContextThe key question to ask in the strand

of context is, “Where is the client placed in the social and physical circumstances abounding him/her and how do these various contexts affect his/her leisure?” Through context assessment, the thera-

peutic recreation specialist considers the impact of the physical and psychological situations, the family, the community, the nation and the cultures on client self-def-initions and presenting problems. For ex-ample, devout Arab Muslims usually have well-defined, traditional roles for men and women, and as such cross-gender leisure is frowned upon, and (ideally) the sex of the practitioner should match the sex of the patient (Yehieli & Gray, 2005). Sample interview probes for assessing the client’s social context could include the following:

• How would you describe your ethnic heritage and how does it influence your leisure pursuits?

• How would you describe your social class and how does this class status influence your leisure desires?

• What type of resources can you draw on from those around you that might make your leisure more enjoyable?

• What religious traditions, if any, are you part of? What role does religious faith play in your life and in your lei-sure activities?

Furthermore, during context assessment, McAuliffe, Erickson, and Kress (2005) suggested that if a practitioner is working with a client and does not understand cer-tain cultural dimensions, then the practi-tioner should be open to seeking greater learning. For example, McAuliffe, Erick-son, and Kress report a mental health counseling situation where the therapist was working with a Puerto Rican man and needed to involve the client’s pastor in conducting the assessment and devel-oping the treatment plan because religion was such a paramount value to this client.

Depending on the cultural back-ground of the client, psychometric as-sessment scales can be used to help un-derstand the contexts and worldviews of

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clients. For example, the Individual-Col-lectivism Interpersonal Assessment In-ventory (ICIAI) (see Matsumoto, Weiss-man, Preston, Brown, & Kupperbusch, 1997) can be used to determine whether clients are more individualistic or collec-tivistic in their cultural values, which has direct implications for leisure behaviors. According to Klieber, Walker and Man-nell (2010), the leisure needs of people with individualistic values may align to Maslow’s (1968) view of the higher-order need of self-actualization; whereas, the leisure needs of people with collectivistic values may align to Schutte and Ciarlan-te’s (1998) view of the higher-order need of status (status replaces self-actualization because it is socially directed, not person-ally directed like self-actualization). If a formal assessment suggested a client has collectivistic values and needs, a thera-peutic recreation specialists may want to choose, for example, against using the self-actualization based health protec-tion/health promotion model of thera-peutic recreation practice (see Austin, 2009) and chose or adapt a practice mod-el aligned to collectivistic worldviews.

Life PhaseIn the next stage, known as life phase,

the key question to ask is, “When will (or has) the client engage(d) in the sequence of psychosocial tasks that are related to leisure behavior and experiences?” These psychosocial phases may include familiar approaches drawn from (and Western based) psychology, such as Erickson’s (1963) or Levinson’s (1978) stages of hu-man development. This can also include psychosocial phases, such as the stage of ethnic identity development. Ethnic identity is a set of self-ideas concerning one’s own ethnic group membership (Sue & Sue, 2007).

Understanding ethnic identity de-velopment of individuals from diverse

cultures who participate in leisure activi-ties helps therapeutic recreation special-ists recognize ethnic difference, within-group and between groups difference, and individual differences when respond-ing to culturally different clients (Dieser, 1997). There are different ethnic minor-ity models. Cross (1971, 1995) created a Black identity development model, Ki-tano (1982) created a Japanese American identity model, and Ruiz (1990) created a Hispanic American identity development model. However, the Minority Identity Development (MID) Model is a compre-hensive ethnic minority identity model that cuts across different ethnic minor-ity backgrounds (e.g., Asian Americans, African Americans) and has support by many cross-cultural experts (e.g., Atkin-son, 2003; Pederson, 2000; Sue & Sue, 2007).

The MID model consists of five stages. Conformity is the first and low-est stage of minority/ethnic development, which consists of individuals from differ-ing ethnic backgrounds giving preference for values of the dominant culture over those of their own cultural group. At-titudes toward their own cultural group are self-depreciating, whereas attitudes toward the dominant culture are appreci-ating. In the second stage of dissonance, confusion and conflict toward dominant cultural systems and the individual’s own cultural systems occur. An individual’s at-titude toward his/her culture group and the dominant cultural group is marked by conflict between depreciating and appre-ciating. The third stage of resistance (also called immersion) is the active rejection of the dominant culture and the active involvement of the individual’s own cul-tural customs and traditions. Attitudes toward one’s own cultural group are self-appreciating, whereas attitudes toward the dominant culture are self-depreciat-ing. The next stage is introspection. It is


in this phase that the individual questions the values of both his/her minority group and the dominant group. The last stage of synergetic articulation and awareness is when the person develops a cultural iden-tity that is based on both the dominant and minority cultural group values. The most balanced and healthy development stage is the synergetic articulation and awareness stage.

An individual’s minority/ethnic identity and development has direct im-plications to leisure participation and how he/she will react to therapeutic rec-reation intervention planned and to the therapeutic recreation specialists. For ex-ample, Dieser (1997) provided a brief per-sonal narrative regarding how an individ-ual’s minority/ethnic identity had direct implications to a community oriented therapeutic recreation program when he worked with adolescents in a gang-pre-vention program in a low socioeconom-ic neighborhood. Because most of the program participants were from ethnic minority backgrounds Dieser wanted to highlight ethnic diversity and help these young men and women have a sense of ethnic dignity/pride. Dieser reported that almost all 11 participants from diverse ethnic backgrounds belittled the cultural based activities with one individual stat-ing, “It’s not cool to be Hispanic” and another participant calling ethnic leisure awareness “stupid.” Although these com-ments could be a result of many differ-ent factors (e.g., boring programs, lack of leisure resources) after processing the depreciating reactions, Dieser wondered if the depreciating behavior could be a re-sult of participants acting from the con-formity stage of ethnic identity (lowest stage of ethnic development).

In relation to ethnic identity de-velopment, understanding White racial identity development is viewed as a para-

mount part of cross-cultural counseling (e.g., Sue & Sue, 2007) and cross-cultur-al education (e.g., Singleton & Linton, 2006), especially among human service professionals who are White. In the field of counseling psychology, for example, there have been a number of multicul-tural experts who have emphasized the need for White counselors to deal with their concepts of Whiteness and to exam-ine their own ethnicity and how it relates to racism (e.g., Carter, 1995; Ponterotto, 1988).

Helms (1984, 1990, 1992, 1995) cre-ated an elaborate White racial identity model, which Sue and Sue (2007) sug-gest is the most influential and important White identity model to be proposed. This model has six stages. The first stage is known as contact. In the contact stage, which is the lowest developmental stage, a White person is satisfied with the racial status quo and oblivious to racism and one’s participation in it. If racial factors influence life decisions, they do so in a simplistic fashion. The next stage, dis-integration, is marked by disorientation and anxiety provoked by irresolvable racial moral dilemmas that force one to choose between own-group loyalty and humanism. A White person might be sty-mied by life situations that arouse racial dilemmas. The third stage, reintegration, is marked by an idealization of one’s so-cioracial group, denigration, and intoler-ance for other groups. Racial factors may strongly influence life decisions. Pseudo independence is the fourth stage. In it, a White person intellectualizes commit-ments to one’s own socioracial group and has deceptive tolerance of other groups. The fifth stage, immersion/emersion, is a search toward an understanding of the personal meaning of racism and the ways by which one benefits by White-ness and a redefinition of Whiteness. Life

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choices may incorporate racial activism. Autonomy, the sixth stage, is oriented to-ward informed positive socioracial group commitment, use of internal standards for self-definition, and the capacity to re-linquish the privileges of racism. White people in this stage may avoid life options that require participation in racial op-pression. The most balanced and healthy development stage is the autonomy stage.

Life phase assessment should occur by asking questions that are based on well-established psychosocial models. Sample interview questions include:

• (If working with a client who is a parent) At this time of your life, how is the balance of work, family, and leisure going for you?

• (If working with an adolescent) How are you doing in school? Are you in-volved in any school based clubs or sports or any community recreation activities?

• (If working with a client from an eth-nic minority) Can you share with me your self-ideas or values concerning your ethnic background and how this might affect your leisure pur-suits?

StageThe key question to ask in the stage

component of the CPSS model is “How does the client currently make meaning in life or develop cognitively and how does leisure influence meaningfulness in life?” Some of the stage theories to assess meaning-making are Piaget’s (1963) cog-nitive development, Perry’s (1970) ethnic and intellectual development, Kohlberg (1981) and Gilligan’s (1982) moral devel-opment, and Maslow’s (1968) hierarchy of needs. Beyond these developmental theo-ries, therapeutic recreation specialists should also understand how certain theo-ries of leisure are connected to meaning-

making in general. For example, serious leisure (Stebbins, 2007) and flow (Csik-szentmihalyi, 1997) are distinguished by several durable benefits, including fulfill-ment, meaning in one’s life, and personal enrichment (self-actualization). Further-more, therapeutic recreation specialists need to understand cross-cultural stage theories related to meaning-making. For example, drawing on Maslow’s hierarchy of needs, Schutte and Ciarlante (1998) posited that while physiological and safe-ty/security needs are universal, that be-longingness, ego/esteem and self-actual-ization are western based needs that may not be appropriate needs for people who are Asian. If working with Asian clients, Schutte and Ciarlante suggested the need of status should replace self-actualization because the need of status is collectivistic and the need of self-actualization is indi-vidualistic. Schutte and Ciarlante further suggest that the needs of admiration and affiliation should replace the Western and White needs of ego/esteem and be-longingness. Sample interview questions include:

• What is important to you and how can leisure involvement help you ac-complish this?

• (If working with a White person who seems to identify with individualistic values) Are the concepts of belong-ing and reaching your full potential (self-actualization) important to you and if so, how can leisure pursuits help in this area?

• (If working with an Asian person who seems to identify with collectiv-istic values) Are the concepts of af-filiation and status important to you and if so, how can leisure pursuits help in this area?

• Have you ever been so engaged in a leisure activity that you lost complete


track of time? If so, can you explain it to me?

• Can leisure or volunteer activity help you develop the moral values of care and responsibility?

An excellent source related to stage-evoking interview methods is the book Ways of Knowing Interview Schedule (see Belenky, Clinchy, Goldberger, & Tarule, 1997).

StyleIn the last stage, known as personal-

ity style, the key question to ask is “What tendencies does the person show in his/her interests, abilities, values, and tem-perament?” In short, the therapeutic rec-reation specialists would look for person-ality traits or preferences and use them to build leisure behaviors and experiences.

Drawing on both the Leisure and Well-being Model (see Carruthers & Hood, 2007; Hood & Carruthers, 2007) and positive psychology (see Peterson, 2006; Seligman, 2002, 2011; Synder & Lo-pez, 2007) therapeutic recreation special-ists locate signature/character strengths and connect them to interests and abili-ties that are meaning-making in life. Ac-cording to Peterson (2007), signature/character strengths are individual traits within a person and include bravery, courage, curiosity, kindness, gratitude, and so forth (see Peterson & Seligman [2004] for a classification system of twen-ty four signature strengths). For example, if a therapeutic recreation specialist was working with a client with a diagnosis of oppositional defiance disorder, which has a diagnostic criteria related to defiant be-haviors (personality trait), and this per-son had a deep love of animals and desire to volunteer at an animal shelter, along with having signature/character strengths of bravery and persistence, a therapeutic

recreation specialists might see the defi-ant personality as a strength and, there-fore, try to cultivate and direct the client’s defiant behavior toward animal advocacy, thus focusing on the healthy and posi-tive dimensions of a diagnostic feature.1 Sample interview questions for assessing the client’s personality style include:

• What work and leisure environments do you prefer or have you preferred?

• Name some of your interests, which may include any school subject?

• How do you prefer to socialize?• In regard to leisure options, how do

you tend to make your decisions: carefully, quickly, or somewhere in-between?

Because assessment related to personal-ity traits lies in the domain of psychology (e.g., the Myers Briggs Type Indicator [see Myers & Briggs, 1998]) working in collaboration with a psychologist, or us-ing personality testing data as a second-ary source, is warranted.

Context-Phase-Stage-Style Worksheet

A CPSS worksheet, adapted from

McAuliffe, Erickson, and Kress (2005), for constructive developmental assess-ment helps therapeutic recreation spe-cialists as decisions are made about treat-ment goals (see Figure 1). This worksheet has a two-fold purpose. First, it serves as a guide to assessing client’s constructions and developmental background and ca-

1One of the key elements of Developmental Counsel-ing and Therapy (DCT), which is also connected to positive psychology, is building on the healthy dimensions of mental health disorders and directing clients toward creating community change (see Ivey, 1973, Ivey & Ivey, 1998; Ivey, & Ivey,& Myers, & Sweeney, 2005).

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pacities, such as understanding culture and where a client might be related to

Erickson’s psychosocial developmental stages or minority identity development.

The CPSS Model: Assessing Client Context, Phase, Stage, and Style

Client Name: Age: CONTEXT = Where is the client placed in the social and physical circum-stances abounding him/her and how do these various contexts affect his/her leisure?

Examples (add more pertaining to TR setting and purpose):

Situation: What is the client’s strengths and presenting problems and how is leisure associated with it (e.g., leisure barriers/constraints, leisure resources, lei-sure behavior associated with physical and/or psychological diagnosis)

Family: What is the relationship of leisure to family? (e.g., life stage, family sup-port, enmeshment)

Community/culture: How does pertinent characteristics of the client’s cultural identity affect leisure? (e.g., gender, ability, race, religion, ethnicity, age, class, sexual orientation)

TRS’s Background: How does TRS’s own life situations, family, community, and culture affect a TR treatment plan (e.g., cultural background, religion, class)TR Plan related to context

PHASE = When will (or has) the client engage(d) in the sequence of psycho-social tasks that are related to leisure behavior and experiences?

Examples (add more pertaining to TR setting and purpose):General psychosocial observations Eriksonian perspectiveCareer/career aspirations and impact on leisureEthnic-identityTRS’s own current phase issues (e.g., self-psychosocial observations, Erikso-nian stages, stage of ethnic-identity):TR Plan related to phase:

Figure 1. Worksheet for Constructive-Developmental Assessment (cont.)


STAGE = How does the client currently make meaning in life or develop cog-nitively and how does leisure influence meaningfulness in life?

Examples (add more pertaining to TR setting and purpose):

Life purpose within cultural backgroundMeaning-making aspects of leisureTRS’s own meaning-making values:TR Plan related to stage (e.g., How leisure involvement can enhance client’s pur-pose of life)

STYLE = What tendencies does the person show in his/her interests, abilities, values, and temperament?

Examples (add more pertaining to TR setting and purpose)Clients personality styleAdvantage of this personality stylePlan to connect leisure to life problems within the client’s personality style:TRS’s own personality styles and how it might impact client and treatment plan: OTHER CONSIDERATIONS: (e.g., maladaptive thinking, different theories of leisure, TR practice models of choice, leisure or therapy orientation to practice, facilitation techniques and treatment models/theories)

Figure 1. Worksheet for Constructive-Developmental Assessment (cont.)

Second, and equally important, this worksheet is used to develop self-reflec-tive therapeutic recreation specialists who “foreground” their own constructs by reflecting on their own social con-texts, life-phase issues, stage tenden-cies, and personality traits. By using the CPSS worksheet, taking the time to be reflective about each client and one’s own (therapeutic recreation specialist) cul-tural assumptions during the assessment process, a therapeutic recreation special-ists might become aware of the client’s cultural values and contexts or their own cultural concerns, biases, and prejudices. For example, a therapeutic recreation specialists might realize that in past as-sessment procedures he/she may not have been reflective about the ethnicity

of a client (therapeutic recreation special-ists in the “contact” stage of White iden-tity development) and that this lack of cultural awareness could have led to un-intentional acts of racism or harm, such as creating treatment goals of functional independence for a client who values col-lectivistic behaviors. To this end, and to reflect on the manuscript introduction, a White therapeutic recreation specialists who does ask “What should I do during the first meeting or assessment with an African American client versus an Asian client?” could locate himself/herself in the “immersion/emersion” stage of White identity development and affirm that he/she is acting in a cross-culturally compe-tent manner.

Dieser 11

Furthermore, the CPSS worksheet concludes with a reflective stage beyond social contexts, life-phase issues, stage tendencies, and personality traits related to other considerations. Other consid-erations range from anything related to therapeutic recreation service delivery, such as partnership implications with other applied health professions, to choosing which therapeutic recreation orientation or practice model to use.

Conclusion and Future Directions

The CPSS model is an interactive as-sessment framework to gain information about clients on how their social contexts and cultural identities are related to their presenting problem and leisure behav-iors. This assessment framework also helps therapeutic recreation specialists understand their own social contexts and cultural identities and assumes that they have a solid understating of cross-cultur-al issues pertaining to human develop-ment. A concern, however, is the number of studies which suggest that therapeutic recreation specialists do not have ad-

equate cross cultural competencies (Blair & Coyle, 2005; Dieser, 2003, Stone 2003, 2009; Stone & Gladwell, 2004).

If therapeutic recreation is to de-velop cross-cultural competencies related to assessment and general practice, pro-fessional associations, certification, and accreditation agencies need to mandate greater attention toward cross-cultural competencies. For example, and al-though a step in the right direction, it is not enough that the National Council for Therapeutic Recreation Certification (2012) added examination content relat-ed to “diversity factors” under the broad-er heading of “Foundational Knowledge.” Each sub heading of the NCTRC exami-nation content—including assessment —should have content related to cross-cultural awareness, knowledge, and skills. Furthermore, mainstream textbooks related to therapeutic recreation assess-ment (e.g., burlingame & Blaschko, 2010; Howe, 1989; Stumbo 1997, 2001, 2009) need to dedicate more time and space to cross-cultural factors.

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Cross-Cultural Assessment in Therapeutic Recreation