Development of Culturally Sensitive Psychotherapists

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  • Professional Psychology: Research and Practice1989, Vol. 20, No. 6, 369-376

    Copyright 1989 by the American Psychological Association, Inc.0735-7028/89/S00.75

    Development of Culturally Sensitive Psychotherapists

    Steven Regeser Lopez, K. Pany Grover, Debra Holland, Melissa J. Johnson, Craig D. Kain,Kristi Kanel, Claude Ann Mellins, and Maureen Culkin Rhyne

    University of Southern California

    We propose a developmental model to describe how student-therapists learn to appropriately con-sider cultural factors in their clinical work with culturally diverse clients. The model is derived fromdiscussions held in a seminar concerning mental health services and culture and from students'written accounts of how they considered cultural factors in providing therapy. Vignettes based onthe written accounts are presented to illustrate the key developmental processes hypothesized tounderlie psychotherapists' growing cultural sensitivity. The proposed model is contrasted with pastmodels of therapist development. A research agenda guided by a social cognitive perspective is offeredto test the proposed model.

    Many authors have written about how mental health profes-sionals need to be sensitive to cultural issues in their clinicalpractice. Some authors have framed these concerns within thecontext of ethics (Pedersen & Marsella, 1982). Others have at-tempted to identify specific competencies and guidelines associ-ated with the effective treatment and assessment of special pop-ulations (Figueroa, Sandoval, & Merino, 1984; D. W. Sue etal., 1982; S. Sue & Zane, 1987). The perspective taken in thisliterature is that of the expert pointing out why cultural skillsare important and what one should do to enhance one's exper-tise in this area. Authors have given little attention to the per-spective of the student developing or improving skills in the as-sessment and treatment of special populations. Given the over-all lack of attention to students' training in these areas, we knowlittle about the developmental processes associated with suchtraining.

    Our main purpose was to consider the process by which ther-

    apists-in-training develop cultural sensitivity. Our conceptual-ization is guided by a developmental perspective (Loganbill,Hardy, & Delworth, 1982; Stoltenberg & Delworth, 1987) anda social cognitive perspective (Abramson, 1988; Fiske & Taylor,1984; Showers & Cantor, 1985). First, we believe that the con-cept of developmental stages is a useful heuristic for examiningthe growing expertise of student-therapists; that is, therapists'functioning is likely to proceed through stages or levels thatbuild on previous levels and represent progressively more com-plex and adaptive responses (Stoltenberg & Delworth, 1987).Second, the social cognitive framework enables us to considerhow student-therapists process information (e.g., test hypothe-ses) as they develop their expertise. This framework is particu-larly helpful in delineating hypotheses that can be tested in eval-uations of the proposed developmental model of cultural sensi-tivity.

    The impetus of this article came from a seminar concerningissues that arise in the delivery of mental health services to cul-

    STEVEN REGESER LOPEZ, PhD, is an Associate Professor of Psychologyat the University of Southern California (USC). His research concernshow clinicians consider cultural factors in assessment and psycho-therapy.K. PANY GROVER received her PhD in counseling psychology fromUSC. Her research interests include the study of interethnic offspringand their self-concept, identity issues, and psychological adjustment ascompared with those of intraethnic offspring.DEBRA HOLLAND received her MS and is currently pursuing her doc-torate in counseling psychology from USC. Her clinical practice andresearch focus on adult children of dysfunctional families.MELISSA J. JOHNSON, MS, is a doctoral candidate in counseling psy-chology at USC. Her areas of specialization are gender and nuclearthreat concerns.CRAIG D. KAIN received his PhD in counseling psychology from USC.He has a private practice in West Hollywood, California, and editedthe book No Longer Immune: A Counselor's Guide to AIDS, recentlypublished by the American Association for Counseling and Develop-ment.KRISTI KANEL received her MS in counseling psychology from Califor-nia State University, Fullerton (CSUF), and is currently working on her

    doctorate in counseling psychology at USC. She teaches human ser-vice and psychology courses at CSUF and Rancho Santiago Collegeand engages in private practice as a marriage, family, and child coun-selor.CLAUDE ANN MELLINS, MA, is currently a psychology intern at Co-lumbia Presbyterian Medical Center in New \brk and will receive herdoctorate in clinical psychology from USC. Her dissertation researchconcerns genetic and environmental influences on how children copewith stress.MAUREEN CULKIN RHYNE is a doctoral candidate in counseling psy-chology at USC. She is a psychotherapist and assistant professor in theDepartment of Nursing at California State University, Long Beach, andher research focuses on divorcing families.THIS ARTICLE WAS PRESENTED at "Psychotherapeutic InterventionsWith Hispanic and Native American Children and Families," a confer-ence sponsored by the University of New Mexico School of Medicine,May 1988.CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed toSteven Regeser Lopez, Department of Psychology, University of South-ern California, Los Angeles, California 90089-1061.

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  • 370 LOPEZ ET AL.

    tural minorities. Borrowing from a recent study in which clini-cians were asked to briefly recount a time when they consideredcultural factors in their evaluation of culturally diiferent clients(Lopez & Hernandez, 1986), the instructor asked the students,who were all involved in some clinical work, to keep a weeklyjournal describing how they considered cultural issues in theirclinical practice. The students were enrolled in doctoral pro-grams in either counseling or clinical psychology. The class wascomposed of 5 White women, 1 White man, and 1 woman bornin India and raised primarily in the United States. Initially, theweekly journal assignment was viewed by the instructor as aminor adjunct to a course that was to be concerned primarilywith research. The journal entries proved to be a most stimulat-ing vehicle by which to address many of the complexities inher-ent in considering cultural factors. As the course progressed,the clinical issues raised by the journal entries proved to be ofconsiderable interest to both the students and the instructor.After just a few weeks, much more time was devoted to the vi-gnettes and the ensuing discussions than was originallyplanned. From these discussions came the idea that studentswere proceeding in a stagelike fashion as they increased theircultural sensitivity. Further discussion and reflection served toidentify the hypothesized stages.

    We present vignettes to illustrate the characteristics of thestages that we believe reflect the development of cultural sensi-tivity. Stage 1 is an unawareness of cultural issues; Stage 2 is aheightened awareness of culture; Stage 3 is the burden of con-sidering cultural issues; and Stage 4 is moving toward the inte-gration of culture in one's clinical work. After presenting thevignettes representative of each developmental stage, we de-scribe the stage, paying particular attention to what we believeto be the critical processes associated with the therapist's devel-opment. Furthermore, to assess this model's comparability withprevious work, we discuss how each stage compares with thosepresented in other models of therapists' development (Loganbillet al., 1982; Stoltenberg & Delworth, 1987). Last, we offer aresearch agenda to assess the social cognitive processes that un-derlie this developmental model.

    It is important to note that we broadly define culture as thevalues, beliefs, and practices that are frequently shared bygroups identified by variables such as ethnicity, gender, and sex-ual orientation. Although nearly all of the vignettes concernethnic minority group members, there are references to issuesconcerning gender roles and sexual orientation. Though few innumber, the latter references illustrate our belief in a broaddefinition of culture.

    Developmental Stages

    Perhaps the biggest struggle for psychotherapists and studentswho attempt to consider cultural factors in therapy is to knowwhen to apply specific norms for a particular group memberand when to apply universal norms. This conflict has been iden-tified as the etic-emic conflict: Etic refers to universal norms,and emic refers to group-specific norms (Draguns, 1981). Prac-titioners can err on the side of assuming that certain behaviorshave the same meaning for all persons, when in fact the meaningof these behaviors is quite different for certain cultural group

    members. Egeland and her colleagues made this point in de-scribing how diagnosticians may have misinterpreted the ner-vous laughter of Amish bipolar patients as characteristic of ahebephreniclike schizophrenia, instead of social anxiety that re-sults from being in a public institution (hospital) outside theAmish community (Egeland, Hosteller, & Eshleman, 1983).

    In conlrasl lo Ihis lype of error, Iherapisls can err in ihe oppo-site direction of applying special norms to the behavior of aspecific group member, when in fact the special norms may nolapply; ralher, a more universal norm is more appropriate. OnIhe basis of a survey of how menial heallh professionals con-sider cullure in evalualions, Lopez and Hernandez (1986) pro-vided suggestive evidence of Ihis second lype of error. Theyfound lhal clinicians were al risk lo normalize or minimizetheir judgments of pathology when laking cullural factors inloaccount. For example, one clini