Evidence-Based Practice and Its Implications for Culturally Sensitive Treatment

66 journalofMulticulturalcounselinganddevelopMent•april2009•vol.37

articles

©2009americancounselingassociation.allrightsreserved.

evidence-Basedpracticeanditsimplicationsforculturallysensitivetreatment

GargiRoysircar

theauthordiscussestheadherenceofculturallysensitivetreatment(cst)toevidence-basedpractice.cstisdistinguishedfromempiricallysupportedtreatment.therapistsareadvancingcstbydesigningandevaluatinginter-ventionsandevolvingtheirunderstandingofwhatmakescstwork.

laautoradiscutelaadherenciadeltratamientoculturalmentesensible(cst,porsussiglaseninglés)alaprácticabasadaenevidencias.elcstsedistinguedeltratamientoempíricamentesostenido.losterapeutasestándesarrollandoelcstdiseñandoyevaluandointervencionesyevolucionandoensucom-prensióndelosfactoresquehacendelcstuntratamientoeficaz.

WillIbefreetodiscovermyownpath,uncoveranewjourneynooneelsehasknown,designmylifespacesinmynaturalcolorstropicalparadesofevergreens,caribbeanblueseas,sandsurfaces,mountain-rain-banana-leafhorizons.Iwanttoknow.Whoisgoingtotellme?

—SandraMariaEsteves,PuertoRicanAmericanpoeta

StudieshaveshownthatintheUnitedStates,ethnicandracialminoritiesarelesslikelytousementalhealthservices,and,whentheydo,theyarelesslikelytoreceivequalitycarethandoEuropeanAmericans(Lakes,

López,&Garro,2006).Arecentmeta-analysis(Griner&Smith,2006)identifiedreasonsforthisdisparity:(a)culturaldifferencesbetweenclinicianandclient,(b)mistrustofservicesbyminorityclients,(c)clients’socioeconomiclimitations,and(d)clients’help-seekingattitudesandperceptionsoftheirproblems.

Regardingthefirstreasonforthedisparity,culturaldifferencesbetweenclientsandcliniciansmayleadclinicianstomisinterprettheirclients’experiencesaExcerpt from “Who Is Going To Tell Me?” Reprinted with permission from the publisher

of Bluestown Mockingbird Mambo by Sandra Maria Esteves. Copyright © 1980 Arte PúblicoPress–UniversityofHouston.

Editor’s Note. MelbaJ.T.Vasquezservedasactioneditorforthisarticle.—G.R.

Gargi Roysircar, Department of Clinical Psychology, Multicultural Center for Research and Practice, Antioch New England Graduate School. Correspondence concerning this article should be addressed to Gargi Roysircar, Department of Clinical Psychology, Multicultural Center for Research and Practice, Antioch New England Graduate School, 40 Avon Street, Keene, NH 03431-3516 (e-mail: [email protected]).

journalofMulticulturalcounselinganddevelopMent•april2009•vol.37 67

and,thus,failtomeetthoseclients’needs.Regardingthesecondreason,cul-turallydiverseclientsmaymistrustmentalhealthservicesbecauseofhistoricracialdisparitiesintheUnitedStatesandashortageoftherapistsfromtheirownethnicorlinguisticbackground.Thisproblemmaybecompoundedbythelackofservicesincommunitieswhereethnicminoritieslive.Regardingthethirdreasonforthedisparity—socioeconomiclimitations—economicallydisadvantagedclientsmayhavedifficultytravelingtoclinicsoutsideoftheirneighborhoods,beunabletoaffordchildcare,havedifficultyschedulingap-pointmentsduringbusinesshours,ormaynotbeawarethatservicesareavail-able.Finally,clients’perceptionsorunderstandingsoftheirillnessandclients’engagementinhelp-seekingbehaviorsarenotattendedtobytherapists.

Culturallysensitivetreatment(CST)mayincludespecificinterventionsdevel-opedforaparticularculture,oritmayinvolvetheadaptationofanestablishedEuropeanAmericanmethodtoaparticularculture,suchasthetherapeuticalliance,grouptherapy,andfamilytherapy.Intheiranalyticstudy,GrinerandSmith(2006)identifiedCSTsthatdotakeplace,includingculturallyadaptedinterventionsforspecificethnicgroups,whichshowedgreaterimprovementsinoutcomemeasuresthangeneral“multicultural”interventions.CSTsalsoincludedthefollowing:(a)theexplicitincorporationoftheclient’sculturalvaluesintotherapy;(b)racial,ethnic,andlinguisticmatchingofclientandtherapist;(c)therapyprovidedintheclient’snativelanguage;(d)theexplicitculturalormulticulturalparadigmoftheagencyorclinicprovidingservices;(e)consultationwith individualswhoare familiarwithclients’culture;(f)outreacheffortstorecruitunderservedclientele;(g)provisionofservicessuchaschildcaretopromoteclientretention;(h)oraladministrationofmaterialsforilliterateclients;(i)culturalsensitivitytrainingforprofessionalstaff;and(j)provisionofreferralstooutsideagenciesforadditionalservices.

Amongothers,thereisonetraditionaltherapymodalitythatisdifferentfromCST.Thismodalityhasbeencalledempirically supported treatments,whichmostlycomprisecognitive–behavioraltherapy(CBT).CBTinvolvestheblendingofbothbehavioralandcognitiveapproaches.Inpartbecauseoftheincreaseddemandsbymanagedcareinsurancecompaniesforshort,cost-effectivetreat-ments,CBThasbecomeapopularparadigmformanyoftoday’stherapistsintheUnitedStates.Thecognitive–behavioralapproachusespsychoeducation,cognitiverestructuring,behavioralexercises,andhomeworkassignmentstoaddressaspecificproblembehavior.CBTisoneofthetwomostempiricallysupportedtreatmentsforpanicdisorder(theotherbeingpharmacotherapy),withpatientswhoundergothecognitive–behavioraltreatmentreportingpanic-freeratesofabout“80%infollow-upintervalsof1to2years”(Otto,Pollack,&Maki,2000,p.556).Thistypeoftherapyisalsoassociatedwiththelowestdropoutrateincontrolledtreatmenttrials;inaddition,patientsonaverageexperience “statistically significant improvement in overall panic disorderseveritybysession2”(Ottoetal.,2000,p.557).ThetechniquesoutlinedinCBThavebeensubjecttomoreextensiveresearchthantreatmentsoutlined


inanyotherparadigms(Chambless,Baker,Baucom,&Beutler,1998).Withtherecentpushfrominsurancecompaniesforgreateraccountabilitythroughuseofempirically supported treatments, it seems thatCBTisanexcellentfitwithinsurancecompaniesbecauseitensuresreimbursement.Asearlyas1986,AlbertElliswrotethatCBT“stayswithinthescientificmethodandtendstoexcludesomeoftheunscientificaspectsofpsychoanalysis,transpersonalpsychotherapy, and other therapies that promote inefficient and harmfulmethodologies”(Ellis,1989,p.14).

SeveralempiricallysupportedinterventionswithinCBThavetreatmentmanu-alsthatprovideguidancefortherapistsintraining.However,thereissomequestionaboutwhethertheuseofmanualizedtreatmentsmayoverlooktheinfluenceofboththeclient’sandtherapist’scharacteristicsontheoutcomeoftherapy(Deegear&Lawson,2003).Whenconsideringmanualizedtreatment,“Therearethreefundamentalquestionsthatcanbeaskedaboutanytreatment,a)Doesitworkunderspecialexperimentalconditions?b)Doesitworkinpractice?Andc)Isitworkingforthispatient(client)?”(Howard,Moras,Brill,Martinovich,&Lutz,1996,p.1059).CBTandmanualizedtreatmentdoworkinexperimentalconditionsaswellasinpractice.However,forpractitioners,themostimportantofthesethreequestionsisthelastonebecauseitdealswithaparticularclient’sprogress.TheAmericanPsychologicalAssociation’s(APA’s) understanding of evidence-based practice (EBP) incorporates thesignificanceoftheindividualclientintreatmentpractice.

APA’s integration of research and clinical expertise in client contexts

TheAPAneededtorespondtotwopressures:(a)theincreasingpressurefromthird-partypayersandgovernmentfundingagenciestoverifyboththenecessityandutilityofpsychotherapeuticinterventionsand(b)thepressuresfrombothscientistsandpractitionerswithinpsychology.In2005,APAofficiallyendorsedapolicystatementadvocatingtheuseofEBPasameansfordeliveringqualityandcost-effectivetreatmentformetaldisorders(APA,2005).AsdefinedbyAPA(2005,Introductionsection,para.1),“Evidence-basedpracticeinpsychologyistheintegrationofthebestavailableresearchwithclinicalexpertiseinthecontextofpatientcharacteristics,culture,andpreferences.”Iinterpret“clini-calexpertiseinthecontextofaclient’scultureandpreferences”asanunder-standingoftheclient’sworldview.Buttounderstandtheclient’sworldview,thetherapistfirstneedstobecomeawareofhisorherownworldview,assumptions,values,andbiasesandcontrolthesefrombiasinghisorherapproachtotheclient(Roysircar,Arredondo,Fuertes,Ponterotto,&Toporek,2003;D.W.Sue,Arredondo,&McDavis,1992).InEBP,althoughtreatmentisstandardizedandconductedinatime-limitedfashion,goodclinical judgment(interpretedasunbiaseddecisions)andinterpersonalcompetence(interpretedasthethera-peuticalliance)arevaluedforaccuratediagnosesandthefacilitationofsuc-


cessfuloutcomes.AlthoughEBPisnotsynonymouswithempiricallysupportedtreatment,APA’slanguageimpliestheuseofbestresearchevidence.Becauseempiricallysupportedtreatmentsareconsideredlessgeneralizabletoactualclinicalsettings,EBPisinterpretedastheapplicationofresearchknowledgetotherealworldofpractice.

Insum,researchisonecomponentofEBP.Theothertwo—clinicalexpertiseandpatientcharacteristics,culture,values,preferences,andcontexts—speakdirectlytoprofessionalcompetenceinavarietyofareas,including“under-standing the influence of individual, cultural, and contextual differenceson treatment” (APA, 2005, Clinical Expertise section, para. 1) and un-derstandingtheimpactclientinfluenceshaveonservicedelivery.GiventhisunderstandingofEBP,thequestionthatarisesishowCSTfitsinwithEBP.

CST theoryFortherapiststobeawareoftheirpersonalbiases,theymustpossesssophisticatedandongoingmetacognitiveabilitiestomonitortheirculturalassumptions,values,andbiases(Roysircar,2003,2004b,2007;Roysircar,Gard,Hubbell,&Ortega,2005;Roysircar,Hubbell,&Gard,2003).Therapistsmustcontinuouslyevaluateandmodifytheirtheoriesoftherapy,interventions,andclinicalskillstoimproveeffectivenessaswellasotheroutcomes(Nagayama-Hall,2001).Inaddition,therapistsneedtoadvocatechangeinorganizationalstructuresofservicedeliverythatcreatesystemicinequitiesand,asaresultofthisadvocacy,increaseaccesstoservices(Toporek,Gerstein,Fouad,Roysircar,&Israel,2006).Thispracticeframework,whichisanevidence-basedconceptualization,isthefirststepinCST.

attendingtoheterogeneity

Empiricallysupportedtreatmentshaveemphasizedsimilaritiesinhumanbe-havior,suggestingthattailoringspecificapproachesforgroupsorindividualsmaynotbenecessary.Thisconceptualizationisabouttheidentificationofuniversalbehaviors rather than the identificationofdifferences.However,researchhasnotdemonstratedthatanyempiricallysupportedtreatmentthatuniversalizesbehavioriseffectivewithallU.S.ethnicminoritypopulations.CSTs,ontheotherhand,representanattempttocorrectthisimbalancebydirectlyaddressing issuesofdiversityorheterogeneity.Therearebetween-groupaswellaswithin-groupdifferencesthatwouldrequireaformofpsycho-therapythatdiffersfrompsychotherapyforanotherculturalgroupaswellasforanindividualclient.Therefore,simpleinclusionofethnicminoritiesinpsychotherapyisunlikelytoyieldunderstandingsoftheculturalrelevanceoftherapy,interventions,orassessment.Multiculturalresearchalsofailswhenit places ethnicminorities inbroad categories like race andethnicity anddoesnotspecifydefiningcharacteristicsofanindividual,suchasimmigrantgenerationstatus,languageskills,class,sexualidentity,religionorspirituality,andmarginalizationexperiences.


Minorityutilizationandretention

ManyU.S.therapistscommonlyusetherapymethodsthatwerecreatedwithEuropeanAmericanclients inmind.Thesepracticesdonot takeminorityexperiencesintoaccount,whichcanleadtoprematuretermination(S.Sue,1998) or negative help-seeking attitudes and underutilization by minorityclients(Frey&Roysircar,2006).Toimproveminorityutilizationandreten-tion,D.WSueetal.(1992)intheirseminalarticleonmulticulturalcoun-selingcompetenciessuggestedclinicianshavethefollowing15broadskills:(a)respectfordiversereligious/spiritualbeliefsandvalues;(b)respectforindigenoushelpingpracticesandnetworks;(c)anappreciationofthevalueofbilingualism;(d)sensitivitytoconflictsbetweencounselingandculturalvalues; (e) an understanding of institutional barriers; (f) an awareness ofbiasesinassessment;(g)anunderstandingoffamilystructure,hierarchies,values,andbeliefs;(h)knowledgeofdiscriminatorypracticesinsocietyandthe community; (i) an ability to convey appropriate nonverbal messages;(j) an ability to properly use institutional interventions; (k) a willingnesstoconsultwithtraditionalhealersandspiritualleaders;(l)aninterestinaclient’slanguage;(m)anabilitytoappropriatelyusetraditionalassessmentwithdiverseclients;(n)awillingness tostrive toeliminatebias,prejudice,anddiscrimination;and(o)anabilitytoprovideclientswitheducationandinformation.Goingbeyondretentiontoreductionofsymptoms,S.Suehasspoken favorably of client–clinician ethnic match, ethnic-specific services,andclient–cliniciancognitivematch.Cognitivematch isdiscussed later as“sharedworldview.”

constructsforMinorityclientexperiences

Nagayama-Hall(2001)hassaidthatCSTmustincludethreeconstructscom-moninthemulticulturalliterature.Constructsinterpersonal/interdependenceneedsofcollectivisticpeople,racismanddiscriminationexperiencesofpeopleofcolor,andspiritualityorreligiousvalueshavewide-ranginginfluenceonhowpeople live in three-quartersof theworld.Asanexample,Nagayama-Hall said that cognitive approaches for the treatment of depression withU.S.ethnicminoritiesmaybemoresuccessfulbyintegratinginterpersonalaspectsofdepressionbecauseaninterpersonalworldviewismoreconsonantwithcollectivisticcultures.LeongandLee(2006)suggestedthattherapistsinvestigatewhatelementsof their theoryareuniversalandcanbeappliedtoallgroupsandwhichpartsareculturallyspecifictoEuropeanAmericansand,therefore,resultinculturalgaps.Thentherapistscanidentify“culturallyspecific”concepts,suchasthoseidentifiedbyNagayama-Hall,tofillidentifiedgaps.Therapists’abilitytoengageintheintegrationoftheaforementionedconceptualization,whichisevidence-based,withdeliveryprocessesofculturalandlinguisticresponsiveness,equity,andempowermentdistinguishesCST.


CST modelsculturalaccoMModationModel

LeongandLee’s(2006)culturalaccommodationmodel(CAM)seesclientsasbelongingtothreedifferentgrouplevels.Firstandforemost,theyaremembersofhumanityandthussharetraitsandcharacteristicswithallpeople(e.g.,allhumansgothroughdevelopmentalstages).Second,clientsmustbeperceivedinthe“groupdimension,”incorporatingtheirethnicity,race,gender,class,andsoforth.Last,aclientmustbeseenasanindividual,separateanddistinctfromthegroup.LeongandLeehaveproposedthatallclientsbeseenandtreatedinaholisticmanner,withclientconcernsseenasuniversal,group-specific,andindividualistic.BydecidingwhatelementsofatheoryareuniversalandcanbeappliedtoallgroupsandwhichpartsofthetheoryareculturallyspecifictotheEuropeanAmericangroupand,therefore,resultinculturalgaps,thecounseloridentifies“culturallyspecific”conceptsfromthemulticulturalliteraturetofillidentifiedgaps.Thetherapistthentestsanewculturallyspecifictechniquetoseeifitismorevalidthanthepreviouslyunmodifiedtechnique.TheCAM’sgoalistoprovideatheoreticalguideforcounselingworkaswellasforresearchonEBPwithamulticulturalpopulation.

MulticulturalrelationshipModel

Themulticulturalcounselingcompetencies(Roysircaretal.,2003;D.W.Sueetal.,1992)implythattheoreticalmodificationispredicatedontherapistshavingagoodunderstandingoftheirclientsandofthemselves,whichistheculturalawarenesscompetency.Apartfromtheheuristicsaboutculturalawarenessandknowledge,clinicalpragmaticsdemandthattherapistsconnectwiththemulticulturalclientataninterpersonallevel.Interpersonalengagementwiththeclientisoftheutmostimportancefordevelopingabondbetweenthecounselorandclientandforsub-sequentperformanceoftasksandgoals,whichresultinpositiveclientgains.

Mymulticulturalrelationshipmodel(MCRM;Roysircar,2007)makesuseoftheconstructofthemulticulturalcounselingrelationshipthathasbeenidentifiedasasubscaleoftheMulticulturalCounselingInventory(Sodowsky,Taffe,Gutkin,&Wise,1994).TheMCRMisframedwithinthetraditionaltherapyconstructsofthetherapeuticallianceandthecommonfactorsmodel,whicharediscussedlaterinthisarticle.TheMCRMcallsontherapiststolearnfiveinterpersonalengagements:affectivecommunication,relationshipbuilding;diunital/dialecticalreasoning, observation of a client’s local culture, and model managementthroughself-reflexivity.Thesefiveinterpersonalengagementsleadtherapiststocreateconnectionswiththeirclientaswellastheconditionstobettertailorormodifyatherapymodalitytosuitaculturallydifferentclient.

Affective communicationincludesusinghumorandenjoyingtheclient;connectingwiththeclient’ssubjectiveculture,whichincludessocietalvalues,norms,and


practicesthathavebecomepersonalandimplicittotheclient;respondingtoclientconcernsbyreferringbacktotheclient’scontexts;andusingthebehav-ioralresponsesofadmiration,affirmation,andemulation.Relationship buildinginvolvesthetherapistempoweringtheclient,whichallowsforclient–therapistmutualtrust,believability,andcredibility;usingrespectfulcommunicationsthatpreventsubtleracismaswellasunintentionalorintentionalmicroaggressions;knowingwhentolisten,whentoself-disclose,andhowmuchtoself-disclose;pacingwiththeclient;buildingcollaborationandasharedfeedbackprocess;andfindingacommon,universalgroundfortheclientandthetherapisttomeet.Diunital/dialectical reasoning isacognitiveflexibility inrecognizingtwocompeting,evenexclusionary,worldviewsandacknowledgingthattheclient’sworldview,evenwhendifferentfromthetherapist’s,hasreliabilityandvalid-ity.Thusthetherapistacceptspolaritiesandaclient’sworldviewasultimatelymeaningful for that client as his or her reality. Observation of a client’s local culture includesthetherapistaskingtheclienttodescribeanunderstandingofhisorherbehaviorfromwithintheclient’slocalcommunityandhisorhercommunity’sreactiontothespecificbehavior.Thetherapist,thus,observestheclient’sownconceptualizationofculture.Bytreatingeveryminorityclientasanindividual,thetherapistseesculturesasbeinglocalandsubjective,havingpermeableboundaries,changingconstantly,andbeinghighlyheterogeneous.Model management through self-reflexivity referstoaheightenedleveloftherapistself-awareness,whichfeedsameta-analyticunderstandingofallfourinterper-sonalengagements.Asametacognitiveprocess,thecounselor’sself-reflexivitymanagesalltheinterpersonalengagementsasacoherentwhole.

PilotoutcomedatashowinitialsupportfortheMCRM.TherapisttraineeswhocloselyobservedtheMCRM,asmeasuredbyobserverswhoratedtheirprocessnotes(withinalargerstudybyRoysircaretal.[2005],which,however,didnotincludeclientoutcomesincludedhere),expressedlessdisconnectionfromtheirEnglishasasecondlanguage(ESL)middle-schoolclients,andtheirclientsself-reportedsignificantlyhigherpersistence,satisfactionwithservices,well-being,andrelationshipscoresthandidotherESLclientswhosecounselorswereobservedtofollowtheMCRMlessclosely.Table1showscorrelationsofoutcomemeasures,andTable2showsoutcomedifferencesfortwogroupsofcounselortrainees.

Therewere31ESLstudentswhogavesignificantlyhigherself-evaluations(atp<.001top<.01)attheendofa10-sessionmentoringservicethan36otherESLpeers.Observers’ratingsofthesetwoESLgroups’counselortraineeswerethenexamined.Thecounselorsofthe31ESLstudentswhogavemorepositiveself-evaluationshadreceivedhighergradesfromtheirtrainerininterpersonalengagementsreportedinprocessnotes(atp<.01);thesesamecounselorshadbeengivenlowerratingsfordisconnectionbytrainedobserverratersofprocessnotes(atp<.01).Thehigherdegreeofinterpersonalengagementsandlowerdegreeofdisconnectionweredifferentfromthecounselorsoftheother36ESLstudentswhoprovidedlowerself-evaluations.ThispilotstudywasanattempttoconformtoEBPrequirementthatoutcomeresearchaccompanyclinicalexpertise


(onlyasrelevanttotraineedevelopment)inthecontextofpatientcharacteristics,culture,andpreferences.

cognitiveMatchModel

Cognitivematchrepresentsthecongruencebetweenthetherapist’sworldviewandtheclient’sworldview.Cognitivematchismadeproximaltotherapyout-comewhenitistranslatedintocaseconceptualization,strategiesforproblemresolution,andformulationofcounselinggoals—skillsthatadvancethecoun-selingprocess(S.Sue&Zane,1987).Forexample,Martinez-Taboas(2005)asked a Puerto Rican client how she explained her psychogenic seizures,showingrespectfortheclient’sworldviewofspiritistbeliefs.However,healsoincorporatedCBTandexperientialtechniques.Theclient’streatmentgoalwastoconfrontthespiritofhergrandmother,whohadcommittedsuicide,and free herself from guilt and fear. This goal was accomplished throughmany sessions of the empty chair technique. This case study illustratesthebenefitsofhavingaculturalconceptualizationthattakesintoaccounttheclient’s religious attributions with regard to her illness and describes howtheeffectivenessof traditional therapeuticmodalitiescanbeenhancedbyreframingsymptomsfromtheclient’sworldview.

Lakesetal.(2006)suggestedthatcliniciansdiscernwhat isatstake intheclient’slocalsocialworldtodeterminewhatisculturallyimportanttotheclient

Note. N=67eslstudents;N=67counselortrainees.atrainedcoders’frequencycountsofcounselortraineeconnectionanddisconnection.binstructorgrade.*p <.05.**p<.01,two-tailed.

Table 1

Pearson Correlations of english as a Second language (eSl) Students’ Self-Reported Persistence, Well-being, Satisfaction

With Services, Relationship With Counselor, and Observer Ratings of Counselor Trainees’ Connection, Disconnection, and Interpersonal

engagement With eSl Students

Outcome Variableeslstudents

1.eslstudents’persistence2.eslstudents’well-being3.eslstudents’satisfactionwith mentoring4.eslstudents’relationshipwith counselor

trainees5.trainees’connectionwithclientsa6.trainees’disconnectionwith clientsa

7.trainees’followingself-reflection guidelinesoninterpersonal engagementsb

1 2 3 4 5 6 7

— .44**—

.32** .06

—

.38** .13

.39**

—

.35** .10

.34*

.30*

—

–.08–.17

.27

.23

.48*

—

.40** .36**

.36**

.30*

.42**

.04

—


aswellaswhattofocusonintherapy.Incorporatingtheclient’sperspectiveallows anunderstandingof the client’s individual experience.The client isempowered,andacollaborativespiritispromotedthatenhancesthetherapeu-ticalliance.Cliniciansarebetterabletocrossculturaldividesbyrecognizingtheimportanceoftheirclients’localworldview,familysupports,community,andreligiousgroup.Individualidentityisinterwovenwithfamilialandsocialstructuresbecausefamilyandsocialhierarchiesandloyaltiestypicallyremainpowerfulthroughoutthelifetime(Shonfeld-Ringel,2000;Sodowsky,1991).

racisMacknowledgMentModel

RacismanddiscriminationaremorecommontotheexperiencesofU.S.ethnicminoritypersonsthantoCaucasianAmericans.Therapistswhohavenotexperiencedoppressiontothedegreethatmanyethnicminoritypersonshavecouldperceiveracism-inducedanxietyasresidingwithintheindividual.Asaresult,suchtherapistsmayerroneouslysuggestpersonalresponsibilityoraccountability.Thus,themosteffectivemethodsofdealingwithracismmaynotbeintrapersonallybased.

Psychotherapy that addressesoppression, racial identitydevelopment, andrecognitionofvariousintersectinggroupidentitiesofanindividualhasbeen

Table 2

end-of-Service evaluations by english as a Second language (eSl) Students and Observer Ratings of Counselor Trainees Showing

More Multicultural Relationship Versus Counselor Trainees Showing less Multicultural Relationship

Variable

eslstudents’persistenceeslstudents’well-beingeslstudents’satisfaction

withmentoringeslstudents’relationship

withcounselor

trainees’followinginter-personalengagementguidelinesa

trainees’connectionwithclientsb

trainees’disconnectionwithclientsb

M SD M SD t

28.43 4.58

25.06

72.52

23.27

11.29

4.5

4.87 0.75

2.14

6.42

7.48

7.07

2.71

20.35 3.22

16.04

67.11

18.15

9.47

9.35

3.75 0.83

2.18

7.19

8.33

7.15

6.77

7.66 7.00

17.03

3.23

2.63

1.04

–3.74

p d

.001 .001

.001

.01

.01

ns

.01

1.87***1.72***

4.18***

0.79**

0.65**

1.02***

More Positive MC evaluation

less Positive MC evaluation

eslstudentsself-evaluations

observerraters’evaluationsoftraineesinmulticulturalrelationship

Note. N=67eslstudents(n=31withpositiveevaluations;n=36withlesspositiveevalua-tions);N=67counselortrainees.Mc=multicultural.ainstructor grade. btrained coders’ frequency counts of relationship behaviors reported bytraineesinself-reflectiveprocessnotes.**p <.01.***p<.001.


showntobeeffective,evenwhenAfricanAmericanclientsdonotbringupissuesofrace(Fuertes,Mueller,Chauhan,Walker,&Ladany,2002).Interventionsofconsciousness-raisinggroups,rolemodeling,anduseofcommunityresources,basedonaworldviewofBlackracialideologyandAfricanAmericanculturalidentity,havebeenbeneficialforempowerment(Utsey,Bolden,&Brown,2001).Inaddition,researchershavenotedtheeffectivenesswithAfricanAmericanchildrenofsocialjusticeadvocacyinafter-schoolpreventionprograms—calledHeritageProject—thatfocusonthehistoryofAfricanAmericans, includingtheirvalues,strengths,andresilience,andthatimplementJanetHelms’sracialidentitytheory(Thompson,Alfred,Edwards,&Garcia,2006).

acculturationModel

Acculturation has been found to be a significant variable in determiningattitudestowardcounseling,help-seekingbehaviors,andutilizationofhelpresources by Asian ethnic groups (Frey & Roysircar, 2006; Kim & Omizo,2006).Practitionersneedtounderstandhelp-seekingattitudesofAsiansthataredeterminedbyhighversuslowacculturationinordertoincreaseAsianutilizationandretentionrates.AccordingtoAtkinson,Thompson,andGrant(1993),whenworkingwithalessacculturatedclient,thecounselorplaystheroleof theadviser,advocate, facilitatorof indigenous support system,andfacilitatorofindigenoushealingsystems.Asaminorityclient’sacculturationlevelincreases,therolesofacounselorchangetoaconsultant,achangeagent,acounselor,andfinallyapsychotherapist.Eventhosewithbiculturalidenti-tiesmayhavetroublerelatingunderafullyWesternframework,despitetheirstrongersenseofselfandstrongerself-assurancethanlessacculturatedAsians(Roland,2006;Roysircar,2004a).Thepractitioner,thus,isresponsivetothecontinuumoftheclient’sacculturation,thecontinuumofinternal–externalculturalandracialexplanationofproblemetiologies,andthegoalsoffixingacurrentproblemandpreventingfutureproblems(Atkinsonetal.,1993).

Therapistsneedtohelpimmigrantclientsmediatetheconflictingneedsoffamilyclosenessandpersonalindividuality.ImmigrantclientsdonotdefaulttoEuropeanAmericanidealsofindependentself-construalwhenatherapistencouragesthemsimplytodowhattheydesire.Therapistsneedtoactivelylistenandrespondtothedouble-bindmessagesreceivedbythesecond-generationAsianIndianyouths,whoare“Americanized”bytheireducationalandsociallife,whoseparentswantthemtoretaintheir“Indianness,”andwhoheartheircounselorssaythattheycan“choose”tobeneithertypebutjustbethemselves.Thesecondgeneration,hav-ingbeenraisedinAmericaandsparedthefirst-generation’sculturalseparationprocessfromthenatalculture,mayfeellesspressuretoholdorsuppressanyoneaspectoftheirculturalidentity(e.g.,clothing,religion,language,accent,vocationalinterest)andmaycomfortablydeveloptheirownunderstandingofwhatitmeanstobeanAmerican,anIndian,andaHindubyreligion.Itispinningdownhowthesecontextualfactorstranslatetomentalhealthandillnessthatisattheheartoftherapythattakesclientacculturationandenculturationintoaccount.


ThereareseveralreasonsfortheunderutilizationofmentalhealthservicesbyAsianAmericansasrelatedtotheirlowacculturation:alackoftrustinhelpingprofessionalsandtheirservices,alackofknowledgeabouttheavailabilityofservices,astigmaassociatedwithformalhelpseeking,atendencytoattributetofaithandreligion,andalackofAsianmentalhealthprofessionalsandprofessionalswhoaremulticulturallyandlinguisticallycompetent.ManyAsianAmericanshaveacollec-tivisticworldvieworientation,whichemphasizesobtainingguidanceandsupportfromone’sfamilyandcoethnicgroup.Thisemphasisinfluencesthehelpresourcesonechooses.Forexample,acollectiveidentityamongJapanesestudentswasfoundtopredictseekinghelpfromone’sfamilymembers(Yeh&Inose,2002).

spiritualityorreligionModel

Psychotherapyresearchersarelikelytorejectspiritualityorreligionasalegitimateinfluenceonaperson’spsychology.Manyculturallydifferentclientssubscribetoaspiritualselfandmayconsultpsychics,believeinpredestination,orseekreligiousstrengthintheirprayersandplaceofworship.EventhosetherapistswhoattempttounderstandspiritualitymaydosofromaEuropeanAmericanperspectivethatmayreducespiritualityandnon-Westernreligionstoreligiosity,religious“behav-iors,”orindividualconstructionism.Ortheymayviewspiritualpracticeswitharationalistview,suchasinternalversusexternalreligiousorientation.

RefugeesintheUnitedStateswhoareMuslims,suchasSomalis,Iraqis,andSuda-nese,oftensharewithotherrefugeesanexposuretowar-relatedviolence,suchaspersonalinjury,torture,sexualassault,malnutrition,anddisease(Jaranson,Martin,&Ekblad,2000).Muslimrefugees’posttraumaticstressdisorder(PTSD)symptomsarecommonlymanifestedinsomaticcomplaints(Hedayat-Diba,2000);thus,theirPTSDmayremainundiagnosedanduntreated.Inaddition,theyfaceacculturation-relatedproblemsofchronicunemployment,poverty,racialdiscrimination,andlimitedsocialsupport.Finally,Muslimrefugees’traumaexperiencesareexacerbatedbyfeelingsofinsecurityandhopelessnessattributedtorealand/orperceivedreligiousdiscriminationinUnitedStates.Thequestionthatarisesis,WhatcomprisesculturallyandreligiouslysensitivetreatmentofPTSDforMuslimrefugees?Acognitive–behavioristcouldcon-sidertheprocessoftailoringcomponentsoftrauma-focusedcognitive–behavioraltherapy(TF-CBT;Bisson&Cohen,2006)withculturallysignificantissuesofMuslimclients,suchasformalprayers;returntofaith;networksupport;stigma;genderrolesegregation;stoicismforperceivedpunishment;fearofAmericansystems,includ-ingthementalhealthsystem,becauseof theirreligiousaffiliation;andsoforth.TF-CBT’seightcomponentsthatneedculturaladaptationsarecalledPRACTICE:psychoeducation,relaxation,affectiveexpressionandregulation,cognitivecoping,traumanarrativedevelopmentandprocessing,invivogradualexposure,conjointfamilysessions,andenhancementofsafetyandfuturedevelopment.

afinalwordoncst

Pope-Davisetal.(2002)showedthatinsituationswhereclientsfeltthatotherneedsweremoresignificant,theyforgavetheirtherapistfornotprovidingCST.


Theseclientsadapted/acculturatedtotheirtherapists’approachesbutlimitedwhattheywerewillingtodiscuss.Thus,dependingonthetherapist’sculturalsensitivity,minorityclientsdeterminehow,what,andwhenculturalissuesmightbeexploredintherapy.Finally,theclientsthoughtthattherapistsshouldhaveculturallyspecificknowledgeaboutfamilystructuresandrelationships,racism,communicationstyles,culturalbeliefsaboutcounseling,discrimination,sexism,genderroleissues,culturalissuessurroundingsexualorientation,andculturalidentityandnormsforbehavior(Pope-Davisetal.,2002).SomeoftheseclientneedshavebeenaddressedinpreviousCSTmodels.However,oneshouldkeepinmindNagayama-Hall’s(2001)tworeminders:thereisinadequateempiricalevidencethatanyoftheempiricallysupportedtreatmentsiseffectivewithU.S.ethnicminoritypopulations;thereisinadequateempiricalsupportthatCSTsareefficaciouswithregardtotheoutcomeofsymptomreduction.Ontheotherhand,unlikeempiricallysupportedtreatments,CSTsareatanearlystageofdevelopment,andweneedtogivethoughttotheirdevelopment.

culturally adapted therapiesIn addition to proposing CST models, clinicians are recommending thattraditionalmodelsbemodified.Theclient-centeredapproach(MacDougall,2002),forexample,couldidentifyconstructsthatmightmisconstruelossoffaceorsuicidalideationinAsiansasindicatorsoflowself-esteemandcouldreconsider terminology that embodies Western values and abstractions todescribethetherapeuticrelationship.TheRogerianprincipleofvalidatingtheclient’sexperiencewithoutjudgmentmightbemodifiedasaculturallysensitivecommonfactorsapproach.Thegoalofthemodifiedapproachistoestablishatherapeuticrelationshipbyidentifyingasharedclient–counselorworldview,havingaclearunderstandingoftheclient’sexpectations,andusingculturallyappropriateinterventions(Fischer,Jome,&Atkinson,1998).

adaptedcBtandpsychodynaMictherapy

IntheJanuary2006issueofPsychotherapy: Theory, Research, Practice, Training,cliniciansexaminedtheefficacyofpsychodynamic therapy(e.g.,Roland,2006)andCBT(e.g.,Shen, Alden, S�chting, & Tsang, 2006) with Asians andShen,Alden,S�chting,&Tsang,2006) with Asians andwithAsiansandAsianAmericans.Boththerapiesseemedeffectivebutaccomplishedtreatmentgoals indifferentways.Thebehavioral approach showedclear successes.Itwassimpletocarryoutandbenefitedfromsmallculturalmodifications,suchasusageofclientlanguage.CBT(Shenetal.,2006)didnotattempttochangeitsmajorconstructsinanyway,and,consequently,itremainedfirmlyrootedinitsAmericanmethods.Inworkingwithdepression,onegoalwastostampoutcatastrophicthinkingorblack–whitenegativecognitions,whichmeant stampingout fundamentalChinesebeliefs, suchas, “Angerisbad,”“Imusttakecareofothersbeforemyself,”and“IfIsay‘no,’Iamaselfishperson.”Strictmethodologyledtoclientsnotcompletinghome-


workassignmentsbecausetheyworriedaboutfailingtheassignmentsanddislikedcognitiveexercisesthatforcedthemtoexaminemorbidthoughts,whichtheyweretaughttoupholdinChina.Clientscouldnotunderstandthedifferencebetweenhopelessnessandhelplessness.Theseglitcheswereovercome by Cantonese-speaking psychologists. CBT succeeded in allevi-atingpsychopathology.But thequestion isdid itdosoat theexpenseofcompromisingtheclients’culturalidentity?

Cognitive–behavioral therapists who are traditionalists disagree that theirtheorycanbeadaptedtothecultureofindividualcases.Theyrecommendthatthetherapistnotjointheclientinhisorherillnessattributionsandespiritismobeliefsbecausethesearedysfunctionalinnature(Castro-Blanco,2005).Thus,thesetherapistschallengetheaccuracyofespiritismobeliefs,guilt,andotherdysfunctionalbeliefs.However,apuristcognitive–behavioralapproachrunstheriskofunderminingthetherapeuticalliance:agreementontasks,agreementongoals,andempathicattunement(Martinez-Taboas,2005).

BecausemuchoftheresearchdonehasbeencarriedoutonmajorityEuropeanAmericanpopulationsandincontrolledclinicaltrials,somecognitive–behav-ioraltherapistsareagreeabletoaslightlymodifieddeliverymethodtobettersuittheminorityclient.Oneexamplecanbefoundinacognitive–behavioraltreatmentfordepressionthatwasaugmentedtoserveaHispanicpopulation.ThemodificationincludedusingSpanish,makingexamplesculturallyrelevantwhen explaining techniques, and acknowledging the particular values andexperiencesofthegroup(Whaley&Davis,2007).

Conversely,somepsychodynamictherapistshavegoneoutoftheirwaytoavoiddamagetotheclient’ssenseofself(Roland,2006).Forexample,insomecasestheviewpointsofpsychopathologywerealteredinordertobetteraccommodateAsians,andsomedynamicswerenotperceivedasnegative,suchasadependencyrelationshiporatherapeuticrelationshipdevelopingintoalifelongmentor-ingrelationshipwithminimalfinancialcompensationforthetherapist.Suchculturaladaptationsmaybeinconsistentwithpsychodynamictheory.

UltimatelybothpsychodynamictherapyandCBTaresound,butneitherisperfect.BothweredevelopedwithaWesternworldview,anditshows.However,somedegreeofprogresswithregardtoculturaladaptationhasbeenmadebypsychodynamictherapyandCBT,andthatshouldneverbediscounted.

thetherapeuticallianceadaptedforMinorityclients

Researchershavefoundthat,generallyspeaking,treatmentiseffectiveforabroadrangeofproblemsandpsychopathology,regardlessoftheclinician’stherapeuticapproach(Lambert&Archer,2006),perhapsbecauseofsharedcommonfactors(Wampold,2000).Thetherapeuticalliance,ortheclient’ssenseofalliancewiththehealer,hasbeenidentifiedasoneofthemostim-portantcommonfactorsintherapeuticeffectiveness.Thetherapeuticallianceisalsothequalityofinvolvementbetweentherapistandclient,asreflected


in their tasks, teamwork, and personal rapport. In actuality, research hasdemonstratedthatalmostanywell-plannedtreatmenttendstobeefficacious,with the therapeutic relationshipaccounting formorevariance inefficacythanthespecifictherapyparadigm(Wampold,2000).

Although multiple reasons most likely account for high underutilizationanddropoutrates,onepossibilitymaybethatmanyethnicminorityclientsdonotexperiencethetherapeuticalliance.Relatedcausesthatimpedethetherapeuticallianceincludeculturalmisunderstandingsandmiscommunica-tionsbetweentherapistsandclientsbecauseofstereotypes.Thechallengeinlearningaboutculturalgroupsistoavoidstereotyping.Instead,thetherapistshoulduselearnedknowledgetoassesshowapplicablevariousculturalvalues,behaviors,andexpectationsaretoanindividualclient.

Therapists’personalattributesthathavebeenfoundtocontributepositivelytotheallianceincludebeingflexible,honest,respectful,trustworthy,confi-dent,warm,interested,andopen.Techniquessuchasexploring,reflecting,notingpasttherapysuccess,accuratelyinterpreting,facilitatingtheexpres-sionofaffect,andattendingtotheclient’sexperiencehavealsobeenfoundto contribute positively to the alliance. Comas-Diaz (2006) suggested thatalthoughthetherapeuticrelationshiprequiresspecialattentioninmulticul-turaldyads,cliniciansneedtotailortherelationshiptotheindividualclient’sinterpersonalanddevelopmentalneeds.

threatstothealliance

Psychologistsmaynot alwaysbe awarewhen thepotential fordevelopingatherapeuticalliancemaybecompromised.Becauseofahistoryofoppressiveandrejectingexperiences,manyifnotmostethnicminoritiesareeasilyshamed.Ethnicminorityclientsmaybeparticularlysensitivetotheexperiencesofnegativejudgment,rejection,andcriticalnessonthepartofWhitetherapists,withouttheWhitetherapistbeingawareofthis.Ethnicminorityclientsexperienceslightsandoffensessoregularlythatthereisatendencyinthemto“edit”theirresponsestotheirpsychologistsonaregularbasis(Pope-Davisetal.,2002).

Social structures (social class, religious institutions, political institutions,languagerequirements,mentalhealthpolicies)havecompoundingeffectsontherapists’cognitivestructuresandultimately their socialattitudesandbeliefs about people. These effects can result in expressions of stereotypethreat(Steele,1997),racialmicroaggressions(D.W.Sueetal.,2007),andimplicit racism (Dovidio, Kawakami, & Gaertner, 2002). Therapists maynot always know when they convey negative judgments in body language,includingfacialexpressions,voicetone,andeyecontact.Eberhardt(2005)indicated that White participants exhibited more positive evaluation bias(greateramygdalaresponsehabituation)toWhitefaces(in-group)thantoBlackfaces(out-group).BlacksexhibitedamorepositivebiastoBlacksthantoWhitesinwaysneverbeforethoughtpossible.Theimplicationisthateven


psychotherapistsmayexhibit“unintentionalbias”intheirworkwithclientsorpatientswhoareculturallydifferentfromthem.

reducingBiastoincreasealliance

Aspreviouslydiscussed,thefirstandmostcriticalcomponenttoreducingbiasisconstantawarenessofsocialattitudes.Approachingthosedifferentfromuswithinquiry,interest,andopennessmayalsohelptoreduceprejudicialbeliefsandattitudes.Effortandpracticeareneededtochangetheautomaticfavorableperceptionsofthegroupwithpowerandthenegativeperceptionsofthosewhosehistoricalrolesinsocietyhavebeenleftwithnegativeperceptions.Wecan“rewireourcognitivecircuitry”byexplicitlyprocessingourbiases,immersingourselveswithdifferentgroupsandindividuals,reading,andtrainingandpracticingbehavinginwaystochangeoursubconsciousperceptions(e.g.,racialmicroaggressions)inthetherapeuticprocess(i.e.,stayingtunedtoclients,demonstratingculturalempathy,andbeingrespectfulofandopentoworldviews).Wecanchangethe“neuralpathways”developedthroughsocietalnegativebiasesandstereotypes(Eberhardt,2005;Siegel,1999).

conclusionInthisarticle,IhaveassessedtheadherenceofCST,whichincludesculturallyadaptedtherapeuticmodalities,withEBP.TherapistscanadvanceCSTbydesigningandevaluatinginterventionsthatareculturallyrelevant,ratherthanremainingdependentonmanualizedtreatments.AmajorfocusforthecurrentgenerationofculturallysensitivepractitionersistoevolvetheirunderstandingofwhatmakesCSTworkandtoseekevidencetosupportsuchworkbyplayinganincreasedroleinresearchontherapyconceptualization,assessment,andoutcome.

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Evidence-Based Practice and Its Implications for Culturally Sensitive Treatment