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Providing Multicultural Therapy: Developing Cultural Efficacy
by Carol Falender, Ph.D. and Tonya Wood, Ph.D.

4 CE Hours - $99

Last revised: 09/04/2023

Course content © copyright 2023 by Carol Falender, Ph.D. All rights reserved.

   

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Learning Objectives

This is an intermediate level course. After completing this course, mental health professionals will be able to:

The materials in this course are based on the most current information and research available to the authors at the time of writing. The field of multicultural psychotherapy is growing exponentially, and new information may emerge that supplements these course materials. This course material is designed to equip practitioners with a comprehensive understanding of multiple cultural identities, practice parameters, and the strengths of effective practice as well as an understanding of the potential harm inflicted on clients by less-than-competent practice. It is possible that reading about lack of awareness of multicultural factors could be triggering but those effects could be assuaged by enhanced knowledge of positive strategies for practice of effective clinical multicultural psychotherapy and by clinical consultation.

Outline

Introduction

In the ever-changing landscape of society’s racial and cultural diversity, it is imperative that mental health providers are equipped with the tools and knowledge to best serve diverse groups. Having foundational knowledge of theories and concepts of multiculturalism is critical in providing quality and effective psychotherapy. Using a multicultural lens assists therapists in recognizing and valuing the diversity of human experiences and the multiple ways that cultural factors can influence an individual's thoughts, emotions, and behaviors and thus impact psychotherapy.

The most frequent and strongest predictor of client outcome is the therapeutic relationship. Thus, establishment of the therapeutic alliance and identification and management of countertransference or emotional reactivity are central factors. Apropos to the relationship are the identities of each participant – client(s) and therapist(s) – assumptions each makes about the other, openness to the individual cultural diversity factors of each, self-perceptions, and perceptions and behaviors toward clients. Therapist openness to client cultural beliefs, values, perspectives, strengths, and resources, as well as empathic relating, are central to all therapy. Therapist self-knowledge and awareness of personal identities, biases, and worldviews enhance the therapeutic process. How a therapist approaches multicultural factors, ethnicity, race, power, and privilege pave the foundation and formation of the relationship. Interpersonal processes, identifying and addressing strains, enhancing mutual understanding, and initiating problem-solving all inform the therapy. There are many aspects that can inform and strengthen the bond, enhance collaboration, and make for a respectful process that facilitates treatment; similarly, some may hinder, feel unjust or oppressive, or be lacking in empathy.

Therapists who are trained in multiculturalism are better prepared to tailor treatment and address the unique needs of clients from diverse cultural backgrounds. A better understanding of cultural norms, values, and beliefs can influence clients' attitudes toward mental health, help-seeking behaviors, and treatment preferences. Appropriate multicultural training also creates opportunities to better recognize the clinician’s own cultural biases that can impact their work.

In this program, key aspects of multicultural psychotherapy are identified, contextualized in terms of current research and analysis, and strategies are suggested to enhance efficacious practice.

Are We Culturally Efficacious?

Are cultural identities a major factor in treatment? In a recent study it was shown that although therapists may consider themselves culturally self-efficacious, they generally do not even minimally address sociocultural factors or background (Wilcox, Franks, Taylor, Monceaux, & Harris, 2020).

There was a failure by a substantial proportion of participants. Therapists who perceived themselves to be culturally efficacious did not even minimally address clients’ sociocultural context, demonstrating a significant disconnect between self-perception and self- report and actual performance. Further, therapists demonstrated denial of privilege and of oppression, simply suggesting that sometimes dominance of some occurs. Further, tendencies toward perspective-taking and possessing “just world” beliefs were associated with multicultural competence. (Wilcox et al., 2020). So, a critical take-away is to not simply self-assess cultural efficacy generally but rather to consider specific components and behaviors that comprise such efficacy.

It is also important for the clinician to be self-aware of one’s cultural frame and behaviors as one conducts clinical work. Our self-assessment is often not as accurate as we believe it to be, and often differs markedly from observer ratings. With this information, self-assess how often you use multicultural case conceptualization. Specifically, to what extent are culture and context significant components in your case conceptualization.

Given the important premise that all clinical practice is multicultural, clinicians need to have specific strategies to imbue their worldviews in their thinking, conceptualizations, treatment planning, interactions, and relationships. Both clinical practice and clinical supervision are cultural encounters (Falicov, 2014).

How does one strengthen one’s multicultural practice acumen? Concern has been expressed about impact on clinicians of the devaluation of field practicum and the disconnect between academia and the field experience (Giddings, Cleveland, & Smith, 2007), potentially leading to inadequate or harmful clinical practice. Substantial evidence of the existence of harmful supervision during the training trajectory has been revealed (Coleiro, Creaner, & Timulak, 2022) after Ellis et al.’s (2015) shocking finding of high rates of inadequate and harmful clinical supervision during the training trajectory. And if harmful clinical supervision occurs, it will directly and adversely impact clinical practice. Note that in harmful supervision, both clients and supervisees-in-training are harmed.

Guidelines for Multicultural Practice

It is critical for practitioners to be prepared to approach multiculturalism intentionally and systematically as a part of practice and to have requisite knowledge, skills, and attitudes to initiate and maximize efficacy of the cultural encounter in the frame of multicultural practice. A first step is to consider the concept of worldviews.

Worldviews are sets of attitudes, beliefs, assumptions, stories, expectations about the world and social realities – and these inform our every thought and action. They impact what we attend to, how we respond, and our attitudes and behavior toward clients and our clinical work. As a clinician, it is critical to be self-aware and open to input and consideration of how our own early life experiences and identities form our expectations and behavior toward clients. From the very onset of the therapeutic experience, our presentation (and if under supervision, the supervisor’s as well) including attitudes and behavior, set the frame for clinical work and relationship. Openness, supportive quality, and empathy are essential ingredients. The depth and breadth of our worldviews set the stage for our clinical practice.

When the American Psychological Association presented revised multicultural guidelines (2017), they refocused on efforts to address systems-level change rather than traditional approaches to individual-level change. Thus, multiple populations’ historical experiences including power, privilege, and oppression were to be addressed systemically, and attention to be focused on macro levels including racism and multiple other isms (i.e., sexism, racism); also societal structures: economic, educational, access to adequate culturally relevant health care, as well as social and community contexts, all addressing both health and healthcare disparities and access. This shift in focus to systems-level approaches has been slow to reach the mental health communities.

Think about a client you are currently working with or worked with previously. Before you met them for the first time, consider how a combination of your brief information from the client and your own life experience influenced your thoughts about how the client would present for the first session. Reflect on how accurate your expectations were. And think about what factors were operative in your thoughts about how they would present. Examples could be previous clients, referral question(s), phone screening information, and assumptions based on all of those.

To further reflect on these concepts, let’s review the following example.

Consider an adolescent who was referred for depression. The 14-year-old girl was not eager to be in therapy, but her mother insisted. The therapist was unsure how to deal with a reluctant client but began by encouraging her to identify what was going well for her. The therapist wanted to identify three goals but the youth was non-responsive and said therapy was “stupid.” Then the therapist gently asked her about school and home. The client disclosed that she was at a new school and kids at this school were really different from her. The therapist encouraged her to talk about how they were different, and the client said that she is Latina and most of them are not. The therapist explored that with her, and discussion turned to her break-up with her boyfriend, worry about her grades, annoyance with her brother, worry about her upcoming birthday, her grandmother’s efforts to control it, and her feeling overwhelmed. She started to say “quince …” and then stopped and asked the therapist if she even knew what a quinceanera was. The therapist did, asked her a few questions about her many preparations for it, and then encouraged the client to tell her specifically what her worries were. Further discussion resulted in identifying several goals for treatment, both immediate and longer-term ones, as they related to both the celebration and her worries about school performance, isolation, and lack of friends in her new school. The client asked the therapist how she knew so much about “quince” and the therapist told her she had gone to school with several girls growing up who had had one.

All Therapy and Practice is Multicultural

Generally, in training therapists studied “multicultural competence” in preparation for conducting excellent therapy and assessment. Increasingly, concern turned to the inference by some that “competence” was perceived as an endpoint one could achieve and thereafter remain confident in one’s knowledge without ever learning anything more. However, it is increasingly clear that there IS no endpoint and that the components of “competence” – knowledge, skills, and attitudes – are ever-evolving, and that there is no end to learning, experiencing, understanding, relating, and integrating.

Next, researchers turned to Multicultural Orientation (Owen, Tau, Leach, & Rodolfa, 2011), referring to philosophy, values, and beliefs about the importance of multicultural factors including racial and ethnic identities, and the clients’ cultural background in the context of those of the therapist, and how one integrates all of those into the conduct of assessment and intervention with the client(s). Importantly, attention was focused on not simply knowledge, but on attitudes and skills. These are essential, as therapy is anchored in relationship – which is comprised of the working alliance, the “real” relationship, and transference/countertransference or emotional reactivity, and is anchored in collaboration, which implicitly requires goals and tasks for therapy shared between the client and therapist and requires therapist genuineness. When clients viewed their therapist’s multicultural orientation positively, the therapist was perceived to be more believable and credible, and client psychological wellbeing was viewed to be more positively impacted. However, the results were not uniform across various client ethnic and racial groups.

Defining Cultural Competence

While there is agreement about the role and importance of considering culture in assessment, diagnosis, and treatment, there remains a challenge in coming to consensus on defining exactly what “cultural competence” is and how to achieve it in psychotherapy. A 2010 literature review that compared the various conceptualizations and definitions of cultural competence across varied disciplines in healthcare including psychology and social work found a lack of consensus regarding an operationalized definition or concept of cultural competence. The review revealed that across the varied models of cultural competence there was disparate emphasis on what was considered to be the essential components of multicultural counseling.

Across the different models of cultural competence, the authors did however identify four common themes that can be used to develop a framework for providing effective clinical services with clients of diverse cultures and backgrounds:

1) awareness of one's own cultural beliefs and biases;

2) understanding of the client's cultural background;

3) knowledge of culturally appropriate interventions; and

4) development of cross-cultural skills.

Any therapist preparing to work with diverse populations should prepare themselves to gain knowledge and awareness across these four domains (Huey, et al., 2010).

Knowledge, skills and attitudes are relevant and essential. Knowledge and understanding of one’s personal biases, privilege, and assumptions; recognizing, respecting, and honoring clients’ worldviews through inference and action; and being responsive and aware of clients’ worldview and realities are all essential. Attitudes may be implicit. Thus, engaging in reflective practice, ongoing training and supervision, and being open to feedback and self-reflection with respect to metacompetence (openness and thoughtfulness about what one knows and does not know), self-critiquing, and being genuinely open to input and feedback – even though it may be difficult to hear – are all essential components of effective multicultural practice.

And remember there is NO ENDPOINT to cultural competence: It is evolving and changing with experience and with new knowledge, skills, and attitudes.

Training

Graduate Training in Multicultural Practice

Generally, attention to multicultural competence and cultural humility in graduate training may have been limited and varied as a function of when and where one received their training. Collins, Arthur, Brown, & Kennedy (2015) studied student perspectives on graduate training in multiculturalism and social justice. They identified competencies facilitated and those in which barriers were encountered. Facilitated were:

They described the process of relationship-building scaffolded from their own understanding of their own personal biases, privilege, and cultural assumptions and honoring clients’ worldviews. Barriers were student personal, interpersonal, or contextual factors that blocked or interfered with facilitating factors. These included:

Critical questions include how to create a training environment of cultural humility? How do each of us model reflection, acceptance, and openness to acknowledging our own privilege, bias, and worldviews – and how do we demonstrate this in our clinical practice?

Also, whose perception counts? In a meta-analysis, client perceptions of multicultural competence correlated with client outcomes, but therapist self-perceptions of multicultural competence did not (Soto, Smith, Griner, Rodriguez & Bernal, 2018). They described the use of cultural adaptations including holistic/spiritual conceptualization of wellness and engaging in cultural rituals. Areas of cultural adaptation included: language, use of and content of metaphors, general content, goals, methods, and the context. Consider your own use of cultural adaptation and how you enact it. Examples include respectful inquiry about cultural meaning, spirituality in the context of the presenting issues or solutions, harmony, and reflective practice including indicating if the therapist does not understand a concept or practice. However, likely as a result of their level of acculturation, children benefit less from cultural adaptations (Huey & Polo, 2008).

It is suggested that although therapists cannot be competent in every client identity or attribute, they could be aware of, open to, and attempting to adapt treatment to align with the salient intersecting identities, those valued most by the client (e.g., religious, culture-specific) (Soto et al, 2018).

Another question is how accurate is one’s own self-assessment? And how effective is one multicultural course without integrated supervision and ongoing support? Self-assess on your own training during the graduate trajectory and consider the strengths and barriers presented above as well as the evolution of practice and research in the past decade. Remember that your own active efforts to self-assess enhance your self-knowledge and thus your competence.

Multicultural Competence

Recognition must exist that there are multiple factors in the provision of multiculturally relevant therapy. This includes knowledge, skills, and attitudes. Provision of therapy and assessment in a respectful, knowledgeable, and culturally competent manner are essential. There is significant recognition that psychotherapy must be culturally competent and occur through the lens of cultural humility. However, clinicians may find themselves unclear or challenged to do so. Examination of one’s attitudes, beliefs, skills, knowledge, and previous life experience is imperative. Considering one’s assumptions about therapy, therapeutic relationships, psychotherapy models, multicultural psychotherapy, values, and biases are all essential.

Consider the grounding principles of the APA’s Guidelines on Race and Ethnicity (APA, 2019): articulating the critical and ubiquitous influence of ethnicity, race, and related issues of power and privilege with the understanding that social justice is inherent to racial and ethnocultural responsiveness. It is essential for clinicians to be self-aware and proactive in discussion of race and racial identity. This includes attending to power differentials related to race in professional interactions and in relationships, minimizing detrimental effects of unconscious, implicit bias. Race and ethnicity are sources of meaning and context. Some possible steps provided in the guidelines are:

When race is avoided, the avoidance interferes with relationships, promotes social distance, and may be inferred to be (or is) implicit bias or implicit prejudice or represents a set of negative attitudes. These may be manifest as social distance, presumed prejudice, implicit attitudes, micro or macroaggressions that are expressed or experienced, and internalized racism. Implicit bias is automatic and unintentional, and results in assumptions, preferences, aversions, or behavior that results in (unintended) assumptions and actions. For example, when a therapist is more affiliative and responsive to someone with a common name rather than a less usual name that may be associated with a particular ethnicity, or making assumptions about a group or individual based only on race. All of these prevent connection and harm the therapeutic relationship. Race and ethnicity are also associated with experiences of oppression, privilege, and power. Avoidance of the topics may lead to assumptions of disrespect and generally undermine relationship and the framework of social justice and fairness.

The first of these APA guidelines (2019) is to “strive to recognize and engage the influence of race and ethnicity in all aspects of professional activities as an ongoing process” (Guidelines, APA, 2019, p. 9). With value attached and recognition of importance, the clinical guideline sets the stage for discussion and mutual understanding. Guidelines three and four entail striving for awareness of own’s own positionality (and identities) with relation to ethnicity and race, and addressing social inequities and injustices.

Proactive discussion includes engaging in reflective practice including exploration of worldviews and social positions, all of which are impactful on the presenting problem and the therapy that ensues. Thus, it is imperative that clinicians continuously engage in learning about these aspects of culture.

Identities and Perspectives

Race

Black persons are more likely than Hispanics or Asians – and much more likely than White persons – to say that their race is central to their identity. According to the Pew Research Center, about three-quarters of Black adults say being black is extremely or very (74%) important to how they think of themselves; 59% of Hispanics and 56% of Asians say being Hispanic or Asian, respectively, is important, and about three-in-ten in each group say it’s extremely important. In contrast, just 15% of Whites say being white is very or extremely important to how they think of themselves. (pewresearch.org/social-trends/2019/04/09/race-in-america-2019/)

Racial and ethnic identity thus are central to all aspects of self, although the extent is variable; discrimination and racism negatively impact mental health processes and outcomes. Race itself is complex, as it is a social construct that relates to skin color, facial features, hair texture, and body shape (Harrell & Sloan-Pena, 2006).

BIPOC (Black and Indigenous People of Color) individuals are less likely to seek therapy, and when they do, they are more likely to terminate therapy early (Owen et al., 2017). The multicultural competence model proposed that therapists are expected to learn culturally relevant knowledge, be open to challenge their own beliefs regarding marginalized populations (awareness) and use culturally sensitive interventions and skills.

Research has revealed that when race or racism comes up in therapy, regardless of their own race therapists often respond to BIPOC clients with denial, avoidance, or other signs of cultural discomfort. Specifically, when Black clients bring up anti-Black racism in session, particular responses occur. Bartholomew and colleagues identified four such possible therapist responses:

(a) wanting to move beyond strict acknowledgment to ensure acknowledgement of pain and affirmation of experience;
(b) being present in the moment and drawing personal awareness into that moment;
(c) turning inward and engaging with one’s own emotional responses including empathy with those experiences; and
(d) I am versus I should: proactive and reactive comfort including recognition of pain and reacting to it authentically.

Therapist comfort is an essential aspect that increases the likelihood such disclosure and discussion occur. More specifically, therapists’ level of cultural comfort when discussing anti-Black racism with Black clients may be based on their own racial experience or emotions linked to personal racial beliefs, identities, and their own life experience growing up (Bartholomew et al., 2021).

Use of the concept of the ecological niche (Falicov, 2014) – consideration of multiple cultural locations and their intersectionality – is useful in addressing client and therapist identities. Harrell (2014) suggested considering familial and community racial socialization including the salience of race, how much identification with the racial group exists, meanings, beliefs, and judgments about race. Even if client and therapist share the same racial group, intersectional multicultural identities need to be factored in. Misunderstandings may occur if one minimizes race or alternatively excludes other identities and factors, focusing only on race. Harrell (2014) suggests ongoing reflective practice in order to understand the multiple layers of sociopolitical, interpersonal, and intrapersonal meaning of race for the individual and their family, regarding the referral question and the context.

Immigration

Migration is often a neglected multicultural consideration. At least 13.6 percent of the U.S. population is comprised of immigrants (Migration Policy Institute, 2023). However, generally, it is seldom discussed in clinical practice or in clinical supervision. Falicov (2014) highlighted the complexity of experiences in immigration, and the impacts that are often longstanding and profound. She urges consideration of preimmigration, migration, and postmigration considerations in the psychosocial assessment of clients. Further, intersectionality with socioeconomic status, race, gender, gender identity, age, generation, and developmental status at immigration; country of origin (and its proximity, reason for migration including trauma); the process of immigration, whether voluntary or forced; internal or refugee status, impacts, and current immigration status should all be considered as well. Also important is connection with family and friends in the country of origin through telecommunication. Falicov urges a strength-based approach, considering losses in the context of resilience, gains, and triumphs. She also emphasizes cultural humility and intersectionality in a social justice frame.

Understanding family and individual specific stressors, coping, and strengths is essential. Falicov distinguishes between coaxed and unprepared migrations, those that were planned and those that were very much in response to an event, often traumatic. Some of the general issues to be discussed include a genogram of family in the U.S. and in the home country, relationships, and emotional responses, losses, including of employment, professional, or educational status, how family members are learning the new language (which may rely on children who are learning the new language at school and thus are potential translators for the family), migration narratives, and whether children and family members are aware of any or all aspects of the above.

Falicov uses the MECA (Multidimensional Ecosystemic Comparative Approach ) framework including ecological context (e.g., living conditions, school access, limits on upward mobility, financial stressors, physical, psychological, and cultural trauma), family life cycle (e.g. loyalty to family of origin, losses of other generational influence, support), migration/acculturation status (legal status, language acquisition and fluency), and family organization (bonds with family members locally in in country of origin, family hierarchy changes precipitated by migration including employment, roles, language fluency). Further, Falicov describes interventions and therapist roles as a function of stage of migration. Initially, the therapist deals with crises, and helps to address and sometimes restore ecological order within the family. An important aspect is engaging in self-reflection – by the therapist (and the supervisor if there is one) to deconstruct and contextualize through the lens of the personal experience of immigration of each.

Thus, it is essential for the therapist to be self-aware of the impact of their own life experience (or influences on their perspectives on immigration and acculturation) on their clinical work with the family. Examples include a therapist who shares language fluency with the family, although bearing in mind that language fluency does not imply cultural competence or complete understanding of the client experience. In addition to language, consideration of religion, spirituality, family dynamics, ethnic identity, perception of and aspects of discrimination, and understanding causal factors leading to illness, all viewed through a frame of cultural humility, respectful caring, and strength-based approach.

In cases of forced migration, an involuntary displacement and a crisis and upheaval of life expectations with resulting barriers and stigmatization, cultural humility is essential (Adams & Kivlighan, 2019). A high frequency of misdiagnosis and misunderstanding occur when addressing the general physical and psychological consequences of such migration that occurs generally with no warning or preparation. Sensitivity to cultural and situational aspects of emotional expression, exploration of harassment and prejudice, dynamics of resettlement and emotional impact, and general empathic responding are essential.

Socio-economic Status and Social Class

Socio-economic status and social class include not simply income but educational attainment, financial security, and subjective considerations, as well as one’s own and others’ perceptions of economic status, social status and social class. Social class is more than income, education and occupation, and includes economic resources, education, and occupation as well as prestige and power (summarized in Fouad & Chavez-Korell, 2014). The APA guidelines for psychological practice for people with low income and economic marginalization address economic marginalization (APA, 2019).

In their resolution on poverty and socio-economic status (SES), the American Psychological Association (2023) identified the increasing gap between upper and lower SES, the devastating personal and financial repercussions of the confluence of COVID and an economic downturn, and the devastating impact of the intersection of low SES and multiple minoritized identities, historical and systemic discrimination, biased laws and resultant economic inequality. The resolution includes a summary of the current research on the impact of poverty, intersections with multiple identities, and impact on human rights. Economic marginalization results in limited access to supports, resources, and opportunities in life, which limit educational, physical and mental health, achievement, and general quality of life.

Understanding not simply the status or the economic numbers, perhaps represented by fees, but the need for mental health providers to approach these with cultural humility, the therapist needs to frame impacts on the presenting problems and on the possible treatment options, to address specific needs.

Language

Over 350 languages are spoken in the U.S. according to the 2018 U.S. Census. A challenge to mental health is providing competent services to those who seek them. 41 million people spoke Spanish at home. Even if the therapist “speaks” Spanish, they may find they are less equipped to deal with mental health issues or the language specific to those. Bilingual services are severely underrepresented and much needed.

For example, it is important to know that both therapists and clients report reverting to their native language for emotionally intense disclosures or discussions, often referred to as “code-switching” or “language switching” –especially if the memories were encoded in the native language.

Valencia-Garcia and Montoya (2018) state that although the need for bilingual therapists is acute, there is still inadequate training – even though the U.S. census predicts 30% of the population will be Latino by 2050. Common errors are assumptions that if a supervisee or therapist has a Spanish surname, or says they speak “some” Spanish, that they will be fluent and able to conduct therapy bilingually in Spanish or any of the approximately 400 languages spoken in the U.S. Professional fluency is distinct from conversational fluency. Further, a very small minority of bilingual therapists have received bilingual supervision during their training

A result is that ethnic and racial minority students who are bilingual find themselves carrying the burden to provide therapy in a language other than English with no training in therapy or assessment in their native language or language they have studied, nor have they been supervised either in the client language or by a bilingual therapy – often due to the fact that the student is the only person on the staff who speaks the language of the client. Or a translator is provided who is a family member or office worker who has no training in translation and no clinical training to understand relevant communications or to translate them accurately, and may have significant emotional response or involvement in the family situation. This is an area of significant concern and deemed essential for ethical outcomes.

Having a shared language is generally a great strength for therapeutic rapport, but bilingualism should not be viewed as synonymous with cultural competence or knowledge and attitudes, but it is clearly a great strength. Consultation is indicated and essential when conducting evaluations (often high-stakes) or interventions to understand culture and nuance. The value of bilingual therapy with Latino clients was studied. Bilingual therapy was associated with:

(a) Enhanced expression and understanding;
(b) An affirmative experience;
(c) Facilitating therapeutic processes;
(d) Utility of a therapist bilingual orientation, and;
(e) Strengthening the therapeutic relationship (Perez-Rojas et al., 2019).

Religion and Spirituality

Although often neglected or frankly ignored by therapists, religion and spirituality shape personal experience and are an essential aspect of worldview. They may also be a source of strength, comfort, and hope. Or may be a source of distress, negative affect, or anger (Vieten & Lukoff, 2022). However, these subjects are rarely discussed or addressed in training or in clinical practice. Self-awareness and -appraisal are critical for clinicians: considering one’s own faith commitment and attitudes toward religion and spirituality. Gallup polls reveal that the vast majority of the U.S. population report religion is “very or fairly” important; in contrast, mental health professionals may view religion as much less important (Shafranske, 2016).

Approaching religion and spirituality with an attitude of respect and openness and competence is a professional competence, and neglecting to do so reflects a deficit in cultural competence (Vieten & Lukoff, 2022). Vieten and Lukoff (2022, p. 32) described and proposed 16 religious and spiritual competencies for clinical practice. Attitudes and beliefs included demonstrating empathy, respect, and appreciation for clients from diverse spiritual, religious or secular backgrounds and affiliations; having awareness of how one’s own spiritual and/or religious background and beliefs may influence their clinical practice; and attitudes, perceptions, and assumptions about the nature of psychological processes. Knowledge includes knowing that diverse forms of spirituality and/or religion exist, and exploring spiritual and/or religious beliefs, communities, and practices. Skills include helping clients explore and access their own spiritual and/or religious strengths and resources.

Expanding upon cultural humility through the lens of religion and spirituality, Davis and colleagues add essential components of therapist civility, a neglected aspect, with empathy, an affective stance. It includes openness; willingness to recognize and explore different beliefs and perspectives; awareness of one’s own values, beliefs, worldviews, strengths, and areas in development; an egalitarian worldview; openness to diversity and differences, including in values and self-reflective capability; awareness and proactive responding to inequality and prejudice (Davis et al., 2021). An important aspect is how clients perceive their therapists’ cultural humility toward religion and spirituality.

Although they identified their findings as specific to correctional work, Gafford and colleagues describe risk and strengths that are more generally applicable for therapists. Risks include exhibiting moral superiority, discounting the client’s religious awakening or beliefs, viewing faith as a discounting of responsibility, lacking cultural comfort with client identities, and viewing religion as a defense or barrier to treatment. Strengths include openness to client cultural discussions, regulating negative feelings perhaps related to previous clients, exploring cultural values, and openness to discussion of a religiosity-respectful process (Gafford, Raines, Sinha, DeBlaere, Davis, Hook & Owen, 2019)

Disability

Disability is a lasting physical or mental impairment that significantly interferes with an individual’s ability to function in one or more central life activities, such as self-care, ambulation, communication, social interaction, sexual expression, or employment.

Disability is a broad concept used to describe the interaction of physical, neurodivergent, psychological, intellectual, and socioemotional differences with personal and environmental factors including attitudes, cultural beliefs, legal and economic policies, transportation, access, etc. A result may be disability stigma (Balva & Tapia-Fuselier, 2020). Generally, training for therapists on disability ranges from limited to nonexistent. And therapists are often not prepared to work with clients with visible or hidden disabilities. Barriers for the disabled include attitudinal, communication, physical, policy, social, and transportation barriers.

"Ableism” is discrimination toward and social prejudice against individuals with disabilities. The American Psychological Association issued guidelines for Assessment and Intervention with Persons with Disabilities (2022) that advocate for changing ableist practices. That is, addressing and counteracting negative stereotypes and assumptions and implicit bias which often result in microaggressions. As lack of training and experience lead to prejudice, it is essential for therapists to gain experience and to identify and address faulty assumptions and bias. Recommended practices include therapist self-examination of biases, beliefs, and emotional reactions to individuals with disabilities; and considering implicit bias and intersectionality of race, nationality, and other identities with disability. Since attitudes are deep-seated, self-awareness and reflection are imperative. Strength-based approaches are indicated. Imperative is knowledge of the Americans with Disabilities Act (ADA) (1990), the Americans with Disabilities Amendments Act (2008); and the Individuals with Disabilities Education Act (IDEA) (1997). Understanding the function and requirements of reasonable accommodations is essential.

Developmental disabilities refer to limitations in cognitive and functional abilities impacting learning, problem solving, reasoning, planning, and in adaptive behavior such that the individual does not acquire nor evidence skills that would be expected for their developmental or chronological age group and would be necessary for independent functioning as an adult. Neurodiversity refers to the shift to a more positive, strengths-based approach to what were previously referred to as autism, neurodevelopmental disorders, ADHD, and other behavioral differences (Fung, 2021).

Intersectionality

Increasingly it was understood that most important is “intersectionality” or consideration of the multiple identities of the client and therapist (and if under supervision, those of the supervisor as well). This led to the current conceptualization and critical component of multicultural practice, the concept of cultural humility, openness to client diversity statuses, and recognition of the complexity of our own status, and society’s and their intersection in relation to the client’s identities, being respectful, open, and humble. The therapist needs to be open to the worldviews and belief structures of the client(s) – often many within a family constellation – and to be self-aware and monitor our own emotional responses to difference. Further, exploration of “missed opportunities” to discuss culturally relevant aspects of identity, behavior, and relationships in life and in psychotherapy was introduced as there was substantial recognition that such opportunities were frequent.

Recognition grew that client reports of therapist behavior were more complex, multifaceted, and intersectional – these concepts were not able to adequately address them.

Humility generally is described as a fundamental human virtue. It is advocated in religious, spiritual, and philosophical traditions, with adaptations and variations on definition.

The Impact of COVID

Impact of COVID was devastating generally and revealed dramatic health disparities for members of racial and ethnic minority groups who had higher rates of COVID-19 positivity and disease severity than White populations, less access to care, and had more negative outcomes, including death. Causative factors included overrepresentation of members of racial and ethnic minority groups in essential jobs which increased vulnerability and exposure to COVID-19, lack of primary care access, lack of health insurance and access to emergency care, as well as lack of resources available in hospitals, differentially (Magesh et al., 2021). Social, economic, and health inequities were perpetuated and exacerbated. COVID has led to loss of beloved elders, loss of schooling or diminished schooling via telecommunication as racial and ethnic minority students had less consistent access, support, and connection (Falicov, Nino, & D’Urso, 2020). Mental health needs rose as mental health resources were severely disrupted. Recommended practices for clinicians included generally adopting an attitude of cultural humility, focusing on identifying “emotional contagion,” identifying impacts of systemic injustice that are likely being compounded by COVID-19, and recognizing and addressing racial trauma in clients of color (Meyer & Young, 2021). For clinicians, moral injury occurred in that in multiple circumstances they encountered experiences that were in conflict with their personal values, making decisions where all options could lead to negative outcomes, sharing pain and trauma with families, and fearing for their own safety.

Cultural Humility

Clearly, knowledge and skills are not sufficient. The therapist must exhibit an attitude of the essential importance of cultural humility – but simply espousing this is not sufficient; one’s actions and attitudes must be syntonic and evident. This includes active recognition of one’s own beliefs and biases, in value-attached and historical context. Childhood experiences can be emblematic in our current behavior – and may not even be noticed or recognized. Thus, a therapist may make assumptions about a client based on their own life experience, or may have a negative predilection toward an aspect of the client that they have not even recognized or acknowledged. It only becomes recognized through reflection, noticing our own behavior that is unusual or deviates from what one usually does. For example, a client may share an identity with the therapist, for instance coming from the same part of the country, and implicitly, without consciously recognizing it, the therapist may be operating with assumptions based on their OWN life experience – experiences during elementary school, values attached to moving across the country, or multiple identity assumptions (socio-economic status, ethnicity, race, religion, political affiliation, gender, gender identity, sexual orientation, etc.).

“Cultural humility” is a term introduced in 1998 by physicians Melanie Tervalon and Jann Murray-Garcia. It entails humility and engaging in self-reflection and self-critiquing throughout one’s client interactions and in formulations and clinical interventions. Anchored in what we call “metacompetence,” or identifying and “knowing” what we do not know, being humble, open, and resourceful, engaging the client in exploration with respect and acknowledgement that the client knows their own experience substantially more than we do. And, that we truly do not know what we do not know. Cultural humility is both an attitude and a worldview. It has been defined as “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” (Hook et al., 2013, p. 354).

Consider the following dimensions of cultural humility: Accurate perception of one’s own cultural values and other-oriented perspective incorporating respect and respectful process, lack of superiority in attitudes or behavior, openness to feedback (even negative) from others, awareness of judgments.

Words to describe clinical interactions: Open, non-defensive, thoughtfulness and reflection before determining response to culturally loaded queries or topics, respectful curiosity, ability to question our assumptions and beliefs in a cultural frame, markers of cultural humility.

Consider your own cultural identities and which are associated with power; which with privilege vs. prejudice, discrimination, oppression, in a frame of historical context. (Privilege defined as status(es) that afford you a benefit or advantage over others [Falicov, 2014; Hook, Davis, Owen, & DeBlaere, 2017, Falender & Shafranske, 2021]).

Cultural humility entails the specific ability to maintain an interpersonal stance that is respectful and open to the other, to their experiences, worldviews, and to aspects of their personal cultural identity. In displaying respect, therapists do not appear “superior,” instead having a stance of openness and acceptance of the client and their personal experience. The therapist collaborates with the client, hears the client’s disclosures and perspectives, and considers the uniqueness of the client’s presentation of intersectionality, their multiple identities and their intersections (i.e., ethnicity, gender, sexual orientation, age, socioeconomic status, race, religion), mindfully noting their own intersections and attending to not inferring worldviews similar to the client’s. Key to the therapist approach is an attitude of “not knowing” and being open to differing worldviews and experiences that the client presents. We frame not knowing as “metacompetence,” or being open to knowing and identifying what one does not know. That is inclusive of being alert to areas of lesser competence, and being open to disclosing lack of knowledge, skills, or perspective regarding a particular area or areas.

Hook, Davis, Owen, Worthington, and Utsey (2014) caution that rather than assuming knowledge and understanding of diverse clients, therapists remain mindful that we need to be aware of the limits of our knowledge of someone else’s life experience. Cultural humility in the therapist is strongly associated with the therapeutic alliance in that the therapist’s attitudes and values and openness to “other” stance is strongly associated with the working relationship. In fact, cultural humility was judged more important than therapist similarity, knowledge, experience, and skills (Hook et al., 2014).

On a scale of cultural humility developed by Hook and colleagues (2014, p. 357), positive items connoting cultural humility included being respectful, open to exploring, considerate, interested in learning more, open to seeing things from others’ perspectives, open minded; and asking questions when uncertain. Conversely, negative exemplars included assuming one already knows a lot, making assumptions about others, being a “know-it-all,” acting superior, and thinking they know more than they actually do. And client perceptions of a therapist’s degree of cultural humility were generally positively related to higher quality of alliances with the therapist, but that was a finding that required further study.

Cultural humility has been described as composed of cultural humility, cultural opportunities, and cultural comfort. The three pillars are: 1) cultural humility; 2) cultural comfort; and 3) cultural missed opportunities. Cultural humility is defined as the establishment of egalitarian, collaborative relationships with clients while at the same time remaining self-aware and non-defensive regarding the therapists’ own limitations to being other-oriented. Cultural comfort is the level of genuine comfort one has in holding space for multicultural discussions and conducting those in therapy. Cultural comfort has also been described as the ways a therapist finds to be at ease, relaxed, and open when discussing clients' cultural identities in treatment. A research finding is that client perceptions of therapist’s cultural comfort were predictive of decreases in psychological distress (Bartholomew, Perez-Rojas, Lockard, Joy, Robbins, Kang, et al., 2021). Cultural missed opportunities refers to how often and how deeply (and sincerely) a therapist explores (or misses) topics related to culture and identity with a client (Owen, 2013; Owen et al., 2011) and lets opportunities slip by.

Therapists who are rated high on cultural humility and cultural comfort, and low on missed opportunities, demonstrate better treatment outcomes generally.

The client may perceive the therapist as having missed opportunities to discuss their cultural background, wish the therapist had encouraged more discussion of culture and cultural background, avoided topics related to the client’s cultural background, or generally missed opportunities to have deeper discussions on those topics. Conversely, the client may feel gratified that the therapist addressed, in depth, cultural background (Owen, Tao, Drinane, Hook, Davis, & Kune, 2016).

Consider ways a therapist can communicate cultural humility rather than communicating superiority or already knowing. Consider again the words that can be used to describe clinical interactions such as open, non-defensive, thoughtfulness, and reflection before determining responses to culturally loaded queries or topics, respectful curiosity, ability to question our assumptions and beliefs in a cultural frame – are all markers of cultural humility. Think about ways you communicate cultural humility.

Generally, when therapists are culturally humble, they convey openness, respect, and interest. Both verbal and nonverbal expressions are important.

Interestingly, depending on context, identity salience changes. That is, one or several identities may be salient in some situations and others in other situations. For example, one’s religious identity would be salient when one was at a church or temple event, the same individual’s racial identity salient when in a mental health multicultural seminar. Less attention has been devoted to intersectionality, which is a very important factor in understanding identities.

Davis and colleagues (2018) proposed a multicultural orientation framework to address how cultural dynamics influence the process of psychotherapy. That is, as theorists and researchers have long suggested, psychotherapy relationships which include therapist empathy and creating a working relationship with the client are inadequate without consideration of the multicultural factors and dynamics of the client, family, and significant others. So, focus is shifted to what is described as orientation or how the therapist views, organizes, understands what the client says, and how the client creates meaningfulness of the world and relationships within it. They suggested that rather than focusing on “competencies,” which might be perceived as inflexible, the therapist needs to be attuned to context, behavioral change, and meaning. And the therapist does need to attend to identifying and knowing what they do not know, which Falender & Shafranske (2021) refer to as “metacompetence” – the ability to step back and increase awareness that one does not know another’s experience, perceptions, or understanding … and the therapist needs to be open to that recognition. In multicultural therapy (which is ALL therapy), attunement to what one does not know is essential, as is openness to that fact. The client is the expert on their own life and situation; the therapist can assist them in multiple ways, but the client remains the expert on their experience.

Key components of cultural humility include respectful process, openness, and curiosity (Falicov, 2014) as well as attending to intersectional identities of client, therapist, and if there is one, the supervisor.

Another concept, intellectual humility, is also essential in clinical practice. Intellectual humility is best defined as people’s willingness to reconsider their views, to avoid defensiveness when challenged, and to moderate their own need to appear “right.” It is sensitive to counter-evidence, realistic in outlook, strives for accuracy, shows little concern for self-importance, and is corrective of the natural tendency to strongly prioritize one’s own needs. See: templeton.org/discoveries/intellectual-humility.

An additional critical component within multicultural practice is social justice, addressing the fair treatment and equitable status of all individuals and social groups within a state or society. It also refers to advocacy focusing on forms of oppression that limit access and opportunity in society as a function of membership in socio-demographically diverse groups. It is aimed at attending to change in societal values, policies, and practices to increase access to tools of self-determination (derived from Goodman et al. 2004). Social justice has been often sidelined or ignored by mental health professionals with the exception of social workers for whom it is among their guiding principles (NASW, 2019) with articulation of equity and inclusion, spanning voters’ rights, criminal and juvenile justice, environmental justice, immigration, and economic justice. (See the section on Social Justice, below. )

Incorporating social justice includes perspective-taking and consciousness-raising about differences and inequities and addressing those; addressing power (in the therapeutic relationship and societal impact on the client’s presenting problems); perceptions of fairness and lack of such; and expressions of empathy, support, and connection.

Gender, gender identity, sexual orientation, race, ethnicity, and to some extent disability, are being addressed and are increasingly recognized as significant identity factors in mental health practice. However, consider multiple other identities that are NOT being addressed or noticed in mental health, and the intersectionality of identities. Some identities that are less addressed are religion, social class or socioeconomic status, immigration status, education level, and language, to name a few. Socioeconomic status relates to access to resources and power, and positionality in the social class hierarchy. Multiple identities are interrelated.

Cultural Formulation

Recognizing the cultural nuances of different groups is important in order to enhance the effectiveness of treatment outcomes. It increases the awareness and sensitivity in understanding how different symptoms, disorders, and presenting issues may look or manifest within and across different cultural groups. As part of a very thorough clinical intake, the clinician must gather relevant psychosocial, contextual and historical data that is then conceptualized within the social cultural context of the client. Culturally informed intake and case formulation allows the clinician to carefully consider clinically and culturally appropriate diagnoses and treatment recommendations.

Pamela Hays’ ADDRESSING model (Hays 2001) offers a framework for clinicians to consider not only the variables of culture to consider when gathering intake information, and history from a client, but also strategies for self-reflection for the clinician to consider the ways in which their own biases and cultural identities emerge within clinical practice. ADDRESSING stands for:

Integrating the ADDRESSING framework into clinical practice can lead to a cultural understanding of the client which offers the clinician a robust case formulation that examines how social, cultural, historical, and contextual variables are embedded within the development and maintenance of clinical issues. An added benefit to application of Hays’ model is that she encourages the clinician to consider not only their own cultural factors as it relates to the multiple identities of their clients, but also exploration of how these variables differently affect groups based on membership in either the dominant or non-dominant group ( Hays 2022).

Below is a sample vignette which illustrates how critical the integration of culture at time of intake is for clinicians. Please read the vignette and then answer the questions that follow:

Jessie is a 35-year-old single male who presents for an intake session seeking help for symptoms of anxiety and depression which are interfering with his work performance. Jessie has difficulty sleeping at night due to racing thoughts and has recently lost approximately 10 pounds in one month. Jessie works as a software engineer and reports feeling overwhelmed and stressed out by the job, which often requires long hours.

As you read the vignette, did you notice any automatic assumptions regarding Jessie’s gender, race, ethnicity, or age? What are your initial thoughts in terms of the assessment of Jessie’s symptoms and factors contributing to the onset of symptoms? What might be some initial recommendations or considerations for a treatment plan?

Now consider that Jessie is a 35-year-old single woman and is one of few women in her workplace. In what way does that change your conceptualization of the workplace anxiety and any intake questions you may ask. What if Jessie is also Jewish and there has been recent antisemitic violence in the area where her company office is located. This vignette illustrates how therapists working with clients from various cultural backgrounds need to understand and appreciate the systemic, contextual and cultural differences that may impact their clients' mental health and wellbeing.

When attending to diversity factors and in modifying treatment to meet the needs of clients there can be assumptions about appropriateness of evidence-based treatments

To address the role of cultural variables on the diagnosis and treatment of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders - IV (DSM-IV) included an Outline of Cultural Formulation to give clinicians guidance on factors to consider that yield better understanding and consideration of the impact of psychosocial and cultural factors on symptom presentation.

As outlined in the DSM -IV, the Outline of Cultural Formulation (OCF) consists of five components:

1. Cultural Identity of the Individual

What are aspects of the client’s culture, race, ethnicity, nationality that influence the presentation of symptoms as well as the client’s beliefs about mental illness.

2. Cultural Explanation of the Individual’s Illness

Exploration of how the client’s cultural background informs their explanation of the cause and contributions to their psychological distress and mental illness.

3. Cultural Factors Affecting the Psychosocial Environment and Levels of Functioning

Exploration of how client’s level of functioning, interpersonal dynamics, family relationships, and social support systems are affected by cultural variables.

4. Cultural Elements of the Relationship Between the Individual and the Clinician

Encourages therapist to consider similarities and differences between therapist and client to consider if and how those factors can affect the therapeutic relationship.

5. Overall Cultural Assessment for Diagnosis and Care

In this last component, the clinician integrates all the pieces of information together to develop a culturally sensitive formulation which considers how clients will respond to treatment.

While this OCF addressed a previously neglected aspect of diagnosis and treatment planning, there was still a need to provide direction and guidance to therapists on developing a cultural formulation. Authors of the Diagnostic and Statistical Manual, 5th Ed.( DSM 5) were very intentional in designing a Cultural Formulation Interview (CFI) that expanded upon the OCF by detailing specific questions to elicit information related to the client's cultural factors. The CFI defines culture as the following (Aggarwal & Lewis-Fernandez, 2020):

Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their own identities and make sense of experience.

The core CFI is a structured interview comprising 16 questions that are organized around the five domains of the OCF (Aggarwal et al. 2013).

The core CFI is organized into four sections:

1) cultural definition of the problem;

2) cultural perceptions of cause, context, and support;

3) cultural factors affecting self-coping and past help-seeking; and

4) cultural factors affecting current help-seeking (Aggarwal & Lewis-Fernandez, 2015).

In addition to these four sections, there are also three supplemental domains that can be appended to cultural formulation interviews to further assess the socio-cultural factors relevant to an individual’s mental health functioning (Jarvis et al, 2020):

1. Cultural Strengths and Resilience

Within this domain the therapist identifies cultural traditions, rituals and routines that serve as sources of support and can be integrated into treatment planning to promote wellness and recovery.

2. Cultural Challenges or Barriers to Care

This domain provides direction on asking questions about cultural factors or beliefs about mental health that may interfere with accessing or receiving mental health care.

3. Cultural Identity of the Clinician

This supplemental domain has the clinician reflect on their own cultural background and how it might impact the therapeutic relationship. Mental health providers consider cultural biases as well as present ideas and techniques for promoting cultural humility within the therapeutic setting.

There are also twelve additional supplementary modules to the CFI which offer a more in-depth exploration of the five domains as well as considering the specific needs of unique treatment populations such as children, older adults, immigrants, and/or refugees.

A third component of the CFI is an informant version of the CFI that allows the clinician to gather collateral information and obtain the perspectives of family members and social support systems of the CFI. As a clinical intake tool, the CFI assists the clinician by providing a thorough, systematic, culturally informed tool which allows the provider to understand the client’s perspective and worldview and achieves the goal of inviting in the client’s perspective and worldview in consideration of assessment, diagnosis, and treatment.

Let’s now apply Hays’ framework to the following vignette. As you read through the case, consider what aspects of the client’s identity are most salient in presentation of symptoms.

Phil is a 67-year-old heterosexual, self-identified Christian, Caucasian, married male. He states that his doctor suggested he seek therapy after complaints of headaches and stomach pains that had no known medical cause. He recently retired and lives in an urban city with his wife. They have two children and three grandchildren.

During the intake, Phil indicated that he worries all the time, and about “everything under the sun.” For example, he reports equal worry about his wife who is undergoing treatment for breast cancer and whether he returned his book to the library. He recognizes that his wife is more important than a book and is bothered that both cause him similar levels of worry. According to Phil, he is unable to control his worrying. Accompanying this excessive and uncontrollable worry are difficulty falling asleep, impatience with others, difficulty remembering things, and significant back and muscle tension. 

Phil states that he has had a lifelong problem with worry, recalling that his mother called him a “worry wart” as a kid. He reports that he was a good kid in school who made mostly all As and Bs. He graduated from college with a business degree and has worked as an accountant most of his life. He recently retired and has spent most of his time caring for his ill wife. His worrying does wax and wane, and it worsened when his wife was recently diagnosed with breast cancer.

Consider that you are employed at a clinic that uses CBT for anxiety treatment protocol. Phil is initially reluctant to engage in treatment as his experience of his anxiety is physiological and he is unsure of how “talking” about his problems will provide relief. In the initial sessions, you assign homework consistent with your treatment model that Phil does not complete. He is very apologetic and always assures you he will return with his homework done the following week.

Using Pamela Hays ADDRESSing model what cultural factors are relevant for this case? What adaptations if any might be needed to increase engagement and participation in treatment? How might this differ if you were using a different treatment model?

Some of the variables that are important to consider are Phil’s age, status as a recent retiree, cultural norms, and ideas about being a husband, father, and grandfather and how his age and recent retirement affect his role as a father and husband. In what way might his anxiety increase as a result of change in his status in these roles?

Intersectionality

Intersectionality is a term developed in 1989 by the legal and race scholar Kimberle Crenshaw to explain marginalization and oppression. She stated, “Black women are sometimes excluded from feminist theory and antiracist policy discourse because both are predicated on a discrete set of experiences that often does not accurately reflect the interaction of race and gender… Because the intersectional experience is greater than the sum of racism and sexism, any analysis that does not take intersectionality into account cannot sufficiently address the particular manner in which Black women are subordinated” (p. 140).

The concept of intersectionality has been adopted by multiple professions including the American Psychological Association (2017): social identities are interrelated, interwoven, overlapping, and multi-layered. Consideration of privilege and oppression based on social hierarchy addresses societal inequities. Identities are not binary – for example, race – even within racial identity groups, skin color can be associated with power or status. Or for immigration, assimilation may be a significant variable that is associated with different levels of status depending on the context.

Identities

Consider your own identities, intersections, and impacts with a particular client. Do they vary? Are certain identities more prominent with a different client? How does that impact assessment, diagnosis, case conceptualization, therapy? Then consider which of your identities are associated with power and privilege? Which with oppression and marginalization?

Then turn to consideration of your client’s identities. Within a family constellation there may be significant diversity in identities depending on the multiple aspects of identity previously alluded to.

How different will therapy be with a client who shares two or more identities with you versus one who shares none? Are some of these implicit or explicitly discussed? Think of examples in your current experience or during training.

Falicov’s MECA Theory

A different framework developed by Celia Falicov, is also useful in approaching intersectionality and incorporating multiple aspects of diversity into practice. First, Celia Falicov’s Multidimensional Ecosystemic Comparative Approach (MECA) (Falicov, 2014; 2017) provides a framework (Figure 1) that should not be your sole focus, but presents factors that are essential to understand as part of an individual’s ecological niche, how they fit in society. We are all multicultural beings and not subsumed under a particular label or identity but by the intersections of those. These include universals, particulars, or idiosyncratic histories, culture-specific aspects (ethnic values, religious rituals), and each person’s ecological niche or intersectional cultural identifiers. Note that the culture of each participant – client, supervisee, and supervisor – are all included and essential in the cultural map and formulation. Contextually, values, beliefs and meanings are not inferred but are considered in the frame of culture of the clinician and the relationship of those to the client/family.

Note that for Falicov, culture refers to sets of shared worldviews, meanings attached, and adaptive, functional behaviors, all derived from membership and participation in a variety of contexts. These include languages spoken and understood, residing in rural versus urban or suburban areas, race, ethnicity, socioeconomic status, age, gender, sexual orientation, gender identity, religion, disability or ableness, nationality, employment, education, occupation, political ideology, stage of migration/acculturation, and experiencing and identifying with historical moments (Falicov 2014). Exclusion from various contexts may also be essential and critical parts of one’s cultural experience (Falicov 2014).

A first step is self-assessment of the clinician’s own cultural contextual domains and worldview. Consideration includes how the clinician’s own worldviews are impacting questions asked and assumptions made, as well as guiding an empathic process (Falicov, 2014). The process is conducted within an attitude of respectful curiosity and not-knowing, rather than inferring or assuming universals: understanding individual variations and the intersectional complexity.

The MECA Framework Includes

Migration and Uprootings

When, how, and why did the family migrate? And what was the process? Was it traumatic? Migration is viewed in the context of loss and change, including some resultant gains. Families may be fragmented geographically and psychologically as those who migrated become acculturated or as connections are severed or lost completely. Systemic violence could be the precipitant to or result of the uprooting. Injustice and inequality may impact the family members uniformly or individually. Cultural gaps between parents and children and within members of the family thus may be exacerbated by the migration experience and the entry into the new culture and role transformation or changes in traditional roles and subsequent differential wages (i.e., a father who was a lawyer in their country of origin becoming a low wage worker; the mother, previously unemployed working as a seamstress and earning more money). Gender roles may evolve due to media exposure and cultural immersion at school and result in changes to traditional expectations. Such changes might entail highlighting cultural gender restrictions, tensions between roles viewed on media and traditional ones. Also, a son or daughter who becomes fluent quickly may become a translator for the family; the parent may have lost specialized employment status from pre-immigration and be relegated to a lower wage and level; the child(ren) may be left with a family member including a sibling or other person for care; and family dissolution may result from changes in status, self-worth, or other factors. Tensions may arise from role issues, such as women being viewed as “less than” compared to men. Thus, while respect is a high value, conflict may arise from frustration for the undervaluation of the women. Questions include when, why, and how they migrated or moved, current immigration status, connections with the country of origin, including who was left behind, trauma in the country of origin and/or during the immigration experience, injustices, marginalization, unfair treatment, loss of status or security, current family dynamics and changes to those, to name a few. Telecommunication may serve as a powerful connection to those remaining in the home, country of origin, locale.

Ecological Context

This domain considers diversity in where and how the family lives and fits in the sociopolitical environment. This includes racial, ethnic, socioeconomic status/class, religion, educational communities, living and working conditions, involvement with schools and social agencies. Sensitivity to marginalization, consequences of marginalization, discrimination experienced by family members due to race, socio-economic status, documented or undocumented status, or multiple other factors including exposure to racist or sexist stereotypes, all result in powerlessness. Beliefs about physical and mental health, religion, spirituality and magic are little explored in clinical practice, but are highly relevant to clinical work, as are attitudes toward psychotherapy and complementary folk medicine. Exploration of beliefs about personal responsibility, gender and racial socialization, and sources of support through family, churches, or affinity groups and how those relate to coming for psychological intervention, are all important components as it is critical not to make assumptions based on our own experience and beliefs.

Family Organization

This entails a consideration of family structure and values relating to family structure and functions. Is the organization nuclear or extended? What is the degree of connectedness? How hierarchical in terms of respect, decision-making, and parent-child involvement? Some families are collectivist family arrangements with high levels of parent-child involvement, parental respect that endures through the entire life cycle, across generations. Others are nuclear families that favor strength of the parental unit, distinct from others. Nuclear family relationships may favor the strength and power of nonblood relationships, husband and wife. When cultural transformations, migration, or other changes occur, Falicov (2014) identified how this impacts connectedness and separateness, generational hierarchies, communication, conflict resolution, and secrets.

Family Life Cycle

In family life cycle, the clinician assesses age and stage of development: chronological and developmental position in terms of life and professional experience. The clinician considers their own position chronologically, and their internalized norms or ideals about child-rearing and life transitions (e.g., adolescence, adulthood), construction of age-appropriate behavior – what one’s own personal experience was like, what was normative for one’s setting and family, rituals including religious, socio-cultural, or intrinsic to one’s family or milieu, timing of transitions into adulthood or independence, and religious beliefs generally and the impact of these on the presenting problems/issues of the family. Next is conception of family: extended or nuclear family, gender roles, flexibility, and generational considerations (e.g., if there is multi-generational participation in child rearing; caretaking for elders), gender role definition, hierarchies within the family that determine decision making.

Figure 1. MECA (Multidimensional Ecosystemic Comparative Approach) Culture and Context Domains

The intersection of these components provides the clinician with a framework to address individual and families and to understand the complexity of culture and intersections with presenting problems in mental health. Consideration of the ecological niches and worldviews of the clinician(s)/therapist(s), client(s) and families, and, as relevant, supervisor(s), provides a backdrop to contextualize culture and its multiple framing elements that are relevant to diagnosis and treatment.

To illustrate this model, consider the multiple aspects of MECA and how the components of a case and the therapist plan structure and intervention through a multicultural lens.

A new client, a 12-year-old BIPOC male, who presented with significant school discipline problems and poor performance of at least a year’s duration, is being raised by his great aunt and uncle, who are in their late 70s, As they are the only remaining family members after the death of his parents in a car crash when he was seven, they agreed to raise him. His parents had been in and out of jail for years, used illegal drugs, and he had only hazy memories of them. He had been in foster care several times, having been removed from parental custody by the Department of Children’s Services, but then reunited when his parents were deemed ready. His great aunt is White, his great-uncle BIPOC. The client told the therapist during their first session that his aunt had informed him a few weeks prior that the day he turns 18 he will be on his own and no longer live with or be supported by them. He reported he is often hungry as he is growing fast and the lunch he brings to school doesn’t fill him up. The client was initially eager for therapy but warned the therapist not to expect much from him. He described his major (and only) strength is playing football but that is seasonal and, due to his school performance, he may not be allowed to play in the coming season if his grades continue to be below a “C” average. He had played at several previous schools he attended and had been a “pretty strong” quarterback. What is the effect and the range of emotional responses of the child and of the therapist in response to the preliminary information? How would treatment progress, being sensitive to the youth’s presenting problems of school-defiant behavior and his relationship with the family?

The supervisee, a Latina, had a very strong empathic response to the client after this disclosure, felt angry with the great aunt and uncle, and found it difficult to even see the client due to her own empathic reaction and concern for the child. Consider this scenario in a MECA framework and with the assumptions about each domain described above. Consider how you as the clinician would approach therapy. Consider what emotional response this elicits in you, as the supervisor. Then consider how you would proceed.

In the frame of cultural humility, consider the following questions which were previously introduced in this module:

Reflections

Migration and Uprooting

Consider the therapist’s own identity. The therapist felt intense empathy for the youth, for the losses and for the trauma compounded by going to live with people he barely knew and who were not prepared to raise a child or teen. The therapist, a Latina in her late 30s recalled her own childhood, and thought about what the loss of her parents would have meant and how she was blessed with a strong extended family. She reflected on her close family network, strengthened by the fact they were immigrants and found significant support from each other.

From the child’s perspective, she viewed the uprooting as a continuation of the ongoing trauma of parental neglect, foster care, death of his parents, relocating to a new geographical area to live with a much older great aunt and uncle he had never met, changing schools, and losing his one friend.

Ecological Context

Consider the therapist and client differences with respect to power, privilege, identity, and culture and how these potentially increase social and cultural distance and may lead to misunderstandings or miscommunication that may result in ruptures, and may ultimately have potential to contribute to, if not cause, severe alliance ruptures and have definite potential to complicate any rupture repair process (Chang, Dunn, Omidi, 2020), increase social and cultural distance, and render the psychotherapeutic intervention less efficacious.

In this case example, the clinician accepted the client’s belief that they could not make the football team due to ethnicity but learned that assumption was invalid as the client’s counselor indicated it was because of grade point average. The clinician formulated the great aunt and uncle to be unsupportive, potentially limiting caloric input of the youth and being rejecting, with respect to the statement about him “being on his own” at the age of 18. It was difficult for the clinician, who felt significant empathy for the client, to separate these formulations from her work, even though she reluctantly agreed they were not founded on direct data, and data existed to the contrary (as he had a wide range of healthy foods in his backpack and snacked on fruits and vegetables during their sessions). In fact, her supervisor reminded her that in her required meeting with the great aunt and uncle, she had observed them to be eager for intervention, and struggling with the difficulty of raising a teen who had lost so much, sustained unknown amounts of trauma and who felt very disconnected from them, and with their own economic worries as they had planned for a very different retirement. Even when the clinician saw the food on multiple days, and saw evidence of their caring behavior, it was difficult for her to be empathic toward them.

Family Organization and Family Life Cycle

The couple had never raised a child, was struggling financially and emotionally with the task, but was dedicated to “seeing it through” even though they had hoped for a calm retirement, had planned to sell their house and use the proceeds to live on, buy a used RV and see the country until they had to live in a low-income retirement community when they were much older, but now had a child to raise. They had been married for more than 50 years and had a strong relationship, but felt “cracks” emerging in their relationship with respect to efforts to deal with the child. They were increasingly isolated as they no longer had work contacts and now with raising a child, they had little time. His great aunt is White; great-uncle, BIPOC. They were both from intact families and wanted to provide the best they could for him but kept encountering his withdrawal and disinterest in anything they suggested, so they were frustrated and felt rejected and impotent. The great aunt said she had never parented, and her own parents had been formal and not affectionate and her father was rarely present. They both understood the limits of school-based treatment (to focus on the child’s school performance) and had tried to seek out family therapy, but the wait-lists were very long and their finances (both had worked in offices and had limited retirement benefits) did not allow for the fees of an independent provider even if they could have found one.

They were disappointed he was not more connected with them, withdrew a lot, and understood this was at least in part a result of his childhood experiences and trauma, but even when they tried, he would not talk about any of that. He generally simply withdrew. They were older, and not able to participate in sports with him and he would not watch sports on TV with them. They knew he was a strong runner, but he refused to run alone.

They were strict in their rules, mirroring their own childhoods, but found it almost impossible to carry through as he was highly avoidant and creative at escaping any consequences. They described the fact that even at school, he was manipulating the system, getting thrown out of class frequently so that he spent lots of time in the office where there was often food and the office staff was kind to him, so it was more of a reward than a punishment. They said the same kinds of things happened at home, revealing he was smart and very able to get around most rules and consequences. They were used to a hierarchical family structure, and the great uncle was the disciplinarian. The great uncle bemoaned the fact that the child’s mother was deceased as he thought she would have been much more effective parenting this youth. They expressed concern that where they lived was not conducive to raising him. The neighborhood was aged, no children nearby, and crime rates were high.

Consider how you would approach therapy with the child, and what multicultural considerations enter into your strategies. Consider the aspects of Falicov’s model in your planning. Consider factors of the timeline, loss, mourning (and identifying whether the child had an opportunity to mourn), entry into a new school in a new neighborhood (with unknown diversity factors) and with new parental figures – all adjustment issues.

Psychotherapeutic Relationship: Strains and Ruptures

In any psychotherapeutic relationship, a critical component is the therapeutic relationship or the working alliance which entails agreement on goals and tasks and is the foundation of an emotional bond, and then attending to the ongoing process, relationship, and monitoring for strains or ruptures that may arise. These could be due to misunderstandings, different worldviews or belief structures, or multiple other factors. In addition, maintenance of reflective practice requires one to be self-aware of emotional state and changes to that, unusual emotional responses, assumptions, and the impact of client disclosures or presentation including multicultural identities, difference, assumptions of sameness or difference.

Therapists should be attentive to identification of transference and countertransference with the client. That includes therapist emotional reactions such as boredom, anger, irritation, sexual attraction or arousal, to name a few. These emotional reactions are critical to be self-aware of and are extremely important in psychotherapy. Sometimes the strength of such therapist response is shocking to the therapist and it is most important that the therapist identify such differences in clinical response to a client, their own emotional response or reactivity, and how to manage those. Some may be representative of experiences in the past or relationships with others outside the clinical realm. Gelso and Hayes described countertransference as the therapist’s internal or external reactions shaped by either (or both) the therapist’s past experiences or present emotional conflicts and vulnerabilities (Gelso & Hayes, 2007). Therapist self-awareness and self-insight are critical components, as is the therapist monitoring their own personal responses, identifying anxiety that arises, perhaps with respect to culture or cultural difference, identifying and addressing/managing anxiety that may arise, and, as necessary, receiving cultural or general consultation from a peer or supervisor to address these aspects. Countertransference may manifest in deviations from more normative therapeutic interactions. For example, the therapist may have an intense emotional reaction to the client that is unexpected and highly unusual. That might manifest as spontaneous sharing of personal stories, or acting in ways that are inconsistent with the therapist’s normative clinical behavior.

Culture and multicultural factors are always in the room, in the virtual connection, and generally in the relationship, informing values and worldviews, but they may often not be acknowledged or addressed. Multiple factors intersect and should be considered. First is the impact of the personal cultural background of client and therapist on potential countertransference. Second are shared and overlapping assumptions and familiarity with the cultural identities, as shared identities may be highly disparate given one’s other identities (socioeconomic status, immigration history, educational level, employment). Third, what level of importance or recognition of culture and identities has occurred in the treatment from its onset? How have you, the therapist, initiated discussion and recognition of the client's cultural context, connection to the presenting issues, and cultural disclosures? And the worldviews resultant from those? Falicov’s (2023) model is useful in these determinations.

Consider the risk for rupture in the therapeutic relationship. It is known that therapist and client (as well as the supervisor, should the therapist be under supervision) exhibit differences in power, privilege, identity, and culture and that these increase social and cultural distance and have the potential to contribute to alliance strains or even ruptures. All of this complicates the repair process. Reflect on cases you have carried and any risk factors and actual strains or ruptures that have occurred. Examples include misunderstanding or making assumptions based on something a client said that was not correctly interpreted.

Possible Avenues for Multicultural Interventions

Additional Considerations – Lenses

Considering clinical cases through a social constructivist, social action oriented frame entails encouraging perspective-taking, including steps of noting exceptions to observations, moving toward externalizing the problem from the individual, considering processes of deconstruction including thinking about how the issue originated, the belief systems of the youth and the family, reflecting and taking different roles (having the youth reflect on what they would do as a parental figure, collaboratively developing hypotheses). Also, to note exceptions (tell me about the times you were not depressed (or demoralized) this week … think about the chains of behavior that occur when you are depressed (you cause a problem in class, you get sent to the office, you eat food, but you miss class and then fail your next text so then you are further from your goal of being able to play football next year). Measure affective response – depressed mood, “disinterest,” “unmotivated,” “connected,” “happy,” “involved,” or others collaboratively developed.

Give feedback to the client – about the football team membership failure and discuss what IS within their power to change.

Think about how the sequence of events turned out – what were the good consequences that happened; what were the problematic ones? How could those be shifted? What IS within your control. How could the counselor advocate for the client?

Cultural Countertransference

Cultural countertransference is a phenomenon originating from implicit or conscious beliefs, assumptions, biases, and unresolved conflicts of the therapist or elicited by the client or setting-specific issues, or by general stimuli. It could be triggered by cultural events or perceptions of those including spoken language; race, ethnic, and sexual identities; cultural mores; generational differences; and/or by childhood personal cultural experiences. The resultant countertransference could manifest through actions, attitudes, emotional responses, or implicit assumptions (Hayes, Gelso, Goldberg, & Kivlighan, 2018). It could result in a client not being forthcoming or comfortable with the therapist or the whole Western idea of therapy, strain, rupture, and even withdrawal from services. However, such phenomena are generally not addressed even though successful countertransference management is positively related to better therapy outcomes. When countertransference management occurs in clinical sessions, it includes consideration of the emotional response of self and the client, enhanced self-awareness in the moment, connection, empathic understanding, anxiety management, and self-integration (Perez-Rojas et al., 2017).

Disregard for cultural countertransference might include the therapist discouraging discussion of or discounting the role of any cultural influence or component on the presenting problem, the therapeutic relationship, or the general milieu of the client. Other evidence could be client or therapist detachment in the session, discounting validity of perceptions of the other, or withdrawal from treatment. Or a client who does not seem comfortable enough to self-disclose and thus does not appear to you to be a “good” therapy client.

How to proceed? Perhaps by discussing the therapist’s expectation for self-disclosure and how it may not be culturally syntonic or seem safe. And by understanding what the client’s expectations are from you and what they hope to gain by coming – or if required to come by some individual or entity, exploring the feelings and context surrounding that. Ethical aspects include clarity about limits of confidentiality and general informed consent so the client gains understanding about the context and expectations. Therapists should be mindful of their own cultural expectations – in an instance when a family wanted the grandmother to come to treatment with them, the therapist refused, saying that she is not part of the nuclear family, not understanding the role of respect for elders, multiple generations, power, and self-determination within family constellations as critical considerations. Therapists’ beliefs about whether cultural events had happened was mediated by multiple aspects including therapist overwhelm or disorganized countertransference reactions and more colorblindness. In those instances, therapists were less likely to believe microaggressions had occurred to clients (Dictato & Torres-Harding, 2022).

Consider cultural microaggressions that could occur without therapist awareness. For example, assumptions the therapist could make based on diversity dimensions. An example is assuming lack of (English) language facility due to client appearance or reticence to speak.

Use of Falicov’s model provides a prototype encouraging the therapist to self-assess and consider the client (and as relevant, the supervisor) through multiple cultural lenses.

Consider a situation with a client when either your emotional response or your behavior deviated from the norm or elicited a response different from what you expected. Think about the aspects of the situation that were operative. Consider cultural factors. How did you respond, and proceed? Did you identify countertransferential aspects of the event? How did the client respond?

Navigating Privilege and Oppression

In many therapeutic relationships, issues of privilege and oppression exist but are generally not addressed.

However, clinicians need to be mindful of the disproportionate risk of adverse health outcomes that exist for multiple minority populations (e.g., Helminen et al., 2022). These may manifest as depression, anxiety, substance use, suicide, school dropout, and general psychological distress and may not be disclosed or easily addressed. Self-compassion is conceptualized as a way in which personal self-appraisal and response to one’s own emotional experiences could be an important key to enhancing self-kindness and mindfulness, and coping with the stress evoked by minority stressors that may go unaddressed generally as well as in clinical encounters.

Miville et al. (2009, p. 236) described strategies to navigate privilege, oppression, and gender and they are summarized below:

Addressing and Resolving Conflicts

1. Resolve conflicts

Gender and multiple identities result in multiple messages about constructing gender roles, some of which may have been internalized from childhood. Some may relate to current tensions in language. Stereotypes of empathic, nurturing females, strong and assertive males, and conflict between individualistic values, egalitarian roles, and clear sex role definitions may arise. So in clinical practice, be thoughtful about language with clients, reflect on one’s own identities and about gender language that is syntonic with the client. Be reflective about stereotypes that may exist that are reflective of one’s cultural history growing up, regional differences, and current language – and be attentive to the client’s own self-designations, familial issues, conflicts, syntonic language, and their particular phrasing regarding those issues.

2. Navigate privilege and oppression

Consider the larger sociopolitical context and the dominant/subordinate relationships; move toward mutual respect and mutuality within families and toward others.

3. Understand one’s impact on others

Internalizing (negative) gender or racist stereotypes may involve enacting roles that are oppressive and potentially lead to harm; help clients and yourself critically examine beliefs and consider the consequences of behaviors and their impact on others to address beliefs and self-images.

4. Transform self-perceptions

Identify struggles between cultural prescriptions and stereotypes and how those apply to one’s personal life, expression, and relationships and are manifest in therapy.

5. Consider intersectional identities

Consider the full gamut of cultural identities and their intersectionality (APA 2017) (including sexual orientation, religion, socioeconomic status, and multiple identities).

6. Navigate emotions

Increase awareness of the impact of negative stereotypes and contextual cultural expectations and norms; learn to navigate one’s own emotions in the context of societal expectations.

7. Construct (and reconstruct) roles in family, community, and society

Communicate and uphold responsibility, balancing roles.

Now read this case vignette and respond to the questions that follow.

Minh, a 15-year-old Vietnamese-American client, was referred for school failure after she had been an “A” student but had a difficult break-up with her boyfriend and felt alienated, devastated, and hopeless. Her grades had fallen precipitously and her school counselor referred her for therapy to help her recoup before she lost her chance to get a scholarship to college. Minh’s grandfather was a U.S. military officer, her grandmother, Vietnamese. They migrated with Minh’s mother to the U.S. in the 1990s but Minh disclosed that no one talked about her cultural heritage, and she became even more depressed when she was assigned to write an essay about personal family history. Minh’s therapist, a Latina, recently licensed, had attempted to address culture but beyond the one disclosure about the essay on family history, Minh put her head down and refused to discuss it except to say it was very depressing and no one talked about anything.

Consider what therapeutic strategies you might initiate to work with Minh. How would you encourage the therapist to approach Minh with cultural humility? Consider cultural opportunities and strength-based approaches including her excellent grade history, her curiosity and eagerness to find out more, and the information she already has. Think about your own personal response to Minh’s situation.

Self Awareness

A primary issue in the multicultural context is self-awareness. Most of the multicultural frameworks (rooted in the work of Sue, Arredondo, and McDavis, 1992) consider self-awareness to be an essential first step in the process of becoming more “culturally competent.” There are multiple deterrents to enhanced self-awareness including the fact that White therapists may not consider themselves to have a culture, or if they do, they question whether it is relevant. There is also disregard of White privilege, and as long as it is disregarded, the multiple power differentials in the therapy equation are disregarded. Self-awareness has not traditionally been a part of training programs. As if therapy were value-free – a premise long discounted – training programs have not attended to what values, assumptions, and belief structures each of us brings to our practice of therapy.

A second key deterrent is resistance to content, i.e., believing there are no differences among ethnic groups, or feeling a lack of safety in discussing diversity, culture, or trauma.

A third deterrent is neglecting the concept of ecological niches or diversity as an important part of the equation. What are ecological niches? Think of all the descriptors that go into your identity .For example, gender, religion, profession, sexual orientation, gender identity, culture, ethnicity, socio-economic status, race, and so forth. It has been speculated that each individual could develop an “equation” to describe which of one’s niche characteristics are most impactful, and how they interact. This whole area of discussion requires openness to discussion and self-awareness of culture and diversity status.

Self-awareness by the therapist of their personal discomfort discussing any of these topics is critical and may require consultation or supervision or one could risk strains, ruptures, and loss of clients in therapy as a result (Adams & Kivlighan, 2019). Further, client comfort or discomfort in disclosing pain, hardship, or loss, could prevent cultural issues from being discussed.

A strength-based approach is useful in therapist inquiry about relational stressors including community or familial supports; openness to indigenous or other rituals, including those for healing; and attending to individual and family strengths and resilience. Overlooking any of these could represent missed opportunities for cultural openings that could facilitate understanding, compassion, and insight.

Understanding the issues of the multiple generations who migrated leads to assisting with cultural transitions and balancing generational hierarchies, all too often neglected in therapists’ conceptualizations. Falicov (2014) describes the complexities of respecting the hierarchy and strengthening it, as well as the various viewpoints of different family members. Balancing acculturation with adaptation and addressing cultural dilemmas requires therapist skill and flexibility. There are also significant issues of therapist language and cultural competence to conduct such work.

Clinicians learn critical self-awareness of how power, privilege, culture, and identity inform both our internal experience and our affective and behavioral responding in the moment. and our perceptions of others. Therapists should use wise affect, respond to negative emotions that have potential to lead to disconnection, and through positive emotions, enhance caring and connection. This requires the ability to empathize with the client’s experience and be sensitive to the ways the interaction and relationship will be shaped by dynamics of oppression. Through interpersonal engagement, empathize with the client’s experience and be sensitive to the ways the relationship is shaped by dynamics and history. Our behavior, dress, nonverbal communication, and language all communicate messages that are powerful.

Therapists’ understanding of their own racial identity and biases are positively associated with clients’ perception of the therapist’s skills and improves the quality of the therapeutic alliance (Chang et al, 2021).

Cultural Biases: Confirmation; Implicit Bias

Cultural biases may develop from childhood or from experience and may be positive or negative, favoring certain individuals, groups, or identities, or else disfavoring, avoiding, or stigmatizing them. Individuals are aware of some biases, and unaware of others. Racism and sexism are examples of these biases.

Among biases which are known to exist are:

(Hook et al., 2017)

Therapists are not always rational, dispassionate actors and evaluators and may use heuristics, rules, or shortcuts that are culturally bound in making judgments and that result in cognitive bias in decision-making. Heuristics, or mental shortcuts, may include implicit biases, described as habits of mind, that have significant potential to affect viewpoints and evaluations of situations, and those may result in undetected prejudices and erroneous judgments that may lead to more positive or more negative evaluations and actions, but in fact may be based on irrelevant factors.

In the instance of confirmation bias, the tendency is to seek information that conforms to our beliefs. Thus, the clinician interprets, prioritizes, and recalls information that confirms or supports one’s prior beliefs or values based on personal life experience. Conversely, this leads to discounting information that does not conform, so that one selectively attends to or even seeks out information that confirms an impression, opinion, or conclusion rather than looking for and attending to that information which does not.

An example would be a therapist who starts working with a client, learns that they attended the same high school (although separated by many years), and works from the assumption that the client had a similar schooling experience to their own. Even when the client gives the therapist information that is not consistent with the therapist’s assumption, the therapist persists in that assumption, confident in their own experience and attending only to aspects that coincide with it and not being aware of that thinking error.

Tversky and Kahneman (1973) defined the “availability heuristic” as how vividly and saliently particular social and cultural events and experiences strongly influence decision-making and even perceptions. The availability heuristic is a cognitive bias that influences decisions so as to be based on false perceptions from recent memory. Thus, the most vivid experiences stand out and influence our perceptions. For example, events drawn from one’s personal experience are more readily available, so if someone was queried about frequency of deaths – accidents versus medical conditions such as heart disease – they might respond “accidental,” having witnessed so many online or on video and heard about them in news reports. In attribution error, there is the tendency to place greater emphasis on an individual’s personal characteristics and less emphasis on social and situational forces when judging behavior. All of these biases impact our cultural perceptions and relationships.

Cultural biases may emanate from childhood or life experience. They can be positive or negative. These include explicit biases, in which individuals are aware of their specific biases, and they may be negative or positive. They may be reflected in distance or anxiety toward difference. Implicit cultural messages may be verbal or behavioral (startling, moving away from). These may have arisen from negative past experiences, personal cultural struggles, or changes to cultural identities over time. Cultural biases may take the form of patronizing, overidentification, idealization, or failure to challenge behaviors.

A cultural bias could also be the assumption that a client who comes alone to therapy does not want the therapeutic process to involve family members or others in the therapy, either in the formulation of the problem or in the sessions, and wants a totally individualistic approach. Or it could be the therapist discounting the reason the client says they are coming to therapy, for example when the client says they just “feel like a failure” to their family, but the therapist frames it individualistically as depression.

For clinicians, a reflective process and self-awareness are essential so that recent vivid experience is distinguished from a careful dispassionate analytic approach that demonstrates distance from emotions and experience. Biases are introduced by disproportionately attending to certain rules, failure to adhere to professional boundaries perhaps manifest as intrusive advocacy, forcing the client to do something the therapist or supervisor feels is correct, or allowing personal values to trump professional ones (Knapp, Handelsman, Gottlieb, & Vandecreek, 2013).

Clinicians may rely on shortcuts or heuristics, that is to say rules or shortcuts in thinking that have worked successfully over time but may cloak undetected prejudices that lead to more positive evaluations based on irrelevant factors such as common experiences or identities or personal attractiveness, as distinguished from competence or performance (Kahneman & Tversky, 1973). An example of an anchoring heuristic is that a potential client hears from a friend that her therapy costs $40 an hour so when the potential client hears that the therapist she is considering costs $100, she has “anchored” her idea of fees to $40, not considering the quality or training of the therapist or reports of efficacy. Another example, the familiarity heuristic, relates to the tendency to have more favorable opinions of places or people one has experienced previously, as opposed to new, unfamiliar ones.

Kahneman and Tversky (1973) found that by requiring interviewers to consider a series of specific attributes of job applicants separately, evaluating individual characteristics independently rather than making a holistic judgment about the person, resulted in more accurate and reliable judgments with less variability.

Microaggressions

Sue and colleagues described racial microaggressions as “the everyday slights, insults, put-downs, invalidations, and offensive behaviors that people of color experience in daily interactions with generally well-intentioned White Americans who may be unaware that they have engaged in racially demeaning ways toward target groups (Sue et al., 2007), (Sue et al., 2019, p. 129). Microaggressions have been identified and discussed targeting multiple minority populations including women, LGBTQIA2S+ (lesbian, gay, bisexual, transgender and/or gender expansive, queer and/or questioning, intersex, asexual, and two-spirit), ethnic minorities including Asian-Americans and Latino-Americans, individuals who have immigrated from any country, religious group members, to name a few. Microaggressions have also been identified as frequent occurrences in clinical settings, in therapy sessions, both individual and group, and in clinical supervision. Although as Sue and colleagues describe, many downplay the significance and impact of microaggressions, in fact they inflict substantial harm both on the intended recipient, and also on the setting in which they occur, creating a toxic work environment. They are actually “macroacts of bias and discrimination” (Sue et al., 2019, p. 130). Microaggressions are traumatizing.

Sue (2010) gave examples of microaggressions that include a faculty member of color being mistaken for a service worker, an example of a theme of being a second-class citizen, or when race is brought up in classroom discussion, asking a student of color “Why are you always so angry?”

Therapists may inadvertently use microaggressions in their work with clients. These include statements that seem oblivious to racial or other identity tensions, making jokes or comments that are offensive to women or to diverse groups, or generally being dismissive of identity factors in interactions and psychotherapy with clients who are Black, Indigenous, or women of color (DeBlaere et al., 2022) among many others. These comments were more frequently heard from White therapists, and their impact may be moderated by attitudes of cultural humility.

Kivlighan et al. (2021) reported that 72% of their 71 ethnic and racial minority clients in 38 therapy groups reported at least one racial microaggression during their group therapy – and they reported those were associated with low cultural comfort among those clients.

When microaggressions occur, they tend to be normalized or overlooked, but they create an environment of disrespect and invalidation.

Sue and colleagues (2019) described the harm done when these microaggressions – which are actually “macroaggressions” – occur and suggested none are “micro”. Those who hear them are either targets, allies, or bystanders. Targets are the object to whom prejudice, and discrimination are directed. Allies are members of dominant social groups and have the power to move toward eradication of prejudice. Bystanders may be well-intentioned but may anticipate negative reactions to their responding and so step back.

To directly address the aggressions, Sue and colleagues (2019) suggest micro interventions which include:

(a) make the invisible visible, challenging the stereotype, asking for clarification, and circulating literature or soliciting feedback from others;

(b) disarm the microaggression by expressing disagreement, interrupting, or redirecting;

(c) educate the perpetrator by appealing to the individual’s values and principles, instituting long-term mandated training; and

(d) seek external reinforcement or support.

However, such findings are indicative of the urgent need for more training, reflection, and cultural humility in all clinical interactions. Self-assess your use of microaggressions – through the lens of the client. Jokes or throw-away comments may be microaggressions.

Consider possible responses when you hear a microaggression from a colleague. Which micro-intervention might you use? What would stop you from using one? How could you increase the probability of using a micro-intervention?

Cultural humility is one intervention to mediate negative effects of microaggressions within the therapeutic relationship (DeBleare et al 2023).

Identities and Intersectionality

The frameworks of both Falicov and Hays offer strategies to examine the places of power and privilege held by the therapist. In her book Connecting Across Cultures: A helper’s toolkit (2012), Dr. Hays provides a series of questions which have the therapist engage in introspection and curiously investigate their own identities and privileges. From these questions, the individual designs what Hays coins as a “culture sketch.” Adapted from her ADDRESSING multicultural framework, the culture sketch brings forth the complexity of social-cultural variables and helps bring awareness to places where a mental health provider may hold privilege in cross-cultural interactions with clients (Hays 2012).

As stated previously, the construct of “intersectionality” is derived from the work of Kimberle Crenshaw (McCall, 2015) and represents the constellation that race, ethnicity, gender, gender identity, sexual orientation, socio-economic status, religion, spirituality, disability/ableness, and other identity dimensions and statuses are social constructions that collectively encompass human identities. Intersectionality refers to proactively integrating the multiple identities and their resultant privilege and oppression to amplify understanding of context, mental health, and effective intervention.

Internalized stigma or “isms” can result in prejudice, stigma, and negative mental health outcomes. Unfortunately, multiple identities and their intersections have been generally neglected in training, literature, and practice.

Among those neglected are gender variant nonbinary and transgender identities. Recognize that a binary expectation generally exists from the time a client contacts a mental health provider or setting. Generally, intake forms include “male/female” choices; in some settings there is “other.” Consider your own forms and ways of greeting potential clients. Consider whether you identify and disclose your own pronouns.

Binary refers to classification of gender into two distinct and opposite forms of masculine and feminine, whether determined by social system, cultural belief, or other factors in combination. One’s gender identity and sexual orientation are unrelated. Transgender and gender variant affirmative counseling and psychological practice needs to be current, culturally relevant, responsive to the client and the multiple social identities, addressing social inequities, enhancing resilience and coping, advocating to reduce systemic barriers to mental and physical health, and building upon client strengths (Singh & Dickey, 2017). Cisgender refers to those whose gender identity corresponds with the sex registered for them at birth.

Generally, a binary worldview predominates. That is, individuals are perceived as either male or female. For example, asking if one was “born a boy or girl” reflects the therapist’s binary orientation. Further, a total or “laser” focus on gender identities ignores other intersectional identities such as race, ethnicity, religion, spirituality, socio-economic status, migration and immigration status, disability or ableness, examples of intersectionality, considering multiple identities and their interactions.

Sex is assigned at birth and is binary, generally relating to anatomy. Gender refers to social constructs: roles, behaviors, activity choices, etc., that society considers appropriate. Sexual orientation refers to a pattern of emotional, romantic, and/or sexual attraction of men to women or women to men (heterosexual), of women to women or men to men (homosexual), or by men or women to both sexes (bisexual). It also refers to an individual’s evolving sense of personal and social identity that is based on attraction, related behaviors, and, potentially, membership in a community of others who share those attractions and behaviors. Nonbinary refers to people whose gender does not fall within binary categories of man and woman. Thus the term “nonbinary” refers to individuals who do not define themselves as either “male” or “female.” It can be expressed as an absence of gender, presence of multiple genders, or as gender expansive, not fitting neatly into any category.

Pronouns for nonbinary individuals may include they/them/theirs, or alternate between she/her/hers and he/him/his.

Sexual orientation and gender identity are not the same. Children generally identify their gender between the ages of three and five. Gender identity refers to a person’s internal sense of identified gender; gender expression refers to how an individual communicates gender identity to others through their behavior, dress, presentation, voice, or bodily characteristics. “Trans” may be used as shorthand for “transgender,” referring to individuals whose gender identity or gender expression does not correspond to the sex they were assigned at birth. Gender nonconforming also means not conforming to the gender identified at birth. Some clients may use an “in-between” or other terms not within the gender binary, for example, “genderqueer.”

Sexual orientation refers to one’s consistent physical, romantic, and/or emotional attraction to another person, whereas gender identity refers to one’s internal and individual experience and expression of gender. Gender expression is how a person publicly expresses or presents their gender: behavior, appearance such as dress, hair, make-up, body language and voice. A person’s chosen name and pronouns are also ways to express gender.

Clients and therapists alike may not disclose gender identity or other identities due to concern about stigmatization or pigeon-holing – assuming aspects of identity that are not accurate or due to multiple situational, political, or other factors. Further, “cisgender” or denoting a person whose gender identity corresponds with the sex registered for them at birth, generally is associated with privilege in many settings and interactions. In the case of children or individuals who request the use of pronouns that differ from those assigned at birth, or who already use pronouns that differ from those assigned at birth, who often encounter stigmatization and social oppression, and who may identify as trans or gender-diverse, the therapist needs to self-assess their own training and general orientation toward binary and nonbinary designations.

Disclosure of one’s personal pronouns is an important practice. Failure to use the client’s pronouns is perceived as a signal of not being respectful or inclusive in gender identity. Consider your own setting(s) and use of personal pronouns. Consider situations when pronouns have been misused or disregarded and the impact of that on the individuals. Also consider whether gender identity is simply ignored and the message that is communicated by that. “Misgendering” refers to using language or pronouns that are not accurate for gender.

Frequent heterosexist and gender microaggressions or macroaggressions occur. LGBT trainees report infrequent discussion of cultural diversity and downplaying or disregarding the importance of sexual orientation and other intersectional cultural identities/considerations (Hagler, 2020). No microaggressions are acceptable in a clinical or training environment as they connote disrespect, bias, and a lack of safety.

The intersections of LGBT and religion are increasingly challenging and complex, as sexual minority individuals may experience conflict among family members, across generations, their religion, and their sexual orientation. This may result in a combination of withdrawing from formal religion, escalating family conflict, and distress.

Resources are available

The American Psychological Association (APA, 2021) – APA Guidelines for Psychological Practice with Sexual Minority Persons

A Guide for Understanding Supporting, and Affirming LGBTQI2-S Children, Youth, and Families

Guidelines for Affirmative Social Work Education, (Craig et al., 2016)

AAMFT Gender Identity

Racial and Ethnic Diversity Trauma

Directly related to the therapeutic relationship and to worldviews associated with clinical assessment and treatment, is knowledge and competence with respect to racial group membership, exposure to racial trauma, including prejudice and discrimination (Pieterse, 2018). Membership in a particular racial or ethnic group has led to job loss or rejection, loss of opportunities, and painfully incorrect assumptions. Much of the trauma literature has omitted mention of these forms of trauma. Some issues to address – and to self-assess on – are how you identify and approach racial trauma. Consider the example of the BIPOC and/or religious diverse supervisee who comes to you to tell you her client used pejorative racial/ethnic language in session. It was not directly aimed at them but was very hurtful. Or the client discloses that they felt disrespected by office staff. Or they describe their own personal history of trauma that was evoked by the client or staff. Pieterse (2018) suggested some possible approaches:

If in fact, the situation is related to clinic staff, it is critical for the therapist to address this within the proper setting.

Mental health professionals are strongly encouraged to engage in processes such as acknowledging and addressing traumatic stress resulting from racism; being informed and knowledgeable about the nature of racism; and engaging in ongoing self-evaluation as part of creating an anti-racist clinical practice. ( Pieterse 2023)

With continuous self-examination and exploration of implicit bias, therapists can best position themselves to be effective in cross-cultural interactions with clients

In 2021, the American Psychological Association (APA) established a standard definition of racism and issued a resolution apologizing for their role in “Promoting, Perpetuating, and Failing to Challenge Racism, Racial Discrimination, and Human Hierarchy in U.S” (APA 2021)

As you read through the resolution, what thoughts and reactions do you notice? What are clinical practices that you can adopt into your work that reflect some of the commitments mentioned in this statement?

Dealing with Racism-related Stress and Racial Trauma when Working with Clients of Color

Pieterse and colleagues (2023) provided invaluable guidance for working with racism-related stress and racial trauma when working with clients of color. Experiences of racism are identified as having the potential to result in traumatic stress reactions, a fact generally overlooked by mental health professions but one that has been borne out by multiple research and experiential studies. Experience of racism is a traumatic event that may be “chronic, cumulative, and intergenerational” (p. 2) and may be passed to future generations in multiple ways including through storytelling. The authors note that not all race-related events may be traumatic, but those that are negative, sudden in occurrence, and uncontrollable have significant potential to be. For the therapist, awareness and self-awareness are critical first steps toward acknowledging that racism is traumatic and is associated with significant mental health outcomes including anger, anxiety, and depression. Further, racism and racial oppression are violence, but these are easily overlooked as a causative factor in mental health diagnosis and conceptualization. Thus, it is essential to ask and understand what has happened to the client in their experience of racism and oppression. Racial oppression may be overlooked, but minimizing or ignoring it is a form of retraumatization. Pieterse and colleagues urge clinicians to move from conceptualizing what is wrong with the client to considering what events have occurred/what has happened to the client.

In describing a facilitative process, Pieterse and colleagues proposed that clinicians must be courageous in addressing race and racial impact. The clinician must be attuned and ready to address racial misunderstandings and potential microaggressions that may occur in the client-therapist interaction or those that are reported to the therapist by the client. They urge immediacy, addressing in the moment dynamics and interactions. Attention to the therapeutic alliance is essential, attending to its formation, goals, tasks, and power and privilege. The authors identify the high rates of racial microaggressions and other misunderstandings that occur and their potential for rupture without dedicated repair.

Essential components are cultural humility, empathy, and empathic validation, marked by efforts to empathize and contextualize experience and to engage in therapeutic empathy, trying to see through the client’s lens of experience.

Specific techniques for facilitative processes include enhancing adaptive coping to racial events utilizing mindfulness focused on stress reduction, empowerment, supporting and validating the impacts and potential shame associated with racial trauma. They also suggest the approaches of processing of racial trauma through empathic attunement and seeing the traumatic events through the lens of the client.

Strategies to assist the client in moving forward include empowerment, generally reframing from victim to survivor, enhancing a sense of agency or the power to be proactive. Also a strategy generally is to elevate anti-racism, and for professionals to decenter Eurocentric and Western approaches, including and valuing writings and practices of racial and cultural communities that were marginalized through colonization.

Social Justice

Social justice refers to increasing well-being among marginalized communities, decreasing social inequities, and promoting and enhancing human values of equality and justice by facilitating removal of barriers to opportunity and well-being.

Self-awareness is a complex competency, including a requisite self-understanding of personal identities, values, beliefs, biases, personal privilege, motivation to learn about culture and cultural worldviews, identification and understanding of oppression, marginalization, prejudice, and health disparities; employing skills of cultural humility, self-awareness, and the knowledge, skills and attitudes requisite to serve myriad diverse client populations.

Social justice is a core value of the profession of social work, including advocacy to decrease human suffering and to promote human values of equality and justice, and is a significant aspect of psychology counseling programs. Social justice is defined as the “process of acknowledging systemic societal inequities and oppression while acting responsibly to eliminate the systemic oppression in the forms of racism, sexism, heterosexism, classism, and other biases in clinical practice both on individual and distributive levels” (Odegard & Vereen, 2010, p. 130). An understanding of social justice encompasses privilege and oppression, marginalization, educational disparities, unintentional educational practices, cultural worldviews, unequal opportunity, and inequities in all realms.

Individually, persons have multiple identities, intersections of privileged and marginalized. Thus, there is intersectionality between multiculturalism and social justice.

In a study of how individuals developed a social justice orientation, counseling psychology students and professionals identified critical incidents that influenced them: the influence of significant persons (mentors, parents, family, and peers) with mentors who introduced them to integrating social justice into research and academic studies, and families and classmates who fought for social justice and modeled the behavior for them. Exposure to injustice, oppression, loss of privilege – personally or by witnessing critical events – were associated with supporting development of social justice in their orientation by increasing/deepening their awareness of injustice and solidifying their commitment to a social justice agenda (Caldwell & Vera, 2010).

For clinicians, an understanding of the requisite attitudes, values, frame, and context of social justice is a competency. It requires self-knowledge of one’s own identities and privilege; self-awareness of one’s impact on others, including clients; attention to the clients’ worldviews, for example referring to Falicov’s model and understanding the role of therapist as advocate, assisting the individual or family with interpersonal, institutional, community, public policy advocacy efforts, referrals, and support. For example, interpersonal might include food or housing referrals or childcare resources. Others might involve advocacy to impact local, state, or national policy for homelessness, hunger, poverty, or the mentally ill.

Microaggressions are another manifestation of verbal and behavioral cues that recreate and serve to reinforce discriminatory and oppressive social patterns (Owen et al., 2014) and inflict pain. Microaggressions include derogatory remarks denigrating culture, and assumptions of financial or other limitations due to identity. Examples are assuming a client cannot afford to buy a book or object relevant to therapy, or surprise when a diverse client possesses a doctoral degree. High numbers of microaggressions occur in group therapy (Kivlighan, Swancy, Smith, & Brennaman, 2021). Microaggressions include avoidance of or minimizing relevance of cultural issues or use of cultural stereotypes, even if unintentional (Owen et al., 2016). Microaggressions cause strain or ruptures, and the therapist may lack awareness of the source. Chang and colleagues (2021) discuss the phenomenon of White clients challenging BIPOC therapist credentials as a reflection of cultural stereotypes that such therapists are less qualified or are affirmative action hires.

Cultural mis-attunement may occur when clients share meaningful, cultural, emotionally laden experiences only to have the therapist minimize or ignore the disclosures or turn inward and talk about their own emotional experience, deflecting from the client. Or when a BIPOC client is described as “angry” and the therapist addresses that anger purely as a behavioral phenomenon and deals with strategies to manage anger rather than addressing the underlying cultural milieu in which the anger is a survival strategy against a lifetime of oppression.

Emotional expression is another cultural variant. Self-awareness of the cultural nuances of relationship and communication in providing therapy is essential. Self-awareness includes awareness of our own identities and use of Falicov’s graphic to consider our attitudes, privilege, perceived power, and culture and how these impact our attitudes and behaviors toward our clients – and toward perceived difference and sameness. Self-awareness extends to identifying personal emotional response to clients and attending to that, obtaining consultation as indicated, identifying feelings of discomfort, or other responses that arise.

Trina and Joseph are a heterosexual married couple who have been together for approximately six years. They recently started experiencing difficulties in their relationship due to what they describe as “poor communication.” During the intake session, Joseph expresses his concerns about their frequent arguments that often escalate into heated conflicts. Trina agrees and states that she wishes they could talk calmly without getting into screaming matches. She begins to detail a recent fight they had in which Joseph yelled at her. Joseph immediately gets upset and says firmly “I was not yelling.” As Joseph begins to speak you notice tension in your own body increasing. Trina and Joseph also notice the change and Trina comments “See, you’re even upsetting the therapist.”

In this example it would be important to attend to not only the discrepancy in the couple’s characterization of the fight, but also the reaction that you noticed in your own body during the session. It would be important to inquire about what, if any, family norms or experiences in the couple’s childhood history inform their individual communication and conflict resolution style. Increased understanding of what messages they received about expression of emotion could help inform what clinical approach you use and what potential interventions to introduce to the couple. Finally, attending to your reaction and exploring whether you were reacting to Joseph’s specific comment, the rise of tension between the couple, or a recent fight you had with your partner would be the first step in addressing the possible cross-cultural interactions showing up within the therapy.

Essential components to address ruptures include: Identification of client response and withdrawal and the ability to address these in an empathic manner; accurate self-awareness of the impacts of power, privilege, and culture on perceptions and relationships with clients; self-awareness of negative emotions and empathy to manifest toward clients and difference; ability to empathically engage without becoming defensive or withdrawing emotionally from difference and oppression; and moving forward to repair and be present with the client in the moment to process the event(s), impacts, and the relationship moving forward.

International

Worldviews impact every aspect of our perceptions and relationships with clients and others. Consider two dimensions that define our view of culture. First is unilateral globalization, based on belief in the superiority of one’s own culture, values, and ideals, and imposing that standard on all individuals and cultures – one culture dominates and subjugates others.

In contrast, enlightened globalization is based on understanding, dialogue, respect, integrating knowledge to foster cultural development, with recognition that each culture has a different set of values, beliefs, skills, and resources (Kim & Park, 2007).

Colonialism is a result of unilateral globalization. Colonialism is a confluence of profound negative social and emotional consequences that result when one ethnic or cultural group subjugates another. Colonization refers to processes whereby a country or group transports and implants settlers in another country with the aim of domination. Results include loss of original inhabitants’ tribal lands, their traditional ways of economic support, destruction and degradation and then loss of social patterns, traditions, power, roles, self-respect, loss of language, cultural practices, autonomy, self-determination, and cultural mores.

And there is simultaneously, an elevation of the mores and power of the dominant Western European groups (Hernandez et al., 2010; Hernandez-Wolfe, 2011) and their cultural mores which are in sharp distinction from those of the country being overtaken and dominated. The domination is divisive, resulting in subjugation, dehumanization, and a loss of culture.

Attention is being devoted to mental health systems through the lens of colonization. Significant losses described which are highly relevant for clinical practice are those of well-being and spirituality. Further, recognition of our own privilege helps to foster humility (Hernandez-Wolfe, 2011) and compassion in our work.

Multicultural Theoretical Orientations

As other disciplines such as political science and law bring attention to greater understanding of how systemic racism, discrimination, and marginalization affects individuals, families, and social institutions, the mental health field has also incorporated these concepts into multicultural frameworks that offer clinicians alternative strategies to understanding of effective clinical treatments tailored to meet the needs of diverse populations. Feminist theories and Relational Cultural Theory (RCT) are two examples of such multicultural theories.

Feminist theory assumes a perspective which aims to understand how gender influences the client’s experiences and shapes their beliefs and behaviors. These Feminist theories and their application in psychological practice grew from the Women’s Movement in the 1960s because of concerns that traditional psychotherapies did not adequately acknowledge or address gender and social-political issues that differentially affected all persons, but women in particular. During this time there was a surge of collective theories, concepts, and ideas that began to note the absence of consideration of gender in the conceptualization and understanding of social systems and human behavior. Consider the impact of the intersection of gender and culture on the development and well-being of individuals and how it continues to evolve. Feminist theories are broadly applied to a variety of clinical issues including trauma and sexual abuse, with a central focus on understanding how social and cultural norms influence the presentation of clinical issues such as eating disorders and trauma, particularly in response to gendered violence and personal identity.

As a theoretical framework, feminist theory emphasizes the intersection of gender and culture in the development of the individual (regardless of gender identity). There is also consideration of how social and political constructs such as discrimination, oppression, and sexism impact our clients and it offers strategies for addressing that in treatment. While there is no unified definition of feminist theory, there are underlying principles that guide the use of it in clinical practice.

The four clinical components (Israeli & Santor, 2000) of feminist theory include:

Additional guiding principles of feminist theory highlight its attention to social justice, empowerment, equality and inclusion:

There are four approaches to feminist theory (liberal feminism, cultural feminism, radical feminism, and social feminism) that can be applied to case conceptualizations (Draganovic 2012).

Black Feminist Counseling Theory

Black feminist theorists explore the specific and unique challenges faced by Black women which should be integrated into psychological theory and practice. Three specific strategies informed by Black feminist theories include the use of critical affirmations, raising black consciousness, and intentional self-definition (Oliphant et. Al, 2022)

Mujerista Counseling Theory

Womanist theory focuses on BIPOC communities while Mujerista theories focus on experiences of Latinx women. Mujerista is a term that emerged within Latinx communities to describe a feminist perspective that is centered around the experiences, struggles, and liberation of Latina and Hispanic women. As a feminist theory, it emphasizes intersectionality, cultural identity, and social justice in understanding how systems of oppression uniquely affect Latina and Hispanic women. Both in theory and practice, Mujerista recognizes the interconnectedness of different forms of discrimination and advocates for political and social change.

Relational Cultural Theory (RCT)

As a multicultural theory, RCT complements the multicultural/social justice movement by (a) identifying how contextual and sociocultural challenges impede individuals’ ability to create, sustain, and participate in growth-fostering relationships in therapy and in life and (b) illuminating the complexities of human development by offering an expansive examination of the development of relational competencies over the life span. (Comstock et al, 2008).

Embedded within RCT are seven core tenets (Comstock et al, 2008) that anchor clinical case formulation in an understanding of human development. RCT centers the role of relationships as a measure and function of psychological wellness. This premise operates from a collectivist perspective that is more culturally congruent than some other theoretical perspectives. Review the seven tenets and consider with what client populations this conceptual framework could be useful:

1. People grow through and toward relationships throughout their lifespan.

2. Movement toward mutuality rather than separation characterizes mature functioning.

3. The ability to participate in increasingly complex and diversified relational networks characterizes psychological growth.

4. Mutual empathy and mutual empowerment are at the core of growth-fostering relationships.

5. Authenticity is necessary for real engagement in growth-fostering relationships.

6. When people contribute to the development of growth-fostering relationships, they grow as a result of their participation in such relationships.

7. The goal of development is the realization of increased relational competence over the life span.

Treatment Considerations

While there is consensus that attending to socio-cultural and individual factors will enhance treatment outcome, there continues to be ongoing discussion in research literature regarding cultural adaptations of diverse clients. Researchers and treatment developers have long been criticized for neglecting cultural variables in both treatment development, design, and evaluation.

A 2008 review of effective treatments for ethnic minority youth (Huey & Polo) highlighted the importance of therapist knowledge and skills in cross-cultural effectiveness as enhancing treatment outcomes for ethnically diverse youth. This meta-analysis primarily focused on reviewing the impact of the cultural adaptation of EBTs (evidence-based therapies) for ethnic and racial minorities in enhancing treatment outcomes. Their work highlights the importance of considering cultural factors such as values, beliefs, and traditions when designing and implementing EBTs. The researchers indicate that failing to consider socio-cultural variables, including acculturation status, can result in inaccurate diagnosis, less effective treatment, and a lack of engagement from individuals from diverse cultural backgrounds.( Huey et. al. 2014)

A ten-year follow-up to the review of psychosocial treatments for ethnic minority youth revealed that there remains few evidence-based treatments, specifically for Asian and Native American youth (Huey et. al. 2019).

One such treatment model is Brief and Strategic Family Therapy (BSFT) developed by Jose Szapocznik. Szapocznik’s pioneer model is one that built upon systems therapy in the 1970s and 1980s primarily with Cuban American families. This model was created for specific attention to cultural norms, values, and clinical issues for Hispanic youth and families, specifically Cuban American families. One unique aspect of this model is that he added a bicultural effectiveness training which made the acculturation elements of the population intended for the intervention more explicit than in other treatment models. Acculturation dynamics were central to the model.

There is general recognition that Cognitive Behavioral Therapy (CBT) treatment approaches were developed in Western countries and reflect that strong cultural bias. As Falicov (2014) and others describe, multicultural factors are central to identity in all cultures. Cultural ruptures occur frequently in psychotherapy. They can result from affective mis-attunement including failure of empathy or misunderstanding occurring through a cultural lens, misunderstandings which may or may not be recognized, relational disconnects relating to cultural mores or misunderstandings, or relational disconnects or misalignments resulting in strains or ruptures (Chang, Omidi, & Dunn, 2021). Chang and colleagues state that understanding of clients is difficult and elusive, and often therapists misunderstand while believing that they can understand the processes of socialization. However, those misunderstandings occur through differential socialization and assumptions based on personal processes and through lenses of privilege versus internalized oppression. These internalized scripts become automatic and are enacted without conscious awareness. They foster strains and ruptures and generally disconnect any potentially internalized oppression. Therapists then impose cultural, racial, or sexual stereotypes on clients without conscious awareness they are doing so. These may be represented in assumptions, language, or attitudes.

Clinicians are encouraged to identify strategies that will allow them to consider unique needs of diverse groups while also implementing treatment modalities in a manner that maintains fidelity to the clinical model. Several authors provide guidance on culturally informed strategies to effectively integrate culture into evidence-based treatments. Pamela Hays (2009) outlined the following 10 steps that can be used when integrating a multicultural framework into CBT:

In contrast, Falicov would want to know more about the ecological context and stressors, family constellation, relationships, and relationship to culture. In practice, essential are demonstrating curiosity and respect, culture-specific adaptation, and transformation of theories such as attachment and individuation. Regarding social justice, attention is given to power differences and contextual stressors tied to gender, sexual orientation, gender identity, race, social class, and minority status. And in practice, empowerment, cultural resistance, social action, and legitimization of local knowledge are critical.

So for Falicov, focus is on intersectionality, context, relationships, and approaching clinical work with respect, curiosity, reflection, and openness. (Falicov, 2014, p. 28)

A recent article (Huey et al, 2023) expanded upon Hays’ work to explore what, if any, adaptations are needed to ensure integrity and effectiveness of Cognitive Behavioral Therapy with diverse populations. This work continues to support the efficacy of CBT for culturally diverse groups while emphasizing the need for clinical training in both cultural competence and evidence-based strategies for cultural adaptations (Huey et al., 2023). It is important to consider not only adaptations made to treatment outcomes but also the role of therapists receiving training in cultural competence in order to improve treatment efficacy with diverse clients (Huey, 2014).

While the literature on culturally sensitive EBTs remains lacking (Huey et al., 2023), there is emerging support for personalized psychotherapy tailored for the individual. The personal relevance of the psychotherapy (PROP) model proposed by Hall et al. (2021) is one strategic method to integrate and account for the dimensions of culture outlined in this course. Within the PROP model, clinicians are encouraged to consider individual, group, and universal factors that are relevant not only in the development and diagnosis of psychopathology, but also in selecting and implementing treatment intervention. As an illustration, read through the following vignette and respond to the following questions.

Kai is a 20-year-old gay Asian cisgendered male who seeks services at his university counseling center. At intake, he reports that he feels depressed and is experiencing a significant amount of stress about school, commenting that he’ll “probably flunk out.” He has a 2.0 GPA and has experienced a significant decline in his grades over the past year. He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. Kai states that since elementary school he has always been “shy” and had trouble making friends. He does report having a very small and cohesive group of friends from elementary through high school that he met mostly at church. He indicates that his level of anxiety significantly amplified at the start of the COVID-19 pandemic. When meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him, often assuming that they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After social interactions, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since resuming classes in person, he has increased his isolation from peers, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. As summer approaches and he prepares to return home to his family, he is seeking help to let his parents know that graduation will likely be delayed.

In considering possible diagnoses, what are the individual behaviors and symptoms displayed by Kai that inform and clarify diagnoses? He shows some signs of anxiety and depression. Some of those symptoms possibly were exacerbated by the COVID-19 pandemic and others may by culturally congruent.

In what way does Kai’s early history, age, gender identity, sexual orientation, and his current status as a college student add to your understanding of the salience of these behaviors in his overall health and well-being? As a college student, he is in a developmental stage of life in which socializing with peers, identity formation, and experimentation with different identities are normative. The amount of social isolation that he describes is not only possibly emblematic of a psychiatric disorder, it is developmentally incongruent for his age.

What do you identify as priority targets of treatment according to how Kai is presenting and his reason for seeking services? What additional information about Kai, his family and his social support system is important to know before determining possible intervention? Some of Kai’s symptoms are culturally congruent so it would be important to first consider potential impact of targeting behaviors that someone from a different cultural perspective would assess as problematic yet may not be a source of distress for Kai and his family of origin. A therapist errs if their targets of treatment are inconsistent with his cultural norms and expectations of his community.

While we know that generally CBT is an effective treatment for anxiety and depression, would specific traits that Kai displays such as distorted thoughts and ruminations help determine if CBT is indicated or contraindicated for him? Before initiating services, a clinician would also need to consider aspects of his current setting and family life that could impact treatment and need to be modified or adapted. Other universal factors to consider would be what group cultural values or norm should be integrated into treatment.

In Falicov’s model, the therapist focuses on relationship, on current stressors and strengths, approaching Kai with curiosity and respect, increasing understanding of his family of origin, the onset of his school difficulties, the relationship of those to his family constellation and peer group so as to understand the onset, precursors, and current impact of the actions he feels he must take, how his parents have responded previously, identifying patterns of avoidance and their efficacy short and long-term, general parent-client dissonance, COVID-19, and their impact on his presenting problem. The therapist would identify and address family roles, boundaries, avoidance as coping, and imbalances that have arisen through Kai’s college trajectory that may have been rooted in family relationships and patterns that have become increasingly less adaptive with maturation. The therapist would explore the role of the church, how impactful that had been, and what resources he has available to use religion, spirituality and the church currently, as well as other positive coping to enhance the client’s personal agency and control which could positively influence his life.

Identifying and applying an evidence-informed approach can provide a roadmap of how to deliver culturally congruent and effective treatment for diverse populations.

Meredith is a 52-year-old divorced Black female. She lives alone and works in sales. She has a 24-year-old daughter that she has a strained relationship with and rarely sees. She comes to therapy seeking assistance for workplace harassment. She has been employed with her company for 18 months and was recently placed on a Performance Improvement Plan due to decline in her sales. She works remotely and only goes out into the field to make customer visits. She believes the write-up was racially motivated. She denies a previous history of mental health issues. She reports an increase in depression and anxiety since the disciplinary action from Human Resources. She is having trouble concentrating at work and has canceled several meetings with her supervisor. She states that she is usually a happy person, but the work situation has changed her mood. She indicates that she is isolating from her friends and not spending time outside of her home. As part of your clinical intake, you provide her with PHQ 9 and GAD 7 to complete, however she neglects to finish them each week.

As you prepare to consider a diagnosis, consider what cultural factors impact symptomatology and possible diagnoses.

In generating intake questions to help develop a culturally informed case conceptualization use DSM 5 Cultural Formulation Interview to develop a list of questions and considerations for this client:

What is found when considering social, cultural, and contextual variables in symptom presentation?

What are cross-cultural factors that you must take into consideration for you in your work with this specific client?

How do you as a therapist approach this client from a place of cultural humility in a manner that establishes trust?

In your third session, Meredith reveals that she was terminated from her previous job for frequent absences and poor work performance. She reports that her absences were secondary to a vehicle motor accident which involved her and another motorist. She reports having similar symptoms and difficulties at work now that she had after her accident.

A month after she was placed on a workplace performance improvement plan, she applied for short term disability but was declined. Since then, she is asking you for assistance with filing an appeal as well as a complaint to her current company about racial discrimination.

How do you respond to this client’s report of racism?

What strategies do you use to address racism in psychotherapy with the client?

How does the therapist balance legal, ethical, multicultural, and clinical aspects of treatment? What personal factors of the therapist will impact treatment? Do you consider the role of cultural consultation from a peer or previous supervisor in order to enhance treatment?

Summary

Attending to the varied aspects of diversity and multiculturalism is a critical aspect of psychotherapy that improves and enhances the experience of our clients and their treatment outcomes. Integrating diversity into our assessment, conceptualization, diagnosis, and treatment, we improve our quality of care and create welcoming environments for all populations. As we grow in our skills and competencies it is essential that we remain committed to the principles of multiculturalism, recognize diversity as a strength, and develop effective training and clinical services that convey value and respect for everyone.

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