Psychotherapy Bulletin

Psychotherapy Bulletin

I was inspired to write this piece by my postdoctoral mentor, Joanna Drinane, who asked about the integration of my two programs of study. To make a long story short, I achieved my PhD in Human Development and Family Studies some years ago and joined the Master’s in Clinical Mental Health Program at the University of Utah in 2021. In many ways, my experiences point to the inevitability of this choice, and how I arrived here is a conversation worth having another time. In this article, I hope to address Dr. Drinane’s call, which I understood as: “What lens do I bring to the study and practice of psychotherapy, having come to this field from a different (but related) discipline?”  

 The relevance of developmental psychology may already be obvious; training programs require a lifespan development course for graduation, and although some traditions are less preoccupied with the history clients bring into the therapy room, precious few would argue against the projection of past experiences into the present, willingly or otherwise. Notwithstanding, this piece focuses on Urie Bronfenbrenner’s bioecological systems theory, which has significantly influenced my professional development and scholarship. First, I will highlight a few propositions from the ecological systems approach to inspire renewed interest among scholars in psychotherapy. Next, I argue for a stronger inclusion of the theory’s original formulation into discussions of multicultural competence (MCC). Lastly, I conclude by framing psychotherapy through the lens of the theory’s latter formulation (see Rosa & Tudge, 2013, for more information on the theory’s phases) and offer possible directions for future research on therapeutic outcomes. 

Most students of psychology and related fields have been exposed to Bronfenbrenner’s ecological model of human development, which depicts the developing person nested in contexts of ascending proximity (see Bronfenbrenner, 1977; 1979). Much else beyond this may be scarcely known, so I present several of its propositions with germaneness to counseling psychology to furnish a wider understanding and function. Consider Proposition 4: 

“Ecological experiments must take into account aspects of the physical environment as possible indirect influences on social processes taking place within the setting,” (Bronfenbrenner, 1977, p. 523). 

If we substitute “ecological experiments” with “psychotherapy,” we meet a useful directive (although the astute reader may ask whether psychotherapy is not also an ecological experiment?). As psychotherapists, we must never neglect the power of the physical environment and the messages it communicates to the individual. Yet, modest research surrounds the physical features of the therapeutic environment that support or hinder its processes and goals (see Pressly & Heesacker, 2001; Sinclair, 2021). Do therapists design the space to reflect their tastes, meet clients’ needs, or both? Are clients invited to give feedback? I am curious about what insights a nationwide representative study would return. Taking the matter a step further, research in counseling psychology may benefit more generally from engaging with principles from environmental psychology. By way of illustration, where is our attention drawn when a client reports distress? Do we ask which characteristics of their environment (e.g., noise, clutter) may be contributing? If not, we may fail to capture meaningful elements useful for intervention.  

Another likely familiar aspect of the theory is its terminology of microsystems, an immediate setting where a person engages in roles and activities (e.g., the therapy space is sometimes conceptualized as a microsystem). However, the theory’s strength lies in articulating the interactive relations between people, places, objects, and processes. For that reason, clinical practice may profit from greater reflection on Proposition 5: 

“An ecological approach invites consideration of the joint impact of two or more settings or their elements. This is the requirement, wherever possible, of analyzing interactions between settings” (Bronfenbrenner, 1977, p. 523). 

Those acquainted with the model may recognize this as the mesosystem, the “interdependencies between settings” that the individual typically occupies (e.g., home, work/school). A mesosystem forms when a person enters a new setting and links are made between the systems either by the primary person or significant others. The criteria for mesosystem formation include cognitive and affective structures (McIntosh et al., 2008), such as when a client reports using interpersonal skills gained in therapy at work. This point may appear unnecessary since this emphasis is inherent to the therapeutic process. Yet, the givens are often the first to collapse through mistaken disregard. An essential task of psychotherapy is to make the unspoken spoken.  

I advance that a mesosystem focus is needed for therapy to have the greatest effect. To do so, clinicians must commit to tracking mesosystem dynamics (again, see McIntosh et al., 2008), soliciting information about how therapy influences other important settings to the client, and vice versa. One mesosystem proxy intervention is to assess changes to the home, school/work, and neighborhood environments on client forms (preferably single items). Time in session may be used to make connections to how these contexts affect clients’ progress and the contributions of therapy, positive or negative. Additionally, measurements of mesosystem interaction support partnerships across healthcare settings on behalf of clients (e.g., clients seeking gender-affirmative care, support for symptoms related to premenstrual dysphoric disorder, and pre- and post-therapy related to bariatric surgeries). We can all agree that psychotherapy does not occur in a vacuum, and mesosystem measures enable clinicians and clients to make important relations to contexts outside the therapy room.  

Building upon this point, the most recognized thrust of the theory is found in Proposition 8, which concerns itself with the impact of distal contexts on the individual (Bronfenbrenner, 1977). I raise it here to transition into a discussion of MCCs. Most practitioners are familiar with Sue et al.’s (1992) tripartite model of multicultural competencies. This model upholds an ambitious charge to counselors wishing to be culturally skilled. The nine competency areas are undoubtedly beneficial if clinicians diligently commit to them, yet limitations remain. Take the question posed by Owen et al. (2011): at what point has one procured sufficient awareness, knowledge, and skills to be culturally competent? Still, my grievance with traditional definitions of MCCs is two-fold: 1) application is difficult due to its broad scope, and 2) the emphasis on identity categories is lopsided. Both criticisms stem from a shared problem: it is unclear where the focus should be placed. I bring Bronfenbrenner’s theory into the discussion to offer something concrete.  

To be sure, I am not the first to discuss Bronfenbrenner’s theory in conjunction with multicultural issues in counseling. The theory has been used to provide a rationale for why culturally competent therapy is needed (Greenleaf & Williams, 2009; Ratts et al., 2016) and why it works (Chu et al., 2016). I do not disagree with these uses but propose that a deeper treatment may support the development of clinicians’ MCCs. The theory is, at the heart, a practical one born from a sincere desire to bring greater ecological validity to research in human development. With this understanding in mind, uses of this theory cannot remain wholly conceptual but must also include specific applications to maintain the spirit of the approach. My position is that the ecological systems theory lends itself to the dynamic sizing needed for the skillful administration of MCCs. Upon what do I base this claim? In my view, current MCC approaches are polarized into vague abstraction or rely on pre-established identity labels when what is needed is flexibility to zoom in and out. Just as the theory is neither fully macro nor micro, so too is sitting with a cultural being. Cultural conversations cannot be so distal that making it person-specific becomes unwieldly, nor can it be so proximal that the context is reduced or ignored. I have observed that the tendency towards the micro-level often makes things personal (and subsequently about comfort), and the move towards the macro-level is often done without making matters concrete. These punctuations convey what clinicians think is most important, and needlessly separate the person from culture and culture from the person. Cultural conversations are nuanced and require movement throughout all levels, and a different way is one rooted in holding the complexity simultaneously and systematically. The ecological systems framework itself could be leveraged as a tool in this regard. For example, a clinician who uses the theory to increase their MCCs may explore the following during the intake: 

  • Mesosystem: Which spaces do you spend the most time? What people, objects and symbols come to mind when you think of these spaces? 
  • Exosystem: Can you describe your typical media consumption (i.e., how often do you engage with books, television, social media, news, etc.)? Will you tell me about your favorite media as a child/today?  
  • Macrosystem: We are all impacted by factors outside of our immediate control (e.g., the economy, politics, laws, etc.). Which of these factors most influence you and your life? What cultural celebrations do you honor? 
  • Chronosystem: What stands out to you as key transitions in your life so far? Are there any world events that hold particular significance? What does it mean for you to begin therapy at this moment in your life?  

The suggested interventions are not exhaustive, and clinicians may want to align the questions with the presenting concern. For instance, if a person is seeking support for relational issues, then it may be advantageous to pose ecosystem questions related to the extended family. Nevertheless, what I hope is immediately clear is that a richer portrait of the person is formed, which does not rely on the counselor making judgments about cultural information based either on visible identity markers or preconceived knowledge. I believe this approach supports the invitation of cultural dialogue, and such an approach is crucial given the fraught landscape depicted by MCC research findings.   

Tao et al. (2015) conducted the first meta-analysis of clients’ perceptions of the therapist’s MCC and its relationship to treatment outcomes and therapeutic processes. One takeaway is that MCC and other therapeutic processes work together to produce therapeutic change. This finding left open questions about the true association between MCC and therapy outcomes and the distinctiveness of MCC. A related question in the literature on multicultural counseling is who profits most from MCC, minority clients, or clients in general? A recent study suggests that MCC is a common factor but that the working alliance is impacted by MCC, especially for racial/ethnic minorities (Bathje et al., 2022). While this information adds to previous research (Drinane et al., 2016), its methods are somewhat recursive and reductive: High cultural salience was defined only in terms of race, and it was expected that MCC would not be important for White therapist-client dyads (and subsequent surprise that MCC did indeed matter to them). This work is predicated on past findings that White-White pairs do not have cultural conversations. The question becomes: if White therapists are not having cultural conversations with White clients, how will they manage these conversations with marginalized clients?  

My argument is not to diminish the very real disparities in psychotherapy outcomes for marginalized clients. Instead, my aim is to point out the implications of limiting diversity to identity categories.  For example, the focus sometimes turns to recommendations for identity matching, which has its own consequences: more burdens for minority clinicians and lack of accountability for clinicians with majority identities. The broader problem of limiting diversity and part of my problem with the traditional MCC approach is that it easily gives way to stereotypes and takes for granted that culture is persons in context. Moving toward intersectionality is a good approach, but focusing on interactions among identity categories is a different manifestation of the same problem. The ecological systems theory resolves this conflict by exploring interactions between identity and context. Elsewhere, I explored the heterogeneity of immigrant experiences (Cassells, 2018) and interactions between poverty and place (Cassells & Evans, 2017). The same can be restated here. A racial minority client who lived most of their life in suburbia is likely different from one who lived in an urban setting or one who migrated to the United States. Clients from resource-rich environments are different from those from resource-scarce environments, even if they hold the same gender identities or sexual orientations. Failure to consider the context alongside the person leads to the erasure of key contextual information and missed points of connection. I hasten to add that genuine empathy and validation stem from entering another’s world, something that is not achieved simply by knowing about multicultural factors. 

My point is that the ecological systems approach allows multicultural content to be unconstrained. A generous interpretation of why cultural conversations may be avoided in therapy or result in microaggressions is that therapists struggle to find an entry point. A clinician with an ecologically-informed perspective would pivot to mesosystem interventions during sessions. For example: “Tell me about your neighborhood during childhood/now.” And “If you had to tell me one thing about your world, what it looks like, and what it means to you, what would that be?” I want to underline this point about neighborhoods because much can be known about an individual’s world from viewing this context (Whipple et al., 2010). Therefore, asking questions about the neighborhood is likely to generate sociocultural content that can be used to: 1) build rapport, 2) celebrate difference, 3) discuss issues of social justice, 4) externalize experiences of oppression. As mentioned earlier, the personification of MCC makes it easy for defenses to be activated in client and counselors. My rendering of the ecological systems approach aims to arm clinicians with a technique that captures the broad array of clients’ lived experiences while also minimizing the potential for resistances. Before I conclude this section, I would also like to advocate for the development of MCC measures that tap counselors’ ability to invite cultural conversations, as I believe this offers a more tangible demonstration of therapists’ MCCs. 

I turn now to the final aim of this article. By way of framing, my singular preoccupation, personally and professionally, has centered on restoring dignity and freedom to those disenfranchised by oppressive life conditions. Coming into the counseling field, I grapple with whether the therapeutic space possesses sufficient power to withstand severe social forces. Said differently, can a strong therapeutic relationship overcome hardship outside of the room? I admit to oscillating between hope and cynicism. When I am most hopeful, I am reminded of the charge set forth by Bronfenbrenner towards the end of his life and career. In his later writings, Bronfenbrenner issued several hypotheses for future testing by scholars of developmental science that are of equal relevance to psychotherapy research.  

Unlike the original formulation of his work, the bioecological systems theory and its linchpin, proximal processes, often receive less attention (see Bronfenbrenner & Morris, 2007; Bronfenbenner & Evans, 2000, for review). Bronfenbrenner and Ceci (1994) explain that proximal processes are the mechanisms through which the contributions of genetic-environmental interactions to development are actualized. We can thus account for human potential by examining an individual’s experiences with people, objects, and symbols in their immediate contexts over time. Like interactions between parent and child during play, therapy offers similar reciprocal interactions that support competencies. From this lens, psychotherapy may be characterized as a type of proximal process. As I see it, the hope of psychotherapy is that positive psychological outcomes are possible through extended interactions in a secure environment with a trusted other. However, what happens when a person leaves that secure environment and returns to an invalidating one? To state my curiosity again: To what extent are the effects of contextual factors on psychological functioning remediated by the working alliance? Let us examine Hypothesis 3: 

“If persons are exposed over extended periods of time to settings that provide developmental resources and encourage engagement in proximal processes to a degree not experienced in the other settings in their lives, then the power of proximal processes to actualize genetic potentials for developmental competence will be greater for those living in more disadvantaged and disorganized environments.” (Bronfenbrenner & Ceci,1994, p. 579). 

In what direction does this prediction go with respect to clients in harsh environments is a question worth pondering as a field. Will more or less time be needed with these clients? My worry has been that the most marginalized individuals may need long-term therapy (counter to Hypothesis 3), which may be difficult for those with limited resources (e.g., time, money, etc.). At the same time, it may be the case that the injection of positive proximal processes from therapy results in immediate gains (aligned with Hypothesis 3). To know more, research in the field needs to collect variables related to the person, process, context, and time. Though we tend to collect information on the setting in which psychotherapy takes place, information on the client’s environment (e.g., home, neighborhood) tends to be under collected.  

Other questions relevant to psychotherapy that emerge from Hypothesis 3 are:  

  • What are the physical and social environments like of those who benefit most from therapy?  
  • Do clients inhabiting harsh environments benefit more from therapy than those in less harsh environments?  
  • If we can hold the process constant (i.e., keep the therapist the same) and allow the clients’ environments to vary or remain constant, what may we learn about individuals’ differential susceptibility to therapeutic change and how much time is needed to produce change?  
  • Are clients from similar environments experiencing similar levels of change with the same therapist? And if not, what characteristics of the person and/or therapeutic alliance produce different outcomes?  

The reader may also want to consider the notion of inverse proximal processes (Merçon-Vargas et al., 2020) and what the impact of repeated microaggressions in therapy may engender. My goal is to inspire myself and other researchers in the field to imagine creative research designs that may answer the questions above and, more broadly, provide insight into the persons and conditions that contribute to therapy’s effectiveness.   

I would be remiss if I concluded without acknowledging my mentors, Drs. Gary Evans and Lorraine Maxwell, who taught me what it truly means to view humans in context. I hope this piece is useful to psychotherapists and researchers seeking to see the fullness of a person and what supports they need to promote healthy growth. 

Cite This Article

Cassells, R. (2023). Bronfenbrenner and psychotherapy: A Tale by an emerging clinician. Psychotherapy Bulletin, 58(4), 7-12.

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