Psychotherapy Bulletin

Psychotherapy Bulletin

Clinical Impact Statement: A review of the existing research on the effectiveness of multicultural competencies indicates mixed results and various limitations, and suggests the need for further research using stronger measures and real clients. Given that APA and training programs endorse multicultural competencies, it is important to conduct further research on its effectiveness using stronger measures and real clients from diverse backgrounds.

Due to changes in demographics in the United States, counselors and therapists are likely to serve clients who have a culturally diverse background. Data from the 2010 United States (U.S.) Census indicated that foreign-born individuals represented 13.3% of the U.S. population, some 42.3 million people (Colby & Ortman, 2014). In 2014, the U.S. population by race was represented by 62.2% of non-Latina/o Whites, while multiracial individuals and racial and ethnic minorities represented 37.8% (Colby & Ortman, 2014). By 2044, this percentage is expected to grow to more than 50% for racial and ethnic minorities, and by 2060, 20% of U.S. population is expected to be foreign born (Colby & Ortman, 2014).

These changes demand that counselors and therapists prepare to effectively serve the needs of these diverse populations. Although there has been growth in research and services on the health and mental health needs of racial and ethnic minorities, racial and ethnic minority populations in the U.S. suffer disproportionally from mental health disparities (Dillon et al., 2016; Holden et al., 2014; Smedley, Stith, & Nelson, 2003). The health disparities literature indicates that compared to White Americans, racial and ethnic minorities are less likely to have access to mental health services, less likely to utilize mental health services, more likely to receive lower quality mental health care, and less likely to retain treatment (Dillon et al., 2016; Holden et al., 2014). Racial and ethnic minorities are also more likely to leave treatment prematurely and less likely to seek mental health care (Holden & Xanthos, 2009). When they do seek mental health care, they are more likely to be underdiagnosed and undertreated for affective disorders, overdiagnosed and overtreated for psychotic disorders, and less likely to receive newer and more comprehensive care (Agency for Healthcare Research and Quality [, 2013; Greenberg & Rosenheck, 2003). Research has indicated that a lack of culturally competent care contributes to these disparities (Holden & Xanthos, 2009; Shim et al., 2013; van Ryn & Fu, 2003). The overall disparities in mental healthcare have been associated with a lack of cultural competency (Holden et al., 2014; Holden & Xanthos, 2009; Shim et al. 2013). Researchers and leaders in mental health care, including the American Psychological Association (APA), have recommended and mandated mental health professionals provide culturally competent care to reduce mental health disparities (APA, 2010, 2017; Arredondo et al., 1996; Sue et al., 1982).  

APA ethical principles (2010) and the American Counseling Association (ACA) Code of Ethics (2014) advise psychologists and counselors on the boundaries of competence and instructs them to only provide services to populations included in their education, training, supervised experience, consultation, study, or professional experiences. The APA (2003) has provided guidelines for multicultural education, training, research, practice, and organizational change for psychologists. Ratts, Singh, NassarMcMillan, Butler, and McCullough (2016) also developed multicultural and social justice counseling competencies that offer guidance for counselors in practice and research. These guidelines, ethical principles, and codes suggest that it is unethical for counselors and psychologists to provide services to culturally diverse populations if they have not had any education and training in multicultural competencies.

Although the need for multicultural competencies has been widely accepted and multicultural competency guidelines have been widely implemented in professional psychological organizations and training programs (Worthington, Soth-McNett, & Moreno, 2007), there is still surprisingly little empirical research (Worthington et al., 2007) that directly examines the effectiveness of multicultural competencies (MCC), and the validity of the widely used tripartite model of MCC (Sue et al., 1982). Multicultural competence, as defined by D. W. Sue (2001), is obtaining the awareness, knowledge, and skills to work with people of diverse backgrounds in an effective manner. Sue and colleagues (1982) developed the tripartite model of MCCs that include attitudes and beliefs, knowledge, and skills. They proposed that 1) culturally competent mental health providers are aware of their own beliefs, attitudes, values, and worldviews that might impact their work with their clients; 2) they have the knowledge of beliefs, attitudes, values, and worldviews that are common to the specific populations they work with; and 3) they have the skills necessary to work with diverse populations (Sue et al., 1982).

As the acceptance of MCC has grown over the last three decades, there have been many conceptual and indirect empirical research on MCC (Ridley & Shaw-Ridley, 2011; Worthington et al., 2007). However, much of the empirical MCC literature includes studies with flaws in their methodologies (Ridley & Shaw-Ridley, 2011), measures with poor validity (Kitaoka, 2005), and an overreliance on analogue studies, college student populations, and indirect measures (Worthington & Dillon, 2011; Worthington et al., 2007). The existing literature has a lack of empirical studies examining MCCs using strong measures and research design, real clients, and participants who are representative of the population at large. Below I provide a review of the existing MCC literature that demonstrates the need for additional research examining the efficacy of MCC in psychotherapy.

Multicultural Competency

Scholars and researchers have defined MCC in various ways (Cornish, Schreier, Nadkarni, Henderson Metzger, & Rodolfa, 2010). D. W. Sue, Arredondo, and McDavis (1992) defined MCC as counselors having the awareness of their own worldviews, biases, and beliefs related to racial and ethnic minorities, understanding the worldviews of individual clients, and acquiring and using culturally responsive interventions and strategies in their work with clients. According to S. Sue (1998), MCC is the ability to appreciate diverse cultures and populations, and the ability to effectively work with culturally diverse individuals. He stressed that MCC is possessing culture-specific skills needed to work effectively with clients from specific populations. Cornish and colleagues (2010) defined MCC as, “the extent to which a psychotherapist is actively engaged in the process of self-awareness, obtaining knowledge, and implementing skills in working with diverse individuals” (p. 7). Likewise, Owen, Tao, Leach, and Rodolfa (2011), focused on the behavior of the counselor, and defined MCC as “a way of doing” that evaluates the counselor’s ability to apply their multicultural awareness and knowledge in counseling (p. 274). The definitions and dimensions of MCC continue to be defined and redefined, along with models counselors can use to develop their MCCs.

Multicultural Competency Model

Similar to the definition of MCC, there are many conceptualizations of MCC. One of the most widely used and most researched models (Worthington et al., 2007) of MCCs in the literature is the tripartite model (Sue et al., 1982; Sue et al., 1992). As noted, Sue and colleagues’ (1992) conceptualization of MCCs include three dimensions: 1) beliefs and attitudes, 2) knowledge, and 3) skills (Sue et al., 1982, Sue et al., 1992). Sue and colleagues (1992) described the three dimensions of culturally competent counselors as: 1) being aware of their own values, beliefs, and worldviews, and limitations that might impact their work with a culturally different client; paying special attention to the impact ethnocentrism might have on their work with racially, ethnically, and otherwise culturally different clients; 2) making a genuine effort to understand the client’s values, beliefs, and worldviews, and how those impact the client’s life; the counselor approaches this in a nonjudgmental manner and accepts the client’s worldviews as a valid way of life; 3) and possessing the skills and interventions necessary for working with the culturally different client, as well as practicing them in their work with the particular client (Sue et al. 1982; Sue et al., 1992; S. Sue et al., 1998). For the purposes of this study, the tripartite model of MCC will be used to conceptualize MCC.

Empirical Literature

Research supports that therapist training in multicultural issues and therapist MCC may predict psychotherapy processes and outcomes. In a study that investigated clients’ perceptions of therapists and client attrition, Wade and Bernstein (1991) found that therapists who attended a culture sensitivity training received higher ratings from clients on expertness, trustworthiness, attractiveness, unconditional regard, and empathy compared to counselors who did not receive a culture sensitivity training. Clients of therapists who attended a culture sensitivity training attended more follow-up sessions and reported higher satisfaction with the therapeutic process compared to clients of therapists who did not attend a culture sensitivity training. The results of this study found that training accounted for increased client satisfaction and client attrition for both Black and White counselors, and that ethnic matching did not account for client perception of therapist MCC and psychotherapy outcomes.

In another study, Constantine (2001) found that counselors who reported higher levels of formal multicultural training rated higher on a self-report measure of empathy, and that counselors who had an integrative theoretical orientation were more likely to be rated higher on their multicultural case conceptualization ability. The use of multicultural case conceptualization ability provided assessment of demonstrated skills rather than self-reported empathy or self-reported awareness, knowledge, or skills alone (Constantine, 2001). These findings support that culture sensitivity training plays an important role in enhancing MCC and improving psychotherapy processes and outcomes (Wade & Bernstein, 1991).

In analogue studies with African American (Poston, Craine, & Atkinson, 1991; Thompson, Worthington, & Atkinson, 1994), Mexican American (Atkinson, Casas, & Abreu, 1992), Japanese American (Atkinson & Matsushita, 1991), and other Asian American clients (Gim, Atkinson, & Kim, 1991; Kim, Li, & Liang, 2002), MCC scholars have found that culturally congruent and culturally responsive verbalizations in therapy had a more positive impact on client outcomes compared to verbalizations that focus on the universality of human experiences. Kim, Li, and Liang’s (2002) study (= 78) on Asian American clients’ (recruited from undergraduate psychology and Asian American studies courses) experiences in psychotherapy showed that clients reported higher working alliance and higher therapist empathic understanding when their therapists used interventions that sought immediate resolution of problems rather than focusing on gaining insight through exploration. Clients with higher adherence to Asian values reported higher therapist MCC when therapist encouraged emotional expression rather than expression of cognitions. These results are congruent with the Asian value of favoring immediate problem resolution early in therapy and anticipating emotional needs of others for interpersonal harmony (Sue & Sue, 2012). 

A relationship between therapist MCC and psychotherapy processes and psychotherapy outcomes with actual clients has also been found. In a meta-analysis of 20 independent samples, Tao, Owen, Pace, and Imel (2015) found strong and positive effects of client perceptions of therapist MCC on important psychotherapy processes (= .58 to .72), such as therapeutic alliance, and a moderate relationship between MCCs and psychotherapy outcomes (= .29). This association between clients’ ratings of therapist MCC and psychotherapy outcomes is supported by similar findings in the empirical literature, such as the association between therapist MCC and psychotherapy processes that include working alliance, empathy, genuineness, goal consensus and collaboration, and alliance-rupture repair (e.g., Elliott, Bohart, Watson, & Greenberg, 2011; Norcross & Lambert, 2011). The strong correlations between therapist MCC and psychotherapy process suggest that the two processes might occur simultaneously. When the client perceives the therapist as multiculturally competent, the client is more likely to have a strong therapeutic alliance with the therapist (Tao et al., 2015).  

In addition to influencing perceptions of greater understanding and stronger therapeutic alliance, therapist MCC may also predict client satisfaction. Constantine’s (2002) study of clients of color (N = 112) at a college counseling center found that clients’ perceptions of their counselors’ (trainees) MCC and general counseling competencies predicted their satisfaction with treatment. Moreover, clients’ perception of their counselors’ MCC predicted satisfaction beyond the variance previously accounted for by general counseling competencies (Constantine, 2002). Constantine also found that clients’ perceptions of their counselors’ MCCs mediated the relationship between their general counseling competence and treatment satisfaction (Constantine, 2002). In a later study, Constantine (2007) examined the experience of African American clients (= 40) with White therapists (= 19) and found that clients’ perceptions of microaggressions in therapy, therapist MCC, and therapists’ general counseling competence were not significantly associated with client satisfaction. However, the results of this study did indicate that higher perceptions of microaggressions were predictive of weaker therapeutic alliance and lower ratings of MCC and general counseling competence. These findings suggest that therapist MCC is an important relational factor in therapy. 

Therapeutic Alliance

One of the most important components of psychotherapy is therapeutic alliance. Therapeutic alliance refers to the quality of relationship between the therapist and client, the therapist’s ability to engage the client and aid in effecting change in the client (Owen, Tao, Imel, Wampold, & Rodolfa, 2014). The negative impact of therapist biases and discriminatory attitudes on the therapeutic relationship and treatment outcomes are documented in several studies (e.g., Constantine, 2007; Owen et al., 2014; Owen, Tao, & Rodolfa, 2010). Owen et al. (2014) examined the therapeutic experiences of racial and ethnic minority clients (= 120) at a university counseling center to explore whether experiences of microaggressions are being addressed in therapy. They found that 53% of clients reported experiencing racial and ethnic microaggressions from their therapists, and 76% of those clients reported that the microaggressions were not addressed as part of therapy. The results indicated that clients’ perceptions of microaggression had a negative relationship with therapeutic alliance, even after controlling for clients’ psychological well-being, number of sessions, and therapist racial and ethnic identity. Furthermore, therapeutic alliance ratings were even lower for clients who experienced microaggressions, but did not discuss it with their therapists, compared to clients who experienced microaggressions and discussed it with their therapist and clients who did not experience any microaggressions.

In another study with 121 female clients and 37 therapists, Owen et al. (2010) found that female clients’ reports of gender-based microaggressions had a negative association with therapeutic alliance and therapy outcomes. The results also demonstrated that clients’ perception of a strong therapeutic alliance could have a mediating effect on the relationship between perception of microaggressions and psychotherapy outcomes. These findings suggest that therapist biases can cause ruptures in the therapeutic relationship and may impact treatment outcomes and client attrition, particularly when the ruptures are not repaired (Owen, Tao, et al., 2014; Owen et al., 2010).  

The literature on alliance and psychotherapy outcomes indicate that stronger therapeutic alliance is associated with improved outcomes (Owen, 2012; Owen, Tao, et al., 2011; Owen, Reese, Quirk, & Rodolfa, 2013; Zilcha-Mano & Errázuriz, 2015; Zilcha-Mano et al., 2015). In a study with 232 clients and 29 therapists, Owen, Imel, et al. (2011) found that clients’ ratings of microaggressions had a negative relationship with treatment outcomes. However, clients’ ratings of therapeutic alliance mediated the relationship between clients’ perceptions of microaggressions in therapy and treatment outcomes.

Meta-analyses of psychotherapy studies indicate that therapeutic alliance (Connors, Carroll, DiClemente, Longabaugh, & Donovan, 1997; Norcross, 2010) and empathy are good predictors of successful treatment outcome (Greenberg, Watson, Elliot, & Bohart, 2001). Still, therapists exhibit difficulties with accurately assessing both therapeutic alliance and empathy in clinical practice (Greenberg et al., 2001). Greenberg et al. (2001) found discrepancies in the ability to assess empathy in treatment among clients, observers, and therapists. Client’s ratings of empathy (r = .25) were the most predictive of treatment outcomes compared to observer ratings (= .23) and therapist ratings (r = .18). Thus, therapist ratings were the least predictive of treatment outcomes (Greenberg et al., 2001). Given the average premature termination rate, deterioration rate, no reliable change rate, and discrepancy between therapists’ perceptions and client perceptions, it appears that therapists’ perceptions of their effectiveness with some clients are inaccurate. This finding supports evidence from other empirical studies that found therapists are often inaccurate in their assessment of therapeutic alliance and treatment outcomes, suggesting the need for improvement in research, education, and training to enhance therapists’ ability to accurately assess therapeutic alliance and treatment progress.

Limitations in Existing MCC Research           

As the MCC literature has grown over the last three decades, scholars have raised concerns about the limitations of the empirical studies in the current literature. Limitations of MCC research include the effectiveness of existing measures, use of indirect variables to measure MCCs and psychotherapy outcome, use of self-report measures, scant inclusion of real clients, and lack of diversity in participants. These limitations suggest that findings of the MCC literature are debatable, as discussed below.

The validity of many of the existing MCC assessment instruments has been questioned (Kitaoka, 2005; Ridley & Shaw-Ridley, 2011). Research indicates that the theoretical bases of the current MCC assessment tools are questionable due to discrepancies in the factor structures (Constantine, Gloria, & Ladany, 2002; Kitaoka, 2005). Some “direct” measures use specific MCC models to assess therapist MCC by focusing on the therapists’ skills and interventions, while “indirect” measures focus on concepts related to MCC, such as engaging in microaggressions or measuring cultural humility (Tao et al., 2015). Additionally, outcome variables in MCC studies that investigate effectiveness of MCCs also use indirect measures. For example, some studies focus on treatment attrition as indicator of therapeutic change or treatment effectiveness, as well as client perception of counselor as an indicator of effective counseling (Ridley & Shaw-Ridley, 2011). Another critique of MCC measures is that some self-report measures of MCC might be assessing counselors’ self-efficacy in multicultural counseling instead of MCC (Constantine & Ladany, 2000; Ottavi, Pope-Davis, & Dings, 1994).

Several MCC assessment tools are self-report measures, which are vulnerable to social desirability. Some limitations of using self-report measures include the possible influence of social desirability, political correctness, and attitudinal and attributional biases (Worthington et al., 2007). Constantine and Ladany (2000) found that social desirability attitudes are linked with the subscales of three of the four MCC measures they investigated. The three MCC measures are the Multicultural Counseling Inventory (MCI; Sodowsky, Taffe, Gutkin, & Wise, 1994), the Multicultural Awareness-Knowledge-and-Skills Survey (MAKSS; D’Andrea, Daniels, & Heck, 1991; Kim, Cartwright, Asay, & D’Andrea, 2003), and the modified self-report version of the Cross-Cultural Counseling Inventory-Revised (CCCI-R; LaFromboise, Coleman, & Hernandez, 1991). Their study also indicates that after controlling for social desirability, there was no association between the reported MCC and multicultural case conceptualization ability (Constantine & Ladany, 2000). Due to these results, Constantine and Ladany (2000) recommend the use of social desirability measures in MCC studies that use existing self-report measures.

Another limitation of the existing literature concerns the use of analogue research. Worthington and colleagues (2007) noted that 24.7% of the studies in their meta-analysis of MCC research used analogue research (i.e., research in a laboratory setting meant to approximate reality), and 82.4% of studies that included client ratings of counselor MCCs included pseudo clients. Study participants also lack diversity as there is an overreliance of White, female, young college students and underrepresentation of real clients from racially diverse and low socioeconomic backgrounds (Worthington et al., 2007). Given that clients from diverse racial and low socioeconomic backgrounds are the biggest consumers of mental health services in the U.S. and that the preponderance of evidence indicates worse outcomes for racial minority clients compared to White clients (Holden et al., 2014), there is surprisingly little research that examines the experiences of these clients in the MCC literature. Inconsistent findings in existing studies that have examined therapist MCC and treatment outcomes are also concerning. Some studies indicate that there is a positive relationship between multicultural competencies and therapy outcomes (Atkinson & Lowe, 1995; Ponterotto, Fuertes, & Chen, 2000), while others indicate a lack of association or weak relationship between therapists’ multicultural competencies and treatment outcome (Owen, Leach, et al., 2011; Tao et al., 2015).

Although MCC have been widely endorsed and implemented in professional organizations and training programs (Constantine & Ladany, 2000; Worthington et al., 2007), there is a dearth of empirical research evaluating the influence of multicultural competencies on psychotherapy processes and outcomes with real clients (Ridley & Shaw-Ridley, 2011; Worthington et al., 2007; Worthington & Dillon, 2011). Existing multicultural competencies studies with actual clients have focused on the client’s perspective, and there is a paucity of research that includes both client and therapist perspectives on multicultural competencies, therapeutic alliance, and treatment outcomes. Due to the abovementioned limitations of current studies and difficulties of capturing components of MCC, additional empirical research on psychotherapy processes and outcomes is necessary (Ridley & Shaw-Ridley, 2011; Worthington & Dillon, 2011; Worthington et al., 2007).

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Farook, M. W. (2018). The state of multicultural counseling competencies research. Psychotherapy Bulletin, 53(4), 48-58.

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