Collaboration in Culturally Responsive Therapy

Collaboration in Culturally Responsive Therapy: Establishing A Strong Therapeutic Alliance Across Cultural Lines

Anu Asnaani, M.A. and Boston University, Boston, MA

Stefan G. Hofmann, Ph.D. Boston University, Boston, MA

Abstract Achieving effectiveness of therapeutic interventions across a diversity of patients continues to be a foremost concern of clinicians and clinical researchers alike. Further, across theoretical orientations and in all treatment modalities, therapy alliance remains a critical component to determine such favorable outcome from therapy. Yet, there remains a scarcity of empirical data testing specific features that most readily facilitate effective collaboration in a multi-cultural therapy relationship. This article reviews the literature on terminology, empirical findings, and features to enhance collaboration in multi-cultural therapy, suggesting guidelines for achieving this goal in therapy with patients (and therapists) of various cultural/racial backgrounds. This is followed by a multi-cultural case study presenting with several co-morbid Axis I disorders, to exemplify the application of these guidelines over the course of therapy.

The role of culture in psychotherapy has been gaining significant attention in the past few decades (Wohl, 1989; Seiden, 1999; Draguns, 1997), particularly as the populations seeking psychological services grow increasingly diverse. Indeed, an often prominently stated aim of training programs for mental health practitioners includes the need to ensure the cultural competency of those delivering psychological treatments (Heppner, Leong, & Gerstein, 2008). Unfortunately, often this recognized need is insufficiently met because (1) of a lack of a definitive structure and specific goals to achieve this cultural competency in therapists, and (2) scant empirical data to support one training model over another (Laungani, 2005; Whaley & Davis, 1997). This distinct gap between stated intent of incorporating cultural differences into current evidence-based treatments, and actual clear guidelines for accomplishing this goal must be more directly addressed.

Further, the importance of establishing a strong rapport with patients and developing a firm therapist-patient alliance to target emotional symptoms remains an overarching goal of the field of mental health (Taber, Leibert, & Agaskar, 2011). This article therefore aims to review the empirical literature on effective enhancement of collaboration in the multicultural therapy setting, to reveal the common and specific features across a range of treatment modalities. This is followed by a case study of an actual patient to exemplify how these features may be incorporated into treatment with a multicultural client, both in terms of establishment/maintenance of a strong working alliance during treatment, and then in healthy termination of the therapy relationship after a course of treatment.

Corresponding author for proofs and reprints: Stefan G. Hofmann, Ph.D., Department of Psychology, Boston University, 648 Beacon St., 6th floor, Boston, MA 02215, shofmann@bu.edu.

Author Note Dr. Hofmann is a paid consultant of Merck Pharmaceutical (Schering-Plough) for work unrelated to this study. This study was partially supported by NIMH grants MH-078308 and MH-081116 awarded to Dr. Hofmann and MH-73937.

NIH Public Access Author Manuscript J Clin Psychol. Author manuscript; available in PMC 2013 May 02.

Published in final edited form as: J Clin Psychol. 2012 February ; 68(2): 187–197. doi:10.1002/jclp.21829.

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Key Terms Researchers have provided several relevant working definitions within cultural therapy that are noted here. The first is culture itself, which in the currently discussed context broadly refers to a system of beliefs, perspectives, and values a group of a particular race/ethnicity or geographic region collectively share. Of course, cultural influence does not work in a vacuum, and Hays (2008) coined an acronym that serves as a reminder to clinicians about the multi-faceted nature of multi-cultural therapy (MCT) in terms of what they need to be ADDRESSING: Age and generational influences, Developmental disabilities and Disabilities obtained in later life), Religion and spiritual orientation, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender. Such a term captures the complexity of cultural identity and the number of factors to consider when we discuss the impact of cross-cultural differences in therapy.

In addition, cultural identity of an individual is tied into other key processes not noted in even this rather comprehensive acronym, such as discrimination and acculturative stress. Briefly, cultural/racial discrimination can be described as a differential treatment of an individual specifically due to certain negative beliefs about that person’s cultural/racial group membership (Karlsen & Nazroo, 2002), and has been found to be linked to negative psychological outcomes (Chou, Asnaani, & Hofmann, in press). Acculturative stress is more specific to recently immigrated individuals who are undergoing the often difficult process of acquiring and assimilating the cultural characteristics of the host country (Hwang & Ting, 2008), such that one’s own cultural identity is constantly being challenged and changed to varying degrees. Finally, a major construct that certainly influences each individual’s cultural beliefs is the idea of individualism versus collectivism, or independence versus interdependence (Markus & Kitayama, 1991). This broader concept delineates key differences between taking a collectivist/interdependent world view (i.e. that the greatest priority lies in maintaining harmony within the cultural group, and thus individual gain is deemphasized), from an individualist/independent value system (i.e. focus on individual achievement and success is deserving of the greatest social admiration/reward). Indeed, several empirical studies have found differences based on this construct in acceptability towards, and extent of, certain psychological symptoms, including social anxiety (Heinrichs et al., 2006), and depression, personality disorder features, and OCD (Caldwell-Harris & Aycicegi, 2006). Again, these are important considerations that inform our understanding of the cultural lens of patients engaging in something as personally revealing as psychological therapy.

One other concept that is of particular importance in the current discussion is that of cross- cultural competency, which provides an index of how skilled (1) a clinician feels about their abilities to manage cultural issues raised in therapy, and (2) a patient perceives the clinician to be in their ability to handle such topics in the therapeutic context (Lee, 2011). A survey of 689 APA-licensed psychologists found that while practitioners reported having discussions about cross-cultural issues, they only did this with less than half of their cross-ethnic/racial clients, although this was for a variety of verbalized reasons (Maxie & Arnold, 2006). Further, the therapists most likely to discuss cultural differences with patients were those who were older, female, of non-minority racial status, those who felt they were less experienced with treating diverse clients, and those who felt training is an important feature of effective therapy delivery. Indeed, a considerable amount of discussion has revolved around the need to develop a cultural competency in the field of cross-cultural psychotherapy (Sue, 1998; Kaweski, 2010; Taylor, Gambourg, Rivera, & Laureano, 2006). Yet, an empirical study examining the impact of the competency ratings by 143 patients of their therapists (N= 31) found no significant association between patients’ perceptions of therapist cross-cultural competency and actual therapy outcome (Owen, Leach, Wampold, &

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Rodolfa, 2010). Such a finding indicates that the process is likely to be more complex than simply providing superficial mention of cultural issues during therapy, or clinicians’ degree of experience with diverse patients. Other experts in cross-cultural treatment have noted that simply instructing clinicians to simply be sensitive to cultural differences or to familiarize themselves with the culture-specific norms of clients is insufficient and not particularly beneficial (Sue & Zane, 2009). Given this inconsistency in the literature on the impact of cultural competency on outcome, there needs to be a more systematic empirical study of this concept across a diversity of populations.

Empirical Data Identifying Specific Features While differential rates in report and diagnosis of certain disorders across race-ethnic groups in the United States have been noted in several large-scale epidemiological studies (Grant et al., 2005a,b; Pole et al., 2008; Asnaani, Richey, Dimaite, Hinton, & Hofmann, 2010), the empirical data in the efficacy and structure of culturally responsive therapy is still limited. One meta-analysis examining a mix of 65 experimental and quasi-experimental studies (which included 8, 620 participants) revealed a modest effect size (d = 0.46) in favor of culturally-adapted treatments for clients of color as compared to traditional treatment procedures (Smith, Rodriguez, & Bernal, 2011). Further, results indicated that when mental health treatments were designed targeting one particular cultural group in mind, these treatments outperformed other treatments serving patients from a variety of cultural backgrounds. Such findings highlight two needs: (1) more rigorous, stricter treatment designs to fully examine the relative benefit of culturally-specific treatments, and (2) more systematic research into the specific components of culturally-sensitive therapy that predict maximal benefit to clients. While both of these needs are recognized by proponents of culturally-responsive psychotherapy, there have been a reasonable number of smaller qualitative studies on specific aspects of multicultural therapy. Such studies provide rich insight into the factors that clinicians are advised to consider when engaging in therapy with clients of varying cultural backgrounds, and preliminary directions for most robust, experimental study designs.

One study by Tsang, Bogo, & Lee (2011) analyzed the session transcript data of nine cases from pre- to post-treatment. Complex coding procedures from a narrative research perspective were supplemented by the information provided on various process and symptom measures (which were both subjective and objective in nature). The analysis revealed that therapists who actively and positively engaged in cross-cultural conversations during therapy more effectively expressed an understanding of what the patient’s goals and needs in therapy were, appeared more emotionally in-tune with clients, and demonstrated appropriate management of cultural experiences raised by the client.

Another qualitative study investigated the impact of how practitioners from a dynamic or relational treatment perspective addressed cultural issues with clients on the strength of the treatment alliance (Lee, 2009). The therapists in this study consisted of 4 white clinicians, and the content of their therapy sessions with 6 minority patients were analyzed using Conversation Analysis and Structural Analysis of Social Behavior. The study results revealed that therapists’ specific interactions during cross-cultural discussions were associated with the Bond subscale of the Working Alliance Inventory-Short Revised (WAI- SR; Hatcher & Gillaspy, 2006), which measures the interpersonal connection shared between clinician and patient. There was no significant association between these moment- by-moment interactions and the other two main subscales, i.e. extent of agreement on the target of treatment (Goals subscale) or degree of agreement on what needs to be done specifically to achieve these goals (Tasks subscale). Again, it appears that cultural congruence between client and therapist plays a role in enhancing the moment-to-moment

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collaboration and alliance of the therapeutic relationship. Such a finding further points to the need to incorporate cross-cultural features explicitly into treatment to facilitate the therapy relationship, regardless of treatment modality.

Features of Effective Collaboration in Multicultural Therapy Taken together, the empirical and observational findings discussed thus far reveal several data-driven guidelines and hypotheses about how therapists’ cross-cultural competency may be improved, and how the therapeutic bond may be most strengthened in a cross-cultural therapy setting. In addition, there are several other cross-cultural models examining the establishment of a strong working alliance, which are themselves grounded in existing evidence-based research findings (e.g., Hays, 2009; Fontes, 2008; Sue & Zane, 2009). The common features and themes as gleaned from these various sources are integrated to produce the following guidelines for practitioners.

Guideline #1: Conduct a thorough culturally-informed but person-specific functional assessment of presenting problem

Before modifying an existing treatment to be more culturally sensitive, therapists should fully assess how much of the individual patient’s presenting problems may be interlinked to his or her cultural identity/related constructs. That is, clinicians must be wary of premature adoption of a modified treatment simply because an individual is from a particular cultural group (Sue & Zane, 2009). All patients must still be regarded as unique individuals who lie on a more dynamic spectrum of cultural identification, and cultural groups must be seen as heterogeneous populations with some more or less likely dominant themes. Related to this, before engaging in any adaptation of existing treatment techniques, there must be adequate information gathered about how cultural beliefs are specifically shaping or maintaining problematic emotional symptoms. A clinician should not make blanket assumptions about how a specific cultural belief introduced by patients informs their experience of distress. After a comprehensive functional assessment of the patient’s problems, the clinician can consider the remaining guidelines.

Guideline #2: Engage in self-education about specific cultural norms and consult the literature for culture-specific treatment techniques

As the meta-analytic findings by Smith and colleagues (2011) would indicate, patients might most benefit from treatments that have been specifically modified for a certain population rather than more generally culture-sensitive treatment techniques. As mentioned earlier, it is imperative that as we embark on cross-cultural therapy that we stay as close to the empirical data to guide us about effective treatments with different populations. Therapists should therefore first refer to the literature about whether specific cultural adaptations of existing treatments have already been tested and validated (e.g. Latinos: Borrego, 2010; Native Americans: BigFoot & Schmidt, 2009; East Asians: Hwang, Wood, Lin & Cheung, 2006; Southeast Asians: Otto & Hinton, 2006; African Americans: Kelly, 2006). Further, such a review of the literature will enlighten the therapist on what beliefs are the norm of that culture to reduce miscommunication in therapy, and will garner patient confidence in the therapist’s abilities and knowledge.

Guideline #3: Ensure adequate and effective training of therapists in cross-cultural competency

While the literature is mixed (e.g. Owen et al., 2010), there is some evidence that patients’ perceptions of how culturally competent the provider is can affect the working alliance (Maxie & Arnold, 2006). Also, it is clear that cross-cultural therapy is a complex and multi- layered process, and therefore ensuring cultural competency in mental health work is not

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simple for trainees to undergo. It is therefore obviously not enough to assume that garnering cross-cultural competency is just a matter of educating oneself about cultural differences between therapist and client (Sue & Zane, 2009). Rather, others have suggested that therapists need to have a keen awareness of their own cultural and racial identity, and how this may impact their relationship with clients (Plummer, 1997). For instance, multicultural researchers have noted the importance of having practitioners discuss their feelings about treating cross-cultural patients with their professional peers or supervisors (Barbarin, 1984), and exploring attitudes toward psychological help-seeking in their own communities (Chung & Lu, 1996). Such a reflection is indicative of an appreciation for the bidirectional influence of culture in a therapy interaction, to facilitate a healthy dialogue about sensitive cross- cultural topics that might arise during treatment.

Guideline #4: Explore the patient’s perspective on both seeking psychological treatment, and the nature of the therapeutic relationship

There have been observed differences in perceptions of obtaining mental health treatment among minority groups, and empirical evidence for the distinctly higher stigma associated with obtaining psychological help in a number of minority cultures (Shea & Yeh, 2008; Alvidrez & Azocar, 1999). Therefore, it may become necessary to first address the stigma around receiving such treatment, particularly assessing for the impacts of this on the individual’s sociocultural network. For instance, an individual identifying with predominantly collectivist or interdependent cultural values may regard the need for therapy as a sign of weakness and embarrassment to one’s family or community (Furukawa & Hunt, 2011), and this topic must be made explicit, particularly if treatment progress or adherence becomes stalled. In addition, giving validation and respect for the client’s perspective on mental health treatment will further enhance clinician-patient trust and bolster the therapeutic bond.

A related matter is being aware of the preference for a preconceived ideal of an appropriate relationship between the client and clinician. Specifically, most treatment perspectives in the West emphasize a collaborative therapeutic relationship (Taber et al., 2011), but this might be isolating or confusing to individuals from certain cultural backgrounds. In fact, individuals identifying with cultures which are hierarchy-based (e.g., Eastern cultures) might expect a more directive, authoritarian approach in the therapy relationship (Tsui, 1985), and an over-emphasis on an equal therapist-patient relationship and socratic, open-ended questioning might raise doubt in the patient about the therapist’s capabilities to treat the problem at hand. On the other hand, certain treatment perspectives (e.g. CBT) involve a considerable amount of direct questioning, which might be construed as disrespectful in other cultures (such as Native Americans, and older European Americans; Hays, 2009). Such considerations serve as a reminder of the importance of thorough initial assessment of an individual’s cultural beliefs and influences, to prevent an early rupture in the therapeutic alliance.

Guideline #5: Be aware of the importance of respect in the cross-cultural therapy setting Clinicians engaging in multi-cultural therapy must set an overarching tone of respect in order to meet the goals of therapy collaboratively with the client. This means allowing individuals to fully express their individual stories and to explain how their cultural beliefs have been uniquely part of this story (Coronado & Peake, 1992). Furthermore, establishing trust in the therapy relationship is intricately interconnected to the level of respect shared between the client and therapist. To that end, it is important that therapists validate the client’s experiences, including encounters with cultural or racial discrimination, and possible oppression in the majority culture. Patients want to feel believed and therefore clinicians are advised to assume the reported incident occurred just as it was described by the patient, to

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provide support around such an experience, and then to later examine how much that experience has influenced the current symptoms of interest (Kelly, 2006). Aligning oneself with patients by demonstrating full support for the difficult race- or culture-related stressors they may be facing will mitigate hesitation in discussing such sensitive issues with the therapist (Vasquez, 2007).

Guideline #6: Identify and incorporate client’s culturally-related strengths and resources into treatment

One general guideline across contemporary models of psychotherapy refers to an exploration of individual strengths in order to enhance treatment success and adherence, and this can be taken one step further in MCT. For instance, the identified culture itself can be a major resource and provide an extensive support network for the client (Cross, 2003). Also, culture itself influences a range of culture-specific skills (e.g. naturalistic medicinal knowledge, cooking, fishing, farming, etc.), coping mechanisms (e.g. culture-specific metaphors for understanding emotional symptoms; Hinton, Lewis-Fernandez, & Pollack, 2009), interpersonal organizations and community resources (culturally-oriented political or social causes, places for worship, or financial resources), and artistic outlets for emotion (through dance, art, and music; Hays, 2007).

Thus, it is important to bring these culture-influenced strengths of the individual to the therapy discussion, particularly if these positive attributes may be incorporated into treatment techniques and practice. Hays (2009) astutely notes, however, that certain cultures (e.g. Asians & Native Americans) are culturally socialized to be modest about individual strengths, and therefore these might not be easily verbalized if such individuals are directly questioned about their own strengths. It is therefore suggested that individuals from this more interdependent cultural set-up be asked to think what other significant individuals in their lives might say the strengths of the patient are, in order to access this information and incorporate it into the therapeutic relationship more readily.

Guideline #7: Identify and utilize technique-specific cultural modifications Finally, as clinicians and clinical researchers, our foremost concern in mental health treatment is ensuring adequate delivery of treatment techniques that will result in noticeable improvement in our clients’ symptoms. Therefore, while it is reasonable to utilize treatment techniques that have been seen to be efficacious, we must be ready to modify these techniques in a culturally-sensitive fashion. Again, it is ideal to make cultural modifications that have been validated in the population of interest, but in the absence of definitive empirical evidence for all possible modifications, we must use our cross-cultural knowledge to make reasonable changes to effective techniques. For instance, in the CBT framework, we often ask clients to question the validity or reasonableness of a particular negative automatic thought, but this might be regarded as uncaring on the part of the therapist, and places negative judgment on the client’s belief system (Wood & Mallinckrodt, 1990). The therapist might choose instead to take a more culturally responsive approach (Beck, 2005) and ask clients to question the utility or helpfulness of the thought, encouraging them to weigh out the pros and cons of holding on to this belief. Similarly, CBT often leads to an eventual challenging of core (negative) beliefs that a patient holds about themselves or the world. Therapists must be cautious of directing patients to challenge their core cultural beliefs, even if a particular belief of the client seems incongruent or problematic within the therapist’s own cultural value system.

With these guidelines in mind, the next section describes a case treated by one of the authors (AA) and highlights the practical use of these techniques throughout the treatment episode.

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The influence of these culturally-responsive directives are demonstrated in the progressive development of a strong working alliance in the following clinical case study.

Application of Alliance-Building Techniques: The Case of Karen1

Karen was a 37-year-old Jamaican-American female and a single mother of 3 teenage-age children, who had recently lost her job due to a change in ownership at her medical insurance firm. Karen presented to our cognitive-behavioral treatment (CBT) clinic with a primary diagnosis of panic disorder with significant agoraphobia, and additional diagnoses of obsessive-compulsive disorder and generalized anxiety disorder. She had also had a past history of major depression and post-traumatic stress disorder from chronic and multiple traumatic experiences. Karen had pursued significant prior treatment, but with little relief in her ongoing anxiety symptoms.

She had decided to pursue treatment at our clinic because she had read about the efficacy of CBT for treatment of various anxiety symptoms. She also hoped that the more structured and short-term nature of this type of treatment might help her develop a more healthy attachment to her provider, which had been difficult in the past. It therefore became apparent from early on in treatment that one therapy goal would have to be to effectively develop a strong working alliance while balancing reasonable boundaries to keep the purpose of the therapeutic relationship clear. This goal was explicitly stated from the outset, and framed as being in the best interest of both the patient’s progress and to maintain treatment fidelity and effectiveness. However, it was recognized that much of Karen’s current support system lay in the familiarity of relationships in her religious and ethnic community, therefore it might take some time for her to feel comfortable with a more formalized and boundary-imposed relationship with her therapist.

Guideline #1: Conduct a thorough culturally-informed but person-specific functional assessment of presenting problem

The primary aim in the first several sessions was to fully explore the role of cultural beliefs in the development and maintenance of Karen’s symptoms. Within the first session itself, Karen expressed her strong religious belief and heavy involvement in church. Related to this, it was clear that Karen received many negative messages from her children, mother, and church friends about both her experience of panic-symptoms, and her decision to receive “outside” (i.e. outside of the Caribbean American community) psychological help. This did not deter Karen from seeking treatment, but through therapist exploration, Karen admitted that this certainly fueled her own negative beliefs about being different from everyone around her and made her feel discouraged about ever becoming better. She also felt depressed about not being able to “kick these symptoms” on her own simply through prayer and faith as others suggested, and felt like a failure about this perceived deficiency.

With these larger cultural themes in mind, the therapy content started focusing on specific anxiety symptoms, and explored how culture infused her psychological symptoms in more detail. For instance, Karen reported that her obsessive thoughts about being poisoned by others (which would result in avoidance of eating or drinking items given to her by others at their homes, or in other settings outside her own home) stemmed from a strong belief in black magic, and that others were trying to harm her out of jealousy and control by

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