MULTICULTURAL EVIDENCE-BASED PRACTICE

MULTICULTURAL EVIDENCE-BASED PRACTICE

Chapter Objectives

1. Become familiar with the role and importance of using research to determine what therapy treatment is best suited for diverse clients.

2. Define empirically supported treatments (ESTs).

3. Know the rationale for the development of empirically supported relationships (ESRs). Be able to describe the relationship variables that are considered to be research supported.

4. Become aware of how evidence-based practice (EBP) and multicultural counseling are converging.

5. Describe the modifications that need to be made in the counseling alliance (empathy and relationship building) to work with different ethnic groups.

6. Describe how EBP differs from ESTs and ESRs. Be able to outline the advantages of focusing on client values and preferences.

7. Describe similarities and differences between EBP and cultural competence.

8. Become cognizant of the advantages and disadvantages of using “culturally adapted” forms of research-based psychotherapies.

Case Study

Hajimi Matsumoto

Hajimi was a first-generation, 18-year-old, Japanese American male who lived most of his life in Japan before returning to the United States. He came to the university counseling center suffering from a severe social phobia. I was a White American female psychology intern being supervised by Dr. Katsumoto, a female Japanese American staff psychologist known for her work on multicultural psychology and cultural competence. I had seen the client, Hajimi, for approximately six sessions. Hajimi was an extremely shy young man who spoke in a barely audible voice, responded in short but polite statements, avoided eye contact, and sat facing my window rather than me. When I first met him, he would not shake my hand but simply nodded his head in acknowledgment. He fidgeted in his seat and seemed extremely uncomfortable in my presence. He described high anxiety in social or performance situations and was extremely nervous around women. He was afraid of being belittled by others, didn’t know how to make “small talk,” and constantly obsessed as to whether his personal hygiene (bad breath or body odor) might be offensive. Yet on none of his visits to my office did I detect any sort of strong or disagreeable odor.

Hajimi was referred to the counseling center by one of his professors after a particularly embarrassing and humiliating situation that occurred in the classroom: He “froze” in front of fellow students while doing a team oral presentation. Despite having detailed notes, he stammered, stuttered, and broke out in a profuse sweat that made it impossible to continue. When one of his female classmates on the team tried to offer support by placing her arm on his shoulder, Hajimi felt sure she could feel the perspiration on his shirt and panicked. He became embarrassed, broke away from her, quickly excused himself, and left the classroom. Apparently, these types of anxiety-provoking situations and encounters were very common in his life.

As all interns needed to take responsibility for making a client presentation at bimonthly case conference meetings, I chose to present my client, Hajimi. Case conferences are usually attended by staff psychologists, student interns, and the consulting psychiatrist. The psychiatrist, Dr. Machovitch, a White male at the medical school, was known for his psychodynamic orientation, whereas most of the psychologists at the center had either a multicultural or behavioral approach. After I had provided a detailed history of Hajimi including his symptoms and possible etiological factors, and offered a proposed treatment plan, a clear difference of opinion began to emerge between Drs. Machovitch and Katsumoto and another psychologist, Dr. Barnard. The three had quite a heated exchange, and I felt caught in the middle because they each recommended a different approach. Further, they all differed in their analysis and diagnosis of the problem.

Client Background:

Hajimi was the only son of a traditional Japanese couple who had wanted many more children but for unknown reasons could not conceive any others. All their hopes for carrying on the family name resided in Hajimi. When Hajimi was first born, the parents were overjoyed to have a son, but as time wore on, the father became disappointed in his son’s effeminate behavior, hypersensitivity, inability to control his emotions, and social-outcast role among classmates. The father belittled him, seemed to be ashamed to introduce Hajimi to friends, and isolated him from family gatherings. Whenever Hajimi would do something wrong and show remorse by crying, his father would say in Japanese, “Leave me, you offend me.” The mother, who was more sympathetic to Hajimi’s needs, nevertheless seldom intervened when her husband berated Hajimi almost on a daily basis. On one particularly angry encounter in which his father severely criticized him, Hajimi wept openly in front of his mother. His mother tried to console him by placing her arms around his shoulder and reassuring him that one day his father would be proud of him. Rather than being comforted, however, her actions seemed to cause further distress as he quickly ran to his bedroom and slammed the door.

Although Hajimi had done well academically in his early years, his grades began to suffer in college. Much of this was due to his severe social phobia, which affected his ability to speak up in classes and isolated him from fellow students and teachers. He was awkward and inept in social situations, became anxious around people, and would seldom speak. In his physical education classes, which required dancing with girls, he would panic and perspire freely. He felt embarrassed to touch the hands of his partner or to have them touch him for fear they would find his wet hands and clothes offensive. Hajimi often expressed his belief that he was not perfect enough. In school, he became increasingly obsessed with avoiding failure, playing it safe, and not making mistakes. Unfortunately, this approach had a negative impact on his academic work, as he would often take incompletes and withdraw from classes for fear that he was not doing well. He would frequently choose a college course on the basis of whether it offered a pass/no pass option. Hajimi admitted to an intense fear of failure and was aware that these choices allowed him to temporarily avoid poor grades. He knew that failing grades generated only greater criticism from his father.

Theoretical Differences

The disagreement among the three therapists as to the diagnosis and treatment of Hajimi appeared tied to their theoretical orientations and/or their clinical experiences. Dr. Katsumoto stressed cultural factors, whereas Dr. Machovitch believed a psychodynamic approach was clearly indicated in work with Hajimi. The discussion was compounded by Dr. Barnard, a male psychologist with a strong cognitive-behavioral orientation who argued for a behavioral program of assertiveness training and systematic desensitization of his social phobia. The gist of their positions can be captured in the following snapshots of their arguments.

Dr. Katsumoto (Cultural Analysis):

Sociodemographic factors such as race, culture, and ethnicity are important in understanding Hajimi’s difficulties. Many of the behaviors exhibited by him may be cultural dictates rather than pathology. For example, his behavior in the counseling session (lack of eye contact, low tone of voice, short but polite responses, and social distance) with the counselor may not be considered pathological in Japanese culture. Although I do believe he suffers from psychological problems, the diagnosis of social phobia may be inaccurate and lead to an inappropriate treatment plan. Even DSM-5 recognizes the existence of cultural syndromes, which are locality-specific patterns of aberrant behavior not linked to a specific DSM diagnosis. For example, in Japan and Korea, there is a condition called ‘taijin kyofusho’ that resembles a social phobia, which is accompanied by an intense fear that the person’s body, its parts, or its functions displease or are offensive to people. It is often manifested in a fear that one’s body odor may prove interpersonally repulsive. This psychological problem is actually listed in the Japanese manual of mental disorders. My suggestion would be to explore the possible adaptation of indigenous methods of treatment found effective in Japan. Although he is an American citizen, I believe he is more Japanese than Japanese American.

Dr. Machovitch (Psychodynamic Analysis):

Hajimi’s social phobia is caused by a deep-seated underlying childhood conflict with his parents. The phobia is a symptom and symbolic of unresolved Oedipal feelings toward both parents that are reenacted in almost all his social relationships. His strong need for social approval from his father, his feelings of hostility toward him, and an intense fear of the father (fear of castration) make him uncomfortable and anxious around men and especially around authority figures. His unresolved oedipal relationship with his mother has impaired his ability to relate to members of the opposite sex and has contributed to his anxiety in developing intimacy with others. Note his intense feelings of anxiety around women and his overreaction to being touched by them.

As a female therapist [reference to me as the intern], you probably evoke this conflict as well. I believe that Hajimi, at crucial psychosexual stages, did not receive the love and care a child needs to develop into a healthy adult. He was neglected, rejected, and maternally/paternally isolated, a condition that symbolized all his social relationships. Because he felt unloved and worthless, Hajimi reenacts his pathological relationship with his parents in other social situations. Note, for example, the symbolic relationship between the father’s repetitive declarations that Hajimi is ‘offensive, ‘ and Hajimi’s fear that he will offend others; similar reactions to attempts by his mother and female classmate to comfort him; avoidance of being touched; and many other symbolic parallels. My suggestion is to deal with Hajimi’s transference neurosis through an insight process so that he may be able to distinguish the pathological relationships of the past with the healthy ones he encounters now.

Dr. Barnard (Cognitive-Behavioral Analysis):

All of these explanations appear well and good, but the ultimate test of therapeutic effectiveness must be guided by the research literature. Work on empirically supported treatments suggests that cognitive-behavioral approaches have been shown to be most effective in the treatment of phobias. Although culture is important and a psychodynamic explanation seems appealing, we should be ethically obligated to select the treatment based upon what research has shown works. Describing the client’s problems in measurable and specific terms rather than abstract concepts will ultimately lead to a better treatment plan. For example, the roots of Hajimi’s problems can be traced to his behavioral repertoire. Many of the behaviors he has learned are inappropriate, and his repertoire lacks useful, productive social skills. He has little practice in social relationships, lacks good role models, and has difficulty distinguishing between appropriate and inappropriate behaviors.

In addition, his constant belittlement by his father has probably created in his mind an irrational belief system that leads him to distort or misinterpret events: Others will reject him, he is worthless, and he will offend others. Much of this, no doubt, comes from the father’s constant criticisms and belittlement. This leads Hajimi to believe that he is ‘worthless’ and will always be worthless. I believe that a program of assertiveness training, systematic desensitization, and relaxation exercises will help him immensely to develop social skills and to combat his high performance and interpersonal anxieties. Further, I would supplement his behavioral program with a cognitive treatment plan that (a) identifies irrational thinking and beliefs, (b) teaches him cognitive restructuring methods to combat them, and (c) replaces them with positive and more realistic self-appraisals. If you look at the research literature on treating social phobias, you cannot deny their effectiveness in treating this type of disorder.

Reflection and Discussion Questions

1. Before you continue reading, reflect upon what you believe to be the source of Hajimi’s problems. What is causing him to be so anxious around people? What role do his parents play in the manifestation of his disorder?

2. How would you characterize your therapeutic orientation, and can you apply it to this case? Do your classmates and fellow peers offer different explanations? How would you work with Hajimi? Can you be specific in describing your treatment plan?

3. Are you knowledgeable about what research has shown about treating the type of disorder exhibited by Hajimi? How would you go about finding the information?

4. What role do you believe culture plays in Hajimi’s problems?

The case of Hajimi and the three differing treatment perspectives raises important therapeutic issues that have literally spawned the movement toward evidence-based practice (EBP).

First, after careful assessment of the presenting problem and related factors, how do counselors decide on the most appropriate treatment for individuals from different ethnic groups? Indeed, this question is relevant to all groups regardless of race, culture, or ethnicity. Certainly, Drs. Katsumoto, Machovitch, and Barnard make important points, and their diagnosis, assessment, and treatment recommendations seem to make sense from their theoretical orientations. Because this text is about multicultural counseling, you might mistakenly assume that we will take the side of Dr. Katsumoto because she offers a perspective that we have emphasized throughout the text. As indicated in Chapter 2, however, it is entirely possible that all three perspectives may be right, but they may be limited in how they view the totality of the human condition. The cultural perspective views Hajimi as a cultural being, the psychodynamic perspective views him as a historical-developmental being, and the cognitive-behavioral approach views him as a behaving-and-thinking being (Ivey, Ivey, & Zalaquett, 2014). As we have emphasized throughout, we are all of these and more.

Second, historically therapeutic strategies used in treatment were often based on (a) the clinician’s specific therapeutic orientation (à la Drs. Katsumoto, Machovitch, and Barnard), (b) ideas shared by “experts” in psychotherapy, or (c) “clinical intuition and experience” derived from years of work with clients. These approaches are problematic because there are countless “experts” and, at last count, some 400 schools of psychotherapy, each purporting that their techniques are valid (Corey, 2013); moreover, treatment is often implemented without questioning the relevance or appropriateness of a particular technique or approach for a specific client. Furthermore, reliance on clinical “intuition” to guide one’s therapeutic approach can result in ineffective treatment. Thus it appears that the choice of a treatment plan is dictated by one’s theoretical orientation, expert opinion, and/or clinical intuition. In other words, different mental health professionals may differ significantly from one another in how they conceptualize and treat a problem of the client. Given these points, who are we to believe and how do we resolve this problem?

Third, this question has propelled the field of mental health practice, including multicultural counseling/therapy, to consider the role of science and research in the treatment of mental disorders (Morales & Norcross, 2010). Of the three analyses given, Dr. Barnard brings up the issue of using the research literature to guide us in the choice of intervention techniques. Yet he offers a seemingly flawed culture-free or neutral interpretation of empirically supported treatments (ESTs), an issue we address shortly. Nevertheless, Dr. Barnard does raise very important questions for the field of multicultural counseling and therapy to consider. How important is it for counselors to be aware of and to utilize interventions that have research support? What interventions have been demonstrated in research to be effective for treating mental disorders? Has research on EBP been conducted on racial/ethnic minority groups, or is it simply for members of the majority culture (D. W. Sue, 2015)? To help answer these questions, we consider the evolution of ESTs, empirically supported relationships (ESRs), and EBP as they apply to diverse populations.

Evidence-Based Practice (EBP) and Multiculturalism

The importance of EBP is becoming increasingly accepted in the field of multicultural counseling. Discussions of EBP originally focused on research-supported therapies for specific disorders, but the dialogue has now broadened to include clinical expertise, including “understanding the influence of individual and cultural differences on treatment” and the importance of considering client “characteristics, culture, and preferences in assessment, treatment plans, and therapeutic outcome” (American Psychological Association, Presidential Task Force on Evidence-Based Practice, 2006). In an article titled “Evidence-Based Practices with Ethnic Minorities: Strange Bedfellows No More,” Morales and Norcross (2010) describe how multiculturalism and evidence-based treatment (EBT), two forces that were “inexorable” and “separate” are now converging and how they can complement each other. The authors state: “Multiculturalism without strong research risks becoming an empty political value, and EBT without cultural sensitivity risks irrelevancy” (p. 823).

Although the authors are optimistic about the convergence of these forces, there is still resistance to EBP among some individuals within the field of multicultural counseling (Wendt, Gone, & Nagata, 2015; D. W. Sue, 2015). As BigFoot and Schmidt (2010) note, “Historically, government and social service organization utilization of nonadapted or poorly adapted mental health treatments with diverse populations has led to widespread distrust and reluctance in such populations to seek mental health services” (p. 849). Conflicts often exist between the values espoused in conventional psychotherapy and the cultural values and beliefs of ethnic minorities (Lau, Fung, & Yung, 2010; Nagayama-Hall, 2001). As we have discussed in previous chapters, Western approaches to psychological treatment are often based on individualistic value systems instead of on the interdependent values found in many ethnic minority communities. Additionally, conventional therapies often ignore cultural influences, disregard spiritual and other healing processes, and pathologize the behavior and values of ethnic minorities and other diverse groups (S. Sue, Zane, Nagayama-Hall, & Berger, 2009).

It is apparent that conventional delivery of Western-based therapies may not be meeting the needs of many individuals from ethnic and other cultural minorities. These groups tend to underutilize mental health services (Thurston & Phares, 2008) and are more likely to attend fewer sessions or drop out of therapy sooner, compared with their White counterparts (Fortuna, Alegria, & Gao, 2010; Lester, Resick, Young-Xu, & Artz, 2010; Triffleman & Pole, 2010). Unfortunately, research on the effectiveness of empirically supported therapies for ethnic minorities is limited, as these groups are often not included or specifically identified in research investigations of particular treatments.

Although questions remain regarding the validity of evidence-based approaches for ethnic minority populations and other diverse populations (Bernal & Sáez-Santiago, 2006), we believe that EBPs offer an opportunity for infusing multicultural and diversity sensitivity into psychotherapy. In addition, all mental health professions (psychiatry, social work, clinical psychology, and counseling) now espouse the view that treatment should have a research base. Evidence-based interventions are increasingly promoted in social work (Bledsoe et al., 2007; Gibbs & Gambrill, 2002), school psychology (Kratochwill, 2002), clinical psychology (Deegear & Lawson, 2003), counseling (American Counseling Association, 2014; Chwalisz, 2001), and psychiatry.

In this chapter we will discuss the evolution of EBP, the integration of EST and ESR variables into multicultural counseling, and the relevance of enhancing cultural elements in therapy. We will also show how culturally sensitive strategies can become an important component of EBPs.

Empirically Supported Treatment (EST)

The concept of ESTs was popularized when the American Psychological Association began promoting the use of “validated” or research-supported treatments—specific treatments confirmed as effective for specific disorders. Not only were ESTs seen as an effective response to concerns about the use of unsupported techniques and psychotherapies, but they also address the issue of unintended harm that can result from ineffective or hazardous treatments (Lilienfeld, 2007; Wendt, Gone & Nagata, 2015). ESTs typically involve a very specific treatment protocol for specific disorders. Because variability among therapists might produce error variance in research studies and because it is important for ESTs to be easily replicable as originally designed, ESTs are conducted using manuals.

According to the guidelines of the task force charged with defining and identifying ESTs (Chambless & Hollon, 1998), they must demonstrate (a) superiority to a placebo in two or more methodologically rigorous, controlled studies, (b) equivalence to a well-established treatment in several rigorous and independent controlled studies, usually randomized controlled trials, or (c) efficacy in a large series of single-case controlled designs (i.e., within-subjects designs that systematically compare the effects of a treatment with those of a control condition).

ESTs have been identified for anxiety, depressive, and stress-related disorders; obesity and eating disorders; severe mental conditions such as schizophrenia and bipolar disorder; substance abuse and dependence; childhood disorders; and borderline personality disorder. Several hundred different manualized treatments are listed as empirically supported (Chambless & Ollendick, 2001; Society of Clinical Psychology, 2011). (See Table 9.1 for a few examples of empirically supported therapies.)

TABLE 9.1 Examples of Empirically Supported Treatments (ESTs)

Source: Chambless & Hollon (1998).

“Well-Established” Treatments “Probably Efficacious” Treatments
Cognitive-behavioral therapy for panic disorder Cognitive therapy for obsessive-compulsive disorder (OCD)
Exposure/guided mastery for specific phobias Exposure treatment for posttraumatic stress disorder (PTSD)
Cognitive therapy for depression Brief dynamic therapy for depression
Cognitive-behavioral therapy for bulimia Interpersonal therapy for bulimia
Cognitive-behavioral relapse prevention for cocaine dependence Brief dynamic therapy for opiate dependence
Behavior therapy for headache Reminiscence therapy for geriatrics patients
Behavioral marital therapy Emotionally focused couples therapy

Additionally, the American Psychological Association has developed a list of ESTs and practice guidelines for ethnic minorities (American Psychological Association, 1993); women and girls (American Psychological Association, 2007); older adults (American Psychological Association, 2014); and lesbian, gay, and bisexual clients (American Psychological Association, 2012). These guidelines can be consulted and modified, if necessary, in working with clients from these groups.

The rationale behind the establishment of ESTs is admirable; we believe that decisions regarding treatment approaches for particular issues or disorders should be based on research findings rather than on idiosyncratic, personal beliefs or sketchy theories. We owe it to our clients to provide them with treatment that has demonstrated efficacy. However, it is our contention that relying only on manualized treatment methods, albeit research-supported approaches, is insufficient with many clients and many mental health problems (D. W. Sue, 2015). Additionally, most ESTs have not been specifically demonstrated to be effective with ethnic minorities or other diverse populations. The shortcomings of the EST approach are summarized here:

· Owing to the focus on choosing treatment based on the specific disorder, contextual, cultural, and other environmental influences are not adequately considered (D. W. Sue, 2015).

· The validity of ESTs for minority group members is often questionable because these groups are not included in many clinical trials (Bernal & Sáez-Santiago, 2006; S. Sue et al., 2006).

· The importance of the therapist–client relationship is not adequately acknowledged. A number of studies have found that therapist effects contribute significantly to the outcome of psychotherapy. In many cases, these effects exceed those produced by specific techniques (Wampold, 2001).

· Too much emphasis is placed on randomized controlled trials versus other forms of research, such as qualitative research designs.

When treating clients with specific disorders, multicultural therapists have had the choice of ignoring ESTs or adapting them. Increasingly, there have been attempts to develop “cultural adaptations” of certain ESTs. For example, Organista (2000) made the following modifications to empirically supported cognitive-behavioral strategies when working with low-income Latinos suffering from depression:

1. Engagement strategies. Recognizing the importance of personalismo (the value of personal relationships), initial sessions are devoted to relationship building. Time is allotted for presentaciones(introductions), during which personal information is exchanged between counselor and client and issues that may affect ethnic minorities, such as acculturation difficulties, culture shock, and discrimination, are discussed.

2. Activity schedules. In the treatment of depression, a common recommendation is for clients to take some time off for themselves. This idea may run counter to the Latino/a value of connectedness and putting the needs of the family ahead of oneself. Therefore, instead of solitary activities, clients can choose social activities they find enjoyable, such as visiting neighbors, family outings, or taking children to the park. In recognizing the income status of clients, activities discussed are generally free or affordable.

3. Assertiveness training. Assertiveness is discussed within the context of Latino values. Culturally acceptable ways of expressing assertiveness, such as prefacing statements with con todo respeto (with all due respect) and me permite expresar mis sentimientos? (Is it okay if I express my feelings?) are discussed, as well as strategies for using assertion with spouses or higher-status individuals.

4. Cognitive restructuring. Rather than labeling thoughts that can reduce or increase depression as rational or irrational, the terms “helpful thoughts” and “unhelpful thoughts” are used. Recognizing the religious nature of many Latinos, the saying Ayudate, que Dios te ayudara (i.e., “God helps those who help themselves”) is used to encourage follow-through with behavioral assignments.

This adapted approach, which maintains fidelity to both empirically supported techniques and cultural influences, has resulted in a lower dropout rate and better outcome for low-income Latino/a clients compared to nonmodified therapy. Cultural adaptations can include factors such as (a) matching language, racial or ethnic backgrounds of client and therapist; (b) incorporating cultural values in the specific treatment strategies; (c) utilizing cultural sayings or metaphors in treatment; and (d) considering the impact of environmental variables, such as acculturation conflicts, discrimination, and income status.

Culturally adapted ESTs have been successfully used with Latino/a and Haitian American adolescents (Duarte-Velez, Guillermo, & Bonilla, 2010; Nicholas, Arntz, Hirsch, & Schmiedigen, 2011); Asian Americans experiencing phobias (Huey & Pan, 2006); Latino/a adults experiencing depression (Aguilera, Garza, & Munoz, 2010); American Indians suffering from trauma (BigFoot & Schmidt, 2010); African Americans recovering from substance abuse (Cunningham, Foster, & Warner, 2010); and Chinese immigrant families (Lau et al., 2010).

Horrell (2008) reviewed 12 studies on the effectiveness of cognitive-behavioral therapy for African, Asian, and Hispanic Americans experiencing a variety of psychological disorders; the majority of these studies involved some type of cultural modification. Although the results for African American clients were mixed, Asian and Hispanic American clients demonstrated significant treatment gains over those in placebo or wait-list control conditions. Overall, evidence is increasing that ESTs can be effective with ethnic minorities, particularly when the approach includes cultural adaptation.

A meta-analysis of studies involving the adaptation of ESTs to clients’ cultural background revealed that adapted treatments for clients of color are moderately more effective than nonadapted treatments and that the most effective therapies were those that had the most cultural adaptations (Smith, Rodriguez, & Bernal, 2011). In a review of both published and unpublished studies of culturally adapted therapies, it was found that culturally adapted psychotherapy is more effective than nonadapted psychotherapy for ethnic minorities (Benish, Quintana, & Wampold, 2011).

Interestingly, these researchers believe that cultural adaptations are effective because most adapted therapies in their review allowed the therapist to explore the “illness myth” of the client (i.e., the client’s explanation of his or her symptoms and beliefs about possible etiology, prognosis, and effective treatment). As the researchers conclude, “The superior outcomes resulting from myth adaptation indicate the importance of therapist inquiry and effort into understanding clients’ beliefs about etiology, types of symptoms experienced, prediction of the course of illness, and consequences of the illness, as well as client opinion about what constitutes acceptable treatment”(Benish et al., 2011 p. 287). Even if a client’s perspective regarding his or her symptoms is maladaptive, the process of listening and assessing client beliefs appears to enhance outcome. This approach seems also present in the “Cultural Formulation Outline Interview” advocated in DSM-5 (American Psychiatric Association, 2013).

ESTs are useful in providing clinicians with information regarding which therapies are most effective with specific disorders. We should always be aware of experimentally supported techniques when working with client problems. However, the identification of treatments is only one step in a complex process; it is vital that we also consider contextual and cultural influences and therapist–client relationship factors in treatment outcome. This view (i.e., that contextual and therapist factors are also important in therapy outcome) allows the field to move beyond the traditional clinical framework in which an “objective” illness can be diagnosed and a specific cure recommended, to a greater understanding of the complexities involved in mental health issues and psychological disorders.

Implications

The applicability of many ESTs for many diverse groups has been insufficiently researched. Yet mental health practitioners are faced with the challenge of selecting effective interventions for their clients’ mental health issues. For clients of color, we have the option of using a standard EST for the disorder, finding an EST (or adapted EST) with research demonstrating effectiveness for members of the client’s ethnic group with the client’s disorder (which is highly unlikely), or taking the time to develop and research a culture-specific EBT for the client’s disorder. The latter would be inordinately difficult for most practitioners to accomplish. Additionally, culture-specific treatments may not be effective with people of color who are more acculturated. Thus, in choosing a treatment strategy, we believe that the best approach (given the current state of research) is for the counselor to select an intervention that is research based and subsequently adapt the approach for the individual client according to the client’s individual characteristics, values, and preferences.

Reflection and Discussion Questions

1. What are your thoughts concerning the use of ESTs in your own practice? What reactions do you have about using research on therapeutic effectiveness to guide your work? Has your training exposed you to EBP? What challenges would you face trying to implement such an approach?

2. What would you need to know about ESTs and the cultural background of diverse clients in order to develop a culturally adapted therapeutic approach? Although it would be a massive undertaking, can you and your classmates discuss what specific steps need to be taken to culturally adapt an EST to African Americans, Asian Americans, and Latinos?

3. Do you believe that simply adapting ESTs to the cultural context of clients is sufficient in working with people of color?

Empirically Supported Relationships (ESRs)

Not everyone believes that cultural adaptations of empirically supported treatments are sufficient to deal with cultural differences, and some express concern that such adaptations result in the imposition of EuroAmerican norms on ethnic minorities. As Gone (2009) argues, ESTs cannot be “adorned” with “a few beads here, some feathers there” (p. 760). Those critical of reliance on ESTs alone cite the multitude of other factors impacting treatment outcome, such as the therapeutic relationship, client values and beliefs, and the working alliance between client and therapist (DeAngelis, 2005; D. W. Sue, 2015). To remedy this shortcoming, the American Psychological Association Division 29 Psychotherapy Task Force was formed to review research and identify characteristics responsible for effective therapeutic relationships and to determine means of tailoring therapy to individual clients (Ackerman et al., 2001).

This focus provided the first opportunity for the inclusion of multicultural concerns within the evidence-based movement. It is widely agreed that the quality of the working relationship between the therapist and the client (i.e., the therapeutic alliance) is consistently related to treatment outcome (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Weinberger, 2002). This relationship may assume even greater significance for clients from diverse backgrounds (Davis, Ancis, & Ashby, 2015). In fact, difficulties in the therapeutic alliance may be a factor in the underutilization of mental health services and early termination of therapy seen with minority clients. After reviewing the research on therapist–client relationship variables as they relate to treatment outcome, the APA Division 29 Task Force reached these conclusions (Ackerman et al., 2001):

1. The therapeutic relationship makes substantial and consistent contributions to psychotherapy outcome, independent of the specific type of treatment.

2. The therapy relationship acts in concert with discrete interventions, client characteristics, and clinician qualities in determining treatment effectiveness.

3. Adapting or tailoring the therapy relationship to specific client needs and characteristics (in addition to diagnosis) enhances the effectiveness of treatment.

4. Practice and treatment guidelines should explicitly address therapist behaviors and qualities that promote a facilitative therapy relationship.

According to the APA Task Force, a number of relationship variables are considered “demonstratively effective” or “promising and probably effective” based on research findings (see Table 9.2). ESR variables include the development of a strong therapeutic alliance, a solid interpersonal bond (i.e., a collaborative, empathetic relationship based on positive regard, respect, warmth, and genuineness), and effective management of countertransference—all factors known to be critical for effective multicultural counseling. We elaborate on these relationship variables in the next few sections.

TABLE 9.2 Empirically Supported Relationship (ESR) Variables

Source: From Ackerman et al. (2001).

Demonstrably Effective Promising and Probably Effective
Therapeutic alliance Positive regard
Cohesion in group therapy Congruence/genuineness
Empathy Feedback
Goal consensus and collaboration Repair of alliance ruptures
Customizing therapy Self-disclosure
Management of countertransference

The Therapeutic Alliance

Research on empirically supported relationships has consistently identified the importance of a strong therapeutic alliance, which includes the core conditions of effective treatment described by Rogers (1957): empathy, respect, genuineness, and warmth. These dynamics typify a therapeutic relationship in which a client feels understood, safe, and encouraged to disclose intimate material. These characteristics transcend the therapist’s therapeutic orientation or approach to treatment. The therapeutic relationship, or working alliance, is an important factor in effective treatment. Clients specifically asked about what contributed to the success of treatment often point to a sense of connection with their therapist. Connectedness has been described as having feelings of closeness with the therapist, working together in an enabling atmosphere, receiving support for change, and being provided an equality of status within the working relationship (Ribner & Knei-Paz, 2002). As we noted in Chapter 2, cultural humility may be a major aspect in the therapeutic alliance contributing to cultural competence (Hook, Davis, Owen, Worthington, & Utsey, 2013; Owen et al., 2014).

Similarly, clients report that therapist behaviors such as “openness to ideas, experiences, and feelings” or being “nonjudgmental and noncritical,” “genuine,” “warm,” and “validating of experiences” are helpful in therapy (Curtis, Field, Knann-Kostman, & Mannix, 2004). A counselor’s relationship skills and ability to develop a therapeutic alliance contribute significantly to satisfaction among clients of color (Constantine, 2002). Mulvaney-Day, Earl, Diaz-Linhart, and Alegria (2011) found that relationship variables with the therapist were particularly important for African American and Latino/a clients and concluded that the basic yearning for authentic connection with a provider transcends racial categories (p. 36). Thus the importance of feeling accepted by a therapist on an emotional and cognitive level seems to be a universal prerequisite for an effective therapeutic alliance.

Conceptualization of the therapeutic alliance often comprises three elements: (a) an emotional or interpersonal bond between the therapist and the client; (b) mutual agreement on appropriate goals, with an emphasis on changes valued by the client; and (c) intervention strategies or tasks that are viewed as important and relevant by both the client and the therapist (Garber, 2004). Defined in this manner, the therapeutic alliance exerts positive influences on outcome across different treatment modalities, accounting for a substantial proportion of outcome variance (Hojat et al., 2011; Zuroff & Blatt, 2006). In fact, the therapist–client relationship contributes as much as 30 percent to the variance in therapeutic outcome (Lambert & Barley, 2001).

We believe that the therapeutic alliance is of critical importance in the outcome of therapy for ethnic minority clients and will describe possible modifications that may help clinicians enhance this relationship. It is important to remember that there is no set formula or response that will ensure the formation of a strong therapeutic alliance with a particular client. In fact, counselors often need to demonstrate behavioral flexibility to achieve a good working relationship with clients; this may be particularly true when working with individuals from diverse populations.

In a qualitative study involving Black, Asian, Latino/a, and multiracial clients, most preferred an active counselor role, which was characterized by the counselor offering concrete suggestions, providing direct answers, challenging the client’s thinking with thought-provoking questions, and providing psychoeducation regarding the therapy (Chang & Berk, 2009). Mulvaney-Day and colleagues (2011) found variability in the counseling relational style preferred by ethnic minority clients. A summary of the preferred relationship styles reported by the African American, Latino/a, and non-Latino White clients in their sample is presented in Table 9.3.

TABLE 9.3 Relational-Style Counselor Preferences of Ethnic Group Clients

Source: Mulvaney-Day et al. (2011).

Themes African American Clients Latino Clients Non-Latino White Clients
Listening Listen to who the client really is; recognize that clients are experts on themselves. Listen in a way that communicates “paying attention.” Listen so that the client is comfortable enough to talk and express feelings.
Understanding Understand beyond immediate impressions; understand hidden aspects of the client. Understand feelings of client. Understand complexity of client choices and circumstances.
Counselor Qualities Counselor should “lower” self to client’s level; egalitarian relationship. Be authoritative, but connect first, then offer concrete advice and solutions. Not judge because of social distance; maintain professional distance but be human.
Spending Time Not listed as factor Take time to connect deeply. Allow time for feelings to emerge at their own pace.

Mental health practitioners need to be adaptable with their relationship skills in order to address the preferences and expectations of their clients. For example, many African American clients appear to value social interaction as opposed to problem-solving approaches, especially during initial sessions, whereas Latino/a clients seem to prefer a more interpersonal approach rather than clinical distance (Gloria & Peregoy, 1996; Kennedy, 2003). We have also seen earlier that many Asian American clients may prefer a problem-solving approach initially. However, these are broad generalizations, and counselors must test out the effectiveness of different relational skills with a particular client, assessing the impact of their interactions with the client and asking themselves questions such as “Does the client seem to be responding positively to my relational style?” and “Have I succeeded in developing a collaborative and supportive relationship with this client?” and modifying the approach when necessary. Although it is important not to react to clients in a stereotypic manner, it is important to continually be aware of cultural and societal issues that may affect the client. Asian, Black, Latino/a, and multiracial clients who were dissatisfied in cross-racial therapy complained about their therapist’s lack of knowledge about racial identity development; the dynamics of power and privilege; the effects of racism, discrimination, and oppression due to their minority status (or multiple minority statuses); and cultural stigma associated with seeking help (Chang & Berk, 2009).

Cultural information is useful in providing general guidelines regarding an ethnic minority client’s counseling-style preference or issues that need to be addressed in therapy. However, as a counselor develops a comprehensive understanding of each client’s background, values, strengths, and concerns, it is essential that the counselor determine whether general cultural information “fits” the individual client. This ongoing “search for understanding” is important with respect to each of the following components of the therapeutic alliance.

Emotional or Interpersonal Bond

The formation of a bond between the therapist and the client is a very important aspect of the therapeutic relationship and is defined as a collaborative partnership based on empathypositive regard, genuineness, respect, warmth, and self-disclosure. For an optimal outcome, the client must feel connected with, respected by, and understood by the therapist. In addition, the therapist must identify issues that may detract from the relationship, such as countertransference (i.e., reactions to the client based on the therapist’s own personal issues). These qualities are described in detail below; their importance may vary according to the type of mental health issue being addressed and characteristics of the client (e.g., gender, socioeconomic status, ethnicity, cultural background).

The development of an emotional bond is enhanced by collaboration, a shared process in which a client’s views are respected and his or her participation is encouraged in all phases of the therapy. An egalitarian stance and encouragement of sharing and self-disclosure facilitate the development of empathy (Dyche & Zayas, 2001) and reduce the power differential between therapist and client. The potential for a positive therapeutic outcome is increased when the client is “on board” regarding the definition of the problem, identification of goals, and choice of interventions. When differences exist between a client’s view of a problem and the therapist’s theoretical conceptualization, negative dynamics are likely to occur. Collaboration regarding definition of the problem reduces this possibility and is most effective when employed consistently throughout therapy.

Empathy

Empathy is known to significantly enhance the therapeutic bondEmpathy is defined as the ability to place oneself in the client’s world, to feel or think from the client’s perspective, or to be attuned to the client. Empathy allows therapists to form an emotional bond with clients, helping the clients to feel understood. It is not enough for the therapist to simply communicate this understanding; the client must perceive the responses from the therapist as empathetic. This is why it is vital for therapists to be aware of client receptivity by evaluating both verbal and nonverbal responses from the client (“How is the client responding to what I am saying?” “What are the client’s verbal and bodily cues communicating?”). Empathy can be demonstrated in several different ways—having an emotional understanding or emotional connection with the client (emotional empathy) or understanding the client’s predicament cognitively, whether on an individual, family, or societal level (cognitive empathy). Following is an illustration of emotional empathy:

A White male therapist in his late 20s is beginning therapy with a recently immigrated 39-year-old West Indian woman. The client expresses concern about her adolescent daughter, who she describes as behaving in an angry, hostile way toward her fiancé. The woman is well dressed and is somewhat abrupt, seeming to be impatient with the therapist. Though not a parent himself, the therapist recognizes the distress behind his client’s sternness, and thinking of the struggles he had with his own father, he responds to the woman’s obvious discomfort saying, “I imagine that must hurt you.” This intuitive response from the therapist reduces the woman’s embarrassment, and she pauses from the angry story of her daughter’s ungratefulness to wipe a tear (Dyche & Zayas, 2001, p. 249).

Many counselors are trained to be very direct with emotional responses, using statements such as “You feel hurt” or “You sound hurt” in an effort to demonstrate empathy. The response “I imagine that must hurt you” would be rated a more intermediate response. Statements that are even less direct might include “Some people might feel hurt by that” or “If I was in the same situation, I would feel hurt.” We have found that people differ in their reaction to the directness of emotional empathy, depending on such factors as the gender, ethnicity, or cultural background of the counselor or the client; the degree of comfort and emotional bonding with the therapist; and the specific issue involved.

For example, when working with Asian international students, we have found that although there are individual differences in preference, many prefer a less direct style of emotional empathy. However, some Asian international students are fine with direct emotional empathy (this is why the counselor must be flexible and test out different forms of empathy with clients rather than prejudging them because of membership in a specific group). In general, recognition of emotional issues through either indirect or direct empathy increases the client’s feeling of being understood. Effective therapists continually evaluate client responses and thus are able to determine if the degree and style of emotional empathy being used is enhancing (or detracting) from the emotional bond between therapist and client.

Cognitive empathy involves the therapist’s ability to understand the issues facing the client. For example, in the case just described, the therapist might explore the possibility that the daughter’s anger is related to her immigration experiences by saying, “Sometimes moving to a new country can be difficult.” The degree of directness can be varied by making the observation tentative by prefacing statements with “I wonder if. . .?” or “Is it possible that. . .?” Cognitive empathy can also be demonstrated by communicating an understanding of the client’s worldview, including the influences of family issues or discriminatory experiences, such as racism, heterosexism, ageism, or sexism. By exploring or including broader societal elements such as these, a therapist is able to incorporate diversity or cross-cultural perspectives and potentially enhance understanding of the client’s concerns.

Communicating an understanding of different worldviews and acknowledging the possibility of cultural influences can increase the therapist’s credibility with the client. When working with diverse clients, we believe that empathy must include the ability to accept and be open to multiple perspectives of personal, societal, and cultural realities. This can be achieved by exploring the impact of cultural differences or diversity issues on client problems, goals, and solutions (Chung & Bernak, 2002; Dyche & Zayas, 2001).

Empathy may be difficult in multicultural counseling if counselors are unable to identify personal cultural blinders or values they may hold. For example, among counselors working with African American clients, those with color-blind racial attitudes (i.e., a belief that race is not a significant factor in determining one’s chances in society) showed lower levels of empathy than those who were aware of the significance of racial factors (Burkard & Knox, 2004). Some research suggests that counselors’ multicultural counseling competence (awareness of issues of race and discrimination, and knowledge of their social impact on clients) accounts for a large proportion of the variance in ratings of counselor competence, expertise, and trustworthiness made by clients of color (Constantine, 2002; Fuertes & Brobst, 2002).

In a study of gay and bisexual clients, a counselor’s universal–diversity orientation (i.e., interest in diversity, contact with diverse groups, comfort with similarities and differences) was positively related to client ratings of the therapeutic alliance, whereas, surprisingly, similarities in sexual orientation between therapist and client were not. Universal–diversity orientation may facilitate therapy through affirmation and understanding of the issues that culturally diverse clients are facing (Stracuzzi, Mohr, & Fuertes, 2011).

In contrast, the therapeutic alliance can be adversely affected when ethnic minority clients perceive a therapist to be culturally insensitive or believe that the therapist is minimizing the importance of racial and cultural issues or pathologizing cultural values or communication styles (Constantine, 2007; D. W. Sue, Bucceri, Lin, Nadal, & Torino, 2007). This finding is likely true with other diverse groups who may endure heterosexism, ageism, religious intolerance, and/or prejudice against disability. Sensitivity to the possible impact of racial and societal issues can be made through statements such as the following:

· “How have experiences with discrimination or unfairness had an impact on the problems you are dealing with?”

· “Sometimes it’s difficult to meet the societal demands of being a man (or a woman). How has this influenced your expression of emotions?”

· “Some people believe that family members should be involved in making decisions for individuals in the family. Is this true in your family?”

· “Being or feeling different can be related to messages we receive from our family, society, or religious institutions. Have you considered whether your feelings of isolation are related to messages you are getting from others?”

· “ Families change over time. What are some of the standards or values you learned as a young child? I wonder if the conflicts in your family are related to differences in expectations between you and your parents.

These examples are stated in a very tentative manner. If a counselor has sufficient information, more direct statements of cognitive empathy can be made. We believe that the perception of and response to empathy varies from individual to individual. There are no set responses that will convey empathy and understanding to all clients. In general, therapists must learn to evaluate their use of both cognitive and emotional empathy to determine whether it is improving the emotional bond with the client and to make modifications, if needed, to enhance the client’s perception of empathy within the relationship.

Positive Regard, Respect, Warmth, and Genuineness

The characteristics of positive regard, respect, warmth, and genuineness are important qualities in establishing an emotional bondPositive regard is the demonstration by the therapist that he or she sees the strengths and positive aspects of the client, including appreciation for the values and differences displayed by the client. Positive regard is demonstrated when the counselor identifies and focuses on the strengths and assets of the individual rather than attending only to deficits or problems. This is especially important for members of ethnic minorities and other diverse groups whose behaviors are often pathologized. Respect is shown by being attentive and by demonstrating that you view the client as an important person. Behaviors such as asking clients how they would like to be addressed, showing that their comments and insights are valuable, and tailoring your interaction according to their needs or values are all ways of communicating respect. Warmth is the emotional feeling received by the client when the therapist conveys verbal and nonverbal signs of appreciation and acceptance. Smiling, the use of humor, or showing interest in the client can convey this feeling. Genuineness can be displayed in many different ways. It generally means a therapist is responding to a client openly and in a “real” manner, rather than responding in accordance with expected roles. These interpersonal attributes can strengthen the therapist–client alliance and increase the client’s trust, cooperation, and motivation to participate in therapy.

Self-Disclosure

Although self-disclosure is considered to be a “promising and probably effective” technique (Ackerman et al., 2001), the topic of a therapist revealing personal thoughts or personal information remains controversial. In one study, brief or limited therapist self-disclosure in response to comparable self-disclosure by the client was associated with reductions in symptom distress and greater liking for the therapist (Barrett & Berman, 2001).

Counselor disclosure in cross-cultural situations (e.g., sharing reactions to clients’ experiences of racism or oppression) may also enhance the therapeutic alliance (Burkard, Knox, Groen, Perez, & Hess, 2006; Cashwell, Shcherbakova, & Cashwell, 2003). Self-disclosures may show the therapist’s human qualities and lead to the development of closer ties with the client. Research to determine the impact of therapist self-disclosure is difficult since it depends on many variables, such as the type of disclosure, its timing and frequency, and client characteristics. Although many clients report that therapist self-disclosure enhances the therapeutic relationship, some self-disclosures by a therapist (e.g., being wealthy or politically conservative) can actually interfere with the therapist–client relationship (Chang & Berk, 2009).

Some therapists feel that self-disclosure is not appropriate in therapy, and they either will not answer personal questions or will bounce the question back to the client. However, some clients who ask, “Has this ever happened to you?” may be doing so in an attempt to normalize their experience. Bouncing the question back to the client by saying, “Let’s find out why you want to know this,” can be perceived as patronizing rather than helpful (Hays, 2001). Should you make self-disclosures to a client? The answer is, “It depends.” Sharing experiences or reactions can strengthen the emotional bond between therapist and client. However, such self-disclosure should be limited and aimed at helping the client with his or her issues. If the requests for self-disclosure become frequent or too personal, the therapist should explore with the client the reason for the inquiries.

Management of Countertransference

Appropriate management of countertransference can enhance the therapeutic alliance, as well as minimize ruptures in the therapeutic relationship. Countertransference involves the therapist’s emotional reaction to the client based on the therapist’s own set of attitudes, beliefs, values, or experiences. These emotional reactions, whether negative or positive, can bias a therapist’s judgment when working with a client. For example, a therapist might exhibit negative reactions to a client owing to factors such as heterosexism, racism, or classism. Additionally, difficulty can occur when clients demonstrate values and perspectives similar to the therapist’s own; such similarity may reduce therapist objectivity. Therapists sometimes overidentify with clients who are similar to them and subsequently underestimate the client’s role in interpersonal difficulties. As we have seen in Chapter 3, this is most likely to happen in interracial/interethnic therapeutic relationships. These unconscious reactions can interfere with the formation of a healthy therapeutic emotional bond with the client. Because of the negative impact of countertransference, clinicians should examine their experiences, values, and beliefs when experiencing an emotional reaction to a client that is beyond what is expected from the therapy session.

A scientific frame of mind necessitates the examination of one’s own values and beliefs in order to anticipate the impact of possible differences and similarities in worldviews on the therapeutic alliance. Multicultural therapists have been in the forefront of stressing the importance of acknowledging the influence of values, preferences, and worldviews on psychotherapy and the psychotherapist. It is important to be self-aware and recognize when personal needs or values are being activated in the therapeutic relationship and to not project our reactions onto clients (Brems, 2000).

Goal Consensus

An agreement on goals between the therapist and the client (i.e., goal consensus) is another important relationship variable. Unless the client agrees on what the goals should be, little progress will be made. As therapists, we too easily envision what the appropriate outcome should be when working with a client and become dismayed or discouraged when a client does not feel the same way or seems satisfied with more limited solutions. Goals should be determined in a collaborative manner with input from both client and therapist. Although it is very important to get the client’s response in regard to the problem and goals, the therapist has the important task of clarifying client statements and providing tentative suggestions.

Clients often identify global goals, such as “wanting to improve self-esteem.” The therapist’s job is to help the client define the goal more specifically and to foster alternative ways of interpreting situations (Hilsenroth & Cromer, 2007). Concrete goals enhance the ability to measure progress in therapy. To obtain more specificity regarding a global goal, therapists can ask such questions as: “What does your low self-esteem prevent you from doing?” “How would your life be different if you had high self-esteem?” “What would you be able to do if you had more self-esteem?” or “How would you know if you are improving in self-esteem?” The answer to these questions, such as “being able to hold a job or ask for a raise,” “feeling more comfortable in group situations,” or “standing up for myself,” can help identify aspects of self-esteem that are more concrete. Each of these responses can be used to define sub-goals. A client might be asked, “What are small steps that you can make that will show you are moving in the direction of higher self-esteem?”

Once goals are identified, the client and the therapist can work together to identify which strategies and techniques will be employed to help the client achieve the stated goals. In order for interventions to be useful, they need to make sense to the client. For ethnic minority clients, interventions may require “cultural adaptation,” such as that described in the study by Huey and Pan (2006), in which the treatment of phobias was modified for Asian Americans by emphasizing the strategy of emotional control and maximizing a directive role for the therapist.

Although the selection of interventions depends upon the presenting problem and diagnosis, psychological interventions are most effective when they are consistent with client characteristics, including the client’s culture and values (La Roche, Batista, & D’Angelo, 2011). It is also important that the client believe that the therapeutic approach will be helpful. In a study by Coombs, Coleman, and Jones (2002), clients who reported “understanding the therapy process” and “having positive expectations of the therapy” were more likely to improve.

Implications of Empirically Supported Relationships (ESRs)

The effectiveness of therapy is highly dependent on the quality of the relationship between the therapist and the client. This finding transcends racial and ethnic differences and contributes up to 30 percent of the variance in treatment outcome. It is evident that the relationship between the therapist and the client is critical. In many cases, when given a choice, clients would select a less effective treatment if it were provided by a caring, empathetic therapist. Ethnic minorities may differ in their relational styles preferences, so therapists should be flexible and evaluate the degree of fit between their relational style and that preferred by their client, and should vary their approach, if necessary, to improve the therapeutic alliance. As mentioned by Benish, Quintana, and Wampold (2011), exploring the “illness myth” of the client in regard to his or her beliefs regarding etiology, course, and treatment is highly important in the therapeutic relationship and can enhance collaborative identification of goals and interventions.

Reflection and Discussion Questions

1. What was your therapy training in regard to the formation of the therapeutic alliance with a client? Indicate how the relationship skills were discussed in relation to cross-cultural competence.

2. What is your experience in working with ethnic minorities or other diverse populations? Did they appear to require different relationship skills? Did you evaluate the effectiveness of your responses?

Evidence-Based Practice (EBP) and Diversity Issues in Counseling

The American Psychological Association’s focus on empirically supported relationships (ESRs) provided an opening for counselors to address multicultural concerns within an evidence-based framework. However, the broader and more recent focus on evidence-based practice (EBP) has more formally introduced cultural sensitivity as an essential consideration in assessment, case conceptualization, and selection of interventions. Specifically, EBP refers to “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (American Psychological Association, Presidential Task Force on Evidence-Based Practice, 2006, p. 273). (See Figure 9.1.)

Figure 9.1  Three Pillars of Evidence-Based Practice

Source: Morales & Norcross (2010), p. 824.

Empirically based practice includes both evidence-based treatments and relationship variables but is broader and more comprehensive than a combination of the two. How does EBP differ from the EST and ESR frameworks?

First, the assumption underlying EBP is that the search for the “best research evidence” begins with a comprehensive understanding of the client’s background and problem and goes on to consider which therapeutic approach is most likely to provide the best outcome. In other words, the selection of intervention occurs only after individual characteristics, such as cultural background, values, and preferences, are assessed. This allows for the individualizing of therapy with strong consideration given to client background and characteristics.

Second, unlike ESTs, which rely primarily on randomized controlled trials, EBP also accepts research evidence from qualitative studies, clinical observations, systematic case studies, and interventions delivered in naturalistic settings. This broadening of the definition of research allows mental health professionals greater latitude in deciding which therapy may be the best match for a particular client. For example, the National Registry of Evidence-based Programs and Practices (NREPP) provides specific information regarding treatments for substance abuse that consider the race and ethnicity of the participants, and treatments designed for certain ethnic groups, such as the American Indian Life Skills Development Program (Berke, Rozell, Hogan, Norcross, & Karpiak, 2011).

Third, the definition of clinical expertise within the EBP framework focuses not only on the quality of the therapeutic relationship and therapeutic alliance but also on skills essential for comprehensive assessment of the client’s problem and strengths. Additionally, EBP considers clinical expertise involving factors such as knowledge about cultural differences; best practices in assessment, diagnosis, and case conceptualization; strategies for evaluating and selecting appropriate research-based treatments; and adapting selected treatments in a manner that respects the client’s worldview, values, and preferences.

Fourth, EBP is based on an ongoing emphasis on client characteristics, culture, and preferences and the importance of working collaboratively with the client to develop goals and treatment strategies that are mutually agreeable. Identification of client variables includes (a) age and life stage, (b) sociocultural factors (e.g., gender, sexual orientation, ethnicity, disability), (c) environmental stressors (e.g., unemployment, recent life events, racism, health disparities), and (d) personal treatment preferences (i.e., treatment expectations, goals, and beliefs).

Because the focus is on the client and the consideration of cultural variables, EBP sets the stage for a multiculturally sensitive counseling relationship. The following illustration of how EBP and multicultural sensitivity can be integrated is based on the case of Anna, an American Indian female who developed PTSD following a sexual assault.

Anna is a 14-year-old American Indian female who was sexually abused by a 22-year-old male in her small community. Anna disclosed the abuse to her school counselor, who then reported the incident to tribal law enforcement. After word of the incident spread through the community, several individuals accused Anna of lying and then harassed her in an attempt to recant her allegation. Anna began isolating herself at home and stopped attending school. Anna became increasingly depressed and demonstrated symptoms consistent with PTSD. (BigFoot & Schmidt, 2010, p. 854)

BigFoot and Schmidt (2010) were able to meld American Indian traditional healing processes and cultural teachings within an EBP framework. Aspects of this process included assessment of Anna’s personal characteristics and preferences and the influence of culture on her reactions to the trauma. Following careful assessment, intervention strategies were selected based on assessment data, therapist expertise, research regarding effective treatments for posttraumatic stress, and cultural adaptation of the therapy selected. The steps involved the following:

· Research-supported treatments for childhood or adolescent trauma were identified. Trauma-focused cognitive-behavioral therapy (TF-CBT) was chosen because it was seen to complement many of the traditional healing practices used in Anna’s tribe, including traditional beliefs about the relationship between emotions, beliefs, and behaviors. TF-CBT is a conjoint child and family psychotherapy that has been comprehensively evaluated and designated by the National Crime Victims Research and Treatment Center as having the highest level of research support as an “efficacious treatment” for childhood abuse and trauma.

TF-CBT has been evaluated with Caucasian and African American children and adapted for American Indian/Alaska Native populations, Latinos, hearing-impaired individuals, immigrant Cambodians, and children of countries including Zambia, Uganda, South Africa, Pakistan, the Netherlands, Norway, Sweden, Germany, and Cambodia (National Child Traumatic Stress Network, 2008). The components of TF-CBT include a focus on reducing negative emotional and behavioral responses resulting from trauma and correcting trauma-related beliefs through gradual exposure to memories and emotional associations with the traumatic event. Relaxation training is used to reduce negative emotions. Parents are included in the treatment process as emotional support for the child; parents are provided with strategies for helping to manage their child’s emotional reaction to the trauma.

· Client characteristics and values were identified through interviews with Anna and her family and by assessing their tribal and cultural identity. In Anna’s case, both she and her family agreed that she had a strong American

· Indian identity and valued traditional healing approaches. Thus it was decided that a culturally adapted TF-CBT would be the most appropriate. (If Anna and her family had expressed minimal tribal or American Indian cultural identification, standard TF-CBT might have been the treatment of choice.)

· Cultural adaptations of TF-CBT were developed. Because of cultural beliefs that trauma can bring about disharmony and result in distorted beliefs and unhealthy behaviors, traditional healing efforts focus on returning the individual to a state of harmony through teachings, ceremonies, and tribal practices, including a ritual called Honoring Children, Mending the Circle (HC-MC). The Circle represents the interconnectedness of spirituality and healing and the belief that all things have a spiritual nature; prayers, tribal practices, and rituals connect the physical and the spiritual worlds, bringing wellness and harmony. Additionally, adaptation of the affect management, relaxation, cognitive coping, and enhancing the parent–child relationship aspects of TF-CBT incorporated spiritual (saying prayers), relational (support from friends and family), mental (hearing messages of love and support), and physical (helping Anna reacquire physical balance) supports, thus increasing Anna’s feelings of safety and security.

Further adaptation involved the TF-CBT goal of extinguishing the fear response using a “trauma narrative” during which the child “revisits” the traumatic incident and is gradually exposed to threatening cues. In the adaptation, culturally accepted methods for telling the trauma story—including use of a journey stick, tribal dances, and storytelling procedure—were used to facilitate exposure. Relaxation techniques were also adapted by having Anna breathe deeply while focused on culturally relevant images, such as the “sway of wind-swept grasses” or the movement of a “woman’s shawl during a ceremonial dance.”

As BigFoot and Schmidt concluded, “the adaption of TF-CBT within an American Indian/Alaskan Native well-being framework can enhance healing through the blending of science and indigenous cultures. . .The HC-MC adaptation seeks to honor what makes American Indians and Alaska Natives culturally unique through respecting beliefs, practices, and traditions within their families, communities, tribes, and villages that are inherently healing” (2010, p. 855).

Reflection and Discussion Questions

1. What is your reaction to EBP, especially as it applies to ethnic minorities and other diverse populations?

2. It is clear that using an EBP approach requires greater time and effort on the part of clinicians to develop a treatment plan. The implication is that counselors must do out-of-office education or consultation regarding what is available in the research literature that would help inform their practice. Is such an approach too time-consuming? Given that EBP research is exploding in the field, how would you keep current or informed as a practitioner?

Implications for Clinical Practice

1. Realize that the early EST formulations inadequately addressed the needs of marginalized groups in our society, but have begun to incorporate cultural contexts in modifying evidence-based approaches. The standards used to determine ESTs and ESRs were often too rigid and ignored the cultural context in advocating for the role of science and research in the selection of therapeutic treatments and interventions.

2. Be aware that most mental health professionals have moved to the concept of EBP, (a) allowing for a broader array of means to determine the selection, process, and outcome of effective treatments and (b) integrating cultural factors and/or modifying approaches to fit the needs of diverse clients.

3. Know that multicultural counseling and EBP are “strange bedfellows no more” and that it is no longer adequate to devise a treatment plan solely on the basis of one’s theoretical orientation, clinical intuition, or clinical expertise.

4. Be aware that EBP models focusing on client characteristics and evaluating the degree of fit between a therapeutic approach and an individual client have actually legitimized the outcry of those in the field of multicultural counseling—that it is essential to consider the cultural beliefs and values of the client and that relational counselor styles may need to vary according to an individual’s cultural background.

5. Know that the integration of EBP and multiculturalism is resulting in an explosion of research. With the emphasis of the former on client characteristics, values, preference, and culture, EBP and multicultural therapy are becoming inextricably entwined, with each approach adding strengths to the other.

6. Understand that EBP can provide clinicians with information regarding which therapies are most effective with which specific disorders and which specific population. Thus, in choosing a treatment strategy, the best approach (given the current state of research) is for the counselor to select an intervention that is research based (if available) and subsequently adapt the approach for the individual client according to the client’s individual characteristics, values, and preferences.

7. Know that culturally competent counseling and therapy is more than a technique-driven search for effective techniques and strategies. We now know that the therapeutic alliance or working relationship is crucial to therapeutic outcome.

8. Be prepared to modify your therapeutic style to be consistent with the cultural values, life styles, and needs of culturally diverse clients. Remember, respect, unconditional positive regard, warmth, and empathy are most effective in the therapeutic alliance when they are communicated in a culturally consistent manner.

9. Be aware that some research suggests that a counselor’s multicultural counseling competence and humility (awareness of issues of race and discrimination and knowledge of their social impact on clients) accounts for a large proportion of the variance in ratings of counselor competence, expertise, and trustworthiness made by clients of color.

10. It is important to note that most approaches to counseling and therapy attempt to adapt the research findings of EBP to fit the unique cultural characteristics and needs of diverse populations. But what if we approach the challenge to develop culturally appropriate therapeutic techniques and relationships from an indigenous perspective first? This is a question we address in Chapter 10Non-Western Indigenous Methods of Healing.

Summary

The importance of evidence-based practice is becoming increasingly accepted in the field of multicultural counseling. Discussions of EBP originally focused on research-supported therapies for specific disorders, but the dialogue has now broadened to contain clinical expertise, including understanding the influence of individual and cultural differences on treatment and the importance of considering client characteristics and culture. Although optimism about the convergence of these forces is increasing, there is still resistance to EBP among some individuals within the field of multicultural counseling. The applicability of EBP for many diverse groups has been insufficiently researched, and the concept of “evidence” has historically been very narrow. Furthermore, the therapist–client relationship is not adequately acknowledged in the evidence-based treatment and empirically supported treatment formulations.

It is now widely agreed that the quality of the working relationship between the therapist and the client is consistently related to treatment outcome and has led to the formulation of empirically supported relationships. A number of relationship variables are considered effective based on research findings. ESR variables include the development of a strong therapeutic alliance, a solid interpersonal bond (i.e., a collaborative, empathetic relationship based on positive regard, respect, warmth, and genuineness), effective management of countertransference, and goal consensus—all factors known to be critical for effective multicultural counseling.

The assumption underlying EBP is that the best research evidence begins with a comprehensive understanding of the client’s background and problem and goes on to consider which therapeutic approach is most likely to provide the best outcome. This allows for the individualizing of therapy with strong consideration given to client background and characteristics. It broadens the definition of research and allows mental health professionals greater latitude in deciding which therapy may be the best match for a particular client. EBP is based on an ongoing emphasis on client characteristics, culture, and preferences and the importance of working collaboratively with the client to develop goals and treatment strategies that are mutually agreeable. Because the focus is on the client and the consideration of cultural variables, EBP sets the stage for a multiculturally sensitive counseling relationship.

Glossary Terms

Chapter Objectives

1. Become familiar with the role and importance of using research to determine what therapy treatment is best suited for diverse clients.

2. Define empirically supported treatments (ESTs).

3. Know the rationale for the development of empirically supported relationships (ESRs). Be able to describe the relationship variables that are considered to be research supported.

4. Become aware of how evidence-based practice (EBP) and multicultural counseling are converging.

5. Describe the modifications that need to be made in the counseling alliance (empathy and relationship building) to work with different ethnic groups.

6. Describe how EBP differs from ESTs and ESRs. Be able to outline the advantages of focusing on client values and preferences.

7. Describe similarities and differences between EBP and cultural competence.

8. Become cognizant of the advantages and disadvantages of using “culturally adapted” forms of research-based psychotherapies.

Case Study

Hajimi Matsumoto

Hajimi was a first-generation, 18-year-old, Japanese American male who lived most of his life in Japan before returning to the United States. He came to the university counseling center suffering from a severe social phobia. I was a White American female psychology intern being supervised by Dr. Katsumoto, a female Japanese American staff psychologist known for her work on multicultural psychology and cultural competence. I had seen the client, Hajimi, for approximately six sessions. Hajimi was an extremely shy young man who spoke in a barely audible voice, responded in short but polite statements, avoided eye contact, and sat facing my window rather than me. When I first met him, he would not shake my hand but simply nodded his head in acknowledgment. He fidgeted in his seat and seemed extremely uncomfortable in my presence. He described high anxiety in social or performance situations and was extremely nervous around women. He was afraid of being belittled by others, didn’t know how to make “small talk,” and constantly obsessed as to whether his personal hygiene (bad breath or body odor) might be offensive. Yet on none of his visits to my office did I detect any sort of strong or disagreeable odor.

Hajimi was referred to the counseling center by one of his professors after a particularly embarrassing and humiliating situation that occurred in the classroom: He “froze” in front of fellow students while doing a team oral presentation. Despite having detailed notes, he stammered, stuttered, and broke out in a profuse sweat that made it impossible to continue. When one of his female classmates on the team tried to offer support by placing her arm on his shoulder, Hajimi felt sure she could feel the perspiration on his shirt and panicked. He became embarrassed, broke away from her, quickly excused himself, and left the classroom. Apparently, these types of anxiety-provoking situations and encounters were very common in his life.

As all interns needed to take responsibility for making a client presentation at bimonthly case conference meetings, I chose to present my client, Hajimi. Case conferences are usually attended by staff psychologists, student interns, and the consulting psychiatrist. The psychiatrist, Dr. Machovitch, a White male at the medical school, was known for his psychodynamic orientation, whereas most of the psychologists at the center had either a multicultural or behavioral approach. After I had provided a detailed history of Hajimi including his symptoms and possible etiological factors, and offered a proposed treatment plan, a clear difference of opinion began to emerge between Drs. Machovitch and Katsumoto and another psychologist, Dr. Barnard. The three had quite a heated exchange, and I felt caught in the middle because they each recommended a different approach. Further, they all differed in their analysis and diagnosis of the problem.

Client Background:

Hajimi was the only son of a traditional Japanese couple who had wanted many more children but for unknown reasons could not conceive any others. All their hopes for carrying on the family name resided in Hajimi. When Hajimi was first born, the parents were overjoyed to have a son, but as time wore on, the father became disappointed in his son’s effeminate behavior, hypersensitivity, inability to control his emotions, and social-outcast role among classmates. The father belittled him, seemed to be ashamed to introduce Hajimi to friends, and isolated him from family gatherings. Whenever Hajimi would do something wrong and show remorse by crying, his father would say in Japanese, “Leave me, you offend me.” The mother, who was more sympathetic to Hajimi’s needs, nevertheless seldom intervened when her husband berated Hajimi almost on a daily basis. On one particularly angry encounter in which his father severely criticized him, Hajimi wept openly in front of his mother. His mother tried to console him by placing her arms around his shoulder and reassuring him that one day his father would be proud of him. Rather than being comforted, however, her actions seemed to cause further distress as he quickly ran to his bedroom and slammed the door.

Although Hajimi had done well academically in his early years, his grades began to suffer in college. Much of this was due to his severe social phobia, which affected his ability to speak up in classes and isolated him from fellow students and teachers. He was awkward and inept in social situations, became anxious around people, and would seldom speak. In his physical education classes, which required dancing with girls, he would panic and perspire freely. He felt embarrassed to touch the hands of his partner or to have them touch him for fear they would find his wet hands and clothes offensive. Hajimi often expressed his belief that he was not perfect enough. In school, he became increasingly obsessed with avoiding failure, playing it safe, and not making mistakes. Unfortunately, this approach had a negative impact on his academic work, as he would often take incompletes and withdraw from classes for fear that he was not doing well. He would frequently choose a college course on the basis of whether it offered a pass/no pass option. Hajimi admitted to an intense fear of failure and was aware that these choices allowed him to temporarily avoid poor grades. He knew that failing grades generated only greater criticism from his father.

Theoretical Differences

The disagreement among the three therapists as to the diagnosis and treatment of Hajimi appeared tied to their theoretical orientations and/or their clinical experiences. Dr. Katsumoto stressed cultural factors, whereas Dr. Machovitch believed a psychodynamic approach was clearly indicated in work with Hajimi. The discussion was compounded by Dr. Barnard, a male psychologist with a strong cognitive-behavioral orientation who argued for a behavioral program of assertiveness training and systematic desensitization of his social phobia. The gist of their positions can be captured in the following snapshots of their arguments.

Dr. Katsumoto (Cultural Analysis):

Sociodemographic factors such as race, culture, and ethnicity are important in understanding Hajimi’s difficulties. Many of the behaviors exhibited by him may be cultural dictates rather than pathology. For example, his behavior in the counseling session (lack of eye contact, low tone of voice, short but polite responses, and social distance) with the counselor may not be considered pathological in Japanese culture. Although I do believe he suffers from psychological problems, the diagnosis of social phobia may be inaccurate and lead to an inappropriate treatment plan. Even DSM-5 recognizes the existence of cultural syndromes, which are locality-specific patterns of aberrant behavior not linked to a specific DSM diagnosis. For example, in Japan and Korea, there is a condition called ‘taijin kyofusho’ that resembles a social phobia, which is accompanied by an intense fear that the person’s body, its parts, or its functions displease or are offensive to people. It is often manifested in a fear that one’s body odor may prove interpersonally repulsive. This psychological problem is actually listed in the Japanese manual of mental disorders. My suggestion would be to explore the possible adaptation of indigenous methods of treatment found effective in Japan. Although he is an American citizen, I believe he is more Japanese than Japanese American.

Dr. Machovitch (Psychodynamic Analysis):

Hajimi’s social phobia is caused by a deep-seated underlying childhood conflict with his parents. The phobia is a symptom and symbolic of unresolved Oedipal feelings toward both parents that are reenacted in almost all his social relationships. His strong need for social approval from his father, his feelings of hostility toward him, and an intense fear of the father (fear of castration) make him uncomfortable and anxious around men and especially around authority figures. His unresolved oedipal relationship with his mother has impaired his ability to relate to members of the opposite sex and has contributed to his anxiety in developing intimacy with others. Note his intense feelings of anxiety around women and his overreaction to being touched by them.

As a female therapist [reference to me as the intern], you probably evoke this conflict as well. I believe that Hajimi, at crucial psychosexual stages, did not receive the love and care a child needs to develop into a healthy adult. He was neglected, rejected, and maternally/paternally isolated, a condition that symbolized all his social relationships. Because he felt unloved and worthless, Hajimi reenacts his pathological relationship with his parents in other social situations. Note, for example, the symbolic relationship between the father’s repetitive declarations that Hajimi is ‘offensive, ‘ and Hajimi’s fear that he will offend others; similar reactions to attempts by his mother and female classmate to comfort him; avoidance of being touched; and many other symbolic parallels. My suggestion is to deal with Hajimi’s transference neurosis through an insight process so that he may be able to distinguish the pathological relationships of the past with the healthy ones he encounters now.

Dr. Barnard (Cognitive-Behavioral Analysis):

All of these explanations appear well and good, but the ultimate test of therapeutic effectiveness must be guided by the research literature. Work on empirically supported treatments suggests that cognitive-behavioral approaches have been shown to be most effective in the treatment of phobias. Although culture is important and a psychodynamic explanation seems appealing, we should be ethically obligated to select the treatment based upon what research has shown works. Describing the client’s problems in measurable and specific terms rather than abstract concepts will ultimately lead to a better treatment plan. For example, the roots of Hajimi’s problems can be traced to his behavioral repertoire. Many of the behaviors he has learned are inappropriate, and his repertoire lacks useful, productive social skills. He has little practice in social relationships, lacks good role models, and has difficulty distinguishing between appropriate and inappropriate behaviors.

In addition, his constant belittlement by his father has probably created in his mind an irrational belief system that leads him to distort or misinterpret events: Others will reject him, he is worthless, and he will offend others. Much of this, no doubt, comes from the father’s constant criticisms and belittlement. This leads Hajimi to believe that he is ‘worthless’ and will always be worthless. I believe that a program of assertiveness training, systematic desensitization, and relaxation exercises will help him immensely to develop social skills and to combat his high performance and interpersonal anxieties. Further, I would supplement his behavioral program with a cognitive treatment plan that (a) identifies irrational thinking and beliefs, (b) teaches him cognitive restructuring methods to combat them, and (c) replaces them with positive and more realistic self-appraisals. If you look at the research literature on treating social phobias, you cannot deny their effectiveness in treating this type of disorder.

Reflection and Discussion Questions

1. Before you continue reading, reflect upon what you believe to be the source of Hajimi’s problems. What is causing him to be so anxious around people? What role do his parents play in the manifestation of his disorder?

2. How would you characterize your therapeutic orientation, and can you apply it to this case? Do your classmates and fellow peers offer different explanations? How would you work with Hajimi? Can you be specific in describing your treatment plan?

3. Are you knowledgeable about what research has shown about treating the type of disorder exhibited by Hajimi? How would you go about finding the information?

4. What role do you believe culture plays in Hajimi’s problems?

The case of Hajimi and the three differing treatment perspectives raises important therapeutic issues that have literally spawned the movement toward evidence-based practice (EBP).

First, after careful assessment of the presenting problem and related factors, how do counselors decide on the most appropriate treatment for individuals from different ethnic groups? Indeed, this question is relevant to all groups regardless of race, culture, or ethnicity. Certainly, Drs. Katsumoto, Machovitch, and Barnard make important points, and their diagnosis, assessment, and treatment recommendations seem to make sense from their theoretical orientations. Because this text is about multicultural counseling, you might mistakenly assume that we will take the side of Dr. Katsumoto because she offers a perspective that we have emphasized throughout the text. As indicated in Chapter 2, however, it is entirely possible that all three perspectives may be right, but they may be limited in how they view the totality of the human condition. The cultural perspective views Hajimi as a cultural being, the psychodynamic perspective views him as a historical-developmental being, and the cognitive-behavioral approach views him as a behaving-and-thinking being (Ivey, Ivey, & Zalaquett, 2014). As we have emphasized throughout, we are all of these and more.

Second, historically therapeutic strategies used in treatment were often based on (a) the clinician’s specific therapeutic orientation (à la Drs. Katsumoto, Machovitch, and Barnard), (b) ideas shared by “experts” in psychotherapy, or (c) “clinical intuition and experience” derived from years of work with clients. These approaches are problematic because there are countless “experts” and, at last count, some 400 schools of psychotherapy, each purporting that their techniques are valid (Corey, 2013); moreover, treatment is often implemented without questioning the relevance or appropriateness of a particular technique or approach for a specific client. Furthermore, reliance on clinical “intuition” to guide one’s therapeutic approach can result in ineffective treatment. Thus it appears that the choice of a treatment plan is dictated by one’s theoretical orientation, expert opinion, and/or clinical intuition. In other words, different mental health professionals may differ significantly from one another in how they conceptualize and treat a problem of the client. Given these points, who are we to believe and how do we resolve this problem?

Third, this question has propelled the field of mental health practice, including multicultural counseling/therapy, to consider the role of science and research in the treatment of mental disorders (Morales & Norcross, 2010). Of the three analyses given, Dr. Barnard brings up the issue of using the research literature to guide us in the choice of intervention techniques. Yet he offers a seemingly flawed culture-free or neutral interpretation of empirically supported treatments (ESTs), an issue we address shortly. Nevertheless, Dr. Barnard does raise very important questions for the field of multicultural counseling and therapy to consider. How important is it for counselors to be aware of and to utilize interventions that have research support? What interventions have been demonstrated in research to be effective for treating mental disorders? Has research on EBP been conducted on racial/ethnic minority groups, or is it simply for members of the majority culture (D. W. Sue, 2015)? To help answer these questions, we consider the evolution of ESTs, empirically supported relationships (ESRs), and EBP as they apply to diverse populations.

Evidence-Based Practice (EBP) and Multiculturalism

The importance of EBP is becoming increasingly accepted in the field of multicultural counseling. Discussions of EBP originally focused on research-supported therapies for specific disorders, but the dialogue has now broadened to include clinical expertise, including “understanding the influence of individual and cultural differences on treatment” and the importance of considering client “characteristics, culture, and preferences in assessment, treatment plans, and therapeutic outcome” (American Psychological Association, Presidential Task Force on Evidence-Based Practice, 2006). In an article titled “Evidence-Based Practices with Ethnic Minorities: Strange Bedfellows No More,” Morales and Norcross (2010) describe how multiculturalism and evidence-based treatment (EBT), two forces that were “inexorable” and “separate” are now converging and how they can complement each other. The authors state: “Multiculturalism without strong research risks becoming an empty political value, and EBT without cultural sensitivity risks irrelevancy” (p. 823).

Although the authors are optimistic about the convergence of these forces, there is still resistance to EBP among some individuals within the field of multicultural counseling (Wendt, Gone, & Nagata, 2015; D. W. Sue, 2015). As BigFoot and Schmidt (2010) note, “Historically, government and social service organization utilization of nonadapted or poorly adapted mental health treatments with diverse populations has led to widespread distrust and reluctance in such populations to seek mental health services” (p. 849). Conflicts often exist between the values espoused in conventional psychotherapy and the cultural values and beliefs of ethnic minorities (Lau, Fung, & Yung, 2010; Nagayama-Hall, 2001). As we have discussed in previous chapters, Western approaches to psychological treatment are often based on individualistic value systems instead of on the interdependent values found in many ethnic minority communities. Additionally, conventional therapies often ignore cultural influences, disregard spiritual and other healing processes, and pathologize the behavior and values of ethnic minorities and other diverse groups (S. Sue, Zane, Nagayama-Hall, & Berger, 2009).

It is apparent that conventional delivery of Western-based therapies may not be meeting the needs of many individuals from ethnic and other cultural minorities. These groups tend to underutilize mental health services (Thurston & Phares, 2008) and are more likely to attend fewer sessions or drop out of therapy sooner, compared with their White counterparts (Fortuna, Alegria, & Gao, 2010; Lester, Resick, Young-Xu, & Artz, 2010; Triffleman & Pole, 2010). Unfortunately, research on the effectiveness of empirically supported therapies for ethnic minorities is limited, as these groups are often not included or specifically identified in research investigations of particular treatments.

Although questions remain regarding the validity of evidence-based approaches for ethnic minority populations and other diverse populations (Bernal & Sáez-Santiago, 2006), we believe that EBPs offer an opportunity for infusing multicultural and diversity sensitivity into psychotherapy. In addition, all mental health professions (psychiatry, social work, clinical psychology, and counseling) now espouse the view that treatment should have a research base. Evidence-based interventions are increasingly promoted in social work (Bledsoe et al., 2007; Gibbs & Gambrill, 2002), school psychology (Kratochwill, 2002), clinical psychology (Deegear & Lawson, 2003), counseling (American Counseling Association, 2014; Chwalisz, 2001), and psychiatry.

In this chapter we will discuss the evolution of EBP, the integration of EST and ESR variables into multicultural counseling, and the relevance of enhancing cultural elements in therapy. We will also show how culturally sensitive strategies can become an important component of EBPs.

Empirically Supported Treatment (EST)

The concept of ESTs was popularized when the American Psychological Association began promoting the use of “validated” or research-supported treatments—specific treatments confirmed as effective for specific disorders. Not only were ESTs seen as an effective response to concerns about the use of unsupported techniques and psychotherapies, but they also address the issue of unintended harm that can result from ineffective or hazardous treatments (Lilienfeld, 2007; Wendt, Gone & Nagata, 2015). ESTs typically involve a very specific treatment protocol for specific disorders. Because variability among therapists might produce error variance in research studies and because it is important for ESTs to be easily replicable as originally designed, ESTs are conducted using manuals.

According to the guidelines of the task force charged with defining and identifying ESTs (Chambless & Hollon, 1998), they must demonstrate (a) superiority to a placebo in two or more methodologically rigorous, controlled studies, (b) equivalence to a well-established treatment in several rigorous and independent controlled studies, usually randomized controlled trials, or (c) efficacy in a large series of single-case controlled designs (i.e., within-subjects designs that systematically compare the effects of a treatment with those of a control condition).

ESTs have been identified for anxiety, depressive, and stress-related disorders; obesity and eating disorders; severe mental conditions such as schizophrenia and bipolar disorder; substance abuse and dependence; childhood disorders; and borderline personality disorder. Several hundred different manualized treatments are listed as empirically supported (Chambless & Ollendick, 2001; Society of Clinical Psychology, 2011). (See Table 9.1 for a few examples of empirically supported therapies.)

TABLE 9.1 Examples of Empirically Supported Treatments (ESTs)

Source: Chambless & Hollon (1998).

“Well-Established” Treatments “Probably Efficacious” Treatments
Cognitive-behavioral therapy for panic disorder Cognitive therapy for obsessive-compulsive disorder (OCD)
Exposure/guided mastery for specific phobias Exposure treatment for posttraumatic stress disorder (PTSD)
Cognitive therapy for depression Brief dynamic therapy for depression
Cognitive-behavioral therapy for bulimia Interpersonal therapy for bulimia
Cognitive-behavioral relapse prevention for cocaine dependence Brief dynamic therapy for opiate dependence
Behavior therapy for headache Reminiscence therapy for geriatrics patients
Behavioral marital therapy Emotionally focused couples therapy

Additionally, the American Psychological Association has developed a list of ESTs and practice guidelines for ethnic minorities (American Psychological Association, 1993); women and girls (American Psychological Association, 2007); older adults (American Psychological Association, 2014); and lesbian, gay, and bisexual clients (American Psychological Association, 2012). These guidelines can be consulted and modified, if necessary, in working with clients from these groups.

The rationale behind the establishment of ESTs is admirable; we believe that decisions regarding treatment approaches for particular issues or disorders should be based on research findings rather than on idiosyncratic, personal beliefs or sketchy theories. We owe it to our clients to provide them with treatment that has demonstrated efficacy. However, it is our contention that relying only on manualized treatment methods, albeit research-supported approaches, is insufficient with many clients and many mental health problems (D. W. Sue, 2015). Additionally, most ESTs have not been specifically demonstrated to be effective with ethnic minorities or other diverse populations. The shortcomings of the EST approach are summarized here:

· Owing to the focus on choosing treatment based on the specific disorder, contextual, cultural, and other environmental influences are not adequately considered (D. W. Sue, 2015).

· The validity of ESTs for minority group members is often questionable because these groups are not included in many clinical trials (Bernal & Sáez-Santiago, 2006; S. Sue et al., 2006).

· The importance of the therapist–client relationship is not adequately acknowledged. A number of studies have found that therapist effects contribute significantly to the outcome of psychotherapy. In many cases, these effects exceed those produced by specific techniques (Wampold, 2001).

· Too much emphasis is placed on randomized controlled trials versus other forms of research, such as qualitative research designs.

When treating clients with specific disorders, multicultural therapists have had the choice of ignoring ESTs or adapting them. Increasingly, there have been attempts to develop “cultural adaptations” of certain ESTs. For example, Organista (2000) made the following modifications to empirically supported cognitive-behavioral strategies when working with low-income Latinos suffering from depression:

1. Engagement strategies. Recognizing the importance of personalismo (the value of personal relationships), initial sessions are devoted to relationship building. Time is allotted for presentaciones(introductions), during which personal information is exchanged between counselor and client and issues that may affect ethnic minorities, such as acculturation difficulties, culture shock, and discrimination, are discussed.

2. Activity schedules. In the treatment of depression, a common recommendation is for clients to take some time off for themselves. This idea may run counter to the Latino/a value of connectedness and putting the needs of the family ahead of oneself. Therefore, instead of solitary activities, clients can choose social activities they find enjoyable, such as visiting neighbors, family outings, or taking children to the park. In recognizing the income status of clients, activities discussed are generally free or affordable.

3. Assertiveness training. Assertiveness is discussed within the context of Latino values. Culturally acceptable ways of expressing assertiveness, such as prefacing statements with con todo respeto (with all due respect) and me permite expresar mis sentimientos? (Is it okay if I express my feelings?) are discussed, as well as strategies for using assertion with spouses or higher-status individuals.

4. Cognitive restructuring. Rather than labeling thoughts that can reduce or increase depression as rational or irrational, the terms “helpful thoughts” and “unhelpful thoughts” are used. Recognizing the religious nature of many Latinos, the saying Ayudate, que Dios te ayudara (i.e., “God helps those who help themselves”) is used to encourage follow-through with behavioral assignments.

This adapted approach, which maintains fidelity to both empirically supported techniques and cultural influences, has resulted in a lower dropout rate and better outcome for low-income Latino/a clients compared to nonmodified therapy. Cultural adaptations can include factors such as (a) matching language, racial or ethnic backgrounds of client and therapist; (b) incorporating cultural values in the specific treatment strategies; (c) utilizing cultural sayings or metaphors in treatment; and (d) considering the impact of environmental variables, such as acculturation conflicts, discrimination, and income status.

Culturally adapted ESTs have been successfully used with Latino/a and Haitian American adolescents (Duarte-Velez, Guillermo, & Bonilla, 2010; Nicholas, Arntz, Hirsch, & Schmiedigen, 2011); Asian Americans experiencing phobias (Huey & Pan, 2006); Latino/a adults experiencing depression (Aguilera, Garza, & Munoz, 2010); American Indians suffering from trauma (BigFoot & Schmidt, 2010); African Americans recovering from substance abuse (Cunningham, Foster, & Warner, 2010); and Chinese immigrant families (Lau et al., 2010).

Horrell (2008) reviewed 12 studies on the effectiveness of cognitive-behavioral therapy for African, Asian, and Hispanic Americans experiencing a variety of psychological disorders; the majority of these studies involved some type of cultural modification. Although the results for African American clients were mixed, Asian and Hispanic American clients demonstrated significant treatment gains over those in placebo or wait-list control conditions. Overall, evidence is increasing that ESTs can be effective with ethnic minorities, particularly when the approach includes cultural adaptation.

A meta-analysis of studies involving the adaptation of ESTs to clients’ cultural background revealed that adapted treatments for clients of color are moderately more effective than nonadapted treatments and that the most effective therapies were those that had the most cultural adaptations (Smith, Rodriguez, & Bernal, 2011). In a review of both published and unpublished studies of culturally adapted therapies, it was found that culturally adapted psychotherapy is more effective than nonadapted psychotherapy for ethnic minorities (Benish, Quintana, & Wampold, 2011).

Interestingly, these researchers believe that cultural adaptations are effective because most adapted therapies in their review allowed the therapist to explore the “illness myth” of the client (i.e., the client’s explanation of his or her symptoms and beliefs about possible etiology, prognosis, and effective treatment). As the researchers conclude, “The superior outcomes resulting from myth adaptation indicate the importance of therapist inquiry and effort into understanding clients’ beliefs about etiology, types of symptoms experienced, prediction of the course of illness, and consequences of the illness, as well as client opinion about what constitutes acceptable treatment”(Benish et al., 2011 p. 287). Even if a client’s perspective regarding his or her symptoms is maladaptive, the process of listening and assessing client beliefs appears to enhance outcome. This approach seems also present in the “Cultural Formulation Outline Interview” advocated in DSM-5 (American Psychiatric Association, 2013).

ESTs are useful in providing clinicians with information regarding which therapies are most effective with specific disorders. We should always be aware of experimentally supported techniques when working with client problems. However, the identification of treatments is only one step in a complex process; it is vital that we also consider contextual and cultural influences and therapist–client relationship factors in treatment outcome. This view (i.e., that contextual and therapist factors are also important in therapy outcome) allows the field to move beyond the traditional clinical framework in which an “objective” illness can be diagnosed and a specific cure recommended, to a greater understanding of the complexities involved in mental health issues and psychological disorders.

Implications

The applicability of many ESTs for many diverse groups has been insufficiently researched. Yet mental health practitioners are faced with the challenge of selecting effective interventions for their clients’ mental health issues. For clients of color, we have the option of using a standard EST for the disorder, finding an EST (or adapted EST) with research demonstrating effectiveness for members of the client’s ethnic group with the client’s disorder (which is highly unlikely), or taking the time to develop and research a culture-specific EBT for the client’s disorder. The latter would be inordinately difficult for most practitioners to accomplish. Additionally, culture-specific treatments may not be effective with people of color who are more acculturated. Thus, in choosing a treatment strategy, we believe that the best approach (given the current state of research) is for the counselor to select an intervention that is research based and subsequently adapt the approach for the individual client according to the client’s individual characteristics, values, and preferences.

Reflection and Discussion Questions

1. What are your thoughts concerning the use of ESTs in your own practice? What reactions do you have about using research on therapeutic effectiveness to guide your work? Has your training exposed you to EBP? What challenges would you face trying to implement such an approach?

2. What would you need to know about ESTs and the cultural background of diverse clients in order to develop a culturally adapted therapeutic approach? Although it would be a massive undertaking, can you and your classmates discuss what specific steps need to be taken to culturally adapt an EST to African Americans, Asian Americans, and Latinos?

3. Do you believe that simply adapting ESTs to the cultural context of clients is sufficient in working with people of color?

Empirically Supported Relationships (ESRs)

Not everyone believes that cultural adaptations of empirically supported treatments are sufficient to deal with cultural differences, and some express concern that such adaptations result in the imposition of EuroAmerican norms on ethnic minorities. As Gone (2009) argues, ESTs cannot be “adorned” with “a few beads here, some feathers there” (p. 760). Those critical of reliance on ESTs alone cite the multitude of other factors impacting treatment outcome, such as the therapeutic relationship, client values and beliefs, and the working alliance between client and therapist (DeAngelis, 2005; D. W. Sue, 2015). To remedy this shortcoming, the American Psychological Association Division 29 Psychotherapy Task Force was formed to review research and identify characteristics responsible for effective therapeutic relationships and to determine means of tailoring therapy to individual clients (Ackerman et al., 2001).

This focus provided the first opportunity for the inclusion of multicultural concerns within the evidence-based movement. It is widely agreed that the quality of the working relationship between the therapist and the client (i.e., the therapeutic alliance) is consistently related to treatment outcome (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Weinberger, 2002). This relationship may assume even greater significance for clients from diverse backgrounds (Davis, Ancis, & Ashby, 2015). In fact, difficulties in the therapeutic alliance may be a factor in the underutilization of mental health services and early termination of therapy seen with minority clients. After reviewing the research on therapist–client relationship variables as they relate to treatment outcome, the APA Division 29 Task Force reached these conclusions (Ackerman et al., 2001):

1. The therapeutic relationship makes substantial and consistent contributions to psychotherapy outcome, independent of the specific type of treatment.

2. The therapy relationship acts in concert with discrete interventions, client characteristics, and clinician qualities in determining treatment effectiveness.

3. Adapting or tailoring the therapy relationship to specific client needs and characteristics (in addition to diagnosis) enhances the effectiveness of treatment.

4. Practice and treatment guidelines should explicitly address therapist behaviors and qualities that promote a facilitative therapy relationship.

According to the APA Task Force, a number of relationship variables are considered “demonstratively effective” or “promising and probably effective” based on research findings (see Table 9.2). ESR variables include the development of a strong therapeutic alliance, a solid interpersonal bond (i.e., a collaborative, empathetic relationship based on positive regard, respect, warmth, and genuineness), and effective management of countertransference—all factors known to be critical for effective multicultural counseling. We elaborate on these relationship variables in the next few sections.

TABLE 9.2 Empirically Supported Relationship (ESR) Variables

Source: From Ackerman et al. (2001).

Demonstrably Effective Promising and Probably Effective
Therapeutic alliance Positive regard
Cohesion in group therapy Congruence/genuineness
Empathy Feedback
Goal consensus and collaboration Repair of alliance ruptures
Customizing therapy Self-disclosure
Management of countertransference

The Therapeutic Alliance

Research on empirically supported relationships has consistently identified the importance of a strong therapeutic alliance, which includes the core conditions of effective treatment described by Rogers (1957): empathy, respect, genuineness, and warmth. These dynamics typify a therapeutic relationship in which a client feels understood, safe, and encouraged to disclose intimate material. These characteristics transcend the therapist’s therapeutic orientation or approach to treatment. The therapeutic relationship, or working alliance, is an important factor in effective treatment. Clients specifically asked about what contributed to the success of treatment often point to a sense of connection with their therapist. Connectedness has been described as having feelings of closeness with the therapist, working together in an enabling atmosphere, receiving support for change, and being provided an equality of status within the working relationship (Ribner & Knei-Paz, 2002). As we noted in Chapter 2, cultural humility may be a major aspect in the therapeutic alliance contributing to cultural competence (Hook, Davis, Owen, Worthington, & Utsey, 2013; Owen et al., 2014).

Similarly, clients report that therapist behaviors such as “openness to ideas, experiences, and feelings” or being “nonjudgmental and noncritical,” “genuine,” “warm,” and “validating of experiences” are helpful in therapy (Curtis, Field, Knann-Kostman, & Mannix, 2004). A counselor’s relationship skills and ability to develop a therapeutic alliance contribute significantly to satisfaction among clients of color (Constantine, 2002). Mulvaney-Day, Earl, Diaz-Linhart, and Alegria (2011) found that relationship variables with the therapist were particularly important for African American and Latino/a clients and concluded that the basic yearning for authentic connection with a provider transcends racial categories (p. 36). Thus the importance of feeling accepted by a therapist on an emotional and cognitive level seems to be a universal prerequisite for an effective therapeutic alliance.

Conceptualization of the therapeutic alliance often comprises three elements: (a) an emotional or interpersonal bond between the therapist and the client; (b) mutual agreement on appropriate goals, with an emphasis on changes valued by the client; and (c) intervention strategies or tasks that are viewed as important and relevant by both the client and the therapist (Garber, 2004). Defined in this manner, the therapeutic alliance exerts positive influences on outcome across different treatment modalities, accounting for a substantial proportion of outcome variance (Hojat et al., 2011; Zuroff & Blatt, 2006). In fact, the therapist–client relationship contributes as much as 30 percent to the variance in therapeutic outcome (Lambert & Barley, 2001).

We believe that the therapeutic alliance is of critical importance in the outcome of therapy for ethnic minority clients and will describe possible modifications that may help clinicians enhance this relationship. It is important to remember that there is no set formula or response that will ensure the formation of a strong therapeutic alliance with a particular client. In fact, counselors often need to demonstrate behavioral flexibility to achieve a good working relationship with clients; this may be particularly true when working with individuals from diverse populations.

In a qualitative study involving Black, Asian, Latino/a, and multiracial clients, most preferred an active counselor role, which was characterized by the counselor offering concrete suggestions, providing direct answers, challenging the client’s thinking with thought-provoking questions, and providing psychoeducation regarding the therapy (Chang & Berk, 2009). Mulvaney-Day and colleagues (2011) found variability in the counseling relational style preferred by ethnic minority clients. A summary of the preferred relationship styles reported by the African American, Latino/a, and non-Latino White clients in their sample is presented in Table 9.3.

TABLE 9.3 Relational-Style Counselor Preferences of Ethnic Group Clients

Source: Mulvaney-Day et al. (2011).

Themes African American Clients Latino Clients Non-Latino White Clients
Listening Listen to who the client really is; recognize that clients are experts on themselves. Listen in a way that communicates “paying attention.” Listen so that the client is comfortable enough to talk and express feelings.
Understanding Understand beyond immediate impressions; understand hidden aspects of the client. Understand feelings of client. Understand complexity of client choices and circumstances.
Counselor Qualities Counselor should “lower” self to client’s level; egalitarian relationship. Be authoritative, but connect first, then offer concrete advice and solutions. Not judge because of social distance; maintain professional distance but be human.
Spending Time Not listed as factor Take time to connect deeply. Allow time for feelings to emerge at their own pace.

Mental health practitioners need to be adaptable with their relationship skills in order to address the preferences and expectations of their clients. For example, many African American clients appear to value social interaction as opposed to problem-solving approaches, especially during initial sessions, whereas Latino/a clients seem to prefer a more interpersonal approach rather than clinical distance (Gloria & Peregoy, 1996; Kennedy, 2003). We have also seen earlier that many Asian American clients may prefer a problem-solving approach initially. However, these are broad generalizations, and counselors must test out the effectiveness of different relational skills with a particular client, assessing the impact of their interactions with the client and asking themselves questions such as “Does the client seem to be responding positively to my relational style?” and “Have I succeeded in developing a collaborative and supportive relationship with this client?” and modifying the approach when necessary. Although it is important not to react to clients in a stereotypic manner, it is important to continually be aware of cultural and societal issues that may affect the client. Asian, Black, Latino/a, and multiracial clients who were dissatisfied in cross-racial therapy complained about their therapist’s lack of knowledge about racial identity development; the dynamics of power and privilege; the effects of racism, discrimination, and oppression due to their minority status (or multiple minority statuses); and cultural stigma associated with seeking help (Chang & Berk, 2009).

Cultural information is useful in providing general guidelines regarding an ethnic minority client’s counseling-style preference or issues that need to be addressed in therapy. However, as a counselor develops a comprehensive understanding of each client’s background, values, strengths, and concerns, it is essential that the counselor determine whether general cultural information “fits” the individual client. This ongoing “search for understanding” is important with respect to each of the following components of the therapeutic alliance.

Emotional or Interpersonal Bond

The formation of a bond between the therapist and the client is a very important aspect of the therapeutic relationship and is defined as a collaborative partnership based on empathypositive regard, genuineness, respect, warmth, and self-disclosure. For an optimal outcome, the client must feel connected with, respected by, and understood by the therapist. In addition, the therapist must identify issues that may detract from the relationship, such as countertransference (i.e., reactions to the client based on the therapist’s own personal issues). These qualities are described in detail below; their importance may vary according to the type of mental health issue being addressed and characteristics of the client (e.g., gender, socioeconomic status, ethnicity, cultural background).

The development of an emotional bond is enhanced by collaboration, a shared process in which a client’s views are respected and his or her participation is encouraged in all phases of the therapy. An egalitarian stance and encouragement of sharing and self-disclosure facilitate the development of empathy (Dyche & Zayas, 2001) and reduce the power differential between therapist and client. The potential for a positive therapeutic outcome is increased when the client is “on board” regarding the definition of the problem, identification of goals, and choice of interventions. When differences exist between a client’s view of a problem and the therapist’s theoretical conceptualization, negative dynamics are likely to occur. Collaboration regarding definition of the problem reduces this possibility and is most effective when employed consistently throughout therapy.

Empathy

Empathy is known to significantly enhance the therapeutic bondEmpathy is defined as the ability to place oneself in the client’s world, to feel or think from the client’s perspective, or to be attuned to the client. Empathy allows therapists to form an emotional bond with clients, helping the clients to feel understood. It is not enough for the therapist to simply communicate this understanding; the client must perceive the responses from the therapist as empathetic. This is why it is vital for therapists to be aware of client receptivity by evaluating both verbal and nonverbal responses from the client (“How is the client responding to what I am saying?” “What are the client’s verbal and bodily cues communicating?”). Empathy can be demonstrated in several different ways—having an emotional understanding or emotional connection with the client (emotional empathy) or understanding the client’s predicament cognitively, whether on an individual, family, or societal level (cognitive empathy). Following is an illustration of emotional empathy:

A White male therapist in his late 20s is beginning therapy with a recently immigrated 39-year-old West Indian woman. The client expresses concern about her adolescent daughter, who she describes as behaving in an angry, hostile way toward her fiancé. The woman is well dressed and is somewhat abrupt, seeming to be impatient with the therapist. Though not a parent himself, the therapist recognizes the distress behind his client’s sternness, and thinking of the struggles he had with his own father, he responds to the woman’s obvious discomfort saying, “I imagine that must hurt you.” This intuitive response from the therapist reduces the woman’s embarrassment, and she pauses from the angry story of her daughter’s ungratefulness to wipe a tear (Dyche & Zayas, 2001, p. 249).

Many counselors are trained to be very direct with emotional responses, using statements such as “You feel hurt” or “You sound hurt” in an effort to demonstrate empathy. The response “I imagine that must hurt you” would be rated a more intermediate response. Statements that are even less direct might include “Some people might feel hurt by that” or “If I was in the same situation, I would feel hurt.” We have found that people differ in their reaction to the directness of emotional empathy, depending on such factors as the gender, ethnicity, or cultural background of the counselor or the client; the degree of comfort and emotional bonding with the therapist; and the specific issue involved.

For example, when working with Asian international students, we have found that although there are individual differences in preference, many prefer a less direct style of emotional empathy. However, some Asian international students are fine with direct emotional empathy (this is why the counselor must be flexible and test out different forms of empathy with clients rather than prejudging them because of membership in a specific group). In general, recognition of emotional issues through either indirect or direct empathy increases the client’s feeling of being understood. Effective therapists continually evaluate client responses and thus are able to determine if the degree and style of emotional empathy being used is enhancing (or detracting) from the emotional bond between therapist and client.

Cognitive empathy involves the therapist’s ability to understand the issues facing the client. For example, in the case just described, the therapist might explore the possibility that the daughter’s anger is related to her immigration experiences by saying, “Sometimes moving to a new country can be difficult.” The degree of directness can be varied by making the observation tentative by prefacing statements with “I wonder if. . .?” or “Is it possible that. . .?” Cognitive empathy can also be demonstrated by communicating an understanding of the client’s worldview, including the influences of family issues or discriminatory experiences, such as racism, heterosexism, ageism, or sexism. By exploring or including broader societal elements such as these, a therapist is able to incorporate diversity or cross-cultural perspectives and potentially enhance understanding of the client’s concerns.

Communicating an understanding of different worldviews and acknowledging the possibility of cultural influences can increase the therapist’s credibility with the client. When working with diverse clients, we believe that empathy must include the ability to accept and be open to multiple perspectives of personal, societal, and cultural realities. This can be achieved by exploring the impact of cultural differences or diversity issues on client problems, goals, and solutions (Chung & Bernak, 2002; Dyche & Zayas, 2001).

Empathy may be difficult in multicultural counseling if counselors are unable to identify personal cultural blinders or values they may hold. For example, among counselors working with African American clients, those with color-blind racial attitudes (i.e., a belief that race is not a significant factor in determining one’s chances in society) showed lower levels of empathy than those who were aware of the significance of racial factors (Burkard & Knox, 2004). Some research suggests that counselors’ multicultural counseling competence (awareness of issues of race and discrimination, and knowledge of their social impact on clients) accounts for a large proportion of the variance in ratings of counselor competence, expertise, and trustworthiness made by clients of color (Constantine, 2002; Fuertes & Brobst, 2002).

In a study of gay and bisexual clients, a counselor’s universal–diversity orientation (i.e., interest in diversity, contact with diverse groups, comfort with similarities and differences) was positively related to client ratings of the therapeutic alliance, whereas, surprisingly, similarities in sexual orientation between therapist and client were not. Universal–diversity orientation may facilitate therapy through affirmation and understanding of the issues that culturally diverse clients are facing (Stracuzzi, Mohr, & Fuertes, 2011).

In contrast, the therapeutic alliance can be adversely affected when ethnic minority clients perceive a therapist to be culturally insensitive or believe that the therapist is minimizing the importance of racial and cultural issues or pathologizing cultural values or communication styles (Constantine, 2007; D. W. Sue, Bucceri, Lin, Nadal, & Torino, 2007). This finding is likely true with other diverse groups who may endure heterosexism, ageism, religious intolerance, and/or prejudice against disability. Sensitivity to the possible impact of racial and societal issues can be made through statements such as the following:

· “How have experiences with discrimination or unfairness had an impact on the problems you are dealing with?”

· “Sometimes it’s difficult to meet the societal demands of being a man (or a woman). How has this influenced your expression of emotions?”

· “Some people believe that family members should be involved in making decisions for individuals in the family. Is this true in your family?”

· “Being or feeling different can be related to messages we receive from our family, society, or religious institutions. Have you considered whether your feelings of isolation are related to messages you are getting from others?”

· “ Families change over time. What are some of the standards or values you learned as a young child? I wonder if the conflicts in your family are related to differences in expectations between you and your parents.

These examples are stated in a very tentative manner. If a counselor has sufficient information, more direct statements of cognitive empathy can be made. We believe that the perception of and response to empathy varies from individual to individual. There are no set responses that will convey empathy and understanding to all clients. In general, therapists must learn to evaluate their use of both cognitive and emotional empathy to determine whether it is improving the emotional bond with the client and to make modifications, if needed, to enhance the client’s perception of empathy within the relationship.

Positive Regard, Respect, Warmth, and Genuineness

The characteristics of positive regard, respect, warmth, and genuineness are important qualities in establishing an emotional bondPositive regard is the demonstration by the therapist that he or she sees the strengths and positive aspects of the client, including appreciation for the values and differences displayed by the client. Positive regard is demonstrated when the counselor identifies and focuses on the strengths and assets of the individual rather than attending only to deficits or problems. This is especially important for members of ethnic minorities and other diverse groups whose behaviors are often pathologized. Respect is shown by being attentive and by demonstrating that you view the client as an important person. Behaviors such as asking clients how they would like to be addressed, showing that their comments and insights are valuable, and tailoring your interaction according to their needs or values are all ways of communicating respect. Warmth is the emotional feeling received by the client when the therapist conveys verbal and nonverbal signs of appreciation and acceptance. Smiling, the use of humor, or showing interest in the client can convey this feeling. Genuineness can be displayed in many different ways. It generally means a therapist is responding to a client openly and in a “real” manner, rather than responding in accordance with expected roles. These interpersonal attributes can strengthen the therapist–client alliance and increase the client’s trust, cooperation, and motivation to participate in therapy.

Self-Disclosure

Although self-disclosure is considered to be a “promising and probably effective” technique (Ackerman et al., 2001), the topic of a therapist revealing personal thoughts or personal information remains controversial. In one study, brief or limited therapist self-disclosure in response to comparable self-disclosure by the client was associated with reductions in symptom distress and greater liking for the therapist (Barrett & Berman, 2001).

Counselor disclosure in cross-cultural situations (e.g., sharing reactions to clients’ experiences of racism or oppression) may also enhance the therapeutic alliance (Burkard, Knox, Groen, Perez, & Hess, 2006; Cashwell, Shcherbakova, & Cashwell, 2003). Self-disclosures may show the therapist’s human qualities and lead to the development of closer ties with the client. Research to determine the impact of therapist self-disclosure is difficult since it depends on many variables, such as the type of disclosure, its timing and frequency, and client characteristics. Although many clients report that therapist self-disclosure enhances the therapeutic relationship, some self-disclosures by a therapist (e.g., being wealthy or politically conservative) can actually interfere with the therapist–client relationship (Chang & Berk, 2009).

Some therapists feel that self-disclosure is not appropriate in therapy, and they either will not answer personal questions or will bounce the question back to the client. However, some clients who ask, “Has this ever happened to you?” may be doing so in an attempt to normalize their experience. Bouncing the question back to the client by saying, “Let’s find out why you want to know this,” can be perceived as patronizing rather than helpful (Hays, 2001). Should you make self-disclosures to a client? The answer is, “It depends.” Sharing experiences or reactions can strengthen the emotional bond between therapist and client. However, such self-disclosure should be limited and aimed at helping the client with his or her issues. If the requests for self-disclosure become frequent or too personal, the therapist should explore with the client the reason for the inquiries.

Management of Countertransference

Appropriate management of countertransference can enhance the therapeutic alliance, as well as minimize ruptures in the therapeutic relationship. Countertransference involves the therapist’s emotional reaction to the client based on the therapist’s own set of attitudes, beliefs, values, or experiences. These emotional reactions, whether negative or positive, can bias a therapist’s judgment when working with a client. For example, a therapist might exhibit negative reactions to a client owing to factors such as heterosexism, racism, or classism. Additionally, difficulty can occur when clients demonstrate values and perspectives similar to the therapist’s own; such similarity may reduce therapist objectivity. Therapists sometimes overidentify with clients who are similar to them and subsequently underestimate the client’s role in interpersonal difficulties. As we have seen in Chapter 3, this is most likely to happen in interracial/interethnic therapeutic relationships. These unconscious reactions can interfere with the formation of a healthy therapeutic emotional bond with the client. Because of the negative impact of countertransference, clinicians should examine their experiences, values, and beliefs when experiencing an emotional reaction to a client that is beyond what is expected from the therapy session.

A scientific frame of mind necessitates the examination of one’s own values and beliefs in order to anticipate the impact of possible differences and similarities in worldviews on the therapeutic alliance. Multicultural therapists have been in the forefront of stressing the importance of acknowledging the influence of values, preferences, and worldviews on psychotherapy and the psychotherapist. It is important to be self-aware and recognize when personal needs or values are being activated in the therapeutic relationship and to not project our reactions onto clients (Brems, 2000).

Goal Consensus

An agreement on goals between the therapist and the client (i.e., goal consensus) is another important relationship variable. Unless the client agrees on what the goals should be, little progress will be made. As therapists, we too easily envision what the appropriate outcome should be when working with a client and become dismayed or discouraged when a client does not feel the same way or seems satisfied with more limited solutions. Goals should be determined in a collaborative manner with input from both client and therapist. Although it is very important to get the client’s response in regard to the problem and goals, the therapist has the important task of clarifying client statements and providing tentative suggestions.

Clients often identify global goals, such as “wanting to improve self-esteem.” The therapist’s job is to help the client define the goal more specifically and to foster alternative ways of interpreting situations (Hilsenroth & Cromer, 2007). Concrete goals enhance the ability to measure progress in therapy. To obtain more specificity regarding a global goal, therapists can ask such questions as: “What does your low self-esteem prevent you from doing?” “How would your life be different if you had high self-esteem?” “What would you be able to do if you had more self-esteem?” or “How would you know if you are improving in self-esteem?” The answer to these questions, such as “being able to hold a job or ask for a raise,” “feeling more comfortable in group situations,” or “standing up for myself,” can help identify aspects of self-esteem that are more concrete. Each of these responses can be used to define sub-goals. A client might be asked, “What are small steps that you can make that will show you are moving in the direction of higher self-esteem?”

Once goals are identified, the client and the therapist can work together to identify which strategies and techniques will be employed to help the client achieve the stated goals. In order for interventions to be useful, they need to make sense to the client. For ethnic minority clients, interventions may require “cultural adaptation,” such as that described in the study by Huey and Pan (2006), in which the treatment of phobias was modified for Asian Americans by emphasizing the strategy of emotional control and maximizing a directive role for the therapist.

Although the selection of interventions depends upon the presenting problem and diagnosis, psychological interventions are most effective when they are consistent with client characteristics, including the client’s culture and values (La Roche, Batista, & D’Angelo, 2011). It is also important that the client believe that the therapeutic approach will be helpful. In a study by Coombs, Coleman, and Jones (2002), clients who reported “understanding the therapy process” and “having positive expectations of the therapy” were more likely to improve.

Implications of Empirically Supported Relationships (ESRs)

The effectiveness of therapy is highly dependent on the quality of the relationship between the therapist and the client. This finding transcends racial and ethnic differences and contributes up to 30 percent of the variance in treatment outcome. It is evident that the relationship between the therapist and the client is critical. In many cases, when given a choice, clients would select a less effective treatment if it were provided by a caring, empathetic therapist. Ethnic minorities may differ in their relational styles preferences, so therapists should be flexible and evaluate the degree of fit between their relational style and that preferred by their client, and should vary their approach, if necessary, to improve the therapeutic alliance. As mentioned by Benish, Quintana, and Wampold (2011), exploring the “illness myth” of the client in regard to his or her beliefs regarding etiology, course, and treatment is highly important in the therapeutic relationship and can enhance collaborative identification of goals and interventions.

Reflection and Discussion Questions

1. What was your therapy training in regard to the formation of the therapeutic alliance with a client? Indicate how the relationship skills were discussed in relation to cross-cultural competence.

2. What is your experience in working with ethnic minorities or other diverse populations? Did they appear to require different relationship skills? Did you evaluate the effectiveness of your responses?

Evidence-Based Practice (EBP) and Diversity Issues in Counseling

The American Psychological Association’s focus on empirically supported relationships (ESRs) provided an opening for counselors to address multicultural concerns within an evidence-based framework. However, the broader and more recent focus on evidence-based practice (EBP) has more formally introduced cultural sensitivity as an essential consideration in assessment, case conceptualization, and selection of interventions. Specifically, EBP refers to “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (American Psychological Association, Presidential Task Force on Evidence-Based Practice, 2006, p. 273). (See Figure 9.1.)

Figure 9.1  Three Pillars of Evidence-Based Practice

Source: Morales & Norcross (2010), p. 824.

Empirically based practice includes both evidence-based treatments and relationship variables but is broader and more comprehensive than a combination of the two. How does EBP differ from the EST and ESR frameworks?

First, the assumption underlying EBP is that the search for the “best research evidence” begins with a comprehensive understanding of the client’s background and problem and goes on to consider which therapeutic approach is most likely to provide the best outcome. In other words, the selection of intervention occurs only after individual characteristics, such as cultural background, values, and preferences, are assessed. This allows for the individualizing of therapy with strong consideration given to client background and characteristics.

Second, unlike ESTs, which rely primarily on randomized controlled trials, EBP also accepts research evidence from qualitative studies, clinical observations, systematic case studies, and interventions delivered in naturalistic settings. This broadening of the definition of research allows mental health professionals greater latitude in deciding which therapy may be the best match for a particular client. For example, the National Registry of Evidence-based Programs and Practices (NREPP) provides specific information regarding treatments for substance abuse that consider the race and ethnicity of the participants, and treatments designed for certain ethnic groups, such as the American Indian Life Skills Development Program (Berke, Rozell, Hogan, Norcross, & Karpiak, 2011).

Third, the definition of clinical expertise within the EBP framework focuses not only on the quality of the therapeutic relationship and therapeutic alliance but also on skills essential for comprehensive assessment of the client’s problem and strengths. Additionally, EBP considers clinical expertise involving factors such as knowledge about cultural differences; best practices in assessment, diagnosis, and case conceptualization; strategies for evaluating and selecting appropriate research-based treatments; and adapting selected treatments in a manner that respects the client’s worldview, values, and preferences.

Fourth, EBP is based on an ongoing emphasis on client characteristics, culture, and preferences and the importance of working collaboratively with the client to develop goals and treatment strategies that are mutually agreeable. Identification of client variables includes (a) age and life stage, (b) sociocultural factors (e.g., gender, sexual orientation, ethnicity, disability), (c) environmental stressors (e.g., unemployment, recent life events, racism, health disparities), and (d) personal treatment preferences (i.e., treatment expectations, goals, and beliefs).

Because the focus is on the client and the consideration of cultural variables, EBP sets the stage for a multiculturally sensitive counseling relationship. The following illustration of how EBP and multicultural sensitivity can be integrated is based on the case of Anna, an American Indian female who developed PTSD following a sexual assault.

Anna is a 14-year-old American Indian female who was sexually abused by a 22-year-old male in her small community. Anna disclosed the abuse to her school counselor, who then reported the incident to tribal law enforcement. After word of the incident spread through the community, several individuals accused Anna of lying and then harassed her in an attempt to recant her allegation. Anna began isolating herself at home and stopped attending school. Anna became increasingly depressed and demonstrated symptoms consistent with PTSD. (BigFoot & Schmidt, 2010, p. 854)

BigFoot and Schmidt (2010) were able to meld American Indian traditional healing processes and cultural teachings within an EBP framework. Aspects of this process included assessment of Anna’s personal characteristics and preferences and the influence of culture on her reactions to the trauma. Following careful assessment, intervention strategies were selected based on assessment data, therapist expertise, research regarding effective treatments for posttraumatic stress, and cultural adaptation of the therapy selected. The steps involved the following:

· Research-supported treatments for childhood or adolescent trauma were identified. Trauma-focused cognitive-behavioral therapy (TF-CBT) was chosen because it was seen to complement many of the traditional healing practices used in Anna’s tribe, including traditional beliefs about the relationship between emotions, beliefs, and behaviors. TF-CBT is a conjoint child and family psychotherapy that has been comprehensively evaluated and designated by the National Crime Victims Research and Treatment Center as having the highest level of research support as an “efficacious treatment” for childhood abuse and trauma.

TF-CBT has been evaluated with Caucasian and African American children and adapted for American Indian/Alaska Native populations, Latinos, hearing-impaired individuals, immigrant Cambodians, and children of countries including Zambia, Uganda, South Africa, Pakistan, the Netherlands, Norway, Sweden, Germany, and Cambodia (National Child Traumatic Stress Network, 2008). The components of TF-CBT include a focus on reducing negative emotional and behavioral responses resulting from trauma and correcting trauma-related beliefs through gradual exposure to memories and emotional associations with the traumatic event. Relaxation training is used to reduce negative emotions. Parents are included in the treatment process as emotional support for the child; parents are provided with strategies for helping to manage their child’s emotional reaction to the trauma.

· Client characteristics and values were identified through interviews with Anna and her family and by assessing their tribal and cultural identity. In Anna’s case, both she and her family agreed that she had a strong American

· Indian identity and valued traditional healing approaches. Thus it was decided that a culturally adapted TF-CBT would be the most appropriate. (If Anna and her family had expressed minimal tribal or American Indian cultural identification, standard TF-CBT might have been the treatment of choice.)

· Cultural adaptations of TF-CBT were developed. Because of cultural beliefs that trauma can bring about disharmony and result in distorted beliefs and unhealthy behaviors, traditional healing efforts focus on returning the individual to a state of harmony through teachings, ceremonies, and tribal practices, including a ritual called Honoring Children, Mending the Circle (HC-MC). The Circle represents the interconnectedness of spirituality and healing and the belief that all things have a spiritual nature; prayers, tribal practices, and rituals connect the physical and the spiritual worlds, bringing wellness and harmony. Additionally, adaptation of the affect management, relaxation, cognitive coping, and enhancing the parent–child relationship aspects of TF-CBT incorporated spiritual (saying prayers), relational (support from friends and family), mental (hearing messages of love and support), and physical (helping Anna reacquire physical balance) supports, thus increasing Anna’s feelings of safety and security.

Further adaptation involved the TF-CBT goal of extinguishing the fear response using a “trauma narrative” during which the child “revisits” the traumatic incident and is gradually exposed to threatening cues. In the adaptation, culturally accepted methods for telling the trauma story—including use of a journey stick, tribal dances, and storytelling procedure—were used to facilitate exposure. Relaxation techniques were also adapted by having Anna breathe deeply while focused on culturally relevant images, such as the “sway of wind-swept grasses” or the movement of a “woman’s shawl during a ceremonial dance.”

As BigFoot and Schmidt concluded, “the adaption of TF-CBT within an American Indian/Alaskan Native well-being framework can enhance healing through the blending of science and indigenous cultures. . .The HC-MC adaptation seeks to honor what makes American Indians and Alaska Natives culturally unique through respecting beliefs, practices, and traditions within their families, communities, tribes, and villages that are inherently healing” (2010, p. 855).

Reflection and Discussion Questions

1. What is your reaction to EBP, especially as it applies to ethnic minorities and other diverse populations?

2. It is clear that using an EBP approach requires greater time and effort on the part of clinicians to develop a treatment plan. The implication is that counselors must do out-of-office education or consultation regarding what is available in the research literature that would help inform their practice. Is such an approach too time-consuming? Given that EBP research is exploding in the field, how would you keep current or informed as a practitioner?

Implications for Clinical Practice

1. Realize that the early EST formulations inadequately addressed the needs of marginalized groups in our society, but have begun to incorporate cultural contexts in modifying evidence-based approaches. The standards used to determine ESTs and ESRs were often too rigid and ignored the cultural context in advocating for the role of science and research in the selection of therapeutic treatments and interventions.

2. Be aware that most mental health professionals have moved to the concept of EBP, (a) allowing for a broader array of means to determine the selection, process, and outcome of effective treatments and (b) integrating cultural factors and/or modifying approaches to fit the needs of diverse clients.

3. Know that multicultural counseling and EBP are “strange bedfellows no more” and that it is no longer adequate to devise a treatment plan solely on the basis of one’s theoretical orientation, clinical intuition, or clinical expertise.

4. Be aware that EBP models focusing on client characteristics and evaluating the degree of fit between a therapeutic approach and an individual client have actually legitimized the outcry of those in the field of multicultural counseling—that it is essential to consider the cultural beliefs and values of the client and that relational counselor styles may need to vary according to an individual’s cultural background.

5. Know that the integration of EBP and multiculturalism is resulting in an explosion of research. With the emphasis of the former on client characteristics, values, preference, and culture, EBP and multicultural therapy are becoming inextricably entwined, with each approach adding strengths to the other.

6. Understand that EBP can provide clinicians with information regarding which therapies are most effective with which specific disorders and which specific population. Thus, in choosing a treatment strategy, the best approach (given the current state of research) is for the counselor to select an intervention that is research based (if available) and subsequently adapt the approach for the individual client according to the client’s individual characteristics, values, and preferences.

7. Know that culturally competent counseling and therapy is more than a technique-driven search for effective techniques and strategies. We now know that the therapeutic alliance or working relationship is crucial to therapeutic outcome.

8. Be prepared to modify your therapeutic style to be consistent with the cultural values, life styles, and needs of culturally diverse clients. Remember, respect, unconditional positive regard, warmth, and empathy are most effective in the therapeutic alliance when they are communicated in a culturally consistent manner.

9. Be aware that some research suggests that a counselor’s multicultural counseling competence and humility (awareness of issues of race and discrimination and knowledge of their social impact on clients) accounts for a large proportion of the variance in ratings of counselor competence, expertise, and trustworthiness made by clients of color.

10. It is important to note that most approaches to counseling and therapy attempt to adapt the research findings of EBP to fit the unique cultural characteristics and needs of diverse populations. But what if we approach the challenge to develop culturally appropriate therapeutic techniques and relationships from an indigenous perspective first? This is a question we address in Chapter 10Non-Western Indigenous Methods of Healing.

Summary

The importance of evidence-based practice is becoming increasingly accepted in the field of multicultural counseling. Discussions of EBP originally focused on research-supported therapies for specific disorders, but the dialogue has now broadened to contain clinical expertise, including understanding the influence of individual and cultural differences on treatment and the importance of considering client characteristics and culture. Although optimism about the convergence of these forces is increasing, there is still resistance to EBP among some individuals within the field of multicultural counseling. The applicability of EBP for many diverse groups has been insufficiently researched, and the concept of “evidence” has historically been very narrow. Furthermore, the therapist–client relationship is not adequately acknowledged in the evidence-based treatment and empirically supported treatment formulations.

It is now widely agreed that the quality of the working relationship between the therapist and the client is consistently related to treatment outcome and has led to the formulation of empirically supported relationships. A number of relationship variables are considered effective based on research findings. ESR variables include the development of a strong therapeutic alliance, a solid interpersonal bond (i.e., a collaborative, empathetic relationship based on positive regard, respect, warmth, and genuineness), effective management of countertransference, and goal consensus—all factors known to be critical for effective multicultural counseling.

The assumption underlying EBP is that the best research evidence begins with a comprehensive understanding of the client’s background and problem and goes on to consider which therapeutic approach is most likely to provide the best outcome. This allows for the individualizing of therapy with strong consideration given to client background and characteristics. It broadens the definition of research and allows mental health professionals greater latitude in deciding which therapy may be the best match for a particular client. EBP is based on an ongoing emphasis on client characteristics, culture, and preferences and the importance of working collaboratively with the client to develop goals and treatment strategies that are mutually agreeable. Because the focus is on the client and the consideration of cultural variables, EBP sets the stage for a multiculturally sensitive counseling relationship.

Glossary Terms

Place this order or similar order and get an amazing discount. USE Discount code “GET20” for 20% discount