Multiculturally Competent Psychotherapy

Introduction

Psychotherapy is one of the major interventions used in psychiatry. Over the years psychotherapy has evolved to include the use of empirically supported treatments in practice. Empirically supported treatments are psychotherapies that have been shown to be effective in the treatment of specific mental health disorders. For a treatment to be considered as empirical, it has to satisfy the following criteria. It has to show that it is superior to a placebo or it should be equal to an already established treatment in at least two random control trials (Roche & Christopher, 2008). Specialist research centers agree on the efficacy of cognitive behavioral therapy (CBT) as an empirically supported treatment for various psychological problems (Durham, 2000). We live in a society with diverse demographics that account for cultural differences. Individual differences come in form of ethnicity, race, spirituality, gender, sexuality and age. In the context of psychology, it calls for culturally sensitive therapies since the counselor and the client do form part of this culturally diverse society. Culturally sensitive empirically supported treatments have been cited as the future of psychotherapy, yet questions still arise as to the relevance of this treatment in certain populations. There is no empirically supported treatment that meets all the criteria that indicates treatment efficacy amongst minority groups.

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Culturally sensitive therapies

Culturally sensitive therapies are the product of culturally sensitive therapists, who are aware of their own culture as well as the culture of their client (Cardemil, 2008). Empirically supported therapies like cognitive behavior therapy can be incorporated into any of these culturally sensitive therapies that serve to make culture their main focus. It has been shown through research that clients from minority groups do not prioritize psychiatric counseling. Many of them relate counseling to particularly white ethnic groups of middle or higher classes. This mindset serves to alienate people from other cultures. Initially, counselors used one style of interviewing and applied it to all clients. In the spirit of universality and essentialism, earlier concepts actually applied western concepts to non –western cultures. This approach was found to have its challenges in addressing cultural differences, especially in addressing the issue of racism since it fails to empower individuals to overcome the cultural obstacles set by society.

Several studies have been done that all seem to find a common ground in the fact that racial and ethnic minority groups do not seem to benefit from psychotherapeutic interventions that are designed for whites. Since these minority groups do not seek out psychiatric help, the disability burden that arises from unmet mental health needs is comparatively higher than in cultures that use psychiatric interventions. Cultural prejudices such as racism, poverty, lack of education, violence and political neglect all play a role in affecting the mental health of these minority groups. For this reason, psychotherapists have found it necessary to develop a multicultural approach to counseling. Cultural sensitivity provides counselors with the proper guiding principles to develop an entirely new treatment approach that takes into account the impact of culture on a client’s behavior (Schaeffer & Martin, 1975).

Culture

Culture can be defined as a dynamic process that borrows from international views and ways of living in a physical and social environment that is shared by groups and passed on from generation to generation. Each client is unique and when they approach a counselor for psychiatric help, it is the duty of the counselor to appreciate these individual cultural differences. Therapeutic treatments such as CBT need to address cultural differences by incorporating specific cultural conceptions to help the counselor understand the societal structure issues that affect client behavior, most notably race, gender, sexual orientation and social class. A theory of multicultural counseling was put forward by Sue (1998) in which the shortcomings that accompany current counseling theories are challenged. The current theories of psychotherapy do not sufficiently deal with the issue of cultural diversity brought about by demographic differences. They fail to project culture as a complex melt pot of individuals rather than the assumption that culture is chaotic. Another point to note is that demographic differences are rapidly taking root in our society to such an extent that psychotherapists and counselors come across a wide variety of client groups who are different from each other on the basis of ethnicity, race and culture.

Effect of cultural identity

Multicultural therapy is culture-centered and acknowledges that cultural identity is dynamic and keeps changing depending on the situation. Psychotherapist should be aware of the client’s culture and background in order to understand the best way to approach the counseling section. Clients have different cultural backgrounds that affect their behavior. It requires that the psychotherapist be culturally competent. Cultural competence entails being aware of the importance of culture and knowing how to incorporate it in the assessment of cross-cultural relations. It also demands vigilance towards the dynamics that result from cultural differences and extending this cultural knowledge to meet the culturally unique needs of their clients (Whaley & King, 2007). Cultural identity is an important aspect in multicultural therapy. For example, an individual may develop a preference for a particular food, simply because it is what they were used to in their culture.

Therefore, adapting to another type of food outside their culture may prove to be challenging. On the other hand, an individual may be influenced by the foreign culture of the society in which he finds himself. Cultural identity is not static but keeps on changing ad the context changes. Similarly acquisition of cultures by individuals may affect their mental health and psychosocial development (Roche & Christopher, 2008). This can either be negative or positive. Cultural assimilation is negative when the foreign culture does not make the individual comfortable. It is good for psychological development especially if the ethnic community is large enough to enable them blend in with the larger community. People may get discriminated in case they fail to thrive in the culture that they are in at a given point in time. This situation may even make them become incapacitated mentally. A psychotherapeutic intervention should not overlook an individual’s acculturation strategy and the flexibility of this culture with the environment.

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Effect of family on shaping behavior

Family is also an important factor for a therapist to understand the cognitive behavior of a client. Family dynamics are influenced by culture. A therapist will have to understand the client’s relations with his family and the larger community and the dominant society in order to gauge the problems that may be the result of acculturative stress and intercultural conflict (Helms & Cook, 1999).

Client/therapist relationship

The attitudes and behavior of a therapist/counselor are very important especially when working with a culturally diverse population. The counselor should be able to understand and develop a strong therapeutic relationship with his client. In order to cultivate this understanding, the therapist needs to have adequate knowledge about different cultures and the underlying issues that affect them. This will help the counselor to develop a counseling approach that is relevant to each culture. Psychotherapies that take a multicultural approach place more value on the relationship between the client and the therapist as well as looking into the sociocultural developmental issues that affect behavior, mainly race, ethnicity, spirituality, religion and social class struggles.

This allows for a seamless flow between conceptualizing the actual problem and the treatment intervention. One such example is the adoption of the cuento therapy which was developed to treat mental disorders in Puerto Rican children. This therapy used culturally relevant values that the children could easily identify with through the use of folktales. Using a therapeutic intervention that bears a cultural meaning is important in motivating the children to pay attention to the therapeutic processes based on their cultural beliefs, values and behaviors (Costantino, Malgady & Rogler, 1986). It was relatively easier for these children to respond to culturally sensitive therapy as compared to the use of standard interventions.

Importance of cultural competency to therapists

Cultural competency is advocated as an important skill for therapists to acquire if they want to achieve higher levels of positive results among their culturally diverse clients. The desirability of cultural competence is that the skill can be learned. It is also flexible, to mean that therapists who ascribe to different schools of psychological thought can use the approach. Moreover, it can be applied in different mental health settings as well as with clients from different racial, ethnic and cultural backgrounds. Despite these advantages, multicultural therapies also have their weaknesses. First and foremost, there is no much difference in the outcomes of standard interventions and culturally adapted interventions and as such, there is general lack of evidence to support its efficacy. Adapting these interventions for each cultural group also proves to be very slow. Training psychotherapists to be culturally competent is very labor intensive and also contributes to the slow pace in which these interventions are adapted. A multicultural approach also seems to generalize culture and fails to acknowledge the heterogeneity that exists within different cultures. A good example in practice would be trying to impose a culturally adapted intervention on a culturally assimilated individual. The desired outcome may not be achieved.

Need for multicultural therapies

In recent times, there has been a growing need for psychotherapists and counselors to be culturally competent because of the increasing shift in the socio-demographics that spell cultural difference (Hays, 2008). The growing cultural differences make it necessary that psychotherapeutic treatments address the needs of a multicultural society. Another reason is that psychotherapy has long been associated with white people of middle social class, thus alienating other ethnic minorities. There is need to address these ethnic disparities in order for therapy to be an all-inclusive discipline.

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Cultural diversity is an important factor that influences human behavior. It requires specialized knowledge and skills for the counselor to make an assessment of the client’s behavior. The Cognitive behavior therapy allows the clients to understand the behavior and the factors that affect their behavior. Now, behavior is subject to a number of factors including genetics, environment, and learning and life experiences. Cognitive Behavior Therapy in a multicultural set-up requires that the counselor should have cultural self-awareness, where he /she completely understand his/her culture. The counselor should be aware of other people’s culture, in this case, the client’s. Thereafter, the counselor can develop appropriate strategies for intervention that best suit his client’s needs. These strategies build on attitudes, beliefs, knowledge and skills. Their inclusion in empirically supported treatments like cognitive behavior therapy makes it more appropriate in a multicultural environment. The importance of skills training and the relationship between client and counselor could not be better stressed (Cardemil, 2008).

Therapy in context

When the client and the counselor are from different cultures, the interventions that the counselor develops to aid his client should allow basic research especially if the client comes from an identified minority group. In order to identify which components of the intervention are relevant to the client, the counselor can apply a standard intervention to the specific ethnic group without any modifications. Finally, the counselor can examine that particular intervention from the perspective of cultural competence which he can then use to assess the potential cultural match of the intervention’s components to the client. Let us look at an example of a poor, Latino single mother who suffers from depression due to the complexities of her existence. A psychotherapist does his research and comes up with the conclusion that the woman likely suffers from depression. The counselor then modifies components of the intervention in order to pick out components that best suit the client. In this case, he can modify service delivery to arrange for the woman’s children to be taken care as well as providing transportation to allow her attend the therapy session.

The nature of the therapeutic relationship can also be changed by having the counselor educate the woman about depression and its treatment before delivering the intervention (Arredondo & Perez, 2003). The CBT intervention is adapted to suit the particular culture of the client. For example, the language used should be relevant to the client’s culture. The counselor can also acknowledge the values and experiences that are unique to that particular culture such as stress due to immigration issues and low socio-economic status. Clearly, adapting cognitive behavior therapy to incorporate a client’s cultural experiences that shapes their behavior becomes more relevant as compared to standard psychotherapeutic interventions. The results are positive and therefore the approach is better at treating psychological problems. Using cognitive behavior therapy as an empirically supported treatment together with adapted interventions is effective in treating psychological problems amongst cultural minority groups. The therapist can establish manual-based treatments and adapt them for a particular culture or he can create new treatments that are meant for a specific cultural group. In as much as culturally adapted interventions may not influence the final results of therapy, they have been found to be effective during the actual therapy session. Individual cultural preferences determine the overall success of the therapy treatment by gauging the client’s responsiveness.

Cultural adaptation in therapy

The success of mental health service delivery therefore lies in the adaptation of cultural competence. This will help alleviate major challenges that come with multicultural counseling mainly the need to seek psychotherapeutic treatment and the ability to continue with therapy until positive results are realized (Brain, 1998). Cultural adaptation in CBT may help increase the number of people seeking mental health services by making the treatment more culturally relevant and attractive to individuals from different cultures. Psychotherapy is a dynamic area that will keep on changing as researchers come up with various test hypotheses. Cultural adaptation allows for an expanded evidence-based practice that enables the inclusion of this hypothesis. Furthermore, the future of professional psychology lies in the integration of cultural competence as our society grows on an ever-increasing sociodemographic scale. It is generally agreed that culture does encompass individual experiences in the context of their culture.

In therapy, it is assumed that individuals can also have some influence in changing their cultural context, especially if it adversely affects their behavior. Psychotherapy must therefore take into account the multicultural differences in terms of treatment factors, methodologies, the client/therapist relationship and the contextual characteristics. An empirically supported treatment should offer maximal efficacy in the treatment of psychiatric disorders. The main purpose of incorporating culture is so as to develop interventions that are suitable for use by all individuals. Generalizing on psychotherapeutic interventions may sideline cultural influences that are specific to a particular group (Artkinson, Morton & Sue, 1998). In the case where a treatment intervention is transported to a cultural group that it was not intended for, proper assessment is necessary so that the treatment remains consistent with meaning systems of a client’s culture.

Patient/therapist characteristics

Differences in patient/therapist characteristics in terms of personality traits, interpersonal skills or distress tolerance usually greatly influence the way a client responds to treatment. This is why emphasis is made on the need for therapists to be culturally competent in order to work effectively with their clients. The match between the therapist’s culture and that of the client also has an impact on the outcome of the therapeutic intervention (Lo & Fung, 2003). Individuals tend to feel comfortable around others with whom they share similarities, in this case, in the cultural context. Conclusive research in this area shows that nearly half the number of clients who start therapy with a therapist from a different culture than their own is likely not to complete the therapy sessions. It all boils down to people from similar cultures understanding the challenges inherent in their culture that affect their lives. It is this understanding that cultural competence seeks to achieve.

The earlier forms of therapy focused on the immediate interpersonal context of the treatment. Contemporary cognitive behavioral therapy as well as other empirically supported treatments now seeks to conceptualize the psychotherapeutic process as being affected by history, environment, community events such as violence and sociopolitical forces like racial discrimination. Psychological researchers are mandated to develop objective strategies to help in the assessment of clients’ diverse, complex and changing socioeconomic and cultural context and possibly link them to specific psychological outcomes (Alvidrez, Azocar & Miranda, 1996).

Individual vs. community approach

Many therapies look at change as something that occurs within an individual therefore the outcome of treatment measure reflects this individual change. These measures include self-esteem, ego, self-actualization and self-control. Therapies such as cognitive behavioral therapy aim to change or improve a person’s behavior therefore using these measures are in line with psychiatric practice. Psychiatric interventions should also be expanded to include community-based treatment elements and to develop outcome measures that reflect these changes such as community empowerment. A treatment concept that focuses on individual change fails because then it will only be viewed as a vehicle that drives change within an individual that is not reflective of the values held by the wider society. Using psychotherapy as an agent of transforming the cultural context makes it more reflective of the needs of individuals that come from different cultures who often are the victims of these very cultures.

Conclusion

There is need for empirically supported therapies like cognitive behavioral therapy to be culturally competent and to adopt a conceptual framework that includes a deeper understanding of culture. Multicultural understanding must come out strongly starting from the design, methodologies and conceptual models. Psychotherapists need to have a clear understanding of culture and objectively look at how culture can influence treatment factors, methodologies, the characteristics of the client and therapist as well as their relationship and the contextual characteristics. Culture should be seen as dynamic, complex and deeply ingrained within the geographical and historical context. In order to be effective in the treatment of psychiatric disorders among a wide cross-section of people, psychotherapeutic interventions must have a multicultural context. Culture is an important factor that influences the behavior of an individual and is an indicator that therapists should look out for in cognitive behavioral therapy. Since the clients have different cultural backgrounds, then the psychotherapist should understand all of them and approach them accordingly. Each may need a different treatment depending on their behavior.

Reference List

Alvidrez, J., Azocar, F & Miranda, J. (1996). Demystifying the concept of ethnicity for psychotherapy researchers. Journal of consulting and clinical psychology, 2(1), 903-908.

Arredondo, P., & Perez, P. (2003). Counseling paradigms for Latin Americans:contemporary considerations. Boston: Allyn & Bacon.

Artkinson, D., Morton, G & Sue, D. (1998). Counseling American minorities: A cross-cultural perspective. New York: McGraw-Hill.

Brain, C. (1998). Advanced psychology. New York: Nelson & Thomas.

Cardemil, E. V. (2008). Culturally sensitive treatments:Need for an organizing framework. Culture Psychology, 3(2), 1- 357.

Costantino, G., Malgady, R & Rogler, L. (1986). Cuento therapy:A culturally sensitive modality for Puerto Rican children. Journal of consulting and clinical psychology, 6(2), 639-645.

Durham, R. (2000). Complexity and collaboration in routine practice of CBT. Journal of mental health, 1(2), 429-444.

Hays, P. (2008). Addressing cultural complexities in practice. Washington: American Psychological Association.

Helms, J & Cook, D. (1999). Using race and culture in counseling and psychotherapy. Boston: Allyn & Bacon.

Lo, H & Fung, K. (2003). Culturally Competent Psychotherapy. Canadian Journal of Psychiatry, 1(2), 161-170.

Roche, M & Christopher, M. (2008). Culture and empirically supported treatments:On the road to a collision? Culture Psychology, 3(1), 1- 333.

Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychology, 1(2), 440-448.

Whaley, A & King, D. (2007). Cultural competence and evidence-based practice in mental health services. Austin: University of Texas.

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