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Culture and Psychotherapy: What Does the Research Say?

August 7, 2020 By scottdm 5 Comments

MLK shotI remember exactly where I was on April 4th, 1968 — in a pool doing laps.  I was a junior member of my hometown’s swim team.   I’d barely started when the coach blew his whistle calling the practice to an abrupt halt.  As we toweled off, he told us something terrible had happened.  It was first time I recall hearing the name, Martin Luther King, Jr..

If I close my eyes, I can easily call up other, vivid memories of traumatic, culture-changing events.  The death of Robert Kennedy.  The Challenger explosion.  The attack on the World Trade Center.  And now, only slightly more than half way through the present year, many more.  The first days of the outbreak and lockdown.  The running tally of deaths on the nightly news.  The lines of people at our local foodbanks.  The images of George Floyd being killed, and weeks of protests against racism and inequality that have followed.

Then and now, I struggle with a stark choice; specifically, to connect or disconnect with events as they unfold.  After all, so much is happening in the kennedyworld and I only have so much bandwidth — and as a person with many advantages, I can disconnect with little real consequence to the well-being of myself and my family.

In the end, however,  I feel ethically compelled to connect, listen, or perhaps more accurately state, hear people — not because I see myself as knowing what to do, but rather because I want to understand if and how I can be helpful.

So, what does the research indicate?

When I was in graduate school, human diversity was treated in what might be called, “the chapter approach.”  Here’s what the field knows about men, for instance, with another on women, African-Americans, Latinos, and so on.  This approach can be directly traced to social, historical, and political events beginning in the 1960’s, and a then growing awareness of the lack of attention paid to diversity in the field of mental health– in particular, culture, race, religion, socioeconomic status, sexual orientation, etc.

For several decades, researchers have built on this framework, developing and testing what have come to be known as “culturally adapted” psychological treatments (e.g., CBT for Latina Women or people of Asian heritage).  Despite years of effort, including scores of randomized trails and meta-analyses,  experts conclude, “Current evidence does not offer a solution to the issue of which components of cultural adaptation are effective, for what population, and whether cultural adaptation works better than noncultural adaption” (1).

floydPart of the problem with this approach is the sheer number of possible adaptations quickly becomes unmanageable. To illustrate, in developing a culturally adapted psychotherapy, where adjustments are made along only 4 of the 13 officially identified dimensions of diversity, a total of 715 different ways exist to adapt service delivery to fit the individual.  Obviously, any approach that results in so many variations is absurd, making it impossible to apply in the real world and risking being nothing more than window dressing — a kind of superficial “gift wrapping” that conceals more than it helps to reveal the identities and objectives of the participants.  More importantly, however, is that the current approach makes a priori decisions about which dimensions are most important to consider when planning and delivering treatment.

What then are therapists who wish to connect more effectively with a broad and diverse clientele to do?  Research makes clear when practitioners are open to exploring clients’ values, background, and culture, good results follow.  Such evidence suggests, in place of competence (i.e., achieving a certain level of pre-determined knowledge about and skills for working with various cultural groups), its better to have an orientation to treatment that enables practitioners to attend to and integrate cultural dynamics as they naturally occur in the therapy process.

One of the lead researchers on multicultural orientation is Professor Jesse Owen at the University of Denver.  Together with a team of investigators, he’s identified three core principles that both encompass and can guide a therapist’s attitudes, in-and-between session actions, and personal reactions regarding the role of culture in therapy.  Interestingly, much of what he and the group have discovered fits with what my colleagues and I have been learning from our study of highly effective psychotherapists.  I won’t give it away here.  You can watch the interview yourself.

OK.  That’s it for now.  Please let me know your thoughts.

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Intensive Oct 2020 online

 

 

Filed Under: Feedback Informed Treatment - FIT

Comments

  1. Nikki says

    August 11, 2020 at 9:33 am

    Thanks for sharing Scott. Very timely, as I’ve recently started a Post grad paper on engagement in rehabilitation with a focus on engagement with Māori (NZ). I’ll definitely be looking into Jesse’s papers.

    Reply
  2. Joseph Maizlish says

    August 11, 2020 at 5:21 pm

    The term “cultural humility” responds to concerns I’ve had since my graduate course long ago in cultures and psychotherapy, which though informative did not caution us against stereotyping and presumption, the dehumanization about which Dr. Owen warned. Each patient is their own culture, their own mix of identities, values, and the experiences that brought the client to carry them.

    That “humility” sounds lot like Feedback-Informed Therapy, with its inquiry about and readiness to consider patient responses.

    Since early life attachment problems are causally related to many problems in later childhood and adulthood, it makes sense that the approach of FIT and Dr. Owen’s Framework are a good match for good outcomes!

    Reply
  3. gloria sayler says

    August 11, 2020 at 6:18 pm

    Thanks, Scott. I find this very useful. As a social worker, I was trained to start where the client is, and that included the cultural context as well as the familial and personal one. I have found that allows me to not prejudge or categorize a client and his/her/their dilemmas.

    Reply
  4. Jim Reynolds says

    August 11, 2020 at 9:01 pm

    Dear Scott,

    Your blog interview with Jesse Owen was really interesting. I love that his 3-pillar framework starts off with humility. On that note, I confess my first reaction when seeing him on the video was along the lines of –

    “Oh great, another White guy talking about other cultures.” That was my first, unguarded response that was quickly followed by recognizing how judgmental that was and reminding myself to be more open minded. You can imagine the irony of me then hearing his self-description as a male, White-passing, bi-racial person.

    My Sesame Street word for the day – humility.

    Jim

    Reply
  5. Michael McCarthy says

    August 19, 2020 at 12:08 am

    I agree, Scott. We cannot make assumptions based only on ethnicity, gender, race, faith, sexual orientation, gender identity or any other characteristics. The research I’ve seen indicates the f-values show that there is more diversity within groups than between.

    I have an anecdote. I was coming back from a mid-session break one time, only to hear a fellow student (female and White) say to the Black instructor that she was raised “poor” so she had a special understanding of what it meant to be Black

    The instructor replied, “Where did you get the idea that all Black folks are poor?”

    Clients are more than happy to share what their characteristic mean to them.

    Reply

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