Multicultural Theories
of Psychotherapies
Slides created by
Barbara A. Cubic, Ph.D.
Professor
Eastern Virginia Medical School
To accompany
Current Psychotherapies 10
Learning Objectives
 This
presentation will focus on:
• Overview of multicultural issues
related to psychotherapies
• History of multicultural
approaches
• Ways to integrate multicultural
issues into therapies
• Research on multiculturalism
Are Prevailing Therapies
Relevant to the Culturally Diverse?
Most therapeutic orientations
recognize individual differences
must be respected.
 However, dominant models of
psychotherapy tend to be grounded
in a monocultural perspective.
 As such, they support mainstream
cultural values that neglect
multicultural worldviews.

Dominant Models
of Psychotherapy

May unintentionally promote
ethnocentrism.
• The belief that one’s worldview is
inherently superior and desirable to
others.
Terminology
 Culture is defined as an


individual’s total environment.
Worldview refers to people’s
systemized ideas and beliefs
about the universe.
Multicultural refers to the
interaction between people
across a culture.
Multicultural Psychotherapies

Promote cultural sensitivity.
• Awareness, respect, and appreciation
for cultural diversity.
Believe definitions of health,
illness, healing, normality, and
abnormality are culturally
embedded.
 Promote empowerment and social
justice and affirm strengths.

Multicultural Psychotherapies
Consider power differentials based on:
•
•
•
•
Race
Gender
Social class
Sexual
orientation
• Age
• Religion
•
•
•
•
•
•
National origin
Ability/disability
Language
Place of residence
Ideology
Membership in
other marginalized
groups
Unity through
diversity is a
multicultural maxim.
BASIC
CONCEPTS
Multiculturalism



Acknowledges the presence of diverse
worldviews.
Views each culture as unique and
dynamic, to be understood within its
own context.
Embodies cultural constructionism.
• A process whereby individuals construct
their world through social processes that
contain cultural symbols and metaphors.
Worldviews

Harry Triandis (1995)
• Classified worldviews according to
how individuals define themselves
and relate to others across an
individualist-collective spectrum.
– Collectivistic: Identity is associated with
relationships to others.
– Denominated: View themselves
independently from others.
Multicultural Psychotherapists

Work towards cultural competence,
an individual.
• Becomes aware of their worldview.
• Examines their attitude towards
cultural differences.
• Learns about different worldviews.
• Develops multicultural skills.
• Learns about one’s position in
relation to societal power and
privilege.
Multicultural Guidelines

Guidelines for Providers of
Psychological Services to Ethnic,
Linguistic, and Culturally Diverse Clients
• Exhorted practitioners to:
– Recognize cultural diversity.
– Understand central role culture, ethnicity, and race
play in culturally diverse individuals.
– Appreciate the significant impact of
socioeconomic and political factors on mental
health.
– Help clients understand their cultural
identification.
Multicultural Guidelines

Guidelines on Multicultural Education,
Training, Research, Practice, and
Organizational Change
• We are cultural beings.
– Value cultural sensitivity and awareness.
– Use multicultural constructs in education.
– Conduct culture-centered and ethical
psychological research with culturally diverse
individuals.
– Use culturally appropriate skills.
– Implement organizational change process.
Cultural Competence
is a Lifelong Process

Cross and colleagues (1989)
identified a cultural spectrum
from:
•
•
•
•
•
Destructiveness
Incapability
Blindness
Pre-competence
Competence
Cultural Competence
is a Lifelong Process
Destructiveness
Incapability
Blindness
Pre-competence
Competence
Destructiveness
 Attitudes,
policies, and
practices are destructive to
cultures and individuals.
Incapacity
Racial superiority of the
dominant group.
 Cultural blindness: Belief that
culture makes no difference.

Blindness
 Individuals
believe that culture
makes no difference.
• The values of the dominant culture
are universally applicable and
beneficial.
Cultural Pre-Competence

Do not know exactly how to
proceed.
Cultural Competence

Possessing a set of knowledge,
behaviors, attitudes, skills, and
policies needed to work
effectively in multicultural
situations.
Cultural Competence
Guidelines for Organizations

Therapists should:
• Evaluate institution’s mission statement to
include diversity.
• Assess diversity policies.
• Evaluate how people of color perceive
specific policies.
• Acknowledge within group diversity.
• Be aware that diversity requires
examination.
• Recognize that multicultural sensitivity may
mean advocating.
Multicultural Practitioners Can Help
Organizations Achieve Cultural Competence
1.
2.
3.
4.
5.
6.
Include community representation and
input at all stages of implementation.
Integrate all organizational systems.
Ensure changes made are manageable,
measurable, and sustainable.
Make the business case for cultural
competency polices.
Require commitment from leadership.
Help establish staff training on an
ongoing basis.
Empowerment



Racial micro-aggressions refer to
assaults individuals experience because
of race, color, and ethnicity.
Cultural trauma refers to a legacy of
adversity, pain, and suffering among
many minority group members.
Research has identified a human
tendency to categorize individuals into
in- and out-group members leading to
unconscious biases.
Empowerment: Multicultural
Psychotherapists Subscribe To
1.
2.
3.
4.
Reality is constructed into a
context.
Experience is valuable knowledge.
Learning/healing results from
sharing multiple perspectives.
Learning/healing is anchored in
meaningful and relevant contexts.
Empowerment
Emphasis on empowerment
frequently leads psychotherapists
to commit to social justice.
 Psychotherapy will be
unsuccessful if clients feel that
their therapist is unconsciously
racist, ethnocentric, sexist, elitist,
xenophobic, homophobic, etc.

Multicultural Psychotherapies’
Underlying Assumptions
 Culture
is complex and
dynamic.
 Every encounter is
multicultural.
 Reality is constructed and
embedded in context.
Western Worldview’s Dominance
of Mainstream Psychotherapy




Multicultural psychotherapies are
relevant to all individuals.
Cultural competence is crucial for
effective psychotherapy.
Multicultural psychotherapists engage in
self-awareness.
Healing:
• Empowers individuals and groups.
• Involves multiple perspectives.
• Holistic and liberatory.
Comparing
Multicultural
Approaches to Other
Therapy Systems
Impact of Culture
on Treatment Outcomes

In contrast to European-Americans,
African Americans:
• Tend to drop out of CBT at a higher
rate.
• Found treatment less positive after
receiving services even when they
expressed positive expectations
initially.
Culture Affects
Psychotherapeutic Process




Culture’s impact is greater on therapy
process than outcome.
Personal/collective history is important
in people of color’s lives.
Transcultural psychiatry and
psychology advocate for the use of
community/indigenous resources.
Minority empowerment movements
further the development of multicultural
psychotherapies.
HISTORY OF
MULTICULTURAL
PSYCHOTHERAPIES
Multicultural Psychotherapies:
Interdisciplinary Origins

Early theoretical influences
include:
•
•
•
•
•
Psychological anthropology
Ethnopsychology
Cultural anthropology
Psychoanalytic anthropology
Folk healing
Evidenced Based Practices
(EBP)

EBP appear effective for a number
of culturally diverse populations.
Paulo Freire (1973)
Identified dominant models of
education as instruments of
oppression.
 Conscientization: Critical
consciousness as a process of
person and social liberation.

• Involves questions of What? Why? How? For
whom? Against whom? By whom? In favor of
whom? In favor of what? To what end?
• Helps oppressed individuals to author their
own reality.
Types of Therapy/Counseling:
Re-evaluation Counseling (RC)
An empowering co-counseling
approach where two or more
individuals take turns listening to
each other without interruption.
 “Counselor” encourages the
“client” to discharge emotions
(catharsis).
 Next, “client” becomes the
“counselor” and listens.

Types of Therapy/Counseling:
Feminist Therapy
 Attempts to empower all people and
promote equality at individual,
interpersonal, institutional, national,
and international levels.
 Women of Color feminist therapists
address the interactions between
racism, sexism, classism,
heterosexism, ethnocentrism, ableism,
and other forms of oppression.
Types of Therapy/Counseling:
Ethnic Family Therapy






Know their own culture.
Avoid ethnocentric attitudes and
behaviors.
Achieve an insider status.
Use intermediaries.
Have selective disclosure.
Often use cultural genograms.
CURRENT STATUS
OF
MULTICULTURAL
PSYCHOTHERAPIES
Current Status: Three Models

Multicultural psychotherapists
practice following three models
(or a combination thereof).
1. Cultural adaptation of dominant
psychotherapy
Current Status: Three Models
2. Ethnic psychotherapies
– Integrates cultural variables in treatment
through the examination of worldviews,
cultural transitions, relationships and
context.
– Based on a philosophical spiritual
foundation that promotes connective,
ancestral and sacred affiliations in
healing.
Current Status: Three Models
2. Ethnic psychotherapies (continued)
– Include approaches based on Eastern
philosophical traditions and narratives as
a collectivistic way of relating.
• Testimonio: Chronicles traumatic experiences
in Latin America.
• Cuento therapy: Empirically proven to be an
effective treatment for Puerto Rican children.
• Dichos (sayings): Form of flash psychotherapy
that consists of Spanish proverbs or idiomatic
expressions capturing folk wisdom.
Current Status: Three Models
3. Holistic approaches
•
•
Folk healing is form of indigenous
psychotherapy.
Fosters empowerment, encourages
liberation, and promotes spiritual
development.
Current Status


Several professional and academic
organizations have supported the
development of multicultural
psychotherapies.
Publications on the topic include:
• Cultural Diversity and Ethnic Minority
Psychology
• Journal of Multicultural Counseling and
Development
• Psychology of Women Quarterly
• Women and Therapy
8 Cultural Dimensions
Bernal, Bonilla
and Bellido
1.
2.
3.
4.
5.
6.
7.
8.
Eight Cultural
Dimensions
Language: Fits clients worldview.
Persons: Therapeutic relationship.
Metaphors: Shared concepts of a cultural group.
Content: Therapist’s cultural knowledge.
Concepts: Treatment concepts culturally consonant
with client’s context.
Goals: Objectives congruent with client’s adaptive
cultural values.
Method: Cultural adaptation and validation of
methods and instruments.
Context: Client’s environment, including history and
sociopolitical circumstances.
Ricardo Munoz’s Suggestions
for Culturally Adapting CBT
Involvement of culturally diverse
people in the development of
interventions.
 Inclusion of collectivisitic values.
 Attention to religion/spirituality.
 Relevance of acculturation.
 Acknowledgement of the effects of
oppression.

Pamela Hays (2001)
Framework
A
D
D
R
E
S
S
I
N
G
Age
Developmental
Disabilities (acquired)
Religion
Ethnicity
Socioeconomic status
Sexual orientation
Indigenous heritage
National origin
Gender
Culturally Sensitive
Psychotherapy (CSP)
 Targets specific
ethnocultural groups.
• A group may benefit from a
specific intervention more
than from interventions
designed for others.
APA Multicultural
Guidelines No. 5

Encourages psychologists to
strive to learn about non-Western
healing traditions and to
acknowledge and enlist the
assistance of recognized helpers
and traditional healers in
treatment.
Other Approaches

Carolyn Attneave’s Network Therapy
• Community-based approach.
• Recreates the social context clan’s network to
mobilize a person’s family and social support.

Ignacio Martin-Baro’s Psychology of Liberation
• Collaborative approach focused on assisting
oppressed clients in developing critical analysis and
engaging in transformative actions.
• Resonates with African-American psychology as it is
based on Black liberation theology and Africanist
traditions.
THEORY OF
PERSONALITY
Multicultural Clinicians Adhere
to Diverse Theories of Personality

A unique contribution of
multicultural psychotherapy is the
formulation of cultural identity
development theories.
• View the self as an internal
representation of culture.
• Ethnic and racial identity stage affects
beliefs, emotions, behaviors, attitudes,
expectations, and interpersonal style.
Diverse Models of Identity Development Propose
Members of Groups Move Through Stages
Value Dominant Group/De-Value Own Group
Value Own Group/De-Value Dominant Group
Integrate Appreciation for Multiple Groups
Ethnic Minority Groups
(Atkinson, Morten & Sue, 1998)

Conformity
• Internalize racism.
• Choose dominant groups’ values, lifestyles,
role models.

Dissonance
• Question and suspect dominant group’s
values.

Resistance-immersion
•
Endorse minority-held values, reject
dominant culture’s values.
Ethnic Minority Groups
(Atkinson, Morten & Sue, 1998)

Introspection
• Establish their own racial ethnic identity.

Synergistic
• Experience self-fulfillment without
categorically accepting minority values.
White American Groups
(Helms, 1990)

Contact
• Individuals are aware of minorities, but do
not perceive themselves as racial beings.

Disintegration
• Acknowledge prejudice and discrimination.

Reintegration
• Engage in blaming the victim and in reverse
discrimination.
White American Groups
(Helms, 1990)

Pseudoindependence
• Become interested in understanding cultural
differences.

Autonomy
• Accept, respect, and appreciate both
minority and majority group members.
Model of Bi-Racial Identity
Formation (Poston, 1990)
Personal identity
 Choice of group categorization
 Enmeshment or denial
 Appreciation
 Integration

Gay and Lesbian Groups
(Cass, 2002)

Confusion
• Questions their sexual orientation.

Comparison
• Accepts possibility that they may be a
sexual minority.

Tolerance
• Recognition that one is gay or lesbian.
Gay and Lesbian Groups
(Cass, 2002)

Acceptance
• Increases contact with other gays and
lesbians.

Pride
• Prefer to be gay or lesbian.

Synthesis
• People find peace with their own sexual
orientation.
Feministic Identity
(Downing & Rush, 1985)
Passive/acceptance
 Revelations
 Embeddedness/emanation
 Synthesis
 Active commitment

No Unifying
Theory of Psychotherapy

Focus is on how the therapist can
understand the life of a culturally
different client.
• Therapeutic alliance requires cultural
congruence between clients’ and
therapists’ worldviews.
• To begin moving towards cultural selfawareness, the therapist identifies the
dominant culture’s values in which
they communicate and practice.
Bennet’s (2004) Multicultural
Sensitivity Development Model

The ethnocentric stages:
• Denial: Deny existence of cultural
differences, avoid culturally diverse
people.
• Defense: Recognize other cultures
but denigrate them.
• Minimization: View own culture as
universal.
Bennet’s (2004) Multicultural
Sensitivity Development Model

The ethnorelative stages:
• Acceptance: Recognize and value
cultural differences.
• Adaptation: Develop multicultural
skills.
• Integration: Sense of self expands to
include diverse worldviews.
Multiculturalism and Therapy

Atkinson, Thompson and Grant
(1993) asserted that:
• Low acculturated clients expect
therapists to behave as advisor,
advocate, and or facilitator of
indigenous support systems.
• More acculturated clients may expect
their clinician to act as a consultant,
change agent, counselor and or
psychotherapist.
Multiculturalism and Therapy


Besides acculturation, clients’
expectations are shaped by
interpersonal needs, developmental
stages, ethnic identity, spirituality, and
other factors.
Most dominant psychotherapists ignore
transferential cultural issues.
• Multicultural psychotherapists examine it
through a dialogue on cultural differences
and similarities.
Cultural Empathy



Empathy is an interpersonal concept
referring to a clinician’s capacity to
attend to the emotional experience of
clients.
Somatic aspect of empathy refers to
non-verbal communication and body
language.
Cognitive aspect of empathy occurs by
becoming an empathic witness.
Cultural Empathy



Affective component involves emotional
connectedness.
Development of affective empathy is
critical in multicultural psychotherapy.
Learned ability to obtain understanding
of the experience of culturally diverse
individuals informed by cultural
knowledge and interpretation.
Cultural Empathy



Cultural empathy is the ability to place
self in the other’s culture and is
developed through self-reflection.
Therapy promulgates the projection of
conscious and/or unconscious
messages about the client and
therapist’s cultures.
Clients of color expect
psychotherapists to demonstrate
cultural credibility.
Comas-Diaz & Jacobsen (1991)

Intra-ethnic transference may
transform the therapist into one of
several roles:
•
•
•
•
Omniscient/omnipotent therapist
Traitor
Auto-racist
Ambivalent
Comas-Diaz & Jacobsen (1991)

Inter-ethnic transferential
reactions may lead the patient to:
• Overcompliance and friendliness.
• Denial.
• Mistrust, suspiciousness and
hostility.
• Ambivalence.
Interethnic Dyads
Countertransferential Reactions


Denial of cultural differences
Clinical anthropologist’s syndrome
• Excessive curiosity about clients’
ethnocultural backgrounds at the expense
of their psychological needs.




Guilt (re: societal and political realities)
Pity
Aggression
Ambivalence
Intraethnic Dyads
Countertransferential Reactions

Us and them mentality
• Shared victimization.

Cultural myopia
• Inability to see clearly due to ethnocultural
factors that obscure therapy.





Distancing
Survivor’s guilt
Overidentification
Ambivalence
Anger
MECHANISMS
OF
PSYCHOTHERAPY
Mechanisms of Psychotherapy
 Multicultural psychotherapists
may:
• Use contemplative practices.
• Promote spiritual development
• Foster creativity through use of art,
folklore, ethnic practices, and
other creative cultural forms.
• Lead the patient to cultural
consciousness.
─ Example: The affirmation, redemption,
and celebration of one’s ethnicity and
culture.
Ethnopsychopharmacology



Field that specializes in the relationship
between ethnicity and responses to
medications.
Ethnocentrism has resulted in culturally
diverse clients’ mistrust of
psychopharmacology.
Racial and ethnic groups may respond
or use medications differently.
Ethnopsychopharmacology



African Americans with affective disorders are
often misdiagnosed and thus mistreated with
antipsychotic medications.
Common for Latinos to share medications with
family members and significant others (due to
familism), self-medicate and combine
medications with herbal remedies.
Diets of some people of color contain foods
that are incompatible with certain kinds of
psychotropic medications.
Multiculturalism
 Multicultural psychotherapies
apply to everyone and are
particularly helpful when
individuals present to treatment
with identity issues, relationship
problems, cultural adaptation,
ethnic and racial stressors, and
conflicts of diverse nature.
Multicultural Assessment:
Explanatory Model

Explanatory model of distress
• A culture-centered assessment
based on an anthropological
method that elicits a clients’
perspectives of their illness,
experience and healing.
Multicultural Assessment:
Cultural Formulation

Cultural formulation and analysis
• Process oriented approach that places
diagnosis in cultural context examining:
– Individual’s cultural identity.
– Cultural explanations for individual illnesses.
– Cultural factors related to the psychosocial
environment and levels of functioning.
– Cultural elements of the therapist-client
relationship.
– Overall cultural assessment of diagnosis and
treatment.
Multicultural Assessment:
Genograms

Cultural genogram
• Diagram of a genealogical tree
highlighting dynamics from a
nuclear to an extended family
perspective.
• www.genopro.com/genogram_rules/default.htm
Multicultural Assessment:
Genograms




Cultural genogram places individuals
within their communal contexts.
Uses three or more generations of
ancestors.
Clients invited to use imagination to
summon up family information (e.g.
photos).
Share the symbols used in family
genograms.
Multicultural Assessment:
Genograms
Important factors might include:





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

Individual and family
culture(s)
Meaning of race and
ethnicity
Sexual orientation
Family
Social class
Marriage
Gender roles
Relations

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

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
Migration
Refugee experience
Acculturation
Stress
Spirituality and faith
History and politics
Trauma (i.e., sexual
and gender trauma)
Meaning of
differences
Ethnocultural Assessment
Explores diverse stages in cultural identity development
Heritage
Explores ethnocultural ancestry, history,
genetics, and sociopolitical contexts and
cultural trauma.
Family saga
Entails examining the family, clan and group
story.
Niche
Attends to the post-transition analysis with
special emphasis on client’s intellectual and
emotional interpretation of family saga.
Self adjustment Cultural resilience assessed during this stage.
Relationships
Explores clients’ significant affiliations,
including exploration of the therapist-client
relationship.
Multicultural Assessment
 Multicultural assessments can
be complemented with a power
differential analysis.
•
An analysis of the client’s cultural
group’s social status compared
to the therapist.
Evidence for Integrating
Multicultural Issues into Therapy

Karlsson (2005)
• Inconclusive results and low validity
for ethnic matching.
– Evidence suggests clients working with
psychotherapists of similar ethnic
backgrounds and languages tend to
remain in treatment longer.
– Ethnic and linguistic match does not
necessarily translate into mutual cultural
identification; nor is it necessarily
desirable for some clients.
Evidence for Integrating
Multicultural Issues into Therapy
More research is needed on
multicultural psychotherapies.
 Multicultural therapists
advocate for research funding
that is applicable to the lives of
culturally diverse individuals
and communities.
