University of Southern California Dissertations and Theses

Towards validating therapists’ in-session behaviors of cultural competence

(USC Thesis Other)

Towards validating therapists’ in-session behaviors of cultural competence

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Running head: VALIDATING THERAPISTS’ CULTURAL COMPETENCE 1

Towards Validating Therapists’ In-Session Behaviors of Cultural Competence

Eduardo O. Jones

University of Southern California

Author Note

Eduardo O. Jones, Department of Psychology, University of Southern California.
A thesis presented to the faculty of the USC Graduate School University of Southern
California in partial fulfillment of the requirements for the degree Masters of Arts (Psychology)
May 2013.
Correspondence concerning this article should be addressed to Eduardo Jones,
Department of Psychology, University of Southern California, Los Angeles, CA 90089. E-mail:
eduardoj@usc.edu

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 2

Table of Contents
Abstract ............................................................................................................................................3
Introduction ......................................................................................................................................4
Methods............................................................................................................................................9
Participants ...................................................................................................................................9
Procedures ....................................................................................................................................9
Coding Procedure .......................................................................................................................10
Coder Reliability ........................................................................................................................12
Therapy Process and Outcome Measures ...................................................................................13
Results ............................................................................................................................................15
Discussion ......................................................................................................................................20
Limitations .................................................................................................................................22
Conclusion ..................................................................................................................................25
References ......................................................................................................................................26
Tables .............................................................................................................................................33

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 3

Abstract

Most cultural competency models lack reference to specific therapist in-session behaviors that
are deemed culturally competent. The Shifting Cultural Lenses (SCL) model (Lakes, López &
Garro, 2006) operationalizes therapists’ behaviors as shifting between the client’s and therapist's
views and deriving a shared understanding. Shifting between the client’s and therapist’s views
are coded as: (a) accessing the client’s view, and (b) explicitly presenting the therapist’s view.
Developing a shared narrative is coded as (c) integrating the client’s view, (d) seeking buy-in of
the therapist’s view, and (e) negotiating a shared view. This study tests the hypotheses that these
behaviors will be associated with positive treatment processes and outcomes in a sample of
therapist and Latino client dyads (n = 17) obtained in community mental health settings.
Therapists’ in-session behaviors were obtained via recordings of the first two sessions and clients
completed therapy process and outcome measures at therapy session 1, therapy session 2, 1-
month follow-up, 2-month follow-up, and 3-month follow-up. The results indicated that
therapists were more likely to exhibit the in-session behaviors of accessing the client’s view (M
= 2.50, SD = 1.04) and presenting the therapist’s view (M = 2.21, SD = 0.80) than they were to
exhibit behaviors associated with developing a shared narrative (M = 0.21 to 1.21). Integrating
the client’s view was positively associated with therapy processes, including the working
alliance, perceptions of therapist’s warmth, and satisfaction with services at therapy session 2
and 2-month follow-up. None of the other SCL codes were consistently related to treatment
processes or outcomes.
Keywords: cultural competence, psychotherapy process, psychotherapy outcomes
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 4

Towards Validating Therapists’ In-Session Behaviors of Cultural Competence

The topic of cultural competency has generated widespread interest and attention in recent
years. Its emergence as a focal point of clinical psychology has largely come about due to the
increasing diversity of our nation. Today, ethnic minorities make up 28% of the U.S. population
(U.S. Census, 2010). By 2042, demographers predict that ethnic minorities will comprise 50
percent or more of the population (U.S. Census Bureau News, 2008).With the U.S. rapidly
growing in ethnic diversity, there has been an increased need to ensure that health care
specialists, including mental health providers, are equipped to meet the needs of the diverse
communities they serve. This need has been highlighted by research documenting marked
disparities in mental health treatment among ethnic minorities. Even when other factors are
controlled for (e.g., SES, insurance status), ethnic minorities are less likely to receive mental
health care than European Americans (Abe-Kim et al., 2007; Barrio et al., 2003; Bender et al.,
2007; Garland et al., 2005; Pole, Gone, & Kulkarni, 2008). When they do receive care, they are
more likely to receive a poorer quality of care and to terminate services prematurely (Flaskerud
& Hu, 1994; Melfi, Croghan, Hanna, & Robinson, 2000; Miranda & Cooper, 2004; Zane,
Enomoto, & Chun, 1994). As a result, ethnic minorities experience a disproportionate burden
related to mental illness (U.S. Department of Health and Human Services, 2001). These
disparities suggest there is a need to increase the quality and availability of mental health
resources to diverse communities.
Consistent findings documenting disparities in mental health care among ethnic minorities
have led some researchers to question whether traditional psychotherapies, including evidence-
based treatments, benefit ethnic minorities equally well as European Americans (Bernal &
Scharró-del-Río, 2001; Hall, 2001; S. Sue, 1998; S.Sue; 1999). Historically, research involving
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 5

evidence-based treatments (EBTs) has failed to include adequate samples of ethnic minorities (S.
Sue, 1999). More recently, evidence in support of the efficacy of EBTs with ethnic minorities
has begun to emerge (Huey & Polo, 2008; Huey & Jones, 2012). Still, there remains unanswered
questions regarding how best to address disparities in mental health care and whether evidence-
based treatments in their current form benefit ethnic minorities and European Americans equally.
The paucity of research demonstrating that EBTs are equally effective with ethnic minorities
in real-world settings (e.g., community mental health centers) has led researchers to call for
treatments to be culturally competent as one way to improve the quality of services available to
minorities. While experts have yet to agree on a single definition of cultural competence, most
definitions converge on the need of therapists to have the knowledge and skills to effectively
engage and treat individuals of diverse cultural backgrounds (Cunningham, Foster, & Henggeler,
2002; S. Sue, Zane, Hall, & Berger, 2009).
The call for culturally competent treatment has led to the American Psychological
Association adopting the “Guidelines on Multicultural Education, Training, Research and
Organizational Change for Psychologists,” emphasizing the need for mental health specialists to
recognize the importance of diversity, cultural awareness, and multicultural-sensitivity in both
research and clinical practice (APA, 2003). The guidelines echo concerns that “traditional
Eurocentric therapeutic and intervention models in which most therapists have been trained are
based on and designed to meet the needs of a small proportion of the population” and may not
adequately address the needs of more ethnically diverse communities (APA, 2003).
The APA guidelines are largely based on the Multicultural Counseling Competencies
(MCCs), the most widely recognized model of cultural competence to date (Arredondo et al.,
1996; Sue, Arredondo, & McDavis, 1992; Sue et al., 1998). This model defines the culturally
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 6

competent clinician as one who has the cultural awareness, knowledge, and skills to effectively
work with ethnic minorities (D. W. Sue, Arredondo, & McDavis, 1992; D.W. Sue & Sue, 2008).
Therapists must be aware of their own cultural values and biases, have awareness and knowledge
of their client’s worldview, and have knowledge of culturally appropriate intervention strategies
in treating clients from diverse backgrounds. Although the Multicultural Competencies make
numerous recommendations for gaining the knowledge and awareness to treat individuals of
diverse backgrounds, their recommendations for implementing “culturally appropriate
intervention strategies” are somewhat more limited.
In implementing culturally appropriate intervention strategies, the Multicultural
Competencies (MCCs) state that culturally competent therapists “are not averse to seeking
consultation with traditional healers or religious and spiritual leaders,” “take responsibility for
educating their clients to the process of psychological intervention,” and “understand that
helping styles may be culturally bound and are willing to modify their style” (see Arredondo,
1999 for a complete list). Presumably, these are the intervention techniques and skills that
clinicians need to possess in working with ethnic minorities. Although the researchers see the
value in such recommendations, they offer few specific in-session behaviors that are deemed
culturally competent. What behaviors should therapists exhibit to better understand their clients’
worldviews? How can they “modify their style” to effectively engage and treat ethnic minorities?
Without more directive behavioral recommendations, therapists are left empty handed in how to
apply many of the MCCs.
A second limitation of the Multicultural Competencies (MCCs) lies in their assessment.
Research examining the relationship of self-report cultural competence measures has found that
therapist-report and observer-report measures of therapists’ MCCs fail to correlate with each
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 7

other (Constantine, 2001; Worthington, Mobley, Franks, & Tan, 2000), and therapist-report and
client-report of therapists’ MCCs also fail to correlate (Fuentes et al., 2006). More recent
research on the MCCs found that therapists accounted for less than 1% of the variance in their
clients’ rating of their MCCs and that therapists’ MCCs were not related to client outcomes
(Owen, Leach, Wampold, & Rodolfa, 2011). Although several self-report measures of MCCs
have demonstrated sufficient degrees of reliability, a lack of empirical evidence associating self-
report MCCs with observer-rated MCCs, client-rated MCCs, or therapy outcomes with ethnic
minorities has led to concerns regarding the criterion validity of these instruments (Dunn, Smith,
& Montoya, 2006). The limitations of the MCCs suggest that there is a need for new behavior-
oriented models and assessment methods of cultural competence.
The Shifting Cultural Lenses (SCL) cultural competence model addresses these limitations. It
defines the essence of cultural competency as the “ability of the therapist to move between two
cultural perspectives in understanding the culturally based meaning of clients from diverse
cultural backgrounds” (López, 1997). Therapists must simultaneously be aware of their own
cultural perspective and that of the client while moving between the two perspectives or lenses;
doing so facilitates the ability of clinicians to derive a shared understanding, or narrative, of the
client’s problems and treatment goals. This process-oriented model looks at the client-therapist
interaction to understand culture and focuses on how clinicians ascribe meaning and integrate
their clients’ worldviews. An emphasis on treatment processes (e.g., therapeutic alliance) has
been advocated as a promising method to address the complexities underlying culture in mental
health treatment (Cunningham, Foster, & Warner, 2010; Lakes, López, & Garro, 2006; López,
1997; Whaley & Davis, 2007).
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 8

In addition to providing a useful theoretical framework for understanding cultural
competence, the SCL model specifies measurable culturally competent therapist in-session
behaviors that can be assessed through a behavioral observation coding system. These behaviors
consist of the essential elements needed for therapists to shift between cultural lenses and
develop a shared narrative with clients. The first in-session behavior is accessing the client’s
view (C). This refers to the degree to which the therapist inquires about key aspects of the
client’s perspective including, but not limited to, defining the problem, explanation of the
problem behavior, and treatment goals. The second in-session behavior, the therapist expressing
their view (T), involves the therapist explicitly relaying their own cultural perspective and
possible interpretation of the client’s view as an alternative view that is neither presumed to be
superior or inferior to the client’s perspective. The third in-session behavior builds upon the
previous two to develop a shared narrative with the client. This narrative can be developed by
integrating the client’s view within the therapist’s perspective (Si), by working towards the
client’s buy-in with the therapist’s view (Sb), and by negotiating the therapist and client
differences with the client (Sn). To date, there has been no systematic examination of the
Shifting Cultural Lenses (SCL) model as it relates to everyday clinical practice.
The purpose of this pilot study is to evaluate whether the SCL behavioral code ratings are
associated with treatment processes and outcomes within a small existing dataset (n=17) of
Latino clients being treated in community mental health settings. The first aim of the study is to
assess the degree to which the behavioral codes are represented in clinical practice by reporting
the average code ratings across sessions and their distribution. A second and third aim of the
study is to assess whether therapists’ in-session behaviors that reflect the SCL model are
positively associated with more favorable treatment processes and outcomes. It is hypothesized
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 9

that therapists’ in-session behavioral codes will be positively correlated with client-therapist
working alliance, clients’ perceptions of therapist warmth, client satisfaction with services,
treatment attendance, and a reduction in clients’ psychological distress.
Method
Participants
Seventeen client-therapist dyads were enrolled in the study from community mental
health settings in Southern California. Nine of the therapists were female and eight male (see
Table 1). Five therapists reported their ethnicity as Euro-American, six as Hispanic, and six as
other. Ten were marriage and family therapist, four social workers, two psychologists, and one
other. On average, they had 4.77 years of clinical experience (SD = 4.45). All therapists reported
English fluency and 11 of 17 therapists reported Spanish fluency.
Clients included fourteen females and three males. The average client age was 40 years,
ranging from 22-70 years. By study design, all clients were Latino. Six clients identified as
Hispanic, five as Mexican, five as Mexican-American, and one as Puerto Rican. Eight clients
reported being single, four married, three divorced, and two other. Ten clients reported being
born in the United States, five in Mexico, one in Puerto Rico, and one in El Salvador. On
average, clients lived in the United States for 24 years, although this number differed
considerably between clients and ranged from 1-53 years (SD = 15.08). The clients averaged
nine years of education (SD = 3.53). Fourteen of 17 clients reported English fluency and 14 of
17 reported Spanish fluency.
Procedures
Research staff visited community mental health clinics throughout Southern California
and presented the research study to clinic therapists. Interested therapists contacted clinic
administrators or research staff regarding participation in the study. The research team visited
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 10

therapists individually or in groups to answer questions and obtain informed consent. Therapists
who agreed to participate in the study also agreed to ask new Latino clients if they were
interested in participating. The therapist contacted the research team to inform them when their
client was interested in participating. Prior to the client beginning treatment, research staff
scheduled to meet with the interested client individually to obtain informed consent. Clients who
agreed to participate had their therapy sessions either videotaped (n =8) or audiotaped (n =9). A
total of 14 clients had their first two sessions whereas three clients only had one therapy session
recorded. Research staff met with clients following their first two therapy sessions to administer
self-report measures. At 1-month, 2-month and 3-month follow-up the research team contacted
participating clients by telephone to administer treatment process and outcome measures. Only
five participants remained for the 3-month follow-up. As a result, analyses were only conducted
up to the second month follow-up.
Coding Procedures
Dr. Ribas and López developed the coding manual for the Shifting Cultural Lenses model in
tandem with the coders, who received training in the model from Dr. López. Prior to coding, all
therapy sessions were transcribed verbatim by one of four coders and reviewed for accuracy by a
second coder. With a hard copy of the session transcript in-hand, raters first watched the entire
videotaped session or listened to the audiotaped session. If needed, they then re-read the
transcript before carrying out coding. Therapy sessions were divided into 10-minute intervals
(from 4 to 6 total intervals) and coders were instructed to rate each interval and the overall
session according to five SCL codes of therapists’ verbal behavior on a 5-point scale: 0) none, 1)
a little, 2) some, 3) quite a bit, and 4) a great deal.
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 11

The first behavioral code, accessing the client’s view (C), includes questions such as “What
would you say the main issues between you and your partner are?” and “What do you think led
to these problems?” The second SCL code is the therapist expressing their view as their own
(T). Examples of the therapist communicating their own view include statements like “It seems
to me that the attempts you make to improve things are the very things that make the other
anxious and defensive” or “I am going to tell you how to express your feelings in a way that does
not include accusation and blame.” Here, the therapist directly offers their own perspective on
the cause of the client’s problem and what might constitute effective treatment.
The therapist can develop a shared narrative, either through shared integration (Si), working
towards buy-in (Sb), and/or negotiating a shared narrative (Sn). An example of the therapist
integrating the client’s view (Si) is “I understand you found a spiritual healer to help you last
time you had this same problem. Perhaps you can also try and re-contact that spiritual healer to
get as much help as possible.” In this statement, the therapist uses information the client has
provided about what has been useful in the past and suggests including this type of healing for
the current problem. Statements indicating the therapist is working towards client buy-in (Sb)
include “Now I’m going to tell you what I think is going on, the way I see things. But I really
want your input. If I say something that makes a lot of sense, please let me know. If I say
something where, you see it in a different way, or it doesn’t fit, same thing.” The therapist is
explicitly telling the client that she is going to provide her view but is simultaneously asking the
client to acknowledge whether this perspective makes sense with her own worldview – she is
working towards getting the client to buy-in to her perspective. An example of the therapist
negotiating a shared narrative (Sn) is “this task of thinking about positive things that happened
makes some people feel better, but you say it makes you feel worse. I understand that. How can
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 12

we change this activity to make it work for you?” The therapist acknowledges the client’s
experience of not benefiting from a treatment exercise and opens up a conversation with the
client as to how they might adapt the activity to make it more rewarding for the client. The
therapist is attempting to develop a shared understanding with the client through negotiation.
These examples are drawn from the SCL coding manual and provide concrete examples to help
inform and anchor coder ratings. Coders are instructed to take into account both the quality and
quantity of statements reflective of the SCL behavioral codes in their session ratings.
Coder Reliability
Inter-rater reliability was assessed through intra-class correlation coefficients (ICCs) between
four coders and the criterion established in consensus coder meetings in a prior assessment using
11 couples and 4 individual therapy sessions (Ribas et al., 2012; Shrout & Fleiss, 1979). ICC
reliability for 10-minute intervals during individual therapy sessions for each code ranged from
.86-.99 for accessing the client’s view (C), .91-.97 for expressing the therapist’s view, .67-.78 for
shared integration (Si), and .82-.95 for working towards buy-in (Sb). The reliabilities of the SCL
code ratings for the overall session ranged from .62-.93 for C, .82-.97 for T, .67 -.78 for Si, and
from .75-.93 for Sb. No instances of shared negotiation were found in sessions that were rated
for reliability. In the current sample, sixteen of the seventeen first therapy session recordings
were rated for reliability across three coders. ICCs for the overall sessions were similar to those
reported in the previous assessment and ranged from 91-.92 for C, .80-.87 for T, .69 -.91 for Si,
and from .81-.90 for Sb. Too few instances of shared negotiation were found in sessions that
were rated for reliability to calculate an ICC.

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 13

Therapy Process and Outcome Measures
Treatment processes and outcomes were assessed using client and therapist self-report
measures. Client-therapist working alliance was assessed using client-report on the Working
Alliance Inventory – Short Form (WAI-S), a 12-item measure with a 7-point Likert scale,
“Never” to “Always.” Total scores range from 12 to 84, with higher scores indicating a stronger
working alliance. Items include “The therapist and I agree about the things I will need to do in
therapy to improve my situation” and “The therapist and I are working towards mutually agreed
upon goals.” The WAI-S has been found to be moderately predictive of therapy improvement
ratings (Busseri & Tyler, 2003). Internal consistency of the measure for the study sample was
high (Cronbach’s α = .93), and is consistent with previous estimates of the instruments reliability
(Busseri & Tyler, 2003).
In addition to measuring the working alliance, a novel measure was created to assess
clients’ perceptions of therapist warmth (WARMTH). This brief 4-item client-report measure
consisted of items such as “How much interest do you feel your clinician expressed towards
you?” and “Overall, how warm do you think your clinician was towards you?” Items were rated
on a 10-point Likert scale, “Not at all warm” to “Very warm indeed,” with scores ranging from
0 to 40 and higher scores indicating greater perceptions of the therapist’s warmth. Because this is
a novel measure, no previous psychometric data is available. Within the study sample, internal
consistency of the measure was high (Cronbach’s α = .93).
To assess clients’ overall satisfaction with services, clients completed the Client
Satisfaction Questionnaire (CSQ-8), a widely-used 8-item self-report measure for which a
Spanish language version has been tested. Items are rated on a 4-point Likert scale, “Quite
dissatisfied” to “Very Satisfied,” with scores ranging from 8 to 32 and higher scores indicating
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 14

greater satisfaction with services. Items include “How would you rate the quality of service you
received?” and “Have the services you received helped you to deal more effectively with your
problems?” The internal consistency of this measure for Latinos and Euro-Americans and for
Spanish-speaking and English-speaking persons is similar (e.g., Cronbach’s α’s .83-.90;
(Roberts, Attkisson, & Mendias, 1984), and is consistent with the study’s sample (Cronbach’s α
=.83).
Treatment attendance was assessed using a brief therapist-report measure to determine
how many scheduled therapy appointments clients had attended and missed over the past month.
Attendance was operationalized as an index score involving the number of sessions attended
divided by the number of sessions scheduled. Scores ranged from 0 to 1, with 1 indicating all
scheduled sessions were attended over the previous month, .5 indicating half of the scheduled
sessions were attended over the past month, and 0 indicating none of the scheduled sessions were
attended over the past month. This index is considered to be a more sensitive measure of
treatment attendance than the number of sessions attended because it also takes into account the
number of missed appointments (Choi & Medalia, 2005; S. Sue, Fujino, Hu, Takeuchi, & Zane,
1991).
Finally, to assess symptom severity, clients completed the Brief Symptom Inventory-18
(BSI-18), a widely-used 18-item self-report instrument of symptom distress that asks clients to
rate how often they have experienced depression, anxiety, and somatic symptoms within the past
seven days. Examples of items included on the BSI-18 are “feeling blue,” “feeling weak in parts
of your body,” and “nausea or upset stomach.” Clients rate each symptom on a 5-point Likert
scale from “Not at All” to “Extremely.” Total scores range from range from 0 to 72, with higher
scores indicating more symptom distress. To assess change in symptom severity over treatment,
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 15

the change in BSI-18 scores were calculated between the first therapy session to the second
therapy session, second therapy session to 1-month follow-up, and second therapy session to 2-
month follow-up. A Spanish version of the measure was found to have strong internal
consistency with a U.S. Latina community sample (Cronbach’s α = .89; Prelaw, Weaver,
Swenson, & Bowman, 2005). This is consistent with the estimated reliability of the measure
within the study’s sample (Cronbach’s α = .95).
Results
To address the first aim of this study, the degree to which therapists’ behaviors were
reflective of the Shifting Cultural Lenses (SCL) model was assessed. Observer ratings of
therapists’ SCL behaviors were examined across the first two therapy sessions. Table 2 shows
the descriptive statistics for therapists’ ratings of SCL behavioral codes in their first and second
sessions as well as the average ratings across both sessions. On average, therapists’ sessions were
coded higher on accessing the client’s view (M = 2.5, SD = 1.04) and expressing their view as
their own (M = 2.21, SD =.80), then they were on any of the shared narrative behavioral codes,
including integration (M = 1.21, SD =.75), working towards client buy-in (M =.64, SD =.57), and
negotiation (M =.21, SD =.43). Paired t-tests were conducted to determine whether the
difference between the therapists’ code ratings on accessing the client’s view (C) and expressing
the therapist’s view (T) were greater than the shared narrative behavioral codes. Therapists’ code
ratings on both C and T were significantly greater than therapists’ code ratings on shared
integration (Sn) and working towards client buy-in (Sb; (p <.01). Two therapists’ received a
rating of 2 (some) on negotiation in the first therapy session while all other therapists were coded
as 0 (none) in both the first and second therapy session. Overall, the ratings for shared
negotiation were consistently too low to be included in subsequent analysis.
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 16

The second aim of the study was addressed by examining the relationship between the
SCL code ratings and treatment processes. First, it is worth noting that clients’ ratings on all
three process measures (WAI-S, WARMTH, and CSQ-8) were heavily negatively skewed, with
clients endorsing relatively high scores on each measure across all four assessment points. On
the WAI-S 7-point Likert scale, clients on average rated the working alliance as approximately a
six (M total score = 70.18-73.73), with very little change across assessment points (see Table 3).
A similar pattern held true for the WARMTH measure; average ratings on the 10-point Likert
scale were 8.08-9.02 (M total score = 32.30-36.07), suggesting clients perceived their therapist as
very warm at each assessment point (see Table 4). On the CSQ-8 4-point Likert scale, clients’
average ratings were between 3.35-3.46 (M total score = 26.44-27.43), indicating high levels of
satisfaction with services beginning at the first therapy session and continuing through 2-months
follow-up (see Table 5). Table 6 shows the correlations between these three measures in the first
two therapy sessions.
The relationship between the four SCL code ratings and the three process measures were
evaluated by computing correlations using Pearson’s r and a 20% Winsorized correlation.
Outliers can unduly influence a dataset, particularly a small one, but can be guarded against by
using data trimming (Wilcox, 2005). A 20% Winsorized correlation trims the top and bottom
20% of the data values and then changes these values to the last data points not trimmed before
computing a Pearson’s r with the new Winsorized values. This method is known to account for
outliers in the marginal distribution better than Pearson’s r and provides a useful comparison
with the Pearson’s r (Wilcox, 2005). Correlations were computed between the SCL code overall
session ratings in the first two therapy sessions and the therapy process measures at therapy
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 17

session 1 (assessment point 1), therapy session 2 (assessment point 2), 1-month follow-up
(assessment point 3), and 2-month follow-up (assessment point 4).
In the first therapy session, none of the correlations between the SCL code ratings and
therapy process measures were statistically significant (p <.05, 1-tailed; see Table 7). In the
second therapy session, developing a shared narrative through integration (Si) emerged as
significantly associated with all three therapy process measures (p <.05, 1-tailed) using both the
Pearson’s r (r =.48-.54) and the 20% Winsorized correlation (r
w
= .47-.69). Working towards
client buy-in (Sb) was significantly positively associated with clients’ ratings of the WAI-S using
the 20% Winsorized correlation (r
w
= .47, p <.05, 1-tailed), but not using Pearson’s r. Overall, in
the second therapy session 4 of the 12 correlations computed between the SCL codes and the
treatment process measures were positively associated and greater than .30 using Pearson’s r and
4 of 12 using the 20% Winsorized correlation (see Table 8).
To assess whether the SCL code ratings for the first two therapy sessions were related to
treatment processes beyond the first two sessions, the SCL code ratings from session one and
two were averaged and correlations were computed with client self-report process measures at 1-
month and 2-month follow-up. At 1-month follow-up, integration (Si) was no longer
significantly associated with any of the three treatment process measures, but the magnitudes of
the correlations remained near or above .30 using both Pearson’s r and the 20% Winsorized
correlation (see Table 9). In addition, the therapists’ expression of their view (T) was
significantly positively associated with clients’ perception of warmth using the 20% Winsorized
correlation (r
w
= .32, p <.05, 1-tailed), but not using Pearson’s r. The magnitude of correlations
between T and the treatment process measures was .37-.41 using Pearson’s r and .29-.37 using
the 20% Winsorized correlation. Seven of the 12 correlations computed were positively
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 18

associated and greater than .30 using Pearson’s r and 4 of 12 using the 20% Winsorized
correlation.
At 2-month follow-up, observer ratings of the therapist expressing their view (T) and
shared integration (Si) again were positively associated with treatment process measures (see
Table 10). T was significantly positively associated with clients’ perception of therapist warmth
using Pearson’s r (r = .59, p < .05, 1-tailed), but not using the 20% Winsorized correlation. Si
was found to be significantly positively associated with all three process measures using
Pearson’s r, and with the WARMTH and CSQ-8 using the 20% Winsorized correlation. The
magnitudes of the correlations between Si and the therapy process measures ranged from .64-.68
using Pearson’s r and .50-.64 using the 20% Winsorized correlation. Six of the 12 correlations
computed were positively associated and greater than .30 using Pearson’s r and 4 of 12 using the
20% Winsorized correlation.
To assess the study’s third aim of evaluating the relationship between the SCL code
ratings, correlations between the SCL code ratings, therapists’ report of client treatment
attendance, and the change in clients’ Brief Symptom Inventory 18 (BSI-18) scores were
computed. This analysis was used to determine whether any of the SCL code ratings were
linearly related to clients’ treatment attendance or the symptom change. Treatment attendance
was assessed at 1-month and 2-month follow-up and was operationalized as the number of
sessions attended in the previous month divided by the total number of sessions scheduled. This
ratio both accounts for total number of sessions attended as well as number of scheduled sessions
missed. At 1-month follow-up, clients’ average treatment attendance score was .78, indicating
that clients attended slightly more than 3 of their 4 scheduled sessions in the previous month (see
Table 11). Treatment attendance was not significantly associated with any of the SCL codes at
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 19

this point (see Table 9). At 2-month follow-up, clients’ average treatment attendance scores
decreased to .66, and accessing the client’s view was found to be significantly negatively
associated with treatment attendance using Pearson’s r, but not using the 20% Winsorized
correlation (r = -.65, p < .05, 1-tailed; see Table 10). Additionally, at 2-month follow-up
expressing the therapist’s view was significantly associated with treatment attendance using the
20% Winsorized correlation (r
w
= .79, p <.05, 1-tailed), but not Pearson’s r. Overall, correlations
between SCL codes and treatment attendance ranged from -.65 to -.31 at 2-month follow-up
using Pearson’s r and -.79 to -.33 using the 20% Winsorized correlation. These negative
correlations are in the opposite direction of what was hypothesized.
Clients completed the Brief Symptom Inventory-18 (BSI-18) at the first therapy session,
second therapy session, 1-month and 2-month follow-up. The difference in BSI-18 scores at each
assessment point was used as an index of whether clients’ symptomology increased or decreased
over time. Table 12 displays the descriptive statistics for clients’ BSI-18 scores at each
assessment point. At the first therapy session, client’s symptoms fell in the moderate range, with
average client ratings of 1.84 on the 5-point Likert scale of the BSI-18 (M total score = 33.18).
The scores decreased between the first therapy session and second therapy session, and between
the second therapy session and 2-month follow-up; however, between the second therapy session
and 1-month follow-up, scores increased slightly. At 2-month follow-up, the average client
rating on the 5-point scale of the BSI-18 scale was 1.29 (M total score = 23.30), falling between
the mild and moderate range of symptom distress.
Correlations between the SCL behavioral code ratings and the change in BSI-18 scores
across assessment points were inconsistent. At therapy session 2, working towards client buy-in
(Sb) was significantly negatively associated with the clients’ change in symptom distress from
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 20

session 1 to session 2 using the 20% Winsorized correlation (r
w
= -.82; p <.01, 1-tailed), but not
using Pearson’s r. None of the other SCL codes were significantly associated to changes in the
BSI-18 at therapy session 2 (see Table 8). At 1-month follow-up, changes in BSI-18 scores were
not significantly associated with any of the SCL codes using Pearson’s r or the 20% Winsorized
correlation (see Table 9). At 2-month follow-up, changes in BSI-18 scores were significantly
negatively associated with the therapist expressing their view using Pearson’s r (r = -.66, p <.05,
1-tailed), but not using the 20% Winsorized correlation. Overall, 2 of the 4 correlations were in
the negative direction and were less than -.30 in magnitude using Pearson’s r and the 20%
Winsorized correlation (see Table 10).
Discussion
The purpose of this pilot study was three-fold: a) to assess the degree to which therapists’
exhibited behaviors reflective of the Shifting Cultural Lenses (SCL) model in a naturalistic
setting, b) to examine the association between observer ratings of therapists’ SCL behaviors and
therapy process measures, and c) to examine the association between observer ratings of
therapists’ SCL behaviors and therapy outcomes. In addressing the study’s first aim, therapists
were found to be more likely to access the client’s view and express their own view than they
were to develop a shared narrative, either through shared integration, working towards buy-in, or
through shared negotiation. The relatively low ratings of therapists on the three SCL codes
related to developing a shared narrative suggests that these behaviors are more involved and
complex than either accessing the client’s view or expressing the therapist’s view. Instances of
shared negotiation were particularly infrequent and prevented us from examining its relationship
to therapy processes or outcomes. The low frequency of the shared narrative codes may reflect,
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 21

at least in part, the early phase of the therapy process. Later stages of therapy may reveal a higher
frequency of the shared narrative codes.
The results of the associations between the SCL code ratings and therapy processes, the
study’s second aim, were mixed. Within the first therapy session, none of the SCL codes were
found to be significantly associated with the therapy process measures. However, in the second
therapy session and at 2-month follow-up, shared integration was found to be significantly
associated with clients’ self-report of the working alliance, perceptions of therapist’s warmth,
and satisfaction with services. The more therapists integrated the client’s views during therapy,
the more clients held a positive view toward the therapist and the services they received.
Although some of the other SCL codes were found to be significantly associated with some of
the treatment process measures at various assessment points, shared integration was the SCL
code that was most consistently associated with these measures across the four assessment
points.
There were mixed findings with regard to therapy outcomes as well. The majority of the
correlations between the SCL code ratings and the change in reported symptoms (i.e., BSI-18
scores) were negatively associated at 2-month follow-up, and the therapist expressing their view
was statistically significant. The more therapists’ behaviors reflected the SCL model, the fewer
reported symptoms. However, this pattern did not hold true at the other assessment points,
particularly at 1-month follow-up. One possible explanation for this is that there was very little
change in the average clients’ reported symptoms between session 2 and 1-month follow-up (see
Table 12), making it difficult to detect an association between the SCL codes and the change in
reported symptoms at this point. The correlations between SCL codes and treatment attendance
were perhaps the most puzzling. Although most were not statistically significant, the majority of
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 22

the SCL code ratings were negatively associated with treatment attendance at 1-month and 2-
month follow-up. This result was the direct opposite of what was hypothesized and suggests that
higher SCL code ratings were associated with fewer attended scheduled therapy sessions.
Given these inconsistencies, it is difficult to make firm conclusions about the association
between observer ratings of therapists’ SCL behaviors and therapy processes and outcomes. On
one hand, the findings that the majority of the correlations between the SCL code ratings and
therapy process measures were positively associated, some being statistically significantly,
leaves open the possibility that the SCL behavioral codes are related to treatment processes, and
that therapist behaviors reflective of the SCL model may be therapeutic. On the other hand, the
lack of consistent associations between the SCL code ratings and therapy process and outcome
measures across assessment points, suggests that it is premature to conclude that any specific
SCL behavior is related to treatment processes or outcomes.
Limitations
There are five noteworthy limitations to this study that have implications for interpreting
the study’s findings. First, the study’s small sample size limits power, the ability to detect
significant associations among study variables. Because this was an exploratory pilot study,
familywise error rate was not controlled for, which may have resulted in a higher probability of
false discoveries (i.e., Type I error). Second, the high degree of attrition between assessment
points, especially at 1-month, 2-month, and 3-month follow-up, further reduces study power.
Although this level of attrition is not uncommon in community mental health centers (Gonzalez,
Weersing, Warnick, Scahill, & Woolston, 2011), it limits the ability to detect significant
associations between study variables long-term. With no data on why the attrition occurred (e.g.,
drop-out, treatment completion), conclusions cannot be drawn as to whether study variables were
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 23

related to treatment processes and outcomes for clients who did not complete study measures at
follow-up assessment points.
A third limitation of this study was the type of analysis used. Pearson’s r and the 20%
Winsorized correlation were used to measure associations between SCL code ratings and therapy
process and outcome measures. This type of analysis does not permit causal statements to be
made about the relationship between variables even if significant associations are detected (i.e.,
correlation is not causation). Although the 20% Winsorized correlation provides some protection
against univariate outliers (e.g., outliers on the x-axis or y-axis), it does not take into account the
overall structure of the data (Wilcox, 2005). Bivariate outliers may still have been present and
unduly influenced the data. Another concern is that both measures of association assume a linear
relationship between variables. There exists the possibility that the relationships between the
SCL code ratings and therapy process and outcome measures are not linear, but might instead be
curvilinear, or exhibit some other type of pattern. With an increased sample size, a more detailed
analysis could be conducted using methods that do not assume linearity (e.g., robust regression,
smoothers).
Fourth, within the study’s sample, there was limited variability in the treatment process
measures. Clients’ scores on all three process measures (WAI-S, WARMTH, and CSQ-8) were
heavily negatively skewed, with clients endorsing relatively high scores on each measure across
all four assessment points, potentially indicating a ceiling effect. Analysis of clients’ scores on
the therapy process measures revealed that all three were significantly positively associated with
each other, calling into question the discriminant validity of the instruments. This may explain
why clients’ responses exhibited such a similar pattern across the three therapy process measures
at each assessment point. Because study research assistants administered and collected therapy
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 24

process measures from clients, there may have been a social desirability bias that could have
inadvertently influenced clients’ ratings and positively inflated their endorsements of the
working alliance, perception of therapist’s warmth, and satisfaction with services. Since the
researchers were only able to collect therapy process measures from clients still participating in
the study and receiving services at follow-up assessment points, this could have also resulted in a
selection bias. Clients whose working alliance, perception of therapist’s warmth, or satisfaction
with services diminished over time may have discontinued services and withdrew their
participation from the study, leaving only those clients with higher levels of satisfaction with
treatment to complete study measures. The heavily skewed process measures and limited
variability across assessment points reduces the likelihood of detecting significant associations
between observer ratings of therapists’ SCL behaviors and therapy processes.
The fifth limitation of the study was that session recordings were only obtained for the
first two therapy sessions, and therefore the relationship between observer ratings of therapists’
SCL behaviors and therapy process and outcome measures could only be evaluated using these
two points. This limited analysis to whether SCL code ratings at the beginning of treatment were
related to treatment processes and outcomes later on in treatment. Without having session
recordings to rate therapists’ behaviors at follow-up assessment points, there is no way of
determining whether therapists’ behaviors reflective of the SCL model remained constant or
varied over treatment. Treatment processes and outcomes at 1-month and 2-month follow-up
may have been more strongly related to therapists’ in-session behaviors at these two assessment
points than therapists’ behaviors at the beginning of treatment.

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 25

Conclusion
This study is the first of its kind to behaviorally operationalize in-session culturally
competent therapist behaviors and evaluate the association between these behaviors and
treatment processes and outcomes. A strength of this study is that it included observer ratings
(i.e., coders) of therapists’ culturally competent behaviors as opposed to therapists’ or clients’
ratings, which are less objective. A second noteworthy strength of this study is that participants
were being treated in community mental health settings, where ethnic minorities are most likely
to seek treatment. This study answers the call of the field to conduct effectiveness research in
real-world settings with real-world clients (Whaley & Davis, 2007). Future research should
continue to examine whether therapists’ culturally competent in-session behaviors are related to
improved therapy processes and outcomes for diverse clients. Only by continuing to
operationalize cultural competency into observable in-session behaviors can the field move past
its historically theoretical roots and begin to bridge the gap between cultural competence and
evidence-based practice.
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 26

References

Abe-Kim, J., Takeuchi, D. T., Hong, S., Zane, N., Sue, S., Spencer, M. S., Appel, H. et al.,
(2007). Use of mental health-related services among immigrant and US-born Asian
Americans: Results from the National Latino and Asian American study. American
Journal of Public Health, 97(1), 91-98. doi: 10.2105/ajph.2006.098541
APA. (2003). Guidelines on multicultural education, training, research, practice, and
organizational change for Psychologists. American Psychologist, 58(5), 377-402. doi:
10.1037/0003-066x.58.5.377
Arredondo, P., Toporek, R., Brown, S. P., Sanchez, J., Locke, D. C., Sanchez, J., & Stadler, H.
(1996). Operationalization of the Multicultural Counseling Competencies. Journal of
Multicultural Counseling & Development, 24(1), 42-78.
Barrio, C., Yamada, A. M., Hough, R. L., Hawthorne, W., Garcia, P., & Jeste, D. V. (2003).
Ethnic Disparities in Use of Public Mental Health Case Management Services Among
Patients With Schizophrenia. Psychiatric Services, 54(9), 1264-1270. doi:
10.1176/appi.ps.54.9.1264
Bender, D. S., Skodol, A. E., Dyck, I. R., Markowitz, J. C., Shea, M. T., Yen, S., . . . Grilo, C.
M. (2007). Ethnicity and mental health treatment utilization by patients with personality
disorders. Journal of Consulting and Clinical Psychology, 75(6), 992-999. doi:
10.1037/0022-006x.75.6.992
Bernal, G., & Scharró-del-Río, M. R. (2001). Are empirically supported treatments valid for
ethnic minorities? Toward an alternative approach for treatment research. Cultural
Diversity and Ethnic Minority Psychology, 7(4), 328-342. doi: 10.1037/1099-
9809.7.4.328
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 27

Busseri, M. A., & Tyler, J. D. (2003). Interchangeability of the Working Alliance Inventory and
Working Alliance Inventory, Short Form. Psychological Assessment, 15(2), 193-197. doi:
10.1037/1040-3590.15.2.193
Choi, J., & Medalia, A. (2005). Factors Associated With a Positive Response to Cognitive
Remediation in a Community Psychiatric Sample. Psychiatric Services, 56(5), 602-604.
doi: 10.1176/appi.ps.56.5.602
Constantine, M. G. (2001). Predictors of observer ratings of multicultural counseling competence
in Black, Latino, and White American trainees. Journal of Counseling Psychology, 48(4),
456-462. doi: 10.1037/0022-0167.48.4.456
Cunningham, P. B., Foster, S. L., & Henggeler, S. W. (2002). The elusive concept of cultural
competence. Children's Services: Social Policy, Research, & Practice, 5(3), 231-243.
doi: 10.1207/s15326918cs0503_7
Cunningham, P. B., Foster, S. L., & Warner, S. E. (2010). Culturally relevant family-based
treatment for adolescent delinquency and substance abuse: Understanding within-session
processes. Journal of Clinical Psychology, 66(8), 830-846. doi: 10.1002/jclp.20709
Dunn, T. W., Smith, T. B., & Montoya, J. A. (2006). Multicultural Competency Instrumentation:
A Review and Analysis of Reliability Generalization. Journal of Counseling &
Development, 84(4), 471-482.
Flaskerud, J. H., & Hu, L. (1994). Participation in and outcome of treatment for major depression
among low income asian-americans. Psychiatry Research, 53(3), 289-300.
doi:10.1016/0165-1781(94)90056-6
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 28

Fuertes, J. N., Stracuzzi, T. I., Bennett, J., Scheinholtz, J., Mislowack, A., Hersh, M., & Cheng,
D. (2006). Therapist multicultural competency: A study of therapy dyads. Psychotherapy,
43, 480–490. doi:10.1037/0033-3204.43.4.480
Garland, A. F., Lau, A. S., Yeh, M., McCabe, K. M., Hough, R. L., & Landsverk, J. A. (2005).
Racial and Ethnic Differences in Utilization of Mental Health Services Among High-Risk
Youths. The American Journal of Psychiatry, 162(7), 1336-1343. doi:
10.1176/appi.ajp.162.7.1336
Gonzalez, A., Weersing, V. R., Warnick, E. M., Scahill, L. D., & Woolston, J. L. (2011).
Predictors of treatment attrition among an outpatient clinic sample of youths with
clinically significant anxiety. Administration and Policy in Mental Health and Mental
Health Services Research, 38(5), 356-367. doi:10.1007/s10488-010-0323-y
Hall, G. C. N. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and
conceptual issues. Journal of Consulting and Clinical Psychology, 69, 502–510.
Herman, K. C., Tucker, C. M., Ferdinand, L. A., Mirsu-Paun, A., Hasan, N. T., & Beato, C.
(2007). Culturally sensitive health care and counseling psychology: An overview. The
Counseling Psychologist, 35(5), 633-649. doi: 10.1177/0011000007301672
Huey, S. J., Jr., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic minority
youth. Journal of Clinical Child and Adolescent Psychology, 37(1), 262-301. doi:
10.1080/15374410701820174
Huey, S. J., Jr. & Jones, E. O. (in press). Improving Treatment Access, Engagement, and
Outcomes for Culturally Diverse Youth and Families. In F. Paniagua & A. Yamada
(Eds.), Handbook of Multicultural Mental Health. Elsevier Inc.
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 29

Hwang, W.-C. (2006). Acculturative family distancing: Theory, research, and clinical practice.
Psychotherapy: Theory, Research, Practice, Training, 43(4), 397-409. doi:
10.1037/0033-3204.43.4.397
Lakes, K., López, S. R., & Garro, L. C. (2006). Cultural competence and psychotherapy:
Applying anthropologically informed conceptions of culture. Psychotherapy: Theory,
Research, Practice, Training, 43(4), 380-396. doi: 10.1037/0033-3204.43.4.380
López, S. R. (1997). Cultural competence in psychotherapy: A guide for clinicians and their
supervisors. In C. E. Watkins, Jr. (Ed.), Handbook of psychotherapy supervision. (pp.
570-588). Hoboken, NJ US: John Wiley & Sons Inc.
Melfi, C. A., Croghan, T. W., Hanna, M. P., & Robinson, R. L. (2000). Racial variation in
antidepressant treatment in a medicaid population. Journal of Clinical Psychiatry, 61(1),
16-21. doi:10.4088/JCP.v61n0105
Miranda, J., & Cooper, L. A. (2004). Disparities in care for depression among primary care
patients. Journal of General Internal Medicine, 19(2), 120-126. doi:10.1111/j.1525-
1497.2004.30272.x
Owen, J., Leach, M. M., Wampold, B., & Rodolfa, E. (2011). Client and therapist variability in
clients perceptions of their therapists multicultural competencies. Journal of Counseling
Psychology, 58(1), 1-9. doi:10.1037/a0021496
Pole, N., Gone, J. P., & Kulkarni, M. (2008). Posttraumatic Stress Disorder Among Ethnoracial
Minorities in the United States. Clinical Psychology: Science & Practice, 15(1), 35-61.
doi: 10.1111/j.1468-2850.2008.00109.x
Prelaw, H. M., Weaver, S. R., Swenson, R. R., & Bowman, M. A. (2005). A Preliminary
Investigation of the Validity and Reliability of the Brief-Symptom Inventory-18 in
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 30

Economically Disadvantaged Latina American Mothers. Journal of Community
Psychology, 33(2), 139-155. doi: 10.1002/jcop.20041
Ribas, A. C., López, S. R., Sheinbaum, T., Santos, M., Benalcázar, A. (2012). Towards
Evidence-Based Cultural Competence: A Coding System of Clinicians’ In-Session
Behaviors. Unpublished manuscript, Departement of Psychology, University of Southern
California, Los Angeles, California.
Ridley, C. R. (1985). Imperatives for ethnic and cultural relevance in psychology training
programs. Professional Psychology: Research and Practice, 16(5), 611-622. doi:
10.1037/0735-7028.16.5.611
Roberts, R. E., Attkisson, C. C., & Mendias, R. M. (1984). Assessing the Client Satisfaction
Questionnaire in English and Spanish. Hispanic Journal of Behavioral Sciences, 6(4),
385-396. doi: 10.1177/07399863840064004
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability.
Psychological Bulletin, 86(2), 420-428. doi: 10.1037/0033-2909.86.2.420
Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and
standards: A call to the profession. Journal of Counseling & Development, 70(4), 477-
486.
Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5th ed.).
Hoboken, NJ US: John Wiley & Sons Inc.
Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American
Psychologist, 53(4), 440-448. doi: 10.1037/0003-066x.53.4.440
Sue, S. (1999). Science, ethnicity, and bias: Where have we gone wrong? American
Psychologist, 54(12), 1070-1077. doi: 10.1037/0003-066x.54.12.1070
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 31

Sue, S., Fujino, D. C., Hu, L.-t., Takeuchi, D. T., & Zane, N. W. S. (1991). Community mental
health services for ethnic minority groups: A test of the cultural responsiveness
hypothesis. Journal of Consulting and Clinical Psychology, 59(4), 533-540. doi:
10.1037/0022-006x.59.4.533
Sue, S., Zane, N., Hall, G. C. N., & Berger, L. K. (2009). The case for cultural competency in
psychotherapeutic interventions. Annual Review of Psychology, 60, 525-548. doi:
10.1146/annurev.psych.60.110707.163651
U.S. Census Bureau News. (2008). An Older and More Diverse Nation by Mid Century.
Retrieved August 28, 2009 from http://www.census.gov/Press-
Release/www/releases/archives/population/012496.html
U.S. Census, (2010). Hispanic and Asian Populations Grew Fastest During the Decade.
Retrieved from http://2010.census.gov/news/releases/operations/cb11-cn125.html
U.S. Department of Health and Human Services, (2001). Mental Health: Culture, race, and
ethnicity—A supplement to Mental Health: A Report of the Surgeon General. Rockville,
MD.
Weersing, V. R., & Weisz, J. R. (2002). Community clinic treatment of depressed youth:
Benchmarking usual care against CBT clinical trials. Journal of Consulting and Clinical
Psychology, 70(2), 299-310. doi: 10.1037/0022-006x.70.2.299
Weinrach, S. G., & Thomas, K. R. (2002). A Critical Analysis of the Multicultural Counseling
Competencies: Implications for the Practice of Mental Health Counseling. [Article].
Journal of Mental Health Counseling, 24(1), 20.
Weinrach, S. G., & Thomas, K. R. (2004). The AMCD Multicultural Counseling Competencies:
A Critically Flawed Initiative. Journal of Mental Health Counseling, 26(1), 81-93.
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 32

Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based practice in
mental health services: A complementary perspective. American Psychologist, 62(6),
563-574. doi: 10.1037/0003-066x.62.6.563
Wilcox, R. R. (2005). Introduction to robust estimation and hypothesis testing. Amsterdam:
Elsevier.
Worthington, R. L., Mobley, M., Franks, R. P., & Tan, J. A. (2000). Multicultural counseling
competencies: Verbal content, counselor attributions, and social desirability. Journal of
Counseling Psychology, 47(4), 460-468. doi: 10.1037/0022-0167.47.4.460
Zane, N., Enomoto, K., & Chun, C. (1994). Treatment outcomes of asian- and white-american
clients in outpatient therapy. Journal of Community Psychology, 22(2), 177-191.
doi:10.1002/1520-6629(199404)22:2<177::AID-JCOP2290220212>3.0.CO;2-7
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 33

Table 1.

Participant Characteristics
Clients Therapists
Gender
Male 3 8
Female 14 9
Age 40.00 (14.45)
English proficiency
Very well 6 15
Good 8 2
Not so good 1
Very badly 2
Spanish proficiency
Very well 8 5
Good 6 6
Not so good 1
Very badly 2 6
Ethnicity
Euro-American 5
Hispanic 6 6
Mexican 5
Mexican-American 5
Puerto Rican 1
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 34

Other 6
Place of birth
United States 10
Mexico 5
Puerto Rico 1
El Salvador 1
Marital Status
Single 8
Married 4
Divorced 3
Other 2
Discipline
Marriage and Family Therapist 10
Social Worker 4
Psychologist 2
Other 1
Average years of clinical experience 4.77 (4.45)
Average years living in U.S. 24.41 (15.08)
Average years of education completed 9.09 (3.53)

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 35

Table 2.
Descriptive Statistics of Shifting Cultural Lenses (SCL) Behavioral Codes

SCL Codes n Range M SD
Accessing Client’s View (C)
Session 1 17 1-4 2.53 1.01
Session 2 14 1-4 2.38 1.08
Average 14 1-4 2.50 1.04
Therapist Expressing View (T)
Session 1 17 1-4 1.82 .88
Session 2 14 1-4 2.50 .94
Average 14 1-3.5 2.21 .80
Shared Integration (Si)
Session 1 17 0-3 1.12 .93
Session 2 14 0-3 1.29 .91
Average 14 0-2.5 1.21 .75
Working Towards Client Buy-In (Sb)
Session 1 17 0-2 0.65 .70
Session 2 14 0-2 0.64 .63
Average 14 0-2 0.64 .57
Negotiation a Shared Narrative (Sn)
Session 1 17 0-2 0.35 .79
Session 2 14 0 .00 .00
Average 14 0-1 0.21 .43
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 36

Table 3.
Descriptive Statistics on the Working Alliance Inventory - Short Form
Assess.
Point
n Range M SD Mean of
Mean
a
SD
1 17 51-84 70.18 10.22 5.85 .85
2 14 53-84 73.43 10.97 6.14 .91
3 9 51-84 72.00 10.76 6.00 .90
4 10 51-84 72.80 11.59 6.07 .97
a
. This is the mean divided by the number of scale items (12). It allows for interpretation of the
mean score according to the measures 7-point Likert scale.

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 37

Table 4.
Descriptive Statistics on Client’s Perception of Therapist Warmth
Assess.
Point
n Range M SD Mean of
Mean
a

SD
1 17 17-40 35.76 6.76 8.94 .68
2 14 20-40 36.07 5.73 9.02 .57
3 9 15-40 35.33 7.71 8.83 .77
4 10 29-40 32.30 9.08 8.08 .91
a
. This is the mean divided by the number of scale items (4). It allows for interpretation of the
mean score according to the measures 10-point Likert scale.

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 38

Table 5.
Descriptive Statistics on the Client Satisfaction Questionnaire-8
Assess.
Point
n Range M SD Mean of
Mean
a
SD
1 17 18-32 26.82 3.71 3.35 .46
2 14 20-32 27.43 4.11 3.43 .51
3 9 17-32 26.44 5.34 3.46 .67
4 10 21-32 27.60 4.22 3.45 .53
a
.

This is the mean divided by the number of scale items (8). It allows for interpretation of the
mean score according to the measures 4-point Likert scale.

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 39

Table 6.
Correlations of Therapy Session 1 and Session 2 Process Measures
Therapy Session 1 (n = 17)
WAI-S WARMTH CSQ-8
WAI-S - .81** .87**
WARMTH - - .71**
CSQ-8 - - -
Therapy Session 2 (n = 14)
WAI-S WARMTH CSQ-8
WAI-S - .68** .83**
WARMTH - - .61*
CSQ-8 - - -
Note. WAI-S = Working Alliance Inventory-Short Form; WARMTH = client’s perception of
therapist warmth; CSQ-8 = Client Satisfaction Questionnaire-8
*p <.05 (1-tailed)
**p <.01 (1-tailed)

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 40

Table 7.
Correlations of Therapy Session 1 SCL Code Ratings and Therapy Process Measures (n=17)
Pearson’s r
SCL Codes WAI-S WARMTH CSQ-8
C .09 (.36) .20 (.42) -.02 (.46)
T .05 (.42) .22 (.20) -.05 (.43)
Si -.01 (.49) .13 (.30) .01 (.49)
Sb .38 (.06) .38 (.07) .33 (.09)
20% Winsorized Correlation
C .04 (.44) .06 (.22) -.27 (.15)
T .05 (.42) .04 (.44) -.12 (.33)
Si -.04 (.43) - -.13(.31)
Sb .38 (.07) .25 (.17) .31 (.12)
Note. C = accessing the client’s view; T = therapist expressing their own view; Si = shared
integration; Sb = working towards client buy-in, WAI-S = Working Alliance Inventory – Short
Form; WARMTH = client’s perception of therapist warmth; CSQ-8 = Client Satisfaction
Questionnaire-8; the 20% Winsorized correlation for one cell could not be calculated due to
small sample size and discrete nature of the data.
( ) – p-value; 1-tailed

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 41

Table 8.
Correlations of Therapy Session 2 SCL Code Ratings and Therapy Process and Outcome
Measures (n=14)
Pearson’s r
SCL Codes WAI-S WARMTH CSQ-8 BSI Change
C .09 (.38) .03 (.46) -.19 (.25) .11 (.35)
T .02 (.47) .11 (.36) .04 (.45) .42 (.07)
Si .49* (.037) .48* (.041) .54* (.02) .21 (.45)
Sb .44 (.06) .33 (.13) .27 (.18) -.28 (.16)
20% Winsorized Correlation
C -.07 (.41) .10 (.37) -.31 (.15) .08 (.36)
T -.20 (.25) .22 (.23) -.15 (.30) .09 (.39)
Si .47* (.049) .69** (.006) .53* (.03) .05 (.43)
Sb .48* (.046) .19 (.25) .21 (.24) -.82** (.00)
Note. C = accessing the client’s view; T = therapist expressing their own view; Si = shared
integration; Sb = working towards client buy-in; WAI-S = Working Alliance Inventory – Short
Form; WARMTH = client’s perception of therapist warmth; CSQ-8 = Client Satisfaction
Questionnaire-8; BSI Change = change in Brief Symptom Inventory-18 scores from first therapy
session to second therapy session
( ) – p-value; 1-tailed
*p <.05 (1-tailed)
**p <.01 (1-tailed)

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 42

Table 9.
Correlations of the Average SCL Code Ratings and Therapy Process and Outcome Measures at
1-Month Follow-Up (n=9)
Pearson’s r
SCL Codes WAI-S WARMTH CSQ-8 BSI Change TA
a
C -.25 (.52) -.21(.30) -.14 (.73) .38 (.16) -.36 (.14)
T .41 (.14) .42 (.13) .37 (.16) .05 (.45) -.01 (49)
Si .38 (.16) .36 (.17) .34 (.18) .17 (.34) .06 (.44)
Sb .15 (.35) .35 (.18) .27 (.24) .02 (.48) -.31 (.18)
20% Winsorized Correlation
C -.24 (.27) -.11 (.49) -.16 (.34) .35 (.19) -.27 (.23)
T .37 (.16) .32* (.04) .29 (.23) .14 (.36) -.18 (.30)
Si .38 (.17) .52 (.09) .29 (.23) .20 (.31) -.04 (.46)
Sb -.16 (.34) .13 (.37) .03 (.47) -.30 (.23) -.43 (.11)
Note. C = accessing the client’s view; T = therapist expressing their own view; Si = shared
integration; Sb = working towards client buy-in; WAI-S = Working Alliance Inventory – Short
Form; WARMTH = client’s perception of therapist warmth; CSQ-8 = Client Satisfaction
Questionnaire-8; BSI Change = change in Brief Symptom Inventory-18 scores from the second
therapy session to 1-month follow-up; TA = treatment attendance
( ) – p-value; 1-tailed
*p <.05 (1-tailed)
a
. n = 11
VALIDATING THERAPISTS’ CULTURAL COMPETENCE 43

Table 10.
Correlations of Average SCL Code Ratings and Therapy Process and Outcome Measures at 2-
Month Follow-Up (n=10)
Pearson’s r
SCL Codes WAI-S WARMTH CSQ-8 BSI Change TA
a
C .12 (.37) -.08 (.42) .15 (.48) -.06 (.44) -.65* (.03)
T .44 (.10) .59* (.04) .43 (.11) -.66* (.02) -.49 (.09)
Si .68* (.02) .64* (.02) .64* (.02) -.48 (.08) -.58 (.05)
Sb .22 (.27) .24 (.26) .39 (.13) .32 (.18) -.31 (.21)
20% Winsorized Correlation
C -.15 (.35) -.09 (.42) N/A .01 (.49) -.57 (.07)
T .14 (.36) .47 (.10) .26 (.25) -.50 (.09) -.79* (.01)
Si .57 (.06) .62* (.04) .64* (.04) -.57 (.07) -.33 (.20)
Sb .20 (.30) .05 (.45) .16 (.34) .20 (.30) -.51 (.09)
Note. C = accessing the client’s view; T = therapist expressing their own view; Si = shared
integration; Sb = working towards client buy-in; WAI-S = Working Alliance Inventory – Short
Form; WARMTH = client’s perception of therapist warmth; CSQ-8 = Client Satisfaction
Questionnaire-8; BSI Change = change in Brief Symptom Inventory-18 scores from the second
therapy session to 2-month follow-up; TA = treatment attendance
( ) – p-value; 1-tailed
*p <.05 (1-tailed)
a
. n = 10

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 44

Table 11.
Descriptive Statistics on Treatment Attendance at 1-Month and 2-Month Follow-Up
Assess.
Point
n

M

SD
Scheduled
Sessions
Sessions
Missed
TA Index
Score
TA Index
Score
3 11 4.00 0.82 .78 .19
4 10

3.30 1.11 .66 .28
Note. TA Index Score = number of scheduled sessions in previous month divided by number of
sessions attended; Data from assessment point 3 (1-month follow-up) includes data for three
client-therapist that treatment attendance data could not be obtained for at the fourth assessment
point. Data from assessment point 4 (2-month follow-up) includes two client-therapist dyads that
treatment attendance data was not available for in the third assessment point.

VALIDATING THERAPISTS’ CULTURAL COMPETENCE 45

Table 12.
Descriptive Statistics on the Brief Symptom Inventory 18
Assess.
Point
n Range M SD Mean of
Mean
a
SD
1 17 0-66 33.18 21.56 1.84 1.98
2 14 3-61 27.36 15.83 1.52 .88
3 9 4-64 29.11 21.91 1.38 1.22
4 10 1-55 23.30 16.32 1.29 .91
a
.This is the mean divided by the number of scale items (18). It allows for interpretation of the
mean score according to the measures 5-point scale.

Abstract (if available)

Abstract Most cultural competency models lack reference to specific therapist in-session behaviors that are deemed culturally competent. The Shifting Cultural Lenses (SCL) model (Lakes, López & Garro, 2006) operationalizes therapists’ behaviors as shifting between the client’s and therapist's views and deriving a shared understanding. Shifting between the client’s and therapist’s views are coded as: (a) accessing the client’s view, and (b) explicitly presenting the therapist’s view. Developing a shared narrative is coded as (c) integrating the client’s view, (d) seeking buy-in of the therapist’s view, and (e) negotiating a shared view. This study tests the hypotheses that these behaviors will be associated with positive treatment processes and outcomes in a sample of therapist and Latino client dyads (n = 17) obtained in community mental health settings. Therapists’ in-session behaviors were obtained via recordings of the first two sessions and clients completed therapy process and outcome measures at therapy session 1, therapy session 2, 1-month follow-up, 2-month follow-up, and 3-month follow-up. The results indicated that therapists were more likely to exhibit the in-session behaviors of accessing the client’s view (M = 2.50, SD = 1.04) and presenting the therapist’s view (M = 2.21, SD = 0.80) than they were to exhibit behaviors associated with developing a shared narrative (M = 0.21 to 1.21). Integrating the client’s view was positively associated with therapy processes, including the working alliance, perceptions of therapist’s warmth, and satisfaction with services at therapy session 2 and 2-month follow-up. None of the other SCL codes were consistently related to treatment processes or outcomes.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Within session therapist behavior in multisystemic therapy

PDF

Affirmation and majority students: Can affirmation impair math performance?

PDF

Evaluating a cultural process model of depression and suicidality in Latino adolescents

PDF

Culture, causal attribution, and social support-seeking in Asian college students

PDF

Assessing therapeutic change mechanisms in motivational interviewing using the articulated thoughts in simulated situations paradigm

PDF

The impacts of the COVID-19 pandemic on therapy utilization among racially/ethnically and socio-economically diverse children with autism spectrum disorder

PDF

Opportunity beliefs and behavioral outcomes in Latinx youth: an exploration of Ogbu’s cultural-ecological model

PDF

Perspective taking behavior and social outcomes in late adolescence

PDF

Perceived discrimination and Latino youth adjustment: examining the influence of relinquished control and immigration status

PDF

A "second chance" program for vulnerable young adults: a program evaluation and a randomized controlled trial of adjunctive motivational interviewing to improve retention

PDF

Is affluence a developmental risk for Hong Kong Chinese adolescents?

PDF

Social norms intervention to promote help-seeking with depressed Asian and European Americans: A pilot study

PDF

The successful African American Parenting (SAAP) Program: an evaluation of a culturally sensitive parenting intervention

PDF

Age differences in jealousy: an ATSS examination of the role of attributions in the emotional reactions of older and younger adults in relationship-threatening situations

PDF

Renin-angiotensin system antihypertensive medicines with and without blood-brain-barrier crossing potential: effects on cognitive outcomes in the elderly

PDF

The egocentric social networks of Black adolescents and sources of racial socialization messages

PDF

Savoring the service: a mixed-methods study of Latine community health workers’ health promotion efforts

PDF

Depression severity, self-care behaviors, and self-reported diabetes symptoms and daily functioning among low-income patients receiving depression care

PDF

Using integrative data analysis to evaluate gender differences in effects of multisystemic therapy for justice-involved youth

PDF

Reducing gang involvement through employment: a pilot intervention

Asset Metadata

Creator Jones, Eduardo O. (author)

Core Title Towards validating therapists’ in-session behaviors of cultural competence

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 05/06/2013

Defense Date 05/24/2012

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag cultural competence,OAI-PMH Harvest,psychotherapy outcomes,psychotherapy process

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lopez, Steven R. (committee chair), Huey, Stanley J., Jr. (committee member), Wilcox, Rand R. (committee member)

Creator Email eduardoj@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-251493

Unique identifier UC11288203

Identifier etd-JonesEduar-1656.pdf (filename),usctheses-c3-251493 (legacy record id)

Legacy Identifier etd-JonesEduar-1656-0.pdf

Dmrecord 251493

Document Type Thesis

Rights Jones, Eduardo O.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA