Abstract
This article presents a hypothetical counseling case that demonstrates the use of the process model of multicultural counseling competence. The counselor is an African American woman at a university counseling service, and the client is a young Chinese American woman and a sophomore at the university. First, we present an introduction to the case, giving a profile description of the client and counselor. Second, we unveil the counseling process through the model’s three phases, with demonstrations of the various features of the model. The unfolding format of the case captures the process nature of the model and dynamic interactions in the facilitation of therapeutic change. Selected excerpts illustrate counselor and client dialogue during the course of counseling, and examples of counselor multicultural counseling competencies highlight the prescriptive use of the process model. Third, we provide a reflection of the case, adding commentary on the application of the model.
Significance of the Scholarship to the Public
We demonstrate the practical application of the process model of multicultural counseling competence by walking through a hypothetical case example. This example provides some concreteness to the use of the model, but the intent is not rigid, manualized adherence. Instead, readers are encouraged to reflect on the model’s foundational principles as the case unfolds.
This case illustrates the use of the process model of multicultural counseling competence (Ridley et al., 2021 [this issue]) in the case conceptualization and treatment of a client. This hypothetical case example uses a fictional client and counselor to display potential ways the process model can assist in the incorporation of culture in counseling. This case example will not encompass all the avenues and strategies a mental health provider can take to engage in each component of the process model. Instead, we intend this case to provide a concrete demonstration of the use of the model to interested mental health practitioners. The insights provided by the case should help clinicians to competently treat clients with varied psychological presentations in clinical settings. We constructed the case through brainstorming common concerns college students experience as well as common experiences diverse individuals encounter. We attempted to develop a complex case to align with the majority of clients, without convoluting the case in such a way that would cause confusion as to how to apply the process model when reading the case example. Dr. Morgan, who recently earned her doctorate, is the counselor. She facilitates therapeutic change as she demonstrates deep-structure incorporation of culture through identifying, interpreting, and integrating cultural data about Celeste, her client. Throughout the three phases of counseling, she also demonstrates the clinical operations of developing the therapeutic alliance, infusing preparation, and adapting interventions. In addition, Dr. Morgan uses formative evaluation to monitor the counseling process and summative evaluation to notate therapeutic outcomes.
We organize the article into three sections. First, we introduce the case by describing the profiles of the client and counselor. Second, we take readers through the process of the case to show the application of the model. For clarity, we use names of the model’s features as side headings for the subsections, but since each feature dynamically interacts with the other features, we show interactions across features as well. The multilevel dynamic interactions provide an as realistic as possible view of multicultural counseling competence. Third, we conclude with a reflection on the case, providing critical commentary on the application of the model throughout the course of this case.
Case Introduction
Celeste Liu, the client, is a 19-year-old, single, Chinese American, heterosexual, cisgender woman who uses the pronouns of she/her/hers. She is a sophomore at a university pursuing the premed program. Her academic advisor referred her to the university’s counseling service. Celeste’s presenting concerns are her decline in academic performance this semester and worries about the prospect of losing eligibility for her scholarship (the major source of her financial aid). She is having difficulty passing prerequisite courses to be eligible for her major. She reports symptoms of anxiety, notably sleep deprivation, headaches, tenseness, and ruminating thoughts.
Celeste’s parents are immigrants from China. She and her siblings were born in the United States. Her mother is an accountant, and her father was a corporate executive until his recent layoff due to an economic downturn. The abrupt change in family income has heightened the family’s worries about funding her younger brother’s education, who is a senior in high school and plans to attend college next year. Because she does not want to put further strain on her parents, Celeste has not shared her academic struggles with them. She feels especially anxious whenever her parents express relief that at least she has a scholarship. Celeste’s academic struggles cause frustration because if she wants to pursue a premed course of study, she has to declare her major by the end of her sophomore year and earn good grades. She wants a prestigious and lucrative job, similar to her older sister who now is an attorney. She hopes counseling will help her improve her grades so she will not have to tell her parents about the threat of losing the scholarship.
Family plays a prominent role in Celeste’s life. She maintains strong bonds with her parents and siblings and appreciates their indispensable support. She knows her siblings also value family. Celeste’s parents have always invested in her personal growth and development with particular emphasis on her education and career aspirations. Considering her family’s recent financial reversal, Celeste wants to help them rather than become an additional burden.
Dr. Morgan, a 30-year-old African American woman, is Celeste’s counselor. She holds a doctorate in counseling psychology and has a postdoctoral fellowship position at the university’s counseling service. She is accumulating supervised hours toward her licensure as a psychologist. Dr. Morgan is the first person from her middle-class family to earn a doctoral degree. She ascribes to an integrated theoretical orientation drawing from person-centered therapy and interpersonal therapy. She ardently embraces multiculturalism and social justice.
Demonstrating the Use of the Model
The counseling takes place over the course of an intake plus ten follow-up sessions. The case demonstrates the counselor’s application of the various features of the process model as the counseling unfolds. Since the model is organic, the presentation of the case also demonstrates the multilevel dynamic interactions among the features of the model.
Preparation
Celeste registered for counseling services at the university through the online portal where brief information on her presenting concerns and demographics were collected. This helped Dr. Morgan begin her preparation for meeting with Celeste. Before meeting Celeste, Dr. Morgan had diligently prepared herself through various venues of multicultural training such as coursework, workshops, and continuing education. These experiences built her foundation in cultural awareness, skills, and knowledge. She values education and recognizes her doctoral training as one of her areas of privilege. Growing up, her parents encouraged self-expression and openness. They provided a nurturing environment that was nonthreatening, which she now regards as an integral aspect of her counseling. Her religious beliefs also play an important role in her personal and professional life. Rooted in a Baptist tradition, she derives a sense of purpose and meaning from her faith. To her credit, Dr. Morgan is keenly aware that her beliefs and values inform her perspective on counseling. To hold herself to high standards, however, she avoids imposing her values onto clients and realizes that her awareness cannot be a static process. Thus, she opens herself to continual self-examination and interactions with others’ including her clients, who might challenge her beliefs.
Dr. Morgan places a premium on collaboration. She encourages her clients to voice their opinions throughout the process, help establish treatment goals, and follow through on agreed-upon assignments between sessions. She emphasizes the importance of “being present” in sessions. She values kinship networks as well as independence and autonomy. Influenced by her person-centered leanings, she believes clients are experts on themselves. Therefore, she encourages the development of her clients’ own voices, not only in therapy but also in their everyday lives. As a multiculturalist, she affirms clients using their cultural strengths.
Dr. Morgan has a basic knowledge of family structures, hierarchies, values, and beliefs among Chinese Americans. She learned about this population by studying social science literature and working with Chinese American clients in her predoctoral internship. In particular, she has read the writings of Dr. Derald Wing Sue, Dr. Stanley Sue, Dr. Nolan Zane, and other authors whose research focuses specifically on multicultural counseling. She also attended the annual conference of the Asian American Psychological Association.
Intake Session
During the intake session, Dr. Morgan collects the typical demographic/background data and information about the client’s presenting complaints. She soon recognizes that she and Celeste share similar values about education and family. This became evident as Celeste expressed her desire to improve her grades, keep her scholarship, and not burden her family. Dr. Morgan validates these goals and anticipates that they will collaborate to achieve these goals.
What is not obvious at the outset is Celeste’s emotional self-control and humility. These values shape her attitude toward counseling and become important issues on which to work. For instance, when Celeste began to discuss her anxiety, she presented it in such a controlled fashion that it was difficult to see any noticeable nervousness. Then, Dr. Morgan had to dig and prod to find out about Celeste’s past academic achievements, such as graduating first in her class from high school, which suggested Celeste’s value of humility. In general, her experience with Celeste during the intake reaffirmed to Dr. Morgan the priority she should place on incorporating culture as an integral part of the counseling process.
Developing a Therapeutic Alliance
Dr. Morgan struggled to develop a therapeutic alliance. Although she shared similar values with Celeste about education and family, she discovered that they had dramatically different perspectives on the purpose of counseling. Dr. Morgan’s orientation included an emotions-focused and self-exploration approach, whereas Celeste came assuming the counselor would solve her problems. It is common for clients from Eastern cultures to view counseling somewhat like going to a physician, where they receive medicine to address the problem. Dr. Morgan also noticed that she did not feel a strong connection with Celeste, despite using an emotions-focused approach. Dr. Morgan initally assumed her client was just disengaged. She noticed on the Session Rating Scale (Duncan et al., 2003) that Celeste rated the first session low. The first thing she sought to investigate was the possible influence of their racial backgrounds on the development of an alliance. Using the clinical skill of broaching cultural differences in the early stages of counseling (Day-Vines et al., 2007), she endeavored to honor their differences but move beyond those differences to develop an alliance.
I am an African American woman, and you are an Asian American woman. We both take pride in our heritage, and this makes us special. I wonder, though, if you might have concerns about us working together since we have different cultural backgrounds and experiences. What are your thoughts about this?
After discovering that race was not an issue for Celeste, Dr. Morgan still sought to understand why Celeste rated the sessions as low. She asked if Celeste was committed to making changes. This question confused Celeste because she believed she was very committed to counseling, but she did not think Dr. Morgan was moving her towards change. The question and Celeste’s reaction proved to be a turning point in their relationship. Celeste verbalized her concern that Dr. Morgan was not going to give a quick solution to her problems. Dr. Morgan realized that she and Celeste held different assumptions about the purpose of counseling. She also recalled some reading from her preparation stage that discussed how some Asian Americans value emotional control. Dr. Morgan decided to disclose her own misunderstanding of the situation. She shared that she had felt disconnected from Celeste and had been trying to address this by exploring Celeste’s emotions more. However, Dr. Morgan realized that she had assumed that Celeste would also see counseling as a space for self-exploration and emotional awareness. Dr. Morgan invited Celeste to share her thoughts and reactions to this, while intentionally showing empathy, validation, and patience. She also invited Celeste to ask questions about how other aspects of her identity could pose a barrier in therapy. These gestures, among others, helped to deepen their alliance and empower Celeste.
Deep-Structure Incorporation of Culture
Identifying (Gathering) Cultural Data
After their relationship began to develop, Dr. Morgan wanted to find out directly from Celeste about the cultural values and beliefs that motivate her. She did not want to stereotype Celeste based on what she learned during her preparation.
I think that to help me understand you even better, it would be helpful to understand more about your culture and your environment. Could you tell me about your cultural background?
Well. . . I mean I’m Asian. . . My parents emigrated from China although I was born in the U.S. Is that what you mean?
Sure, that certainly is an example of culture. There isn’t really a right or wrong answer to the question. Culture can come from so many pieces of identity like your gender, your age, your socioeconomic status, your religion, your sexual orientation. . . So for you, what would you say are the most important cultural influences on you?
Hmm. . . I guess I would still say being Asian then. My parents still hold on to being from China originally. And even though I’m not exactly as Chinese as they are, that still has an influence on my life. I mean, it’s different since I was born here, but I’ve been part of a lot of friend groups with other Asian kids whose parents were immigrants too. Plus, I know other people will always see me as Asian, you know?
It sounds like being Asian has a complex meaning for you. There’s a way your parents see it, a way your peers see it, and a way you see it?
Yeah, you know I guess I’ve never described it that way, but you’re right. Being Asian means different things to me, partly depending on which people I’m around and interacting with. [pause] But it can even have different meanings even around the same people. . .
[pause] Could you tell me more about that?
Well, for instance, with my friends who are Asian, it can be something we bond over and share jokes about. So it can be nice to feel like there’s this unspoken understanding. But at the same time, sometimes it can bother me because I feel like it means they make assumptions about me that aren’t necessarily true. . . I don’t know, does that make sense? Now that I said that out loud, it kind of seems like I’m being picky. Like I’m unhappy either way.
I think what you’ve said so far does make sense. It sounds like you feel frustrated because you do like some things that come with being Asian but you also notice other things that you like less.
Yeah, like take my career for example. I mean, I know I already said a big reason I’ve decided to come to counseling is that I’m worried about what I’m going to do with my future and whether my grades will hold me back. And I think that’s because I have career ambitions, you know. I want to do something meaningful with my life, not just get-by or be mediocre. But sometimes I feel like people kind of brush that off. Because they see that as stereotypical for an Asian or something.
I imagine that’s pretty hurtful.
It really is! [pause] I actually am an ambitious person. And it’s not just because of my culture. Like I know that I probably was influenced and shaped by my Asian culture and my parents, but it’s not just because of that. It’s not like I want a certain future just because other people value it or pressure me.
It sounds like you’re saying that there’s both a cultural influence and a personal aspect to your career ambitions.
Yeah. . . yeah, that sounds right.
[pause] So I feel like you’ve already begun touching on this, but I’d like to dive a little deeper if that’s okay. [Celeste nods.] What are some of the values from your culture that are deeply important to you?
Hmmm. . . [pause] I guess the first one that comes to mind is not being a burden to others. Like, being responsible for yourself is a way to be considerate and respectful of others. When you take care of yourself and your own responsibilities, that means other people don’t have to clean up after you.
So being considerate and respectful of others is really important to you, which is why you don’t want to be a burden.
Yeah, even when a subject or hobby or whatever didn’t come easily to me, I always tried to figure out ways to make progress. Like I asked for help if I needed it, like by staying after school with the teacher or reviewing with friends. But I mean that I took responsibility for my own improvement. I didn’t just expect someone else to come to rescue me or fix it for me because. . . you know. That’s inconsiderate and irresponsible.
It sounds like taking responsibility and being considerate are closely related to each other.
Yeah, and I think that’s also why figuring out my career is so important to me. I want to be able to take care of myself financially. I want to be able to help my family, not be a burden to them.
Later, Dr. Morgan wants to help Celeste move to problem-solving. She takes a question directly from the Cultural Formulation Interview (American Psychiatric Association, 2013).
What do others in your family, your friends, or your community think is causing your problem?
I. . . (hesitates) I haven’t told them, really, so I guess they haven’t had the chance to say what they think.
What has made you hesitant to tell them?
I don’t want to make things harder for my family. My parents already have financial pressures without me losing my scholarship because of poor grades. If I can just improve my grades, I won’t even have to worry about them.
It sounds like you are concerned about negatively affecting your family.
Yeah, I guess. I mean, I want good grades for more than myself (pauses). My parents used to tell me how hard they studied to come to America. They saw how academic success led to a better life. So. . . I want to make sure I get good grades. This way I would feel that they worked hard for something. And it also means I won’t be a burden to them.
So good grades are for your family as much as they are for you.
Yeah. . . (Celeste shrugs). But I am not sure how talking about grades will help. I want to get rid of my anxiety, not just talk about it.
I’m hearing some frustration with just talking about this. Is that right?
Yeah. . . no, well, I mean. . . (hesitates, then speaks faster) I believe the best thing to do with a problem is to find solutions. I need answers. When you have difficulties, it’s more helpful to think about the next step than to just feel bad. I guess that’s why I am here, for concrete solutions.
After this exchange, Dr. Morgan gathers more information that builds on the narrative. In response to some seemingly contradictory statements from Celeste, Dr. Morgan decides to reframe the question.
Celeste I would like to go back to your comment that good grades are not just for you. I think there may be more to your comment than what you actually said because you suggested something a little different earlier. If they did know, what do you guess your family, friends, or community would say is causing your problem?
If I become a burden, if I lose my scholarship, it would be awful. Everyone in my family would be upset—my parents, my sister, and my brother, even my grandparents, who still are in China.
It sounds like you are carrying a heavy emotional burden just at the thought of putting additional financial burden on your family. Then you compound the burden you carry by putting a lot of effort into keeping it away from them.
You know. I just can’t stop thinking about how much turmoil this would create. I do not think I could stand it.
Interpreting Cultural Data
Throughout counseling, Dr. Morgan continues to gather cultural data. At the same time, she begins to make interpretations. When Celeste said, “I do not think I could stand it,” Dr. Morgan marks this comment as an important data point. She wants to determine whether this is culturally driven or unique to Celeste. She recalls reading that second-generation Chinese Americans often begin to place less value on the traditions of their parents while trying to fit in with their non-Asian peers. She also found research revealing that conflicts with parents are common among Asian American college students (Lee et al., 2005).
This prompted Dr. Morgan to set forth a couple of clinical hypotheses around the theme of an acculturation conflict. First, Dr. Morgan surmises that Celeste avoids discussing her grades with her parents to keep harmony, but the avoidance is actually anxiety provoking. Dr. Morgan also hypothesizes that Celeste might be distraught about her failure to live up to some traditional Chinese values such as filial piety (respecting elders), potential loss of face, and shaming the family. These values reflect a collectivist worldview. On the other hand, she surmises the way Celeste handles the problem by not sharing it with the family shows another side of her, reflecting an individualistic worldview. Not only is she disappointed in herself, she feels that she should find solutions on her own and without the help of her family. Growing up in the United States, she has gained a streak of independence and self-reliance.
To test these hypotheses, Dr. Morgan returns to data gathering, where she finds that Celeste’s traditional cultural values, not just idiosyncratic preferences, primarily motivate Celeste. Additionally, it was important for Dr. Morgan to understand Celeste’s experiences with her intersectional identities versus just concentrating on her racial identity as a Chinese American when shaping her interpretation. This is due to the knowledge that some of Celeste’s identities may be more prone to discrimination, prejudice, or stereotypes than those of others. Dr. Morgan was careful to avoid any simplifying language and checked in with Celeste to explore which identities were salient in her world. Celeste identified her Chinese heritage and American upbringing as being the most prevalent parts for her. Therefore, Dr. Morgan focused on those identities. However, Dr. Morgan was still intentional in conceptualizing Celeste as a whole.
Is your desire not to make things harder for your family unique to you, or would others from your culture do the same?
Even though I want to make it for myself, I have no choice but to put my family first. Any of my friends would do the same thing. Besides, my parents would feel like I disrespected them. Chinese parents from their generation make a big deal about children respecting their elders and not bringing shame on their family. I just could not do that.
Dr. Morgan now has clear self-report evidence of cultural influence on Celeste’s behavior. Augmented by a discussion with a Chinese American psychologist she knows, Dr. Morgan gathers some preliminary base-rate data in which she learns that fear of being a burden to the family is common in this population. Dr. Morgan concludes that some of Celeste’s environmental and dispositional stressors complicate her anxiety. She is anxious about her family’s reactions, and she compounds her condition with her need to be the model Asian daughter and protect her family. Ironically, she forcefully expresses disdain for the model minority stereotype. This combination of issues puts Celeste in a debilitating cycle.
Integrating Cultural Data
Integrating cultural data is the process of using the gathered and interpreted cultural data to inform and develop a sound case-conceptualization and comprehensive treatment plan. Because this entire article represents the unfolding of this process, we do not elaborate more about integrating cultural data in this section.
Infusing Preparation
As counseling progresses, Dr. Morgan raises the issue of bicultural identity and Celeste’s personal navigation as a Chinese American between two cultures. She asks Celeste how she attributes her own personal meaning to her bicultural experiences. Although Dr. Morgan uses her prior knowledge to formulate and test hypotheses, she does so without imposing stereotypical attributions onto Celeste. Counselors can use their multicultural knowledge as a template but then explore how individual clients uniquely attribute meaning to their experiences.
Dr. Morgan helps Celeste examine how navigating between the two cultures also may contribute to Celeste’s overall anxiety about academic performance. For example, Celeste discusses how her independence propels her to take leadership positions in various student clubs even though her parents ask her to focus on academics, viewing organizations as distractions. This disagreement frustrates Celeste, and she feels additional pressure to perform well academically to show her parents she can balance the two. Another difficulty stemming from her bicultural identity is Celeste’s approach to problem solving. Her parents taught her the importance of finding solutions, so Celeste prefers to focus on this instead of sharing her emotions with others. This is one reason Celeste is reluctant to express negative or potentially burdensome emotions to others. In other ways, Celeste does successfully navigate between the two cultures. For instance, she has built a support system of peers in college who share her values of academic achievement.
Dr. Morgan already knows that collectivism and family harmony is prominent in Asian cultures. She integrates this knowledge by asking how these values fit with Celeste’s personal strength of independence. Asking directly helps Dr. Morgan to not presume she knows and gives Celeste space to reflect on how cultural conflict may contribute to her overall anxiety. Celeste explains how her independence is complementary to family harmony. By taking care of her own needs and problems, Celeste can then support her family rather than burdening them with her own concerns. In other ways, though, independence conflicts with family harmony. For instance, Celeste knows voicing conflicting opinions can create unwanted friction, so she often stays silent despite having strong personal views.
Dr. Morgan also uses appropriate self-disclosure to build the therapeutic alliance. She shares how she grew up in a predominantly White school district, which made her feel very different from her peers. When she attended college, it became difficult to fit in with some of the Black students on campus because they thought she “acted too White.” This self-disclosure by the counselor serves as a point of connection. Celeste identifies with struggling to fit into the general culture on campus even though she has connected with a group of high achievers through student organizations.
Adapting Interventions
One strategy Dr. Morgan used to help Celeste explore her feelings was by using handouts for understanding and naming emotions from a dialectical behavior therapy (Linehan, 2015) workbook. Dr. Morgan’s intervention is consistent with her theoretical perspective that self-exploration helps reduce psychological distress. Despite Dr. Morgan’s belief in the importance of direct coping, she soon recognizes that Celeste is uncomfortable processing some of her emotions in sessions, often using deflection tactics such as jumping around to other topics. As she evaluates this behavior, Dr. Morgan becomes aware that either Celeste is resistant to change or there may be a problem with the intervention. Dr. Morgan then discusses the difficulties of expressing emotions. This opens the door for Celeste to reveal that emotional control is valued more than emotional expression in her family and her larger culture.
In light of what Celeste shares, Dr. Morgan realizes that her interventions are grounded in Western ideology. Encouraging Celeste to articulate her feelings interferes with her value of maintaining harmony with others since emotions tend to “center on the needs and responses of others rather than the self” (Shibusawa & Chung, 2009, p. 313). Therefore, Dr. Morgan intentionally chooses to validate emotional control as normal. She also decides to capitalize on Celeste’s value and strength in problem solving rather than insist on an emotions-focused approach.
To facilitate therapeutic change, Dr. Morgan applies the “wrapping and unwrapping emotions” strategy (Shibusawa & Chung, 2009). The goal is to validate Celeste’s anxiety without pushing her to express it directly. Dr. Morgan learned this strategy by reading literature on ways to establish a relationship with emotionally conservative East Asian clients. Based on the relational-cultural theory, healing occurs when the relationship is mutually empathic and growth-focused (Comstock et al., 2008). Dr. Morgan talks about how the extremes of emotions are unhealthy. She learns that rather than trying to push Celeste to express herself, she should focus on the reasons behind her complaints, as they can help her understand the emotions Celeste is experiencing without directly talking about them. Rather than uncovering her client’s emotions, she reframes her thinking to align with how Chinese and Japanese present their gifts as wrapped. The more that Dr. Morgan allows Celeste to explore her inner emotions at her pace, the more she can comfortably express them outwardly.
Celeste shows incremental therapeutic changes by using more “I feel. . .” statements. She discusses how she feels like a failure and inadequate. She believes this leads to feeling ashamed for not giving more to her family the way she knows she could. Her perfectionistic tendencies to achieve also result from her desire to be a contributing member of her family. Rather than pushing Celeste to experience her emotions deeply, Dr. Morgan allows her to “wrap up” her feelings when the subject becomes too much for her. However, Dr. Morgan knows she can not facilitate the therapeutic process without emotional processing, so she encourages Celeste to feel discomfort. Furthermore, Dr. Morgan teaches Celeste to practice mindfulness with an external focus (Hall et al., 2011). For example, Dr. Morgan encourages Celeste to remain aware of the difficulties her family has but, at times, mindfully redirect her attention back to her schoolwork. She discusses with Celeste how stressful it must be to have so much responsibility and pressure to succeed for her family. Dr. Morgan allows her to express those emotions but also interrupts Celeste from time to time to help her recognize the situations she can and cannot control. This helps Celeste take a more proactive approach but also to step back from difficulties that may seem too overwhelming to face.
Dr. Morgan then uses several strategies from established interventions that she frames within the context of meeting Celeste’s personal priorities and cultural obligations. Specifically, she uses adaptations of cognitive behavioral therapy for Chinese Americans to improve Celeste’s academic achievement (Chen & Davenport, 2005). Dr. Morgan provides psychoeducation on self-efficacy and its influences on academic achievement. She describes the contribution of automatic negative thoughts to anxiety and ways to identify them. Then, she role-plays cognitive restructuring to change negative thoughts into positive self-talk messages and cognitive errors associated with her perfectionism such as dichotomous thinking. Dr. Morgan teaches Celeste problem-solving skills by identifying problematic behaviors. Using Socratic questioning, Dr. Morgan helps Celeste explore a range of problem-solving alternatives. Instead of forcing Celeste to remove herself completely from her comfort zone, Dr. Morgan adapts her approach by changing her style to meet Celeste’s needs. As a result, Celeste reports a greater sense of control and reduction in her anxiety.
Evaluating and Therapeutic Outcome
After ten sessions, Dr. Morgan conducts a summative evaluation of therapeutic changes using quantitative and qualitative techniques. Quantitatively, she evaluates Celeste’s progress using the Outcome Questionnarie-45 (OQ-45) and tracking her academic performance (Lambert et al., 2004). Although the OQ-45 lacks cross-cultural empirical support, it still is a useful evaluative tool since clinicians deeply incorporate culture during the overall evaluation process. Qualitatively, she asked Celeste for self-reports of newly acquired skills in handling her emotions. Celeste reports that her anxiety symptoms have reduced largely because she has learned to accept her setbacks and value her contributions to her family.
Celeste is able to capitalize on her cultural strengths (solution-focused) and worldview (importance of family) to take effective action to improve her grades and maintain her scholarship. Celeste learned to use mindfulness techniques to reduce her anxiety. She learned to challenge negative thought patterns that exacerbated her symptoms of anxiety. In addition to learning these coping mechanisms in counseling, Dr. Morgan helped Celeste incorporate the “wrapping and unwrapping emotions” technique along with mindfulness techniques to address her anxiety. By reducing her perfectionistic tendencies and developing a more realistic approach to academic performance, Celeste feels higher self-efficacy. The drop in Celeste’s OQ-45 scores and improvement in her grades indicate these skills and strategies helped Celeste accept her feelings and handle her anxiety effectively. Although Celeste has made significant progress towards her initial goals for therapy, Dr. Morgan notes that Celeste could still benefit from further counseling to address her career concerns and her bicultural experiences.
Reflection on the Case
This case illustrates the practical use of the process model of multicultural counseling competence. Given the myriad of exigencies that are possible in counseling, we acknowledge that counselors will encounter their individual challenges in using the model. Some of these will be unique to the client, counselor, or client–counselor relationship. Other challenges will stem from unanswered applications of the model. Here are some that we put forth.
First, some applications of the model still warrant better prescription. For instance, the translation of the awareness-skills-knowledge (ASK) framework into clinical practice has much room for explication. We have attempted to explain these components with concrete steps, but readers who still have questions may find few additional resources to clarify these components.
Second, to reiterate the process model is not a theory or system of counseling, its utility with a variety of therapeutic orientations is an important advantage. Yet this advantage comes with a price. Using the process model within the parameters of the various theoretical orientations demands new and creative ways of thinking about process and cultural adaptation. We think this clinical case reflects the real-life challenges that counselors encounter in their work.
Third, evaluation remains a major area of concern since the multicultural literature devotes limited attention to this topic. The multiple aspects of counseling—such as the therapeutic alliance, cultural self-awareness, selection of interventions, clients’ progress, and therapeutic outcomes—are subject to evaluation. Evaluating each of these aspects of counseling requires a unique skill set. Employing the two types of evaluation, formative and summative, is equally concerning. Both are critical to the demonstration of multicultural counseling competence. Selecting evaluation techniques, either quantitative or qualitative, add another layer of concern. Determining how to measure process and outcome also begs for clinical acumen.
Clearly, the many issues involved in evaluation of multicultural counseling competence, and the limited attention in the literature, raises many questions. This article only scratches the surface. Like all clients, Celeste entered counseling with her unique psychological presentation, and Dr. Morgan began the process with her unique preparation. Within this context, Dr. Morgan had to evaluate the counseling on multiple levels. Prominent among these was Dr. Morgan’s need for continuous self-assessment to improve her own multicultural counseling competence. This is an illustration of dynamic interaction. Like all of the clinical activities in this process model, evaluation and preparation are not mutually exclusive.
Fourth, as revealed in this case, the model’s flexibility as a strength shows that therapeutic changes are not linear. Dr. Morgan had to cycle back to previous stages in trying to incorporate culture. This enabled her to adjust her conceptualization of Celeste, which then informed her adaptation of treatment. The model’s flexibility also manifests itself in the individualization of treatment. It is applicable to a wide range of individuals with different presenting concerns. Finally, the process model is applicable to counselors and clients of different backgrounds, as in the case of Dr. Morgan and Celeste.
Fifth, the case shows the necessity of preparation. We should never overlook the importance of cultural awareness, skills, and knowledge as the foundation. Preparation begins before meeting with clients, but this component of the competence does not stop at the intake. Throughout counseling, Dr. Morgan continued her multicultural training, referred to the literature to learn about Chinese Americans, and modified her interventions to adapt to Celeste’s cultural needs. In fact, all of her clinical activities were purposeful, resulting in Celeste’s improvement of grades in her courses and change as measured by the OQ-45.
In conclusion, this case seeks to help counselors put their multicultural competence into practice. The case shows that the reality of this competence is complex and nuanced. Using the process model of multicultural counseling competence, the counselor deeply incorporated culture in counseling to enhance the quality of the process, bridged barriers between herself and the client, and ultimately facilitated therapeutic change. We hope that supervisors, graduate trainees, and practitioners learn from this case and improve their competence facilitating therapeutic change with diverse clientele.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
