The Process Model of Multicultural Counseling Competence ψ

Abstract

The mental health professions need to reconceptualize multicultural counseling competence and innovate their models in order to provide better guidance to their professionals. To this end, we first redefine multicultural counseling competence with the goal of overcoming its pervasive definitional problems. We then propose the process model of multicultural counseling competence, which aims to rectify the limitations of the existing models. Our model integrates strengths of the three major models—skills-based, adaptation, and process-oriented—while also adding new components. Seven foundational principles undergird our complex and dynamic model. The model consists of three distinct phases: preparation, intake and in-sessions, and termination. In addition, the model consists of five clinical operations. The superordinate operation is deep-structure incorporation of culture. Subordinating to and rotating around this superordinate operation are: infusing preparation, developing a therapeutic alliance, adapting interventions, and evaluating process and outcome. Although these clinical operations interact dynamically at multiple levels within the model, the ultimate purpose is still the attainment of positive therapeutic outcomes.

Keywords

construct definition model building theory into practice therapeutic change diversity training

Significance of the Scholarship to the Public

We redefine multicultural counseling competence in an attempt to overcome the previously identified definitional problems. Based on this definition, we present the process model of multicultural counseling competence, which aims to integrate the strengths of existing models and rectify their limitations by adding new components. This article explains the foundational principles and design components of the model, followed by an example of its practical application in the subsequent article.

Mental health professionals need better guidance in grappling with their multicultural counseling competence. The grappling stems primarily from the enormous body of work that leaves considerable confusion as to the meaning of the construct. A sound reconceptualization and remodeling of the construct can provide that needed guidance. In the second article of this Major Contribution (Ridley et al., 2021 [this issue]), several members of our research team discussed flaws in the presentation of multicultural counseling competence in the literature. They identified 10 definitional problems of the construct and six limitations of the three major models of multicultural counseling competence—skills-based, adaptation, and process-oriented. The authors reached this conclusion:

Practitioners of the profession find themselves lost or stuck in their attempts to demonstrate multicultural counseling competence, even though they have an abundance of available resources. . . .

Overall, there is compelling evidence for the need to rejuvenate psychology’s conceptualization of multicultural counseling competence. The suggested improvements to existing definitions and models should enhance the utility of the construct, making it easier for practitioners to recognize, cultivate, and demonstrate this competence in their work with clients. (Ridley et al., 2021, pp. 526–527)

In alignment with this conclusion, we place priority on clearing up the confusion. Our intent is to advance a sounder definition of multicultural counseling competence and overcome the conceptual and operational impasses that impede progress in the use of the construct (Mollen & Ridley, 2021 [this issue]). Worthington and Dillon (2011) similarly called for revision and advancement of theory in this area. Although these authors were referring to the tripartite model of multicultural counseling competencies (American Psychological Association [APA], 2003; Arredondo et al., 1996; Sue, et al., 1992; Sue et al., 1982), we extend the need for revision to the two other major models noted by Huey et al. (2014).

The purpose of this article is to introduce the process model of multicultural counseling competence. Built on the foundation of our redefinition of multicultural counseling competence, the process model offers an intentional and dynamic incorporation of culture into counseling and psychotherapy.¹ The process model borrows from and integrates components of the construct’s three major models while striving to overcome their limitations. In addition, the process model adds new components that are missing in the other models. Finally, it provides guidance on its practical application—something we believe meets the vital needs of grappling practitioners.

To achieve our objective, we have organized the article into three major sections. In the first section, we redefine multicultural counseling competence. In the second section, we postulate the centrality of deep-structure incorporation of culture in the construct. In the third section, we present the process model, explaining its guiding principles, and then describing its component parts along with examples of their implementation. We conclude with an invitation to stakeholders in the profession to participate in the conversation.

Redefinition of Multicultural Counseling Competence

In the construct multicultural counseling competence, the word multicultural modifies counseling competence. Ridley et al. (2011) defined counseling competence as “the determination, facilitation, evaluation, and sustaining of positive therapeutic outcomes” (p. 835). Using this definition as a frame of reference, we define multicultural counseling competence as the facilitation of therapeutic change through the deep-structure incorporation of culture into counseling and psychotherapy. We define therapeutic change as constructive and holistic second-order transformations in clients’ psychological presentations. Therefore, the facilitation of therapeutic change is a purposeful process that requires the coordination and management of a variety of competencies and clinical activities.

In defining the construct, we distinguish multicultural counseling competence from multicultural counseling competencies. The former is an umbrella concept that subordinates multicultural competencies. We follow the lead of other authors (e.g., Kaslow et al., 2004; Marrelli et al., 2005) and resonate especially with Leigh et al. (2007), whose definition of competencies is “demonstrable components of competence” (p. 464). We add that competencies are the actionable and purposeful behaviors that clinicians employ to translate multicultural concepts and ideas into the facilitative activities of therapeutic change.

In positing our definition of the construct, we also are compelled to ask a critical question. What then is multicultural about multicultural counseling competence? Answering this question is essential to create a model that guides the demonstration of this competence. We contend that the answer lies in the centrality and deep incorporation of culture in counseling which is expanded on next.

Centrality of Deep-Structure Incorporation of Culture

Culture acts as “an invisible and silent participant in the counseling transactions of the counselor and counselee” (Draguns, 1989, p. 6). Whether counselors are aware of culture’s participation or understand how it participates begs the issue. The fact is that all people are cultural beings who behave based on cultural values and expectations and bring experiences of culture into counseling. Additionally, counseling itself occurs within a cultural context (APA, 2017; Kirmayer, 2007; Pedersen, 1990). Therefore, counselors and therapists are amiss if they overlook or discount the significance of culture in counseling. As Draguns (1989) continued, “If the role of culture is overlooked, the flow of communication can be obstructed, and the development of a relationship may be aborted” (p. 6).

By embracing the premise of culture’s significant participation, we need to know exactly what we mean by culture. Numerous definitions appear in the literature. To comport with professional psychology, we elect to use the definition of culture in the Multicultural Guidelines: An Ecological Approach to Context, History, and Intersectionality, 2017:

Belief systems and value orientations that influence customs, norms, practices, and social institutions, including psychological processes (language, care-taking practices, media, educational systems) and organizations (media, educational systems). Culture has been described as the embodiment of a worldview through learned and transmitted beliefs, values, and practices, including religious and spiritual traditions. It also encompasses a way of living informed by the historical, economic, ecological, and political forces on a group. (APA, 2017, p. 165)

This definition reveals observable and unobservable aspects of culture. Observable aspects are things such as customs, practices, and language. Unobservable aspects are things such as values and beliefs. As therapists, we should be interested in the role of both in therapy. We should be interested especially in the role of unobservable aspects of culture because clinicians are more prone to overlook them, despite their powerful influence on the process. We assert that determining the influence of cultural values and beliefs on client behavior, managing their influence on the dynamics of the therapeutic relationship, and leveraging these aspects of culture to facilitate therapeutic change is the purview of multicultural counseling competence.

How Much Culture is Required?

Considering its significant participation in counseling, clinicians should seek to understand how culture participates, and how clinicians can leverage culture to facilitate therapeutic change. Accordingly, Gone (2010) asked, “How much ‘culture’ is required for the culturally competent practice of psychotherapy with the culturally different?” (p. 169). His question implies that the deep incorporation of culture not only is central to multicultural counseling competence, but the demonstration of this competence is impossible without it. As he stated in this additional commentary:

Attaining cultural competence in the practice of psychotherapy with culturally diverse clients should presumably extend well beyond mere cosmetic alterations in the counseling process. Otherwise, such superficial modifications might simply mislead potential clients into participating in otherwise conventional “West-is-best” interventions. (Gone, 2010, p. 169)

Few scholars have attempted to answer Gone’s (2010) poignant query. He suggested a deeper inclusion of culture in psychotherapy that goes beyond “cosmetic alterations” and “superficial modifications.” On this basis, we question the extent to which many clinicians demonstrate depth, purposefulness, and explicitness in their incorporation of culture in counseling. We speculate that shallowness, purposelessness, and inexplicitness prevail among many clinicians. We also believe that much of the shallowness reflects clinicians’ “burden of considering culture” (López et al., 1989, p. 373) and results in unintentional adverse consequences for clients (Ridley, 2005).

Beyond Surface-Structure Incorporation

In developing the process model, we attempted to answer Gone’s (2010) question. We present an example that illustrates a poor answer—one with too little culture to meet the requirement of multicultural counseling competence. Ridley (2005) related the experience of a Japanese international student who scheduled an appointment at her university counseling center. At the outset of the session, the counseling psychologist asked a series of questions about the client’s experiences in Japan. The psychologist mostly asked questions about her history of romantic relationships and showed her biased assumptions about dating norms in Japan. Presumably, this line of inquiry represented the psychologist’s effort to gather cultural data and display cultural sensitivity. However after the barrage of questions, the psychologist delved into other topics and did not attempt to connect the initial questions to the client’s psychological presentation and treatment goals.

We can explain the psychologist’s behavior on two levels. On a surface level, the psychologist did incorporate culture into counseling, for she asked culturally related questions. However, did this clinical activity actually demonstrate multicultural counseling competence? In her mind, and perhaps the mind of other professionals, her interest and inquiry reflected a type of competence. However, on an in-depth level, the psychologist did not incorporate culture into counseling. Despite probably good intentions, her clinical actions did not facilitate therapeutic change. In fact, her surface and superficial approach offended the client, who never returned to counseling.

In fairness, the psychologist likely did not know what cultural data to gather, how to gather it, or what to do with it. She is an example of a clinician grappling with multicultural counseling competence, and her actions reflect more on the state of the profession than on her as a professional. Many counselors similarly find themselves in a quandary to demonstrate the intentional, purposeful, and beneficial use of cultural data in therapy. Even more troubling than superficial attempts to address culture, some therapists who self-reported as multiculturally competent actually neglected to address cultural concerns at all (Wilcox et al., 2020).

We advocate the deep-structure incorporation of culture, as opposed to surface-structure incorporation (or neglect of incorporation). We borrow these terms from Resnicow et al. (1999), who introduced the concepts of surface structure and deep structure as dimensions of cultural sensitivity in their model of public health interventions. Surface structure manifests itself as “matching intervention materials and messages to observable, ‘superficial’ characteristics of a target population” (Resnicow et al., 1999, p. 10). As applied to counseling, Hwang (2011) suggested that examples of surface structure in counseling might involve interpreters, therapists who speak a client’s native language or have the same ethnicity, and clinics with accessibility to local neighborhoods or culturally aesthetic designs. On the other hand, deep structure manifests itself as “incorporating the cultural, social, historical, environmental, and psychological forces that influence the target behavior in the proposed target population” (Resnicow, et al., 1999, p. 10). Hwang stated that deep structure involves incorporating clients’ ideas, beliefs, and values into counseling. He also pointed out that this incorporation is of greater difficulty, but has the potential to improve treatment outcomes.

We embrace Resnicow et al.’s (1999) terminology but differ from them along several lines. First, we use surface-structure and deep-structure as adjectives that modify incorporation rather than as nouns. Thus, we employ the phrases deep-structure incorporation of culture and surface-structure incorporation of culture. Second, we argue that the deep-structure incorporation of culture is the central activity of multicultural counseling competence and that all other activities involved in demonstrating this competence are subordinate to this superordinate activity. Third, in general, Resnicow et al. (1999) advocate the use of “ethnically matched staff to recruit as well as to deliver and evaluate programs” (p. 11). This implies that matched staff members can do something important with cultural data over and above that of unmatched staff members. We believe that all counselors, not just those who are ethnically or culturally similar to their clients, should develop deep-structure incorporation of culture. Fourth, we posit that the incorporation of culture applies to all health-promoting interventions, including counseling and psychotherapy, and not only public health. Fifth, we conceptualize the incorporation of culture as existing along a continuum, in which the depth of incorporation determines the degree of competence. This distinction reaffirms the centrality of deep-structure incorporation of culture in multicultural counseling competence.

In essence, deep-structure incorporation of culture stands in contrast to surface-structure incorporation. The psychologist who counseled the Japanese client in the example, vividly depicts what happens when the incorporation is shallow. Even if her data gathering was adequate, she still needed to interpret and integrate the data into a meaningful case conceptualization, leading to goal setting and adapted interventions. Instead, her purposeless and unfocused approach guaranteed the cultural data were dead on arrival. Clinicians who do not make incorporation of culture central in counseling and therapy almost guarantee their own multicultural counseling incompetence.

Presentation of the Process Model

The process model of multicultural counseling competence is a logical outgrowth of our redefinition of the construct. Figure 1 explicitly depicts the central role of deeply incorporating culture. In proposing the model, we assert that multicultural counseling competence comprises complex and dynamic interactions, or as Hwang (2011) stated, “a complex interplay between clinical and cultural issues” (p. 238). We differentiate our model from other process-oriented models primarily because of the rampant ambiguity about that component in other models.

Figure 1.

The process model of multicultural counseling competence.

Foundational Principles

Seven principles undergird the process model of multicultural counseling competence. Collectively, the principles form a bedrock providing the intentionality and outlook to demonstrate multicultural counseling competence. The utility of the model rests on the integrity of this foundation, which is why we now set forth our principles and open them up for criticism. We hope that this transparency ensures consistency between the process model’s foundation and utility.

1. Purposeful Facilitation of Therapeutic Change

This is the cornerstone of the process model’s foundation, upon which the other foundational principles depend. It should be obvious that the principle emanates from our definition of multicultural counseling competence. If the model is thought of as a tool, every action using the model should support this purposefulness. Taking a cue from Warren (1995), we further suggest that the facilitation of therapeutic change not only dictates the actions to take in demonstrating this type of competence, but the actions not to take. Otherwise, whether intentional or unintentional, these actions would be misdirected. Therefore, in building the model, we carefully laid out examples of purposeful actions and operations.

2. Culturally General in the Application

The deep-structure incorporation of culture makes the model equally applicable to all counseling relationships, while the design of the model enables an equitable application to each counseling relationship. These dual attributes make it possible for clinicians to apply the model to the uniqueness of every client and place the application of the model on the culturally general side of the culturally general/culturally specific debate (Ridley et al., 2021). Consequently, the model does not exclude counseling relationships in which counselors and clients fit into predetermined racial, cultural, ethnic, religious, and lifestyle groups.

3. Process-Oriented Rather Than Content-Oriented

A process is an unfolding of operations or actions that gradually lead to desired outcomes (Mish, 1984). Two keywords in this definition are “unfolding” and “gradually.” Movement toward desired outcomes takes place over time. Therefore, the nature of multicultural counseling competence is “a progressive process of movement toward therapeutic outcomes” (Ridley et al., 2011, p. 838). The process model stands in contrast to the content approach to multicultural counseling, which emphasizes clinicians’ knowledge of the characteristics, cultural values, and beliefs of various cultural groups (López et al., 2002). The content approach seems to be based on the questionable assumption that clinicians can translate their knowledge into competent practice without guidance. Moreover, the content approach makes clinicians more vulnerable to cultural stereotyping (López, et al. 2002; Whaley & Davis, 2007). In their widely used text, Counseling the Culturally Diverse: Theory and Practice, Sue et al. (2019) extensively use a content-oriented approach. They devote thirteen chapters to describing the demographics and characteristics of different multicultural populations. Armed with this invaluable information but without counseling guidance, it cannot be assumed that clinicians can translate that knowledge into actionable clinical activities. Our model aims to provide guidance on the translating of cultural knowledge about clients into action and tailoring of treatment to them as individuals.

4. Affirming and not Dismissing the Three Major Models

We acknowledge the tremendous value and respective contributions of the skills-based, adaptation-based, and process-based models. Even with their limitations, these models have advanced the field, provided innovation, and moved us closer to an acceptable standard of practice. One of our goals in creating a new model was to retain the notable features of these models because we considered them essential to multicultural counseling competence. Furthermore, we wanted to continue rather than diminish the legacy of our predecessors. We affirm the major models by rethinking them and showing how their features can foster competence.

5. Integrative and not Piecemeal

As noted, the design of the process model includes features from each of the three major models as well as new features and linkages. Its integration and coherence stand in contrast to the orthogonality, lack of integration, and gaps in the designs of the skills-based, adaptation, and process-oriented models (Ridley et al., 2021). Although we acknowledge that the adaptation and process-oriented models emerged as counters to the one-size-fits-all assumption undergirding the skills-based model (Bernal et al., 2009; Sue et al., 2009), we nevertheless aim to intentionally integrate components of all three models rather than stand alone from them. Our model therefore subsumes a variety of competencies, operations, and skills that participate in an overarching process of incorporating culture into interventions (La Roche & Christopher, 2009).

6. Comprehensive but Simplified

Multicultural counseling competence is a complex construct (Ridley et al., 2021). Therefore, the design of a model to demonstrate this competence should represent the complexity necessary for this demonstration. The design includes several component parts and interactions among those parts. In designing the process model, we attempted to overcome the errors of oversimplification (having too few components and interactions) and complication (having too many components and interactions) by simplifying the design. The simplification manifests as an attempt to create an accurate representation of the components and interactions of this competence so that the clinicians have a useful tool.

7. Complementary of Psychotherapeutic Systems

Multicultural counseling competence is not a stand-alone therapeutic orientation or system of psychotherapy, although it purports to facilitate therapeutic change. It complements and augments rather than replaces counseling systems (Whaley & Davis, 2007). The complementary nature derives from an understanding of the difference between psychotherapy and multicultural counseling competence. Prochaska and Norcross (2018) defined psychotherapy as the application of clinical methods and interpersonal stances, the purpose of which is to modify clients’ “behaviors, cognitions, emotions, and/or other interpersonal characteristics” (p. 2). Clinical methods of change are the distinguishing feature of systems of psychotherapy. Our model has clinical operations, but not new methods, that directly activate the mechanisms of therapeutic change. The deep-structure incorporation of culture is the pre-eminent feature that adds value to existing therapeutic systems. However, to demonstrate the model’s utility, clinicians must be adept in using these systems.

Design of the Process Model

The process model consists of four important components: phases of counseling, clinical multilevel dynamic interactions, clinical operations, and therapeutic outcome. The phases of counseling—preparation, intake and in-sessions, and termination—provide a timeframe for the use of this model. During each of these phases, clinicians apply various clinical operations, with a superordinate clinical operation overarching the four subordinate clinical operations. This superordinate clinical operation, deep-structure incorporation of culture, consists of three competencies: (a) identifying cultural data, (b) interpreting cultural data, and (c) integrating cultural data. The four subordinate clinical operations are as follows: (a) infusing preparation, (b) developing a therapeutic alliance, (c) adapting interventions, and (d) evaluating process and outcome. These subordinate clinical operations influence each other and interplay with the superordinate clinical operation to create a multilevel dynamic interaction within the process model. Clinicians must coordinate the clinical operations and manage their multilevel dynamic interactions with the ultimate goal of facilitating a therapeutic outcome. We acknowledge that the sheer number of components and interactions between them makes this model complex. However, we believe that this complexity distinguishes the process model of multicultural counseling competence from other models of the construct.

To use the process model, clinicians understand that it does not replace but complements counseling and psychotherapy. Because the mechanisms of change are inherent in the interventions of these systems, clinicians can use the model as a tool to enhance intervention and optimize the mechanisms of change. Given the process nature of the model, the execution of the clinical operations is organic. Except in the first phase of preparation, where there is no direct interaction with clients, the clinical operations take place continually and interactively throughout the process of counseling rather than in a fixed predetermined order. From the outset of counseling, clinicians should keep in the forefront of their thinking the superordinate function of the deep-structure incorporation of culture, around which the subordinate operations rotate. In this way, they can incorporate culture throughout counseling as they develop a therapeutic alliance and execute the subordinate clinical operations. Simultaneously, they continue to seek opportunities to infuse their learnings from the preparation.

Components of the Model

We acknowledge that some of the components, especially the phases of counseling, are not unique to our model. Whereas the overall model is new, we intentionally build these existing components into the design. Otherwise, the model would lack the complexity needed for its completeness.

Phases of Counseling

In any process, there is a dimension of time, and counseling is no exception. Therefore, our model includes a component that corresponds to the time dimension—the phases of counseling. The model begins with the preparation phase, continues with the intake and in-sessions phase, and concludes with the termination phase. The phases themselves are not meant to be entirely novel, as they primarily provide a division of time that encapsulates therapeutic change. Instead, what is unique is the implementation of the process model’s clinical operations, multilevel interactions, and therapeutic outcome throughout these phases.

Preparation Phase

This phase begins before clinicians meet their client. The goal is for clinicians to develop their awareness, knowledge, and skills (Sue, 2001). We use the acronym ASK (awareness, skills, knowledge) to indicate preparation. Despite its paramount importance, the learning and preparations here do not fully capture multicultural counseling competence but infuse the clinical operations in subsequent phases of the process. This development largely occurs prior to engaging in clinical work (preparation) with the expectation of utilizing them during clinical work with clients (application). However, preparation also can occur through clinicians’ actual experiences in counseling—what they might learn from clients that could inform their multicultural counseling competence. Of course, their commitment should be client-centered, such that they always use their learning to the benefit of clients through adherence to the ethical principles of beneficence and nonmaleficence. Furthermore, clinicians should continue their preparation over the course of their careers as lifelong learners. Overall, preparation occurs in three major ways: outside of counseling, during counseling, and continuous lifelong learning.

Awareness refers to the clinicians’ recognition of their own cultural identities and those of their clients. This includes awareness of personal biases, values, and worldviews. Clinicians are encouraged to engage in deliberate self-reflection on their power and privilege within their therapeutic relationships and everyday work with trainees, scholars, researchers, and professionals within the mental health field (APA, 2017). For example, an African-American client may hesitate to share with a White clinician the stress of experiencing microaggressions. The clinician may be oblivious to the power and privilege differentials in the relationship, resulting in a failure to create a perceived safe environment to disclose these types of issues. The clinician must be mindful of maintaining an open, empathic, and nonjudgmental stance throughout the counseling process as well as the realization of personal strengths and areas for growth.

Knowledge refers to information about cultural group values, dynamics, and historical–social issues (Sue, 2001). It can be learned through literature, continuing education, supervision, and conversations between peers and/or members from various cultural and minority groups. Additionally, it is imperative for clinicians to consider how the sociopolitical environment and structural and systemic issues affect clients’ experiences (APA, 2017). Critical thinking about information is an essential aspect of knowledge.

Skills refer to the foundational verbal and nonverbal counseling behaviors and microskills that are culturally appropriate and sensitive. It is important to note that awareness and knowledge are assumed to translate into skills. Since skills involve direct interactions with clients, their selection and application require purposefulness.

Intake and In-Sessions Phase

During this phase, which is the heart of counseling, therapists implement all of the clinical activities that are facilitative of therapeutic change. Therapists typically screen clients for their basic demographic information, presenting concerns, safety concerns, and other pertinent information. After conducting the intake, they typically formulate a case conceptualization (that may include a diagnosis), set treatment goals, and execute relevant interventions. As they engage in these clinical activities, they also execute the clinical operations associated with the deep-structure incorporation of culture. This execution is done in alignment with the clinical activities of the particular case. There is no absolute rule to determine which interventions clinicians should implement, nor the duration of the therapy. Each case varies, depending on the client’s presenting complaint and the exigencies of the situation. However, clinicians should allow the foundational principles of the process model to guide all of their clinical activities. Furthermore, they should regard the clients’ achievement of positive therapeutic outcomes as the ultimate criterion for determining the duration of therapy.

Termination Phase

As clients move toward the achievement of their treatment goals, therapists should begin to prepare them to end counseling. The goal of this phase is to help clients function without ongoing therapeutic support, while sustaining the gains they have made. Therefore, consistent with our process orientation, the real test of the utility of our model lies in clients’ maintenance of therapeutic change after termination. For maximal benefit to clients, termination should be timely in that this phase should not begin prematurely, nor delayed unnecessarily. This is why clinicians should base their decision to terminate on the evaluation of the therapeutic process and outcome—one of the model’s clinical operations. The deep-structure incorporation of culture applies as much in this phase as it does to the intake and in-sessions phase but with one notable difference; the termination phase has a set of phase-specific counseling tasks. Ridley and Shaw-Ridley (2010), for instance, conceptualized termination within the context of culture. They described three aspects of the phase: pretermination, active termination, and posttermination, each of which has its own treatment tasks. In alignment with our process model, clinicians should not only perform the tasks specific to termination but incorporate culture as they are performing them.

Multilevel Dynamic Interactions

The process model of multicultural counseling competence includes clinical operations that interact with each other at multiple levels. Since these operations do not occur in isolation, the inner workings of the process model involve, as previously noted, an interplay of complex clinical and cultural dynamics (Hwang, 2011). We note five implications that result from the multilevel dynamic interactions within the model.

First, the interactions form a cyclic pattern whereby every subordinate clinical operation rotates around the deep-structure incorporation of culture. This cycle is ongoing and concludes only upon termination. The cycle also entails bidirectional interactions between the superordinate and subordinate operations. Without this superordinate clinical operation as the centerpiece and organizing axis, we would have nothing upon which to enhance the facilitation of therapeutic change beyond conventional counseling and psychotherapy.

Second, several of the interactions are multidirectional. These interactions are most prominent among the clinical operations of adapting interventions, infusing preparation, and developing a therapeutic alliance (or Cultural AID). Clinicians weave in and out of these clinical operations. The acronym Cultural AID is indicative of these multidirectional interactions. Thus, there is no particular order of operations. Rather, the acronym AID serves as a helpful way to remind therapists to adapt their interventions, infuse their preparation into their work, and develop a strong therapeutic alliance in a culturally helpful manner.

Third, the interactions allow for flexible usage of the process model. As previously mentioned, the process model extends to any counseling relationship and has utility under a variety of treatment conditions, including differing presenting problems, therapeutic orientations, and experiential levels of clinicians. Furthermore, it is useful as a tool for professional training and supervision. Essentially, all clinicians should be able to extract benefits from the model, even if they do not achieve their ideal standard of competence.

Fourth, the interactions allow prescription of intervening without binding clinicians to a rigid protocol. Any attempt at rote application of the clinical operations would be virtually impossible, since such an approach contradicts the process nature of the model. The rule of thumb is that the foundational principles of the model should guide clinicians’ judicious execution of the clinical operations. Therefore, prescriptiveness does not equal the use of manuals but rather serves to create guidance to the fluidity of multicultural counseling competence.

Fifth, the interactions support progressive, nonlinear therapeutic change. Few clients follow a straight path to positive therapeutic outcomes. The model accounts for the forward and backward movement of clients, lapses and relapses. Clinicians can use the dynamic interactions of the model to motivate, engage, and re-engage clients in counseling.

Clinical Operations

During the actual counseling and psychotherapy portion of the process model, clinicians engage in five clinical operations: deep-structure incorporation of culture, adapting interventions, infusing preparation, developing a therapeutic alliance, and evaluating process and outcome. As a process model, clinicians can employ these operations judiciously at any time during the second and third phases. The criterion for rotating in and out of the operations is purposefulness, which admittedly is a matter of clinical judgment. Although each operation is critical to the demonstration of multicultural counseling competence, none is sufficient on its own.

Deep-Structure Incorporation of Culture

The purpose of this superordinate operation is to maximize the impact of the subordinate operations— infusing preparation, developing a therapeutic alliance, adapting interventions, and evaluating therapeutic process and outcome. Without incorporating culture, which occurs throughout the course of counseling and intersects all aspects of counseling, the maximal impacts of these other operations on therapeutic change would not be possible. This operation consists of three subordinate multicultural competencies: identifying or gathering cultural data, interpreting cultural data, and integrating cultural data. Cultural values, beliefs, assumptions, and norms make up the primary data of interest because they are integral to individuals’ psychological presentations and influence the counseling relationship. Cultural values are defined as core beliefs, principles, and ideas that motivate behavior. A value held among Hindus in India is the law of karma, which is the belief that the sum of an individual’s actions in their present and previous states of existence decide their fate in the present. Therefore, a normative belief held among Hindus is that suffering is due to the deeds individuals have committed in their present and past lives. Suffering and hardships in life are attributable to karma.

To incorporate culture at a deep level, clinicians must remain mindful of the multilevel dynamic interaction of the process model and consequently the necessity of judiciously using the three subordinating competencies. Injudiciously, clinicians could implement these competencies in a sequential and rote manner. They could begin with identification, proceed to interpretation, and then to integration. Then they could begin the cycle over again and move through the competencies in rigid sequence. In alignment with the principles and fundamental nature of the process model, however, they should implement these competencies in a dynamic and organic manner. Once clinicians initiate the cycle of incorporation by identifying cultural data, they then can move back and forth between the competencies, always with the goal of gaining better insights into their clients. The deep-structure incorporation of culture assumes that the soundest case conceptualizations and predicating interventions depend on this superordinate operation.

Identification of Cultural Data

Before counselors and therapists use cultural data in a therapeutic way, they first have to know what data about their clients exist. They certainly cannot interpret or integrate cultural data of which they are unaware. We offer seven principles for gathering cultural data. These principles should guide clinicians throughout this clinical operation.

Deeper than surface level. Information like demographics or overt artifacts of culture are important, but these do not constitute deep-level culture. To find the deeper significance of culture, clinicians should identify the values, beliefs, and assumptions salient to the client’s identity. As previously stated, these are integral to understanding psychological presentations and counseling relationships.

Case-by-case basis. Identifying cultural data is a unique process for every client. Even clients from similar racial and cultural backgrounds vary significantly in their psychological presentations and adherence to cultural values, beliefs, and assumptions. Some clients may espouse traditional values and beliefs from their culture, and others may be nontraditional. This is another reason why simply knowing demographic characteristics lends itself to a superficial understanding of a client’s identity.

Salience. A significant piece of identity for one client may not be for another. Some clients may weigh their race more heavily, others their sexual orientation, others their religion, and still many others the intersection of identities. Therefore, clinicians cannot assume what will be salient for any client. As Root (1996) exclaimed, because identities are complex, clinicians cannot assume they know the significance of any part of someone’s identity.

Data for therapeutic alliance. An easy to overlook area for gathering cultural data is the therapeutic alliance. Although we discuss this topic later, we emphasize its relevance here because of its richness as a source of relational dynamics imbued with culture. Clinicians can gain insight into clients through such dynamics as microaggressions, therapeutic ruptures, cultural transference, and pseudo-transference (Owen, et al., 2011; Ridley, 2005). In addition, clients from many cultures, such as East Asians, are sensitive to cultural issues such as the loss of face (Zane & Yeh, 2002). Counselors should not assume that they can begin therapy by intensely inquiring about these issues. They might offend clients and possibly cause premature terminations. The prudent course of action is to establish a good working alliance from the outset, gauge each client’s sensitivity, and delve into sensitive issues with caution.

Direct approach. Some clients will volunteer certain aspects of their identity with little coaxing, whereas others may not think it necessary or appropriate. Instead of expecting clients to bring attention to cultural data, clinicians need to direct attention to this information. They can ask about the clients’ experience and interpretation of their cultural values and probe for why the beliefs, values, and assumptions hold personal meaning.

Balance of Inquiry. Clinicians should balance focused inquiry with allowing space for clients’ self-disclosures. To focus the inquiry, they should ask for data relevant to the presenting complaint. The questions should be general or open-ended enough to allow clients to interpret or direct the clinician to which part of their identity they see as most relevant. If a client experiences anxiety or depression, for instance, clinicians might inquire about the beliefs held in the culture specifically related to these conditions. Then, they can query the client to personalize the beliefs to their complaints.

Nonjudgmental. Affirming clients for their willingness to self-disclose differs from affirming the content of their disclosures. Failing to recognize the difference easily can lead to becoming judgmental about clients’ values and beliefs. Judgmental clinicians can undermine the whole treatment endeavor. Therefore, clinicians should anticipate that some clients might share information foreign to their experiences or make them feel uncomfortable.

After considering these seven principles, clinicians can take two steps. First, they can familiarize themselves with the general characteristics of the target population, for which many resources are available (e.g., Sue et al., 2019). This familiarization takes place during the preparation phase, in which general knowledge of the culture serves as an initial reference for understanding clients. However, as pointed out earlier, clinicians must be careful about the potential for cultural stereotyping that comes from overgeneralizing and making attributions that do not fit clients as individuals.

Second, clinicians can prevail upon several protocols to help them gather cultural data: the ADDRESSING framework (Hays, 2016), the RESPECTFUL model (D’Andrea & Daniels, 2001), and the Cultural Formulation Interview (CFI; American Psychiatric Association, 2013). Each of these protocols provides specific areas of inquiry related to clients’ cultural identities and experiences. Although these protocols offer some helpful guidance, counselors should not solely rely on them. Their biggest limitation is not in specifying the areas in which to inquire, but the absence of principles to probe deeply within the areas, such as those we recommend above.

We provide a clinical case vignette throughout the remainder of this major section. The multiple parts of the vignette illustrate the implementation of the process model with glimpses into the unfolding of its clinical operations. Next is the introduction to the clinical case.

Clinical Case. A Mexican American female doctoral-trainee counseled a 62-year-old Mexican American male at a community clinic (Ridley et al., 2017). The client presented with several physical problems, many of which stemmed from a stressful lifestyle of overworking and overextending himself. Before going to counseling, he had a heart attack and was hypertensive. For many years, he worked two jobs at 50–60 hours a week to provide a comfortable life for his family. Not only did he overextend himself, but he also set up a paradigm whereby his family members became irresponsible and unreliable, adding additional stressor to his life. Before trying to interpret his behavior, the clinician had to determine if cultural values were at the root of his behavior. To do this, the clinician simply asked the client why it was necessary for him to work so much. Her inquiry focused on the presenting complaints but was open-ended so that the client did not feel restricted in how he could respond. Depending on his response, the clinician was prepared to probe more deeply for the cultural aspects of the complaints.

Interpretation of Cultural Data

Once clinicians identify cultural data, they move into the realm of interpretation. To interpret is to give psychological meaning to the data, using this insight to conceptualize clients as unique individuals and link their functioning to its consequences. Of particular interest, again, is the influence of clients’ identified cultural values, beliefs, and assumptions on their presenting thoughts, feelings, and behaviors. Does the influence promote healthy or unhealthy psychological functioning? Clinicians should be able to recognize when culture significantly underscores clients’ self-defeating behavior. Consider a depressed client who, despite relentless efforts to excel academically, cannot gain recognition for the highest academic honors. The accompanying shame and loss of face, as is the case for some individuals from East Asian cultures, may link to an extreme adherence to cultural values that precipitates the behavior and undergirds the depression. The interpretation of cultural data to explain functionality ultimately is a matter of clinical judgment that inevitably entails a certain amount of subjectivity and makes clinicians vulnerable to judgmental inaccuracy (Spengler et al., 2009). To counter inaccuracy and maximize their potential for making sound interpretations, clinicians need reliable standards upon which to render their judgments.

We theorize five transtheoretical, transdiagnostic criteria for interpreting culture’s influence on the client’s psychological functioning and well-being. The first is extremism. Here, clients take their behavioral expression of cultural beliefs and values to exaggerated lengths. Often the expression is atypical, even for the person’s culture. Admittedly, this entails clinical judgment, and may be the most difficult criterion for clinicians, especially if the judgment conflicts with the client’s own beliefs about what is cultural. To overcome the potential for bias, clinicians are encouraged to consult with professional and community resources. The second is self-defeat, in which the behavioral expression has harmful consequences for the individual. The third is the patterned nature of the behavioral expression. It is repetitious, which means that it is expressly predictable. The fourth is the presence of secondary gains associated with the behavioral expression. Seemingly ironic, individuals accrue psychological benefits even from extremism and self-defeat. The fifth is resistance, in which clients oppose the replacement of their self-defeating behavior with self-enhancing behavior. This resistance poses considerable challenges to clinicians who seek to help clients change.

Interpretation requires a balancing of these criteria. This does not mean clinicians always can check off each criterion before arriving at a sound interpretation. Determining if behavior is extreme for culture or uncovering secondary gains may require examination of a client’s patterned behavior, self-defeating consequences, and resistance to change. A sound interpretation also does not mean that clinicians take a casual approach to using the criteria. The general rule is to pursue all of the criteria, aiming to include as many as possible, in interpreting cultural data.

In using these criteria, we offer several additional suggestions. First, making sound interpretations requires clinicians to be aware of the cultural values, beliefs, and norms that shape their own worldview. Otherwise, they risk clouding their interpretations and projecting their culturally learned expectations onto their clients (Triandis, 1972). As mentioned, awareness begins in the preparation stage, where clinicians determine what is acceptable and unacceptable, or even pathological, in their own cultural worldview. They should acknowledge that the meaning of normality varies across cultures. This enables them to overcome pseudo-etic interpretations, in which they interpret cultural data as though it is true etic but overlook their own emic biases (Triandis et al., 1973). Comprehensive interpretations also include an understanding of the intersectional identities of their clients. Intersectionality is not solely recognizing their multiple identities, but rather the relationship between them, as well as the inequalities, power dynamics, and oppression of their social context (Hopkins, 2019). Therefore, when conceptualizing clients, clinicians must seek to understand the significance clients place on their own various identities and the interplay among them. Clinicians should also consider their personal power and privileges and how these relate to the client. In the clinical case study, for example, although the clinician and client share similar cultural heritage, they do not share educational level or income potential. This might affect the way the clinician interprets the cultural information if there is not an understanding of intersectionality, power and privilege, and other factors.

Clinical Case (Continued). Upon the clinician’s inquiry, the client immediately gave a cultural explanation without the need for coaxing. It was obvious that he viewed his behavior as normal, claiming machismo as an expectation in his culture. He fully endorsed the idea that men in his culture work hard to support their families. However, his explanation was not so clear-cut. After hearing his story, the clinician began to piece together a somewhat different interpretation. She drew on several key criteria: the client’s behavior was self-defeating, and he had an extreme and distorted view of the cultural value of machismo. Although the clinician did not have empirical base-rate data, she had rudimentary data on this cultural value. A more positive view, sometimes called caballerismo, honors male chivalry and respect in the culture without extremism. Therefore, the client’s extreme and excessive behavior, not machismo itself, was the source of his dysfunction. Moreover, the counselor traced the origins of the behavior to the client’s adolescence in Mexico, at which time he began to work full-time to help support his family after a gang killed his father. In that the behavior was a pattern established in the client’s young life, the clinician wondered what else might be involved in his behavior. Eventually, she learned that the client did not want to disappoint his father, whom he believed would be proud of him. Therefore, he simply could not see his behavior through any other prisms. These various strands helped the clinician to see the culture’s role in his problem presentation.

Second, clinicians can invoke the five decisional tasks for interpreting cultural data (Ridley et al., 1998). These tasks are: (a) differentiate cultural data from idiosyncratic data, (b) apply base rate information to cultural data, (c) differentiate dispositional stressors from environmental stressors, (d) differentiate clinically significant data from clinically insignificant data, and (e) formulate a working hypothesis. We suggest that the tasks are parallel rather than sequential, which accords with the dynamic interactions and organic nature of the process model.

Third, to make sound interpretations, clinicians should re-examine their own well-meaning cultural sensitivity. In multicultural literature, we find tacit advocacy of the indiscriminate acceptance of clients’ cultural values and behaviors. Hays (2009), for example, argued that clinicians should not challenge clients’ core cultural beliefs; to do so would indicate disrespect and naiveté. We disagree. Of course, clinicians should always show respect to clients’ cultures, and they should understand that culture is integral to personal identity. However, some clients are extreme in their values and beliefs even for their culture, and their extremism can have self-defeating consequences (Ridley et al., 2008). Well-meaning clinicians who avoid cultural confrontation are nontherapeutic, and their avoidance amounts to complicity with the very clients they claim they are helping.

Hwang (2011) gave an excellent example of an Asian American client whose fatalism required cultural confrontation. As a core cultural and religious value of Buddhism, the client would use the teaching “life is suffering” as an excuse for taking no initiative to solve personal problems. While accepting that life can bring suffering, inaction in the face of difficulties is an extreme behavior that reinforces personal problems. The culturally competent therapist shows respect and sensitivity to the client’s culture. At the same time, the therapist interprets the client’s pattern of extremism as self-defeating. Failing to recognize the detrimental effects of this attitude about fatalism is a setup for ineffective psychotherapy. Interpretation of cultural data requires paying attention to the client’s cultural values and personal meaning assigned to them, while also recognizing how extreme use of these values may contribute to a self-defeating pattern.

Clinical Case (Continued). To continue her interpretation, the clinician had to show sensitivity by affirming and respecting the client’s culture. In no way did she insinuate anything disparaging about his cultural values. Then, she had to engage in a cultural confrontation by helping him understand that his rendition of machismo had self-defeating consequences. This entailed some psychoeducation to help him grasp the psychological significance of his behavioral extremes. Prior to the confrontation, the client had little insight into the relationship between the causes and consequences of his lifestyle. It was simply a matter of machismo and machismo without question. Using Cognitive-Behavior Therapy (CBT) as her primary theoretical orientation, the clinician additionally challenged the client’s cognitive error of dichotomous thinking: to be macho was an all-or-nothing proposition.

Integration of Cultural Data

The identification and interpretation of cultural data afford clinicians the opportunity to move beyond surface level incorporation of culture. However, the integration of cultural data serves as another key method in deeply incorporating culture in psychotherapy. In this subordinate operation, clinicians use the identified and interpreted cultural data in every aspect of therapy, including the case conceptualization (and diagnosis), alliance building, goal setting, and treatment selection. For instance, the setting of treatment goals emanates from a formulation of the client as a unique cultural individual, which derives from identification and interpretation of cultural data.

One easily overlooked aspect of integration is the monitoring of the therapeutic process. Clinicians must be vigilant in challenging clients to change some of their attitudes about culture when doing so could be therapeutic. Simultaneously, they must guard against superimposing their cultural values and expecting clients’ comportment as evidence of change. Wendt et al. (2015) elaborated on this clinical challenge:

We simply recommend greater attention to, and empirical documentation of, when and how clients’ cultural values change over the course of therapy, whether these changes come about through a clinician’s unquestioned values, and whether these changes are seen as harmful to the needs of ethnoracial minority individuals and communities. (p. 350)

One example is a counselor helping a conflicted Latina student reframe her attendance at a university far away from her home (Ridley et al., 2008). The client was anxious and depressed about the distance and financial burden placed on her family and much of the conflict was rooted in familismo. First, the counselor re-examined her cultural values and beliefs. Then, the counselor helped the client to reframe the experience from the client’s cultural perspective. Pursuing a college degree did not have to mean an abandonment of the family but an expression of just the opposite. Afterward, the student saw herself as becoming empowered to help the family break the cycle of intergenerational poverty. The shorter-term experience of leaving home to go away to college became secondary to the longer-term benefit of helping the family.

In general, clinicians should seek to be thorough and comprehensive in their approach to integration. A good exercise for them is to periodically review their counseling cases to see if they follow any notable patterns. Where do they tend to integrate cultural factors into counseling? Do they integrate through multiple phases and facets of counseling? Are they consistent in the depth of their integration? Are there populations in which their integration is in-depth and others, shallower? Answers to these questions could be revealing.

Infusing Preparation

This clinical operation involves clinicians using the knowledge they gained through training and study outside of therapy to inform their clinical activities inside therapy. Specifically, clinicians draw upon their multicultural awareness, knowledge, and skills to facilitate therapeutic change. Always client-centered, infusing preparation may take the form of using knowledge of certain subcultural values to explore their impact on clients. It may begin with clinicians’ self-reflection about how their worldview shapes the therapeutic process and/or entail utilizing skills such as cultural empathy or managing cultural conflict with clients. Infusing preparation should contribute to clinicians’ ongoing development of multicultural counseling competence by strengthening their awareness, knowledge, and skills. Moreover, clinicians should continue to develop in these areas outside of therapy even as they provide in-session therapy.

Developing a Therapeutic Alliance

The therapeutic alliance has several components, including emotional bonding, agreement on goal setting, collaboration, and negotiation between therapists and their clients (Greenson, 1965; Bordin, 1979; Horvath et al., 2011). Collectively, they illustrate why an alliance plays an important role in therapy. Recent research suggests that the building or repairing of an alliance is itself therapeutic. Changing the interaction between the therapist and client can be curative (Hatcher, 2010; Zilcha-Mano, 2017).

Clinicians should attune themselves to the differences in cultural values and beliefs between themselves and their clients. Attending to these differences serves the twofold purpose of overcoming possible cultural impediments and enhancing the quality of the therapeutic alliance. In particular, therapists can attend to issues such as microaggressions, therapeutic alliance ruptures, and cultural transference. Multiculturalists have long argued that establishing a working alliance is critical in multicultural counseling, especially since issues of race, ethnicity, and culture can arouse strong feelings, attitudes, and mistrust (Whaley, 2001; McGoldrick et al., 2005). According to some scholars, clinicians should explore cultural and racial issues early in counseling (Spurlock, 1985; Sykes, 1987) and move between their own cultural perspectives and those of their clients (López, 1997). Hence, the attention and exploration of culture and race in the development of the therapeutic alliance enhance the counseling process.

Clinical Case (Continued). Although the doctoral-trainee assigned to counsel the Mexican American client was fluently bilingual, the initial sessions did not go well. Tension was in the air between her and the client. At first, the clinician attempted to conduct therapy in Spanish, but that did not resonate well with the client. Sharing her frustration in supervision, the supervisor suggested she attempt to conduct therapy in English. Acting on this advice, the strain in the relationship continued. By happenstance, the clinician and client began to communicate in Spanglish (a hybrid of Spanish and English). From that point on, the clinician could establish a strong therapeutic alliance with the client. Two important observations come from this turn of events. First, understanding some aspects of the client’s cultural experience was critical to establishing a therapeutic alliance. Of course, it would have been desirable for the clinician to inquire about language preference rather than finding out incidentally. The supervisor did not have the insight to suggest it, but this speaks to the importance of exploring racial and cultural issues early in therapy. Second, matching the clinician and client on their backgrounds as Mexican Americans was a reasonable supervisory decision. However, the surface matching was not an adequate condition for establishing an alliance. The clinician also had to match the client in the process of counseling. The clinician found common ground in their Spanglish.

Adapting Interventions

This operation entails the systematic modification of established intervention protocols, the purpose of which is to make them more compatible with clients’ cultural experiences (Benish et al., 2011; Bernal et al., 2009). The intended benefits of modification, also referred to as tailoring, are the optimization of communication between therapists and clients, active engagement of clients in the therapeutic process, and activation of the curative factors inherent in psychological treatments. Adaptation does not mean a fundamental change in the nature of interventions. The underpinning theoretical and scientific mechanisms of change are not modifiable, as should adherence to its protocols. Adaptation therefore means adding cultural features in implementing interventions.

Consider adapting systematic desensitization and flooding. Both interventions require exposing clients to noxious stimuli, albeit, the first through gradual exposure and the second through intense and prolonged exposure. The mechanism of change in both interventions is extinction. The cultural adaptation of these interventions does not change their respective protocols or underlying mechanisms of extinction. To engage clients in the process of exposure, however, the interventions could include the addition of complementary cultural idioms, metaphors, stories, and rituals.

In one of the most elaborate cultural adaptations to psychotherapy, Bernal et al. (1995) described eight modifiable dimensions: language, persons, metaphors, content, concepts, goals, methods, and context. These dimensions give clinicians a wide range of options for adapting interventions, especially if they are creative. For example, an African American young man seen in a community clinic enjoyed writing lyrics to rap music and rapping with his friends. At the behest of the clinical supervisor who recognized this as a significant touchpoint, the clinician assigned the client homework to compose lyrics about his life. The client returned to counseling excited to share his rapping with the clinician. More importantly, insightful discussions about his experiences, struggles, and aspirations ensued. Although this way of intervening may seem unconventional, that is precisely the point of adaptation: the leveraging of culture.

Clinical Case (Continued). The doctoral-trainee adapted the interventions in several ways. First, besides speaking in Spanglish, the counselor collaborated with the client to establish treatment goals. The major treatment goal was for the client to adopt a self-enhancing lifestyle as a replacement for his self-defeating pattern. This was no easy sell, for the client resisted the idea initially because, again, it did not comport with his cultural orientation. To foster the collaboration, the clinician put a positive cultural spin on his machismo—that it was already in his mindset to take charge, be responsible, and find solutions to problems. This time, it was about taking charge of his health and emotional problems. The clinician also reframed the clients’ behavior in terms of the Latinx value of familismo, which emphasizes unity, respect, and tradition in the family. In his family, this meant that family comes first, and just like when he was an adolescent who put a priority on the welfare of the family, this time investing in his health meant investing in the family’s welfare. His unhealthy lifestyle created hardships for those he loves. Using this reframing method of CBT, the clinician helped the client to recognize that he actually was undermining the family’s welfare. He was putting his family at risk, and continuing his brand of machismo would ultimately mean that he could not support the family. Once the client embraced this reframe, the clinician helped him to begin to change behaviors as part of a CBT framework. Without an accurate interpretation of the cultural data, the clinician could not have effectively reframed the client’s psychological presentation.

Evaluating Process and Outcome

The effectiveness of counseling hinges on clients achieving their goals, and clients’ achievement of their goals hinges on therapists ensuring an alignment between those goals and the therapeutic proccesses employed. This requires clinicians to evaluate the therapeutic process and outcomes before drawing any conclusions about their clients’ progress. Two types of evaluation, process and outcome, can help to ensure the effectiveness of counseling (Lauver & Harvey, 1997). Process evaluation involves the continual monitoring or tracking of clients’ progress and the therapeutic alliance throughout counseling. Clinicians use this information to make actionable and client-specific adjustments to improve the process. Outcome evaluation involves determining the extent to which clients actually achieve their goals. Typically, this determination occurs near the end of counseling. Alternatively, these types of evaluations respectively have the names normative and summative.

In addition, evaluations can be quantitative or qualitative. The Working Alliance Inventory (Horvath & Greenberg, 1989) is a quantitative tool to track the development of the therapeutic alliance from the perspectives of both client and clinician. Clinicians also can conduct an evaluation informally by discussing with clients their respective perceptions of the counseling process. Instruments such as Outcome Questionnaire 45 (OQ-45), Patient Health Questionnaire 9 (PHQ-9), and Symptom Checklist-90 (SCL-90) can provide an objective measurement of treatment outcomes. Clinicians also have the option of devising informal evaluations tailored specifically to the client’s goals. These measures can include a quantitative component such as ratings on a Likert scale and a qualitative component to explain the ratings. Clinicians and clients can respond to the measures independently and then compare and contrast their responses, allowing productive discussions to emerge from their collaborative evaluations.

Clinical Case (Continued). The clinician monitored the client’s progress during the treatment. Without an accurate interpretation of the cultural data, the clinician could not have effectively integrated the data into the evaluation. Considering the client’s value of familismo, the counselor gave weekly assignments to explore how his family was supporting him in making changes to his lifestyle. As therapy approached the termination phase, the client signed a release of information that allowed his family to come to a session and discuss his progress. The session was a milestone. The family members expressed their deep concerns about the client’s health and provided an update on his progress outside of therapy.

Therapeutic Outcome

The unequivocal purpose in using the process model of multicultural counseling competence is client attainment of positive therapeutic outcomes (Ridley et al., 2021). We highlight this final feature because of its elevated importance. The omission of therapeutic outcome would make the model purposeless, and its explicit notation is another differentiation of the process model from other models. Realistically, most clinicians have the experience of counseling clients, some of whom do not change or make little progress. Regrettably, in most models of multicultural counseling competence, the assumption is that therapeutic change somehow will occur. In our model, we specify this as the superordinate goal that guides other clinical activities involved in multicultural counseling competence.

Lyons et al. (1997) postulated three attributes of therapeutic outcomes: characteristics of clients, changes in these characteristics that occur over time, and the results of the treatment or intervention. Earlier, we described therapeutic changes as constructive and holistic second-order transformations in clients’ psychological presentations. For each client, clinicians should collaborate with the client to establish treatment goals to help them achieve their individual outcomes. We therefore view the attainment of positive therapeutic outcomes as the ultimate test of the model’s utility.

Implications for Research

As a new conceptualization, the process model of multicultural counseling competence does not currently have a body of research that serves as its evidence basis. We regard this state of affairs as both a shortcoming and an opportunity. As a shortcoming, we cannot definitively claim the process model’s effectiveness or efficacy; the model requires testing and verification. As an opportunity, we are committed to a program of research on the process model. We anticipate that such a program will provide the underpinnings of evidence on the process model’s viability or otherwise lead us toward making necessary conceptual changes to improve the model.

In light of the process model’s complexity, we recognize the challenges inherent in this research endeavor. There is a need to begin by investigating the various components of the process model. However, to begin by testing the process model comprehensively is nearly a research impossibility. An alternative is to investigate parts of the model and selected interactions within the model. For instance, scholars might seek to find the most effective ways of identifying, interpreting, and integrating cultural data in counseling. As researchers and scholars gain a better understanding of how these processes work, they can better investigate the interactions of the deep-structure incorporation of culture with the subordinate processes. As the research agenda makes progress, the authors anticipate eventually employing the model in clinical trials.

There also is a need to develop research tools to measure the constructs in the model. For example, there are no measures of a multicultural therapeutic alliance. Consequently, before we can test the model comprehensively, a critical part of the research agenda is instrument development. An establishment of psychometrically sound tools could range from rating scales to behavioral observations.

To really demonstrate the usefulness of this process model and show its generalizability, we must conduct studies across a wide range of populations such as racial, ethnic, and cultural populations. These differences in participants should include therapists and clients, as well as racially and ethnically matched and unmatched dyads. Furthermore, we can use a variety of research methods, including quantitative and qualitative designs, experimental and quasi-experimental designs, single-case designs, and archival studies. Overall, the point of this programmatic research is to subject our model to rigorous inquiry. We would be pleased to synthesize the accumulated findings, revise the model as warranted, and if the evidence is compelling, dismantle it from the very foundation and rebuild it again conceptually.

To these ends, the first two investigations are underway. These proofs of concept studies are doctoral dissertations conducted by members of the research team under the direction of the senior author. One study entails a teaching method for parts of the model, as introduced in a workshop format. The other is a qualitative investigation of clinical supervisors’ evaluations of multicultural counseling competence. In the future, we anticipate many studies, and we invite interested colleagues in the profession to join us in this research agenda. The opportunity is enormous.

Conclusion

The process model of multicultural counseling competence is a tool to help mental health professionals use culture beneficially to facilitate therapeutic change. Our hope is that the process model encourages researchers to advance knowledge and providers to improve their practice. We consider the process model a work in progress and therefore, invite all stakeholders in the mental health professions—scholars, researchers, educators, supervisors, clinicians, administrators, policymakers, and students—to participate in this conversation. We call on scholars and researchers to challenge their thinking, critically examine their foundational principles, test the model empirically, and revise it as necessary. We call on educators and supervisors to press students and trainees toward greater competence. We call on clinicians to put the process model into practice and behave as scientist–practitioners who inform research with the model and use research to improve the model. We call on students to register their voices by articulating their experiences using the model and pointing out their satisfaction and dissatisfaction. To conclude, we hope the model is an impetus for a new standard of multicultural counseling competence.

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.

ORCID iD

Charles R. Ridley

Notes

Author Biographies

Charles R. Ridley, PhD, is a professor in the counseling psychology program at Texas A&M University. He received his doctorate from the University of Minnesota. His research interests include multicultural counseling competence, thematic mapping in case conceptualization, and the scientist–practitioner model. He is a Fellow of the APA (Divisions 17 and 45) and licensed psychologist in a part-time private practice.

Ankita Sahu, MEd, is a doctoral candidate in the counseling psychology PhD program at Texas A&M University. She holds an MEd in prevention science from University of Oregon and a BA in psychology from the University of Minnesota. Her research interests include multicultural training and supervision with special emphasis on the translation of multicultural theories and principles into practice and exploration of Trainees of Color experiences’ with multicultural training/supervision.

Katie Console, MEd, is a doctoral candidate in the counseling psychology PhD program at Texas A&M University. She holds an MEd in educational psychology from Texas A&M University and a BS in psychology and Spanish from Harding University. Her research interests include multicultural counseling competence, telepsychology, and disparities in mental health care.

Shruti Surya, PhD, is with the Central Texas Veterans Healthcare System in Austin, Texas. She received her doctorate in counseling psychology from Texas A&M University. Her clinical interests include health behavior management, patient and family adjustment to chronic illness, substance use, and comorbid mood/affective disorders. Her research interests involve integrating multicultural psychology with health psychology to address mental and physical health disparities.

Vy Tran, MEd, is a doctoral candidate in the counseling psychology program at Texas A&M University. She will complete her internship at Texas Woman’s University, Counseling and Psychological Services. Her primary research interests are in clinical supervision and multiculturalism. Her clinical interests are working with clients who experienced childhood trauma and sexual abuse, as well as working to strengthen self-esteem, relationships, and identity development.

Siming Xie, MA, is a doctoral candidate in the counseling psychology program at Texas A&M University. He holds a MA in counseling and student personnel psychology from the University of Minnesota and a BS in clinical medicine from Jilin University, China. His research interests are in multicultural counseling and the mental health of the minority population. Siming will be completing his internship at the University of Houston Clear Lake.

Caroliina Yin, MEd, is a doctoral candidate in the counseling psychology PhD program at Texas A&M University. She holds an MEd in educational psychology from Texas A&M University and a BA in biology from New Jersey Institute of Technology. Her research interests include the operationalization of multicultural counseling competence and of boundary setting between personal and professional life. She is also passionate about promoting systemic change through administrative roles.

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