Defining and assessing key behavioral indicators of the Shifting Cultural Lenses model of cultural competence

Abstract

Models of cultural competence highlight the importance of the sociocultural world that is inhabited by patients, and the question of how best to integrate sociocultural factors into clinical assessment and intervention. However, one significant limitation of such approaches is that they leave unclear what type of in-session therapist behaviors actually reflect cultural competence. We draw on the Shifting Cultural Lenses model to operationalize culturally competent in-session behaviors. We argue that a key component of cultural competence is the collaborative relationship between therapists and patients, in which therapists shift between their own cultural lenses and those of their clients, as they co-construct shared narratives together. Accordingly, we propose that culturally competent therapist behaviors include accessing the client’s views, explicitly presenting their own views as mental health care professionals, and working towards a shared understanding. We further specify the latter set of behaviors as including the practitioner’s integration of the patient’s view, their encouragement of the patient to consider their professional view, and the negotiation of a shared view. We developed a coding system to identify these therapist behaviors and examined the reliability of raters across 11 couple and 4 individual therapy sessions. We assessed whether the behavioral codes varied in expected ways over the first 3 sessions of 2 therapists’ couple therapy as well. Operationalizing the behavioral indicators of the Shifting Cultural Lenses model opens the door to the integration of both process- and content-oriented approaches to cultural competence.

Keywords

behavioral observation coding therapists’ dialogue cultural competence mental health care providers

Introduction

In the United States, growing racial and ethnic diversity (Colby & Ortman, 2015) and the significant racial and ethnic disparities in mental health care (López, Barrio, Kopelowicz, & Vega, 2012; Snowden, 2012; S. Sue, Cheng, Saad, & Chu, 2012) are two important reasons to improve mental health care providers’ skills in working with racial and ethnic minority groups. Current models of cultural competence have rightly pointed out the importance of the sociocultural world that is inhabited by patients, and have raised the question of how best to integrate such factors into clinical assessment and intervention (for the consideration of cultural competence at the level of the organization or service model, see Guerrero, 2013; Kirmayer, Groleau, Guzder, Blake, & Jarvis, 2003).

Limitations to current models of therapistcultural competence

There are two key limitations to the dominant models of therapist cultural competence. The first is that, in such models, culture is oftentimes conceptualized as equivalent to ethnicity, race, or nationality. A frequently cited model of cultural competence focuses on therapists’ self-awareness, knowledge, and perceived competence (e.g., D. W. Sue & Sue, 2014). Another model is based on adaptations of treatment to existing evidence-based treatments (for reviews, see Hall, Ibaraki, Huang, Marti, & Stice, 2016; Huey, Tilley, Jones, & Smith, 2014). Both of these approaches primarily situate culture as a phenomenon pertaining to racial and ethnic minority groups. In the former approach, therapists are urged to learn specific knowledge about a given ethnic or racial group. In the latter model, existing evidence-based treatments are adjusted to a group’s values, beliefs, or practices. Both approaches do well to consider important group-based knowledge in carrying out interventions. The downside of such racially and ethnically centred approaches, however, is that they risk promoting group stereotypes (Good & Hannah, 2015) and limit the reach of cultural competence. Indeed, culture expresses itself in many ways, in addition to processes associated with race, ethnicity, and nationality (Kirmayer, 2012; Kleinman & Benson, 2006; López & Guarnaccia, 2000). The recent American Psychological Association’s multicultural guidelines (2017) point out the importance of intersectionality and the numerous social identities that must be considered in clinical practice.

The second key limitation of the dominant models of cultural competence is that they have paid insufficient attention to clinicians’ in-session behaviors (Ridley, Baker, & Hill, 2001; Tao, Owen, Pace, & Imel, 2015). Worthington, Soth-McNett, and Moreno (2007) reported that, over a 20-year period of multicultural competence research, only three out of 81 published studies used independent raters to assess providers’ behaviors; most studies were based on self-report measures of multicultural competence. Observer-rated measures can strengthen the empirical basis of cultural competence. This is primarily a concern for the general cultural competence models, and less so for culturally adapted evidence-based treatments, as the latter oftentimes have clearly defined treatments coded in dedicated manuals.

The Cultural Formulation Interview

The Cultural Formulation Interview (CFI) is one model that does not suffer from either of these limitations. It comprises 16 questions that clinicians can use to assess specific cultural domains in the early stage of treatment (Lewis-Fernandez et al., 2014). The cultural domains assessed by the CFI are (a) problem definition, (b) perceptions of cause, context, and support, (c) views of self-coping and past help-seeking, and (d) current help-seeking. The questions are individualized and can apply to a wide range of social groups in accessing relevant culturally based conceptions. The questions are also clearly laid out, which facilitates the assessment of whether clinicians asked a given question and how they did so. For example, to assess the problem definition, clinicians are instructed to ask the following question: “People often understand their problems in their own way, which may be similar to or different from how doctors describe the problem. How would you describe your problem?” Another strength of the CFI is that there is a growing evidence base for the feasibility, acceptability, and utility of this approach across the world (Lewis-Fernandez et al., 2017). The CFI is also prominently integrated in the DSM-5 (American Psychiatric Association, 2013), and a published handbook provides the background, context, and detailed guidance to train clinicians in its use (Lewis-Fernandez, Aggarwal, Hinton, Hinton, & Kirmayer, 2016). The CFI is arguably the gold standard of general cultural competence models in mental health settings today.

The CFI is, however, not without its limitations. Its main limitation is that, as a model of cultural competence, the CFI pays little attention to how clinicians are to use the obtained data to promote treatment planning, patient engagement, and their patients’ mental health. One exception is that practitioners are instructed to use the problem definition of the patient in discussing the presenting problem. Given that the CFI has its origin in diagnosis, specifically the DSM-IV outline for cultural formulation (American Psychiatric Association, 1994), it is understandable that the focus is on the early stages of the clinical encounter.

The Shifting Cultural Lenses model

In this study, we consider another approach to cultural competence, the Shifting Cultural Lenses model, which we have developed elsewhere (Lakes, López, & Garro, 2006; López, 1997). Like other cultural competence models, prior versions of this model have been largely conceptual in nature. In developing the model, we first drew on Kleinman’s conceptualization of ethnographers shifting their analytic lenses between the “experience-near” categories of the individuals or groups that they are studying and the ethnographers’ own “experience-near” categories (Kleinman & Kleinman, 1991). By doing so, ethnographers derive a socially grounded understanding of the individuals or groups under study. We argued that clinicians also shift their lenses in working with their patients, and we delineated the domains in which they do so: engagement, assessment, theory (of presenting problem and intervention), and treatment method. We also presented research and clinical cases to illustrate the value of applying this conceptualization (López, 1997).

In a subsequent conceptual paper (Lakes et al., 2006), we further developed the model in two important ways. We first elaborated a definition of culture that draws on Kleinman’s (1995) conceptualization of experience as that which is at stake in one’s local, social, and moral world. The notion of “what is at stake” reflects what matters to people. While there is some congruence with past definitions, which tend to focus more on values, beliefs, and practices (Hall, 2001), a major difference is that this definition grounds values and beliefs in the social and moral worlds of individuals, as opposed to their specific ethnic, racial, or national group. Second, we applied Mattingly and Lawlor’s (2001) conception of a shared narrative to guide clinicians on how best to integrate the cultural notions held by the help-seeker with those held by the practitioner. We argued that developing a shared understanding involves engaging in a collaborative relationship that facilitates the patient and therapist’s agreeing on treatment goals and treatment methods. Shared narratives can reflect the help-seeker’s views, the practitioner’s views, or some integration of the two. The key questions are whether the two parties agree on a given treatment direction and whether they are working from the same narrative (see also Benish, Quintana, & Wampold, 2011). Thus, efforts on the part of the therapist to negotiate a shared understanding are critical to our model of cultural competence.

One strength of the Shifting Cultural Lenses model is that, like the CFI, it does not focus on a given racial or ethnic group. It can be applied to many groups, including persons from the presumed majority group. Another advantage is that the concept of a shared narrative provides a framework that can guide clinicians’ use of cultural data to inform their clinical activities. Clinicians are not merely encouraged to obtain the client’s view, but instead they are guided to find common ground with their clients. A third strength of the model is that it can apply to most phases of clinical work, from engagement and assessment through to treatment. One limitation of the model is that it is has been largely conceptual in nature, lacking clearly laid out practitioner guidelines (Mollen, Ridley, & Hill, 2003). In addition, there is no evidence of the model’s treatment efficacy or effectiveness.

Proposed behavioral indicators of the ShiftingCultural Lenses model

The purpose of the present study is to move beyond conceptualization and begin to operationalize the culturally competent in-session therapist behaviors that reflect the Shifting Cultural Lenses model. As a first step, we reviewed the assessment research literature about therapists’ cultural competence. As noted earlier, the assessment of cultural competence has been largely limited to self-report measures (e.g., Gamst et al., 2004). The existing behavioral observations of clinicians are based primarily on therapy with a particular ethnic or racial group (e.g., African Americans; Cunningham, Foster, & Warner, 2010). The self-report measures and the group-specific therapist codes are not consistent with our aim of identifying behavioral indicators of a process-oriented model of cultural competence. We then turned to the more general therapist–client interaction coding systems (e.g., Angus, Levitt, & Hardtke, 1999). We found that these approaches did not address behaviors central to our model. For example, McLeod and Weisz (2005) included client behaviors that reflected the therapeutic alliance or the client’s participation in therapy. Client behavior is certainly important to the therapeutic encounter, but our focus is on therapist behavior. Given the limitations of the assessment procedures both for cultural competence and for general therapist–client interactions, we decided to develop our own coding system.

To operationalize the Shifting Cultural Lenses model with its emphasis on shifting between the client’s and therapist’s view and deriving a shared narrative, we considered three provider behavioral domains: (a) accessing their client’s view, (b) presenting clearly their own view, and (c) negotiating both perspectives to derive an agreed-upon understanding. Accessing the patient’s view refers to the practitioner asking the patient about their perspective on all key aspects of treatment (from defining to explaining the problem) and demonstrating to the client their understanding of the client’s views. This is consistent with Falicov’s (2014) description of the therapist’s stance as one of “not-knowing,” a stance that reflects cultural curiosity (Dyche & Zayas, 1995) and open-mindedness (Jenks, 2011). The humanistic tradition’s focus on empathy is also relevant here, as the therapist tries to understand accurately the client’s views (Cormier & Cormier, 1998), and tries to communicate this understanding to the client (Rogers, 1951, 1957). Doing so helps clinicians learn the cultural meanings of the client (González, Biever, & Gardner, 1994).

Although learning the client’s perspective is essential to cultural competence, it is not sufficient. Therapists must also communicate their own perspective to the client in a manner that makes it clear that it is their view, not some presumed fact. The inclusion of this dimension was influenced in part by empirically supported treatments (e.g., Beck, Rush, Shaw, & Emery, 1979), in which therapists were trained to describe both the treatment’s theory and methods in a clear and straightforward manner to the patient. Our development of this dimension was also influenced by the literature on patient involvement in health care decision-making, which requires explicitness on the part both of patients and providers in discussing their views and treatment preferences (Charles, Gafni, & Whelan, 1997; Elwyn et al., 2001; Lindhiem, Bennett, Trentacosta, & McLear, 2014). By acknowledging both perspectives, the therapist opens up the possibility to negotiate or build a shared narrative—an understanding upon which both parties can agree. Mattingly and Lawlor (2001) observed, in a pediatric hospital setting, that greater congruence between health care practitioners’ and parents’ “healing dramas” was related to more successful clinical interactions. Working toward establishing a shared narrative can also help reduce the power differential between therapist and patient. The three behavioral domains are similar to a long-standing cultural training tool developed for family residency training, referred to as LEARN. This acronym represents the following steps: listen to the patient’s perception of the problem, explain your perceptions of the problem, acknowledge and discuss the differences and similarities, recommend treatment, and negotiate agreement (Berlin & Fowkes, 1983).

As a first step to deriving behavioral codes, we opted to cast a wide net to capture the identified therapist behaviors. Specifically, we chose not to limit the clinician behaviors to specific content areas thought to be cultural in nature. By doing so, we were able to assess the therapists’ overall ability to shift lenses and to derive a shared understanding. Another reason for casting a wider net is that it is not always clear when a specific matter in therapy is a culturally shared view or an idiosyncratic view held by the help-seeker. The literature can guide us in identifying some notions—for example, the use of idioms of distress (e.g., nervios for Latinos; Salgado de Snyder, Diaz-Perez, & Ojeda, 2000). However, outside of well-documented culturally based notions, it can be difficult to discern in a given session what is culturally based or idiosyncratic. If one considers intersectionality and people’s many social identities (e.g., ethnicity, race, gender, sexual orientation, age, rural/urban), there are many ways the content raised by patients can reflect socially grounded conceptions within the assessment and treatment domains (Fung & Lo, 2017; Hays, 2016). A further consideration is that individual experience interacts with culturally shared experience to create diverse expressions of culturally grounded notions (Garro, 2000). Given these challenges in the operationalization of the behavioral codes, we thought it best, as an initial step, to not restrict the content to presumed culturally based notions. Cultural issues will come up. The focus, however, will be on the therapists’ behavior, not whether the issue is cultural in nature.

Study overview

To operationalize the culturally competent in-session therapist behaviors that reflect the Shifting Cultural Lenses model, we first delineated a set of specific therapist behavioral codes thought to reflect (a) shifting perspectives between the therapist and client and (b) deriving a shared narrative. We then assessed whether a set of raters could reliably code the proposed in-session behavioral indicators. In an initial step to examine the validity of the codes, we also examined whether the codes were sensitive to expected changes in the course of a specific psychosocial intervention. Finally, we illustrated the coding system with the transcript of a segment of an actual therapy session.

Methods

Therapy session videos and transcripts

As a first step in the development and evaluation of the coding system, we sought a bank of videotaped therapy sessions. Dr. Andrew Christensen from the University of California, Los Angeles gave us permission to use videotapes of couple therapy sessions, which were part of a clinical trial to examine two different types of treatment for couples: traditional behavioral couple therapy (TBCT) versus integrative behavioral couple therapy (IBCT) (Christensen et al., 2004). TBCT focuses on making positive changes in each partner’s behavior to create less punishing and more rewarding interactions, while IBCT builds on these factors and adds a focus on emotional acceptance. One advantage of using these taped sessions is that both treatments are manualized and have a specific structure that each therapist is trained to follow. As a result, treatment goals vary by session, which provides a means to assess whether our coding system is sensitive to the adjustments that providers make across treatment sessions. Our coding team was unaware of the specific type of couple treatment being administered.

Overall, we obtained 35 taped sessions, which featured the interactions of four therapists and six couples (two of the therapists saw two couples). The tapes corresponded to the first five or six sessions with each couple, including individual sessions with each member of the couple. Therapy sessions ranged in length from 30 to 60 minutes. Altogether, we used 24 of these sessions to develop and refine our coding system, and 11 sessions to establish the reliability of our coders and coding system. Therapists were licensed clinical psychologists with between 7 and 15 years of experience postlicensure. One therapist was African American, two were Latinos, and one was Caucasian American. Two of the therapists were women and two were men. The couples were of various racial and ethnic backgrounds; we did not have access to their self-identified race or ethnicity. All therapy sessions were transcribed verbatim without identifying information; we used clients’ initials instead of their names. The transcripts were divided among the four raters and reviewed for accuracy. All raters were trained to deal with confidential and clinically sensitive material, and completed training in human subjects research. The research protocol was approved by the University of Southern California’s Office for the Protection of Research Subjects (UP-07-0431).

Given that most therapy is conducted with individuals, not couples, we assessed whether this coding system can also be reliably applied to individual treatment sessions. For this subsample, coders rated four individual sessions (a total of 22 10-minute intervals) with three therapists from community mental health centers (one psychologist, one marriage and family therapist, and one clinical social worker). The four patients were all of Latino origin.

In selecting the therapists and the patients, we did not consider variability in the level of cultural competence of the therapists, nor did we consider variability of the sociocultural background of the patients. Given the small size of our sample of therapists and patients, we did not attempt to generalize our findings to other therapists. We viewed this study as a first step to assess if the identified codes that were generated from our conceptual model could capture key aspects of the therapy process and if the codes could be reliably identified.

Procedures

Coders

A team of four coders, three of whom were women, rated the therapy sessions reported in this study. Their ages ranged from 24 to 30 years of age. Three of our coders had completed their undergraduate degrees majoring in psychology and one completed a psychology minor. All coders identified as Latinx and were bilingual in Spanish and English, as the focus of the next research phase would be on the treatment of Latinos. Three coders rated the couple therapy sessions and two coders rated the individual sessions. The coding supervisor, a postdoctoral fellow in clinical psychology, rated all couple and individual sessions.

Coder training

The principal investigator (SRL) provided initial training in the Shifting Cultural Lenses model, which included 10 hours of readings, workshop activities, and group discussions. The principal investigator and the coding supervisor drafted a preliminary coding manual with the codes and coding guidelines. Coders referred to the manual while carrying out their rating. The coding supervisor led two weekly meetings to review each coder’s ratings, to address coding difficulties, to establish consensus, and, whenever necessary, to modify the existing criteria. Consensus was established either by the opinion of the majority, by adherence to applicable coding criteria, or by the coding supervisor. When codes were unreliable, the group met with the principal investigator to monitor the coders’ adherence to the model and refine the coding guidelines. Codes that repeatedly exhibited low reliability (ICCs < .60; Chicchetti & Sparrow, 1981) were revised or eliminated. For example, we initially attempted to identify the specific treatment domains (e.g., problem definition and treatment method) in which the therapist’s behaviors occurred. The coders were unable to distinguish reliably between the domains and therefore these codes were dropped.

Coding procedures

The therapy sessions were divided into 10-minute intervals, and the intervals were marked on the transcripts. Coders were first instructed to watch the complete videotaped session (or to listen if there was only an audio recording) and follow along with the transcript. They then rated each 10-minute interval and the overall session. Watching the complete session and rating the overall session helped the coder understand a given statement in the context of the full session. The unit of analysis that we report is the overall session rating of the five codes for a single treatment session. This applied to both individual and couple cases.

Results

Coding system

Our first goal was to develop a coding system based on the conceptual framework and identified behavioral indicators of the Shifting Cultural Lenses model. We developed five codes that correspond to the main behavioral indicators of our model. These codes describe behaviors of the therapist that can take place in any treatment domain, from engagement to assessment, theory, and treatment methods (López, 1997). The first code reflects efforts of the therapist to access, explore, and understand their clients’ views (C). The second code (T) represents attempts by the therapist to clearly communicate his or her views to the patient, and to help the patient to understand the therapist’s views. The third coding domain was subdivided into three codes that correspond to the three ways therapists can work with their clients to develop a shared narrative (S): (a) by integrating the client’s views (Si), (b) by asking for the client’s buy-in to the therapist’s views (Sb), and (c) by negotiating different options with the client (Sn). Table 1 provides examples of codable statements in each behavioral dimension that were drawn from our training tapes and from our coding manual. Additional criteria for each code are provided in our coding manual. It is important to note that the therapists’ utterances will draw heavily from what the therapists learn from their patients. A therapist’s view may in fact be their view of what the patient stated.

Table 1.

Examples of codable therapist statements.

Accessing the client’s views (C)	What do you think led to you developing these problems? How did they come about? Was your previous marriage counseling helpful to you Joanne? In what way? I will ask you next Peter, as I want your view as well.
Providing the therapist’s views (T)	I’m wondering if what is most frustrating for you is that the very attempts you make to improve your relations with your friends actually end up making your relationships worse. I think that is when you really feel stuck. Based on what you told me, it seems to me that the common theme to your problems is how to spend your free time; whether it is together or apart.
Shared narrative: Integrating the client’s views (Si)	You really have done a good job of identifying your negative thoughts Jonathan. And you see the relationship between your negativity and your feeling down. That’s great. But you say you have a difficult time challenging those thoughts. How ‘bout if we turn our attention to how best to neutralize or at least minimize those negative thoughts? One of the areas that we are going to work on is communication. You mentioned having outbursts with Elvira. You also described dishonesties in the past and a lack of trust and communication. So, communication is going to be a crucial part of our work together.
Shared narrative: Working towards buy-in (Sb)	This entire trauma that you suffered causes you a lot of pain. But the reality is that sometimes, when you talk about it, it may give you some kind of relief that someone else knows what you’ve been through. What do you think of that? Now I’m going to tell you what I think is going on in your relationship, the way I see things. But I really want your input. If I say something that makes a lot of sense, please acknowledge that. If I say something where you see it in a different way or it doesn’t fit, let me know. Does that work?
Shared narrative: Negotiation (Sn)	I understand that you think you need to be involved with people who have weaker personalities to maintain your individuality, but that gives me a sense that you feel more comfortable in relationships where you can maintain some control. Do you see the difference? So, you think that your fighting has to do with the clash between your two strong personalities. I get it. But my guess is that if we work on improving your communication skills, we will see a significant reduction in your fighting.

For every 10-minute interval and for the overall session, coders indicated the degree to which the therapist’s behavior reflected each of the five codes (C, T, Si, Sb, and Sn). We provided the following anchors for the interval ratings: none (0), a little (1), some (2), quite a bit (3), and a great deal (4), with descriptors for each anchor that account for the quality and quantity of therapist statements. For example, for accessing the client’s view (C), a rating of 1 (a little) corresponds to the therapist minimally asking for or referring to the client’s perspective with factual, close-ended questions. A rating of 1 indicates that the therapist’s utterances minimally reflect the client’s perspective, with limited references to or demonstrations of understanding the client’s view. On the opposite end of the spectrum, a rating of 4 indicates that the practitioner has demonstrated efforts to understand the client’s experience throughout the interval or overall session. In such a case, the provider deliberately asks for the patient’s views rather than making assumptions, and is vigilant in asking and referring to the client’s perspective to make sure that they understand it correctly. There is an explicit and comprehensive attempt to access the client’s views.

Reliability

Our second goal was to assess the reliability of the raters’ coding. Given that our coding system underwent considerable modification over the training period, our reliability analysis pertains to the sessions coded after establishing the final criteria. Three coders and the coding supervisor coded 11 sessions of two therapists with two couples (including two individual sessions), for a total of 52 10-minute intervals. To assess interrater reliability, we computed intraclass correlation coefficients (ICCs) between each coder and the criterion established in the consensus meetings (Shrout & Fleiss, 1979). Table 2 displays coders’ agreement with consensus in identifying the behavioral dimensions of the therapist across the 52 10-minute intervals, and for the 11 overall session ratings of couple therapy.

Table 2.

Reliability coefficients of four coders for 10-minute interval and overall couple therapy session ratings.

	Intraclass correlations
Codes	10-min intervals (N = 52)	Overall session (N = 11)
Accessing the client’s views	.86, .87, .88, .99	.62, .63, .71, .93
Providing the therapist’s views	.91, .92, .96, .97	.82, .90, .93, .97
Shared narrative:
Integrating the client’s views	.64, .70, .77, .78	.75, .86, .92, .93
Working towards buy-in	.82, .91, .92, .95	.91, .94, 1.0, 1.0
Negotiation^a

Note. Each number represents the intraclass coefficient correlation between the codes of one of four raters and the criterion codes across 52 10-minute intervals and 11 therapy sessions.

Unable to assess the reliability of the ratings of this code, as there was only one positive code noted in all intervals.

Our raters reached acceptable to excellent levels of reliability with consensus in coding 10-minute intervals and overall sessions for couple therapy. For the 10-minute intervals, only one of the 16 ICCs (four raters of four codes) dropped below .70, whereas eight of the ICCs reached .90 and above. A similar pattern was observed for the overall session ratings, with only two out of 16 ICCs falling below .70, and eight ICCs reaching at least .90. We were unable to assess the coders’ reliability in their ratings of the therapists’ shared negotiation (Sn), which was one of the three codes of the shared narrative. Only one instance of this code was identified across all sessions. Two coders rated this instance as shared negotiation and two coders did not rate it. The coders’ discussion of this instance resulted in further refining the definition of this code for greater clarity.

For the four individual therapy sessions (22 10-minute intervals), the reliabilities of three raters with consensus ratings ranged from .92 to .94 (for C), .77 to 1.0 (for T), .77 to .93 (for Si), and .76 to .93 (for Sb). For the overall session ratings, reliabilities ranged from .90 to 1.0 (for C), .50 to 1.0 (for T), and .75 to 1.0 (for Sb). The reliabilities were .75 for Si. No rater coded instances of negotiation for the overall sessions.

Code shifts across couple therapy sessions

Our third goal was to assess whether the in-session behavioral codes are sensitive to changes in therapy content for the 11 treatment sessions for the two couples that we used to assess the coders’ reliability. The therapist for one couple applied integrative behavioral couple therapy (IBCT) and the therapist for the other couple applied traditional behavioral couple therapy (TBCT). For both therapies, assessment is the focus in the early stages of treatment (first and second sessions). Thus, in both couple therapies, the modal in-session behavior at this time should be accessing the client’s views (C), with much less attention to presenting the therapist’s views (T) or to developing a shared narrative (Si, Sb, Sn).

For both IBCT and TBCT, the third session is called the feedback session. In IBCT, the therapist is instructed to provide the couple with a formulation and a treatment plan by engaging in a dialogue with the couple. Therapists are taught to present tentatively the formulation and to elicit feedback. The marital partners themselves are viewed as the experts about what ails them, and they contribute actively to the working formulation. The purpose of this exercise is to derive a mutually acceptable treatment plan. Generally speaking, TBCT shares this view of the feedback session, though it might be considered more prescriptive than IBCT; that is, TBCT promotes specific interventions (e.g., communication training). Nevertheless, compared to the early assessment sessions, we expected that the feedback sessions for both types of therapy would result in higher ratings of therapists presenting their views (T) and developing shared understandings (Si, Sb, Sn). Given that much of the feedback is based on what the therapist learns, there should be a number of efforts to integrate the client’s views (Si). In addition, the treatment method encourages the practitioner to elicit feedback and derive a mutually acceptable treatment plan, suggesting that there will be an increased number of codes of shared buy-in (Sb) and shared negotiation (Sn).

Figure 1 depicts the summary of the global ratings of the two couple therapists. Therapist A was practicing IBCT and Therapist B was practicing TBCT. (Please note that the individual second sessions with the husband and wife were not available for the coding of Therapist B.) An examination of the figure reveals support for the three expected patterns of clinician behaviors. First, accessing the client’s view (C) is the modal behavior in three of the four evaluation sessions, specifically Sessions 2H and 2W for Therapist A, and Session 1 for Therapist B. The overall session rating for C in each of those sessions is 3, the highest rating of all the codes during those sessions. The only discrepancy pertains to Session 1 for Therapist A, where stating the therapist’s view (T) is the modal in-session behavior, with a rating of 4 compared to C which was given a rating of 2.

Figure 1.

Therapist ratings across sessions for two therapist–couple dyads.

We also observed expected shifts in the therapists’ behaviors between their prior assessment sessions (for Therapist A: Sessions 1, 2H, and 2W; for Therapist B: Session 1) and their feedback session (Session 3 for both therapists). The ratings for accessing the client’s view (C) declined for both therapists (for Therapist A: ratings of 2, 3, 3 to 1; for Therapist B: ratings of 3 to 2). In contrast, the ratings of the therapists presenting their views (T) increased for the most part for both therapists (Therapist A: ratings of 4, 1, 2 to 4; Therapist B: ratings of 1 to 4). Clearly, the modal response during the feedback sessions is the therapist presenting their views (T). There were noticeable increases in shared narrative building between the prior assessment session and the feedback session as well. For Therapist A, there was an increase in the ratings of the therapist’s shared integration (Si) of the client’s views from 0, 1, 1 to 3, and an increase in the ratings of the therapist’s shared buy-in (Sb) from 0, 0, 0 to 1. For Therapist B, the increases between the assessment sessions and feedback session concerned Si (1 to 2), Sb (1 to 3) and Sn (0 to 1). The fact that the changes in the ratings correspond to the predicted shifts in carrying out the initial sessions of couple therapy, by two different therapists with different couples, provides preliminary support for the intended meaning of the codes with this sample.

Discussion

We were successful in creating a measure of therapists’ in-session behaviors that reflects therapists shifting between their client’s views and their own views and deriving a shared narrative. We trained coders to identify these behaviors in both couple therapy and individual therapy. The generally high ICCs demonstrate that the coders reliably applied the coding system with the sample of treatment sessions. In addition, the coding scheme proved to be sensitive to expected changes in two therapists’ behaviors during the early phases of couple therapy. Altogether, these findings indicate that the coding system has promise as a measure of in-session clinician behavior that is congruent with key aspects of the Shifting Cultural Lenses model of cultural competence.

Illustrations of behavioral indicators

To illustrate the relevance of the behavioral codes for the assessment of cultural competence, we present brief vignettes of therapist–patient dialogue that reflect the five behavioral indicators that we have identified. These excerpts were taken from the early stages in the evaluation of a cultural competence training of therapists who work in the public mental health sector with individual adult clients. Both excerpts were drawn from the first session with a 35-year-old married Mexican American woman with three children who sought help for panic attacks. The therapist is a middle-aged Caucasian man with a Master’s degree in Marriage and Family Therapy and 17 years of clinical experience. He described himself as a narrative therapist. This first example primarily reflects learning of the client’s perspective (C) regarding the problem definition. In addition, there is evidence that the provider is using the client’s problem definition, which reflects the code of integrating the client’s view (Si). The instances of the therapist’s coded behavior are noted in the transcribed section with their respective initials. “Th” refers to the therapist speaking and “Cl” refers to the client speaking. Th

So one of the things that I want to ask is, is if you were to give this a name, this, this, that, now like your husband says, “You, you’re gonna have one aren’t you?” You know? Well what is what, what is that thing called? What would, what would, if you were to give this thing a name. (C)

He calls me a chiriplolca.

A chiriplolca?

Uh huh. [laughs] He calls it the chiripo-plolca. In other words, I don’t know, I guess the shakes, the shivers.

OK.

Chiriplolca. He calls it that [laughs]. Yeah.

… and that’s, and that is the shakes? (C)

Uh huh.

En español … Chiri, chiriplolca … Now, so if we call this thing the chiriplolca, we’ll know what that means right?

Yes. Yes.

OK. So let me ask you—if, if this was like a, uh, if, if this was like a pet that moved into the house … or … a roommate or something like that, we, we called it, we called this roommate the, the chiriplolca, when would you say it started to take up residence in you life? When did it want to rent a room? [laughs] (C) (Si)

… When I had my kids. I had one, when I had the postpartum depression. When I had K. in 2000. And then I had H. at 2004.

So, it would kinda move in, stay for a while, and then it would move out. Is that right? (C)

Right.

OK. So now chiripolcla, it wanted to come in and it would, it would be a temporary renter. For how long? How long? (Si) (C)

Two years.

In this case, the therapist asks what the patient and her husband call her problem using their own words. She says “chiriplolca.” The therapist explores the meaning of this idiomatic expression, which she refers to as the shakes or shivers. This expression likely originated from “Chaparrón Bonaparte,” one of the television characters portrayed by the well-known Mexican comedian Chespirito. The character used the term “chiripiolca” to represent a behavioral act of repeatedly twisting his torso and lifting his leg at the knee until his counterpart “Lucas” hit him to stop the “chiripiolca.” Although the therapist may have his own definition for the problem (panic attacks), he uses the client’s definition to assess the onset and duration of the problem, despite his difficulties in pronouncing the word. This exchange fits with two codes—accessing the client’s perspective (C) and integrating the client’s perspective (Si). Although the actual numerical rating for this exchange would depend on what else was said during the 10-minute interval, these comments contribute to at least a rating of 2 out of 4 for both of these codes. It is worth noting that we learned that the provider had no prior knowledge of the concept “chiripiolca.” Consistent with a process model, he asked the client for the meaning of this word and then applied it in the session.

We now present a segment of the same session that includes the other codes, including presenting the therapist’s view (T), negotiating a shared narrative (Sn), and attempting to foster buy-in of the therapist’s view (Sb). In this example, the same client describes her belief that her behavior sets a bad example for her children. Cl

Yeah. I’m not saying I’m a very intelligent lady. I’m not, I, but I want to be … I want to be something in my life for [begins to cry] my children not to give up in school the way I did, and the struggles that I’m having now and—I just want it to be better. And before anything is better, it’s me who has the [sic] give the example.

Ummm … So this battle isn’t just your battle. You’re really battling for your kids and the kind of future that you want for them … Wow. So N … . you live with this awareness that there’s an audience watching you … a lot, in, in, in your children.

Yes.

OK. What do you think they’re learning from you right now? (C)

Trauma, trauma.

You think they are learning trauma from you? (C)

Um hmm … because I’m everyday crying … Constantly … And them telling me, “Why you crying now? Why you crying now?” I try to make it a 5-minute thing, but sometimes I’m cleaning, cooking, or have the radio on, my, just tears just fall.

Yeah. And so they see those tears and they, they might ask about them … And you would like them not to see tears falling (C). Now, are they still seeing you cook while the tears are flo, falling?

Yeah.

Wow. What do you think they are learning about you in that? (C)

Negative.

Negative, really? What would they be learning about you that’s negative in that? (C)

Well because I’m doing everyday chores. I’m, I’m doing my cleaning, cooking, laundry…

Yes. I’m hearing that.

… and, um, picking up my children too. Taking them to and from school … and … I don’t want them to think that I’m not happy doing it.

Ohhhhhh. OK. I see. You see, I had a different, a little bit different perspective on that, but I, I can see what you’re saying … You want your kids to have a sense that you enjoy the life that you are making for them … What, what I thought … What I thought your kids might be getting from that is that “Mom’s pretty courageous, and she’s very determined, and even if she is feeling things strongly, she keeps doing what we need in order to keep our home together, and our life together.” (T) (Sn)

Yeah.

Is that possible for them to, to see it that way? (Sb)

Yes. I never sat down and talk to them about it, but I hope that’s what they’re thinking, but in their little minds I don’t know what they’re thinking … I never asked them a question about that.

In this brief interaction, the therapist does an excellent job of accessing the client’s view regarding what it is that she thinks that the children are learning from her. The client is concerned that her children see her as not enjoying her maternal role. This then enables the practitioner to begin negotiating a shared understanding (Sn) by offering an alternative perspective, one that he clearly framed as his view (T). He suggests that her children might be learning that their mother is courageous because, despite feeling sad, she carries on with her household duties. This offering was coded as an initial step in negotiating a shared narrative (Sn). Finally, the therapist asks if it is possible that her children could see her behavior as courageous. By asking this, the therapist is assessing whether his client might agree with this alternative perspective, which would then be coded as attempting to obtain “buy-in” from the client (Sb).

With this example, we want to note that there is no obvious cultural notion that is being communicated here—at least, no obvious notion of what is traditionally considered culture, such as the familism and spirituality of specific racial and ethnic minority group members. Instead, we argue that her conception of her behavior as “trauma” and as negativity, and the therapist’s conception of her behavior as courage are both cultural constructions. These constructions may or may not pertain to a specific social category or group such as ethnicity or race. They are cultural constructions nevertheless, and in our view, it is very helpful to identify, express, and negotiate these constructions.

Although these excerpts serve to illustrate the application of all the codes, they fall short of an ideal exemplar of the Shifting Cultural Lenses model of cultural competence. It would have been useful for the therapist to explore further what the client’s view of “chiripiolca” was, as well as her view of trauma and postpartum depression. Agreeing on a particular label is a step forward, but an assessment and understanding of the key constructs that underlie the client’s predicament is critical to the Shifting Cultural Lenses model. Further assessment is especially important because the client referred to the “chiripiolca” label as having been generated by her husband. It would have been helpful to have learned her views of “chiripiolca,” positive and negative, and to consider their implications for treatment. Finally, the statement coded as a shared narrative represents an initial step to develop a co-constructed narrative. It does not represent a clear fully formed example of this category. The therapist examined whether the client is open to consider his narrative, and the client agreed. Given that the codes reflect the therapist’s behavior, evidence that he later pursues these elaborations of this narrative would reflect a stronger instance of the shared narrative code (Sn).

Implications

A key advantage of the Shifting Cultural Lenses model and other process models of cultural competence (e.g., cultural accommodation: Leong, 2007; and dynamic sizing: S. Sue, 1998) is that their principles are not tied to specific racial or ethnic groups. As a result, there is less risk of stereotyping a given individual than there may be with models developed for specific groups. In addition, process models of cultural competence can extend to a wide range of sociocultural groups and contexts, beyond ethnicity and race. Although the models have been developed largely to improve services for minority group members, culture applies to all individuals. Process models have the potential for greater reach than treatments designed specifically for a given group, or existing treatments that are culturally adapted for specific groups.

One challenge for process models of cultural competence is that they are largely conceptual in nature, and it is not clear how clinicians implement their principles or conceptualizations (Mollen et al., 2003; S. Sue, Zane, Hall, & Berger, 2009). The present study takes an important first step to operationalize the Shifting Cultural Lenses model by identifying the specific in-session therapist behaviors that represent key aspects of the model. This can facilitate further research to test the validity of the coding measure and of the model more generally. In addition, behaviorally anchored trainings can be conducted and evaluated to see if such trainings improve care.

Operationalizing the Shifting Cultural Lenses model can also help to address another criticism of process cultural competence models: that they reflect general clinical processes, with little if any cultural content (Wendt & Gone, 2012). One way to address this limitation is to integrate the behavioral indicators with more content-oriented approaches to cultural competence. As noted earlier, one critique of cultural adaptations of evidence-based treatments is that they do not give sufficient attention to within-group variability (Castro, Barrera, & Steiker, 2010). By accessing the client’s views of a given clinical predicament and its treatment components, and by negotiating a shared narrative, steps can be taken to individualize or tailor culturally adapted treatments (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003). A good example of this is Kopelowicz et al.’s (2012) cultural adaptation of McFarlane’s (2002) multifamily group (MFG) treatment to enhance treatment adherence of Spanish-speaking Mexican Americans with schizophrenia. Clinicians systematically assessed the beliefs, attitudes, and resources regarding treatment adherence of each patient, and then drew on the social norms and sociocultural resources of the multiple families attending the group to help patients achieve their treatment goals. For example, if a given patient was reluctant to take medication for fear that they could become dependent on the drug, which is a common belief encountered among Latinx patients (Vargas et al., 2015), the clinician would use MFG’s problem-solving method and draw upon the group resources to help determine what course of action to take, including how to best figure out if the medication does cause dependence. The strength of this process-oriented cultural adaptation is that it recognizes that there can be important sociocultural barriers and facilitators to treatment, but it does not assume what the given attitudes, social norms, and sociocultural resources are as a function of the patient’s ethnicity or race.

The behavioral indicators of the Shifting Cultural Lenses model might also be helpful to other approaches to cultural competence that emphasize certain stages of treatment. One such model is the CFI discussed earlier. The CFI does an excellent job of identifying a wide range of possible cultural matters early in treatment around issues of diagnosis and of setting the treatment plan. Although there are some exceptions (e.g., clinicians are instructed to use the client’s label of the problem definition), the CFI is not clear about how clinicians are to use such information to promote engagement, adherence, and other related clinical processes beyond the early stages of treatment. The behavioral indicators of the Shifting Cultural Lenses model could be useful in guiding providers on how best to develop shared narratives with the accessed cultural data in progressing through all stages of treatment. Doing so would represent the integration of process-oriented and content-oriented models of cultural competence.

Operationalizing the behavioral indicators of this process model also opens the door to exploring how they can be applied to evidence-based models more generally. One approach is to evaluate available treatments and to examine how well the behavioral indicators are represented. As a first step, this can be carried out by carefully reviewing treatment manuals. We have done this with one treatment, the standard MFG treatment of schizophrenia (McFarlane, 2002). We learned that therapists are clearly instructed to use the patient’s definition of the presenting problem. Regarding treatment methods and conceptualization, however, the treatment manual provides little to no guidance in accessing the clients’ views, suggesting little opportunity to derive a shared understanding (Lopez, Kopelowicz, & Cañive, 2002). This review suggests specific areas where the behavioral indicators of the Shifting Cultural Lenses model can be integrated.

Linking culture to the behavioral indicators

Although we accomplished our goal of operationalizing key components of the Shifting Cultural Lenses model, we did not develop a code for the clinician tying the patient’s meaning to the patient’s local, social, and moral worlds—which is the model’s definition of culture. In a preliminary effort to identify what is at stake for each client, raters identified social world indicators and pointed out main themes of what matters to the client. For example, in the previous case illustration, what mattered to the mother is to be a good role model for her children. She stated,

I need to leave … that good example for my children, because I don’t want them to be … the way I was. Didn’t finish high school, never finished … a job, or I ah, I always gave up. No, I don’t like that, that of myself so I want them to be better.

Identifying that which is at stake in the patient’s local social world, however, reflects the coders’ views about what matters to patients, not the practitioners’ ability to identify this domain. We are exploring other avenues to monitor the clinicians’ ability to identify what is at stake and what matters for each client. Doing so will likely increase attention to explicit cultural dialogues.

Limitations

As an initial effort to develop a behavioral assessment of the Shifting Cultural Lenses model, we did not distinguish between quantity and quality of the identified therapist behaviors. Adherence to a given treatment modality and competence or skillfulness are complex constructs that have been studied in many ways (Waltz, Addis, Koerner, & Jacobson, 1993). Future efforts should differentiate between the occurrence of given therapist behaviors and the skill with which they are carried out. Also reflective of the early development of this assessment tool is that one of the codes—negotiation—could not be identified reliably because it had a very low base rate in the coded sessions. It is not clear why this happened. Such behaviors may occur later in the therapeutic process or they just may not be part of the repertoire of our sample of therapists. We considered the possibility that the absence of negotiation behaviors may be a function of the therapy format; namely, couple therapy. That appears not to be the case, however, as we did not find negotiation in our individual sessions either. It could be that this code is not clearly defined and that it overlaps with the other shared narrative codes. It seems possible that an instance of negotiation could also involve integrating the client’s view and asking the client to buy into the therapist’s view. We have tried to address this weakness by providing additional guidelines to facilitate the identification of in-session negotiation. Another drawback of the current coding scheme is that it does not attend to the affective quality of the patient–provider exchange. Prior research in medical settings with African American patients suggests that assessments of this domain (e.g., through the use of the Roter interaction analysis system) can provide valuable insights into the provider–patient interaction (Johnson, Roter, Powe, & Cooper, 2004).

Another limitation is that the observed shifts in the therapists’ in-session behavior could have been due to other factors than the shift in the specific treatment aims for a given session. Rater bias is not likely a valid explanation, as the raters were naïve to the specific treatment goals of a given session. Observing shifts across a much larger sample with other treatment models is needed.

Conclusion

Our coding system represents a first effort in developing a direct measure of therapists’ behaviors that reflect shifting their perspectives and deriving a shared narrative. These are fundamental in-session behaviors that represent key aspects of the Shifting Cultural Lenses model of cultural competence and processes upon which other cultural dialogues can be built. Operationalizing these behavioral indicators contributes to advancing the Shifting Cultural Lenses model, and also has the potential to inform other approaches to cultural competence, including more content-oriented approaches.

Footnotes

Acknowledgements

We thank Andrew Christensen, Carol Falender, and Dianna M. Gonzalez for their valuable assistance.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Institute of Mental Health (R34 MH071498) and the Southern (California) Counties Regional Partnership.

ORCID iD

Steven Regeser López

Steven Regeser López, PhD, is a Professor of Psychology and Social Work at the University of Southern California. His research provides a critical cultural perspective to the study of psychopathology, assessment, and intervention of Latinx and other ethnic minority groups. López and his research team have developed studies along three pathways to care for those with serious mental illness: (a) illness recognition, (b) family caregiving, and (c) cultural competence of clinicians. With funding from the United States’ National Institute of Mental Health, he carried out a community campaign to reduce the duration of untreated psychosis among Latinos with first-episode psychotic disorders.

Ana Ribas, PhD, is a psychologist in private practice, and a therapist and clinical supervisor at the University of California, Los Angeles (UCLA) Adult OCD Intensive Treatment Program. She was a psychologist at the UCLA Counseling Center where she specialized in underserved populations, and provided clinical services in Spanish and Portuguese. Dr. Ribas was a Clinical Research Coordinator at the Culture and Mental Health Lab at the Department of Psychology of the University of Southern California, where she supervised the Shifting Cultural Lenses research team. Her published works focus on the effects of social support on the quality of life of Latinos with mental illness, and on disability stigma in Portugal.

Tamara Sheinbaum, PhD, is a Postdoctoral Scholar in the Culture and Mental Health Lab in the Department of Psychology at the University of Southern California. She holds a postdoctoral fellowship jointly awarded by the University of Southern California and the National Council of Science and Technology in Mexico. Her current research revolves around understanding how interpersonal adversity, attachment, and family relationships relate to the development and expression of psychopathology, particularly psychosis. She is also interested in the translation of this understanding into preventive interventions for vulnerable populations.

Maria M. Santos, PhD, is Assistant Professor of Psychology at the California State University, San Bernardino. Prior to her faculty position, she was a Postdoctoral Research Associate in the Department of Psychology at the University of Southern California. Her research has centered on evaluating behavioral activation for depression, particularly with Latinos, to better understand for whom and how the treatment works. Her current research focuses on evaluating the fit of behavioral activation for the treatment of first-episode psychosis.

Aldo Benalcazar, LCSW, works for Los Angeles County Department of Mental Health (DMH) as a psychiatric social worker. Mr. Benalcazar has provided direct clinical services to at-risk children, adolescents, and their families applying various evidence-based practices, such as “Incredible Years.” In October of 2017, Mr. Benalcazar entered the Family Preservation Program as a mental health liaison, working to enhance the collaboration between the DMH, the Department of Children and Family Services, and community-led agencies in ensuring the delivery of mental health services to families in need. Mr. Benalcazar is particularly interested in the role of positive parenting in the development of resilience in children, as well as its role in diminishing behavioral challenges.

Linda C. Garro, PhD, holds doctorates in social sciences–anthropology (1983, University of California, Irvine) and cognitive psychology (1982, Duke University). She is Professor of Anthropology at UCLA. Her research activities are in medical and psychological anthropology and include matters of health and illness in everyday life contexts; representing cultural knowledge about illness; and remembering as a jointly social, cultural, and cognitive process. She received the Society for Psychological Anthropology’s Stirling Award and a 5-year Research Scholar Award from Canada’s National Health Research and Development Program. She was elected to the executive boards of the Society for Psychological Anthropology and the Society of Medical Anthropology, and for the latter she served as president (2012–2016).

Alex Kopelowicz, MD, is Chief of Psychiatry at Olive View-UCLA Medical Center and Professor and Vice-Chair of the Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA. Dr. Kopelowicz researches psychosocial interventions for serious mental disorders among Hispanic populations. He is currently the Principal Investigator of a funded project by the United States’ National Institute of Nursing Research that is testing the efficacy of multifamily groups to improve the outcomes of Mexican American patients with Type 2 diabetes. His published works focus on social skills training, family psychoeducation, supported employment, and other psychosocial interventions for individuals with psychotic disorders.

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