The Case for Cultural Competency in Psychotherapeutic ...

ANRV364-PS60-20 ARI 27 October 2008 16:21

The Case for CulturalCompetency inPsychotherapeuticInterventionsStanley Sue,1 Nolan Zane,1

Gordon C. Nagayama Hall,2 and Lauren K. Berger1

1Department of Psychology, University of California, Davis, California 95616;2Department of Psychology, University of Oregon, Eugene, Oregon 97403;email: [email protected], [email protected], [email protected], [email protected]

Annu. Rev. Psychol. 2009. 60:525–48

First published online as a Review in Advance onAugust 25, 2008

The Annual Review of Psychology is online atpsych.annualreviews.org

This article’s doi:10.1146/annurev.psych.60.110707.163651

Copyright c© 2009 by Annual Reviews.All rights reserved

0066-4308/09/0110-0525$20.00

Key Words

cultural adaptation, ethnic minority, evidence-based practice,treatment outcomes, mental health

AbstractCultural competency practices have been widely adopted in the mentalhealth field because of the disparities in the quality of services deliv-ered to ethnic minority groups. In this review, we examine the mean-ing of cultural competency, positions that have been taken in favor ofand against it, and the guidelines for its practice in the mental healthfield. Empirical research that tests the benefits of cultural competencyis discussed.

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Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . 526WHAT IS CULTURAL

COMPETENCY? . . . . . . . . . . . . . . . . . 527Can Cultural Competency be

Distinguished from Competencyin General? . . . . . . . . . . . . . . . . . . . . . 528

Differing Definitions . . . . . . . . . . . . . . . 528RESISTANCE TO CULTURAL

COMPETENCY . . . . . . . . . . . . . . . . . . 530WHAT HAS BEEN

ACCOMPLISHED SO FAR? . . . . . . 532WHAT KINDS OF CULTURAL

COMPETENCYINTERVENTIONS HAVEBEEN ATTEMPTED? . . . . . . . . . . . . 534Method of Delivery . . . . . . . . . . . . . . . . 534Content . . . . . . . . . . . . . . . . . . . . . . . . . . . 535Storytelling . . . . . . . . . . . . . . . . . . . . . . . . 536Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537Cognitive Behavioral Therapy . . . . . . 537

IS TREATMENT GENERALLYEFFECTIVE WITH ETHNICMINORITY POPULATIONS? . . . . 538

DO CULTURAL COMPETENCYADAPTATIONSDEMONSTRATE POSITIVEAND INCREMENTAL EFFECTSON TREATMENT? . . . . . . . . . . . . . . 539

FINAL THOUGHTS . . . . . . . . . . . . . . . . 541

INTRODUCTION

The notion that culturally competent servicesshould be available to members of ethnic mi-nority groups has been articulated for at leastfour decades. Multiculturalism, diversity, andcultural competency are currently hot and im-portant topics for mental health professionals(Pistole 2004, Whaley & Davis 2007). Origi-nally conceptualized as cultural responsivenessor sensitivity, cultural competency is now advo-cated and, at times, mandated by professionalorganizations; local, state, and federal agencies;

and various professions. Yet, the concept hasalso been a source of controversy concerning itsnecessity, empirical research base, and politicalimplications. This review examines many of thekey issues surrounding cultural competency—namely, its definition, rationale, empirical sup-port, and effects. We have not attempted tobe exhaustive in our review of the relevant re-search; instead, we have examined the major is-sues and trends in cultural competency.

Many prominent health care organizationsare now calling for culturally competent healthcare and culturally competent professionals(Herman et al. 2004). Appeals for cultural com-petency grew out of concerns for the status ofethnic minority group populations (i.e., AfricanAmericans, American Indians and Alaska Na-tives, Asian Americans, and Hispanics). Theseconcerns were prompted by the growing di-versity of the U.S. population, which neces-sitated changes in the mental health systemto meet the different needs of multiculturalpopulations. Further troubling were the well-documented health status disparities betweendifferent ethnic and racial groups, as well as thenationally publicized studies regarding culturalbias in health care decision making and recom-mendations (Schulman et al. 1999). The evi-dence revealed that mental health services werenot accessible, available, or effectively deliv-ered to these populations. Compared to whiteAmericans, ethnic minority groups were foundto underutilize services or prematurely termi-nate treatment (Pole et al. 2008, Sue 1998).Racial and ethnic minorities receive a lowerquality of health care than do nonminorities,have less access to care, and are not as likely tobe given effective, state-of-the-art treatments(U.S. Surgeon General 2001). The disparitiesexist because of service inadequacies rather thanany possible differences in need for services oraccess-related factors, such as insurance status(Smedley et al. 2003).

Justice or ethical grounds have also pro-pelled cultural competency (Whaley & Davis2007). The goals of many professional orga-nizations include equity and fairness in the

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delivery of services. For example, one of theguiding principles of the American Psycholog-ical Association (2002, pp. 1062–1063) is that:

Psychologists recognize that fairness and jus-tice entitle all persons to access to and bene-fit from the contributions of psychology andto equal quality in the processes, procedures,and services being conducted by psycholo-gists. Psychologists exercise reasonable judg-ment and take precautions to ensure that theirpotential biases, the boundaries of their com-petence, and the limitations of their expertisedo not lead to or condone unjust practices.

Ridley (1985) has argued that cultural com-petence is an ethical obligation and that cross-cultural skills should be placed on a level ofparity with other specialized therapeutic skills.As an alternative to the passive “do no harm”approach in ethical standards in many help-ing professions, Hall et al. (2003) advocatedthat ethical standards mandate cultural com-petence via collaboration with, and sometimesdeference to, ethnic minority communities andexperts.

The delivery of quality services is especiallydifficult because of cultural and institutionalinfluences that determine the nature of ser-vices. For example, Bernal & Scharron-Del-Rıo (2001) maintain that ethnic and culturalfactors should be considered in psychosocialtreatments for many reasons. They propose thatpsychotherapy itself is a cultural phenomenonthat plays a key role in the treatment process.In addition, ethnic and cultural concepts mayclash with mainstream values inherent to tra-ditional psychotherapies. The sources of treat-ment disparities are complex, are based on his-toric and contemporary inequities, and involvemany players at several different levels, includ-ing health systems, their administrative andbureaucratic processes, utilization managers,health care professionals, and patients (Smedleyet al. 2003).

Although the problems giving rise to the cul-tural competency movement are multifaceted,our focus in this review is to analyze therapist

and treatment tactics that are considered cultur-ally competent. In the focus on cultural com-petency, we acknowledge the social and psy-chological diversity that exists among membersof any ethnic minority group and the tendencyto generalize information across distinct ethnicgroups. The discussion of cultural competenceissues for a particular ethnic minority group be-comes even more challenging in view of the lim-ited amount of empirically based informationavailable on cultural influences in mental healthtreatment. Considering these limitations, weproceed as judiciously as we can, examiningkey cultural tendencies and issues likely to beencountered in psychotherapy and counseling,drawing out some implications from the ex-tant research, and offering some suggestionsfor research that may produce more cultur-ally informed mental health practices. We alsorecognize that culture is only one relevant fac-tor in providing effective mental health treat-ment and that depending on the circumstances,other aspects of clients may be more influen-tial. The literature reviewed represents trendsthat have been observed and should be consid-ered as guidelines or working hypotheses oftenlinked with culturally competent mental healthcare for ethnic minority clientele.

WHAT IS CULTURALCOMPETENCY?

From the outset, we want to indicate that ourcoverage is limited. In cultural competence, it isimportant to distinguish between three levels ofanalysis: provider and treatment level, agencyor institutional level (e.g., the operations of amental health agency), and systems level (e.g.,systems of care in a community). Our focus is onthe first level—that of the provider, therapist,or counselor and that of the specific treatmentused.

To evaluate the validity, utility, and empiri-cal basis of cultural competency, one must firstbe able to define the construct. Competenceis usually defined as an ability to perform atask or the quality of being adequately preparedor qualified. If therapists or counselors are

www.annualreviews.org • Case for Cultural Competency 527

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generally competent to conduct psychotherapy,they should be able to demonstrate their skillswith a range of culturally diverse clients. Pro-ponents of cultural competency, however, be-lieve that competency is largely a relative skill orquality, depending on one’s cultural expertise ororientation. Their definitions of cultural com-petency assume that expertise or effectivenessin treatment can differ according to the client’sethnic or racial group. As Hall (2001) noted, ad-vocates of cultural competency or sensitivity ap-preciate the importance of cultural mechanismsand argue that simply exporting a method fromone cultural group to another is inadequate.

Can Cultural Competency beDistinguished from Competencyin General?

Is there evidence that cultural competency canbe distinguished from competency in general?The two may overlap but also have somedistinct effects. Fuertes and colleagues (2006)found that ethnic minority clients rated theirtherapists as being higher in multiculturalcompetency if the therapists were rated highon therapeutic alliance and empathy. Thesetwo characteristics are considered good ingre-dients in all treatments. Fuertes et al. (2006)recommend that therapists receive training intraditional areas such as relationship buildingand in communicating empathy. At the sametime, they believe it is important that therapistsbe trained to competently handle the culture-based concerns that their clients bring to ther-apy. Another study suggests that the two aresomewhat distinct. Constantine (2002) corre-lated African American, American Indian, AsianAmerican, and Hispanic clients’ treatment sat-isfaction with two measures of competency: onethat assessed counselors’ competency in general(i.e., the Counselor Rating Form–Short) andthe other that measured cross-cultural compe-tence in particular (Cross-Cultural CounselingInventory–Revised). Although the two well-established competency measures were some-what related, the cross-cultural competencymeasure contributed significantly to client

satisfaction beyond general competency. Therewas also evidence that ethnic minority clients’perceptions of their counselors’ multiculturalcounseling competence partially mediated therelationship between general counseling com-petence ratings and satisfaction with counsel-ing. Thus, cultural competency may be mean-ingfully distinguished from competency ingeneral.

Differing Definitions

But how does one define the concept? In thepast, terms such as “cultural sensitivity,” “cul-tural responsiveness,” and “multicultural com-petence” were used to convey the significanceof attending to cultural issues in therapy andcounseling. Despite consensus over the impor-tance and significance of cultural values and be-haviors in treatment, investigators have actuallyvaried in their specific assumptions or focus forcultural competency. Many models of cultur-ally sensitive therapy have been developed (Hallet al. 2003). Some describe characteristics ofcultural competency. For example, ingredientsviewed by some as essential for cultural compe-tence include having an understanding, appre-ciation, and respect for cultural differences andsimilarities within, among, and between cultur-ally diverse patient groups (U.S. Dept. HealthHuman Serv. 2002). Culturally competent carehas been defined as a system that acknowledgesthe importance and incorporation of culture,assessment of cross-cultural relations, vigilancetoward the dynamics that result from culturaldifferences, expansion of cultural knowledge,and adaptation of interventions to meet cultur-ally unique needs (Whaley & Davis 2007).

Others emphasize the outcome of culturalexpertise. Thus, having cultural knowledge orskills is important to the extent that positiveoutcomes are achieved, such as:

� The capacity to perform and obtain pos-itive clinical outcomes in cross-culturalencounters (Lo & Fung 2003).

� The acquisition of awareness, knowledge,and skills needed to function effectively in

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a pluralistic democratic society (i.e., theability to communicate, interact, nego-tiate, and intervene on behalf of clientsfrom diverse backgrounds) (Alvarez &Chen 2008, D.W. Sue & Torino 2005).

� The possession of cultural knowledge andskills of a particular culture to deliver ef-fective interventions to members of thatculture (S. Sue 1998).

� The ability to work effectively in cross-cultural situations using a set of congru-ent behaviors, attitudes, and policies thatcome together in a system, agency, oramong professionals (Agency for Health-care Research and Quality 2004).

Although the varying definitions overlap tosome degree, one meaningful way of conceptu-alizing the definitions of competency is to notethat some emphasize the (a) kind of person oneis, (b) skills or intervention tactics that one uses,or (c) processes involved. In terms of the kindof person one is, D.W. Sue and colleagues (Sueet al. 1982, 1992) argue that the culturally com-petent counselor has:

� Cultural awareness and beliefs: Theprovider is sensitive to her or his per-sonal values and biases and how these mayinfluence perceptions of the client, theclient’s problem, and the counseling re-lationship.

� Cultural knowledge: The counselor hasknowledge of the client’s culture, world-view, and expectations for the counselingrelationship.

� Cultural skills: The counselor has theability to intervene in a manner that isculturally sensitive and relevant.

In this view, cultural competency involvesa constellation of the right personal character-istics (awareness, knowledge, and skills) thata counselor or therapist should have. Everycounselor should possess these characteristics.This model for cultural competency is the mostwidely recognized framework, and it formed thebasis for much of the multicultural guidelinesadopted by the American Psychological Asso-ciation (Am. Psychol. Assoc. 2003) as well as the

multicultural counseling competencies adoptedby the organization’s Division 17.

The skills or tactics model views culturalcompetency as a skill to be learned or a strategyto use in working with culturally diverse clients.One chooses to exercise the skill or to use acultural adaptation under the appropriate cir-cumstances. Cultural competency is essentiallysimilar to other specialized therapeutic skillssuch as expertise in sexual dysfunctions and de-pressive disorders (Ridley 1985). In this view,acquisition of multicultural competence wouldinvolve in-depth training and supervised expe-rience as found in the development of other psy-chotherapeutic competencies (Whaley & Davis2007).

Finally, process-oriented models focus onthe complex client-therapist-treatment inter-actions and processes involved. For example,Lopez (1997) considers the essence of culturalcompetence to be “the ability of the thera-pist to move between two cultural perspectivesin understanding the culturally based meaningof clients from diverse cultural backgrounds”(p. 573). S. Sue (1998) views cultural compe-tence as a multidimensional process. He pro-poses that three important characteristics un-derlie cultural competency among providers:scientific mindedness (i.e., forming and testinghypotheses), dynamic sizing (i.e., flexibility ingeneralizing and individualizing), and culture-specific resources (i.e., having knowledge andskills to work with other cultures) in responseto different kinds of clients.

The definitions of cultural competence havepoints of convergence and divergence (Whaley& Davis 2007). They all agree that knowl-edge, skills, and problem solving germane tothe cultural background of the help seekerare fundamental. Nevertheless, the differentdefinitions vary with respect to their empha-sis on global characteristics, knowledge, skills,awareness, problem-solving abilities, aspira-tions, processes, etc. The definitions also varyas to how amenable they are to research test-ing. The kind-of-person model and the pro-cess model pose problems in terms of empir-ical testing. In both models, characteristics of


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culturally competent therapists or interactingprocesses are difficult to specify and opera-tionalize for research. On the other hand, theskills or cultural adaptation model can be morereadily tested. In this model, researchers intro-duce the skill or cultural adaptation of treat-ment and compare the effects with other treat-ment or no-treatment control groups.

In general, it has been difficult to developresearch strategies, isolate components, devisetheories of cultural competency, and implementtraining strategies. Some limitations in culturalsensitivity or competency are that it (a) hasvarious meanings, (b) includes inadequate de-scriptors, (c) is not theoretically grounded, and(d ) is restricted by a lack of measurements andresearch designs for evaluating its impact intreatment.

RESISTANCE TO CULTURALCOMPETENCY

It is not surprising that cultural competencyor multiculturalism has come under attack. Be-cause of the lack of research on cultural com-petency, some have challenged it as being moti-vated by “political correctness” (Satel & Forster1999) and untested in clinical trials (Satel 2000).

One of the important debates in the lit-erature concerning cultural competency canbe found in the attempt to establish mul-ticultural counseling competencies or multi-cultural guidelines for the American MentalHealth Counseling Association. The guide-lines, many of which are highly similar tothe ones adopted by the American Psycho-logical Association (2003), stimulated civil butcontentious exchanges. The debated issues re-volved around several key questions, articu-lated largely by Thomas & Weinrach (2004),Weinrach & Thomas (2002, 2004), Vontress &Jackson (2004), and Patterson (2004):

1. Are cultural competency proponentsstereotyping ethnic minority clients?

Because cultural competency advo-cates emphasize the need to understandthe cultural values and worldviews of

members of different cultural groups,Weinrach & Thomas (2002, 2004) havesuggested that the position that mem-bers of these groups behave similarlyis inadvertently racist, stereotypic, andprejudicial. Herman et al. (2007) andHwang (2006) made similar points morerecently. They ask whether it is possibleto conduct culturally competent counsel-ing given the risks associated with im-plementing counseling in a manner thatfails to attend to a client’s individualdifferences and inadvertently promotesculture-related stereotypes of clients. Forexample, important individual differencesamong American Indian clients includeethnic identity, acculturation, residentialsituation, and tribal background (Trim-ble 2003, 2008). By addressing presumedcultural orientations of, say, American In-dians, therapists may fail to consider ac-culturated American Indian clients whodo not hold traditional Native Americanperspectives.

2. By advocating for multicultural compe-tencies for ethnic minority groups, are wediscriminating against or ignoring otherdiversity characteristics such as gender,sexual orientation, and social class?

The cultural competency movement,for the most part, has been addressed tothe needs of African Americans, Ameri-can Indians and Native Alaskans, AsianAmericans, and Hispanics. Weinrach &Thomas (2002) believe that the designa-tion of only a few minority groups as wor-thy of the profession’s attention is pro-foundly demeaning to those minoritiesnot included and that the concerns ofother diverse populations, such as womenand persons with disabilities, are ignored.

3. Is the role of culture and minority groupstatus in mental health overemphasized inmulticulturalism?

Weinrach & Thomas (2002, 2004)have also raised the issue that multicul-tural proponents have emphasized thatexternal or environmental forces, such

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as racism and oppression, largely causeclients’ emotional disturbance. Intrapsy-chic causes are minimized. Weinrach &Thomas argue that a focus on race is anoutmoded notion. Race does not providean adequate explanation of the humancondition. Attempts to invoke race as suchhave been appropriately labeled as racistand inadvertently contribute to America’spreoccupation with the pigmentation of aperson’s skin. Vontress & Jackson (2004)maintain that mental health counselorsshould look at all factors that affect aclient’s situation. Race may or may not beone of them. They believe that in general,race is not the real problem in the UnitedStates today. The significance that clientsattach to it is the most important con-sideration. However, Vontress & Jackson(2004) believe that in this country, the at-tention given to discussing cultural differ-ences and similarities is good for societyand for our profession.

Finally, Patterson (2004) is concernedover the emphasis on cultural differences.He notes that it has not been fruitfulto assume that simply having knowledgeof the culture of the client will lead tomore appropriate and effective therapy.The first faulty assumption is that coun-seling or psychotherapy is a matter of in-formation, knowledge, practices, skills, ortechniques. Rather, the competent men-tal health counselor is one who providesan effective therapeutic relationship. Thesecond faulty assumption is that client dif-ferences are more important than clientsimilarities. He argues that a treatmentsuch as client-centered therapy is a uni-versal system that cuts across cultures.However, methods that are considereduniversal usually are Western methodsthat are assumed to apply to other groups.Most Western therapeutic methods relyheavily on verbal and emotional expres-sion. Yet, among persons of East Asianancestry, talking has been found to inter-fere with thinking (Kim 2002), and emo-

tional expression may be dependent oncultural norms (Chentsova-Dutton et al.2007). In fact, recent research indicatesthat the psychological consequences ofemotional suppression and control candiffer depending on the cultural context(Butler et al. 2007).

4. Is the emotional and political context ofthe debate creating incivility?

Weinrach & Thomas (2004) have in-dicated that support for cultural compe-tency, created as a logical consequence ofthe 1960s civil rights movement, is of-ten used as a litmus test of one’s commit-ment to a nonracist society. Weinrach &Thomas (2004, pp. 90–91) state:

Among other goals, they were intended tosensitize White mental health professionalsto the unique cultural distinctiveness of maleclients on the basis of membership in four vis-ible minority groups. At the symbolic level,they have successfully brought to professionalcounselors’ awareness the importance of at-tending to the diverse counseling needs of vis-ible minorities. On the applied level, they havebeen a failure, as we see it. We would prefer tosee their demise in order to foster the recogni-tion that client needs should not be assumedto be based upon group membership alone,but rather on the unique constellation of indi-vidual client characteristics, including but notlimited to cultural distinctiveness.

They lament the fact that persons who refuseto adopt the competencies may be accused ofdisplaying “unintentional racism” or the resultsof “the insidious ethnocentric aspect of our cul-tural conditioning” (see Ivey & Ivey 1997, D.W.Sue 1996).

Although heated at times, the debates inthe literature have been instructive. First, theyhelp to clarify positions and misunderstandings.For example, most advocates of cultural com-petency do not see external factors (e.g., racism)as the sole or primary cause of mental disordersor that attention to ethnicity and race lessensconcern over other diversity or individual


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differences (e.g., gender, sexual orientation, so-cial class, etc.) factors (Arredondo & Toporek2004, Coleman 2004). They recognize individ-ual differences within various ethnic groups,such as the multitude of groups considered His-panic (e.g., Mexican, Puerto Rican, and CubanAmerican). Even within a particular group, suchas Mexican Americans, there may be consid-erable variations in level of acculturation thataffect the outcomes of cultural competency in-terventions, as we note below. The emphasison ethnicity and race is a reaction to centuriesof ethnocentric bias against, and inattention to,the importance of culture and minority groupstatus. If, as Bernal & Scharron-Del-Rıo (2001)have argued, psychotherapy itself is a culturalphenomenon, ethnic minority concepts mayconflict with mainstream values inherent to tra-ditional psychotherapies. Cultural values of in-terdependence and spirituality, and discrimina-tion in the psychotherapy of ethnic minorities,are often ignored in treatment approaches toethnic minority clients (Hall 2001). In orderto achieve the ecological validity of interven-tions, these cultural values must be consideredin all treatments (Bernal 2006). Given the grow-ing ethnic minority populations and the exist-ing disparities in health and treatment, specialattention to race and ethnicity is needed.

Second, there is no single multicultural ori-entation or cultural competency viewpoint, asnoted in our discussion of the definitions of cul-tural competency. Yet, critics often attack cul-tural competency by characterizing it with ex-treme positions (a straw man approach). Satel &Forster (1999) have asserted that the most rad-ical vision of cultural competence claims thatmembership in an oppressed group is a client’smost clinically important attribute. This asser-tion is misleading because few, if any, wouldadvocate such a view. In addition, cultural com-petency tactics appear to vary according to thekind of client and the kind of disorders experi-enced by the client (discussed below).

Third, discussions of culture, ethnicityand race, and multiculturalism are frequentlyheated and emotional. Emotional reactions tothe issues are not unexpected. Race and ethnic-

ity have been highly controversial throughoutthe history of the United States. As noted byPope-Davis et al. (2001, pp. 128–129):

It is our contention that multiculturalism is in-fused with political meaning. The word itselfis a symbol—a trigger—of change that oftenelicits a range of emotional responses. . . . Webelieve that it is also important to acknowledgethat, given the history of psychology’s inade-quacies with diverse populations, multicultur-alism is not an apoliticized theory. Much ofthe research done in the multicultural arenaattempts to shift current thinking and insti-tutional practices toward greater equality andrecognition of diverse needs and perspectives.This agenda . . . implicates the subjective mo-tivation of the researchers in the product.

Finally, much consensus exists over thenecessity for more research and over themultitude of unanswered questions and issues.Ridley et al. (1994) indicate that culturalcompetency lacks theoretical grounding andadequate measures of the construct. Moreover,little research examines ethnic variations in re-sponse to treatment (Mak et al. 2007). Despitethe questions raised over cultural competencyadaptations, the magnitude of mental healthdisparities in access to and quality of servicesfor ethnic minority populations has spurredactions to address the problems.

WHAT HAS BEENACCOMPLISHED SO FAR?

Awareness of treatment disparities and the ef-fects on mental health have stimulated the es-tablishment of local, state, and federal guide-lines for the delivery of culturally competentservices. For example, the following federalagencies are among the many that have Web-sites that explain their cultural competency rec-ommendations and guidelines:

� Administration on Aging, U.S. De-partment of Health & Human Services(HHS) (http://www.aoa.dhhs.gov/prof/adddiv/cultural/addiv cult.asp)

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� Office of Minority Health, HHS (http://www.omhrc.gov/templates/browse.aspx?lvl=1&lvlID=3)

� Health Resources and ServicesAdministration (http://www.hrsa.gov/culturalcompetence/)

� Substance Abuse and Mental HealthServices Administration (http://mentalhealth.samhsa.gov/dtac/CulturalCompetency.asp)

In terms of psychology organizations, coun-seling psychologists were among the first toextensively discuss and debate cultural compe-tency issues through organizations such as theAssociation for Non-White Concerns in Per-sonnel and Guidance in the 1970s and the As-sociation for Multicultural Counseling and De-velopment in the 1980s. Subsequently, manycounseling psychologists through APA Division17 (Counseling Psychology) and the NationalInstitute for Multicultural Competence advo-cated for multicultural guidelines. Among clin-ical psychologists, APA Division 12 (Society ofClinical Psychology) established the section onthe Clinical Psychology of Ethnic Minorities.

The APA has also had a history of in-volvement in ethnic, culture, and professionalpractice. The adoption of the Guidelines onMulticultural Education, Training, Research, Prac-tice, and Organizational Change for Psychologistshad implications not only for mental healthservices but also for education, training, andresearch (Am. Psychol. Assoc. 2003). Theseguidelines provided a context for service de-livery: “Psychologists are encouraged to applyculturally appropriate skills in clinical and otherapplied psychological practices . . .” (p. 390).Cross-culturally sensitive practitioners are en-couraged to develop skills and practices thatare attuned to the unique worldviews and cul-tural backgrounds of clients by striving to in-corporate understanding of a client’s ethnic,linguistic, racial, and cultural background intotherapy” (p. 391).

Other professional organizations have is-sued statements, guidelines, or policies re-

garding cultural competency. For example,the American Psychiatric Association’s Steer-ing Committee to Reduce Disparities in Accessto Psychiatric Care (2004) developed an actionplan to reduce disparities and to increase cul-tural awareness. Similarly, the National Associ-ation of Social Workers defined cultural compe-tency as a set of congruent behaviors, attitudes,and policies that come together in a system oragency or among professionals and enable thesystem, agency, or professionals to work effec-tively in multicultural situations. It then devel-oped standards for cultural competence in so-cial work practice (Natl. Assoc. Social Workers2007).

In the past two decades, cultural competencyhas been mandated to reduce mental health dis-parities; at the very least, cultural competencyis recommended by various institutions, gov-ernmental bodies, and professional organiza-tions. However, the mandates are rather hor-tatory or aspirational in nature because precisetactics and implementation strategies are un-clear. Research is needed to gain knowledgeabout what works in cultural competency andhow it works. It should be noted that most def-initions of cultural competency do not includetreatment outcomes as the major criteria forcompetence. This is surprising since it seemsreasonable that if certain therapist skills or ori-entations are more culturally competent, theseshould be related to better treatment outcomesfor ethnic minority clients (or at the minimum,equitable outcomes relative to those of main-stream clients). The proliferation of operationaldefinitions of cultural competence may stemfrom the fact that these notions of competencehave not been held empirically accountable totreatment outcomes—the gold standard (U.S.Surgeon General 2001).

We indicate below the kinds of interven-tions that characterize cultural competency. Weexamine the research studies that have testedthe effects of culturally competent interven-tions and discuss outcomes of these studies inthe final section.


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WHAT KINDS OF CULTURALCOMPETENCY INTERVENTIONSHAVE BEEN ATTEMPTED?

Considerable variation exists in the studies ofculturally competent interventions. The inter-ventions have ranged in terms of:

� Intervention approach. A narrow inter-vention is changing a specific feature ofstandard treatment practice such as con-ducting treatment in the ethnic languageof the client. Broader interventions arethose in which the general treatment ap-proach is determined by the client’s eth-nicity or in which many different featuresare based on cultural considerations (e.g.,not only having a language match be-tween client and therapist but also an eth-nic and cultural match).

� Client problems and issues (e.g., rape pre-vention, treatment of schizophrenia, pre-vention of drug abuse, depression, andself-esteem).

� Ethnic/racial groups (African American,American Indian and Alaskan Natives,Asian Americans, and Hispanics). Moststudies have been conducted on AfricanAmericans and Hispanics. Very few haveincluded American Indians and AlaskanNatives. Some investigations involvemore than one ethnic/racial group.

� Intervention type. Studies vary accordingto individual versus group interventions,treatment versus prevention, and use ofstandard treatments (e.g., cognitive be-havioral treatment) versus specially de-veloped interventions (e.g., cuento therapyfor Puerto Ricans).

The studies also vary considerably on thetype of research design (experimental, correla-tional, and archival), outcome measures used,the inclusion of control or alternative inter-vention groups, rigor in design, follow-up as-sessment, and sample size. In any event, wehave classified the studies into certain categoriesfor heuristic purposes only. We discuss culturecompetency in terms of method of delivery,content, and specialized interventions, which

have been programmatically examined, such ascognitive behavioral treatments, storytelling in-terventions, and family therapies.

Method of Delivery

Method of delivery is intended to make the in-tervention more culturally consistent, increasecredibility of the treatment or provider, or makethe treatment understandable to ethnic minor-ity clients. Delivery methods include interven-tion tactics that respond to the ethnic languageof clients (e.g., translating materials or havingbilingual therapists), varying the interpersonalstyle of the intervention (e.g., showing respeto orculturally appropriate respect with Hispanics),or providing a cultural context for interventions(Andres-Hyman et al. 2006). These changesshare a common feature in that they involvegeneric applications; they can be implementedacross most types of treatment (e.g., psychody-namic, behavioral, and cognitive-behavioral).

A minimum requirement of the interven-tion is that therapists must be able to com-municate with clients in a manner that is cul-turally acceptable and appropriate. Clients whohave limited English proficiency have difficul-ties entering, continuing, and benefiting fromtreatment (Snowden et al. 2007) and appearto need culturally adapted interventions morethan do clients who are acculturated and havegreater English proficiency (Sue et al. 1991). Anumber of investigations used therapists whospeak the ethnic language of clients who havelimited English proficiency. These studies ex-plicitly report that treatment was conductedby therapists who were bilingual or who spokethe language of their clients. The languageshave included Spanish (e.g., Armengol 1999,Gallagher-Thompson et al. 2001, Guinn &Vincent 2002, Kopelowicz et al. 2003, Martinez& Eddy 2005), Korean (Shin 2004, Shin &Lukens 2002), and Chinese (Dai et al. 1999).Some studies attempted to see if ethnic matchor a related form of match (e.g., cognitivematch) between provider and client affectedintervention outcomes or processes (Campbell& Alexander 2002, Flaskerud 1986, Flaskerud

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& Hu 1994, Mathews et al. 2002, Sue et al.1991, Takeuchi et al. 1995, Zane et al. 2005).Rather than examining specific therapist-clientmatches in language or other aspects, somestudies have simply examined institutional re-sources (e.g., the extent to which agencies hadtherapists who could conduct treatment in theethnic language of clients) and then corre-lated treatment outcomes for ethnic clients(Campbell & Alexander 2002, Flaskerud 1986,Flaskerud & Hu 1994, Gamst et al. 2003, Lau& Zane 2000, S. Sue et al. 1991, Yeh et al.1994). In all of the studies, it is difficult to ascer-tain the precise factors that account for clientoutcomes. As mentioned above, most investi-gations have included many different featuresof cultural competency, and language was onlyone of them. For example, having bilingual staffmay provide not only language match but alsocultural or ethnic match.

Besides language, other cultural compe-tency adaptations were reflected in commu-nication patterns. For instance, patterns ofinteractions common among less-acculturatedHispanic/Latinos were followed in Armengol’s(1999) study involving support group therapy. Aformal mode of address was used if that was thestated preference of participants. Even whenfirst names were preferred, the more formalpersonal pronoun form of “you” (i.e., “usted”)was employed. Participants also addressed thegroup facilitator by her professional title (Doc-tora), even when using her first name. Theuse of such practices is consistent with cul-tural values involving respeto and deference to-ward authority figures. These communicationpatterns have also been employed in other in-tervention strategies such as cognitive behav-ioral treatment and interpersonal psychother-apy (Miranda et al. 2003a, Rossello et al. 2008).Although showing respect is desirable regard-less of the client’s culture, knowledge of the cul-ture determines how effectively that respect isshown and delivered.

In some intervention approaches, culturallyconsistent adaptations have involved the initi-ation of ceremonies that reflect cultural ritualssuch as a unity circle, a drum call, the pouring of

libation to the ancestors, and a blessing for theday, which are African-based rituals (Harvey &Hill 2004), and use of ethnic foods during in-tervention (Longshore & Grills 2000).

Content

Content refers to the discussion of, or dealingwith, cultural patterns, immigration, minoritystatus, racism, and cultural background expe-riences in the intervention. The introductionof content may serve to increase understand-ability and credibility of the intervention andto demonstrate the pertinence of the interven-tion to the real-life problems experienced byclients (Ponterotto et al. 2006). Most interven-tions have both delivery and content elements.For example, in a culturally adapted manage-ment training intervention for Latino parents,Martinez & Eddy (2005) not only conductedtraining sessions in Spanish but also addressedculturally relevant immigration and accultura-tion issues. Similarly, relevant cultural contentwas included in a support group interventionfor Hispanic traumatic brain injury survivors(Armengol 1999) and in an educational inter-vention program for low-acculturated Latinas(Guinn & Vincent 2002). The interventions in-cluded discussions of language, acculturation,spirituality, stressors inherent in the migratoryexperience, attitudes and beliefs about disabilityand health care, and support networks.

Interventions involving African Amer-ican girls (Belgrave 2002, Belgrave et al.2000), youths (Cherry et al. 1998, Harvey& Hill 2004, Jackson-Gilfort et al. 2001),and adults (Longshore & Grills 2000) haveincorporated principles of spirituality, har-mony, collective responsibility, oral tradition,holistic approach, experiences with prejudiceand discrimination, racial socialization, andinterpersonal/communal orientation that areoften found in African American worldviews.In a rape prevention program that includedmany African Americans, Heppner et al. (1999)introduced culturally relevant content (e.g., in-cluding specific information about race-relatedrape myths and statistics on prevalence rates


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for both blacks and whites and having blackand white guest speakers discuss their sexualviolence experiences in a cultural context toincrease the personal relevancy of the mes-sage). Robinson et al. (2003) studied the effectsof school-based health center programs forAfrican American students. All of the programswere intended to promote an African Americanatmosphere and theme. Features ranged fromhaving school decorations and posters (repre-senting Afrocentric perspectives and positiveAfrican American role models) to employingAfrican American staff and tailoring services tobe delivered in a culturally sensitive manner.

Culturally adapted content has also beenused with other ethnic minority groups suchas American Indians and Alaska Natives (DeCoteau et al. 2006). Fisher et al. (1996) usedspiritual groups and cultural awareness trainingin a residential treatment program in Alaska.Schinke et al. (1988) provided biculturallyrelevant examples of verbal and nonverbalmeans of refusing substance use. For instance,leaders modeled how subjects could turndown offers of tobacco, alcohol, and drugsfrom peers without offending their AmericanIndian and non-American Indian friends.While subjects practiced their communicationskills, leaders offered coaching, feedback, andpraise. Zane and colleagues (1998) reportan example of a preventive interventionprogram for Asian Americans. The programwas intended to prevent substance use andto increase the resiliency of high-risk Asianyouths and their families. Group discussionsand skill-building exercises for youths focusedon Asian familial values, acculturation issues,and intergenerational communication. Parentsparticipated in small-group workshops thatalso included topics involving cultural values,intergenerational communication, and family.

The studies indicate that cultural com-petency adaptations can range from simplyproviding ethnic language provisions tointroducing multifaceted changes in interven-tion philosophy, delivery, and format. Somestudies compared cultural adaptations to no-intervention or no-adaptation control groups.

Furthermore, components of cultural compe-tency were not subjected to testing, so it is notpossible to attribute possible positive effects ofintervention to any particular component (e.g.,determining whether treatment outcomeswere caused by ethnic language translationsor introduction of particular ethnic contents).Before we examine the outcome of culturalcompetency interventions, we discuss specifickinds of interventions, developed through moreprogrammatic research, that have used culturaladaptations: storytelling, family interventions,and cognitive behavioral therapy.

StorytellingMany Latinos answer questions by telling astory, thereby allowing the answer to emergeout of their narrative (Comas-Dıaz 2006).In order to improve the self-concept, emo-tional well-being, and adaptive behaviors ofPuerto Rican children, researchers (Costantinoet al. 1986; Malgady et al. 1990a,b) used cuen-tos (Puerto Rican folktales) or biographies ofheroic persons. Folktales often convey a mes-sage or a moral to be emulated by others. Theinvestigators incorporated themes such as socialjudgment, control of aggression, and delay ofgratification within Puerto Rican American cul-ture and experiences. By presenting culturallyfamiliar characters of the same ethnicity as thechildren, they felt that the folktales would serveto motivate attentional processes; make it easierto identify with the beliefs, values, and behav-iors portrayed in the adapted cuentos; and modelfunctional relationships with parental figures.Therapists, mothers, or group leaders read thecuentos bilingually, typically to children at riskfor emotional or behavioral problems.

The research designs of the studies of-ten compared adapted cuento intervention withoriginal folktales (not adapted to U.S. expe-riences) to other forms of intervention (e.g.,art/play therapy) or to a no-intervention con-trol group. Children were randomly assignedto groups. Results across the various studiesyielded favorable emotional and behavioral out-comes for the adapted cuento intervention com-pared with the other groups.

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Family

Szapocznik, Santisteban, and their colleagues(Santisteban et al. 1997, 2003, 2006; Szapoczniket al. 1984, 1986, 1989, 1990, 2003) have sys-tematically investigated the effects of speciallydesigned, culturally adapted treatment inter-ventions in families. Brief structural family ther-apy (BSFT) is an integration of structural andstrategic theory and principles. BSFT was cre-ated because it was found to be adaptable andacceptable for work with Hispanic families. Theinvestigators believe that the modality is espe-cially suited to the needs of the targeted pop-ulations because it emerged out of experiencein working with urban minority group fami-lies (particularly African American and PuertoRican) that were disadvantaged in terms of so-cial, cultural, educational, and political positionin American society. Some components of themodel are used with all families, and others arefamily specific and may be unique to certaincultural groups (i.e., immigration issues, racialprejudice issues). In BSFT, therapists take an ac-tive, directive, present-oriented leadership rolethat matches the expectations of the population.

Moreover, a structural family approachis consistent with Hispanics’ preference forclearly delineated hierarchies within the fam-ily. BSFT was able to directly address commonacculturation-related stressors, such as accul-turation differences and intergenerational con-flicts between children and their parents. Re-search designs for the studies of BSFT oftenincluded randomized control trials. In general,BSFT was found to be as good as or (typi-cally) superior to control conditions in reduc-ing parent and youth reports of problems as-sociated with conduct, family functioning, andtreatment engagement.

Cognitive Behavioral Therapy

A number of studies have examined whetherculturally adapted forms of cognitive behav-ioral therapy (CBT) are more effective thanare nonadapted forms of CBT, whether cul-turally adapted treatment demonstrates posi-tive outcomes, or whether certain components

BSFT: brief structuralfamily therapy

of CBT are more helpful than others ( Jacksonet al. 2006, Shen et al. 2006). These stud-ies are important because CBT is effective formany different problems (e.g., anxiety and de-pression) and for different ethnic populations.Furthermore, because CBT is often deliveredwith a fixed format or manualized script, itcan readily incorporate cultural adaptations andbe tested. For example, Kohn and colleagues(2002) examined the degree to which a manu-alized CBT intervention could be adapted ina culturally sensitive manner in treating de-pressed low-income African American womenexperiencing multiple stressors. The adapta-tions included changes in the language usedto describe cognitive-behavioral techniques andinclusion of culturally specific content (e.g.,African American family issues) in order to bet-ter situate the intervention in an African Ameri-can context. Compared with a nonadapted CBTintervention group, women in the adapted CBTgroup exhibited a larger drop in depression. DeCoteau et al. (2006) have offered general guide-lines for modifying manualized treatments thatare particularly applicable to Native Ameri-cans living on reservations or in rural tribalcommunities.

Miranda and her colleagues (2003a) havestudied whether cultural adaptations to CBTimprove the outcomes of treatment for His-panics. In randomized trials, the adapted formof CBT consisted of having bilingual and bi-cultural providers, translating all materials intoSpanish, training staff to show respeto andsimpatia to patients, and allowing for some-what warmer, more personalized interactionsthan are typical for English-speaking patients.These adaptations were considered to be cul-turally responsive. The patients who receivedthe adapted CBT had lower dropout rates thanthose who received CBT alone. There was in-dication that the effects of adapted CBT werestronger among those whose first language wasSpanish rather than English in terms of greaterimprovement in symptoms and functioning.

Miranda et al. (2003b) have also shownthat quality improvement interventions for de-pressed primary care patients can improve


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IPT: interpersonalpsychotherapy

treatment outcomes for ethnic minority groups.Because ethnic minority clients often receivepoorer quality of services than do white clients(U.S. Surgeon General 2001), the investiga-tors wanted to study the effects of qualityimprovements to care. The culturally adaptedimprovements included the availability of ma-terials in English and Spanish. Hispanic andAfrican American providers were included invideotaped materials for patients. In addition,providers were given training materials thatdealt with cultural beliefs and ways of over-coming barriers to care for Latino and AfricanAmerican patients. The quality improvementinterventions resulted in beneficial outcomes.However, because the study included generalimprovements as well as culturally relevant in-terventions, it was not possible to determinewhat factors in the interventions caused the fa-vorable outcomes.

Rossello & Bernal (1999) found that cul-tural adaptations to CBT and interpersonalpsychotherapy (IPT) were more effective thana wait-list control group in reducing depres-sion among Puerto Rican youths. Rosselloet al. (2008) maintain that certain treatmentapproaches, such as CBT and IPT, may in-trinsically appeal to the cultural orientation ofLatinos. CBT has (a) a didactic orientationthat provides structure to treatment and educa-tion about the therapeutic process; (b) a class-room format that reduces the stigma of psy-chotherapy; (c) a match with client expectationsof receiving a directive and active interventionfrom the provider; (d ) an orientation focusedon the present and on problem solving; and(e) concrete solutions and techniques to be usedwhen facing problems. On the other hand, IPTfocuses largely on the present interpersonalconflicts that are pertinent to Latino valuesof familismo (family) and personalismo (personalconsiderations). The congruence of CBT andIPT with Latino values made it easier for theinvestigators to adapt them for use with PuertoRican adolescents. The adolescents were ran-domly assigned to CBT (individual or grouptreatment) or IPT (individual or group treat-ment). Results revealed that all groups demon-

strated decreases in depressive symptoms withCBT that were superior to IPT.

Other studies have introduced culturaladaptations in cognitive behavioral training.Gallagher-Thompson et al. (2001) designed aculturally sensitive eight-week class that taughtspecific cognitive and behavioral skills for cop-ing with the frustrations associated with care-giving. Hispanic caregivers of dementia victimswere assigned to the training class or to a wait-list control group. At the end of the interven-tion, trained caregivers reported significantlyfewer depressive symptoms than did those inthe control group. Hinton et al. (2005) has alsoused CBT to treat Cambodian refugees by us-ing culturally appropriate visualization tasks.

Findings from the CBT studies provide con-sistent indication that cultural competency in-terventions are effective, and two of the studies(Kohn et al. 2002, Miranda et al. 2003a) foundthat cultural competency adaptations to CBTwere superior to nonadapted CBT.

IS TREATMENT GENERALLYEFFECTIVE WITH ETHNICMINORITY POPULATIONS?

As mentioned above, ethnic and racial dis-parities exist in treatment access and quality.Does this mean that treatment is not effectivewith ethnic minority populations or that eth-nic clients should not seek treatment for mentalhealth problems? Despite the disparities, treat-ment is needed and can be helpful for all popu-lations (President’s New Freedom Commission2003, U.S. Surgeon General 2001). Ethnic mi-nority populations need access to the best formsof treatment. The questions to be answered in-clude what are the best forms of treatment forethnic minority populations and whether cul-tural competency interventions add to positivetreatment outcomes.

In the mental health field, widespread at-tempts have been made to define the best formsof treatment. Outcomes of mental health careare evaluated through two types of research,efficacy and effectiveness studies (Mirandaet al. 2005). Efficacy studies, or randomized,

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controlled trials, are valuable in determiningthe treatment factors that determine outcomes.They are designed to maximize internal va-lidity and are rigorously conducted, often instrictly controlled settings. Effectiveness re-search is typically conducted in more real-lifesituations and may not achieve the rigor andcontrols found in efficacy studies. It often pro-vides greater external validity than internal va-lidity compared to efficacy studies. Efficacy andeffectiveness research is used to guide treatmentrecommendations. The use of research to es-tablish best practices has resulted in the desig-nation of evidence-based practices (EBPs) andempirically supported treatments (ESTs). EBPsare those psychotherapeutic practices that havedemonstrated value through either effective-ness or efficacy research. ESTs are certain typesof EBPs that have been shown through rigorousefficacy research to result in positive outcomes.However, little research has been conducted onthe value of EBPs and ESTs for ethnic minor-ity populations (Constantine et al. 2008). Aslate as 1996, Chambless and colleagues (1996)could not find even one EST study that an-alyzed ethnicity as a variable. More recently,Mak et al. (2007) conducted a review of clin-ical trial studies. They found that most of thestudies reported gender information, and gen-der representation was balanced across stud-ies. However, less than half of the studies pro-vided complete racial/ethnic information withrespect to their samples. Except for whitesand African Americans, all racial/ethnic groupswere underrepresented, and less than half ofthe studies had potential for subgroup analysesby gender and race/ethnicity (Mak et al. 2007).Given the paucity of research, the external va-lidity of EBPs has not been clearly established(Whaley & Davis 2007). The lack of researchhas led many to conclude that the answers arestill unclear as to whether EBPs and ESTs areeffective with these populations and the condi-tions under which such treatments are benefi-cial (Castro et al. 2004, Sue & Zane 2006).

Studies of treatment and preventive inter-vention effects for ethnic minorities were re-viewed by Miranda et al. (2005). In general,

EBPs: evidence-basedpractices

ESTs: empiricallysupported treatments

their review concluded that EBPs were effec-tive with different ethnic minority groups andethnic minority children and adults for a widerange of mental disorders and problem be-haviors (e.g., depression, anxiety, and familyproblems). A meta-analysis of evidence-basedtreatments for ethnic minority youths was con-ducted by Huey & Polo (2008). They found thatthese interventions produced positive overalltreatment effects of medium magnitude. How-ever, the investigators raised the possibility thatthe EBPs and ESTs may sometimes have in-cluded cultural adaptations such as performingthe interventions in the cultural context of theclient, using the client’s ethnic language, or in-tegrating cultural elements. We do not knowthe extent to which research studies use cultur-ally adapted elements but fail to report them.Given the preponderance of evidence that EBPsand ESTs are often effective, are culturally com-petent adaptations needed?

DO CULTURAL COMPETENCYADAPTATIONS DEMONSTRATEPOSITIVE AND INCREMENTALEFFECTS ON TREATMENT?

What does research reveal about the effects ofcultural competency interventions? Two meta-analyses are pertinent to this question. Griner& Smith (2006) directly examined the effectsof cultural competency interventions. Huey &Polo (2008) confined their meta-analysis to eth-nic minority youths and indirectly addressedthe question after examining the outcomesof evidence-based treatments (and not neces-sarily cultural-competency studies) for ethnicminority youths.

Because Griner & Smith (2006) is the onlymeta-analysis to date that has examined the ef-fects of culturally competent interventions, wewant to elaborate on its findings. Their meta-analysis revealed that there are controlled, ex-perimental studies of cultural competency. Formore than two decades, such studies have ap-peared, albeit few in number and varying inmethodological soundness. Studies includedin their meta-analysis largely involved the


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comparison of culturally adapted mental healthinterventions to traditional mental health in-terventions. Griner & Smith (2006) identified76 studies. Their analysis revealed a moder-ate effect size for culturally competent inter-ventions [the random effects weighted aver-age effect size was d = 0.45 (SE = 0.04,p < 0.0001), with a 95% confidence intervalof d = 0.36 to d = 0.53. The data consistedof 72 nonzero effect sizes, of which 68 (94%)were positive and 4 (6%) were negative. Effectsizes ranged from d = −0.48 to d = 2.7].

Importantly, Griner & Smith (2006) at-tempted to control for or clarify the effects ofother possible confounding variables.

(a) Publication bias (e.g., studies with statisti-cally significant results are more likely tobe published than are studies with statis-tically nonsignificant results). Their anal-ysis indicated that publication bias doesnot appear to be a substantial threat tothe results obtained in the meta-analysis.

(b) Participant characteristics (i.e., partici-pant age, clinical status, gender, ethnicity,and level of acculturation). Older individ-uals had higher effect sizes than youngerpersons. In general, ethnicity of the clientdid not moderate the results obtained. Inaddition, for Hispanic clients, ethnicitytended to interact with acculturation inthat low levels of acculturation appearedto profit greatly from culturally compe-tent interventions.

(c) Research procedures (e.g., experimentalversus single-group designs). Overall re-sults were not altered by studies that var-ied as to the research design, inclusion ofcontrol groups, or nature of the controlgroup.

(d) Type of cultural adaptations. Some stud-ies involved individual therapy whereasmany others involved group interven-tions or a combination of the two. Theformat of the intervention did not mod-erate the overall results, nor did the du-ration of interventions. However, stud-ies that were focused on one ethnic/racialpopulation yielded higher effect sizes

than those in which mixed racial popu-lations were included. Studies in whichthere were no reports of attempting tomatch clients and therapists based on eth-nicity had average effect sizes that werehigher than those of studies in whichethnic matching was generally attempted(but not consistently conducted). Studiesin which the client was matched with atherapist based on language (if other thanEnglish) had outcomes that were twiceas effective as were studies that did notmatch language.

The contribution of Griner & Smith (2006)is highly significant. Not only do they provideevidence for the value of cultural competency,but they also examine possible confoundingeffects associated with cultural competency.As recognized by the investigators, theirmeta-analysis was the first one to be appliedto cultural competency studies. Therefore, itincluded all research reports available, regard-less of quality and rigor. Indeed, the reportsvaried considerably in terms of populationstudied (problems/disorders, age groups,ethnicity, etc.), methodology (random versusnonrandom assignment to treatment/controlconditions, follow-up design, measures used,etc.), and type of treatment (e.g., from Englishtranslations of materials to contextual changesin the setting of treatment). Given the diversityof the studies, cultural competency has positiveeffects on treatment outcomes even thoughthe precise factors that account for the effectscannot be easily specified at this time.

Three positions, ranging in favorability tocultural competency adaptations, have been ar-ticulated from reviews. First, Griner & Smith(2006) conclude in their meta-analysis that cul-tural competency interventions have a moder-ate positive effect. Second, Miranda et al. (2005)take a more cautious position because of thelack of adequate tests for cultural competencyeffects. Nevertheless, they state, “In the absenceof efficacy studies, the combined used of pro-tocols or guidelines that consider culture andcontext with evidence-based care is likely to

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facilitate engagement in treatment and prob-ably to enhance outcomes.” Third, in contrastto the conclusions of Smith & Griner (2006),Huey & Polo (2008) state in their meta-analysis:

. . . there is no compelling evidence as yetthat these adaptations actually promote betterclinical outcomes for ethnic minority youth.Overemphasizing the use of conceptually ap-pealing but untested cultural modificationscould inadvertently lead to inefficiencies in theconduct of treatment with ethnic minorities.

Thus, the most discrepant conclusions arederived from the two meta-analyses. The differ-ing conclusions may simply be the result of thenature of the studies. Griner & Smith (2006)included interventions with adults and chil-dren, whereas Huey & Polo (2008) focused onchildren and youths. Interestingly, little over-lap exists in the cultural competency adapta-tion studies that were included in their re-spective meta-analyses, even when one takesinto account the dissimilar time periods forthe reviews. This may reflect different inclu-sion/exclusion criteria used in the two meta-analyses. In addition, differences may exist inhow the studies are interpreted. The relativelyfew rigorous studies that directly compare cul-turally adapted interventions with noncultur-ally adapted interventions also add to the prob-lems in trying to draw conclusions. Two studies(Kohn et al. 2002, Miranda et al. 2003a) com-paring culturally adapted CBT with noncultur-ally adapted CBT demonstrated the superiorityof the cultural interventions. Finally, it is pos-sible that interventions not considered cultur-ally adapted may contain cultural features. Asmentioned above, treatments may include dis-cussions of cultural content even though theyare not intended to be culturally adapted inter-ventions. Or the treatments (e.g., CBT) may beinherently consistent with one’s cultural orien-tation, as argued by Rossello et al. (2008). Ineither case, the manipulation of “not adapted”may be contaminated.

FINAL THOUGHTS

1. The preponderance of evidence showsthat culturally adapted interventions pro-vide benefit to intervention outcomes.This added value is more apparent in theresearch on adults than on children oryouths. The additive effect of culturallyadapted interventions is consistent withresearch examining the extent to whichan intervention is implemented accord-ing to its original design, namely, its fi-delity or is adapted. Blakely et al. (1987)found that adaptations involving addingcertain features to an intervention weremore effective than were adaptations in-volving replacing a component of theintervention.

2. Culturally competent interventions covera whole range of activities (e.g., languagematch, discussions of cultural issues, anddelivery of treatment in a culturally con-sistent manner).

3. Given the relatively few empirical stud-ies of cultural competency, more researchis needed, especially randomized clini-cal trials and “unpackaging” research thatexamines which cultural adaptations areeffective.

4. Therapist, client, and intervention factorsprobably influence who is most likely tobenefit from specific culturally adaptedinterventions. For example, cultural com-petency methods are probably more im-portant with unacculturated than withacculturated ethnic minority clients. In-dividual differences as well as ethnic andcultural differences should be consideredin the nature of the intervention deliverystyles and content.

5. Little consensus currently exists as towhen to use cultural interventions. Somebelieve that all interventions should beculturally competent in that therapistsneed to have appropriate cultural aware-ness, knowledge, and skills to work withclients. The kind-of-person model for


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cultural competency argues for culturalcompetency as an integral part of anytreatment. For other multicultural-ists, cultural interventions should beintroduced under certain conditions.Leong & Lee (2006) have developeda model intended to identify culturalgaps in particular treatments and then toadopt adaptations that address the gaps.Lau (2006) maintains that culturallyadapted treatments should be judiciouslyapplied and are warranted (a) if evidenceexists that a particular clinical problemencountered by a client emerges within adistinct set of risk and resilience factors ina given ethnic community or (b) if clientsfrom a given ethnic community respondpoorly to certain EBT approaches. Inother words, cultural adaptations to EBTshould be used if the problems encoun-tered by individuals are influenced bymembership in a particular (e.g., ethnicminority) community or if members ofthat community respond poorly to a stan-dard EBT treatment. Similarly, Zavfert(2008) proposes that an ideographic ap-proach should be taken that would rely onassessment of key cultural factors that areempirically determined to be most rele-vant to development and maintenance ofa particular problem. When specifyingculturally competent adaptations, theparticular cultural factors affecting theclient are considered as well as individualdifferences in acculturation, experientialbackground, type of disorder, etc.

6. A major disconnect appears to exist be-tween cultural competency guidelines orrecommendations and psychotherapy re-search examining cultural issues in treat-ment. The former has tended to fo-cus on characteristics, values, attitudes,and skills on the part of the therapistthat can minimize the social and cul-tural distance between care provider andclient, whereas the latter has tended to ex-amine changes in treatment proceduresand content that more adequately ad-

dress the cultural experiences of ethnicminority clients. This difference in em-phasis on therapist adaptation as opposedto treatment adaptation may partially ac-count for the slow progress made indeveloping culturally competent mentalhealth care. Norcross & Goldfried (1992)found that therapist and relationship fac-tors accounted for 30% of the improve-ment in psychotherapy patients, whereasclient, family, and other environmentalfactors accounted for 40%. Specific treat-ment techniques when combined withthe expectancy factors commonly associ-ated with placebo effects accounted forthe other 30% of improvement. This re-search strongly suggests that both ther-apist and treatment adaptations warrantattention in cultural competency studies.Clearly, research is needed that investi-gates how these two types of adaptationsinteract and the separate and combinedeffects they have on treatment outcomes.For example, in most treatment adapta-tion studies, the level of therapist skill re-lated to cultural competency is unknownor not assessed. On the other hand, whentherapist cultural competency skills areexamined, it is unclear if therapists whoare deemed culturally competent alsomay be using certain cultural adaptationsin their treatment practices. At the veryleast, these types of adaptations must beexamined or controlled for if research oncultural competence is to proceed in amore informed manner.

7. Finally, the evaluation of the extent towhich therapists and interventions ef-fectively address cultural issues is situ-ated in the complex interplay of processesthat account for behavior and attitudinalchange in psychotherapy. We have notedthat theoretical and methodological inad-equacies in psychotherapy research havecombined to perpetuate imprecise mod-els of change. When it is unclear howpeople change in psychotherapy and whatthey have learned in this process, the task

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of identifying those aspects of treatmentthat would make it culturally responsive

or competent becomes even more diffi-cult (Zane & Sue 1991).

SUMMARY POINTS

1. There is a growing movement to make services more culturally competent.

2. Cultural competency has been defined in many different ways, and it has provoked con-siderable controversy over its assumptions, effects, and necessity.

3. Cultural competency interventions have varied considerably, ranging from encompassingan entire treatment program to selected adaptations to existing treatment procedures.

4. Research on cultural competency has increased over time, although research designs havediffered in the degree of rigor.

5. The available evidence indicates that cultural competency in psychological interventionsand treatments is valuable and needed.

FUTURE ISSUESFurther research is needed to answer the following questions.

1. Is cultural competency better conceptualized as a concrete skill that can be learned byanyone or as a complex process that depends on social interactions?

2. Can a theoretical model be devised that explains cultural competency and why it works?

3. Why do research findings on the effects of culturally competent interventions show somuch variability?

4. How can the multicultural guidelines adopted by the American Psychological Associationbe implemented in research, practice, and training?

5. Can universally beneficial treatment strategies (that apply to everyone) versus beneficialculture-specific interventions (that apply to specific populations) be identified?

DISCLOSURE STATEMENT

The authors are not aware of any biases that might be perceived as affecting the objectivity of thisreview.

ACKNOWLEDGMENT

This study was supported in part by the Asian American Center on Disparities Research (NationalInstitute of Mental Health grant 1P50MH073511-01A2).

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AR364-FM ARI 11 November 2008 15:42

Annual Review ofPsychology

Volume 60, 2009Contents

Prefatory

Emotion Theory and Research: Highlights, Unanswered Questions,and Emerging IssuesCarroll E. Izard � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

Concepts and Categories

Concepts and Categories: A Cognitive Neuropsychological PerspectiveBradford Z. Mahon and Alfonso Caramazza � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �27

Judgment and Decision Making

Mindful Judgment and Decision MakingElke U. Weber and Eric J. Johnson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �53

Comparative Psychology

Comparative Social CognitionNathan J. Emery and Nicola S. Clayton � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �87

Development: Learning, Cognition, and Perception

Learning from Others: Children’s Construction of ConceptsSusan A. Gelman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 115

Early and Middle Childhood

Social Withdrawal in ChildhoodKenneth H. Rubin, Robert J. Coplan, and Julie C. Bowker � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 141

Adulthood and Aging

The Adaptive Brain: Aging and Neurocognitive ScaffoldingDenise C. Park and Patricia Reuter-Lorenz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 173

Substance Abuse Disorders

A Tale of Two Systems: Co-Occurring Mental Health and SubstanceAbuse Disorders Treatment for AdolescentsElizabeth H. Hawkins � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 197

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Therapy for Specific Problems

Therapy for Specific Problems: Youth Tobacco CessationSusan J. Curry, Robin J. Mermelstein, and Amy K. Sporer � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 229

Adult Clinical Neuropsychology

Neuropsychological Assessment of DementiaDavid P. Salmon and Mark W. Bondi � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 257

Child Clinical Neuropsychology

Relations Among Speech, Language, and Reading DisordersBruce F. Pennington and Dorothy V.M. Bishop � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 283

Attitude Structure

Political Ideology: Its Structure, Functions, and Elective AffinitiesJohn T. Jost, Christopher M. Federico, and Jaime L. Napier � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 307

Intergroup relations, stigma, stereotyping, prejudice, discrimination

Prejudice Reduction: What Works? A Review and Assessmentof Research and PracticeElizabeth Levy Paluck and Donald P. Green � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 339

Cultural Influences

Personality: The Universal and the Culturally SpecificSteven J. Heine and Emma E. Buchtel � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 369

Community Psychology

Community Psychology: Individuals and Interventions in CommunityContextEdison J. Trickett � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 395

Leadership

Leadership: Current Theories, Research, and Future DirectionsBruce J. Avolio, Fred O. Walumbwa, and Todd J. Weber � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 421

Training and Development

Benefits of Training and Development for Individuals and Teams,Organizations, and SocietyHerman Aguinis and Kurt Kraiger � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 451

Marketing and Consumer Behavior

Conceptual ConsumptionDan Ariely and Michael I. Norton � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 475

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Psychobiological Mechanisms

Health Psychology: Developing Biologically Plausible Models Linkingthe Social World and Physical HealthGregory E. Miller, Edith Chen, and Steve Cole � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 501

Health and Social Systems

The Case for Cultural Competency in Psychotherapeutic InterventionsStanley Sue, Nolan Zane, Gordon C. Nagayama Hall, and Lauren K. Berger � � � � � � � � � � 525

Research Methodology

Missing Data Analysis: Making It Work in the Real WorldJohn W. Graham � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 549

Psychometrics: Analysis of Latent Variables and Hypothetical Constructs

Latent Variable Modeling of Differences and Changes withLongitudinal DataJohn J. McArdle � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 577

Evaluation

The Renaissance of Field Experimentation in Evaluating InterventionsWilliam R. Shadish and Thomas D. Cook � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 607

Timely Topics

Adolescent Romantic RelationshipsW. Andrew Collins, Deborah P. Welsh, and Wyndol Furman � � � � � � � � � � � � � � � � � � � � � � � � � � � � 631

Imitation, Empathy, and Mirror NeuronsMarco Iacoboni � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 653

Predicting Workplace Aggression and ViolenceJulian Barling, Kathryne E. Dupre, and E. Kevin Kelloway � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 671

The Social Brain: Neural Basis of Social KnowledgeRalph Adolphs � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 693

Workplace Victimization: Aggression from the Target’s PerspectiveKarl Aquino and Stefan Thau � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 717

Indexes

Cumulative Index of Contributing Authors, Volumes 50–60 � � � � � � � � � � � � � � � � � � � � � � � � � � � 743

Cumulative Index of Chapter Titles, Volumes 50–60 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 748

Errata

An online log of corrections to Annual Review of Psychology articles may be found athttp://psych.annualreviews.org/errata.shtml

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