In Review
Culturally Competent Psychotherapy
Hung-Tat Lo, MB, BS, MRCPsych, FRCPC1, Kenneth P Fung, MD FRCPC2
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To provide effective psychotherapy for culturally different patients, therapists need to attain cultural competence, which can be divided broadly into the 2 intersecting dimensions of generic and specific cultural competencies. Generic cultural competence includes the knowledge and skill set necessary to work effectively in any cross-cultural therapeutic encounter. For each phase of psychotherapy— preengagement, engagement, assessment and feedback, treatment, and termination—we discuss clinically relevant generic cultural issues under the following headings: therapist, patient, family or group, and technique. Specific cultural competence enables therapists to work effectively with a specific ethnocultural community and also affects each phase of psychotherapy. A comprehensive assessment and treatment approach is required to consider the specific effects of culture on the patient. Cultural analysis (CA) elaborates the DSM-IV cultural formulation, tailoring it for psychotherapy; it is a clinical tool developed to help therapists systematically review and generate hypotheses regarding cultural influences on the patient’s psychological world. CA examines issues under 3 domains: self, relations, and treatment. We present a case to illustrate the influence of culture on patient presentation, diagnosis, CA, and psychotherapeutic treatment. Successful therapy requires therapists to employ culturally appropriate treatment goals, process, and content. The case also demonstrates various techniques with reference to culture, including countercultural, cultural reinforcing, or culturally congruent strategies and the use of contradictory cultural beliefs. In summary, developing both generic and specific cultural competencies will enhance clinician effectiveness in psychotherapy, as well as in other cross-cultural therapeutic encounters.
(Can J Psychiatry 2003;48:161–170)
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Clinical Implications
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Cultural competence is the product of generic cultural competence and specific cultural competence; both are important in each phase of psychotherapy.
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Systematic consideration of cultural influences on a patient can enhance understanding and facilitate the employment of culturally appropriate psychotherapeutic goals, process, and content.
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Therapists can expand their vision by using cultural knowledge to generate hypotheses and treatment strategies, all of which must always be verified against clinical data to avoid misguided stereotyping.
Limitations
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A validated, comprehensive measure of cultural competence, needed for research and training, is lacking.
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Process and outcomes research in cross-cultural psychotherapy is needed.
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Key Words: cultural competence, cross-cultural, ethnocultural, culture, ethnic, psychotherapy, psychotherapeutic skills, formulation, process, world view
Résumé : Psychothérapie compétente sur le plan culturel
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Psychotherapy is one of the major interventions in psychiatry’s therapeutic armamentarium. Even interventions such as pharmacotherapy have a psychotherapeutic element, although they are not usually considered within the realm of psychotherapy. However, psychotherapy as developed in the West may not be directly applicable in other cultural settings. As North America rapidly becomes more culturally diverse, there is increasing demand for culturally appropriate mental health services. Clinical cultural competence, including the modification of psychotherapy practice to serve the culturally different, is imperative (1,2). A growing body of literature comments on various cultural aspects of psychotherapy (3). We systematically examine this topic according to the competencies required in the various stages and components of therapy.
Figure 1 Generic and specific cultural competence in psychotherapy
Generic and Specific Cultural Competence
The term cultural competence (4) denotes the capacity to perform and obtain positive clinical outcomes in cross-cultural encounters. In considering culturally competent psychotherapy, we will examine the broad field of interactions that influence any sort of primarily verbal exchanges carried out to effect positive change in a patient. There are 2 distinct yet related sets of competencies, each having different training and clinical implications: generic cultural competence is the knowledge and skill set needed in any cross-cultural therapeutic encounter, and specific cultural competence enables clinicians to work effectively with a specific ethnocultural community. To provide culturally competent psychotherapy, both are essential. Schematically, they can be conceptualized as 2 intersecting dimensions: a vertical “generic” axis and a horizontal “specific” axis (Figure 1).
Generic Cultural Competence Axis and Phases of Psychotherapy
Generic cultural competence refers to competence in working with issues that emerge at different phases of psychotherapy, regardless of the cultural group to which a patient belongs. For heuristic purposes, the process of psychotherapy can be divided into the following phases: preengagement, engagement, assessment and feedback, treatment, and termination. Within each phase, we discuss relevant clinical issues in the following areas: therapist, patient, family, and techniques (Table 1).
Preengagement
Factors at work prior to clinical contact may influence the eventual clinical outcome. Working with a culturally different patient places certain demands on the therapist’s skills, some of which may be intuitive, some of which can be learned, and all of which should be considered as essential components of psychotherapeutic training. One such quality is cultural sensitivity, which encompasses attributes such as curiosity, perceptiveness, and respect. Cultural sensitivity is the foundation of cultural competence. The patient’s understanding of the problem is an important factor influencing preengagement. Patients and therapists often have very different explanatory models for an episode of illness. Incongruent understandings of the critical elements of the disorder, its probable etiology, and appropriate solutions can have a profound effect on the clinical encounter (5). The pathway leading to therapy can also influence clinical outcome (6). For example, a patient who has received positive recommendations about a therapist from a community elder may progress more smoothly to the engagement phase than a patient with a cursory referral from a hospital emergency department.
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