Research on therapists’ cultural competence, therapy process in cross-cultural dyads, & cross-cultural differences in gender and sexual orientation

A Knowledge Synthesis of Cross-Cultural Psychotherapy Research: A Critical Review. Eunjung Lee, Andrea Greenblatt, Ran Hu. Journal of Cross-Cultural Psychology, July 7, 2021. https://doi.org/10.1177/00220221211028911

Abstract: This article presents a current knowledge synthesis of empirical studies on cross-cultural psychotherapy since 1980. Guided by a critical review framework, our search in seven relevant databases generated 80 studies published in English. Main themes are organized into (1) therapists’ cultural competence (n = 46); (2) therapy process in cross-cultural dyads (n = 22); and (3) cross-cultural differences in gender, sexual orientation, or social class (n = 12). Compared to previous reviews on cross-cultural psychotherapy, the findings of this review highlight a broad range of methodological rigor in both quantitative and qualitative studies. Most studies examined actual therapy participants rather than participants in analog studies, thus emulating more therapy-near experiences in cross-cultural psychotherapy research. Also, several studies explored cross-cultural compositions beyond racial and ethnic majority therapist-minority client dyads, and included therapists of color as the participants, exploring reverse power dynamics in therapy and giving voices to foreign-born therapists. The therapy process research provides rich and full descriptions around the dynamic and interactional therapy process in cross-cultural dyads, which can be used to foster cultural sensitivities among therapists in their practice and training. We discuss the limitations of the studies included in the review and its implications for psychotherapy practice, training, and future research.

Keywords: cross-cultural competence, cross-cultural psychotherapy process, cultural matching, culturally adapted psychotherapy, multicultural counseling competencies, racial microaggression

Discussion

A critical review does not demonstrate the systematicity of other literature reviews (e.g., a systematic review), thus does not require a formal quality assessment of included studies. Its findings are interpretive and open for “further evaluation, not an endpoint in itself” (Grant & Booth, 2009, p. 97). The current critical review thus provides a renewed understanding of cross-cultural psychotherapy, with the hope that this interpretation yields further inquiries. The current review has several notable contributions to cross-cultural psychotherapy: (1) highlighting the current state of empirical research on cross-cultural psychotherapy using a variety of methods and published in the past 40 years (1980-2019); (2) identifying various cultural compositions of client-therapist dyads that have been studied; (3) giving analytical attention to therapy process factors and micro-analysis of cross-cultural communications, which may sensitize therapists in their interactions with diverse clients in everyday practice; and (4) broadening the construct of culture by raising attention to additional dimensions of culture, such as gender, sexual orientation, or social class, in addition to race and ethnicity.

Overall, research on cultural competence was the most dominant theme identified within the included studies. All studies on cultural competence exclusively focused on racial and ethnic minority clients when examining the impact of therapy approaches. There has been a criticism about how culturally competent therapy (i.e., exclusively focuses on racial and ethnic minority clients and positions therapists in a blank screen) further otherizes racial and ethnic minority clients and reifies Euro-centric notions of psychotherapy (Lee, 2010). In our review, most of the studies attempted to clarify details of demographic information with some variations in its detail except five studies (Cohen, 2016; Goren, 1992; Millard, 2017; Shiner et al., 2017; Ziguras et al., 2003). Although the focus of these studies is on gender, sexual orientation, or class, it also raises some concerns around how culture is conceptualized: understanding gender role in therapy dyads should not be separated from each therapy participant’s cultural values and contexts. Some studies discussed racial and ethnic descriptions of their clients while exploring studies on gender and low income (Wintersteen et al., 2005; Evans et al., 1984; Okun et al., 2017). However, other than using diversity as descriptors of participants, there is little examination of how diversity factors interact with one another and their impact on cross-cultural encounters.

For therapists’ demographic information, some studies expanded on descriptors including the level of clinical training, years of practice experience, exposure to multicultural training, and experiences of working with culturally diverse clients. Paying attention to these therapist factors is promising given the psychotherapy research finding that the therapist factor explains variances in outcomes even in a manualized treatment (Beutler et al., 2016). Also, it highlights that therapist factors are more nuanced than their race, ethnicity, and gender in cross-cultural psychotherapy. Furthermore, all studies exploring therapist factors, such as therapist bias, perceptions, and White identity in cross-cultural or intra-cultural dyads, found that therapists’ responses to clients differ depending on the client’s ethnic identity (i.e., White versus people of color), highlighting the impacts of the therapists’ preconceived notions/biases/White identity on therapeutic relationship building and treatment outcomes (Burkard et al., 1999, 2003; Ridley, 1986; Zane et al., 1994). These studies certainly contribute to current psychotherapy research by de-centering focus solely on racial and ethnic minority clients and re-centering what therapists contribute to cross-cultural encounters in therapy.

Most studies in our review reported minimal information related to the actual implementation of clinical interventions. While 56 studies (70%) mentioned a particular therapy model, most did not provide information such as the total number of sessions, therapists’ therapeutic orientation, and therapy and contents. Only eight studies (Crisante & Ng, 2003; Dansereau et al., 1996; Li & Kim, 2004; Miranda et al., 2003; Moran & Bunn, 2019; Lee & Horvath, 2014; Lee, Tsang, Bogo, Wilson, et al., 2018b; Naeem et al., 2010) provided somewhat detailed therapy descriptions, mainly culturally adaptive or micro-therapy process studies. There are always content variations when applying any therapy model in any therapy dyad composition. If racially matched dyads have better or worse therapy outcomes compared to their counterparts, it would be critical to see under what therapeutic conditions this outcome is valid. Overall, we found a lack of information on the therapy itself, despite the main inquiry being on (cross-cultural) therapy. We wonder if empirical research in cross-cultural psychotherapy may assume the therapy intervention is static while exclusively focusing on demographic cultural differences that exist in therapy dyads. Cultural adaptation is not monolithic but highly multifaceted and contextual. To inform therapists in practice, it would be critical to explicitly document the nature of therapy in future studies.

Recent reviews highlighted the importance of exploring the therapy process in cross-cultural dyads (Worthington et al., 2007; Tao et al., 2018). In our review, we observed increased research on the theme of therapy process in cross-cultural dyads. Specifically, of the 22 studies focused on different therapy process factors in cross-cultural dyads, the majority (71.4%, n = 15) were published after 2010. Untangling complexities among various process factors in cross-cultural dyads, these studies focus on multiple cultural differences that exist between clients and therapists. Some studies focused on process dynamics of White therapists and racial and ethnic minority clients (Burkard et al., 2006; Change & Berk, 2009; Lee & Bhuyan, 2013; Lee & Horvath, 2013, 2014), whereas some explored dynamics of the reverse dyads between therapists of color and White clients (Bayne & Branco, 2018; Okun et al., 2017). Others consider both clients and therapists coming from various cultural diversities (Foster, 2014; Knox et al., 2003; Lee, Tsang, Bogo, Johnstone, et al., 2018a).

In terms of cultural differences residing within therapy dyads, 12.5% of the reviewed studies (n = 10) focused on exploring a process of broaching cultural differences, and others exploring a process of bridging cultural differences. Findings indicated that efforts to bridge, particularly on the part of the therapist, distinguished successful therapy dyads from unsuccessful therapy dyads (e.g., Bayne & Branco, 2017). This demonstrates the critical need to incorporate bridging behaviors into the therapy encounter. In terms of broaching, most studies indicated that not all therapists choose to discuss issues of culture and race with their clients, with several studies noting the negative impacts of racial microaggressions on therapy alliance and outcomes (Foster et al., 2014; Constantine, 2007) yet still little broaching of this experience in therapy (Owen et al., 2014). Further research is needed to examine barriers to broaching within the clinical dyad.

Paying attention to micro-details of cross-cultural encounters in therapy, eight studies of therapy process research utilized audio- and/or video-taped actual therapy sessions (Okun et al., 2017; Lee & Bhuyan, 2013; Lee, Tsang, Bogo, Johnstone, et al., 2018a; Lee, Tsang, Bogo, Wilson, 2018b; Lee et al., 2019; Lee & Horvath, 2013, 2014; Su, 2012). Their findings further demonstrated dynamic processes of cross-cultural interactions. Specifically, these subset studies used naturalistic methods to examine minute-by-minute negotiations within the dyads, allowing for a practical understanding of how culture is negotiated and discussed in cross-cultural clinical encounters that may not be apparent in other forms of research. Instead of focusing on nominal values of race and ethnicity as the parameters of studying cross-cultural competence, these studies pay attention to how differences and similarities are negotiated through a dance of therapy process, which is dynamic, interactive and context-dependent. Using discourse analysis and conversation analysis in process-oriented psychotherapy research may be both methodologically innovative and practically meaningful as these research approaches unveil the complex dynamics of cross-cultural processes.

Our critical review also showed that sexual orientation and class issues were under-conceptualized in studies examining cultural differences in therapy dyads. We found that clients of culturally dominant groups (e.g., heterosexual upper-middle-class men) were rarely perceived as cultural; culture in therapy is positioned as solely linked to the marginalized groups of clients (Moleiro et al., 2018). Despite the importance of clinicians’ self-reflection and capacity to discuss these differences and potential clinical ruptures (Goettsche, 2015), process-oriented psychotherapy research in cross-cultural encounters found that therapists do not often intentionally start conversations with clients about cultural issues (Lee & Horvath, 2013, 2014). For instance, Cohen (2016) found that it is not clinicians but largely clients who initiate conversations about social class and that clinicians typically discuss only the clients’ social class not their own.

Implications for Cross-Cultural Psychotherapy Practice, Training, and Future Research

This review has several implications for practice, training, and research. First, therapists’ self-awareness and critical reflection of their own biases and cultural positions have long been recognized as critical aspects in cross-cultural psychotherapy (Sue et al., 1992). This review revealed that these important tasks of critical reflection are challenging, especially when therapists’ Whiteness and biases are not addressed. Further, not addressing these issues may have detrimental effects on clients, the therapy process, and client outcomes. It is thus critical to continue studying how therapists may engage in critical reflection regularly and identifying approaches that help therapists to mitigate sociocultural biases in their cross-cultural practice.

Second, cultural presentations are subtle and implicitly conveyed, and so it is difficult to illustrate naturally occurring nuanced cultural dynamics and train therapists how to discuss them with clients toward alliance building and achieving therapy goals. Findings from therapy process research provide rich discussion around the complexities of clinical process in cross-cultural dyads. These research examples may work as practice materials to re-script cultural misunderstandings toward repairing alliances in cross-cultural practice and can be used for examples in training therapists, thus closely linking research into practice and education.

Lastly, given the complexities of multiple diversities, clinical dynamics and power are shifting constantly within cross-cultural therapy dyads. With further empirical research on various sources of similarities and differences perceived and experienced by both therapists and clients, we may have more confidence in psychotherapy research being truly cross-cultural.