Cross-Cultural Practice: Assessment, Treatment, and Training

Attention to cultural influences on clinical assessment, therapeutic interventions, and supervision has grown considerably in recent years but still lags far behind other curricular components of training programs for mental health professionals in the United States. The inadequacy of this situation becomes more glaring in the light of the growing numbers of ethnic minorities in the United States, especially in urban settings, where most training centers are located. In another 50 years, about half of the U.S. population is projected to be of minority background (1). Despite recent activity by accrediting professional organizations, training in cultural competence will need to be stepped up considerably to meet this linguistic and cultural challenge. Under the best of circumstances, achieving cultural competence will still be hampered by limited research in key areas of clinical work, such as cultural and socioeconomic determinants of childhood psychopathology, personality disorders, treatment outcomes, and help-seeking and compliance patterns, to name a few. Obviously, research efforts will need to be stepped up as well.

Drs. Gopaul-McNicol and Brice-Baker are well aware of the need for educational materials on cultural competence aimed at mental health trainees and clinicians. Their response is this short guidebook, which culls the counseling psychology literature for general instructions on how to augment clinical skills in the evaluation and treatment of patients from diverse cultural backgrounds. The core of the book consists of three sections focusing on assessment, treatment, and training issues. The Assessment section has chapters on the culturally competent evaluation of children, parenting skills of culturally diverse families, and couples of mixed ethnicity or culture. The Treatment section presents a therapeutic modality created by Dr. Gopaul-McNicol called the multicultural/multimodal/multisystems approach. It consists of an exhaustive synthesis of various systems and family therapies aimed at identifying and incorporating cultural information about the patient and his or her family and community into a treatment approach in four phases—the initial assessment and three forms of intervention: educational, psychological, and empowerment. The last section, Training, outlines key components of a culturally competent curriculum and issues involved in interethnic supervision.

The book is at its best when the authors rely on their extensive clinical background to explore the evaluation and treatment of culturally diverse children and families. Whether for the presentation of comprehensive clinical approaches or the description of key components of a culturally competent clinical curriculum, the book should be read for its clinical insights. For example, clinicians familiar with the limitations of standardized testing among minority children will appreciate the authors’ review of a “bio-ecological approach” that augments psychometric tests with qualitative observations based on real-life applications of intellectual capacities. Those with experience treating immigrant families will recognize the heuristic value of systematizing the multiple hats worn by the clinician (“coach,” legal advisor, therapist, etc.) into a relatively coherent approach, such as the multicultural/multimodal/multisystems approach. Perhaps the best parts of the book are the series of questions raised by the authors in every chapter, thoughtfully guiding the clinician into potentially new areas of clinical exploration.

The major limitation of the book lies in its narrow focus. It is mostly a series of “how-to” instructions, with shallow support from the research literature. Major works in cultural psychiatry and psychology are omitted, sometimes glaringly, such as the work of Szapocnik and colleagues on culturally competent family therapy (2) and the complex body of work on “culture-bound syndromes,” which are presented by the authors in a truncated and often inaccurate fashion. In addition, insufficient attention is paid to issues of socioeconomic status, which tend to confound some of the clinical differences usually ascribed to cultural background. Finally, careful depiction of intraethnic differences is not uniform, resulting at times in somewhat idealized assessments about “many ‘third-world’ countries,” where, for example, “parents and elders are well respected” (p. 15), societies are “homogeneous” and racism is less common (p. 16), or a child’s “excess activity is not perceived as negative” (p. 18). At other times, intraethnic particularities are usefully heightened, such as the importance of identifying distinct cultural influences affecting West Indian immigrant children compared with United States-born African Americans.

No single text can cover the range of material necessary for developing cultural competence in mental health practice. One key point made by the authors, illustrated unintentionally in the limitations of their own work, is precisely the variety of subjects that need to be mastered by clinicians in the process of becoming culturally competent. This book is useful because of its thoughtful clinical insights on topics that should definitely form part of the institutional or informal curriculum of clinicians desiring to augment their cultural competence in order to meet one of the major challenges facing current mental health practice.