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Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Appendix C : Definitions and Measurement of Cross-Cultural Counseling Competencies

Frederick T. L. Leong, Ph.D.
Department of Psychology
Ohio State University

December 1998

Definitions

Multicultural Counseling Versus Cross-cultural Counseling

I believe that it is important to clearly define the constructs under consideration and to differentiate similar but not identical concepts. In our attempts to measure cross-cultural counseling competencies, we need to begin with some definitions and clarifications. First, there has been a tendency in the field to use the terms multicultural counseling and cross-cultural counseling interchangeably. As I have pointed out (Leong, 1994), these are different concepts and the latter term is more appropriate for two different reasons. The first reason has to do with the concept of multicultural which refers to "many cultures". Owing to the multiculturalism movement in the United States, many psychologists and counselors had begun using the term "multicultural counseling" inappropriately to refer to what they do when they work with culturally different clients. They have confused multiculturalism as a social movement with what they do. The more appropriate term is cross-cultural counseling since it accurately describes what they do - a counselor from one particular culture is counseling a client from a different culture.

Multicultural counseling, on the other hand, means counseling with many different cultures and this is rarely what counselors and therapists are doing unless they happened to be conducting group psychotherapy with a culturally heterogeneous group of clients (i.e., counseling with many different cultures). Another exception would be a White European therapist conducting couples therapy with a Hispanic American man married to an African American woman and her co-therapist is an Asian American. Such instances are relatively rare. A White European American counselor seeing an African American client on Monday and a Mexican American client on Wednesday is not conducting "multicultural counseling"; rather she is conducting cross-cultural counseling each time she see a client from a cultural background different from hers. Similarly, a therapist who uses a cognitive-behavioral approach with one client on Monday and a humanistic approach with a different client on Wednesday cannot really claim that he is using a multidimensional eclectic approach to therapy with his clients.

A second and more important reason why we should not use the term multicultural counseling in place of cross-cultural counseling is the nature and extent of our knowledge-base. The majority of the studies that have examined the role of culture and its potential influence on counseling and psychotherapy have been bi-cultural, i.e., it has examined and compared only two cultures. Early research in cross-cultural psychology was heavily influenced by anthropology which tended to study one culture at a time in significant depth. Using this monocultural approach, namely the study of one culture at a time, psychologists would, for example, investigate the nature and existence of schizophrenia in different countries around the world. Cross-cultural psychologists now recognize the extreme limitations of such an approach. This approach not only did not provide for direct comparisons between cultures, which is the primary focus of cross-cultural psychology, but it also provided inferences and conclusions based on implicit and biased assumptions of the investigators who tended to be from the West. This problem in turn gave rise to the second approach in cross-cultural psychology, namely bicultural studies. These studies usually involve directly collecting data from 2 countries and comparing the results (e.g., schizophrenia in Britain and the United States). The limitations of this approach is that later studies could not be easily compared to earlier studies since different instruments, sampling procedures, and designs may have been used even though the same topic was studied in many different bicultural studies. The ideal approach in cross-cultural psychology was of course, the multicultural study, where 3 or more cultures were studied using the same design, instruments, and procedures. The more cultures that were included the better. However, these studies tend to be very expensive to undertake and there are only a handful of them in the cross-cultural psychological literature.

The implications of this methodological dilemma (i.e., multicultural studies are best but too expensive for most investigators to undertake) is that much of the knowledge-base on which cross-cultural psychology in general and cross-cultural counseling in particular is discussed and debated is derived mainly from bicultural and not multicultural studies. This predominance of bicultural studies (only two cultural groups) is also true for racial and ethnic minority psychology. Cultural diversity in the United States is usually represented by five major cultural groups. These groups include White-European Americans, African Americans, Hispanic Americans, Asian Americans, and American Indians. There are actually very few psychological studies of all five groups together using the same design, instruments, and procedures. In fact, most of the studies use the bicultural approach where only 2 groups are compared. Even worse, the typical comparison group is between White-European Americans and African Americans or between White-European Americans and Hispanic Americans. There are actually very few studies comparing African Americans with Hispanic Americans and comparing Hispanic Americans with Asian Americans. In summary, we do not have a knowledge-base to guide multicultural counseling since there are very few multicultural studies.

Cultural Competence Versus Cross-cultural Competence

A second definition problem has to do with the concept of cultural competence versus cross-cultural competence. Most White-European American counselors and psychotherapists have always been a culturally competent psychologists. To be culturally competent is to be able to adapt and function effectively in one's culture. In the same way, African American counselors and psychotherapists are also culturally competent psychologists with reference with their African American cultural heritage. So, the problem is not with cultural competence but with limited cross-cultural competence, i.e., the knowledge and skills to relate and communicate effectively with someone from another culture different from your own.

White-European American psychology has always been a Eurocentric paradigm. his characteristic is not a flaw in and of itself any more that an Afrocentric psychology or an Asian-centered psychology is inherently flawed. No, the first major flaw in White American psychology is not that it is Eurocentric, rather it is that it does not often realize nor acknowledge that it is Eurocentric. The second major flaw is that American psychology operates on the assumption that its theories, scientific data, and formulations are universal when in reality it is quite Eurocentric. In other words, White American psychology not only believes that its culture-specific theories and data are universal, it actively intervenes in the lives and societies of those who are culturally-different with these mistaken or at best untested theories and models.

In essence, White American psychology is a culturally competent psychology on a WITHIN-culture level, namely, its theories and interventions are quite effective and appropriate for White European Americans. However, it is not a culturally competent psychology when it comes to an ACROSS-culture dimension. Hence, as pointed out by Tony Marsella and Paul Pedersen, White-American psychology, as it currently exists, violates it own ethical codes whenever it crosses cultural boundaries without the requisite training and competencies in cross-cultural psychology, and White cultural competence is concerned with how White American psychotherapists can function with White American clients or African American psychotherapists can function with African American clients, cross-cultural competence is concerned with how and whether White American psychotherapists can function effectively with White American clients or vice versa. In other words, what we need to research and measure is NOT cultural competence but cross-cultural competence.

Measurement of Cross-cultural Counseling Competencies

Conceptual Model

In discussing the measurement of cross-cultural counseling competencies, it would be useful to have a conceptual model to guide those discussions. Fortunately, there is a well articulated model for examining cross-cultural counseling competencies. This model was first specified in the position paper on Cross-Cultural Counseling Competencies commissioned by the Division of Counseling Psychology (Division 17) of the American Psychological Association and published in 1982 in The Counseling Psychologist, the Division 17 journal. This model which is the most comprehensive statement to date on the topic of cross-cultural counseling competencies has also generated the most empirical research. It has also undergone some expansion and elaboration (see Pope-Davis & Coleman, 1997; Sue, Carter, Casas, Fouad, Ivey, Jensen, LaFromboise, Manese, Ponterotto, Vazquez-Nuttall ,1998 ).

The Division 17 position paper identified three dimension of cross-cultural counseling competence, Awareness, Knowledge, and Skills. Awareness refers to the counselor's awareness of his or her own cultural background and how this may bias or skew his perception of the client's experiences and problems due to the client's different cultural background. It requires sensitivity to these cultural differences in the client's attitudes, beliefs and values and the important role these differences may play in the counseling relationship. Knowledge refers to the cross-cultural knowledge that the counselor needs to acquire about client's from different cultural backgrounds so that he or she can work effectively with a range of clients. Skills refer to the special abilities that counselors have acquired in order to work effectively with culturally different clients in providing therapeutic interventions that are culturally relevant and culturally effective. Next, we will provide a quick overview of the different instruments that have been developed to measure these cross-cultural counseling competencies. As indicated below, many of these instruments were developed on the basis of the conceptual model proposed in the Division 17 position paper.

Awareness: Attitudes and Beliefs

All three of the instruments reviewed below for the knowledge and skills dimension also contain measures of the awareness dimension. It is assumed that certain attitudes and beliefs may serve as barriers to counselors developing an awareness of the importance of cross-cultural difference and their impact on both the process and outcome of counseling. A discussion of some of the psychological attitudes and beliefs that may serve as barriers are discussed by Leong and Santiago-Rivera (1998). Items that measure this dimension of awareness try to identify these attitudes and beliefs serving as barriers.

A broader approach to this awareness dimension is provided by John Berry and his colleagues (Berry & Kalin, 1995). As mentioned above, there has been a increasing attention to cultural pluralism or multiculturalism as either a national policy or an educational philosophy. For two decades now, Berry and his colleagues have been measuring the multicultural ideology of Canadian citizens. Similar studies have been conducted in the United States. These attitudes towards creating and supporting a culturally pluralistic society has been measured by Berry and his colleagues by using their scale of multicultural ideology in national surveys.

The Multicultural Ideology Scale (MIS) assesses "support for having a totally diverse society in which ethnocultural groups maintain and share their culture with others". It consists 10 items, with five items in a negative direction five in the positive direction. Of these 5 negative items, 2 advocate assimilation ideology, 1 advocates segregation and 2 claim that diversity weakens unity. An example of an item supporting multiculturalism is as follows: "Recognizing that cultural and racial diversity is a fundamental characteristic of Canadian society". An item representing opposition to multiculturalism is as follows: "The unity of this country is weakened by Canadians of different ethnic and cultural backgrounds sticking to their old ways". Berry has found moderate support for multiculturalism in the Canadian population.

This Multicultural Ideology Scale may be a useful measure of support for cultural pluralism in various mental health agencies and training institutions. Unlike the awareness items from the other measures reviewed below, the MIS measures the attitudinal barriers at the institutional and not individual level. As a short measure, it can be used to assess the positive or negative climate in institutions for the support of the development of cross-cultural counseling competencies among its staff or trainees.

Knowledge and Skills

The Cross-cultural Counseling Inventory (CCCI)

The CCCI was developed by LaFromboise, Coleman and Hernandez (1991) to assess counseling effectiveness with culturally diverse clients. The inventory consist of 20 items and is completed by an observer. Using a 6 point Likert type format which ranges from strongly disagree to strongly agree, respondents rate extent to which the inventory items describe the counselor being observed. The CCCI is based on 11 cross-cultural counseling competencies outlined in the Division 17 position paper mentioned above. These competencies are organized around the three dimensions of awareness, knowledge, and skills.

In terms of reliability, the internal consistency of the inventory is adequate ranging from .88 to .92. Using three experts in cross-cultural counseling, inter-rater reliability was found to be around .78. The inter-rater reliability coefficient rose to .84 when one of the problematic vignettes was removed. Content validity was demonstrated when students were able to classify the items from the CCCI into the appropriate dimension (i.e., awareness, knowledge, and skills) with 80 % agreement. Criterion related validity of the CCCI was demonstrated in several studies. Counselors trained in cross-cultural counseling received higher ratings on the CCCI than counselors who did not receive such training. Factor analytic studies were able to capture three factors that resemble the three dimensions outlined in the Division 17 position paper.

Examples of items from the CCCI include the following: (a) Counselor is aware of how own values might affect the clients (awareness item), (b) Counselor demonstrates knowledge about client's culture (knowledge item), (c) Counselor is willing to suggest referral when cultural differences are extensive (skill item).

Multicultural Counseling Awareness Scale (MCAS)

The MCAS is a 45 item self-report scale developed by Ponterotto and his colleagues in 1991 to measure the three dimensions of the Division 17 position paper. The scale uses a 7 point Likert type format to measure knowledge, skills, and awareness with responses ranging from "not at all true" to "totally true". The scale in the accompanying demographic crushed man requires 1525 minutes to complete the scale is a revised version of the 70 item prototype multicultural counseling awareness scale developed by Pont Toronto in 1991. Like the CCCI, the MCAS is conceptually based on the Division 17 competency report . But unlike the CCCI, it is a self-report measure that counselors complete on themselves.

Using item analysis and sequential factor analysis procedures, an original 70 item version was reduced to the final 45 item version. Unlike the CCCI, the MCAS does include several (3) social desirability items. This is particularly important with a self-report measure of counselor competencies within uses like items for revised scale. The remaining 41 are divided into 12 items related to awareness and 29 items pertaining to knowledge and skills.

The reliability of the MCAS is quite acceptable with coefficient alphas around .93 for the full scale. The alpha for the knowledge and skills factor scale was also .93 while the alpha for the awareness factor scale was lower at .78. Other studies have found similar levels of internal consistency with the knowledge and skills factor around .92 and the awareness factor at .72.

In terms of validity, content validity was established by experts judgment of the items in terms of clarity and conciseness and domain appropriateness. Unlike the CCCI, factor analytic studies of the MCAS found that the two factor solution worked best with one factor measuring knowledge and skills (eigen value of 14.4) while a second factor represented awareness (eigen value of 5.2). In terms of criterion related validity, studies found that Ph.D. double respondents scored significantly higher than Masters and Bachelors level respondents on both subscales (knowledge/skills and awareness). It was also found that a sample of national experts scored significantly higher than did both the practicing school counselors and graduate student samples on both knowledge/skills and awareness factors on the MCAS. Furthermore, respondents who had completed a multicultural workshop or received supervised clinical training with the minority clients scored significantly higher on the knowledge/skills factor than those who did not.

Example of items from the MCAS include the following: (a) I feel all the recent attention directed towards multicultural issues in counseling is overdone and not really warranted (awareness item), (b) I am knowledgeable of acculturation models for various ethnic minority groups (knowledge/skill item), and (c) At this point in my professional development, I feel I could benefit little from clinical supervision of my multicultural client case load (social desirability item).

Multicultural Counseling Inventory (MCI)

The MCI was developed by Sodowski and her colleagues (1994). Like the MCAS, it is also a self-report measure and consists of 43 statements measuring cross-cultural counseling competencies across the three dimensions. Using a 4-point Likert scale format, respondents indicate the extent of accuracy of the statements in relation their own work as counselors, psychologists, or trainees. Responses can range from "very inaccurate" to "very accurate". It can be completed in approximately 15 to 25 minutes. Like the CCCI and MCAS, the MCI is based conceptually on the Division 17 position paper and the delineated three categories of competencies. Unlike the previous measures, the MCI has four subscales: (a) Multicultural counseling skills ( 14 items), (b) Multicultural awareness (10 items), and (c) Multicultural counseling knowledge (11 items) and (d) Multicultural counseling relationship (8 items). The unique feature of the MCI is the focus on the multicultural counseling relationship in the fourth subscale. The subscale measures the counselor's stereotypes of ethnic minorities and their comfort level with these clients.

In terms of reliability, the internal consistency coefficient alphas for the MCI is quite acceptable. In one study, the total scale alpha was .90 while the multicultural counseling skills factor alpha was .83; the multicultural awareness factor was also .83; the multicultural counseling knowledge factor was.79, and the multicultural counseling relationship was .71. Content validity of the MCI was demonstrated by expert judgment of item clarity and content. Inter-rater agreement among these experts were high ranging from 75 to 100 percent. Using counselors who had worked 50 percent or more in the multicultural areas, criterion related validity was demonstrated when these counselors scored significantly higher on the multicultural awareness and multicultural counseling relationship factors than those respondents who had worked consistently with less than 50 percent minority client load service agencies. Further evidence of criterion-related validity was found when 42 graduate students in counseling scored significantly higher at post test on three of the MCI scales after completing a one semester multicultural course than those who had not. In terms of the factor structure of the MCI, the four factor model was the most interpretable.

Examples of items from the MCI include the following: (a) When working with minority clients, I have experience at solving problems in unfamiliar settings (awareness item), (b) When working with minority clients, I form effective working relationships with the clients (skill item), (c) When working with minority clients, I use innovative concepts and treatment methods (knowledge item), and (d) When working with minority clients, I perceive that my race causes the clients to mistrust me (relationship item).

Multicultural Awareness Knowledge and Skills Survey (MAKSS)

The MAKSS was designed by D'Andrea, Daniels and Heck (1991) to assess the effectiveness of training students in cross-cultural counseling. It is also a self-report measure consisting of 60 survey items that cover the three dimensions of awareness, knowledge, and skills. While it has some evidence of reliability (alphas ranging from .75 to .96), it has the least supporting research in terms of validity. Due to this limited research, the MAKSS cannot be recommended at this point and will not be reviewed further.

Conclusion: Some Caveats

It is promising that there are now several instruments available to us to measure the various dimensions of cross-cultural counseling competencies. However, in presenting these measures, I also feel that we need to recognize some of the limitations in these measures. First, there is a difference between interpersonal versus therapeutic cross-cultural competencies. The former refers to a set of interpersonal knowledge and skills that enables a person to related effectively with a person from a different culture. This is the same set of interpersonal cross-cultural competencies that many of the workshops and training programs are providing to the managers and supervisors in order for them to work effectively with co-workers and subordinates from many different cultures. Such interpersonal cross-cultural competencies are also useful to counselors and psychotherapists but primarily in the relationship building aspects of the therapy and early on in the counseling relationship. Therapeutic cross-cultural competencies refer to the set of knowledge and skills that a counselor must have in order to intervene effectively with the client's problem in light of his or her cultural background. This set of competencies involve how culture actually affects diagnosis, etiology and presentation of psychopathology, client's conceptualization of mental illness, and the treatment process itself. Unfortunately, our research and theoretical advances have primarily been focused on the interpersonal cross-cultural competencies and much less so on the therapeutic cross-cultural competencies.

Relatedly, it is not surprising then that many of the instruments reviewed above are more concerned with these relationship building elements in the cross-cultural counseling encounter than the actual treatment process. To-date, there have been very few cross-cultural counseling process studies to help delineate what actually happens in cross-cultural counseling relationships beyond the initial few sessions. Instead, most of these studies have been based on analog designs rather than clinical field studies with real clients being treated by practicing counselors and therapists. Furthermore, there is even more limited linkage between these cross-cultural counseling measures and actual counseling outcomes. There are even fewer studies of counseling outcomes in cross-cultural counseling relationships than studies of the counseling process.

There is also the problem of the distinction between knowledge and skills in cross-cultural counseling competencies as delineated in the conceptual model (Division 17 position paper). This model differentiates between knowledge and skills. Conceptually, this distinction makes sense since it is quite possible that a newly trained counselor or psychologist having been exposed to good training program would possess the knowledge about cross-cultural counseling but not the skills. It is only with extended application of this knowledge with real life clients that such skills develop. Yet, at least one of the instruments find that these two dimensions are combined for their respondents (i.e., knowledge and skills are not qualitatively different). For the other measures, I suspect that the skills dimension is being measured at a global and generic level and does not represent a well sampled domain. One just has to review some of the items representative of the skills domain to see how global and non-specific there are. This problem is probably due to the fact that we have not conducted many empirical studies into the actual counseling process in cross-cultural counseling dyads to identify the relevant elements to be measured. As such, our current measurement of cross-cultural counseling skills are quite crude and of unknown predictive validity in relation to actual counseling outcomes.

Finally, it should be pointed out that the two major problems in providing effective mental health services to racial/ethnic and cultural minorities is that of these groups' underutilization of mental health services and their premature termination from such services when they do seek help for their psychological problems. The measures reviewed in this paper only addresses the latter problem (i.e., to minimize ethnic minority clients' premature termination from treatment). This cross-cultural competencies approach, represented by the conceptual model (Division 17 position paper) and the measures reviewed in this paper, is concerned mainly with engaging culturally different clients and minimizing premature termination. There is still the need to address second half of problem, namely underutilization of mental health services by racial and ethnic minorities.

References

Berry, J.W., & Kalin, R. (1995). Multicultural and ethnic attitudes in Canada. Canadian Journal of Behavioral Science, 27, 301-320.

D'Andrea, M., Daniels, J. & Heck, R. (1991). Evaluating the impact of multicultural counseling training. Journal Counseling and Development, 70, 143- 150. LaFromboise, T.D., Coleman, H. & Hernandez, A. ( 1991). Development and factor structure of the cross-cultural counseling inventory-revised. Professional Psychology: Research and Practice, 22, 380-388.

Leong, F.T.L. (1994). Emergence of the cultural dimension: The role and impact of culture on counseling supervision. Counselor Education and Supervision, 34,115-116. (Introduction to special section: Cross-cultural counseling supervision).

Leong, F.T.L. & Santiago-Rivera, A. (1998). Climbing the multiculturalism summit: Challenges and pitfalls. In P. Pedersen (Ed.), Multiculturalism as a fourth force. Washington, D.C.: Taylor & Francis.

Ponterotto, J.G., Rieger, B.P., Barrett, A., & Sparks, R. (1994). Assessing multicultural counseling competence: A review all instrumentation. Journal of Counseling and Development, 72, 316-322.

Pope-Davis, D.B. & Coleman, H.L.K. (1997). Multicultural counseling competencies: assessment, education and training, and supervision. Thousand Oaks, CA: Sage publications.

Sodowsky, G.R., Taffe, R.C., Gutkin, T.B., & Wise, S.L. (1994). Development of the multicultural counseling inventory: itself report measure of multicultural competencies. Journal Counseling Psychology, 41, 137-148.

Sue, D.W., Bernier, J.E., Durran, A., Feinberg, L., Pedersen, P., Smith, E., & Vazquez-Nutall, E. (1982). Position paper: cross-cultural counseling competencies. The Counseling Psychologist, 10, 45- 52.

Sue, D.W., Carter, R.T., Casas, J.M., Fouad, N.A., Ivey, A.E., Jensen, M., LaFromboise, T., Manese, J.E., Ponterotto, J.G., & Vazquez-Nuttall, E. (1998). Multicultural counseling competencies: Individual and organizational development. Thousand Oaks, CA: Sage publications.

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