Collaboration in Multicultural Therapy: Establishing a Strong Therapeutic Alliance Across Cultural Lines

Abstract

Achieving effectiveness of psychotherapy across a diversity of patients continues to be a foremost concern, and the therapy alliance remains a critical component of such favorable outcome across theoretical orientations and treatment formats. This article offers concrete guidance grounded in empirical research on therapist behaviors and treatment features to enhance collaboration in multicultural therapy. This is followed by a multicultural case study of a patient presenting with several co-morbid disorders to exemplify the application of these guidelines over the course of therapy.

The role of culture in psychotherapy has been gaining significant attention in the past few decades, particularly as the populations seeking psychological services grow increasingly diverse. Indeed, an often prominently stated aim of training programs for mental health practitioners includes the need to ensure cultural competency (Heppner, Leong, & Gerstein, 2008). Unfortunately, often this recognized need is insufficiently met because (a) of a lack of a definitive structure and specific goals to achieve this cultural competency in therapists and (b) scant empirical data to support one training model over another (Whaley & Davis, 1997).

At the same time, the importance of establishing a strong relationship with diverse patients and developing a firm therapist-patient alliance remains an overarching goal for practitioners. The contributing and predictive role of a facilitative therapeutic relationship has been empirically demonstrated across theoretical orientations and treatment formats (Norcross, 2011), particularly for clients of historically marginalized populations (Smith, Rodríguez, & Bernal, 2011). In multicultural treatment, establishing working alliance poses specific challenges as compared to traditional conceptions of this important treatment process, given the diversity in social structures and varying importance of hierarchy across cultural groups.

This article therefore aims to provide evidence-based means of enhancing collaboration in the multicultural therapy setting. This is followed by a case study of a patient to exemplify how these features may be incorporated into treatment with a multicultural client, both in terms of establishing a strong working alliance and in terminating treatment.

Multicultural Therapy

We define culture as a system of beliefs, perspectives, and values a group of a particular race/ethnicity or geographic region collectively share. Of course, culture does not work in a vacuum, and Hays (2008) coined an acronym that serves as a reminder to clinicians about the multi-faceted nature of multicultural therapy in terms of what they need to be “ADDRESSING”: Age and generational influences, Developmental disabilities and Disabilities obtained in later life), Religion and spiritual orientation, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender. Such a term captures the complexity of cultural identity and the number of factors to consider when we discuss culture in therapy.

We further define cross-cultural competency as an index of how skilled (a) a clinician feels about his/her abilities to manage cultural issues raised in therapy and (b) a patient perceives the clinician to be to handle such topics in the therapeutic context (Lee, 2011). A survey of 689 licensed psychologists found that although practitioners had discussions during therapy about cross-cultural issues, they did this with less than half of their cross-ethnic/racial clients (Maxie & Arnold, 2006). Therapists most likely to discuss cultural differences with patients were those who were older, female, of nonminority racial status, those who felt they were less experienced with treating diverse clients, and those who felt training is an important feature of effective therapy delivery. To this end, experts in cross-cultural treatment have noted that simply instructing clinicians to be sensitive to cultural differences or to familiarize themselves with the culture-specific norms of clients is insufficient and not particularly beneficial (Sue & Zane, 2009).

The research on the efficacy of culturally responsive therapy is still limited. One meta-analysis examined 65 experimental and quasi-experimental studies (which included 8,620 participants) and revealed a moderate effect size (d = 0.46) in favor of culturally adapted treatments for minority clients of color as compared to traditional treatment procedures (Smith et al., 2011). Results indicated that when mental health treatments were designed to target one particular cultural group, treatment outperformed other treatments serving patients from a variety of cultural backgrounds. Extant research and expert consensus suggest how therapists’ cross-cultural competency may be improved, and how the therapeutic bond may be strengthened in a cross-cultural therapy setting (e.g., Hays, 2009; Norcross, 2011; Sue & Zane, 2009; American Psychological Association, 2002). In what follows, we integrate the common features from these various expert sources into seven guidelines for practitioners.

Conduct a Thorough Culturally Informed But Person-Specific Assessment of Presenting Problem

Before modifying an existing treatment to be more culturally sensitive, therapists should assess how much of the individual patient's presenting problems may be interlinked to his or her cultural identity. That is, clinicians are advised to be wary of premature adoption of a modified treatment simply because an individual is from a particular cultural group (Sue & Zane, 2009). All patients are still regarded as unique individuals who lie on a dynamic spectrum of cultural identification, and cultural groups are most accurately seen as heterogeneous populations with some more or less likely dominant themes. Related to this, before engaging in any adaptation of existing treatment techniques, it is important to gather adequate information about how cultural beliefs are specifically shaping or maintaining problematic emotional symptoms. A clinician is warned against making blanket assumptions about how a specific cultural belief introduced by patients informs their experience of distress. After a comprehensive assessment of the patient's problems, the clinician can consider the remaining guidelines.

Engage in Self-Education About Specific Cultural Norms and Consult the Literature for Culture-Specific Treatments

As the meta-analytic findings by Smith and colleagues (2011) indicate, patients might most benefit from treatments that have been specifically modified for a certain population rather than more generally culture-sensitive treatment techniques. Therapists can first refer to the literature about whether specific cultural adaptations of existing treatments have already been tested and validated (e.g., Latinos: Hinton, Hofmann, Rivra, Otto, & Pollack, 2011; Borrego, 2010; Native Americans: BigFoot & Schmidt, 2009; East Asians: Hinton, Park, Hsia, Hofmann, & Pollack, 2009; Hofmann, Asnaani, & Hinton, 2010; Hwang, Wood, Lin, & Cheung, 2006; Southeast Asians: Hinton et al., 2010; African Americans: Kelly, 2006). Such a review of the literature will enlighten the therapist on what beliefs are the norm of that culture to reduce miscommunication in therapy and will garner patient confidence in the therapist's abilities and knowledge. For instance, such knowledge might inform a practitioner about the appropriateness of self-disclosure in the therapy setting, or how periodic elicitation of feedback during therapy may be received by the client. In cultures where mental health treatment is considered to be a more formal or medical service, self-disclosure might be perceived as unprofessional. Similarly, asking for direct feedback might make the therapist appear either lacking in confidence, or seem punitive towards the patient.

Ensure Effective Training of Therapists in Cross-Cultural Competency

While the literature is mixed, there is some evidence that patients’ perceptions of the therapist's cultural competence can improve the working alliance (e.g., Owen, Leach, Wampold, & Rodolfa, 2010; Maxie & Arnold, 2006). It is certainly not enough to just educate oneself about cultural differences between therapist and client (Sue & Zane, 2009). Rather, therapists need to have a keen awareness of their own cultural and racial identity and develop an understanding for how this may impact their relationship with clients (Plummer, 1997). Practitioners can, for example, discuss their feelings about treating cross-cultural patients with their professional peers or supervisors (Barbarin, 1984) and explore attitudes toward psychological help seeking in their own communities (Chung & Lu, 1996). Such reflection appreciates the bidirectional influence of culture in therapy and facilitates a healthy dialogue about sensitive cross-cultural topics that might arise during treatment.

Explore the Patient's Perspective on Seeking Psychological Treatment and the Therapeutic Relationship

Members of minority groups often differ in their perceptions of obtaining mental health treatment, and empirical evidence indicates higher stigma associated with obtaining psychological help in a number of minority cultures (Shea & Yeh, 2008). For many clients, then, it may prove useful to address the stigma around receiving such treatment, particularly assessing for the impacts of this on the individual's sociocultural network. For instance, an individual identifying with predominantly collectivist or interdependent cultural values may regard the need for therapy as a sign of weakness and embarrassment to one's family or community (Furukawa & Hunt, 2011). In addition, giving validation and respect for the client's perspective on mental health treatment will further enhance clinician-patient trust and bolster the therapeutic bond.

A related matter is being aware of the preference for a preconceived ideal of an appropriate relationship between the client and clinician. Specifically, most treatment perspectives in the West emphasize a collaborative therapeutic relationship (Taber, Leibert, & Agaskar, 2011), but this might be isolating or confusing to individuals from certain cultural backgrounds. In fact, individuals identifying with cultures that are hierarchy-based (e.g., Eastern cultures) might expect a more directive, authoritarian approach in the therapy relationship (Tsui, 1985), and an over-emphasis on an equal therapist-patient relationship and socratic, open-ended questioning might raise doubt in the patient about the therapist's capabilities to treat the problem at hand. That does not mean that the therapist can never be prescriptive or open-ended in their communication with clients from these more hierarchy-based cultures; rather, this particular feature can be tempered to work within the client's expected treatment relationship framework. On the other hand, certain treatment perspectives involve a considerable amount of direct questioning, which might be construed as disrespectful in other cultures (such as Native Americans, and older European Americans; Hays, 2009). Such considerations serve as a reminder of the importance of thorough initial assessment of an individual's cultural beliefs and influences, to prevent an early rupture in the therapeutic alliance.

Be Aware of the Importance of Respect in the Cross-Cultural Therapy Setting

Clinicians engaging in multicultural therapy can create respect to meet treatment goals collaboratively. This means allowing clients to fully express their individual stories and to explain how their cultural beliefs have been uniquely part of this story (Coronado & Peake, 1992). Therapists can validate the client's experiences, including encounters with cultural or racial discrimination and possible oppression in the majority culture. Patients want to feel believed and clinicians are therefore advised to assume the reported incident occurred just as it was described by the patient, to provide support around such an experience, and then to later examine how much that experience has influenced the current symptoms (Kelly, 2006). Aligning oneself with patients by demonstrating full support for their difficult race-related or culture-related stressors will mitigate hesitation in discussing such sensitive issues with the therapist (Vasquez, 2007). Such a practice also falls neatly in line with an emphasis across treatments on providing significant empathy within the therapy relationship, which appears to be a relatively universal positive attribute of therapy, regardless of a client's cultural background.

Identify and Incorporate Client's Cultural Strengths and Resources Into Treatment

The contemporary emphasis on capitalizing on a patient's strengths in order to enhance treatment success can be taken one step further in multicultural therapy. The identified culture itself can be a major resource and provide an extensive support network for the client (Cross, 2003). Also, culture itself influences a range of culture-specific skills (e.g., naturalistic medicinal knowledge, cooking, fishing, farming), coping mechanisms (e.g., culture-specific metaphors for understanding emotional symptoms), interpersonal organizations and community resources (culturally oriented political or social causes, places for worship, or financial resources), and artistic outlets for emotion (through dance, art, and music). Such incorporation of a patient's culture-influenced skill-sets into treatment can also be a vehicle to increase adherence to between-session treatment work to practice concepts provided in therapy.

Thus, it is important to bring these culture-influenced strengths of the individual to the therapy discussion, particularly if these positive attributes may be incorporated into treatment techniques and practice. The clinician is encouraged, however, to use his or her knowledge of the active therapeutic components of the chosen treatment to incorporate such strengths in a way that does not integrally change the treatment, to avoid undermining its intended effectiveness and crucial points of intervention. In addition, Hays (2009) astutely notes that certain cultures (e.g., Asians & Native Americans) are culturally socialized to be modest about individual strengths, and these might not be easily verbalized if such individuals are directly questioned about their own strengths. It is therefore suggested that individuals with a more interdependent orientation be asked to think about what other significant individuals might say the strengths of the patient are to obtain this meaningful information.

Identify and Utilize Technique-Specific Cultural Modifications

Although it is reasonable to utilize treatments that have been proven in research to be efficacious, we must be ready to modify them in a culturally sensitive fashion. Of course, it is ideal to make cultural modifications that have been validated in the population of interest, but in the absence of definitive evidence for all possible modifications, it is useful to apply our cross-cultural knowledge to make treatment adaptations. For instance, in the cognitive-behavioral treatment (CBT) framework, we often ask clients to question the validity or reasonableness of a particular negative automatic thought, but this might be regarded as uncaring on the part of the therapist and place negative judgment on the client's belief system (Hofmann, 2006; Wood & Mallinckrodt, 1990). The therapist might choose instead to take a more culturally responsive approach and ask clients to question the utility or helpfulness of the thought, encouraging them to weigh out the pros and cons of holding on to this belief. Similarly, CBT often leads to an eventual challenging of core beliefs that a patient holds about themselves or the world. Therapists are asked to be cautious of directing patients to challenge their core cultural beliefs, even if a particular belief of the client seems incongruent or problematic within the therapist's own cultural value system.

With these guidelines in mind, we next describe a case treated by one of the authors (AA). The influence of these culturally responsive guidelines are demonstrated in the progressive development of a strong working alliance and ultimately a successful termination process.

Case Illustration

Client Description and Presenting Problem

Karen was a 37-year-old Jamaican American female and a single mother of three teenage children, who had recently lost her job due to a change in ownership at her medical insurance firm. Karen presented to our cognitive-behavioral treatment (CBT) clinic with a primary diagnosis of panic disorder with significant agoraphobia, and additional diagnoses of obsessive-compulsive disorder and generalized anxiety disorder. She had also had a past history of major depression and posttraumatic stress disorder from chronic and multiple traumatic experiences. Karen had pursued significant prior treatment, but with little relief in her ongoing anxiety symptoms.

She had decided to pursue treatment at our clinic because she had read about the efficacy of CBT for treatment of various anxiety symptoms. She also hoped that the more structured and short-term nature of this type of treatment might help her develop a more healthy attachment to her therapist, which had been difficult in the past. It therefore became apparent from early on in treatment that one therapy goal would have to be to effectively develop a strong working alliance while balancing reasonable boundaries to keep the purpose of the therapeutic relationship clear. This goal was explicitly stated from the outset, and framed as being in the best interest of both the patient's progress and to maintain treatment fidelity and effectiveness. However, it was recognized that much of Karen's current support system lay in the familiarity of relationships in her religious and ethnic community, therefore it might take some time for her to feel comfortable with a more formalized and boundary-imposed relationship with her therapist.

Case Formulation

Karen's presenting problems were formulated within a complex, multifaceted social context, given numerous ongoing social stressors such as unemployment, financial difficulty, single parenthood, the experience of chronic childhood abuse, and the witnessing of frequent street violence. Her anxiety symptoms were conceptualized within this confluence of factors. For instance, she described the experience of her first panic attack, which occurred soon after the loss of her brother who was killed suddenly by stray fire in a gunfight, in a situation she felt unable to escape readily, but that was not one that posed any real danger to her safety. Similarly, much of her unease around the experience of anxiety surrounded this belief that she had to be the “strong one” in the family, because of her markedly higher functionality as compared with her relatives. This assumed and expected familial role contributed significantly to her catastrophic worries that her anxiety would leave her incapable to care for herself or others, and her entire family would unravel as a result. In addition, her paranoid obsessions about being harmed or poisoned by others stemmed from actual experiences of being bad-mouthed or manipulated by others in her close social circle, again, because of her employment and educational success relative to her peers. It was important to consider these influential external circumstances to fully understand the manifestation and maintenance of her emotional symptoms and to target her symptoms most effectively.

Course of Treatment

The primary aim in the first several sessions was to fully explore the role of cultural beliefs in the development and maintenance of Karen's symptoms. Within the first session itself, Karen expressed her strong religious belief and heavy involvement in church. Related to this, it was clear that Karen received many negative messages from her children, mother, and church friends about both her experience of panic symptoms, and her decision to receive “outside” (i.e., outside of the Caribbean American community) psychological help. This did not deter Karen from seeking treatment, but through therapist exploration, Karen admitted that this certainly fueled her own negative beliefs about being different from everyone around her and made her feel discouraged about ever becoming better. She also felt depressed about not being able to “kick these symptoms” on her own simply through prayer and faith as others suggested, and felt like a failure about this perceived deficiency.

With these larger cultural themes in mind, the therapy content started focusing on specific anxiety symptoms and explored how culture infused her psychological symptoms in more detail. For instance, Karen reported that her obsessive thoughts about being poisoned by others (which would result in avoidance of eating or drinking items given to her by others at their homes, or in other settings outside her own home) stemmed from a strong belief in black magic, and that others were trying to harm her out of jealousy and control by the Devil.

The strong belief in black magic and having “an evil eye” cast upon someone was recognized as a widely-accepted, culturally-congruent belief in individuals from the Caribbean, and the therapist therefore did not question the validity of this belief. Pathologizing such a common belief from that cultural system as disordered or undesirable was regarded as culturally insensitive and potentially isolating for the patient. Instead, the therapist focused more on increasing her motivation to target the avoidance and interference associated with this thought.

Similarly, given the expressed importance of religion in Karen's life view, the therapist explicitly incorporated Karen's spiritual strengths into the treatment very early on, particularly to target the stigma she experienced from others surrounding her decision to pursue psychological treatment. Specifically, the therapist proposed the idea that Karen's decision to seek formal help to address her anxiety symptoms was an example of her following her own internal spiritual compass to maximize her strengths and abilities to contribute to her community and family. Karen really started identifying with this perspective shift, and became much more receptive to the more traditional treatment techniques presented when they were framed with this religious lens.

An interesting feature regarding these two interrelated themes (philosophical perspective and stigma) was that Karen actually challenged the therapist to reflect at a very early stage in treatment about her own beliefs regarding these issues, and how that might affect the therapeutic relationship. Typically, therapists’ opinions on such topics are avoided; that is, as clinicians, we are instructed to redirect patients’ questions about our own personal beliefs. However, this was recognized as quite likely to be detrimental to the therapeutic alliance, and would run the risk of having Karen disengage from treatment because of a feeling of disconnection from the therapist. An excerpt from the session where the patient directly questioned the therapist about her own beliefs is given below:

Karen

“There's one more thing I need to ask you before we end today. Do you think people who need therapy are weaker?”

Therapist

“I want to make sure I understand what you're asking me, since this seems pretty important to you. Do I think such individuals are weaker than who?—those who do not seek a therapist, or those who do not experience emotional distress? And why is it important for you to know how I feel about it?”

Karen

“Those who do not go to a therapist—I don't think anyone is completely free from emotional distress. Do you think that I really should be able to deal with this on my own, and that generally your work is to help people who are weak?”

Therapist

“First, I completely agree with you—I think each and every one of us struggle with emotional distress, and therapy can be a great way for all of us to get some support and skills to deal with our tough times better. That also means that I actually think you're not weak, but very strong to take the steps to come to therapy, particularly because I know you don't get a lot of support for that from those who are close and important to you. Is that partly why you were asking, to see if I feel the way they [her mother, children, and church community] do?”

Karen

“Kinda, yeah. It's hard not to feel weak, because no one else in my life is in therapy.”

Therapist

“I can completely understand that feeling. You know, Karen, when I told my family that I wanted to study clinical psychology, they were extremely resistant to it. They didn't feel “mental health” was a real thing, and weren't even quite willing to accept that anything except willpower or prayer to a higher power could affect our emotional distress. Yet I had to make a tough decision to stay true to my course of study despite their protest, because I felt that while willpower and spiritual pursuits can be extremely powerful, they are not always effective on their own, in the absence of other resources. I think you and I are a lot alike in that way—both determined to do our best and get the most out of our lives, even when our families or communities might not agree. It's hard to stay patient until they come around and see the benefits like we do though, isn't it?”

Karen

“I know! Sometimes I just want them to open their eyes and minds to see that I was right about this being important and useful for me, and I even think some of them need similar help, but they're too stubborn to get it. You're right, I am determined, and I do feel good about sticking to my beliefs about making my mental health a priority. I can feel God's guidance in doing that. So, even if they disagree, I'm not going to give up on this. I need this jumpstart in my life.”

As exemplified in this excerpt, the therapist adequately revealed some personal beliefs and experience with stigma observed around seeking psychological help in her own life. This was presented after consultation with other clinicians, the literature, and reflection on her personal beliefs towards psychological dysfunction. Even with only this partial disclosure on the part of the therapist, Karen expressed feeling respected and more willing to continue with treatment with this practitioner.

As mentioned previously, Karen reported having several past treatment episodes, with little sustained improvement in her anxiety symptoms. She noted, however, that she had deeply enjoyed several of these therapy experiences, specifically because of the strong therapeutic relationship she shared with the clinicians during those experiences. That being said, in the first session, she verbalized a concern that her close relationship with her past therapists eventually became a disadvantage, primarily because she found it difficult to terminate these relationships or to continue with skills independently once therapy ended. This provided insight into Karen's own perceptions and concerns around an ideal therapist-client relationship.

Boundary setting in the therapy relationship therefore became a shared goal throughout the course of treatment. This had to be handled in a culturally responsive way, because it was important not to make Karen feel isolated in her experiences so she would feel comfortable confiding in the therapist. Yet Karen often pushed the boundaries of the professional therapy relationship by wanting to call “just to chat,” asking the therapist details about her family and upbringing, and wanting the therapist to come to her home community to meet other members of her family and church. These were handled in a manner similar to how matters of religiosity, politics, and related beliefs are typically dealt with in therapy, but the cultural need to feel connected and incorporate the therapist into Karen's own community was acknowledged explicitly.

One recurrent problem area was Karen's ongoing worry surrounding a “love-hate” relationship with her mother. Specifically, she felt significant distress when interacting with her mother, and yet she worried constantly about her mother dying, and felt that she would be unable to function with her mother gone. Most of her inner conflict in this relationship stemmed from a strongly ingrained cultural pressure to maintain an active relationship with her mother, but this relationship posed significant barriers to her own ability to be productive and stress-free. The therapist would have been remiss in this case to suggest to Karen that she disengage from this relationship with her mother (which would be inconsistent with the interdependent family/community system). Instead, Karen was asked to reflect thoroughly on this relationship (with various in-session exercises on the pros and cons of her relationship with her mother) to help her become comfortable with finding her own balance of meeting her familial responsibility and yet protect her own mental health.

Similarly, while Karen expressed many traditional cognitions associated with her agoraphobic concerns (e.g., inability to reach medical help promptly, or to escape when experiencing panic symptoms), she also reported anxiety during exposure exercises around the Center because of a prior experience of racial discrimination when in distress in a similar predominantly White location. This experience was met with empathic validation and it was discussed at length how much her own perceptions of being negatively regarded by others because of her race tie into her fears around being helpless when experiencing panic outside her own geographic community. Once the patient felt supported and listened to around this concern, the therapist worked on gradually exploring how Karen may more rationally weigh out the probability that every individual around her will refuse to help her based on her race/appearance, and she was receptive to this. In particular, the therapist encouraged her to think of the instances in her life that others from the majority culture had actually been caring and helpful towards her, to more rationally evaluate her fears about being completely unsafe or alone.

Again, Karen's major positive characteristics were many, but several were directly linked to her community and spiritual values. A recurrent theme throughout treatment was the importance of belief in God and service to her church. Consequently, this particular community/belief system was often referred to and integrated into the homework exercises and therapy discussions. Aside from its previously described use to increase her motivation to address the anxiety symptoms that were interfering with her meeting her full potential, the use of her community and church involvement were utilized. For instance, as she was nearing the end of treatment, she independently volunteered to work with the clinic administrators to disseminate information about available services, e.g., by going into local churches in her neighborhood to share her positive experiences with therapy and anxiety reduction. This exercise was extremely empowering for Karen and met this need to contribute meaningfully to her community. There was also a focus on strengthening interpersonal relationships with her family members (e.g., going to get her nails done with her adolescent daughter), because of her highly expressed cultural value of staying close-knit as an immigrant family. Thus, spending time engaging in such activities served both as an exposure exercise (to reduce agoraphobic avoidance) and to meet this valued interdependent cultural goal.

Treatment progressed using empirically supported techniques with these cultural guidelines integrated into the session content. Karen actually came for a relatively longer treatment course than what is typical for CBT in this treatment setting (around 30 active treatment sessions), primarily because of other stressors (legal and significant medical conditions involving two of her children) that suddenly happened about 15 sessions into the treatment. At this point in therapy, there had already been a considerable objective and subjective improvement in Karen's anxiety symptoms (particularly in her panic and agoraphobic symptoms). These sudden crises forced the treatment to take a different focus for about five sessions, to maintain the therapeutic alliance and to meet the immediate needs of the patient. Once these external circumstances had reduced in urgency, treatment focus returned to managing with her overall stress level and specific lingering anxiety symptoms.

There appeared to be a plateau reached in several of her symptoms (particularly her chronic worry symptoms), and therefore it was decided that firstline CBT skills needed to be supplemented with other related techniques. Of note, the technique of mindfulness meditation was presented to Karen. However, to make this technique more palatable to this client, mindfulness activities that emphasized resilience (with Karen's history of experienced racism and trauma as an explicit part of the extensive metaphor for meditation) and spiritual values-driven mindfulness practices were presented. Karen really enjoyed these exercises, and reported a significant relief in the frequency and severity of her chronic worry through consistent use of this skill.

Outcome and Prognosis

Termination of therapy was collaboratively decided upon, on the basis of significant reduction in anxiety symptoms, and at a point where the patient herself verbalized a need to detach from her dependence on the therapeutic relationship to try the skills independently. The entire treatment, including the 2-month treatment taper period, comprised 34 treatment sessions. The postassessment, self-report scores for her anxiety symptoms significantly decreased from strong levels at pretreatment to mild or minimal scores at posttreatment on both the Anxiety Sensitivity Index (43 to 22), and Yale-Brown Obsessive Compulsive Scale (23 to 4). Given both this objective and clinical data, and the patient's subjective report of distinct improvement in symptoms, the last four sessions occurred every 2 weeks for the last 2 months of treatment.

At the last session, Karen brought in a gift (a velvet rose) and a card with religious themes as a gesture of gratitude for the therapist. At this particular treatment setting, gifts are usually declined, but the therapist regarded Karen's gift choice as a noted effort to stay within the discussed boundaries, and recognized the card as her desire to express herself from within her own belief system. Given this, the token was accepted by the therapist, and Karen also asked if she could occasionally call the therapist to update her on how things were, which was discussed in terms of reasonable frequency of such updates. Three months after the termination of treatment, Karen called the therapist to let her know she had found a job, and was planning a trip to New York with her friends after over 20 years of feeling too anxious to leave her hometown. The therapist responded to Karen with warm reinforcement for her achievements, and reminded her of how far she had progressed since she had first started treatment almost a year earlier, encouraging her to keep using the skills she had learned.

Clinical Practices and Summary

This case highlights some practical applications of empirically driven guidelines for enhancing collaboration when working with cross-cultural patients. The therapist adapted the treatment process—from assessment, to interventions, through to termination—to make it more culturally relevant to Karen. There was an equal emphasis on delivering an evidence-based treatment and on cultivating a strong therapeutic relationship to meet this goal. Tailoring the treatment procedures to Karen's individual needs (which were largely influenced by group-level cultural, religious, and societal beliefs) probably contributed to her significant progress, as she expressed in the termination session. She reported feeling respected, listened to, and entrusted in contributing to her own progress, which gave her confidence to continue the skills on her own after therapy had ended.

Certainly, the presented case study is not an exhaustive application of the described guidelines. Several other features may aid in treatment engagement of patients from various cultural groups. For instance, clinicians may consider delivering therapy in more naturalistic, familiar settings (such as in the person's residence, place of worship, or general community area) to make the patient feel more comfortable and connected to the treatment (Hickling, 1994). Clinicians should further consider the patient's individual experience, socioeconomic status, and family structure in the broader context of the client's cultural, social, and political history (e.g., Holocaust experiences in Jewish patients, slavery/racism in African Americans, and English-language difficulties and resultant discrimination in Hispanics). Part of the process with familiarizing oneself with the customs and practices of a particular culture is being aware of, and assessing the affect of, these significant historical/social themes. Finally, even clinicians aware of the nuances of cultural considerations and who have engaged in extensive multicultural therapy must challenge themselves to treat each case as unique. Adopting an attitude of openness, curiosity and respect towards clients can go a long way in establishing a strong working alliance between the therapist and patient in the multicultural treatment setting.