The role of culture and cultural techniques in psychotherapy. A critique and reformulation.

" This article examines the role of cultural knowledge and culture-specific techniques in the psychotherapeutic treatment of ethnic minority-group clients. Recommendations that admonish therapists to be culturally sensitive and to know the culture of the client have not been very helpful Such recommendations often fail to specify treatment procedures and to consider within-group heterogeneity among ethnic clients. Similarly, specific techniques based on the presumed cultural values of a client are often applied regardless of their appropriateness to a particular ethnic client. It is suggested that cultural knowledge and culture-consistent strategies be linked to two basic processes--credibility and giving. Analysis of these processes can provide a meaningful method of viewing the role of culture in psychotherapy and also provides suggestions for improving psychotherapy practices, training, and research for ethnic-minority populations. For nearly two decades research has been devoted to the investigation of the adequacy of psychotherapeutic services and treatment practices for ethnic-minority populations. Yet clinical and community psychologists continue to be perplexed by the problem of how to increase the effectiveness of mental health services to these populations. Although it can be legitimately argued that much more research is needed in order to address this problem, perhaps our efforts need to be redirected to some basic issues that have been overlooked. This article examines the principles underlying attempts to develop effective psychotherapy with ethnicminority groups. Several points are made. First, investigators have been remarkably consistent in offering recommendations or suggestions for improving the relationship between therapists and ethnic-minority clients. These recommendations typically involve therapists' knowledge of culture and specific techniques based on this knowledge. Second, the suggestions raise problems for therapists. Third, in order to resolve these problems, research and practice should be redirected to two key processes involving therapist credibility and giving. Fourth, by focusing on these processes, guidelines for therapy, training, and research can be more adequately specified. Although these four points are illustrated primarily with Asian Americans in this article, they have direct relevance to other ethnic or cultural groups. Pr o b l e ms in Providing Effect ive Serv ices The research and clinical literature on the delivery of mental health services to ethnic-minority populations has been quite consistent in drawing attention to inadequacies in the provision of services. For example, in summarh~g the work of its Asian/Pacific-American, Black-American, Hispanic-American, and Nafive-American/Alaska-Native subpanels, the Special Populations Task Force of the President's Commission on Mental Health (1978) coneluded that ethnic minorities "'are clearly underserved or inappropriately served by the current mental health system in this country" (p. 73). The first author (Sue, 1977) studied nearly 14,000 clients in 17 community mental health centers in the greater Seattle area. Results indicated that Blacks and Native Americans were overrepresented in the centers, whereas Asian Americans and Hispanies were underrepresented. The disturbing finding was that regardless of utilization rates, all of the ethnic-minority groups had significantly higher dropout rates than Whites. About half of the ethnic-minority clients failed to return for treatment after one session, compared to the 30% dropout rate of Whites. Without belaboring the point, we believe that there is ample evidence that ethnic minorifies are not faring well in our mental health system. How can these problems be explained? Again, rosearchers and practitioners exhibit remarkable agreement about the reasons for the inadequacies in mental health services. Some of these reasons include the lack of bilingual therapists, stereotypes therapists have of ethnic clients, and discrimination. However, the single most important explanation for the problems in service delivery involves the inability of therapists to provide culturally responsive forms of treatment. The assumption, and a fairly good one, is that most therapists are not familiar with the cultural backgrounds and life-styles of various ethnic-minority groups and have received training primarily developed for Anglo, or mainstream, Americans (Bernal & Padilla, 1982; Chunn, Dunston, & Rzes-Sherifl~ 1983; Wyatt & Parham, 1985). Consequently, therapists are often unable to devise culturally appropriate forms of treatment, and ethnic-minority clients frequently find mental health services strange, foreign, or unhelpful. Szapocznik, Santisteban, Kurfines, Hervis, and Spencer (1982) argued that Hispanic Americans in contrast to Anglo Americans value linearity (i.e., role-structured January 1987 * American Psychologist Copyright 1987 by the American Psychological Association, Inc. 0003-066X187/$00.75 VoL 42, No. I, 37--45 37 rather than egalitarian relationships) and a present-time orientation in therapy. They believe that failure to recognize and utilize these values in treatment is an impediment to effective psychotherapy. Similarly, Nobles (1980) delineated several Black-American cultural traditions including group identification and collectivity, spirituality, and a flexible concept of time. These traditions, along with reactions to racial oppression, must be understood by psychotherapists working with Black Americans (Jones, 1985). The need to appreciate the cultural values of Native-American (Attneave, 1984; Manson & Trimble, 1982) and Asian-American (Kim, 1985) groups has also been emphasized. The Special Populations Task Force of the President's Commission on Mental Health (1978) recommended that "services to be provided for the special populations should be delivered, again with a view toward the best possible of worlds, by persons who share the unique perspective, value system and beliefs of the group being served" (p. 732). New Issues Raised by Contemporary Strategies Because of the unresponsiveness of services to the needs of e thnic minorities, researchers and practitioners advocated changes in the mental health system. The changes had to do with the process of match, or fit: Treatment should match, or fit, the cultural life-style or experiences of clients. Otherwise, ethnic-minority clients would continue to underutilize services, prematurely terminate, or fail to show positive treatment outcomes. Modifications were deemed important at the system level and at the face-to-face, client-therapist level. At the system level several policy recommendations were made (S. Sue, 1977). FLrst, existing mental health services were urged to hire bilingualfoicultural personnel who could work with ethnic-minority clients. The continning education of current staff through seminars, workshops, and lectures on various cultural groups was also deemed important. Indeed, many mental health centers developed continuing education programs on ethnic issues. Second, the initiation of parallel services was necessary in areas where a large ethnic community existed. These services included the creation of mental health centers or sections of mental hospitals that specialiTed in treating these ethnic clients. Finally, nonparaUel services for ethnic-minority clients were advocated. For example, because of the stigma attached to the use of mental health services, new means of delivering such services were needed. Some communities organized multiservice centers where mental health programs could be embedded within legal, social service, and language programs. There is evidence that these three recommendations The first author presented an earlier version of this article as an invited address at the Asian American Psychological Association Convention, August 1985,  Correspondence concerning this article should be addressed to Stanley Sue, Department of Psychology, University of California, Los Angeles, California 90024. are being implemented (see Snowden, 1982; Uba, 1982) and that structural changes have been made in the service delivery sector. We are not implying that newly formed programs are sufficient to meet the needs of ethnic-group populations. The main point is that research and the concept of match have played important roles in influencing system changes. Applying the concept of match, or fit, at the cfienttherapist level has generally meant that (a) more ethnic therapists who presumably are bilingual or are familiar with ethnic cultural values should be recruited into the mental health field, (b) students and therapists should acquire knowledge of ethnic cultures and communities, and (c) traditional forms of treatment should be modified because they are geared primarily for mainstream Americans. These tasks have been difficult and problematic to achieve. For example, it can be difficult to recruit Hispanics who are fluent in Spanish because graduate programs are often reluctant to admit students if their English verbal skills are low. Another problem is that few training programs offer courses in ethnicity or cultural diversity, as mentioned earlier. Perhaps the most difficult issue confronting the mental health field is the role of culture and cultural techniques in psychotherapy. We believe that cultural knowledge and techniques generated by this knowledge are frequently applied in inappropriate ways. The problem is especially apparent when therapists and others act on insufficient knowledge or overgeneralize what they have learned about culturally dissimilar groups. This is illustrated in the following situations: One of our colleagues conveyed the following story to us. His daughter's fourth-grade teacher had just returned from a human relations workshop where she had been exposed to the n_ _*J3e~ty of incorporating "ethnicity" into her instructional planning.