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GENERAL AND MULTICULTURAL CASE CONCEPTUALIZATION SKILLS: A CROSS-SECTIONAL

ANALYSIS OF PSYCHOTHERAPY TRAINEES

DEBBIESIU L. LEE University of Miami

TERENCE J. G. TRACEY Arizona State University

The general and multicultural case con- ceptualization skills of 91 psychother- apy trainees were evaluated for com- plexity and expertness across 3 case scenarios. The cases varied in the ex- tent to which culture was presented in the demographic information and pre- senting concerns. Whereas general case conceptualization skills were found to relate to clinical training, multicultural case conceptualization skills were found to relate to multicultural training. Across cases, advanced trainees dem- onstrated significantly greater complex- ity and expertness than beginners. Trainees consistently included more culturally relevant ideas when culture was explicitly stated in the case as a presenting problem, versus when cul- ture was implied. Last, consistently sig- nificant differences in the case concep- tualizations of White trainees and trainees of color were not found.

Keywords: case conceptualization, mul- ticultural competence, multicultural training, supervision

Case conceptualization skills have long been viewed as critical competencies for psychothera- pists and other mental health professionals

(Falvey, 2001; Goodyear, 1997; Loganbill & Stoltenberg, 1983; Makover, 1996;). Case con- ceptualization, in general, has been defined as the ability to synthesize a large amount of complex and ambiguous information (including cognitive, behavioral, emotional, and interpersonal aspects of the client) into an overall understanding of the client’s level of functioning and producing viable treatment strategies (Loganbill & Stoltenberg, 1983). More recent investigations in the area have focused on multicultural case conceptual- ization, the explicit incorporation of culture in- cluding personal, contextual, and sociopolitical factors in case conceptualization (American Psy- chological Association [APA], 2003; Sue & Sue, 2003). Although we view multicultural concep- tualization as a key aspect of general case con- ceptualization, it has typically been examined as a separate skill (e.g., Constantine & Ladany, 2000; Ladany, Inman, Constantine, & Hofheinz, 1997). Prior research has examined either con- ceptualization skills generally, with no particular emphasis on culture, or specifically relating to cases wherein culture is explicitly made salient.

In this present study, we sought to examine multicultural conceptualization as it was similar and different from a more general case concep- tualization. There is little research exploring these somewhat overlapping skills, and no re- search has investigated how psychotherapy train- ees vary in these two skills across different levels of training. The focus of the study was therefore evaluating both general case conceptualization skills and those specifically involving cultural content as they vary across trainees at different levels of education. We begin by discussing the importance of case conceptualization skills in psychotherapy. We then describe how case con- ceptualization and multicultural case conceptual- ization skills have been defined in past research, using both cognitive and content measures. Last, we outline the variables we believed were impor- tant to examine in our current inquiry (general

Debbiesiu L. Lee, Department of Educational and Psycho- logical Studies, University of Miami; Terence J. G. Tracey, Psychology in Education, Arizona State University.

Correspondence regarding this article should be addressed to Debbiesiu L. Lee, PhD, School of Education, University of Miami, PO 248065, 5202 University Drive, Coral Gables, FL 33146. E-mail: [email protected]

Psychotherapy Theory, Research, Practice, Training Copyright 2008 by the American Psychological Association 2008, Vol. 45, No. 4, 507–522 0033-3204/08/$12.00 DOI: 10.1037/a0014336

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differentiation, multicultural differentiation, inte- gration, and expertness).

Research on case conceptualization skills in psychotherapy training is critical because these skills have been found to directly influence psy- chotherapy outcomes (Johnson & Heppner, 1989; Kendjelic & Eells, 2007; Loganbill & Stolten- berg, 1983). For example, case conceptualization skills have been found to correlate with levels of therapeutic skill (Morran, 1986) and observer and client ratings of therapeutic effectiveness (Mor- ran, Kurpius, Brack, & Rozecki, 1994). Accuracy of therapist conceptualizations, as evidenced through interpretations, has also been found to correlate with client progress (Silberschatz, Fret- ter, & Curtis, 1986) and positive treatment out- comes (Crits-Cristoph, Coppoer, & Luborsky, 1988). Despite the importance of understanding how psychotherapy trainees develop in case con- ceptualization skills, little attention has been paid to this area (Kendjelic & Eells, 2007; Ladany, 2007; Neufeldt et al., 2006). Further, although there has been a notable increase in multicul- tural training for psychotherapy trainees (Hills & Strozier, 1992; Smith, Constantine, Dunn, Dinehart, & Montoya, 2006), there is a paucity of research exploring how this training influ- ences skill-based outcomes (Kendjelic & Eells, 2007; Ladany, 2007). Our research builds on prior studies examining general and multicul- tural case conceptualization.

General case conceptualization skills have been extensively investigated using several dif- ferent paradigms and methods. Some researchers have utilized cognitive approaches toward differ- entiating conceptualization skills, including con- ceptual level (Holloway & Wampold, 1986), con- vergent or divergent conceptual strategies (Hirsch & Stone, 1983), cognitive processing (Hillerbrand & Claiborn, 1990), concept mapping (Martin, Slemon, Hiebert, Hallberg, & Cum- mings, 1989), and cognitive complexity (Ladany, Marotta, & Musa-Burke, 2001; Spengler & Stro- hmer, 1994). These studies appear to indicate that the best conceptualizations are those that reflect the greatest levels of complexity, abstraction, convergence and integration. Other researchers have focused on the content of the conceptualiza- tions. Holloway and Wolleat (1980) and Kurpius, Benjamin, and Morran (1985) examined the in- clusion of key components of conceptualizations, whereas Morran (1986) took into account the actual quality of the conceptualization, as rated

by expert judgment. Although research on general case conceptualization skills have resulted in vari- ous findings, the overall conclusion is that psycho- therapists with more training and/or clinical expe- rience produce conceptualizations that evidence greater complexity and higher order cognitive skills and receive better expert ratings (O’Bryan & Good- year, 1997; Sakai & Nasserbakht, 1997).

Multicultural case conceptualization has been defined predominantly by complexity, and exam- ined in relation to self-report measures. Constan- tine (2001a, 2001b, 2001c) explored multicul- tural case conceptualization in a series of studies. Her method consisted of providing psychother- apy trainees with a written vignette about a client of color struggling with various culturally laden concerns and asking the trainees to write a con- ceptualization addressing both etiology and treat- ment planning. Actual multicultural conceptual- ization skills were not found to be related to self-reported multicultural competence, after so- cial desirability is taken into account (Constan- tine & Ladany, 2000; Ladany et al., 1997). Mul- ticultural case conceptualization skills were however found to correlate positively with eclectic/integrative orientation (Constantine, 2001c), empathy attitudes (Constantine, 2001c), and ethnic tolerance attitudes (Constantine & Gushue, 2003), and negatively with independent self-construals (Constantine, 2001b) and racist attitudes (Constantine & Gushue, 2003). Multi- cultural case conceptualization also related posi- tively to multicultural training (Constantine, 2001b, 2001c; Constantine & Gushue, 2003). Last, trainees of color were found to demonstrate higher multicultural case conceptualization abil- ities than White trainees in one study (Constan- tine, 2001b); however this finding was not con- sistent across studies (Constantine, 2001c; Constantine & Gushue, 2003).

In a more recent study, Neutfeldt et al. (2006) used qualitative analyses to examine the general and multicultural case conceptualization skills of psychotherapy trainees. Seventeen psychotherapy trainees were exposed to two video vignettes of clients (one young, Chinese American female college student and one retired, European Amer- ican, upper middle class, man) and participated in a semistructured interview following each of these videos. Neutfeldt et al. found that psycho- therapy trainees incorporated more diversity fac- tors in their conceptualization of the White client versus the Asian client. Other findings were also

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noted with respect to how trainees varied in their ability to incorporate culture in their conceptual- izations. Given the low sample size and qualita- tive nature of the study however, conclusions regarding the correlates of multicultural case con- ceptualization (such as trainee race or level of training) were limited (Neutfeldt et al., 2006).

Sakai and Nasserbakht (1997) summarized the findings of case conceptualization research, pos- iting that expertise in this area appears to be characterized by three factors: (a) the essential role of experience in increasing skill level, (b) cognitive changes (cognitive complexity in- creases with training and experience), and (c) qualitative shifts in focus (advanced clinicians and novices deem different information as impor- tant in conceptualizing clients). We sought to examine these issues as they relate to both gen- eral and multicultural case conceptualization. The purpose of this study was to explore the general and multicultural case conceptualization skills of psychotherapy trainees across levels of clinical and multicultural training. We employed an in- clusive definition of multicultural, incorporating race, ethnicity, age, sexual orientation, ability, religion, social class, and gender. We wished to determine if similar levels of general and mul- ticultural case conceptualization occurred when trainees were presented with client issues that were explicitly tied to cultural issues ver- sus when they were not. In other words, do psychotherapists’ multicultural case conceptu- alization skills differ from their general case conceptualization skills, and does this relate to the specific client case? We expected that ex- plicitly labeling culture as relevant in client cases will yield more multicultural content in conceptualizations; however, this may not be as pronounced in all psychotherapists. Based on prior findings, psychotherapy trainees of color or those who have had strong multicul- tural training were expected to incorporate cul- ture into all case conceptualizations regardless of its level of explicitness.

Combining methods of previous research, case conceptualization skills were operationalized by level of complexity and expertness. Complexity was further defined by differentiation (the num- ber of ideas presented in the conceptualization) and integration (how cohesively are the ideas presented, i.e., do the ideas connect well with one another). This model of complexity, referred to as integrative complexity, was borrowed from per-

sonality and social psychology (Kelley, 1955; Linville, 1987; Linville & Jones, 1980; Tetlock & Suedfeld, 1988) and has been used in prior re- search studies on case conceptualization and mul- ticultural case conceptualization abilities (Con- stantine, 2001b, 2001c; Constantine & Ladany, 2000; Ladany et al., 1997; Ladany et al., 2001). In this study, differentiation was further divided into general differentiation (number of total ideas presented in the case) and multicultural differen- tiation (number of culturally relevant ideas pre- sented). This allowed us to examine training dif- ferences related to production of general ideas (total ideas) and culture specific ideas. Hence, in our study, multicultural differentiation is a subset of general differentiation.

Although previous studies on complexity in psychology have examined the two core concepts (differentiation and integration) as separate con- structs, studies exploring the complexity of train- ees’ case conceptualizations have combined these two into one scale (Constantine, 2001b, 2001c; Constantine & Gushue, 2003; Ladany et al., 1997, 2001). Higher complexity in case concep- tualization therefore has been defined as having the highest amount of both differentiation and integration. In this study, we chose to retain sep- arate scales for differentiation and integration. We did this because some literature suggests that differentiation skills are not linearly related to level of training. For instance, Stoltenberg, McNeill and Delworth (1998) posited in their Integrated Development Model (IDM) that psy- chotherapy trainees at the middle stages of their training have the highest level of differentiation. Beginning trainees produce the fewest ideas in their conceptualizations, whereas advanced train- ees develop concise conceptualizations (Stolten- berg et al., 1998). At least one study comparing experts and novice therapists supported this no- tion; experts were found to have more succinct (less differentiated ideas) and highly integrated case conceptualizations (Martin et al., 1989).

Of course, these two scales are not completely independent in that a participant would need to state a certain number of ideas to make connec- tions between them (high integration is impossi- ble without high differentiation). However, in collapsing the two scales, researchers precluded the possibility that the case conceptualization contained high differentiation, but low integra- tion. Being able to account for this particular combination is important in trainee development

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models because it describes trainees in the middle stages of their training. This study addressed these methodological limitations in that differen- tiation and integration will be examined indepen- dently. Therefore, each construct may be examined in relation to trainees’ case conceptualizations, al- lowing every possible combination to be captured.

In addition to level of complexity, the expert- ness of the trainees’ case conceptualizations was evaluated. We use the term expertness here to denote a quality pertaining to a case conceptual- ization that is similar to that of experts. We distinguish expertness from expertise, a terminol- ogy often used in the psychology literature to describe the specialized knowledge and skills possessed by a person. Although trainees may exhibit expertness in their conceptualizations, they do not possess expertise, which requires years of experience to develop. To evaluate the expertness of the trainees’ case conceptualiza- tions, we requested expert participation in this study.

Jennings and Skovholdt (1999) posited that a standard for defining psychotherapy expertise in research should include, (a) at least 15 years of experience, (b) qualifications, and (c) peer selec- tion. For this study, we asked several research academicians prominent in the fields of psycho- therapy and multicultural competence to partici- pate as experts. These individuals were chosen because of their outstanding work in the field, including extensive publications in peer- reviewed journals and presentations on multicul- tural competence in psychotherapy (50 � over the past 15 years). Two agreed and participated in the development of expert criterion in this study. We expected that trainee level of matching to this expert conceptualization would significantly in- crease as they progressed through their training. Advanced trainees were expected to generate the most appropriate conceptualizations and treat- ment recommendations.

We examined each of these variables (general differentiation, multicultural differentiation, inte- gration, and expertness) in relation to level of clinical training and/or multicultural training across three different case scenarios. The cases varied in the degree to which culture was explic- itly stated or implied in the demographics and presenting problems of the client. We hypothe- sized that general case conceptualization skills would relate to clinical training, and multicultural case conceptualization skills would relate to mul-

ticultural training. Hence we predicted that gen- eral differentiation and integration would relate significantly to clinical training, and multicultural differentiation would relate significantly with multicultural training. We believed that expert- ness would relate to both clinical and multicul- tural training because it represents both general and multicultural case conceptualization skills. Although we believed that multicultural differen- tiation would not relate significantly to clinical training, we tested this relation to rule out the possibility that we might find significant in- creases in multicultural differentiation by mere advancement in training, rather than multicultural training in particular. Last, because trainees of color have been found to exhibit greater multi- cultural case conceptualization skills in at least one study (Constantine, 2001b), we also exam- ined whether there were significant differences between the case conceptualizations of trainees of color and White trainees.

Method

Participants and Procedures

Psychotherapy trainees in a counseling and counseling psychology program at a Southwest- ern university were asked to participate in this study. Ninety-one trainees completed the study. The age range was 22 to 57 years of age (M � 30.37, SD � 8.40). Twenty-two trainees identi- fied as men, 69 as women. In terms of racial/ ethnic background, 5 students identified as Black/ African American, 6 as Asian/Asian American, 63 as Caucasian/White, 9 as Latino/Latino/a American, 6 as biracial or multiracial, and 2 chose not to respond. No trainee identified as American Indian.

Out of the 91 trainees, 34 identified themselves as doctoral level, 55 as master level, and 2 as nondegree earning trainees. The number of years trainees reported being in their current program ranged from .5 to 6 years (M � 1.74, SD � 1.05). The mean number of courses focusing solely on multicultural issues taken by trainees was 1.46 (SD � 1.39), with the range being from 0 to 6 classes. The number of semesters of supervised practicum experiences endorsed by trainees ranged from 0 to 11 (M � 2.03, SD � 2.55). With respect to theoretical orientation, 34 reported that they favored cognitive– behavioral interventions, 23 humanistic, 38 eclectic, and 6 interpersonal.

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Participation was solicited either through intact classes or through a student listserv. Trainees were provided a written informed consent ex- plaining that participation was voluntary, and that they had the right to choose not to participate free of penalty. They were informed that no rewards were given for participation. Submission of the survey was considered as proof of their consent.

Each volunteer participant was administered a demographic questionnaire and the Three Scenar- ios Survey. Demographic information included the following information: age, sex, degree pro- gram, type of graduate program in which student is enrolled, semesters of supervised practicum experience, years of supervised clinical experi- ence, and amount of multicultural coursework. The Three Scenarios Survey (an instrument cre- ated for the purposes of this study) asked respon- dents to read three different case scenarios and provide a case conceptualization explaining the client’s psychological difficulties and a treatment plan for the client.

Measures

Three Scenarios Survey. This instrument consisted of descriptions of three different coun- seling cases of work with a female client varying on ethnicity (Caucasian American, African American, American Indian) and the explicit cul- tural focus of the presenting problem (overt pre- sentation of cultural material or absence of cul- tural material other than noting ethnicity). To evaluate how differences along these two dimen- sions would affect trainees’ conceptualizations, we carefully constructed client scenarios such that they varied only on these two dimensions. Therefore, each of the clients represented the same gender, sexual orientation, marital status, and relative age. The three cases were Audrey (Caucasian client with no explicit mention of culture in the description), Jennifer (African American client in which culture is not explicitly stated as an aspect of the presenting problem) and Meredith (American Indian client in which cul- turally relevant issues are represented as a major concern for this client). These case descriptions were created to contain the same amount of in- formation, with references to their psychological difficulties, adjustment issues, parent back- ground, peer relations, and alcohol and drug us- age. A rubric was created such that each case scenario indicated six risk factors to the client’s

psychological well-being. The case scenarios were examined by one counseling psychology doctoral student and one other individual with no background in psychology to ensure that the sce- narios adhered to the rubric. Each case scenario contained approximately 200 words (Audrey 207, Jennifer 208, Meredith 211).

Each participant was asked to read a case sce- nario and then provide a case conceptualization including their explanation of the client’s psycho- logical difficulties and a treatment plan for the client. Participants were asked to write at least three sentences for each case conceptualization to avoid skewing of the results based on limited information alone. This procedure has also been used in past studies requiring written conceptu- alizations (Constantine, 2001a, 2001b). To ac- count for ordering effects, the ordering of the scenarios was varied in the surveys. The surveys were then randomly administered. Therefore, each participant had an equal likelihood of re- ceiving a survey of a particular order. We then calculated the number of times each case was administered in each particular order, to check the success of the randomization. In the current data set, Audrey was presented first in the order- ing 33 times, second 28 times and third 30 times. Jennifer was presented first 31 times, second 32 times and third 28 times. Meredith was presented first 27 times, second 31 times, and third 33 times. The responses to the three cases served as the basis for the derivation of the rated measures, that is, amount of general differentiation, amount of multicultural differentiation, level of integra- tion, and degree of expertness.

Rated Measures

Raters unitized the participants’ responses into single concept, coherent grammatical units. These units served as the basis for all derived measures.

Differentiation was defined as simply the num- ber of different ideas in the case conceptualiza- tion and treatment planning sections. A similar method of operationalizing differentiation has been used previously in the literature by Constan- tine (2001a, 2001b, 2001c).

Multicultural differentiation was defined as the number of different ideas that included any spe- cific reference to culture, race, ethnicity, sex, age, socioeconomic status, ability status, and sexual orientation. This measure has not been previously

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used in prior literature, but rather a unique con- tribution of this study.

Integration was defined as the overall cohesion of the conceptualization. A highly integrated treatment included many connections between the differentiated ideas presented in the case con- ceptualization. Raters were asked to rate the over- all integration of both the case conceptualization and treatment plan together using a 5-point Likert-like scale, ranging from 1 (low integra- tion) to 5 (high integration). This method of measuring integration has been used previously in the literature by prior personality and social psychological studies on cognitive complexity to examine such issues as people’s evaluations of social situations, (Tetlock & Suedfeld, 1988), un- derstanding of themselves (Linville, 1987), and understanding of others (Linville & Jones, 1980).

Expertness was a measure of match between the ideas of the participants and those of experts in the field. This variable was included to provide a standard of appropriateness of content with respect to the case conceptualizations. Several recognized experts in multicultural therapy were solicited for cooperation. We believed that ex- perts in multicultural therapy would provide con- ceptualization content that related to both general and multicultural therapy competence. Two very well recognized experts agreed. Both experts have been actively presenting and publishing on the national level in the area of multicultural therapy over the past 15 years (each accruing over 50 national presentation and publications).

Both experts were asked to supply conceptu- alizations for each of the three scenarios. Their conceptualizations combined served as the expert criterion. Each sentence of the experts’ concep- tualizations was broken into single-concept, co- herent grammatical units. To account for the sa- lience of each of the units to the case conceptualization, units that were provided by both experts were given a weight of 2. All other units were assigned a weight of 1.

The number of weighted expert units included in each trainees’ case conceptualization was to- taled (hereon referred to as total score). This total score was then converted into a percentage score so that we could compare expertness ratings across case scenarios (this was necessary because the total possible expert units, hereon referred to as total possible score, varied by case). For each client case therefore, trainees’ total score was divided by the total possible score and multiplied

by one hundred. Hence, expertness is the percent- age each trainee scored out of the total possible expert units. To reach a perfect score on expert- ness (100%) for a given case, trainees would have had to produce all of the same ideas produced by experts for that case.

Raters

Three undergraduate students in their junior (third) year at a 4-year Southwestern university served as raters. We chose undergraduate raters for several reasons: (a) We believed that most individuals with at least a high school education should be able to comprehend the instructions and complete the task, (b) We wanted to ensure that all ratings were based only on the explicit and straightforward definitions we provided and, (c) We wanted to ensure that raters did not read into any idiosyncratic nuanced meaning and more naı̈ve raters (i.e., not experts in the field) were viewed as a safe guard against this. In an effort to ensure the validity of the undergraduate students’ ratings, an advanced counseling psychology doc- toral student also served as a rater. Examination of the reliability coefficients between the coun- seling psychology doctoral student and each of the undergraduate students found that there were no systematic differences between the ratings of the psychology doctoral student and the under- graduate students; hence, lack of psychology training did not appear to affect ratings. All raters were blind as to any of the background informa- tion of the case conceptualizations. Each rater coded all participant responses. All ratings were done independently and to increase reliability, all ratings were averaged over all raters to provide the study indexes.

Raters were provided with written instructions and underwent a 3-hr training with the first author on how to rate the client scenarios. Two 1-hr feedback/check-in sessions were conducted by the first author to ensure reliability as well as lack of rater drift. Interrater reliability for each score was examined using the intraclass correlation co- efficient. Because this study asked the same four raters to rate all of the data, the analysis used to calculate the intraclass correlation coefficients for this study was consistent with Strout and Fleiss’s Case Three (Strout & Fleiss, 1979). Reliability was calculated separately for each case. This very conservative approach, instead of looking at overall reliability, enabled an examination of po-

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tential reliability differences. Intraclass reliability estimates for each of the rated measures (general differentiation, multicultural differentiation, inte- gration, and expertness) ranged from .89 to 1.00 and were all well above standard adequacy cut- offs (e.g., Heppner, Kivlighan, & Wampold, 1999).

Analyses

We wished to examine the mean differences in the conceptualization variables across level of clinical training and multicultural training. The distribution of clinical training (in terms of num- ber of semesters of formal supervised practice) and multicultural training (in terms of multicul- tural classes completed) was negatively skewed with most individuals in the low or middle ranges and a few individuals being very high. Given these distributions we opted for a more robust examination of clinical and multicultural training using three ordered categories for clinical expe- rience (0, one semester, or greater than one se- mester) and four ordered categories for multicul- tural experience (0, 1, 2, more than two multicultural classes completed). We hypothe- sized that general case conceptualization skills (general differentiation, integration, and expert- ness) would significantly differ across levels of clinical training. We believed that multicultural case conceptualization skills (multicultural dif- ferentiation and expertness) would significantly differ across level of multicultural training. Al- though we did not expect significant differences in multicultural differentiation by level of clinical training, we assessed the relation between clinical training and multicultural differentiation to rule out the possibility that a significant increase in multicultural differentiation is a mere function of advancement in overall training, rather than mul- ticultural training per se. Given previous findings in the literature, we also believed that the case conceptualizations of White trainees may differ significantly from trainees of color, with trainees of color including more multicultural content in their conceptualizations.

We examined each of the complexity and ex- pertness variables using a three way multivariate analysis of variance (MANOVA), with client stimuli as the within-subject effect and amount of clinical training and racial group (White vs. trainee of color) as the between-subject effects. In addition to these analyses, multicultural case con-

ceptualization skills (multicultural differentiation and expertness) were also examined with amount of multicultural training as a between-subjects effect. Given the difficulties in studying coun- selor development in which there are often rela- tively small samples, we wanted to ensure enough power in our analyses. Where results have been yielded in the past, the effect sizes have generally been small (i.e., Constantine, 2001b, 2001c; Constantine & Gushue, 2003). Given this and our modest sample size in some analyses, we adopted a test-wise Type I error rate of .05 to provide a balance between protecting against finding differences where they do not truly exist, while increasing the chances of find- ing any differences where they do exist.

Results

The means and standard deviations for all the rated measures, that is, general differentiation, multicultural differentiation, integration, and ex- pertness by clinical training and racial group are listed in Table 1. Means and standard deviations for multicultural differentiation and expertness by multicultural training and racial group are included in Table 2, whereas MANOVA results are summarized in Table 3.

The results of the MANOVA examining gen- eral differentiation indicated that there were no significant differences for any of the within- subjects effects. General differentiation was not found to vary across the three different client stimuli, nor were there differences across client stimuli in the interaction with race or clinical training level. For the between-subjects effects, there were significant differences in general dif- ferentiation by clinical training level, F(2, 87) � 4.89, p � .05, partial �2 � .11, but not for race or the training by race interaction. The Dunnett C post hoc procedure was chosen as a conservative approach to post hoc analysis because it accounts for unequal variance in groups (Green, Salkind, & Akey, 2000), which is probable given the small and uneven sample sizes of the groups in this analysis. The post hoc results on the level of clinical training between-subjects effect indicated that participants who have completed more than one semester of supervised clinical training scored significantly higher on general differenti- ation than participants who have had no super- vised clinical training. There were no differences

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between the students with only one semester of clinical training and either of the other groups.

With regard to integration, none of the within-subjects effects were significant demon- strating that integration did not vary across the different client stimuli. There were significant effects between subjects for clinical training only, F(1, 81) � 10.54, p � .001, partial �2 � .21. Post hoc analysis on the training level effect using Dunnet C revealed that partici- pants who reported completing more than one semester of supervised clinical experience scored significantly higher in integration than those who completed zero or one semester of supervised practicum.

For expertness by clinical training, the MANOVA produced a significant within- subjects effect only for client stimulus, F(2, 81) � 47.08, p � .001, partial �2 � .37, and the three-way interaction of client Stimulus � Race � Clinical Training Level, F(4, 162) � 2.54, p � .05, partial �2 � .06. Post hoc analysis of the client effect revealed that expertness was higher for Client A (Caucasian client) and Client M (American Indian client/culture explicitly stated), than for Client J (African American client/culture implied). Post hoc analysis of the three-way interaction did not produce any con- trasts that were significantly different from each other. Given this and the marginal significance

TABLE 1. Means and Standard Deviations for General Differentiation, Multicultural Differentiation, Integration, and Expertness by Trainees’ Number of Semesters of Completed Supervised Clinical Training

Variable

Client A Client J Client M

n M SD M SD M SD

General differentiationa

Semesters of clinical training 0 White trainees 26 6.89 1.82 6.34 1.57 6.43 1.43 Trainees of color 7 5.93 1.19 6.75 1.31 6.79 1.40 1 White students 18 6.89 1.87 6.99 2.61 7.22 2.77 Trainees of color 7 6.79 1.69 5.93 0.97 6.82 1.30 �1 White trainees 16 8.33 2.07 8.31 1.71 7.08 0.93 Trainees of color 13 7.35 1.76 7.99 2.30 7.69 2.10

Multicultural differentiationb

Semesters of clinical training 0 White trainees 26 0.08 0.39 0.40 0.87 2.63 1.29 Trainees of color 7 0.00 0.00 0.96 0.98 2.71 1.60 1 White students 18 0.06 0.24 0.96 1.12 3.32 1.63 Trainees of color 7 0.00 0.00 0.71 1.50 1.79 1.36 �1 White trainees 17 0.00 0.00 1.43 1.05 2.28 1.30 Trainees of color 13 0.00 0.00 1.65 1.65 3.44 1.03

Integrationc

Semesters of clinical training 0 White trainees 26 2.25 0.83 2.09 0.75 2.45 0.89 Trainees of color 7 2.25 0.65 2.67 0.49 2.61 0.89 1 White students 18 2.33 0.99 2.71 1.00 2.71 1.12 Trainees of color 7 2.39 0.76 2.28 0.62 2.57 0.80 �1 White trainees 16 3.34 0.71 3.19 0.98 3.28 1.17 Trainees of color 13 3.31 1.11 3.00 0.97 3.33 0.79

Expertnessd

Semesters of clinical training 0 White trainees 26 14.86 5.34 6.69 2.43 14.45 5.76 Trainees of color 7 13.48 4.46 10.05 3.88 12.08 5.21 1 White students 18 13.26 5.22 8.04 4.33 14.62 6.34 Trainees of color 7 16.13 4.91 7.31 5.99 15.34 5.84 �1 White trainees 16 18.95 6.71 11.81 3.50 16.31 6.48 Trainees of color 13 17.18 5.56 12.12 2.31 18.10 5.54

Note. Client A � Caucasian; Client J � African American, culture implicit; Client M � American Indian, culture explicit. a Differentiation is reported in actual number of different ideas presented by trainees. b Multicultural differentiation is reported in the actual number of different culturally relevant ideas presented by the trainee. c Integration is reported on a scale ranging from 1 (not integrated at all) to 5 (very well integrated). d Expertness is reported in percentage of total expert content presented by trainees.

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level of this result, we did not interpret it further. For the between subjects effects, expertness was found to differ only across clinical training level, F(2, 81) � 7.99, p � .05, partial �2 � .16. Neither race nor the Race � Clinical Training Level interaction were significant. The post hoc test of the training effect revealed that partici- pants receiving more than one semester of practi- cum experience scored significantly higher in ex- pertness than participants who completed either zero or one semester of supervised practicum. Those who completed no semesters of clinical training also differed significantly from those who complete one semester.

For expertness by multicultural training, the MANOVA produced a significant within subjects effect only for client stimulus, F(2, 156) � 42.94, p � .001, partial �2 � .35. Post hoc analysis of the client effect revealed that expertness was higher for Client A (Caucasian client) and Client M (American Indian client/culture explicitly stated), than for Client J (African American client/culture implied). For the between-subjects effects, expertness was found to differ only across multicultural training level, F(3, 78) � 3.55, p � .05, partial �2 � .12. Neither race nor

the Race � Multicultural Training Level interac- tion were significant. The post hoc test of the multicultural training effect revealed that partic- ipants completing more than two multicultural courses scored higher on expertness than those who have not completed any multicultural course.

Multicultural differentiation was examined dif- ferently than above. Specifically, only cultural cases (i.e., Jennifer, culture implicit, and Meredith, culture explicit) were used to assess for differences in multicultural differentiation be- cause the variance in the multicultural differenti- ation score for Audrey (Caucasian client) was virtually nonexistent. Two MANOVAs were con- ducted on multicultural differentiation for Jen- nifer (culture implicit) and Meredith (culture ex- plicit), but they differed on whether clinical training or multicultural training was incorpo- rated as a between-subjects variable. For the first analysis, level of clinical training was entered with racial group as between-subjects variables and the two client stimuli as the within-subjects factor. For the second analysis, multicultural training was entered with racial group as the between-subjects variables and the same two cli-

TABLE 2. Means and Standard Deviations for Multicultural Differentiation and Expertness by Trainees’ Number of Semesters of Completed Supervised Clinical Training

Variable

Client A Client J Client M

n M SD M SD M SD

Multicultural differentiationa

No. of multicultural classes 0 White trainees 19 0.00 0.00 0.20 0.49 2.67 1.31 Trainees of color 4 0.00 0.00 0.25 0.50 2.44 2.18 1 White trainees 21 0.00 0.00 1.02 1.17 2.77 1.52 Trainees of color 6 0.00 0.00 1.08 1.19 2.50 1.29 2 White trainees 13 0.25 0.62 1.21 1.11 2.35 1.32 Trainees of color 7 0.00 0.00 1.50 1.41 2.36 1.31 �2 White trainees 7 0.00 0.00 1.32 1.26 3.32 1.85 Trainees of color 10 0.00 0.00 1.53 1.87 3.50 1.13

Expertnessb

No. of multicultural classes 0 White trainees 19 14.56 5.74 6.67 2.87 14.16 5.76 Trainees of color 4 13.71 2.87 8.57 3.89 9.93 3.52 1 White trainees 21 14.36 6.16 9.24 4.51 15.41 6.20 Trainees of color 6 15.32 3.60 7.36 3.59 14.83 6.56 2 White trainees 13 17.61 6.40 8.82 3.78 14.95 6.87 Trainees of color 7 14.51 6.30 12.37 4.93 15.55 3.58 �2 White trainees 7 17.86 5.79 10.63 3.85 17.12 4.97 Trainees of color 10 18.23 5.59 11.39 3.56 18.97 4.97

Note. Client A � Caucasian; Client J � African American, culture implicit; Client M � American Indian, culture explicit. a Multicultural differentiation is reported in the actual number of different culturally relevant ideas presented by the trainee. b Ex- pertness is reported in percentage of total expert content presented by trainees.

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TABLE 3. Summary of the MANOVAs Conducted on the Conceptualization Variables Between Training Level and Race Across Specific Client Stimuli

df Pillai’s F p partial �2

General differentiation by clinical training Within-subject effects

Client stimulus 2, 162 0.023 .980 .001 Client � Race 2, 162 2.030 .135 .024 Client � Clinical Training 4, 162 1.817 .128 .043 Client � Race � Clinical Training 4, 162 1.553 .190 .037

Between-subject effects Intercept 1, 81 1435.83 .000 .947 Race 1, 81 0.529 .469 .006 Clinical training 2, 81 4.889 .010 .108 Race � Clinical Training 2, 81 0.117 .890 .003

Multicultural differentiation by clinical training (clients of color only)

Within-subject effects Client stimulus 1, 82 68.663 .000 .456 Client � Race 1, 82 0.464 .498 .006 Client � Clinical Training 2, 82 1.009 .369 .024 Client � Race � Clinical Training 2, 82 2.768 .069 .063

Between-subject effects Intercept 1, 82 270.754 .000 .768 Race 1, 82 0.037 .847 .000 Clinical training 2, 82 2.591 .081 .059 Race � Clinical Training 2, 82 4.380 .016 .097

Integration by clinical training Within-subject effects

Client stimulus 2, 162 1.531 .219 .019 Client � Race 2, 162 0.007 .993 .000 Client � Clinical Training 4, 162 0.719 .580 .017 Client � Race � Clinical Training 4, 162 1.009 .405 .024

Between-subject effects Intercept 1, 81 969.546 .000 .923 Race 1, 81 0.002 .965 .000 Clinical training 2, 81 10.539 .000 .206 Race � Clinical Training 2, 81 0.483 .619 .012

Expertness by clinical training Within-subject effects

Client stimulus 2, 162 59.149 .000 .597 Client � Race 2, 162 0.413 .664 .010 Client � Clinical Training 4, 162 0.527 .716 .013 Client � Race � Clinical Training 4, 162 2.538 .042 .059

Between-subject effects Intercept 1, 81 901.284 .000 .918 Race 1, 81 0.121 .729 .001 Clinical training 2, 81 7.990 .001 .165 Race � Clinical Training 2, 81 0.123 .885 .003

Multicultural differentiation by multicultural training (clients of color only)

Within-subject effects Client stimulus 1, 79 63.916 .000 .447 Client � Race 1, 79 0.286 .595 .004 Client � Multicultural Training 3, 79 1.737 .166 .062 Client � Race � Multicultural Training 3, 79 0.027 .994 .001

Between-subject effects Intercept 1, 79 243.037 .000 .755 Race 1, 79 0.022 .882 .000 Multicultural training 3, 79 2.800 .045 .096 Race � Multicultural Training 3, 79 0.108 .955 .004

(table continues)

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ent stimuli as the within-subject factor. Two sep- arate analyses were conducted because there were no participants indicating both a high level of clinical training and low level of multicultural training, or vice versa, both a low level of clinical training and high level of multicultural training.

For the first analysis focusing on multicultural differentiation across clinical training level, there was a within-subjects effect only for the client stimulus, F(1, 82) � 68.66, p � .001, partial �2 � .46. Participants across all levels included significantly more culture specific ideas in their conceptualizations of Meredith (culture explicit) than in their conceptualizations of Jennifer (cul- ture implicit). There were significant between- subject differences found only for the Race � Clinical Training Level interaction, F(2, 82) � 4.380, p � .05, partial �2 � .097 and not for either the race or clinical training level main effects. For Jennifer (culture implicit), the trend in expert endorsement was linear, wherein train- ees of color and White trainees both increased over training. For Meredith (culture explicit), the results were more complex. For no training, both White trainees and trainees of color had equally moderate scores. With one course of clinical training, the White trainees presented the most cultural content, whereas trainees of color at this stage in their training presented the least. Finally those White trainees with greater than one semes- ter of clinical training demonstrated a decreased amount of cultural content, close to the levels of those without any training. For the trainees of color, the amount of multicultural content was high. In sum, the pattern of multicultural differ- entiation over training levels for White trainees was moderate to high to moderate, where the

pattern for trainees of color was moderate to low to high.

A similar MANOVA was conducted in exam- ining multicultural differentiation and amount of multicultural training (number of completed mul- ticultural courses: 0, 1, 2, or greater than 2) and racial group. Results of the MANOVA indicated significant multicultural training effects, F(1, 79) � 63.92, p � .05, partial �2 � .45. Post hoc analyses on the multicultural training effect re- vealed that participants who reported having completed more than two multicultural courses included significantly more references to cultural issues in their case conceptualizations than par- ticipants who completed less than two courses. Similar to the previous analysis, there was a significant within subject main effect of multicul- tural differentiation for client, F(1, 79) � 63.92, p � .05, partial �2 � .45; indicating significantly more references to culture being incorporated in the culture explicit client, than the culture im- plicit client.

Discussion

The purpose of this study was to gain a better understanding of how psychotherapy trainees dif- fer in their general and multicultural case concep- tualization skills across levels of clinical and multicultural training, client cases, and trainee race. Results were, for the most part, as expected. General case conceptualization skills (general differentiation, integration, and expertness) cor- related significantly with clinical training, and multicultural case conceptualization skills (mul- ticultural differentiation and expertness) corre- lated significantly with multicultural training.

TABLE 3. (continued)

df Pillai’s F p partial �2

Expertness by multicultural training Within-subject effects

Client stimulus 2, 156 42.938 .000 .355 Client � Race 2, 156 0.848 .430 .011 Client � Multicultural Training 6, 156 0.492 .814 .019 Client � Race � Multicultural Training 6, 156 1.421 .210 .052

Between-subject effects Intercept 1, 78 778.547 .000 .919 Race 1, 78 0.003 .956 .000 Multicultural training 3, 78 3.547 .018 .120 Race � Multicultural Training 3, 78 0.211 .889 .008

Note. Client A � Caucasian; Client J � African American, culture implicit; Client M � American Indian, culture explicit; MANOVA � multivariate analysis of variance.

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Across client cases, trainees exhibited similar levels of general case conceptualization skills, but different levels of multicultural case concep- tualization skills. Contrary to our hypothesis, there were no significant differences in the gen- eral or multicultural case conceptualization skills between trainees of color and White trainees. Below we discuss the importance and implica- tions of our findings, summarize the limitations of our study and offer conclusions regarding fu- ture inquiry.

Clinical and Multicultural Training

Following Ladany’s (2007) suggestions, we em- pirically scrutinized psychotherapy training prac- tices in two areas, supervised clinical training and multicultural training. We found that trainees with more than one semester of clinical training exhib- ited significantly greater complexity and expertness in their conceptualizations across clients. Because most psychotherapy training programs require trainees to complete more than one semester of supervised clinical experience, our study pro- vides empirical support for why this requirement is important. We also found that trainees who completed more than two multicultural courses demonstrated greater multicultural case con- ceptualization skills than those who received less than two. Trainees who completed two multicultural courses were not significantly dif- ferent in skill level than those who received one or no course. This is important in that most psychotherapy training programs require only one multicultural course. Our findings suggest that this practice may be inadequate. Of course, further inquiry is needed to substantiate this, as there are other possible explanations for these findings.

One plausible reason for this result is that of self-selection. It is possible that trainees who choose to include more then two multicultural courses into their training experience may be more interested in this topic, and therefore more inclined to incorporate cultural issues in their conceptualizations. Therefore, these findings may confound multicultural training with trainee in- terest. Another possibility is that trainees re- ceived extensive multicultural instruction within their regular coursework (infusion approach), which may elevate multicultural differentiation across levels and thereby confound the relation between multicultural differentiation and multi-

cultural training. Regardless of the reason of this finding, we agree with Ladany’s (2007) argument that psychotherapy training would benefit from researching specific training practices, and how these practices affect the competency develop- ment of trainees.

Our results indicated that multicultural differ- entiation was significantly related to multicultural training, but not clinical training. This confirmed our hypothesis that specific training in multicul- tural issues is critical for increasing multicultural case conceptualization skills of psychotherapy trainees. Although we expected this result, we believe it is imperative that clinical supervisors intentionally incorporate multicultural issues into their conceptualization of all clients. Prior re- search has indicated that when supervisors in- struct trainees to consider cultural issues in case conceptualization, they are more likely to include culturally relevant items treatment planning (Ladany et al., 1997). Although methods of how to address multicultural competencies in the con- text of supervision have been discussed in the literature (APA, 2003), it is important to ascertain to what extent these methods are being used and to determine their overall effectiveness.

Psychotherapy Trainee Development Models

Our findings support prior theory on psycho- therapy trainee development. Trainees who com- pleted more clinical training were better equipped to provide different alternatives to conceptualiz- ing client problems, to present their ideas in a more cohesive fashion, and to offer ideas perti- nent to the client. We also found that case con- ceptualization skills may also manifest variably over the course of clinical training. Whereas dif- ferences in general differentiation and integration were found only between those with no semesters of completed practicum and those who completed more than one semester, significant differences in expertness were found between each level of clinical training. This suggests that the appropri- ateness of trainees’ conceptualizations increases significantly with each incremental practicum, whereas general differentiation and integration may be a more gradual process. More research is needed in this regard to further explicate how different competencies may develop throughout the course of psychotherapy training. This type of research informs what psychotherapy educators may expect of trainees as they progress through-

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out clinical training, and may assist in the cre- ation of developmentally appropriate measures to assess psychotherapy competencies throughout training.

Client Case

Significant differences across client case were found in measures of multicultural case concep- tualization (multicultural differentiation and ex- pertness). However, indicators that only related to general case conceptualization skills (general differentiation and integration) were not found to differ significantly by client case. With multicul- tural differentiation, trainees regardless of race and training level were found to include signifi- cantly more culturally relevant ideas in their con- ceptualizations of Meredith (culture explicit) than that of Jennifer (culture implied). Again, this result differed from that of general differentia- tion, in which participants within each of the training levels included approximately the same amount of different ideas in their conceptualiza- tions of Meredith and Jennifer. However, in mul- ticultural differentiation, for every three cultur- ally relevant ideas they produced for Meredith, they produced one for Jennifer. Trainees must be made aware that regardless of whether culture is made explicit by the client in the presenting issue, it is important to consider how culture affects the experiences of all clients of color.

With respect to Audrey (Caucasian client), almost no trainees included cultural content. However, there was a high level of expertness demonstrated. Further examination of the ex- pert conceptions of this client indicated that there were a few explicit references to culture, although not as much for the other clients. Hence, there appeared to be a lower salience for cultural issues with this client case. This conclusion is consistent in the context of prior discussions that psychotherapy practices origi- nate from a White dominant perspective (Sue & Sue, 2003) and that perhaps there is lesser need to consider culture in working with clients for whom the practices support (Neutfeld et al., 2006). Further research is needed to understand how the lesser attention paid to multicultural issues for White clients, relative to clients of color, may affect actual work with clients and effectiveness of treatment.

Trainee Race

Our results did not support our hypothesis and previous literature findings that case conceptual- ization skills of trainees of color differ signifi- cantly from their White counterparts in their con- ceptualizations of clients of color. There were no differences in the case conceptualization skills between White trainees and trainees of color in general differentiation, integration or expertness in any of the client cases. The only significant difference involving race was the Race � Clini- cal Training Level interaction effect for multicul- tural differentiation scores for Meredith (culture explicit). Given the small and uneven sample sizes for each cell of Race � Clinical Training, we acknowledge that our findings are limited and should be interpreted with caution. However, our findings do underscore the importance of attend- ing to possible individual and developmental dif- ferences between trainees of color and White trainees, rather than previous methods of exam- ining global differences between these groups in multicultural case conceptualization.

Future research would benefit from consider- ing within group differences in multicultural case conceptualization skills. In lieu of posing the question, “Does race matter in the multicultural case conceptualization skills of counselor train- ees?”, researchers may gain a better understand- ing by asking, “How does race matter in the developmental process of multicultural case con- ceptualization skills for counselor trainees?” Fur- ther, it is important to consider individual differ- ences among trainees (such as racial and ethnic identity or life experience) because trainee race, in and of itself, may not be an adequate indicator of how well or often trainees think about the impact of culture. Race should not serve as a proxy for some other measure of individual dif- ference. For example, just because a trainee is Black does not necessarily mean that she would better understand and conceptualize a Black cli- ent who is struggling with race-related issues. Depending on the trainee’s racial identity status (i.e., how she thinks and feels about her own and others’ race), she may be a poor fit for this client (Carter, 1995). The best trainee for this client would arguably be the one who has committed to actively engaging in self and other exploration regarding the importance of race and how race influences people’s experiences and worldviews (regardless of the race of the trainee). Similar

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arguments have been made previously in the mul- ticultural literature (Wang & Sue, 2005), as well as in the case conceptualization literature (Ladany et al., 1997; Neutfeld et al., 2006).

Limitations

This study is not without limitations. Perhaps the largest is the cross sectional analysis of indi- viduals from only one training program. Such an examination makes it difficult to know if indeed these changes occur over the course of training. Only a longitudinal examination would reveal this. Further these results may characterize only one program and not apply elsewhere. The cul- tural content of this training program may not resemble others and/or the students attracted to this program may not be typical. So although we see these results as important, we do see the need for continued research in this area that is longi- tudinal and based across several programs.

Another limitation of this study is the con- founding effect of overall advancement through training. Of course, as psychotherapy trainees advance through their training, they accrue many different experiences through course work and clinical experience that results in their growth over time. It is therefore impossible to conclude in this type of research that only one aspect of training has caused an increase in a certain area of development. For this type of question, exper- imental designs that afford more control are ap- propriate. In this study, we were limited to mak- ing only correlational inferences.

Last, this study is an analogue study. It is possible that trainees may respond differently to a simulated scenario than to an actual client who is in their care. It is possible that they may have increased empathy, and a sharpened awareness of how cultural issues may be affecting the client. Further, the specific case scenarios may have served as another possible limitation for this study, in that we assumed each case we con- structed was representative of a certain level of cultural explicitness. Although we took measures to ensure that the three cases varied only by race and by the degree of “cultural explicitness” (as described in the Method section), we are not able to rule out the possibility that trainees’ responses may be attributed to other factors unique to each case. The inclusion of multiple cases in each level of “cultural explicitness” may have assisted in ruling out this possibility. However, because we

chose not to include more cases due to the de- mand on participants, this remains a limitation for our study.

Implications for Psychotherapy Training

The results of our study have important impli- cations for psychotherapy training. Most impor- tant was our finding that all trainees integrated more culturally relevant ideas into their concep- tualizations regarding a client of color who ex- plicitly expressed cultural issues as a concern. In psychotherapy training, it is crucial to highlight that all people are multicultural beings, and that considerations of culture should be made regard- less of whether the client explicitly reports cul- tural issues as being problematic, and whether the client is a person of color. Therefore, psychother- apy training programs as a whole may wish to consider highlighting the pervasive importance of culture in their work. This focus should be rein- forced in all aspects of training, coursework as well as clinical work. In an atmosphere wherein cultural dynamics are recognized and explored, psychotherapists are challenged to adopt a stance of critically thinking about culture as a context, a necessary and integral aspect of understanding human behavior, as opposed to a consideration reserved only for the few. The paradigm for train- ing should be to incorporate all aspects of culture (race, ethnicity, gender, sexual orientation, abil- ity, religion, and social status) into the overall understanding of the client, and that any under- standing would be incomplete without consider- ing each of these dimensions of cultural identity. It is hoped that eventually trainees would dem- onstrate similar levels of multicultural case con- ceptualization skills, regardless of client demo- graphic or problem.

Future Research Directions

Psychotherapy training research may benefit from continued exploration of developmental models, as well as within-group differences among levels of trainees. Instead of assuming that progression in psychotherapy competencies fol- lows a linear and normative pattern, training pro- grams would benefit from idiographic and idio- thetic research examining how psychotherapy trainees develop over the course of their training (Darcy, Lee & Tracey, 2004). Case conceptual- ization research would gain from continued ex-

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ploration of both complexity and expertness. In studying either of these concepts in exclusion, important information is missed. Last, we advo- cate for more research exploring how case con- ceptualization skills may relate to actual client outcomes. We believe that bridging lines of in- quiry that have developed relatively indepen- dently over the years (case conceptualization, trainee development, multicultural competence, and outcome research) would further this goal. Because the importance of culture has recently been in the forefront of our field, it is surprising that not more studies have emphasized how train- ees conceptualize and work with clients repre- senting a broad range of cultural diversity. Uni- fying our efforts would facilitate the ultimate aim of understanding how to best prepare psychother- apists in skillfully meeting the needs of this in- creasingly pluralistic society.

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