Assignment: Diversity Challenges and Reflections

Couples, Families, & Health

Culture, Personality, Health, and Family Dynamics: Cultural Competence in the Selection of Culturally Sensitive Treatments

Len Sperry1

Abstract Cultural sensitivity and cultural competence in the selection of culturally sensitive treatments is a requisite for effective counseling practice in working with diverse clients and their families, particularly when clients present with health issues or medical problems. Described here is a strategy for selecting culturally sensitive treatments (cultural interventions, culturally sensitive interventions, or culturally sensitive therapy) based on a comprehensive assessment of cultural factors, personality dynamics, family dynamics, and health or medical conditions. A case example is provided that illustrates this strategy.

Keywords acculturation, cultural sensitivity, cultural competency, cultural interventions, culturally sensitive interventions, culturally sensitive therapy

Although most clinicians report that cultural sensitivity and

culturally sensitive treatments are important in providing cultu-

rally competent care to clients, couples, and families, very few

clinicians report that they actually provide culturally sensitive

treatment (Hansen et al., 2006). Arguably, there are various

reasons for this, but a likely explanation is that few clinicians

have had adequate training and experience with culturally sen-

sitive treatment. Such training would include assessment of

such factors as cultural identity, level of acculturation, family

dynamics, and ‘‘explanatory models,’’ indications for the use

of various types of culturally sensitive treatment, and a method

of selecting if, when, and how to use such treatments. The value

of such training and experience is particularly evident when cli-

ents present with health issues or medical conditions (Sperry,

2006). This article addresses these factors and provides a clini-

cally useful strategy for selecting such treatments. It begins by

briefly distinguishing cultural intervention, culturally sensitive

therapy, and culturally sensitive intervention. Then, it provides

a strategy—in the form of guidelines—for making such deci-

sions. A case example illustrates the use of this strategy.

From Cultural Sensitivity to Cultural Competence

Although training programs today seem to be effective in pro-

moting cultural sensitivity, that is, awareness of how cultural

variables may affect the treatment process, they do seem to

be as effective in promoting cultural competency, that is, the

capacity to translate cultural sensitivity into action that results

in effective treatment. This is the consensus among most of the

clinicians and supervisors I have spoken with recently as well

as the conclusion of a recent large-scale survey of practicing

clinicians (Hansen et al., 2006).

Becoming culturally competent involves such essential

skills as the accurate assessment of cultural identity, level of

acculturation, family dynamics, explanatory model, and per-

sonality dynamics as they influence a client’s presenting prob-

lem and the identification and selection of the best ‘‘fit’’ type of

culturally sensitive treatment. Selecting appropriate culturally

sensitive treatment presupposes the clinician has accurately

assessed cultural identity and level of acculturation. Cultural

identity refers to an individual’s self-identification and sense

of belonging to a particular culture or place of origin, while

acculturation is the process and degree to which a client inte-

grates new cultural patterns into his or her original cultural pat-

terns (Paniagua, 2005). Level of acculturation can be

determined based on the client’s language, generation, and

social activities, as these factors are assessed by instruments

such as the Brief Acculturation Scale (Burnam, Hough, Karno,

1 Florida Atlantic University, Boca Raton, FL, USA

Corresponding Author:

Len Sperry, Florida Atlantic University, 659 N.W. 38th Circle, Boca Raton, FL

33431, USA

Email: [email protected]

The Family Journal: Counseling and Therapy for Couples and Families 18(3) 316-320 ª 2010 SAGE Publications DOI: 10.1177/1066480710372129 http://tfj.sagepub.com

316

Escobar, & Telles, 1987). It also presupposes the clinician can

accurately assess personality and relevant family dynamics.

Because family conflicts and marital discord can arise from dif-

ferent levels of acculturation among family members and

spouses leading to anxiety, depression, and noncompliance

with medical regimens, it is essential that the clinician identify

‘‘discrepancies in levels of acculturation among family mem-

bers and clients’ perceptions of ‘elevated levels of acculturative

stress’’’ (Paniagua, 2005, pp. 170, 171). Eliciting a client’s

explanatory model, that is, the personal explanation of the

cause of his or her problems, symptoms, and impaired function-

ing is essential in working with any client who presents with a

health issue or medical condition, and particularly those with

lower levels of acculturation (Sperry, 2006). Related to expla-

natory model is the concept of ‘‘illness perceptions’’ that are a

client’s belief about his or her illness in terms of its identity or

diagnostic label, its cause, its effects, its time line, and the con-

trol of symptoms and recovery from it (Sperry, 2009). Often,

such client explanations and illness perceptions reflect key cul-

tural values, beliefs, sanctions, and taboos that if not heeded

can interfere with the treatment process and outcomes.

Types of Culturally Sensitive Treatments

Based on a comprehensive assessment of the factors and

dynamics affecting the client’s presenting problem, the clini-

cian may select a conventional or a culturally sensitive treat-

ment. This section briefly describes three types of culturally

sensitive treatment (Sperry, 2010).

Cultural Intervention

A cultural intervention is a healing method or activity that is

consistent with the client’s belief system regarding healing and

has the potential to effect a specified change. Some examples

are healing circles, prayer or exorcism, and involvement of tra-

ditional healers from that client’s culture. Sometimes, the use

of cultural interventions requires collaboration with or referral

to such a healer or other experts (Paniagua, 2005). Still, a clin-

ician can begin the treatment process by focusing on core cul-

tural value, such as respito and personalismo, in an effort to

increase clinician’s achieved credibility, that is, the cultural cli-

ent’s perception that the clinician is trustworthy and effective.

Culturally Sensitive Therapy

Culturally sensitive therapy is a psychotherapeutic intervention

that directly addresses the cultural characteristics of diverse cli-

ents, that is, beliefs, customs, attitudes, and their socioeco-

nomic and historical context. Because they use traditional

healing methods and pathways, such approaches are appealing

to certain clients. For example, cuento therapy addresses cultu-

rally relevant variables such as familismo and personalismo

through the use of folk tales (cuentos) and is used with Puerto

Rican children. Likewise, Morita therapy that originated in

Japan and is now used throughout the world for a wide range

of disorders ranging from shyness to schizophrenia. These

kinds of therapy appears to particularly effective in clients with

lower levels of acculturation.

Culturally Sensitive Intervention

A culturally sensitive intervention is a Western psychothera-

peutic intervention that has been adapted or modified to be

responsive to the cultural characteristics of a particular client.

Largely because of their structured and educational focus,

diverse clients seem to find cognitive behavior therapy (CBT)

interventions acceptable and are the most often modified to be

culturally sensitive (Hays & Iwamasa, 2006). For example,

particularly in culturally diverse clients with lower levels of

acculturation, disputation, and cognitive restructuring of a

maladaptive belief are seldom the CBT intervention of choice,

whereas problem solving, skills training, or cognitive replace-

ment interventions (Sperry, 2010) may be more appropriate.

Strategy for Selecting a Culturally Sensitive Treatment

Here is a strategy for selecting culturally sensitive treatment

when indicated. This strategy includes seven specific guide-

lines and is particularly valuable when health issues or medical

conditions are present.

1. Elicit or identify the client’s cultural identity, level of

acculturation, explanatory model, that is, belief about the

cause of their illness (e.g., bad luck, spirits, virus or germ,

heredity, early traumatic experiences, chemical imbalance

in brain, etc.) and treatment expectations. In addition, elicit

the client’s personality dynamics, particularly as they

influence the treatment process.

2. Identify family dynamics and the level of acculturation of

family members who have direct influence on the client. In

addition, elicit their explanatory models of the client’s

health or medical problem and their own expectations for

treatment. Then, estimate the difference, if any, between

the client and family members on these parameters, and its

actual or potential effect on the client’s response to

treatment.

3. Develop a cultural formulation framing the client’s pre-

senting problems within the context of the overall family’s

cultural identity, acculturation levels, explanatory models,

treatment expectations, and the interplay of culture and the

client’s personality dynamics.

4. If a client identifies (cultural identity) primarily with the

mainstream culture and has a high level of acculturation

and there is no obvious indication of prejudice, racism,

or related bias, consider conventional interventions as the

primary treatment method. However, the clinician should

be aware that a culturally sensitive treatment may also

be indicated as the treatment process develops.

5. If a client identifies largely with the mainstream culture

and has a high level of acculturation and there is an

Sperry 317

317

indication of prejudice, racism, or related bias, consider

culturally sensitive interventions or cultural interventions

for cultural aspect of the client’s concern. In addition, it

may be useful to utilize conventional interventions for

related noncultural concerns, that is, personality dynamics.

6. If a client identifies largely with their ethnic background

and level of acculturation is low, consider cultural inter-

ventions or culturally sensitive therapy. This may necessi-

tate collaboration with or referral to an expert and/or an

initial discussion of core cultural values.

7. If a client’s cultural identity is mainstream and accultura-

tion level is high, but that of their family is low, such that

the presenting concern is largely a matter cultural discre-

pancy, consider a cultural intervention with the client and

the family. However, if there is an imminent crisis situa-

tion, consider conventional interventions to reduce the cri-

sis. After it is reduced or eliminated, consider introducing

cultural interventions or culturally sensitive therapy

(Sperry, 2010).

Case Illustration: Strategy for Selecting Culturally Sensitive Treatment

Marques is a 23-year-old single, first generation unmarried

Haitian American male. He presented at mental health clinic

with complaints of sadness and was evaluated by a licensed

mental health counselor who was a middle-aged Caucasian

male. His mood was depressed and he admitted experiencing

increased social isolation, low energy, and hypersomnia, that

is, sleeping 10–12 hr per night. Marques also noted that he was

also having difficulty dealing with a ‘‘tough situation.’’ He pre-

sented as shy and passive while his mood was sad with con-

stricted affect. He is the oldest of three siblings and lives

with his mother and younger sister in a predominantly Haitian

community since migrating from Haiti.

The counselor elicited his explanatory model and health

beliefs. Marques believed that his depression was primarily due

to distress and disappointment about law school, having with-

drawn at the semester break of his first year despite having a

full scholarship. He was tearful in describing his exclusion

from a study group and the complaints of White students that

minorities were admitted only because of affirmative action.

This was particularly troubling to Marques because he had high

law school admission tests (LSATs) and a 3.9 grade point aver-

age (GPA) in his undergraduate studies. He believed he could

not return to school because of fear of reexperiencing racism.

Marques disclosed that when he was in sixth grade, he was hit

in the head with a rock during a confrontation between White

and Haitian student; and afterward avoided all confrontations.

Accordingly, the counselor was not surprised that he had

refused to confront the law school situation and instead quietly

withdrew. His treatment expectations were to ‘‘get rid of the

sadness’’ and to be less troubled by criticism of others and to

better face ‘‘tough situation.’’ Marques identified himself as a

‘‘middle-class American of Haitian heritage’’ and demon-

strated a high level of acculturation. After securing his written

consent, the clinician interviewed Marques’s mother and his

younger sister. They likewise exhibited high levels of accul-

turation and also believed that Marques’s depression stemmed

from his withdrawal from law school. His mother shook her

head and said that while Haitian men tend to be less dominant

than Haitian women, she ‘‘couldn’t understand why he’s so shy

and passive, especially when wronged by others. He’s been this

way since he was a kid.’’ This description seems consistent

with the dynamics of the avoidant personality.

To complete this initial evaluation, the counselor arranged

for a routine medical consultation of Marques because it had

been nearly 2 years since he had completed an annual medical

checkup. The results of that evaluation were positive for a diag-

nosis of hypothyroidism. The physician conjectured that

Marques’s thyroid had been underfunctioning for a year or

more and was hopeful this chronic medical condition could

be controlled by Synthroid that he agreed to take as prescribed.

Because low energy and depression are common symptoms of

hypothyroidism, the counselor evaluated Marques’s symptoms

over the next 4 weeks. By then, lab tests indicated that his

thyroid levels were in the normal range. However, while he had

returned to his previous energy level, he continued to experi-

ence sad feelings and was still socially isolated.

In terms of a clinical and cultural formulation, his depres-

sive symptoms and social isolation appeared to be triggered

and exacerbated by his experience with racism leading to his

withdrawal from school. Prominent was his avoidant behavior

that seemed to be exacerbated by both his avoidant personality

as well as cultural beliefs that appeared to be operative in his

response to Caucasian law students.

Figure 1 visually depicts the relative impact of cultural

dynamics, personality dynamics, and medical condition on

Marques, as he presented for counseling. Note that personality

dynamics were rated as high while cultural dynamics were

rated as midrange and as such were considered contributory

to His initial presentation. In contrast, family dynamics was

rated as low and considered noncontributory. His medical con-

dition was contributory but to a lesser extent than culture or

personality.

Based on this evaluation, a treatment plan was developed in

which both conventional and culturally sensitive treatments

were included. This mutually agreed up treatment plan

involved four treatment targets. The first was depressive symp-

toms that would be addressed with CBT and continuation of

thyroid medication. The medical consultant doubted that an

antidepressant was indicated but left that option open to recon-

sideration at the judgment of the counselor. The second target

was his avoidant personality style and behaviors that were cul-

turally influenced for which a ‘‘culturally sensitive interven-

tion’’ would be directed at dealing more effectively with

‘‘tough situations’’ such as prejudice and racism. The clinic’s

Haitian male therapist would be involved with this treatment

target as well as the third target in which he would serve as a

co-therapist with Marques’ Caucasian counselor in group

therapy. This third target involved the personality component

of Marques’ avoidant personality style for which conflict

318 The Family Journal: Counseling and Therapy for Couples and Families 18(3)

318

resolution and assertive communication skills training would

be a central part of the group work. The fourth target involved

career exploration including the possibility of reinstatement in

law school. His therapist would consult with and involve the

school’s minority affairs director, who was an African Ameri-

can male.

Case Commentary

As a result of the assessment and cultural formulation, it was

determined that Marques would be best treated with conven-

tional interventions aimed at personality dynamics and a ‘‘cul-

turally sensitive intervention’’ aimed at cultural dynamics.

However, had Marques’ explanatory model of depression and

his treatment expectations been more culture based, and his

personality dynamics less dominant, consideration would have

been given to a ‘‘cultural intervention.’’ Similarly, if there was

a discrepancy on acculturation levels between Marques and his

mother and younger sister and/or interfering family dynamics

were operative, cultural interventions and family interventions

might have played a more prominent role in the treatment plan.

Concluding Note

A case was made for the importance of counselors and other

mental health providers to become more culturally sensitive

and culturally competent with regard to determining the need

for and selection of culturally sensitive treatment when indi-

cated. Using the selection strategy described and illustrated

in this article is quite demanding, particularly when the client

presentation involves chronic medical condition and family

dynamics. Among other things, it requires the acquisition of

a number of skill sets and competencies including the assess-

ment of cultural identity, level of acculturation, explanatory

model and illness perceptions, cultural formulation, as well

as assessment of family dynamics, and medical and psycholo-

gical symptoms. Nevertheless, this strategy has the potential to

increase cultural sensitivity and foster cultural competence in

mental health providers.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect

to the authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or

authorship of this article.

References

Burnam, M., Hough, R., Karno, M., Escobar, J., & Telles, C. (1987).

Acculturation and lifetime prevalence of psychiatric disorders

among Mexican Americans in Los Angeles. Journal of Health and

Social Behavior, 278, 89-102.

Influence of cultural dynamics

low high

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Influence of personality dynamics

low high

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Influence of family dynamics

low high

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Influence of health factors

low

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Figure 1. Influence of cultural dynamics, personality dynamics, family dynamics, and health factors on presenting problem in the case of Marques.

Sperry 319

319

Hansen, D., Randazzo, K., Schwartz, A., Marshall, M., Dalis, D.,

Frazier, R., . . . Norvig, G. (2006). Do we practice what we preach?

An exploratory survey of multicultural psychotherapy competen-

cies. Professional Psychology: Research and Practice, 37, 66-74.

Hays, P., & Iwamasa, G. (2006). Culturally responsive

cognitive-behavioral therapy: Assessment, practice, and supervi-

sion. Washington, DC: American Psychological Association Books.

Paniagua, F. (2005). Assessing and treating cultural diverse clients: A

practical guide. Thousand Oaks, CA: SAGE.

Sperry, L. (2006). Psychological treatment of chronic illness: The

biopsychosocial therapy approach. Washington, DC: American

Psychological Association.

Sperry, L. (2009). Treating chronic medical conditions: Cognitive

behavioral strategies and integrative protocols. Washington,

DC: American Psychological Association Books.

Sperry, L. (2010). Highly effective therapy: Developing essential

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York, NY: Routledge.

320 The Family Journal: Counseling and Therapy for Couples and Families 18(3)

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