One 250 Word Answer

Multicultural Counseling Competence Training: Adding Value With Multicultural Consultation Janine M. Jones, Kristin Kawena Begay, Yoko Nakagawa, Molly Cevasco, and Janelle Sit

University of Washington

ABSTRACT This study addresses the culturally responsive training process and highlights the integration of multicultural competence building in counseling consultation. Consultation was struc- tured as client-centered case consultation. Before and after the intervention, clinician competence was assessed with the California Brief Multicultural Counseling Competence Scale (CBMCS). Half the clinicians were trained in a culturally respon- sive model of cognitive behavior therapy (CR-CBT) while the other half were trained in traditional cognitive behavior ther- apy (CBT). All clinicians participated in weekly client-centered case consultation. The change in CBMCS scores was analyzed and a case study of the sessions comparing two clinicians was completed. The combination of direct training in culturally responsive treatment and case consultation led to significantly greater cultural competence for clinicians in the CR-CBT group. The findings indicate that an intentional effort is required for integrating cultural factors into treatment—one cannot rely solely on the client to acknowledge cultural factors in therapy.

Introduction: The rising need for culturally responsive services

The U.S. Census Bureau (2012) reports that about a half (50.4%) of U.S. population younger than 1 year old are ethnic minorities. With 50% of the preschool population exploding to include ethnic minority children, those who serve children in schools need to be prepared to work with all children, regardless of their background. According to the data collected by National Association of School Psychologists (NASP), recruitment and employment of minority school psychologists continues to lag behind the population growth rate (Curtis, Castillo, & Gelley, 2012). For example, in 2009–2010, 90.7% of school psychologists were White/Caucasian, and less than 10% of school psychologists were from ethnic minority backgrounds including Black/ African American (3%), American Indian/Alaska Native (0.6%), Asian/ Pacific Islander (1.3%), Hispanic (3.4%), and Other (1%). As school psychol- ogists play an important role in providing mental health services and

CONTACT Janine M. Jones [email protected] Educational Psychology, University of Washington, Miller 322S, Campus Box 353600, Seattle, WA 98195-3600.

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 2016, VOL. 26, NO. 3, 241–265 http://dx.doi.org/10.1080/10474412.2015.1012671

© 2016 Taylor & Francis

promoting mental health wellness of their students and families, they need to be trained to work in culturally competent ways to meet the demands of an increasing number of minority students and families (Curtis et al., 2012; Malone, 2010). Both the American Psychological Association (APA) and the American Counseling Association (ACA) have adopted guidelines on the advancement in cultural competency for psychologists, counselors, educators, and researchers (APA, 2002; Arredondo, et al., 1996). Similarly, NASP adopted cultural competency guidelines (NASP, 2009), and established a minority recruitment task force (NASP, 2010). These leading organizations recognize the change in the demographics of the U.S. population, while also emphasizing the need to shift away from Eurocentric models of treatment.

The importance of culture in counseling

Culture is a complex factor that requires consideration for all children. A child grows and develops by interacting within their interconnected environ- mental systems. Each layer of their environmental system includes numerous factors such as: internalized beliefs, values, morals, attitudes towards the majority population or oppressors, perceptions of disabilities, mental ill- nesses, and successes and failures (Bronfrenbrenner, 1979). Ample evidence suggests that culture and life circumstances have a significant impact on the assessment, identification, and treatment practice (Bernal & Jimenez-Chafey; Rodriguez, 2009). There is also a body of literature that addresses the preferences of ethnic minority clients for ethnically matched clinicians. In a meta-analysis of 52 studies of ethnic congruence in counseling, they found a moderately strong preference (Cohen’s d = .63) for a same race/ethnicity clinician (Cabral & Smith, 2011). Other studies suggest that client’s decision to work with or leave a therapist may be decided by the level of importance the client places on their cultural values being upheld by the clinician (Ames, 2004; Kohatsu et al., 2000 ; Lopez et al., 1991; Pope-Davis et al., 2002).

Given the representation disparity between school-based minority mental health professionals and school-age children, culturally responsive training is becoming a necessity for school-based mental health clinicians. Cultural alignment may be met through implementing culturally relevant adaptations and subsequently demonstrate to clients that the clinician recognizes the importance of the client’s cultural background. School psychologists, there- fore, need training in building cultural alignment and providing culturally relevant adaptations in the treatment of students from diverse populations. The calls for culturally based adaptations to interventions are longstanding (Sue, 1977; Castro & Alarcon, 2002), but the most appropriate methods for adaptations remain unclear and understudied (Griner, 2006). Some research- ers continue to examine methods for accurate adaptation (Miranda et al., 2005; Okazaki & Sue, 1995) and efficacy (Rossello & Bernal, 1999) of

242 J. M. JONES ET AL.

culturally adapted evidence-based interventions. The data from this pilot study is an additional effort to obtain empirical support for cultural adapta- tions in treatment.

Client-centered case consultation One method of supporting clinicians in their professional role is to use Caplan’s (1970, 1995) model of mental health consultation. The model is a method of supporting professionals in dealing with the psychological aspects of a work-related problem. In the context of counseling, the work problem can be related to providing therapeutic services to a client. In mental health consultation, the professional responsibility of the care of a client remains with the consultee while the consultant offers alternative perspectives, sup- port, and suggestions regarding the mental health care of the client. The consultee is free to accept or reject the advice provided by the consultant because there is a nonhierarchical relationship between the consultee and consultant (Erchul, 2009). A more specific approach to mental health con- sultation is client-centered case consultation (Caplan, 1995). This approach involves the consultant focusing on assisting a consultee determining the best course of action in providing services to a client. In client-centered case consultation, the needs of the client precipitate the consultation request and are the foundation for the consultation sessions. Client-centered case con- sultation is a theoretical and practical approach that lends itself well to supporting counseling trainees (Brown, Pryzwansky, & Schulte, 2006), but has not yet been studied in relation to multicultural consultation for an evidence-based counseling approach.

Training in cultural competency

Treatment techniques in counseling and psychology have been heavily influ- enced by the values of the majority culture and subsequently may cause clinicians to disregard a minority client’s cultural perspective (Hays, 2006). As a result, clinicians need to learn to integrate culture into evidence-based treatment approaches when providing care to diverse populations. Multicultural counseling is a specialty area within psychology that suggests that it is a clinician’s responsibility to build cultural self-awareness, develop cultural understanding of others, and individualize treatment to the cultural needs of the client (Jones, 2009; Sue, Arredondo, and McDavis, 1992). Self- awareness includes learning about his or her own privilege, cultural values, and beliefs. Developing cultural understanding of others involves learning about a client’s cultural heritage, sociopolitical background, beliefs and values, and testing the knowledge with the client directly. Individualized care includes conceptualizing the client’s needs and tailoring treatment to fit within their cultural frame.

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 243

Creating a therapeutic relationship and environment that encompasses cultural responsiveness requires a great deal of consideration. Clinicians attempting to integrate cultural values into their treatments must adapt ele- ments of therapy that are derived from the historically White, middle-class emphasis on individualism (Pedersen, 2004; Thomas, 1999). Additionally, working with a culturally responsive focus requires acknowledging varied socioeconomic statuses among clients (Smith, 2004) as well as client experi- ences of institutionalized racism (Laszloffy & Hardy, 2000; Sue, 1988). Adding another layer of consideration, culturally adapted interventions appear to be most effective when targeted at one specific minority group instead of across varying ethnic groups (Hall, 2001; Miranda, et al. 2005). This necessitates extensive research to further our understanding of culture-specific adaptations and how they fit into evidence-based interventions.

The tripartite model (Sue et al., 1992) is the most well-adopted approach to multicultural competency training. In this approach, the culturally respon- sive clinician demonstrates skills along three dimensions: (1) awareness of how one’s own culture has impacted his or her worldview, values, behavior, and biases; (2) ongoing acquisition of knowledge about other cultures’ world- views and values without judgment; and (3) making intentional efforts to provide culturally responsive intervention (Arredondo, 1999; Sue et al., 1992). Clinicians with multicultural intentionality incorporate cultural com- petency skills in all aspects of clinical care and are able to develop indivi- dualized interventions based on the needs of the client (Jones, 2009). Although all three dimensions of multicultural competencies need to be addressed in training, many training programs spend more time on the first two dimensions of multicultural competencies (e.g., self-awareness and other awareness), but significantly less emphasis on skill development. As a result, students leave their training programs feeling less prepared for cross- cultural clinical practice (Priester et al., 2008). Similarly, other studies showed that clinicians’ training programs did not provide adequate multicultural competency training, and graduates expressed serious concerns regarding inadequate level of skills development in multicultural counseling competen- cies (D’Andrea, Daniels, & Heckman, 2008; Holcomb-McCoy & Myers, 1999; Sammons & Speight, 2008). Hansen et al. (2006) conducted a study of culturally responsive behavior of psychologists in practice and analyzed how often they engaged in culturally relevant behaviors with clients of color and also were asked to rate the level of importance of these behaviors. Their study found a significant discrepancy where clinicians were not behav- ing consistently with what they regarded as important for practice.

Culturally responsive approaches to treatment Counseling psychologists have spent decades focusing on the complexity of cross-cultural counseling and the treatment of adults. Such clinicians have

244 J. M. JONES ET AL.

addressed the importance of training and culturally driven psychotherapy. With the models of treatment in place, however, few clinicians have adopted the approach that culture is not solely equated with race—culture is inclusive of a variety of dimensions that may be interacting simultaneously to affect the counseling relationship. Hays (2006; 2009) was one of the first to develop a framework to guide clinicians in learning the complex factors that encompass the culture of an individual. She refers to the variables as the ADDRESSING framework (Hays, 2006; 2009; Hays & Iwamasa, 2005). ADDRESSING is an acronym for practitioners to use when conceptualizing the clients’ cultural context in clinical work (See Table 1). Each letter in the word is linked to a domain of cultural factors. For example, the A is for Age and generational influences including level of acculturation or acculturation conflict in a home. The E encompasses ethnic and racial identity factors along with a person’s heritage. Using the ADDRESSING framework, Hays analyzes cultural factors in clinical case development and psychotherapy practice.

Table 1. ADDRESSING Framework and the Multicultural Interview. ADDRESSING framework cultural influences

Application to minority groups

Sample questions from Jones Intentional Multicultural Interview Schedule (JIMIS)

Age/generational Children, adolescents, elders

How do you define family? Who is in your family? Who lives in your home?

Developmental disabilities/ Disabilities acquired

Developmental disabilities or acquired disabilities

What are some challenges that you or your family members have to deal with?

Religion & spirituality Religious minority cultures

How does your family deal with feelings? What are some coping strategies that they use? How do religion and spirituality impact your family?

Ethnic and racial identity Ethnic and racial minority cultures

What does your family think about counseling? What do you think about it? What are some things about your family that few people know?

Socioeconomic status Class status (education, income, rural)

If you were to choose a job today, what would it be? Would your family approve of this job? What would your family prefer for you to do when you grow up? What is a job you would like to do, but would never choose it?

Sexual orientation Gay, lesbian, bisexual people

What are some characteristics about you that make you similar or different from people in your peer group? Is there a label that your peers use to describe groups of kids at your school? Which label best identifies your group?

Indigenous heritage Indigenous/aboriginal/ native people

What are some rituals/routines that your family does daily? Which are used to cope with stress?

National origin Refugees, immigrants, international

How and when did your family arrive in the United States? What were the circumstances of their arrival?

Gender Women, transgender people

When there is conflict with peers at school, what is the usual cause? What are some characteristics about you that make you different from people in your peer group? What do you believe are the responsibilities of women or men?

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 245

In school psychology, culturally responsive approaches to clinical practice are still developing. Although many authors have addressed the need for culturally responsive training, supervision, and clinical practice of school psychology (Esquivel, Lopez, & Nahari, 2007; Jones, 2009; Loe & Miranda, 2005; Lopez & Rogers, 2001; Martines, 2008; Newell et al., 2010; Ochoa, Rivera, & Ford, 1997; Rogers, 2006; Rogers & Lopez, 2002; Rogers & Ponterotto, 1997), the approaches and techniques recommended by these multicultural experts has not been fully operationalized into all schools. One approach to building cultural literacy in cross-cultural relationships was described in Jones (2009). Using the Jones intentional multicultural interview schedule (JIMIS), school clinicians can use guided questions to build rapport with clients and simultaneously demonstrate culturally responsive practice. As shown in Table 1, questions from the JIMIS were aligned with the constructs from the ADDRESSING framework (Hays, 2006) and used in training clinicians for culturally responsive treatment. For example, the “I” in ADDRESSING stands for Indigenous heritage, and questions from the JIMIS relating to daily rituals, including those used to cope with stress, correspond to that aspect of the ADDRESSING framework. Additional questions from the JIMIS were aligned with appropriate constructs in the ADDRESSING framework. In this way, clinicians were provided with a structure that allowed them to cover all aspects of the framework through standard, culturally appropriate interview questions. Table 1 illustrates the JIMIS interview questions as an operationalization of the ADDRESSING framework.

Rationale for the study

The present investigation is considered a pilot study to add empirical infor- mation about making cultural adaptations of evidence-based treatments in counseling and to understand the impact of multicultural training on the clinician. Specifically, this study sought to measure change in the clinician, with emphasis on cultural self-awareness, cultural literacy, and multicultural intentionality on clinicians’ cultural competency assessment. Also, this inves- tigation evaluated not only the effectiveness of culturally responsive training prior to the offering the intervention to clients, but also whether multi- cultural skills continue to develop over time through client centered case consultation. For the purposes of this study, the consultants are referred to as “licensed psychologists,” the consultees are referred to as “clinicians,” and the adolescents are referred to as “clients.” In this study, half of the clinicians were trained in a culturally responsive model of cognitive behavioral therapy (CR-CBT), while the other half were trained in a traditional model of cognitive behavioral therapy (CBT). This investigation is unique in that clinicians trained in multicultural counseling were given specific culturally

246 J. M. JONES ET AL.

responsive techniques to increase the clinicians’ multicultural intentionality while the other clinicians were provided training in a traditional evidence- based treatment approach without specific attention to multicultural con- cerns. Through weekly client centered case consultation, the clinicians in both groups had the opportunity to consult with licensed psychologists on the dynamics in the therapy sessions and planning for treatment.

Method

Participants

Eight graduate students were recruited to be clinicians for the pilot inter- vention study. The students were recruited from three universities in the Northwest. The graduate students were trainees from departments of psy- chology, clinical social work, counseling, and school psychology. Recruitment occurred in two phases. First, they were recruited through advertisement (flyers and listserv announcements) and second, through snowball sampling. The first phase led to the recruitment of six clinicians, but one was screened out due to the lack of graduate student status by the start of the treatment phase. Snowball sampling, also termed network sampling, is a technique for locating additional research participants; in this case, by asking the clinicians already recruited to share names of other potential new recruits. This chain- ing process increased the number of clinicians (Vogt, 1999) and yielded three additional graduate students to complete the pool of clinicians. The recruit- ment flyer indicated that the clinicians should demonstrate an interest and/or experience working with diverse populations, but they were otherwise una- ware of the nature of the study. The title of the project was “Child and Adolescent Coping Study.”

Seventy five percent of the recruited clinicians were female. The eight clinicians represented diverse backgrounds: four African American, one Latino, and three were White/Caucasian. All eight clinicians participated in the recruitment and training phases of the study. Attrition occurred with a few of the clinicians after we held a summer training series and prior to the provision of therapy services to the adolescents. Two clinicians moved out of state and one dropped out of the study due to other commitments that disrupted their ability to continue. Thus, the final sample of clinicians for the pilot study included five clinicians (two African American and three White/Caucasian).

After attrition, all of the remaining clinicians were female, with three White clinicians in the CBT group (serving three White female clients), and two African American female clinicians in the CR-CBT group (one serving an African American female client and with one White male client). The majority of the clinicians were in their fourth year of training in their

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 247

respective programs while one was completing the third year of coursework and another was completing her fifth year. The principal investigators screened for clinicians with some experience providing CBT or other ther- apeutic method. The majority had completed between five and seven therapy cases prior to enrolling in the study, with one clinician having completed eight cases as part of her training. In the interview, the clinicians indicated that they had moderate levels of experience with ethnic minority populations (including one study abroad experience). Only one clinician expressed that they had limited experience and access to ethnic minority populations. However, this clinician had served at least one ethnic minority in their training experience. Demographic data was collected at the time of the pretest and aligned to the clinician. Due to the small sample size, we report frequencies rather than means or percentages for the demographic informa- tion that we collected. Table 2 summarizes the participant characteristics for the final sample of clinicians after they were assigned to the intervention groups. Demographic data was derived from the recruitment interview with the principal investigator.

Materials and procedure

To assess change in self-perceptions of cultural competence, the California Brief Multicultural Counseling Scale (CBMCS; Gamst et al., 2004) was administered. The CBMCS is recognized as an effective tool for measuring

Table 2. Participant Characteristics for the Final Sample of Clinicians (N). Background information CBT group CR-CBT group

Gender Male 0 0 Female 3 2

Racial/ethnic background African American 0 2 White/Caucasian 3 0

Years of training Less than 2 years 0 0 3 years 1 0 4 years 1 2 5 years 1 0 6 or more years 0 0

Prior therapy cases completed Less than 5 1 0 5–7 cases 1 2 8 or more cases 1 0

Experience with diverse racial/ethnic populations Very limited experience 1 0 Moderate experience 2 2 Significant experience 0 0

CBT = Cognitive Behavior Therapy; CR-CBT = Culturally-Responsive Cognitive Behavior Therapy.

248 J. M. JONES ET AL.

self-reported multicultural competence skills of mental health clinicians. The scales within the measure are aligned with the tripartite definition of multi- cultural competence (Sue et al., 1992). The CBMCS is a 21-item self-report measure that includes an overall score (range 21 to 84) as well as scores for four subscales: multicultural knowledge (range = 5 to 20), cultural sensitivity (range = 3 to 12), awareness of cultural barriers (range = 6 to 24), and nonethnic ability (range = 7 to 28). The first three scales are aligned with the literature and are measured on several other instruments for assessing cul- tural competence. However, the nonethnic ability scale measures skills that are not assessed on any other tool. The nonethnic ability scale is responsive to the expanded definition of multicultural competence that includes diver- sity beyond ethnicity and race. Thus, the nonethnic ability scale measures competencies associated with working with disabilities, low socioeconomic status, gay and lesbian individuals, and older adults. The CBMCS is the first to measure counselor competencies with the more inclusive definition. Items are rated on a 4-point Likert scale that ranged from “Strongly Disagree” to “Strongly Agree.” There is no neutral response. The overall Cronbach alpha for the CBMCS was .89 while the alphas for the subscales were .80 on the multicultural knowledge scale, .75 on the cultural sensitivity scale, .78 on the awareness of cultural barriers scale, and .90 on the nonethnic ability scale. Gamst et al. (2004) also conducted several studies on the impact of social desirability on the CBMCS scale completion. The results indicated that the subscales were not influenced by social desirability effects (Gamst et al, 2004).

All clinicians were asked to complete the CBMCS shortly after enrolling into the project. Clinicians were divided into two groups based only on their scores on the CBMCS, without regard to any other factors. Pretest scores were calculated and the median score was determined. All clinicians were assigned to one of two groups: the cognitive behavior therapy (CBT) group or the culturally responsive cognitive behavior therapy (CR-CBT) group. The CBT group was comprised of the clinicians with high scores (above the median) while those with scores below the median were assigned to the CR-CBT group. A score above the median indicated that the clinician self- reported a relatively high level of cultural competence in counseling. Those below the median rated themselves as having a lower level of cultural competence. Because the clinicians were participating in training, we decided to assign the clinicians with the lowest scores on cultural competency to the culturally responsive training group. We wanted to assess whether their self- reported cultural competency scores would be comparable to the other group at the end of the intervention phase. The result of partitioning the groups based on CBMCS score led to an equally divided sample of four clinicians in each group. It is notable that all the clinicians in the CR-CBT group (the group that self-identified as having a lower level of cultural competence) were people of color. This was an unexpected outcome, but the purpose of the

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 249

study was to increase cultural competency in clinicians who felt they were lacking in this area. Therefore, the decision was made to maintain the integrity of the divide between those who received higher scores on cultural competency and those who received lower scores. In this way, we could better determine whether the cultural competency training and consultation experiences increased the feelings of cultural competency in counseling. The goals of the research and the methods to achieve the goals were made without regard to the ethnicity of the clinicians, and therefore it was impor- tant to continue in this vein, without allowing the ethnicity of the clinicians to alter how training was imparted.

Prior to beginning therapy with clients for the purposes of the study, all eight of the clinicians participated in a 3-week training experience with the principal investigator—an African American licensed psychologist with 16 years of experience providing therapy services to ethnically and culturally diverse children and adolescents. The clinician training occurred once a week for 4 hours each week. The first training session was an orientation to the procedures of the study including logistics such as room scheduling, access codes, confidential record keeping, and overall expectations. This was com- pleted as a whole group. The second and third training sessions were completed as separate groups and are described in more detail in the following sections.

Training of CBT clinicians The CBT group clinicians received a refresher training in the traditional model cognitive behavioral therapy. The training modules focused on the foundations of the CBT approach including assumptions, key concepts such as self-defeating beliefs, ego and discomfort disturbances, and cognitive distortions. They were also instructed on the basics of the CBT model, the clinicians’ role in CBT, and specific age-informed treatment techniques to use for depression (such as cognitive restructuring). The training series ended with a module on treatment planning and setting goals. In each training, the clinicians were given case scenarios and paired with another clinician to practice the skills during the training. The CBT clinicians were instructed to follow a treatment as usual approach to initiating the first session with their clients. No guidance was given for completing the clinical interviews.

Training of CR-CBT clinicians The CR-CBT group clinicians received the same training content as the CBT group; however, there were additions and adaptations to the material where the training materials were reshaped to include cultural frameworks and treatment perspectives that were guided by principles of culturally responsive care. For example, when instructing on the basics of the model, the licensed

250 J. M. JONES ET AL.

psychologist included information on the strengths and limitations of the CBT approach across cultures. She also included content on bias and privi- lege in American society. The final addition to the CR-CBT training was a module on clinical interviewing. Using the ADDRESSING framework (Hays, 2006; 2009) and the JIMIS (Jones, 2009), the CR-CBT clinicians were trained to use a culturally responsive approach to rapport building and clinical interviewing. This training included explicit instruction in interview techni- ques from the JIMIS that allowed clinicians to be grounded in the ADDRESSING framework and put culture at the forefront of the rapport building process. The ADDRESSING framework was the underlying theory while the JIMIS questions operationalized the theory into specific questions to be asked in the interview. Table 1 provides a sample of the JIMIS interview questions as they align with the ADDRESSING framework. Just like the CBT group, the CR-CBT clinicians were also connected in pairs to practice treatment skills during the training, with support from the licensed psychologist.

Study design

This preliminary study was a nonrandomized two-group pretest-posttest design (with control group). The CBT group was considered the control group with a treatment as usual perspective while the CR-CBT group pro- vided the adapted treatment. This design allowed us to compare the final posttest results between the two groups to determine the overall effectiveness and sustainability of the training intervention. We were also able to assess how both groups changed from pretest to posttest separately.

Treatment implementation The clients for the study were recruited from schools and community centers in an urban area through flyers and newsletters. Adolescents aged 11–16 were invited to participate in screening for eligibility to join the study. All respon- dents participated in an interview with the principal investigator and com- pleted a depression rating scale to determine appropriateness for the study. Adolescents with scores in the moderate range (a score between 50 and 70) were invited to participate. Individuals with scores above 70 were referred to local agencies where more immediate services could be provided. Clients who were approved for the study were randomly assigned to the clinicians. Further information about the clinical sample is located in a separate manu- script (Jones, Begay, Matlack, & Reichardt, 2014). The focus of this paper is on the consultation component.

Both groups initiated treatment between September and October. The clinicians provided 20 counseling sessions to adolescents and their families on a once-weekly basis throughout 1 academic year. All sessions were video

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 251

recorded, transcribed, and clinicians were responsible for completing session notes for each client contact as well as a treatment plan for every client. The session notes were written in the SOAP (Subjective/Objective/Assessment/ Plan) Note format as commonly applied in clinical practice (Weed, 1964).

Consultants When clients were assigned, the clinicians were also assigned a consultant with whom they could meet with weekly. The clinicians in the CBT group were assigned a consultant who was a licensed psychologist in private practice with expertise in dialectical behavior therapy. She was an ethnic minority female (Asian American/White) licensed psychologist. At the time of the study, this consultant had 6 years experience in private practice and had been the director of a specialty clinic for individuals with depression. The consultant for the CR-CBT group was also an ethnic minority female (African American) licensed psychologist but with expertise in multicultural counseling. At the time of the study, she had 10 years experience in private practice working with adolescents with depression and anxiety and 16 years experience providing mental health services to ethnic minority children and adolescents. The CR-CBT consultant was also the licensed psychologist who provided the initial training to all the clinicians in the study. Both consultants served in the capacity with the understanding that all consultation sessions were to be guided by the needs of the client and directed by the consultee. There was no evaluative component to the consultations, and this role was not concurrent with supervision of student clinicians, which was a separate component in the larger study, described elsewhere (see Jones et al., 2014).

Client-centered case consultation The clinicians received 1 hour per week of clinical case consultation with their assigned consultant/licensed psychologist. Weekly sessions were grounded in the client-centered case consultation model, which puts the focus on the client’s needs, and provides appropriate support for consultees to respond to those needs. At the beginning of the work, the consultants established the consultation relationship as collaborative rather than evalua- tive. This encouraged the consultee to be free to share their thoughts and concerns, and to be vulnerable with the consultant while discussing their work with the client. The role of the consultant was to work collaboratively with the clinician to determine efficient ways to assist the client by action planning and building an effective treatment plan. The consultant had no direct contact with the clients, only the clinician. The clinicians were expected to gather the personal, environmental and cultural information about the client so that the consultation sessions could focus on analysis of the multidimensional variables that may impact treatment outcomes. The consultants assisted the clinicians in identifying the problems and factors that

252 J. M. JONES ET AL.

influenced depressive symptoms, addressing strategies that might remediate the symptoms, and developing treatment plans that were implemented with the clients. The weekly consultations followed the same procedures and structure regardless of the intervention group (CBT vs CR-CBT). The con- sultants did not guide the clinicians on the types of information to bring to the consultation sessions. The clinicians were free to determine what infor- mation was needed to develop the treatment plan. The only expectation was that clinicians completed their SOAP case notes prior to each consultation meeting and brought the session video recording for review. Consultants only responded to the information that was provided by the clinicians. At the conclusion of the counseling treatment experience at the end of the academic year, clinicians completed the CBMCS a second time (posttest). The posttest was completed approximately 1 year after the pretest.

Results

Data analysis

Given the small sample size, we opted to report median scores for each group rather than the mean scores that would be heavily influenced by outliers. Table 3 is a summary of the scores from the clinician’s self-report ratings on the California Brief Multicultural Competence Scale (CBMCS).

Change in competence scores within groups It is notable that very little change occurred between phases for the CBT or “treatment as usual” group. In fact, the median score was identical approxi- mately 1 year later. There were single-point differences on all of the scales, but the change in direction (two declined and two increased), resulted in zero change over time. By contrast, the CR-CBT group clinicians showed some

Table 3. Scores for Clinician Cultural Competence at the Pre- and Posttreatment Phases by Scale.

Scale CBMCS total

Cultural knowledge

Cultural awareness

Cultural sensitivity

Nonethnic skill

CBT clinicians 1: Phase 1 (pretest) 68 16 22 12 18 Phase 2 (posttest) 67 15 22 11 19

2: Phase 1 (pretest) 71 17 23 9 22 Phase 2 (posttest) 71 17 24 9 21

3: Phase 1 (pretest) 78 15 24 12 27 Phase 2 (posttest) 79 17 24 12 26

CR-CBT clinicians 1: Phase 1 (pretest) 66 19 23 10 14 Phase 2 (posttest) 73 19 22 11 21

2: Phase 1 (pretest) 66 19 23 10 14 Phase 2 (posttest) 73 19 22 11 21

CBT = Cognitive Behavior Therapy; CR-CBT = Culturally-Responsive Cognitive Behavior Therapy.

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 253

change over time. The total score increased by 7 points. Two of the scales had small changes and just like the CBT group, the change in direction resulted in zero change over time. All of the changes in the CR-CBT group were related to an increase on the nonethnic skill scale.

Change in competence scores between groups To assess the change over time between the clinician groups, we selected a newer method of analyzing small samples of data. The Tau-U (Parker, Vannest, Davis, & Sauber, 2011) is a distribution-free nonparametric approach that allowed us to analyze the non-overlap between the two phases (A = pretest and B = posttest). The Tau-U is derived from the Kendall’s Tau rank correlation and the Mann-Whitney U test between groups. When a small sample conforms to parametric assumptions, the Tau-U can demon- strate a statistical power of 91% to 95%. When the data does not conform to parametric assumptions, the power of the Tau-U can exceed the power of parametric analyses by 115% (Vannest, Parker, & Gonen, 2011). Like the Mann-Whitney U and the Kendall’s rank correlation, the Tau-U follows the “S” sampling distribution. We were able to obtain p values along with confidence intervals using this approach. Of most importance, the Tau-U allowed us to do several contrasts of the treatment phases independently and in groups. The final result is a weighted average that represents the omnibus effect size (Tau-U; Vannest et al., 2011).

Using the Tau-U calculator developed by Vannest and colleagues (2011), we calculated the contrasts for the overall group of clinicians and the two groups of clinicians separately. The Tau-U analysis is multilevel and allows the researcher to assess non-overlap as well as baseline trends and control for both by providing a weighted average across cases (Barnett et al., 2012; Parker et al., 2011). Table 4 shows the weighted average for the Tau-U analysis for the entire group as well as the CBT and the CR-CBT groups separately. As shown in the table, the effect size for the full group of clinicians was not significant (Tau-U = .40; 95%CI, –2.198 to 1.0198; p = .2059.) This indicates that when analyzing the full group, there is no con- sistent improvement in self-perception of cultural competence. This was highly impacted by the differences in consistency patterns between the two

Table 4. Weighted Average for Pretest-Posttest Comparisons Between Groups. Weighted average Tau-U Var-Tau z p

95% confidence interval

All clinicians .400 .3162 1.2649 .2059 –2.198 1.0198 CBT 0.00 .4082 0.0000 1.000 –.8002 0.8002 CR-CBT 1.00 .5000 2.0000 0.0455* 0.0200 1.9800

CBT = Cognitive Behavior Therapy; CR-CBT = Culturally-Responsive Cognitive Behavior Therapy. *p < .05.

254 J. M. JONES ET AL.

groups. However, when the two treatment groups were separated out, a clearer pattern emerged. The CBT group continued to have a nonsignificant p value with a Tau-U effect size of 0.0 (95% CI, −0.8002 to 0.8002; p = 1.0). This indicates that there was no consistency across rankings for each of the clinician contrasts. Some contrasts were negative while others were neutral or slightly positive. Thus, CBT group showed zero consistency between the pre- and post-administration of the CBMCS. However, with a Tau-U effect size of 1.0 (95% CI, 0.0200 to 1.9800; p = .045), the CR-CBT group showed a strong positive relationship between the pretest and the posttest conditions. Meaning, there was a significant effect for CR-CBT clinicians that demon- strated increase in competence scores between the pre- and post-administra- tion of the CBMCS for all clinicians in the CR-CBT group.

Domains of competence As shown in Table 2, the clinicians in the CR-CBT group changed the most on the nonethnic skill scale. Comparatively, the significant difference between the CBT and CR-CBT group scores was most apparent on the nonethnic scale, while the scores on the other three scales were similar between groups. The clinicians within the CBT group rated themselves much higher on the nonethnic skill scale than the CR-CBT clinicians. However, by the end of the intervention, the CR-CBT clinicians had a score that was at the same level as the CBT clinicians. The median values for each group represent the degree of cultural skill the clinician has with nonethnic cultural minorities. There was no significant difference between the groups at the end of the study.

Further analysis: A comparative case study

To better understand the ways in which the CR-CBT training impacted the therapy sessions, the research team qualitatively analyzed the progress notes of the clinicians. One clinician from each of the clinical groups was randomly selected for the analysis. Using grounded theory and theo- retical coding (Hernandez, 2009), the ADDRESSING framework was applied to the coding scheme along with open coding for additional constructs. Using Atlas.ti, a software tool that assists in qualitative analysis, the key-words-in-context technique was used to pull themes from the clinician’s progress notes.

Because the ADDRESSING framework was the theoretical foundation for the study, we explored key words in the clinicians’ progress notes to align with each domain. Four additional themes emerged from the data: school, home/family, friends, and emotional symptoms. Figure 1 compares one of the CBT clinicians to one of the CR-CBT clinicians and shows the number of

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 255

sessions with emphasis on the domains of the ADDRESSING framework as well as the four other themes that emerged from the data.

As shown in Figure 1, the themes that aligned with the ADDRESSING framework were covered in more sessions by the CR-CBT clinician. In fact, only one of the domains was covered by the CBT clinician and that included three sessions with emphasis on socioeconomic status. The other content areas that were frequently addressed by the CR-CBT clinician were age/generational issues, religion, ethnic heritage, sexual orientation, national origin, and gender. None of the sessions by the CBT clinician included discussion of these issues. Of the four other content areas that emerged, two were more frequently occurring in the CR-CBT condition: home/family and friends. The other two (school and emotional symptoms) were more frequent with the CBT condi- tion. Although the content of sessions appeared to be significantly different between the two clinicians with different treatment approaches, the outcomes of perceived cultural competence was equivalent.

Discussion

This study was a preliminary study of the use of multicultural case consulta- tion with clinicians to integrate cultural factors in evidence-based counseling approaches with adolescents. Using a nonrandomized two-group pretest- posttest design, we sought to compare clinician self-perceptions of cultural competence before and after a training intervention. One of the first inter- esting findings from the study was the result of the pretest. Upon analysis of the pretest scores of the CBMCS and assignment of clinicians to the

Figure 1. Graphic representation of the frequency of themes in progress notes by clinician. Values represent the number of sessions that included the theme in the clinician’s progress note. CBT = Cognitive Behavior Therapy; CR-CBT = Culturally-Responsive Cognitive Behavior Therapy.

256 J. M. JONES ET AL.

treatment groups, we were surprised to find that all of the clinicians in the CR-CBT group were clinicians of color. We expected to see racial/ethnic variability in the group membership, but this was not the case. One might also assume that a person of color may be more attuned to cultural dynamics than a person who is from a majority background, thus scoring higher on a measure of cultural competency. This was also not an accurate assumption based on the self-perceptions of the clinician. We ultimately decided that the four clinicians of color might have had a better sense of the complexity of cultural responsiveness. Whereas they may feel more confident in matters of cultural competence relating to race, they may not feel the same way about cultural differences that they have not experienced (such as those found in the nonethnic scale) where the greatest difference was seen between the two groups. It is possible that the CR-CBT clinicians were keenly aware that building cultural competence is a process that develops over time through exposure to diverse groups and relationships (Fields, 2010). Subsequently, they were more comfortable engaging in dialogue with their clients about cultural content (Tummula-Narra, Singer, Li, Esposito, & Ash, 2012). They may have recognized that treatment is complex and requires targeted skills for all populations, and having baseline knowledge for everyone is not possible (Fields, 2010). Simultaneously, the CBT clinicians may have been aligning with formal training experiences in clinical settings as they assessed their cultural competence.

The CBT (treatment as usual/control) group clinicians were compared on cultural competence ratings to clinicians providing a culturally responsive adapted version of CBT (CR-CBT). Our findings show that the clinicians who were trained in the CR-CBT model showed growth over time that developed into a higher level of cultural competence 1 year after the training. As mentioned previously, the CBT group consisted of the clinicians who rated themselves as having a higher level of cultural competence than those who were selected for the CR-CBT group. This approach allowed us to compare the final posttest results between the two groups to determine whether the training intervention provided a change in skill that was com- parable to the knowledge that the CBT group clinicians initially reported. The CBT clinicians’ median score was identical as there was variability for all three clinicians within the group. Because one increased overall, one decreased overall and the third showed a flat profile, the net result was zero change. The case consultation for their group did not include any emphasis on culture, cultural factors, or any cultural variables that may have influenced the treatment. The treatment approach was focused strictly on the processes of cognitive behavior therapy, including coping skill build- ing and goal setting.

The CR-CBT group showed increased skills at the end of the study. The case consultation with the clinicians included a focus on cultural factors from

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 257

the end of the training series forward. The initial interview included ques- tions that helped identify culturally related coping styles without specific direction by the consultant. Cultural factors were included within the treat- ment plans as well as the weekly interventions that were assigned to the adolescents as homework. Throughout the counseling process, clinicians in the CR-CBT group also analyzed cultural factors that may influence the success of a treatment technique and addressed them in the treatment notes. As a result, cultural factors were included from the initial session throughout the treatment. This is likely to be the reason that the cultural competence skills increased over time.

The area that the CR-CBT clinicians developed the most was in the domain of nonethnic skills. The nonethnic skill domain included factors such as socioeconomic status, sexual orientation, and disabilities. The clin- icians in the CR-CBT group rated themselves as having significantly more competence in this area—more so than any of the other areas of cultural competence on the CBMCS. The demographics of the CR-CBT clients included both ethnically matched and ethnically mismatched client/clinician pairs. It appears that in the case of ethnic mismatch, the clinician was attuned to not only ethnic cultural variables, but also nonethnic variables. The CR- CBT consultation included discussion and interpretation of the influence of all cultural variables—including nonethnic factors.

These results provide evidence that the combination of direct training and case consultation that is targeted toward developing cultural competence is beneficial to a clinician’s professional development. The group who initially scored lower overall on the CBMCS ended up not only level with the other group, but also with an even higher score in the end.

Case study findings

The qualitative analysis revealed even more interesting results. The CR-CBT clinician, who began with a clinical interview with questions aligned with the ADDRESSING framework, had more sessions that focused on content related to cultural factors. Seven out of nine categories of the ADDRESSING frame- work were covered in multiple sessions of the culturally responsive (CR-CBT) clinician while only one of the nine categories was included in sessions by the CBT clinician. It appears that direct assessment of each of the ADDRESSING categories at the beginning of treatment primed the client (and the clinician) for recognizing the cultural factors as relevant to the treatment. As a result, the factors reemerged in later sessions. When the CBT group did not have a structure for considering cultural factors, the factors did not spontaneously emerge during treatment. Thus, what appears to be intuitive and naturally occurring in treatment is not—our findings suggest that an intentional effort is required to integrate cultural factors into treatment.

258 J. M. JONES ET AL.

The four factors that emerged that were unrelated to the ADDRESSING framework were present in the work of both the clinicians. The home/family and friends theme were more prevalent with the CR-CBT clinician’s sessions while the school and emotional symptoms themes were more prevalent with the CBT clinician’s sessions. It is notable that the home/family and friends theme are interpersonal while school and emotional symptoms are more intrapersonal. Based on our understanding of cultural paradigms, in collecti- vistic cultures (Pederson, 2004), interpersonal patterns are more directly linked to culture, strengths, and coping while intrapersonal factors are more linked to problem solving, the core function of evidence-based CBT. As shown in Figure 1, sessions in the CR-CBT group focused more on ethnicity, family, and generational conflicts while the CBT sessions focused more on socioeconomic status, school and emotional symptoms. The content of the sessions, therefore, provides an example of how culture manifests throughout treatment.

Limitations

As a preliminary study, one of the greatest limitations is the sample size. With the small sample of clinicians, we were limited to the number of adolescents that could be served. Recruitment of the clinicians was a lengthy, multistep process, so once the clinician training was complete and they were assigned cases, it was impossible to add new clinicians to the project when attrition occurred. The team is now aware of approaches to use that will reduce the likelihood of clinician attrition in the future. The small sample size also hindered the type of analyses that could be completed with the data that was collected. We were limited to nonpara- metric statistics for all hypotheses we wished to test. Although future versions of this study will likely produce data with nonnormal distribu- tions, a larger sample size will enhance the opportunities for more com- plex data analyses including: studying covariates such as the ethnic matching variable, clinician prior clinical experience, and multilevel ana- lyses. In addition, the assignment of clinicians to the CR-CBT group based solely on pretest scores on the CMCBS resulted in all clinicians of color being in this group. While this division was unexpected and may be seen as a limiting factor, we opted to remain true to the original study design and assign to groups solely on the pretest score rather than be influenced by the ethnic background of the clinicians. In future studies, we will randomly assign clinicians to groups to increase the variability of responses on the CBMCS. With the random assignment, future studies will also allow comparison of clinicians of color in both groups to see if the same patterns emerge when all clinicians of color are not clustered together.

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 259

As with any self-report measure, there is always the potential for indivi- duals to respond in a socially desirable way. Thus, social desirability may have impacted the way that respondents rated themselves on the CBMCS (Gamst et al, 2004; Constantine, 1996). For example, social desirability may have accounted for why the clinicians who were not from ethnic minority backgrounds reported higher cultural competency scores at the pretest. Perhaps they rated themselves in an effort to cross-culturally align with the principal investigator (an ethnic minority female). This does not explain why the ethnic minority clinicians rated themselves lower. We were able to find published studies that analyzed clinician self-perceptions of cultural compe- tence (Weatherford & Spokane, 2013), but none that compared those of clinicians of color to others. Thus, we can only extrapolate from the self- perceptions of competence literature that the clinicians of color are more aware of the complexity of multiculturalism.

Opting for measuring the self-ratings of cultural competence at only two time points (before the training and after the intervention) may have missed some unique differences during treatment. Because there was a year between the two administrations, it may have been more beneficial to add two more administrations: once at the intervention midpoint (Session 10) and again as a 3-month follow-up to the intervention. With administrations at four time points, we would be able to identify trends over time for both groups.

Treatment implications and future directions for consultation

Despite the limitations, this preliminary study provides interesting impli- cations for the training of clinicians in cultural responsiveness. We sought to determine whether significant differences occur when clinicians were trained in a culturally adaptive model of care and provided ongoing consultation to supplement clinical work. Like the integration model of multicultural competence training (Newell et al., 2010), we found that the combination of the initial direct training as well as ongoing client centered case consultation were successful in producing positive outcomes for all clinicians in the culturally responsive training group. As in Hansen et al. (2006), the simple presence of multicultural training is not sufficient to enhance culturally competent practice. The client centered case consulta- tion seemed to provide a context for the CR-CBT clinicians to apply and grow their culturally responsive skills over time. Positive outcomes were apparent for both clinicians in the CR-CBT group—ethnically matched and unmatched pairs. Similar to multicultural counseling, the findings suggest that client centered case consultation is an appropriate venue to enhance cultural competence of clinicians. Providing consultation training to students with a structure for culturally responsive care is likely to be the optimal practice in the future.

260 J. M. JONES ET AL.

Relatedly, our observations of both the CBT and CR-CBT clinician pat- terns showed that an intentional focus on cultural factors is needed to produce culturally responsive care. Awareness and understanding of cultural values in the context of the client provides a foundation for treatment that is culturally responsive, individualized, while also applying the techniques of evidence-based treatment.

Future studies with larger samples could test the cross cultural counseling dynamic so that more conclusions can be drawn about ethnic congruence in treatment of adolescents and the relevance of the matching process. According to our preliminary findings, ethnic congruence (Loe & Miranda, 2005) is not necessarily needed for cultural skill development. In general, as long as the training and ongoing case consultation is focused on culturally responsive care, the clinician’s skills increase despite ethnic congruence. Thus, culturally responsive treatment approaches are likely to enhance the competence of the clinician to serve all people and may even enhance clinical outcomes for the adolescents in their care.

Funding

This research was supported by a grant from the University of Washington, Royalty Research Fund.

References

American Counseling Association. (2005). ACA codes of ethics. Retrieved from http://www. counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx

American Psychological Association. (2002). Guidelines on multicultural education, training, research, organizational changes for psychologists. Washington, DC: Author. Retrieved from http://www.apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx

American Psychological Association. (2005). American psychological association statement: Policy statement on evidence-based practice in psychology. Retrieved from http://www.apa. org/practice/resources/evidence/index.aspx

Ames, D. (2004). Strategies for social inference: A similarity contingency model of projection and stereotyping in attribute prevalence estimates. Journal of Personality and Social Psychology, 87, 573–585. doi:10.1037/0022-3514.87.5.573.

Arredondo, P. (1999). Multicultural competencies as tools to address oppression and racism. Journal of Counseling & Development, 77, 102–108.

Arredondo, P., Toporek, R., Brown, S. P., Sanchez, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalizing multicultural competencies. Journal of Multicultural Counseling & Development, 24(1), 42–78.

Barnett, S. D., Heinemann, A. W., Libin, A., Houts, A. C., Gassaway, J., Sen-Gupta, S., . . . Brossart, D. F. (2012). Small N designs for rehabilitation research. Journal of Rehabilitation Research and Development, 49(1), 175–86.

Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40(4), 361–368. doi:10.1037/a0016401

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 261

Brown, D., Pryzwansky, W., & Schulte, A. (2006). Psychological consultation and collabora- tion: Introduction to theory and practice (6th ed.). Boston, MA: Pearson.

Cabral, R. R., & Smith, T. B. (2011). Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology, 58(4), 537–554. doi:10.1037/a0025266.

Caplan, G. (1995). Types of mental health consultation. Journal of Educational and Psychological Consultation, 6(1), 7–21.

Caplan, G. (1970). The theory and practice of mental health consultation. New York, NY: Basic Books.

Castro, F. G., & Alarcon, E. H. (2002). Integrating cultural variables into drug abuse preven- tion and treatment with racial/ethnic minorities. Journal of Drug Issues, 32, 783–810.

Curtis, M. J., Castillo, J. M., & Gelley, C. (2012). School psychology 2010: Demographics, employment, and the context for professional practices (Pt. 1). Communiqué, 40(7), 1, 28–30.

Constantine, M. G., Ladany, N., Inman, A. G., & Ponterotto, J. G. (1996). Students’ percep- tions of multicultural training in counseling psychology programs. Journal of Multicultural Counseling and Development, 24, 241–253.

D’Andrea, M. D., & Heckman, E. F. (2008). Present & future challenges: A 40-year review of multicultural counseling outcome research: Outlining a future research agenda for the multicultural counseling movement. Journal of Counseling & Development, 86, 356–363.

Erchul, W. P. (2009). Gerald Caplan: A tribute to the originator of mental health consulta- tion. Journal of Educational and Psychological Consultation, 19, 95–105.

Esquivel, G. B., Lopez, E. C., & Nahari, S. (Eds.) (2007). Handbook of multicultural school psychology: An interdisciplinary perspective. Mahwah, NJ: Erlbaum.

Fields, A. J. (2010). Multicultural research and practice: Theoretical issues and maximizing cultural exchange. Professional Psychology: Research and Practice, 41, 196–201. doi:10.1037/ a0017938.

Gamst, G., Dana, R. H., Der-Karabetian, A., Aragon, M., Arellano, L., Morrow, G., & Martenson, L. (2004). Cultural competency revised: The California brief multicultural competency scale. Measurement and Evaluation in Counseling and Development, 37(3), 163–183.

Gamst, G., Dana, R. H., Der-Karabetian, A., Aragon, M., Arellano, L., Morrow, G., & Martenson, L. (2008). Cultural competency revised: The California brief multicultural competence scale. In G. C. Gamst, A. Der-Karabetian, & R. H. Dana (Eds.), CBMCS multicultural reader (pp. 3–28). Thousand Oaks, CA: Sage.

Griner, D., & Smith, T. B. (2006). Culturally adapted mental health intervention: A meta- analytic review. Psychotherapy: Theory, Research, Practice, Training, 43(4), 531–48. doi:10.1037/0033-3204.43.4.531

Hall, G. N. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69, 502–510.

Hansen, N. D., Randazzo, K. V., Schwartz, A., Marshall, M., Kalis, D., Frazier, R., . . . Norvig, G. (2006). Do we practice what we preach? An exploratory survey of multicultural psychotherapy competencies. Professional Psychology: Research and Practice, 37, 66–74. doi:10.1037/0735-7028.37.1.66

Hays, P. A. (2009). Integrating evidence-based practice, cognitive-behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40, 354–360. doi:10.1037/a0016250

Hays, P. A. (2006). Introduction: Developing culturally responsive cognitive-behavioral therapies. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive-behavioral

262 J. M. JONES ET AL.

therapy: Assessment, practice, and supervision (pp. 3–19). Washington, DC: American Psychological Association.

Hernandez, C. A. (2009). Theoretical coding in grounded theory. The Grounded Theory Review, 8(3), 51–60.

Holcomb-McCoy, C. C., & Myers, J. E. (1999). Multicultural competence and counselor training: A national survey. Journal of Counseling & Development, 77, 294–302.

Jones, J. M. (2009). Counseling with multicultural intentionality: The process of counseling and integrating client cultural variables. In J. M. Jones (Ed.), The psychology of multi- culturalism in the schools: A primer for practice, training, and research (pp. 191–213). Betheda, MD: National Association of School Psychologists.

Jones, J. M., Begay, K. A., Matlack, A., & Reichardt, S. (2014). Multicultural counseling practice: The session impact and its relationship to depressive outcomes. [Manuscript in preparation.]

Kohatsu, E. L., Dulay, M., Lam, C., Concepcion, W., Perez, P., Lopez, C., & Euler, J. (2000). Using racial identity theory to explore racial mistrust and interracial contact among Asian Americans. Journal of Counseling & Development, 78, 334–342.

Laszloffy, T. A., & Hardy, K. V. Uncommon strategies for a common problem: Addressing racism in family therapy. Family Process, 39(1), 35–50.

Loe, S., & Miranda, A. (2005). An examination of ethnic incongruence in school-based psychological services and diversity-training experiences among school psychologists. Psychology in the Schools, 42(4), 419–432.

Lopez, R. S., Lopez, A. A., & Fong, K. T. (1991). Mexican Americans’ initial preferences for counselors: The role of ethnic factors. Journal of Counseling Psychology, 38(4), 487–496.

Lopez, E. C., & Rogers, M. R. (2001). Conceptualizing cross-cultural school psychology competencies. School Psychology Quarterly, 16, 270–302.

Malone, C. M. (2010). Evaluation multicultural competence in school psychology. Communiqué, 38(7). Retrieved from http://www.nasponline.org/publications/index.aspx

Martines, D. (2008). Multicultural school psychology competencies: A practical guide. Thousand Oaks, CA: Sage.

Miranda, J., Guillermo, B., Lau, A., Kohn, L., Hwang, W.-C., & LaFromboise, T. (2005). State of the science on psychosocial interventions for ethnic minorities. American Review of Clinical Psychology, 1, 113–142.

National Association of School Psychologists. (2009). Culturally competent practice. Retrieved from http://www.nasponline.org/resources/culturalcompetence/index.aspx

Newell, M. L., Nastasi, B. K., Hatzichristou, C., Jones, J. M., Schanding, G. T., & Yetter, G. (2010). Evidence on multicultural training in school psychology: Recommendations for future directions. School Psychology Quarterly, 25(4), 249–278.

Ochoa, S. H., Rivera, B., & Ford, L. (1997). An investigation of school psychology training pertaining to bilingual psychoeducational assessment of primarily Hispanic students: Twenty-five years after Diana v. California. Journal of School Psychology, 35, 329–349.

Okazaki, S., & Sue, S. (1995). Methodological issues in assessment research with ethnic minorities. Psychological Assessment, 7, 367–375.

Parker, R. I., Vannest, K. J., Davis, J. L., & Sauber, S. B. (2011). Combining nonoverlap and trend for single-case research: Tau-U. Behavior Therapy, 42, 284–299.

Pedersen, P. (2004). The multicultural context of mental health. In T. B. Smith (Eds.), Practicing multiculturalism: Affirming diversity in counseling and psychology (pp. 17–32). Boston, MA: Pearson.

Pope-Davis, D. B., Toporek, R. L., Ortega-Villalobos, L., Ligiero, D. P., Brittan-Powell, C. S., Liu, W. M., . . . Liang, C. H. (2002). Client perspectives of multicultural counseling competence: A qualitative examination. The Counseling Psychologist, 30(3), 355–393.

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 263

Priester, P. E., Jones, J. E., Jackson-Bailey, C. M., Jana-Masri, A., Jordan, E. X., & Metz, A. J. (2008). An analysis of content and instructional strategies in multicultural counseling courses. Journal of Multicultural Counseling and Development, 36(1), 29–39. doi:10.1002/ j.2161-1912.2008.tb00067.x

Rogers, M. R. (2006). Exemplary multicultural training in school psychology programs. Cultural Diversity & Ethnic Minority Psychology, 12(1), 115–33. doi:10.1037/1099- 9809.12.1.115

Rogers, M. R., & Lopez, E. C. (2002). Identifying critical cross-cultural school psychology competencies. Journal of School Psychology, 40, 115–141.

Rogers, M., & Ponterotto, J. G. (1997). Development of the multicultural school psychology scale. Psychology in the Schools, 34(3), 211–218.

Rossello, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67(5), 734–745.

Smith, T. B. (2004). A contextual approach to assessment. In T. B. Smith (Ed.), Practicing multiculturalism: Affirming diversity in counseling and psychology (pp. 97–119). Boston, MA: Allyn & Bacon.

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(2), 64–89. doi:10.1002/j.2161-1912.1992.tb00563.x

Sue, S. (1977). Community mental health services to minority groups: Some optimism, some pessimism. American Psychologist, 32, 616–624.

Sue, S. (1988). Psychotherapeutic services for ethnic minorities: Two decades of research findings. American Psychologist, 43(4), 301–308.

Sammons, C. C., & Speight, S. L. (2007). A qualitative investigation of graduate-student changes associated with multicultural counseling courses. The Counseling Psychologist, 36 (6), 814–838. doi:10.1177/0011000008316036

Tummula-Narra, P., Singer, R., Li, Z., Esposito, J., & Ash, S. E. (2012). Individual and systemic factors in clinicians’ self-perceived cultural competence. Professional Psychology: Research and Practice, 43(3), 165–174. doi:10.1037/a0025783

U.S. Census Bureau. (2012, May). Most children younger than 1 are minorities, census bureau reports. Retrieved from http://www.census.gov/newsroom/releases/archives/population/ cb12-90.html

Vannest, K. J., Parker, R. I., & Gonen, O. (2011). Single case research: Web-based calculators for SCR analysis. (Version 1.0) [Web-based application]. College Station, TX: Texas A&M University. Retrieved from http://www.singlecaseresearch.org/

Vogt, W. P. (1999). Dictionary of Statistics and Methodology: A Nontechnical Guide for the Social Sciences. London, UK: Sage.

Weatherford, R. D., & Spokane, R. A. (2013). The relationship between personality disposi- tions, multicultural exposure, and multicultural case conceptualization ability. Training and Education in Professional Psychology, 7(3), 215–224. doi:10.1037/a0033543

Weed, L. L. (1964). Medical records, patient care, and medical education. Irish Journal of Medical Science, 39(6), 271–282. doi:10.1007/BF02945791

Notes on contributors

Janine M. Jones, PhD, NCSP, is an Associate Professor and Director of the School Psychology Program at The University of Washington. She is a licensed psychologist and nationally certified school psychologist who earned her doctoral degree from the University of Texas at

264 J. M. JONES ET AL.

Austin. Her research and scholarship focuses on multiculturalism and culturally inclusive services for children in schools.

Kristin Kawena Begay, MEd, NCSP, is a doctoral candidate in the School Psychology Program at The University of Washington. Her career as a classroom teacher, counselor, and school psychologist has focused on working with indigenous populations, including Native American and Pacific Islander. Her research interests focus on effective teaching strategies and appropriate diagnostic techniques for diverse populations.

Yoko Nakagawa, MEd, NCSP, is a doctoral candidate in the School Psychology Program at The University of Washington. She is a nationally certified school psychologist who is currently working part-time in Federal Way School District, WA, and working on her predoctoral internship at MultiCare Good Samaritan Hospital, Behavioral Health.

Molly Cevasco, EdS, MEd, BCBA, NCSP, is a doctoral student in the School Psychology Program at The University of Washington and is a school-based behavior consultant. She earned her Education Specialist degree in School Psychology from The University of Washington and is a board certified behavior analyst and nationally certified school psychol- ogist. Her research focuses on culturally-relevant, trauma-informed practices for students with emotional and behavioral disabilities.

Janelle Sit, EdS, is a school psychologist in California. She earned her BA in Psychology/Law and Society from the University of California, Riverside and her EdS in School Psychology from The University of Washington. She is a member of the National Association of School Psychologists.

Note: The authors report that to the best of their knowledge neither they nor their affiliated institutions have financial or personal relationships or affiliations that could influence or bias the opinions, decisions, or work presented in this article.

JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 265

Copyright of Journal of Educational & Psychological Consultation is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.