Multicultural counseling competence and client outcome

The purpose of this study was to investigate the relationship between multicultural counseling competence and client outcome. Though the importance of multicultural competence is widely heralded in counseling psychology, a link has not yet been made between multicultural competence, as it is currently understood and measured, and quality of care. This study was an attempt to demonstrate that link, as well as to validate the California Brief Multicultural Competence Scale (CBMCS) by showing that scores on that scale relate positively to improved service to clients. In order to achieve these tasks, client outcome was examined by using information collected at the University of Utah Counseling Center (UCC): Specifically, client scores on the Outcome Questionnaire-45 (OQ-45), a measure of client distress and functioning. Therapists who scored higher on the CBMCS were predicted to see larger reductions of their clients' OQ-45 scores. Hierarchical linear modeling was used to examine the relationship between therapists' multicultural competence and client outcomes. This study found significant relationships between multicultural competence and client outcome. The nature of the relationships, however, was unexpected: The aspect of multicultural competence termed Awareness of Cultural Barriers was positively related to client outcome, whereas the aspect termed Multicultural Knowledge was negatively related to client outcome. This result demonstrates the first link between multicultural counseling competence and quality of care. The positive relationship between Awareness of Cultural Barriers and outcome suggests that at least some forms of multicultural competence indeed play a role in delivering effective counseling to clients. On the other hand, the negative relationship between Multicultural Knowledge and outcome points to a need to revisit assumptions about multicultural counseling competence as it is currently theorized and measured.

MULTICULTURAL COUNSELING COMPETENCE AND CLIENT OUTCOME by Jinna Lee A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science t Department of Educational Psychology The University of Utah December 2007 MUL TlCULTURAL Uni versity Scie nce Educat ional Uni versity ," , Copyright © Jinna Lee 2007 All Rights Reserved ! THE U N I V E R S I T Y OF UTAH G R A D U A T E SCHOOL of a thesis submitted by Jinna Lee This thesis has been read by each member of the following supervisory committee and by f ' , ( - - ' { -- Chaifr Takuya Minami Carla/. Re'-yfesf r<F . Oason Burrow-Sanchez T H E UN VERS I TY UTA H D UA T E SCHOOL SUPERVISORY COMMITTEE APPROVAL fo llowing conun ittee majority vote has been found to be satisfactory. Chaiffakuya , r I Tr ?~';on THE U N I V E R S I T Y OF UTAH G R A D U A T E SCHOOL F I N A L R E A D I N G A P P R O V AL To the Graduate Council of the University of Utah: I have read the thesis of Jinna Lee jn i t s f m a j fo rm and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the supervisory committee and is ready for submission to The Graduate School. Date Takuya Minami Chair: Supervisory Committee Approved for the Major Department ' Robert D. tTill Chair/Dean Approved for the Graduate Council David S. Chapman ^ Dean of The Graduate School UNIVERSITY GRADUATE SCHOOL FINAL READING APPROVAL I have read the thesis of Jinna Lee in its final form arc chalis I2· .- i2. -_C~7_ _ Talru:yIMina~i I/~/{ (.,)" <it LVVV Y , ill \ ABSTRACT The purpose of this study was to investigate the relationship between multicultural counseling competence and client outcome. Though the importance of multicultural competence is widely heralded in counseling psychology, a link has not yet been made between multicultural competence, as it is currently understood and measured, and quality of care. This study was an attempt to demonstrate that link, as well as to validate the California Brief Multicultural Competence Scale (CBMCS) by showing that scores on that scale relate positively to improved service to clients. In order to achieve these tasks, client outcome was examined by using information collected at the University of Utah Counseling Center (UCC): Specifically, client scores on the Outcome Questionnaire-45 (OQ-45), a measure of client distress and functioning. Therapists who scored higher on the CBMCS were predicted to see larger reductions of their clients' OQ-45 scores. Hierarchical linear modeling was used to examine the relationship between therapists' multicultural competence and client outcomes. This study found significant relationships between multicultural competence and client outcome. The nature of the relationships, however, was unexpected: The aspect of multicultural competence termed Awareness of Cultural Barriers was positively related to client outcome, whereas the aspect termed Multicultural Knowledge was negatively related to client outcome. This result demonstrates the first link between multicultural t counseling competence and quality of care. The positive relationship between Awareness of Cultural Barriers and outcome suggests that at least some forms of multicultural competence indeed play a role in delivering effective counseling to clients. On the other hand, the negative relationship between Multicultural Knowledge and outcome points to a need to revisit assumptions about multicultural counseling competence as it is currently theorized and measured. playa v CONTENTS ABSTRACT LIST OF TABLES v Chapter I. INTRODUCTION Multicultural Competence Significance of Outcome Research 1 II. METHOD 1 > Setting 1 Participants 1 Instruments 1 Procedures 2 Design 2 III. RESULTS 2 Preliminary Analysis 2 Therapist Gender, Licensure, and Experience and Outcome 2' Multicultural Competence and Outcome 2' Competence in Religious Diversity and Outcome for LDS Clients 3 IV. DISCUSSION 3- Limitations 4t Conclusions 4i APPENDIX: MMCR 4: REFERENCES 4' .................... ................................................................................................ IV ......................................................................................................... Vll ................................................................................ .. .. ....... I ............................ .. ........................................................ 3 Significance ofOlltcome Research ........................................................................ 13 II . METHOD ............... .. .. ............................................................................................. 16 Setting ................ ............................. .... .... .. .. ... .. .... .. ........................... ... .. .. .. .. ... .... 16 Participants .. .............................................................................. . .............. 17 Instruments ...... ........... ........................... .................... ................... .. .. ... ............ .. ... I a Procedures .............................................................................................. ............... 21 Design ...................................................... .. .. ...... ............................. ..................... 22 ............................................................................................................. 28 .......... ............. ... ................................................................. 28 ................................ 29 Outcome.................................... . ......... 29 ...................... 31 . ................................................................................... .. .......... 34 .. .. . .40 Conclusions .. .. ... ......... 43' APPENDIX : MMCR .. . ....... ...... ................................. ............ ..... 45 REFERENCES ....... . ....................... .................. ........................ 47 • , LIST OF TABLES Table 1. Demographics.... 2. One-Way Random Effects ANOVA 3. Outcome 4. Fixed and Random Effects of CBMCS Subscales 5. Fixed and Random Effects of CBMCS Subscales, LDS Clients 6. of CBMCS Therapists I. General Therapist Demographics .. .. ........................... .. . . .... ... .... .. ...... 19 EffeetsANOYA .............................. . ..... .. ....... 30 Bivariate Correlations Among Therapist Variables, CBMCS Subscale and Overall Percentiles, and ... .. .. .. .. .. .. ....... ..... .. .... .......... ....... .. . .... ... ..... ......... 30 ofCBMCS Subseales ... ............. ........ ............................... .. 3~ ofCBMCS Subseales, .... ... ... ........ ...... .. ...... .. 33 Distribution ofCBMCS Percentile Scores, ... ....... .. .. .. ... ... ... ........ . .. ... .... .. .. .. 39 • 1 CHAPTER I INTRODUCTION Multicultural counseling competence, defined as competence in delivering effective counseling to clients who do not fit the demographic majority (e.g., ethnic minorities, the lesbian, gay, bisexual, transgender, and queer/questioning [LGBTQ] population), has become one of the crucial goals of training and practice in professional psychology (Prediger, 1994). Many training programs, particularly those in counseling psychology, include multicultural training as a required part of their curriculum both in the form of specific courses and in the modification of existing syllabi (Ponterotto, Rieger, Barrett, & Sparks, 1994). The driving forces behind this movement include the desire to uphold a high standard of care for all clients, the necessity of providing competent service in alignment with the ethics of the profession, and the sociopolitical reality of the increasing demographic diversification of the United States (Ibrahim & Arredondo, 1986; Sue, Arredondo, & McDavis, 1992). Most of the advancements in multicultural counseling competence over the past 3 decades, however, have been theoretical and political rather than empirical. To this date, no empirical study has been identified that specifically examined the relationship i between multicultural counseling competency (either as self-perceived competence or competence evaluated by others) and actual client counseling outcome. As a result, despite the near consensus in the field that multicultural counseling competency is crucial^ I trans gender, psychblogy, cuniculum Anedondo, Anedondo, between multicultural counseling competency (either as self-perceived competence or competence evaluated by others) and actual client counseling outcome. As a result, despite the near consensus in the field that multicultural counseling competency is crucial~ it remains an empirical question whether multicultural counseling competency as it is currently theorized ultimately benefits clients. Furthermore, the lack of empiricism prolongs a rather circular debate in the field about the measurement of multicultural counseling competence, as no empirical data exist to ground the discussion. In addition to the fact that operationalization of multicultural counseling competence is still in its infancy (Kocarek, Talbot, Batka, & Anderson, 2001), multicultural counseling competence measures developed over the past 15 years have primarily purported to assist in the training of counselors and psychologists rather than in assessing its relationship to actual clinical outcomes (Ponterotto, Rieger, Barrett, & Sparks, 1994). More specifically, these measures have been used primarily to evaluate training success in multicultural education, which, in most cases, takes the form of classroom learning, such as courses in multicultural counseling. Therefore, some recommend that the use of these measures be strictly limited contexts to the training contexts for which they were originally developed (e.g., Ponterotto et al., 1994). Although such limits appear valid from a psychometric perspective, multicultural competencies that are incorporated into counselor training should ultimately align with better ability to treat multicultural (and perhaps majority) populations. It is only when the factors that these measures intend to capture significantly relate to the ultimate goal of improved clinical outcome that their true validity can be established. Thus, currently available measures of multicultural counseling competence need to be evaluated with regard to their reliability and validity in real clinical practice rather than training. 2 200 1), . aI., improved clinical outcome that their true validity can be established. Thus, currently available measures of multicultural counseling competence need to be evaluated with regard to their reliability and validity in real clinical practice rather than training. ! 3 'i ; (Pope-; t As the importance of multicultural counseling competence gains support not only to those in educational and academic settings but to institutional bodies in the field such as federal and state monitors and professional organizations, it seems inevitable that valid and reliable multicultural counseling competence measures will be in demand to evaluate quality of mental health services and to provide accountability (Holcomb-McCoy, 2000). In other words, considering the time, energy, and other resources spent to train counselors in multicultural counseling competency under the assumption that it relates to actual clinical competence, research is necessary not only to improve our understanding of multicultural counseling competence but also ultimately to demonstrate to clients, institutions, and to the public that this expenditure is worthwhile. Multicultural Competence Definition of Terms In this study, I use the terms multicultural competence and multicultural counseling competence interchangeably. Though there is some debate about the difference between cross-cultural and multicultural competence (Ponterotto et al., 1994), in this thesis I use the term "multicultural" to indicate both concepts. Multicultural refers to counseling involving clients who are culturally different from the mental health provider. Culturally different clients, depending on one's position in the debate, may include not only the so-called visible minorities or ethnic minorities' (though ethnicity is' not uniformly and uncomplicatedly visible) but also other groups such as sexual in multicultural counseling competency under the assumption that it relates to actual clinical competence, research is necessary not only to improve our understanding of multicultural counseling competence but also ultimately to demonstrate to clients, institutions, and to the public that this expenditure is worthwhile. Definition of Terms In this study, I use the terms multicultural competence and multicultural counseling competence interchangeably. Though there is some debate about the difference between cross-cultural and multicultural competence (Ponterotto et aI., 1994), in this thesis I use the term "multicultural" to indicate both concepts. Multicultural refers to counseling involving clients who are culturally different from the mental health provider. Culturally different clients, depending on one's position in the debate, may include not only the so-called visible minorities or ethnic minorities I (though ethnicity is! not uniformly and uncomplicatedly visible) but also other groups such as sexual I I avoid the use of the term "race" and others derived from it because of its problematic status as a biological construct. Though some use the term to imply social and cultural categorizations, I prefer to avoid the common implication that race describes natural biologically-based categories as well (Pope-Davis & Coleman, 1997). 4 minorities, seniors, members of minority religions, and people of different socioeconomic classes (Sue et al., 1992). Some clients may be ethnic minorities as well as members of other minority groups, making them multiple minorities. Though most multicultural research focuses on ethnic minorities, I expand this term to include nonethnic populations for this study. I consider how client outcome and multicultural competence plays out for ethnic minorities, Caucasian clients who are members of other minority groups, and Caucasian clients who do not identify as being in a minority group, other than by gender. History of Multicultural Competence Not surprisingly, people of Caucasian descent have dominated the study and practice of psychological counseling for much of its history in the United States (Sue, 1981). Because of this dominance, Caucasian American values have permeated mental health practice; for example, individualism and the emphasis on developing the self, found in many theories of counseling, are oft-cited as values that are not shared equally across all cultures (Sue, 1981). Concurrent with the U.S. civil rights movement, members of minority groups began writing in the 1960s about the failure of counseling to address the needs of those outside of the Caucasian middle class (Sue, 1981). The profession of psychology officially recognized an ethical duty to provide culturally competent services to a diverse public at the 1973 Vail Conference (Korman, 1974). f Since the 1970s, awareness of the need for multicultural competence in the practice of mental health had slowly taken hold. Attention to multicultural counseling # issues has even been dubbed the Fourth Force, indicating its centrality to contemporary concerns in professional psychology (Ponterotto et al., 1994). However, in contrast to the at, minOlities, practic, e penneated the needs of those outside of the Caucasian middle class (Sue, 1981). The profession of psychology officially recognized an ethical duty to provide culturally competent services' to a diverse public at the 1973 Vail Conference (Korman, 1974). Since the 1970s, awareness of the need for multicultural competence in the practice of mental health had slowly taken hold. Attention to multicultural counseling issues has even been dubbed the Fourth Force, indicating its centrality to contemporary concerns in professional psychology (Ponterotto et a1., 1994). However, in contrast to the 5 exponential growth observed in the theoretical and political dissemination of multicultural competence, research in this area remained sparse in the earlier years. Since Sue and Sue's (1977) article on multicultural issues in counseling drew attention to the multiplicity of meanings and values that complicate counseling across cultures, articles on multicultural competence have appeared in irregular spurts with few publications between 1982 and 1994 (Ridley & Kleiner, 2003). The profusion of studies observed since the late 90s focuses on themes such as the necessity of multicultural competence and describing and assessing multicultural competence (Ridley & Kleiner, 2003). Theoretical Foundations of Multicultural Competence • The most widely used conceptual framework for multicultural competence is Sue's (1982) three-dimensional model (Holcomb-McCoy, 2000). Subsequently, in 1992, Sue, Arredondo, and McDavis refined and revised this model (Sue et al., 1992). The three broad dimensions of multicultural competence that Sue and colleagues identified are Belief/Attitudes, Knowledge, and Skills. All three of these dimensions apply both to the counselor's "awareness of [his/her] own assumptions, values, and beliefs" as well as "understanding the worldview of the culturally different client" (Sue & Arredondo, 1992, p. 481). First, Beliefs/Attitudes refer to characteristics such as knowledge of one's own heritage, awareness of bias, and comfort with cultural differences. Second, Knowledge , refers to specific information about one's own heritage, the heritage and background of other groups, and a familiarity with how sociopolitical factors affect the life and well- * being of others. Third, Skills describes the ability of counselors to understand relevant & and describing and assessing multicultural competence (Ridley & Kleiner, 2003). ! aI., hislher) world view t ~ 6 research related to multiculturalism, involvement in multicultural activities outside of counseling, and self-understanding. In order to research and understand the ability to undertake multicultural counseling, a multiplicity of multicultural competence measures have been created over the past 2 decades. Specifically, these instruments were developed in growing recognition of the need to track progress in the training of multicultural competence (e.g., Byington, Fischer, Walker, & Freedman, 1997). For example, the Multicultural Awareness, Knowledge, and Skills Survey (MAKSS; Kim, Cartwright, Asay, & DAndrea, 2003) was "developed from instructional objectives and training programs" (Kocarek et al., 2001, p. 489). In addition, the three dimensions proposed by Sue and colleagues (1982, 1992) influenced not only how training programs have implemented multicultural teaching but also the structural framework of multicultural competence measures. The most commonly used measures employ subscales that attempt to correspond with the three dimensions of Sue's multicultural competence model. Thus, in most scales, each dimension of Sue's model translates into a subscale upon which multicultural competence is measured. For example, in the Cross-Cultural Counseling Inventory (CCCI; LaFromboise, Coleman, & Hernandez, 1991) the subscales are titled cultural awareness and beliefs, cultural knowledge, and flexibility in multicultural counseling skills (Ponterotto et al., 1994). ; Validity of Sue's Three-Dimensional Model Despite overwhelming endorsement of Sue and colleagues' (1982, 1992) three- , dimensional model in many measures of multicultural competency, the model itself has self-& & D'Andrea, "developed from instructional objectives and training programs" (Kocarek et aI., 2001, p. 489). In addition, the three dimensions proposed by Sue and colleagues (1982, 1992) influehced not only how training programs have implemented multicultural teaching but also the structural framework of multicultural competence measures. The most commonly used measures employ subscales that attempt to correspond with the three dimensions of Sue's multicultural competence model. Thus, in most scales, each dimension of Sue's model translates into a subscale upon which multicultural competence is measured. For example, in the Cross-Cultural Counseling Inventory (CCCI; LaFromboise, Coleman, & Hernandez, 1991) the subscales are titled cultural awareness and beliefs, cultural knowledge, and flexibility in multicultural counseling skills (Ponterotto et aI., 1994). three-dimensional f not experienced much advancement since its formation as a theoretical construct (Gamst et al., 2004). As Gamst et al. note, it still holds true that "item contents were derived from committee consensus rather than empirical identification" (p. 165). In other words, the current endorsement of these three factors (knowledge, skills, and beliefs) and their specific competency areas are not based on empirical support, but rather, upon trends in the field. Further, there are some indications that support for these competencies may not be uniform among actual clients that the theory aims to serve. Fraga, Atkinson, and Wampold (2004) found variability among different ethnic groups in endorsing certain competencies under the three dimensions; for example, subjects tended to differ in the importance placed on knowledge of bias in testing and knowledge of minority group practices, depending on ethnic group membership. Factor analyses have provided, at best, incomplete support for the three-dimensional model upon which the measures are based (Constantine, Gloria, & Ladany, 2002). Gamst et al. (2004) found that the items on the California Brief Multicultural Competence Scale (CBMCS), though conceptually based on Sue's (1982, 1992) three-factor model, resulted in a four-factor solution. The fourth factor, dubbed Nonethnic Ability, appeared to refer to the ability to work with minority groups not primarily characterized by ethnicity-for example, people with disabilities, seniors, and the LGBT population. This new factor, should it prove consistent, may help explain why factor analyses have not shown strong and consistent support for the three factors of Beliefs/Attitude, Knowledge, and Skills (Constantine et al., 2002). Furthermore, the emergence of Nonethnic Ability as an explanatory factor suggests that multicultural competence may play a significant part in providing services 7 aI., Wampold (2004) found variability among different ethnic groups in endorsing certain competencies under the three dimensions; for example, subjects tended to differ in the importance placed on knowledge of bias in testing and knowledge of minority group practices, depending on ethnic group membership. I . Ability, appeared to refer to the ability to work with minority groups not primarily characterized by ethnicity~for example, people with disabilities, seniors, and the LGBT population. This new factor, should it prove consistent, may help explain why factor analyses have not shown strong and consistent support for the three factors of Beliefs/Attitude, Knowledge, and Skills (Constantine et aI., 2002). playa to those of majority ethnic background who are members of other minority groups, such as people with disabilities. Similarly, inclusion of broader factors in the conceptualization of multicultural competence contributes to an ongoing debate in the field as to whether multicultural competence is related to or equivalent with general counseling competence. Again, such a connection has yet to be thoroughly investigated. The few studies conducted on this topic have been inconclusive (e.g., Coleman, 1998; Constantine, 2002), and no study has been identified that explicitly tested the relationship with actual client outcomes. While this does not make Sue's (1982, 1992) model or the instruments developed upon its foundation any less essential to our current understanding of multicultural competence, the model and instruments clearly require empirical research to substantiate their utility. Regardless of the above uncertainty regarding the theory itself, different instruments that purport to measure multicultural competency under Sue's (1982, 1992) model have attempted to establish construct validity with variable success. The most frequent method of claiming construct validity has been associating high multicultural competence scores to amount and type of multicultural training. For example, high scores on the MAKSS have been linked to amount of training and training differences (Ponterotto et al., 1994). Similarly, scores on the Multicultural Competence and Awareness Scale (MCAS, later revised into the MCKAS to include Knowledge; Ponterotto, Gretchen, Utsey, Rieger, & Austin, 2002) also appear to increase with training, though only on two of the three subscales (Kocarek et al., 2001; Pope-Davis & Dings, 1994). This validity, again, is limited to the measures' ability to assess effectiveness in training, and it is therefore uncertain as to whether these instruments . 8 The few studies conducted on this topic have been inconclusive (e.g., Coleman, 1998; Constantine, 2002), and no study has been identified that explicitly tested the relationship with actual client outcomes. While this does not make Sue's (1982, 1992) model or the instruments developed upon its foundation any less essential to our current understanding of multicultural competence, the model and instruments clearly require empirical I . research to substantiate their utility. different multicultural competence scores to amount and type of multicultural training. For example, high scores on, the MAKSS have been linked to amount of training and training differences (Ponterotto et aI., 1994). Similarly, scores on the Multicultural Competence and Awareness Scale (MCAS, later revised !nto the MCKAS to include Knowledge; Ponterotto, Gretchen, Utsey, Rieger, & Austin, 2002) also appear to increase with training, though only on two of the three subscales (Kocarek et aI., 2001; Pope-Davis & Dings, 1994). This validity, again, is limited to the measures' ability to assess effectiveness in training, and it is therefore uncertain as to whether these instruments measure multicultural competence as observed in clinical outcomes-this purported competence may consist mostly of knowledge that does not translate into ability in the field. Another method of construct validation that has been attempted is examining the relationship between scores on the multicultural competence measures and demographic variables such as the counselor's gender and ethnicity (Pope-Davis & Dings, 1994). This method is based on an assumption that women and people of color have likely experienced more discrimination and may thus have gained multicultural competence from their life experiences beyond what is instructed in classrooms. Hypothetically, if multicultural competence is associated with the therapist's minority group membership, minority clients should on average report higher satisfaction and lower drop-out rate with minority therapists. There is no evidence, however, that supports this assumption; rather, results of reviews and meta-analyses on ethnic matching of counselor and client are inconclusive (e.g., Karlsson, 2005; Shin et al., 2005). In addition, although some research has shown that ethnic minorities do tend to score higher on both the CCCI and the MAKSS (Ponterotto et al., 1994), high correlations found between multicultural competency measures and measures of social desirability question this as evidence of construct validity (Constantine & Ladany, 2000; Sodowsky, Kuo-Jackson, Richardson, & Corey, 1998; Worthington, Mobley, Franks, & Tan, 2000). Nevertheless, looking at < counselors' demographics at least has the virtue of attempting to correlate scores with a concept that, while itself theoretical, is separate from the matrix of education and 1 assessment developed from identical theoretical assumptions. outcomes-9 & multicultural competence is associated with the therapist's minority group membership, minonity clients should on average report higher satisfaction and lower drop-out rate with minority therapists. There is no evidence, however, that supports this assumption; rather, results of reviews and meta-analyses on ethnic matching of counselor and client are inconclusive (e.g., Karlsson, 2005; Shin et aI., 2005). In addition, although some research has shown that ethnic minorities do tend to score higher on both the CCCI and the MAKSS (Ponterotto et aI., 1994), high correlations found between multicultural competency measures and measures of social desirability question this as evidence of construct validity (Constantine & Ladany, 2000; Sodowsky, Kuo-Jackson, Richardson, & Corey, 1998; Worthington, Mobley, Franks, & Tan, 2000). Nevertheless, looking at counselors' demographics at least has the virtue of attempting to correlate scores with a concept that, while itself theoretical, is separate from the matrix of education and Yet another common approach to construct validity has been to seek convergence with a different measure that also claims to assess the same construct. Although most multicultural competence measures share the common theoretical foundation, correlations between tests have been relatively low (Kocarek et al., 2001). For example, the Multicultural Counseling Inventory (MCI; Sodowsky, Taffe, Gutkin, & Wise, 1994) and the MCAS seem to cross-validate with each other more successfully than with the MAKSS; however, the MCI and MCKAS, which is the revised version of MCAS, appear to measure fundamentally different concepts (Pope-Davis & Dings, 1994). In addition, convergence becomes difficult to attain when the method of administration differs; as with many other measures in general, self- and other-assessed multicultural competencies do not agree (e.g., Constantine, 2001). Self-report multicultural competence scales have also been evaluated against other criteria to establish content validity. For example, high scores on self-report multicultural competence measures have been linked to favorable faculty judgments of counselors-in-training, high ratings by expert raters with training and experience in multicultural counseling of video vignettes performed by the counselor with a confederate client, and case conceptualization skills (Holcomb-McCoy, 2000; Ponterotto et al., 1994). In another study, however, the link to case conceptualization skills was found to be insignificant if social desirability was added and controlled as a variable (Constantine & Ladany, 2000). 10 aI., & convergence becomes difficult to attain when the method of administration differs; as with many other measures in general, self- and other-assessed multicultural competencies· do not agree (e.g., Constantine, 2001). I . confederate client, and case conceptualization skills (Holcomb-McCoy, 2000; Ponterotto et aI., 1994). In another study, however, the link to case conceptualization skills was found to be insignificant if social desirability was added and controlled as a variable (Constantine & Ladany, 2000). Summary of the Validity of Multicultural Competence Lacking robust or consistent findings, there is no compelling evidence for the validity of the three-dimensional multicultural competence model or the measures based upon it. Notably, tests of validity have not yet been conducted in the context of practice and quality of care. It is only when substantiated in this context that any model and measure of multicultural counseling competence can be validated. In reviews of multicultural competence measures, both from the creators themselves and from other researchers, one theme in particular emerges over and over: the need to validate these measures in the context of quality of care and client outcome. Here is just a sampling of the comments surrounding this issue: Ponterotto et al. (1994) note the need for outcome studies, using information from both counselors and clients; Kocarek et al. (2001) describe the need to demonstrate predictive validity by seeing if training that increases scores on multicultural competence measures actually helps clients; Gamst et al. (2004) observe that researchers still need to make the link between multicultural competencies and service. Fuertes, Bartolomeo, and Nichols (2001) explicitly call for studies examining whether multicultural counseling competence accounts for variance in client outcome, particularly in multiculturally relevant areas such as cultural identity. The repetition of the issue of client outcome in article after article speaks to the necessity of expanding validity measures to include information about how multicultural competence affects counseling in vivo, and how to measure competence for this purpose. 11 measures in the context of quality of care and client outcome. Here is just a sampling of the comments surrounding this issue: Ponterotto et al. (1994) note the need for outcome I . studies, using information from both counselors and clients; Kocarek et al. (2001) describe the need to demonstrate predictive validity by seeing if training that increases scores on multicultural competence measures actually helps clients; Gamst et al. (2004) observe that researchers still need to make the link between multicultural competencies and service. Fuertes, Bartolomeo, and Nichols (2001) explicitly call for studies examining whether multicultural counseling competence accounts for variance in client outcome, particularly in multiculturally relevant areas such as cultural identity. The repetition of the issue of client outcome in article after article speaks to the necessity of expanding validity measures to include information about how multicultural competence' affects counseling in vivo, and how to measure competence for this purpose. 12 Impact of Multicultural Competence on Clients Evidence that client outcome is related to multicultural competence has been suggested by studies on other aspects of multicultural competence and counseling. Researchers have made inroads in relating multicultural competence to client ratings other than outcome, such as satisfaction. For example, Constantine (2002) found that multicultural competence as rated by clients, on the Cross-Cultural Counseling Inventory Revised (CCCI-R), accounted for a significant amount of variance in client satisfaction, above and beyond that accounted for by general counseling competence as measured by the Counseling Rating Form-Short Version (CRF-S; Corrigan & Schmidt, 1983). This link to client satisfaction is a hopeful sign that multicultural counseling competence may " indeed relate to client outcome. However, this link may not hold up when multicultural competence is self-reported, as the self-report MCI did not correlate with the client rated CCCI-R in another study by Constantine (2001). Furthermore, self-reported multicultural competence has been found not to be significantly related to multicultural case conceptualization ability (Ladany, Inman, Constantine, & Hofheinz, 1997). Other studies that suggest a link between multicultural competence and counseling service include Li and Kim's (2004) study, which showed that counseling style (specifically, a directive versus a nondirective style) correlated with higher client ratings of the counselor on cross-cultural competence and a stronger working alliance , between client and counselor. Similarly, Kim, Ng, and Ahn (2005) found a stronger working alliance and counselor empathy when clients and counselors are matched rather * than mismatched in their worldview, suggesting that the ability to see the worldview of the client may impact client outcome. The ability to choose appropriate counseling styles > 1 above and beyond that accounted for by general counseling competence as measured by the Counseling Rating Form-Short Version (CRF-S; Corrigan & Schmidt, 1983). This link to client satisfaction is a hopeful sign that multicultural counseling competence may \ indeeq relate to client outcome. However, this link may not hold up when multicultural competence is self-reported, as the self-report MCI did not correlate with the client rated CCCI-R in another study by Constantine (2001). Furthermore, self-reported multicultural. competence has been found not to be significantly related to multicultural case conceptualization ability (Ladany, Inman, Constantine, & Hofheinz, 1997). working alliance and counselor empathy when clients and counselors are matched rather. than mismatched in their worldview, suggesting that the ability to see the worldview of the client may impact client outcome. The ability to choose appropriate counseling styles 13 and to understand different worldviews is conceptually equivalent to multicultural competence, providing another indication that multicultural competence and counseling effectiveness might be related. On the other hand, an overview of ethnic matching reveals that there is no conclusive evidence that outcomes are improved when clients and therapists are of the same ethnicity (Karlsson, 2005). This finding either runs counter to the hypothesis that counselors of color are more multiculturally competent than majority counselors (Pope-Davis & Ottavi, 1994), or that multicultural competence as it is currently conceptualized is helpful in treating clients of color. Significance of Outcome Research i The studies described above examine the relationship between multicultural competence and constructs that are theorized to contribute to therapeutic outcome, such as client satisfaction, case conceptualization ability, and working alliance. However, these studies cannot replace actual outcome research, which speaks directly to the practical value of therapy. Outcome research, however, is itself a varied field encompassing different methodologies and concerns (Peebles, 2000). Ironically, one of the first studies to cement the importance of outcome research in psychotherapy was Eysenck's notorious 1952 review, which claimed that clients did not measurably benefit from psychotherapy (Eysenck, 1952; Peebles, 2000). f Since then, outcome research has cycled through three generations, each characterized by different methodologies and research questions (Goldfried & Wolfe, • 1996). The first generation of outcome research asked whether psychotherapy was > effective at all; the second, whether particular therapies were effective for particular world views multicu1tural & currently conceptualized is helpful in treating clients of color. I 1952 14 i issues, using mostly graduate students and college students as participants; and the third, whether particular therapies were effective for particular issues, using manualized therapies and clients in clinical settings (Goldfried & Wolfe, 1996). The third generation of outcome research, dominated by clinical trials as exemplified by the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin, Shea, Watkins, & Imber, 1989), has fueled the movement towards evidence-based or empirically supported treatments in psychotherapy (Wampold & Bhati, 2004). This approach to outcome research, based on a medical model that treats counseling as conceptually equivalent to pharmacotherapy, has come under attack for overemphasizing the importance of particular therapies at the expense of other factors, such as the role of the therapist (Wampold & Bhati, 2004). In fact, therapists appear to affect therapy outcome even when delivering standardized treatments (Huppert et al., 2001). Furthermore, the therapist's competence in delivering treatments has been shown to contribute to variance in client improvement (O'Malley, Foley, Rounsaville, & Watkins, 1988). The intent of these outcomes studies is to assess how a particular element in therapy, such as therapist competence, contributes to client change. No studies have yet applied this framework to tease out how multicultural competence might contribute to client outcomes in a naturalistic setting. Present Study My study attempted to address the question, raised repeatedly in the literature, of how multicultural competence relates to quality of care. One method to assess this question is to investigate whether high scores on therapist self-report multicultural & empirically supported treatments in psychotherapy (Wampold & Bhati, 2004). & I . aI., to contribute to variance in client improvement (O'Malley, Foley, Rounsaville, & Watkins, 1988). The intent of these outcomes studies is to assess how a particular element in therapy, such as therapist competence, contributes to client change. No studies have yet applied this framework to tease out how multicultural competence might contribute to client outcomes in a naturalistic setting. . "/I 15 i competence measures currently in use correlate with improved service to clients, as reflected in positive client outcomes. Furthermore, I also attempted to address the question of whether multicultural counseling competence related to quality of care for clients who are not ethnic minorities, but who may be members of other minority groups. To do so, examining the relationship between multicultural competence and client outcome was attempted separately for four groups of clients: clients of color not otherwise of minority status, clients of color who are also members of nonethnic minority groups, Caucasian clients of nonethnic minority groups, and Caucasian clients not of any reported minority status. These groups differ from those used in the bulk of multicultural research and measurement, which focused solely'on ethnic difference and diversity. This study therefore also attempted to address Holcomb-McCoy's (2000) question of whether multicultural competence is related to care even for clients of the ethnic majority. groups, and Caucasian clients not of any reported minority status. These groups differ from those used in the bulk of multicultural research and measurement, which focused solely Ion ethnic difference and diversity. This study therefore also attempted to address HOlcomb-McCoy's (2000) question of whether multicultural competence is related to care even for clients of the ethnic majority. CHAPTER II METHOD Setting The study took place at the University of Utah Counseling Center (UCC), which is an on-campus counseling center serving students and employees at the University of Utah. The University of Utah is located in Salt Lake City, Utah. Salt Lake City is the state capital and home to about 180,000 residents. Of these residents, approximately 80% identify themselves as White, and just under 19% identify as Hispanic or Latino (of any race) as of 2000 {Census 2000, 2000). Though the population is still predominately Caucasian, ethnic change is rapidly occurring in the Salt Lake area: From 2000 to 2003, ethnic minorities accounted for 90% of population growth (Guidos & Rhina, 2004). Salt Lake City is also widely known as the location of the headquarters of The Church of Jesus Christ of Latter Day Saints (LDS), otherwise known as Mormons. In 2002, the estimated portion of people in Salt Lake belonging to the LDS Church was just under 50%; however, it is likely that fewer participate actively in the LDS Church ("Olympic briefs," 2002). ' The University of Utah is a public university serving approximately 30,000 students, including over 6,000 graduate students (University of Utah Facts). The majority of the students are residents of the state of Utah, and only about 10% of students live on campus (University of Utah Facts). Approximately 8% of the students identify as J i The study took place at the University of Utah Counseling Center (UCC), which is an on-campus counselihg center serving students and employees at the University of Utah. The University of Utah is located in Salt Lake City, Utah. Salt Lake City is the state capital and home to about 180,000 residents. Of these residents, approximately 80% identify themselves as White, and just under 19% identify as Hispanic or Latino (of any race) as of 2000 (Census 2000, 2000). Though the population is still predominately Caucasian, ethnic change is rapidly occurring in the Salt Lake area: From 2000 to 2003, ethnic minorities accounted for 90% of population growth (Guidos & Rhina, 2004). Salt Lake City is also widely known as the location of the headquarters of The Church of Jesus Christ of Latter Day Saints (LDS), otherwise known as Mormons. In 2002, the estimated portion of people in Salt Lake belonging to the LDS Church was just under 50%; however, it is likely that fewer participate actively in the LDS Church ("Olympic briefs," 2002). The University of Utah is a public university serving approximately 30,000 1 17 3 members of ethnic minorities, with Asians and Latinos both comprising just under 4% of the student body (Sykes, 2005). The University of Utah Counseling Center provides individual, couples, and group counseling as well as other services to the students as well as to university staff. Over the past 3 years, the UCC has served approximately 2500 students and university employees for mental health counseling. Participants Clients Clients in the study were comprised of both male and female clients age 18 and older who were affiliated with the University of Utah, either as students or faculty/staff, and who voluntarily sought counseling services at the UCC between August 2003 and August 2005. Due to inconsistencies in record-keeping, demographic information was available for only 2057 of the 2532 of the clients who were seen during this time period, Of those 2,057 clients, 744 (36%) identified as male, 1,112 (54%) identified as female, 235 (11%) identified with an ethnicity other than Caucasian, and 108 (5%) identified as gay, lesbian, bisexual, transgendered, or questioning. Client outcomes that are routinely collected at the agency were used, and therefore, there were no additional data collection from clients. Therapists Therapists were recruited from the clinical staff who worked at the counseling center between August 2003 and May 2006. Typically, staff at the UCC consists of a core group of psychologists, clinical social workers, and licensed professional counselors, who train and supervise a rotating group of trainees who spend about 1 year at the center. w-ith faculty/staff, 1] %) 18 During this period, UCC therapists included approximately 8 licensed psychologists, 3 clinical social workers, 1 licensed professional counselor, and 4 psychology postdoctoral trainees, 11 psychology and social work interns, and 5 psychology practicum students. Demographic information about specific therapists was not coded in this study in order to preserve their anonymity; however, general demographic information about UCC therapists (including therapists who did not participate in the study) is reported in Table 1. Instruments OQ-45 The Outcome Questionnaire - 45.2 (OQ-45; Lambert et al., 1996) was used to gauge clinical outcome. The OQ-45 was developed primarily to measure the effectiveness of psychotherapy (Wells, Burlingame, Lambert, & Hoag, 1996). The OQ- 45 is a five-point Likert-type self-report instrument consisting of 45 items that asks subjects to choose from "never" to "always." There are three subscales on the OQ-45: Symptom Distress, Interpersonal Relations, and Social Role. These subscales were developed from literature regarding what behaviors and symptoms are characteristic of the population in therapy, as well as research on the nature of therapy. Additionally, unlike many pre-existing measures, the OQ-45 was developed for use in the field where individuals typically have limited time to devote to completing instruments. t; In research, the OQ-45 has demonstrated concurrent validity with other measures of psychotherapy outcome such as the Symptom Checklist-90-Revised (Derogatis, ' Rickels, & Rock, 1976; Derogatis & Cleary, 1977), the Inventory of Interpersonal Problems (Horowitz, Rosenberg, Baer, & Ureno, 1988), and the Social Adjustment Scale VCC inforn1ation ~ aI., Table 1. General Therapist Demographics Academic Year Male Female Latino/a Asian Other Total 2003-04 13 10 20 2 1 0 23 (56.5%) (43.4%) (87.0%) (8.6%) (4.3%) (0%) 2004-05 11 10 19 1 0 0 21 (52.4%) (47.6%) (90.5%) (4.8%) (0%) (0%) 2005-06 13 9 15 4 2 1 22 (59.1%) (40.9%) (68.2%) ( 18.2) (9.1%) (4.5%) 19 White TOlal . JO I I I JO I I 9. 1%) , , the OQ-45 are also significantly different for clinical as opposed to nonclinical populations, and scores tend to be higher for more pathological populations. These findings speak to the construct validity of the OQ-45. Scores on the OQ-45 have also demonstrated high reliability when administered to undergraduate students (Lambert et al., 1996). CBMCS The California Brief Multicultural Competence Scale (CBMCS) was used to gauge the therapists' multicultural competence. The CBMCS was designed to make quality of care assessments regarding multicultural competence (Gamst et al., 2004). The CBMCS began with items pooled from the Multicultural Competence and Awareness Scale (MCAS, later revised into the MCKAS to include Knowledge; Ponterotto et al., 2002), the Multicultural Awareness, Knowledge, and Skills Survey (Kim et al., 2003), and the Cross-Cultural Counseling Inventory (LaFromboise et al., 1991). These items were then pared down using a four-stage process. In the first stage, 157 Likert-type items, pooled from the four measures named above, were administered to 52 mental health practitioners. Items that correlated significantly with scores on the Marlowe-Crowne Social Desirability Scale (Crowne & Marlowe, 1960) were removed. Items were then removed if they did not correlate with the total score or if the mean scores on the items were extreme in either direction, and a factor analysis led to the creation of four factors. Experts were consulted to assess the content validity of the items. Finally, another factor * analysis confirmed the utility of the four factor model (Gamst et al., 2004). popUlations, aI., 20 aI., CBM~Sbegan aI., aI., ~ confimled aI., 21 The CBMCS thus contains 21 Likert-type items grouped in four factors. The four factors are: Awareness of Cultural Barriers, Multicultural Knowledge, Sensitivity to Consumers, and Nonethnic Ability. Nonethnic Ability refers to the ability to work with multicultural populations not defined by their ethnicity, such as people with disabilities, seniors, and the LGBT population. The CBMCS has shown moderate concurrent validity with the MCI. Construct validity on the CBMCS is suggested by evidence that females tended to score higher than males and doctoral and masters level counselors tended to score higher than those with no graduate training in multicultural competence. The four-factor model has also been shown to account for more variance than Sue's traditional three factor model, which excludes Nonethnic Ability. MMCR A short scale was developed, modeled after the CBMCS in form and wording, which asked therapists to self-assess competence in working with religious diversity, dubbed the Measure of Multicultural Competence, Religious (MMCR; see Appendix). No examination of psychometric properties was conducted for this measure due to low sample size. Procedures Therapists who have worked at the UCC from between August 2003 and May t 2006 were recruited to participate in this study. Recruitment took place during the 2006 spring academic semester (January to May). Trainees and staff members at the UCC, who ~ DCC, 3 were currently seeing clients, were introduced to the study through a quick presentation, and instructed to place completed questionnaires anonymously in a mailbox if they chose to participate. Past trainees, who have already completed client contact at the UCC, were mailed the CBMCS with an introductory letter, along with a self-addressed and stamped envelope for completed questionnaires. The therapists' clinical outcome scores were then tabulated from the already existing OQ-45 database at the UCC. In order to protect confidentiality, the scores on the OQ-45 and the CBMCS were coded separately. The OQ-45 scores were grouped by therapist and assigned therapist IDs that were blind to those involved in the data analysis. The CBMCS surveys were sent to a collaborator unaffiliated with the UCC, along with the coding system used by the counseling center. The collaborator then scored the CBMCS and replaced the therapist names with the same therapist IDs used for the OQ-45. Both sets of data, collected by the UCC and by the collaborator, were then merged. Design This study examined the relationship between therapists' multicultural competence and clinical outcomes using a quasi-experimental associational design. The dependent variable was therapists' clinical outcome, as defined by the effect size estimate (Cohen's d) of their clients' clinical outcomes as measured by the OQ-45. OQ-45 scores are routinely collected at UCC before every session for all clients. Specifically, the effect size estimate is the difference between the clients' OQ-45 score at their final session with • their therapist and the clients' OQ scores at their initial session with their therapist, divided by the standard deviation of the clients' initial scores (Becker, 1988). This effect 22 UCc. OQ-45 scores were grouped by therapist and assigned therapist IDs that were blind to those involved in the data analysis. The CBMCS surveys were sent to a collaborator unaffiliated with the UCC, along with the coding system used by the counseling center. The cqllaborator then scored the CBMCS and replaced the therapist names with the same therapist IDs used for the OQ-45. Both sets of data, collected by the UCC and by the collaborator, were then merged. estimate, effect . • effect 23 it size estimate represents the clients' improvement over the course of treatment. Because at least two OQ-45 scores are needed to calculate the effect size estimate, only clients who were seen for at least two sessions (including intake) were included. Each client was assigned to the therapist who had participated in the greatest number of sessions with that client. If two or more therapists had seen a client the same number of times, only the effect size estimate of the therapist who first saw the client was included. Clients who resumed therapy after a break of 90 days or longer were considered to be in two separate treatments, and might therefore be assigned one therapist for their prebreak sessions and a different therapist postbreak. As client data are nested within therapists, two-level hierarchical linear modeling ' (HLM; Raudenbush & Bryk, 2002) was used for the analysis. At level 1, effect size estimates were modeled to be affected by initial symptom severity and number of sessions with the therapist. These factors have been shown to affect effect size estimates independent of variability due to therapists: initial severity of client distress, as indicated by their initial OQ score, is a known confound to effect size estimates because clients who test high in severity at first session tend to improve more during the course of therapy simply due to regression to the mean, thus inflating effect size estimates for their therapists (Heppner, Kivlighan, & Wampold, 1999). Number of sessions was also included, as the dose effect of psychotherapy has been well established by Howard and , colleagues (e.g., Howard, Kopta, Krause, & Orlinsky, 1986). Prior to testing the multicultural competence moderation hypotheses, a one-way « random effects ANOVA was conducted to see whether there was significant variability among therapists to warrant testing the hypotheses. Specifically, prebreak sessions and a different therapist postbreak. , levell, \ . by their initial OQ score, is a known confound to effect size estimates because clients who test high in severity at first session tend to improve more during the course of therapy simply due to regression to the mean, thus inflating effect size estimates for their therapists (Heppner, Kivlighan, & Wampold, 1999). Number of sessions was also included, as the dose effect of psychotherapy has been well established by Howard and colleagues (e.g., Howard, Kopta, Krause, & Orlinsky, 1986). • ANOV A Specifically, 24 Level 1: Y = /30+j3{ (sessions) j32 (first OQ)+ r (1) Level 2: fl0 = 7m u0 A = 7l0 + M! Here, Y is the clients' effect size estimate, fi0 is the mean effect size estimate of the therapists, is the slope of the effect of the number of sessions on the effect size estimates, y92 is the slope of the effect of the client's first OQ score on the effect size estimates, ym is the grand mean of the effect size estimates, y10 and y20 are average magnitudes of the slopes for the effects of number of sessions and first OQ score, respectively, and u0, ui, and uare the uniquenesses associated with the grand mean and respective slopes. Specifically, whether u0 is significant with the one-way random effects ANOVA determines the feasibility of testing moderation effects. Although there were no specific hypotheses for the potential variability of yw and y20, the decision was made to set these slopes as random effects, as they were expected to vary due to the quasi-experimental nature of client assignment to therapists (i.e., w, and uwere included in the model). Following the one-way random effects ANOVA, therapist variability with regard to their mean effect sizes was hypothesized to be moderated by their multicultural competence, which was therefore included in level 2. However, prior to testing this i hypothesis, gender, years of experience, licensure (i.e., whether the therapist is licensed in a mental health profession), and client hours (i.e., total number of client contact hours t i Levell: Y = Po + PI + P2 OQ) + r Po = roo + Uo PI = rIO +UI P2 = r20 + u2 . Po the therapists, PI is the slope of the effect of the number of sessions on the effect size estimates, P2 is the slope of the effect of the client's first OQ score on the effect size estimates, roo is the grand mean of the effect size estimates, rIO and r20 are average magnitudes of the slopes for the effects of number of sessions and first OQ score, O ' I ' 2 Uo effects ANOV A determines the feasibility of testing moderation effects. Although there rIO r20' ul 2 ANOV A, hypothesis, gender, years of experience, licensure (i.e., whether the therapist is licensed in a mental health profession), and client hours (i.e., total number of client contact hours ' After the preliminary analysis, multicultural competence factors as measured by " the CBMCS subscales were entered in order to see whether variability among therapists could be explained by these factors. The subscales were used for the primary analysis due to the CBMCS's factor structure, per the scale authors' recommendation (Der-Karabetian et al., 2004). The authors also recommended using the CBMCS percentile ranks (rather than raw scores), which were obtained from a transformation table provided with the scale (Der-Karabetian et al., 2004). Therefore, therapists' multicultural competence was represented by their percentile rank on the CBMCS subscales. Specifically, Level 1: Y = j30 + ft (sessions) + J32 (first O Q ) + r (3) Level2: /?0 = Too + Yo\ (MK)+ J / 0 2 ( A C B ) + ^ 0 3 ( S C ) + yM ( N E A ) +w0 # = 7 , 0 + " . Pi ~ Y20 U2 • over the therapist's career) were initially included in this level to test whether therapist demographic factors could explain away the variability among therapists. Specifically, this preliminary examination was modeled as follows: Level 1: Y = p0 + /?, (sessions) /?2 (first O Q ) + r (2) Level 2: p0 ym + y0] (gender) + y02 (years) + y03 (licensure) + y04 (hours) + u0 Pi = Tio + u\ Pi ~ Y20 ~*~ U2 • Specifically, I: = Po P1 + P2 OQ) r 2: Po = Y 00 Y01 Y02 Ym Y04 Uo 25 C1?MCS . aI., 2004). aI., 2004). Specifically, Levell: Po P1(sessions)+ P2(OQ)+ Level 2: Po = Yoo + Y01 (MK)+ Y02 (ACB) + Y03 (Sc)+ Y04 (NEA)+ Uo • ' 26 Here, MK, ACB, SC, and NEA are subscales of the CBMCS assessing Multicultural Knowledge, Awareness of Cultural Barriers, Sensitivity to Consumers, and Nonethnic Ability, respectively. The hypothesis was subsequently tested using the overall percentile score: Level 1: Y p0 + px (sessions) + ft2 (first OQ) + r (4) P0=7m 7m TOTAL) + « 0 Px = 7io + " i Pi ~ 7l0 U2 • I Furthermore, considering the high percentage of clients who are members of the LDS Church, an additional analysis was conducted to determine how therapist effectiveness in working with this religious group might be related to client outcome. Therapists' competence in religious diversity was assessed by using the therapist's gross score on the MMCR. HLM was then used to analyze the relationship between competence in religious diversity and outcome for clients who identify as LDS. As in the pfevious analyses, at level 1, initial symptom severity and number of sessions were modeled to tease out their effect on the effect size estimates. At level 2, therapist variability with regard to their mean effect sizes were hypothesized to be moderated by their multicultural competence, this time measured first by their score on the MMCR, then by the CBMCS subscale percentile ranks, and finally by the overall CBMCS percentile ranks. Specifically, 26 Levell: = /30 /31 /32 Level 2: /30 = roo + rOI (CBMCS_TOTAL)+uo Furtheml0re, considering the high percentage of clients who are members of the LDS Church, an additional analysis was conducted to detemline how therapist effectiveness in working with this religious group might be related to client outcome. Therapists' competence in religious diversity was assessed by using the therapist's gross score on the MMCR. HLM was then used to analyze the relationship between competence in religious diversity and outcome for clients who identify as LDS. As in the previous analyses, at levell, initial symptom severity and number of sessions were modeled to tease out their effect on the effect size estimates. At level 2, therapist variability with regard to their mean effect sizes were hypothesized to be moderated by their multicultural competence, this time measured first by their score on the MMCR, then by the CBMCS sub scale percentile ranks, and finally by the overall CBMCS percentile ranks. Specifically, " Level 1: Y = fi0+ ft (sessions) + ft2 (first OQ) + r Level 2: ft0 = 7 o o + y0 l(MMCR)+«0 27 (5) Pi = 720 + «2 • Levell : ~Po+ p, sess ions )+p, r.rSIOQ)+r Po~roo+r,, MMCR)+uo , . PI =ylO+ u1 P2 =Y2Q+ u2 , • I CHAPTER in RESULTS Preliminary Analysis Results from the one-way random effects ANOVA indicated that there was sufficient variability among therapists when all clients were included in the database (p - .039). Analysis of the subgroup of LDS clients also showed significant variability in therapist effect sizes (p .023). However, sufficient variability was not found for the data sets consisting of clients of ethnic minority status (p .349) or clients of majority ethnic status (Caucasian;/? .0556). Due to low numbers of clients in the database, other datasets consisting of clients of minority status other than ethnicity (sexual minorities, people with disabilities) were not analyzed. Consequently, only the groups consisting of all clients and of LDS clients, regardless of ethnicity or other minority status, were used in subsequent analyses. Results are summarized in Table 2. Bivariate Correlations Pearson product-moment correlation coefficients were calculated among the following independent and dependent variables used in this study: gender, license, years, CBMCS subscale and overall percentiles, and outcome. Therapist demographic variables did not correlate significantly with any of the CBMCS percentiles. All of the subscales j III ANOYA (p = .039). Analysis of the subgroup of LDS clients also showed significant variability in (p = I (p = status (Caucasian; p = .0556). Due to low numbers of clients in the database, other datasets consisting of clients of minority status other than ethnicity (sexual minOlities, people with disabilities) were not analyzed. Consequently, only the groups consisting of all clients and of LDS clients, regardless of ethnicity or other minority status, were used in subsequent analyses. Results are summarized in Table 2. 29 correlated positively (p < .05) with the overall CBMCS percentile, but the subscales did not all correlate significantly with each other. Most notably, Awareness of Cultural Knowledge correlated significantly only with Sensitivity to Consumers. Results are summarized in Table 3. Therapist Gender, Licensure, and Experience and Outcome First, a model was created to examine the relationship of therapist variables (gender, licensure, and experience) to outcome. The obtained result of p - .050, which landed squarely on the border of significance, allowed us to investigate the possible moderation of the multicultural competence variables. None of the variables of gender, licensure, years of practice, or total client hours was significant in their individual contribution to effect size variability at p > .05 (p - .104, .170, .459, .322 for gender, licensure, years of practice, and hours, respectively). As their contributions were not significant, these variables were excluded in following analyses. Multicultural Competence and Outcome Therapist's percentile ranks on the four CBMCS subscales, Multicultural Knowledge, Awareness of Cultural Barriers, Sensitivity to Consumers, and Nonethnic Ability, were introduced into the model to assess whether these specific areas of multicultural competence significantly contributed to reducing variability among therapists. The percentile ranks on the subscales were in fact shown to significantly reduce variability among therapists (i.e., random effects were no longer significant; p - .114 for u0). Examining the fixed effects of the subscales revealed that Multicultural p = \ contribution to effect size variability at p > .05 (p = .104, .170, .459, .322 for gender, licensure, years of practice, and hours, respectively). As their contributions were not significant, these variables were excluded in following analyses. Mliltic;ultural significantly = .114 for u o ). Examining the fixed effects of the subscales revealed that Multicultural 30 Table 2. One-Way Random Effects ANOVA Clients N Ax> i X' P All 979 0.01147 28 42.49600 .039 Caucasian 866 0.01117 28 40.78534 .056 People of Color 96 0.03738 10 11.10650 .349 LDS 241 0.02875 24 39.66264 .023 Table 3. Bivariate Correlations Among Therapist Variables, CBMCS Subscale and Overall Percentiles, and Outcome 1 2 3 4 5 6 7 8 Gender .004 -.011 .007 .343 .116 .105 .268 .325 1 Licensure - -.576* -.116 .178 .111 -.262 -.157 .085 2 Practice Years - .253 -.013 -.068 .272 . .152 -.246 3MK - .139 .424* .267 .691* -.271 4ACB - .251 .033 .377* .214 5SC - .450* .683* -.353 6NEA - .707* -.202 7 Overall CBMCS - -.186 8 Outcome - Note, n = 31. CBMCS = California Brief Multicultural Competence Scale; MK = Multicultural Knowledge; ACB = Awareness of Cultural Barriers; SC = Sensitivity to Consumers; NEA Nonethnic Ability. *p < .05 { roo ? df X-All 0.02875. Licensure 5 SC Note. = = = = = = *p 31 I Knowledge and Awareness of Cultural Barriers significantly related to therapists' clinical outcome (p = .014 and .000 for Multicultural Knowledge and Awareness of Cultural Barriers; Table 4). However, the direction of the relationship differed between the two factors: Multicultural Knowledge was negatively related to clinical outcome, while Awareness of Cultural Barriers was positively related to clinical outcome. The proportion of variance explained by the CBMCS subscales was calculated using the following formula: ioo(random ANOVA)-t m(CBMCS HLM) _ 0.01147 -0.00873 ; r - - 0.2388 . too (random ANO V A) 0.01147 ' Thus, approximately 24% of the true variance attributed to variability among therapists was explained by the CBMCS subscales. u0 = - All) indicated that overall CBMCS percentile does not significantly contribute to Competence in Religious Diversity and Outcome for LDS Clients Scores on the MMCR did not significantly contribute to variability in effect size » (p = .018 for u0 ;p - .516 for YMMCR)- In addition, the percentile scores on the subscales on the CBMCS did not contribute significantly to variability in effect size (p = .035 for = A wareness of variance explained by the CBMCS subscales was calculated using the following formula: Too(randomANOVA)-i\)(JCBMCS -0.00873 ( ) = = 0.2388. Too random ANOVA 0.01147 I Further analysis was then conducted using overall multicultural competence, represented by the therapist's overall percentile rank based on the CBMCS total score. The p value for Uo (p = .032) as well as for the coefficient for the CBMCS total score (p = .127) variability among therapists. .t (p = .018 for Uo ; P = .516 for r MMCR). In addition, the percentile scores on the subscales on the CBMCS did not contribute significantly to variability in effect size (p = .035 for .~ 32 3 .06 ~ .88 for CBMCS subscales), nor did the overall CBMCS percentile score (p for u0;p = .986 for CBMCS total; Table 5). u~; p = - subsca les), ~ .032 u,; p ~ 101al ; , . • , I 33 Table 4. Fixed and Random Effects of CBMCS Subscales Effects: Subscale SE Awareness of Sensitivity to Consumers Nonethnic Ability -0.002398 0.000906 -2.648 0.002470 0.000530 4.663 -0.002384 0.001200 -1.986 0.000238 0.000956 0.248 24 24 24 24 .014 .000 .058 .806 Subscales '00 .00873 Table 5. Fixed and Random Effects of CBMCS Subscales, LDS Clients Fixed Effects: Subscale 7 0j SE df Awareness of Cultural Barriers Sensitivity to Consumers Nonethnic Ability 0.000014 0.000096 0.150 0.000121 0.000061 1.976 -0.000068 0.000133 -0.510 0.000024 0.000075 0.318 26 26 26 26 0.882 0.058 0.614 0.753 Random Effects: "oo df_ Subscales 0.02106 26 40.50970 0.035 • i Fixed YO j t df p Multicultural Knowledge A wareness Cultural Barriers Random Effects: roo df %2 P 24 32.544 .114 YO) t p. Multicultural Knowledge A wareness l.976 roo df x2 p CHAPTER IV DISCUSSION This study attempted to address a question at the core of multicultural counseling competence research: Does multicultural competence, as it is currently conceptualized and measured, relate to quality of care? In order to address this question, this study explored the relationship between scores on a therapist self-report measure of multicultural competence and client outcomes. The most significant findings were that Awareness of Cultural Barriers was positively related to outcome while Multicultural Knowledge was negatively related. This extends previous studies that question the theoretical conceptualization of multicultural competencies. In contrast to the conceptual unity suggested by an overall multicultural competence index, certain components of multicultural competence currently viewed as positively related to one another may in fact be dissimilar. Ultimately, this study showed that multicultural competence does play a role in counseling, but in ways that are dramatically different than the current theory on multicultural competence suggests. accordance with the current theory, multicultural competence and clinical " competence were hypothesized to be positively related to each other; that is, therapists who scored higher on each of the multicultural competence subdomains (i.e., Multicultural Knowledge, Awareness of Cultural Barriers, Sensitivity to Consumers, and Nonethnic Ability) were expected to have better clinical outcomes with their clients. . unity suggested by an overall multicultural competence index, certain components of multicultural competence currently viewed as positively related to one another may in fact be dissimilar. Ultimately, this study showed that multicultural competence does play a ~ole in counseling, but in ways that are dramatically different than the current theory on multicultural competence suggests. In and. Such findings would have lent construct validity to the multicultural competence scale used, the CBMCS, as well as suggested that similar multicultural measures might have utility in assessing actual clinical competency in the field. Scores on the CBMCS were in fact found to relate to client outcome, but the nature of the relationship differed depending upon the subscale in question. Awareness of Cultural Barriers was shown to be positively related to client outcome: High scores on this measure were associated with better client outcomes. This finding is congruent with other studies in the field which showed that abilities similar to multicultural competence, such as matching the client's worldview, resulted in improved service to clients (Kim et al., 2005). Studies that showed the relationship of multicultural competence to other counseling abilities such as case conceptualization skills (Holcomb- McCoy, 2000) are also congruent with this finding. However, this is the first empirical evidence that links multicultural competence to actual client outcomes in the field. As such, it is encouraging evidence that this aspect of multicultural competence is valid and that self-reported Awareness of Cultural Barriers is associated with higher quality of care. Although preliminary, this may be the first step towards empirically demonstrating the utility of multicultural competence in counseling. Perhaps surprisingly, Multicultural Knowledge was shown to be negatively related to client outcome: High scores on this measure were associated with worse client ; outcomes. This finding was unexpected, though in retrospect it does appear to be foreshadowed by the study of Fraga et al. (2004) on the preferences of different ethnic groups for different aspects of multicultural competency, which showed that different multicultural competencies were valued differentially by individuals, depending in part J 35 differed aI., ' Holcomb­McCoy, i a1. different upon ethnic group membership (Fraga et al., 2004). Though the study of Fraga et al. categorized competencies differently than the CBMCS and asked participants only to compare competencies within the three areas of knowledge, beliefs, and skills, their results do appear to line up somewhat with these findings. For example, the knowledge skills (as defined in Fraga's study) that were the most valued by all ethnic groups, knowledge of institutional barriers and awareness of personal stereotypes, both map onto the CBMCS subscale of Awareness of Cultural Barriers. Furthermore, the competency that showed the least agreement in preferences across ethnic groups was knowledge of bias in testing, which maps onto the CBMCS subscale of Multicultural Knowledge. Interestingly, Fraga et al. (2004) noted that European American subjects expressed more preference relative to ethnic minorities for competencies related to knowledge of minority practices, i.e. Multicultural Knowledge. As the majority of the clients in this study were of Caucasian descent, one could argue that Multicultural Knowledge should have correlated positively with client outcomes. On the other hand, it is unlikely that knowledge of ethnic minority cultures would play a role in therapy when the therapist and client are both from the majority ethnic culture. Though more research is warranted to examine the inverse relationship between Multicultural Knowledge and client outcome, looking at the findings of this study in relation to the work of Fraga et al. suggests that the competencies preferred across ethnic groups (which are similar to those j on the CBMCS Awareness of Cultural Barriers subscale) are positively related to client outcomes, while the competencies preferred by European American subjects but not by ' clients of color (Multicultural Knowledges) are actually negatively associated with outcome. 36 aI., a1. sub scale that showed the least agreement in preferences across ethnic groups was knowledge of bias in testing, which maps onto the CBMCS subscale of Multicultural Knowledge. expre~sed playa the therapist and client are both from the majority ethnic culture. Though more research is warranted to examine the inverse relationship between Multicultural Knowledge and client outcome, looking at the findings of this study in relation to the work of Fraga et al. suggests that the competencies preferred across ethnic groups (which are similar to those f on the CBMCS Awareness of Cultural Barriers subscale) are positively related to client outcomes, while the competencies preferred by European American subjects but not by • clients of color (Multicultural Knowledges) are actually negatively associated with outcome. Another, albeit oblique, indication that knowledge and awareness are dissimilar constructs is found in Kocarek's (2001) finding that training increased scores on the Knowledge/Skills subscale of the MCAS (a self-report measure, like the CBMCS) but not on Awareness. It is perhaps unfortunate that training appeared to increase the aspect of multicultural competence that was found to be negatively related with client outcome. An argument could be made that the negative relationship of multicultural knowledge to client outcome points to a need to revise the underlying theoretical model of multicultural competence. It is possible that increased multicultural knowledge, as currently conceptualized and measured, decreases counseling competence, perhaps by creating stereotypical preconceptions about clients and thus interfering with the client-counselor bond. If this is the case, a radical overhaul of multicultural competence theories, training, and practice might be necessary. This study also suggests that training interventions as well as research should view the dimensions of multicultural competence, as currently conceptualized, as separate constructs rather than as a unified construct. Another possibility is that the subscale measure of Multicultural Knowledge is valid, but in the opposite direction: Therapists who report high Multicultural Knowledge may in fact possess relatively low multicultural knowledge. In other words, therapists who actually have increased multicultural knowledge may score themselves lower than therapists who do not know as much, illustrating the adage, "The more you learn, the more you realize you don't know." The Multicultural Knowledge subscale might in fact t be measuring constructs such as multicultural overconfidence on the part of the therapist. Alternately, though the CBMCS was created to control for social desirability (Gamst et al., 2004), there may be a distinct social desirability associated with f 37 Kocarek' s An argument could be made that the negative relationship of multicultural knowledge to client outcome points to a need to revise the underlying theoretical model of multicultural competence. It is possible that increased multicultural knowledge, as currently conceptualized and measured, decreases counseling competence, perhaps by creating stereotypical preconceptions about clients and thus interfering with the client-counselor I bond. If this is the case, a radical overhaul of multicultural competence theories, training, and practice might be necessary. This study also suggests that training interventions as well as research should view the dimensions of multicultural competence, as currently conceptualized, as separate constructs rather than as a unified construct. therapists who do not know as much, illustrating the adage, "The more you learn, the more you realize you don't know." The Multicultural Knowledge subscale might in fact ~ be measuring constructs such as multicultural overconfidence on the part of the therapist. Alternately, though the CBMCS was created to control for social desirability (Gamst et at, 2004), there may be a distinct social desirability associated with multicultural issues, considering the prevalent multiculturally aware climate in the profession of psychology. This hypothesis is partly suggested by the distribution of CBMCS percentiles seen in Table 6, which shows that therapists tended to score higher in Multicultural Knowledge than in the less politically charged area of Nonethnic Ability. Research using alternate measures of multicultural competence, such as assessments by clients or independent observers, may help elucidate what the CBMCS is measuring. Nonethnic Ability and Sensitivity to Consumers were not shown to be related to client outcome. This could indicate that these aspects of multicultural competence do not affect client care. However, a larger sample size, particularly one that allows hypothesis testing for clients of color and other minority groups, may reveal a relationship that went undiscovered in this study. Multicultural competence overall as measured by the total score was not related to client outcome, though subscale scores were related to outcome. This finding bolsters the CBMCS authors' view that the subscales should be treated separately and that the subscales are more meaningful than the overall multicultural competence score. Furthermore, the lack of correlations among the CBMCS subscales (see Table 3) also indicates that the subscales may be measuring distinct constructs, particularly in relation to Awareness of Cultural Barriers, which was not found to relate significantly to any of the other subscales. Given that Awareness of Cultural Barriers was the only factor that positively related to client outcome, the lack of correlations again indicates the importance of examining this aspect of multicultural competence independent of general multicultural competence. During the course of analysis, variables such as gender, licensure, hours of client contact, and years of experience were not found to have a significant impact on client 38 I . Table 6. Distribution of CBMCS Percentile Scores, Therapists (N=31) Awareness Percentile Multicultural of Cultural Sensitivity to Nonethnic Overall Range Knowledge Barriers Consumers Ability 90-100 16 20 6 1 12 80-89 7 6 9 7 6 70-79 1 3 8 7 7 60-69 0 1 0 0 1 50-59 3 0 8 3 1 0-49 4 1 0 13 4 39 Scores. Therapi sts Percenliie of Cultural Sensiti vity Abi lity MCC 1 ()() I 40 outcome. Competency in religious diversity as measured by self-report was not related to outcome for the LDS clients, nor was multicultural competence, either in its subscales or in total. It is uncertain why multicultural competence was not related to outcome for the LDS clients, but the simplest explanation is that the smaller sample size prevented any relationships from being detected, as may be inferred by the near significant relationship between Awareness of Cultural Barriers and client outcome. Obviously, the analysis using the MMCR scale was tainted with the fact that the scale itself was far from valid, as it was created simply to mimic questions in the CBMCS without rigorous psychometric investigation. Additional research is needed to investigate factors that may contribute to competence in working with diverse religious populations, as well as ways to measure such competence. Limitations First of all, this study was limited by its setting, a university counseling center with predominantly ethnic majority college students. Therefore, it is necessary to conduct replications with other populations. In addition, other factors might have influenced the results in unknown ways. For example, therapists were asked to rate themselves in multicultural competence at different times relative to working with clients at UCC: Some had completed their client contacts, some were still seeing UCC clients. Given that,. little is known about the stability of multicultural competence, coupled with the fact that many therapist participants were trainees whose multicultural competence would .» presumably increase over time, these temporal complications may have affected the , results. In this study, the therapists' multicultural competence at the time of assessment significarit it was created simply to mimic questions in the CBMCS without rigorous psychometric investigation. Additional research is needed to investigate factors that may contribute to competence in working with diverse religious populations, as well as ways to measure such oompetence. DCC: DCC that i • was presumed to be equivalent to competence during the time of client contacts. It is quite possible, however, that the therapists' multicultural competence level was higher at the time of assessment than during the time of treatment. Also, it is possible that the assignment of clients to counselors was also nonrandom in relation to multicultural issues: Some counselors might be drawn to clients who present with issues requiring multicultural competence, which might affect the relationship of self-assessed competence to client outcome. This is partly indicated from the fact that close to 60% of the therapists did not have two or more ethnic minority clients, an unexpected finding that suggests that the process of client assignment may be another factor in the multicultural competence and client outcome relationship. For example, the results found in this study may be characteristic only of those who voluntarily choose to work with demographically diverse clients, rather than the population of therapists as a whole. Therapist demographic data as well as therapist preferences in working with multicultural issues, which were not collected in this study to preserve anonymity, might also in the future shed light on the role of multicultural competence in clinical outcome. Investigating other therapist variables related to multicultural issues, such as therapist ethnic identity development, may also explicate what self-report multicultural competence scales are measuring, as well as what therapist characteristics best predict improved client outcome. Replicating this study at other facilities with more diverse populations would help further investigation of the relationship between multicultural competence and client outcome. More research could also illuminate why Nonethnic Ability and Sensitivity to Consumers did not show a significant relationship with client 41 • outcome, by replicating this study with an increased sample size, or employing different measures of those multicultural competencies. This study was also limited by uncertainty about the true construct validity of the measure in assessing multicultural competence (i.e., ability to assess multicultural counseling competence as it relates to actual clinical outcomes) and the inability to assign causality. Another limitation of this study is the possibility that the CBMCS may indeed be measuring multicultural competence, but that the relationship between multicultural competence and outcome might be better accounted for by a third variable, such as general counseling competence, that underlies both increased awareness (and perhaps increased humility about multicultural knowledge) and better client outcomes. It is unclear whether the positively related aspect of multicultural competence, Awareness of Cultural Barriers, measured anything above and beyond general counseling competence. The finding that multicultural competence is related to care for all clients regardless of ethnicity or minority status also indicates that multicultural competence may be closely related or identical to general counseling competence, in contrast to the current notion that multicultural competence is a "special" competence for counseling and is necessary only when therapists are treating diverse populations. Prior studies found the relationship between general and multicultural counseling competence to be inconclusive (e.g., Coleman, 1998; Constantine, 2002). More research is needed to investigate this link, possibly by using general counseling competence as a control when looking at client outcome. Originally, this study was intended to address the question of how multicultural competence related to client outcome for clients of color or other minority status, 42 different \ ethnicityor relationship. • 43 multiple minorities, and for clients of majority status only. Unfortunately, likely due to small sample size, sufficient variability was not found when examining client subgroups to test hypotheses about client group membership. Therefore, this study's findings are limited to the relationship of multicultural competence and outcome for all clients, regardless of their ethnicity or other minority status. Though questions about how client group membership interacts with multicultural competence went unanswered, the discovery of the relationship of multicultural competence to outcome for all clients, most of whom were Caucasian, suggests that multicultural competence plays a role even when delivering counseling to majority clients. ' Conclusions Overall, this study resulted in two major findings: that self-reported Awareness of Cultural Barriers positively relates to client outcomes and that self-reported Multicultural Knowledge negatively relates to client outcomes. Each of these findings requires further clarification to determine if the association is an artifact of the way the measures are constructed or of some third factor like general counseling competence. Alternately, these findings could point to causalities that would have major implications for the study and practice of multicultural counseling competence. On the positive side, the association of Awareness of Cultural Barriers with ' improved client outcomes lends support to some of the underlying assumptions of multicultural counseling competence; namely, that multicultural competence leads to improved quality of care. This conclusion, which is tentatively supported by this study, would help justify the increasing focus on multicultural competence in both counseling J of whom were Caucasian, suggests that multicultural competence plays a role even when delivering counseling to majority clients. • 44 training and practice, albeit with caution. The surprising and potentially disruptive finding that self-reported Multicultural Knowledge may interfere with the delivery of effective counseling signals the need for caution in multicultural training and research. However, given the nascent state of the literature, as well as the limitations of this study, jumping to radical conclusions about the negative impact of multicultural knowledge seems premature. Though more explorations are needed to illuminate causalities that are only suggested by this study, some clinical implications may be drawn from the relationships between multicultural competence and client outcome seen here. Most broadly, this study suggests that clinicians who strive to treat diverse populations by increasing their multicultural competence would benefit from tracking client outcomes rather than relying on multicultural competence measures, perhaps especially self-report measures. This study also suggests that clinicians might concentrate their efforts to educate themselves by increasing awareness of the barriers faced of people who are ethnic minorities, though as cautioned above there is currently no evidence that awareness of cultural bias, or any other multicultural competency, leads directly to improved client service. Most of all, this study illustrates that multicultural counseling competence indeed bears a relationship with counseling in practice, and with quality of care to clients, though that relationship proved more complex than anticipated. This result, though it raises ? more questions than it answers, at least furthers our understanding (or illuminates our lack of understanding) of multicultural issues. Ultimately, I hope that similar as well as more innovative studies will show how best to serve an increasing diverse population. ' seems premature. study also suggests that clinicians might concentrate their efforts to educate themselves by increasing awareness of the baniers faced of people who are ethnic minorities, though as cautioned above there is currently no evidence that awareness of cultural bias, or any other multicultural competency, leads directly to improved client service. more innovative studies will show how best to serve an increasing diverse population. • MMCR APPENDIX • I , 46 Below is a list of statements dealing with multicultural issues within a mental health context. Please indicate the degree to which you agree with each statement by circling the appropriate number. 1. I am aware of the challenges faced by people of various religious/spiritual faiths. 1 2 3 4 2. I am aware of how my own religious/spiritual values might affect my client 1 2 3 4 3. I have an excellent ability to assess, accurately, the mental health needs of people of different religious/spiritual faiths 12 3 4 4. I am aware that counselors frequently impose their own religious/spiritual values upon clients 1 2 3 4 5. I am aware of how my religious/spiritual background and experiences have influenced my attitudes about psychological processes 1 2 3 4 6. I can identify my reactions that are based on stereotypical beliefs about different religious/spiritual groups 1 2 3 4 J faiths ................................. . client. ....................................... . ..... . clients. . . . . . . .. . ............ . procesSes ............................................. . .............. . 234 234 234 234 234 REFERENCES Becker, B. J. (1988). Synthesizing standardized mean-change measures. British Journal of Mathematical & Statistical Psychology, 41(2), 257-278. Byington, K., Fischer, J., Walker, L., & Freedman, E. (1997). Evaluating the effectiveness of a multicultural counseling ethics and assessment training. Journal of Applied Rehabilitation Counseling, 28(A), 15-19. Census 2000 (2000). U.S. Census Bureau. Coleman, H. L. K. (1998). General and multicultural counseling competency: Apples and oranges? Journal of Multicultural Counseling & Development, 26(3), 147-156. Constantine, M. G. (2002). Predictors of satisfaction with counseling: Racial and ethnic ' minority clients' attitudes toward counseling and ratings of their counselors' general and multicultural counseling competence. Journal of Counseling Psychology, 49(2), 255-263. Constantine, M. G. (2001). Predictors of observer ratings of multicultural counseling competence in Black, Latino, and White American trainees. Journal of Counseling Psychology, 48(4), 456-462. Constantine, M. G., Gloria, A. M., & Ladany, N. (2002). The factor structure underlying three self-report multicultural counseling competence scales. Cultural Diversity & Ethnic Minority Psychology, 8(4), 334-345. Constantine, M. G., & Ladany, N. (2000). Self-report multicultural counseling competence scales: Their relation to social desirability attitudes and multicultural case conceptualization ability. Journal of Counseling Psychology, 47(2), 155-164. Corrigan, J. D., & Schmidt, L. D. (1983). Development and validation of revisions in the ?, counselor rating form. Journal of Counseling Psychology, 30(1), 64-75. Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24(4), 349-354. * Der-Karabetian, A., Gamst, G., Dana, R., Aragon, M., Arellano, L., & Morrow, G., et al. (2004). California brief multicultural competence scale: Abbreviated user guide. La Verne, CA: University of La Verne. * Journal Journal 4), \ Counseling 4),456-334-" ~ 1),guide .. 48 Derogatis, L. R., & Cleary, P. A. (1977). Confirmation of the dimensional structure of the SCL-90: A study in construct validation. Journal of Clinical Psychology, 33(4), 981-989. Derogatis, L. R., Rickels, K., & Rock, A. F. (1976). The SCL-90 and the MMPI: A step in the validation of a new self-report scale. British Journal of Psychiatry, 128, 280-289. Elkin, I., Shea, M. T., Watkins, J. T., & Imber, S. D. (1989). National institute of mental health treatment of depression collaborative research program: General effectiveness of treatments. Archives of General Psychiatry, 46( 11), 971-982. Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychology, 16, 319-324. Fraga, E. D., Atkinson, D. R., & Wampold, B. E. (2004). Ethnic group preferences for multicultural counseling competencies. Cultural Diversity & Ethnic Minority , Psychology, 10(1), 53-65. Fuertes, J. N., Bartolomeo, M., & Matthew Nichols, C. (2001). Future research directions in the study of counselor multicultural competency. Journal of Multicultural Counseling & Development, 29(1), 3. Gamst, G., Dana, R. H., Der-Karabetian, A., Aragon, M., Arellano, L., & Morrow, G., et al. (2004). Cultural competency revised: The California brief multicultural competence scale. Measurement & Evaluation in Counseling & Development, 37(3), 163-183. Goldfried, M. R., & Wolfe, B. E. (1996). Psychotherapy practice and research: Repairing a strained relationship. American Psychologist, 57(10), 1007-1016. Guidos, Joe Baird & Rhina. (2004, Sep 30). Utah on a fast track for ethnic change. The Salt Lake Tribune, pp. A.l. Heppner, P. P., Kivlighan, D. M., & Wampold, B. E. (1999). Research design in counseling (2nd ed.). Belmont, CA: Brooks/Cole/Wadsworth. Holcomb-McCoy, C. C. (2000). Multicultural counseling competencies: An exploratory factor analysis. Journal of Multicultural Counseling & Development, 28(2), 83-97. Horowitz, L. M., Rosenberg, S. E., Baer, B. A., & Ureno, G. (1988). Inventory of interpersonal problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56(6), 885-892. Howard, K. I., Kopta, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The dose-effect relationship in psychotherapy. American Psychologist, 41(2), 159-164. ' » Confinnation 33(4), 128, 11), 16,319-1),Multicultural aI. Development, 3),163-51(I. KivIighan, ColelWadsworth. Journal dose-49 Huppert, J. D., Bufka, L. F., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2001). Therapists, therapist variables, and cognitive-behavioral therapy outcome in a multicenter trial for panic disorder. Journal of Consulting and Clinical Psychology, 69(5), 747-755. Ibrahim, F. A. 1., & Arredondo, P. M. 2. (1986). Ethical standards for cross-cultural counseling: Counselor preparation, practice, assessment, and research. Journal of Counseling & Development, 64(5), 349. Karlsson, R. (2005). Ethnic matching between therapist and patient in psychotherapy: An overview of findings, together with methodological and conceptual issues. Cultural Diversity and Ethnic Minority Psychology, 11(2), 113-129. Kim, B. S. K., Cartwright, B. Y., Asay, P. A., & DAndrea, M. J. (2003). A revision of the multicultural awareness, knowledge, and skills survey-counselor edition. Measurement & Evaluation in Counseling & Development, 36(3), 161-180. Kim, B. S. K., Ng, G. F., & Ahn, A. J. (2005). Effects of client expectation for counseling success, client-counselor worldview match, and client adherence to asian and european american cultural values on counseling process with asian americans. 1 Journal of Counseling Psychology, 52(1), 67-76. Kocarek, C. E., Talbot, D. M., Batka, J. C , & Anderson, M. Z. (2001). Reliability and validity of three measures of multicultural competency. Journal of Counseling & Development, 79(4), 486. Korman, M. (1974). National conference on levels and patterns of professional training in psychology: The major themes. American Psychologist, Vol. 29(6), 441-449. Ladany, N., Inman, A. G., Constantine, M. G., & Hofheinz, E. W. (1997). Supervisee multicultural case conceptualization ability and self-reported multicultural competence as functions of supervisee racial identity and supervisor focus. Journal of Counseling Psychology, 44(3), 284-293. LaFromboise, T. D., Coleman, H. L., & Hernandez, A. (1991). Development and factor structure of the cross-cultural counseling inventory-revised. Professional Psychology: Research & Practice, 22(5), 380-388. • Lambert, M. J., Burlingame, G. M., Umphress, V., Hansen, N. B., Vermeersch, D. A., & Clouse, G. C , et al. (1996). The reliability and validity of the outcome questionnaire. Clinical Psychology & Psychotherapy, 3(4), 249-258. * Li, L. C , & Kim, B. S. K. (2004). Effects of counseling style and client adherence to t asian cultural values on counseling process with asian american college students. Journal of Counseling Psychology, 51(2), 158-167. Olympic briefs: Utah's 10 dirtiest words. (2002, Feb 9). The Salt Lake Tribune, pp. 0.18. Butka, Clinical D'Andrea, 1. \ 1. c., 6),441-44(3),inventory--Professional c., 249-c., 50 O'Malley, S. S., Foley, S. H., Rounsaville, B. J., & Watkins, J. T. (1988). Therapist competence and patient outcome in interpersonal psychotherapy of depression. Journal of Consulting and Clinical Psychology, 56(4), 496-501. Peebles, J. (2000). The future of psychotherapy outcome research: Science or political rhetoric? Journal of Psychology: Interdisciplinary and Applied, 134(6), 659-669. Ponterotto, J. G., Rieger, B. P., Barrett, A., & Sparks, R. (1994). Assessing multicultural counseling competence: A review of instrumentation. Journal of Counseling & Development, 72(3), 316-322. Ponterotto, J. G. 1., Gretchen, D. 1., Utsey, S. O. 2., Rieger, B. P. 3., & Austin, R. 1. (2002). A revision of the multicultural counseling awareness scale. Journal of Multicultural Counseling & Development, 30(3), 153. Ponterotto, J. G. 1., Rieger, B. P. 2., Barrett, A. 2., & Sparks, R. 2. (1994). Assessing multicultural counseling competence: A review of instrumentation. Journal of Counseling & Development, 72(3), 316. Pope-Davis, D. B., & Coleman, H. L. K. (1997). Multicultural counseling competencies: Assessment, education and training, and supervision. Thousand Oaks, CA: Sage ' Publications, Inc. Pope-Davis, D. B., & Dings, J. G. (1994). An empirical comparison of two self-report multicultural counseling competency inventories. Measurement & Evaluation in Counseling & Development, 27(2), 93. Pope-Davis, D. B., & Ottavi, T. M. (1994). Examining the association between self-reported multicultural counseling competencies and demographic variables among counselors. Journal of Counseling & Development, 72(6), 651-654. Prediger, D. J. (1994). Multicultural assessment standards: A compilation for counselors. Measurement & Evaluation in Counseling & Development, 27(2), 68. Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and . data analysis methods (2nd ed.). Thousand Oaks: Sage Publications, Inc. Ridley, C. R., & Kleiner, A. J. (2003). Multicultural counseling competence: History, \ themes, and issues. In D. B. Pope-Davis, H. L. K. Coleman, W. M. Liu & R. L. Toporek (Eds.), Handbook of multicultural competencies: In counseling & psychology (pp. 3-20). Thousand Oaks, CA: Sage Publications, Inc. Shin, S., Chow, C , Camacho-Gonsalves, T., Levy, R. J., Allen, I. E., & Leff, H. S. (2005). A meta-analytic review of racial-ethnic matching for african american andt, Caucasian american clients and clinicians. Journal of Counseling Psychology, 52(1), 45-56. .1 1., 1. 496-political. 6),1. R 316-1. R 153. 1. R 3),competencies: I & Dings, J. G. (1994). An empirical comparison of two self-report self­reported 1. Sage R, 1. c., R 1., 1. and" caucasian Psychology, 51 Sodowsky, G. R., Kuo-Jackson, P. Y., Richardson, M. F., & Corey, A. T. (1998). Correlates of self-reported multicultural competencies: Counselor multicultural social desirability, race, social inadequacy, locus of control racial ideology, and multicultural training. Journal of Counseling Psychology, 45(3), 256-264. Sodowsky, G. R., Taffe, R. C , Gutkin, T. B., & Wise, S. L. (1994). Development of the multicultural counseling inventory: A self-report measure of multicultural competencies. Journal of Counseling Psychology, 41(2), 137-148. Sue, D. W., & Arredondo, P. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70(4), 477. Sue, D. W. (1982). Position paper: Cross-cultural counseling competencies. Counseling Psychologist, 10(2), 45-52. Sue, D. W. (1981). Counseling the culturally different: Theory and practice. New York: Wiley. Sue, D. W., Arredondo, & McDavis, R. J. (1992). Multicultural counseling competencies 1 and standards: A call to the profession. Journal of Multicultural Counseling & Development, 20(2), 64. Sykes, S. A. (2005, Nov 21). U. whiter as the state diversifies. The Salt Lake Tribune, pp. A.l. Umphress, V. J., Lambert, M. J., Smart, D. W., & Barlow, S. H. (1997). Concurrent and construct validity of the outcome questionnaire. Journal of Psychoeducational Assessment, 75(1), 40-55. University of Utah Facts. Retrieved August 9, 2006 from http://www.unews.utah.edu/?action=uFacts#whoweare Vermeersch, D. A., Whipple, J. L., Lambert, M. J., Hawkins, E. J., Burchfield, C. M., & Okiishi, J. C. (2004). Outcome questionnaire: Is it sensitive to changes in counseling center clients? Journal of Counseling Psychology, 51(1), 38-49. Wampold, B. E., & Bhati, K. S. (2004). Attending to the omissions: A historical examination of evidence-based practice movements. Professional Psychology: Research and Practice, 35(6), 563-570. t Wells, M. G., Burlingame, G. M., Lambert, M. J., & Hoag, M. J. (1996). Conceptualization and measurement of patient change during psychotherapy: t t E, c., 70(4), Counseling 2),\ I. Psychoeducational 15(9,2006 edu!?action=uFacts#whoweare 1., 1),38-Psychology: Weissman, M. M., & Bothwell, S. (1976). Assessment of social adjustment by patient self-report. Archives of General Psychiatry, 33(9), 1111-1115. 52 Development of the outcome questionnaire and youth outcome questionnaire. Psychotherapy: Theory, Research, Practice, Training, 33(2), 275-283. Worthington, R. L., Mobley, M., Franks, R. P., & Tan, J. A. (2000). Multicultural counseling competencies: Verbal content, counselor attributions, and social desirability. Journal of Counseling Psychology, 47(4), 460-468. | (he OlHcome queslionnaire YOUlh queslionnaire. Research. Practice. Training. 2),275-Muhicuhural con lent, att ributions, desirab ility. Psychology. 4),460-• , I