Sociocultural Factors in Therapy

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Chapter 13 Treatment of Psychological Disorders
treatment, by whom, is most effective for this individual with that specific problem,
under what set of circumstances?” We still have a long way to go to answer the rest
of Paul’s complex question, but empirically oriented clinical psychologists are determined to do so.
The combinations of treatment methods and therapist and client characteristics that
are best suited to solving particular psychological problems have not yet been mapped
out, but there are a few trends. For example, when differences do show up in comparative studies of adult psychotherapy, they tend to reveal a small to moderate advantage
for behavioral and cognitive-behavioral methods, especially in the treatment of phobias
and certain other anxiety disorders (Barrowclough et al., 2001; Borkovec & Costello,
1993; DeRubeis & Crits-Christoph, 1998; Eddy et al., 2004; Hunsley & Di Giulio, 2002;
Lambert & Bergin, 1994; Weisz et al., 1995), as well as bulimia nervosa, an eating disorder (Hendricks & Thompson, 2005; Wilson, 1997). The same tends to be true for child
and adolescent clients (Epstein et al., 1994; Weiss & Weisz, 1995; Weisz et al., 1995).
Further, the client-therapist relationship seems to play a significant role in the success of many forms of treatment (Brown & O’Leary, 2000; Constantino et al., 2005;
Horvath, 2005; Martin, Garske, & Davis, 2000; Messer & Wampold, 2002; Uwe, 2005).
Certain people seem to be particularly effective in forming productive human relationships. Even without formal training, these people can sometimes be as helpful as
professional therapists because of personal qualities that are inspiring, healing, and
soothing to others (Stein & Lambert, 1995). These qualities may help account for the
success of many kinds of therapy.
In summary, the Dodo Bird Verdict is probably incorrect, and it is certainly incomplete. Although different treatments can be equally effective in addressing some disorders, empirical research shows that for other disorders certain therapies are more effective than others. That research provides valuable guidelines for matching treatments to
disorders, but it doesn’t guarantee success. The outcome of any given case will also be
affected by client characteristics, therapist characteristics, and the therapeutic relationship that develops between them (e.g., Hill, 2005; Sherer & Schreibman, 2005). The
challenge now is to combine research on empirically supported therapy methods with
research on the common factors they share and to create a picture of psychotherapy
effectiveness that is based on both sets of data (Messer, 2004; Westen & Bradley, 2005).
Such a comprehensive view would be a useful guide for clinicians practicing today and
an ideal training model for the clinicians of tomorrow.
Given what is known so far, potential clients are well advised to choose a treatment
approach and a therapist based on (1) what treatment approach, methods, and goals
the person finds comfortable and appealing; (2) information about the potential therapist’s “track record” with a particular method for treating problems similar to those
the person faces; and (3) the likelihood of forming a productive relationship with the
therapist. This last consideration assumes special importance when client and therapist
do not share similar social or cultural backgrounds.
Sociocultural Factors in Therapy
Sociocultural differences between clients and therapists—in religious faith, gender, age,
ethnicity, sexual orientation, socioeconomic background, and the like—can sometimes
create miscommunication or mistrust. If it does, their working relationship and the
clients’ motivation to change may both be impaired (Jones, Botsko, & Gorman, 2003;
Pachankis & Goldfried, 2004). Suppose, for example, that a therapist suggests that a
client’s insomnia is a reaction to stress, but the client is sure that it comes as punishment for having offended a long-dead ancestor. That client may not easily accept a
treatment based on the principles of stress management (Wohl, 1995). Similarly, a therapist who believes that people should confront and overcome life’s problems might run
into trouble when treating clients whose cultural or religious training encourages calmly
Evaluating Psychotherapy
523
Special
pretreatment orientation programs may
be offered to clients who, because of sociocultural factors, are unfamiliar with
the rules and procedures of psychotherapy. These programs provide a preview of
what psychotherapy is, how it can help,
and what the client is expected to do to
make it more effective (Reis & Brown,
2006; Sue, Zane, & Young, 1994).
PREPARING FOR THERAPY
accepting such problems (Sundberg & Sue, 1989). In such cases, the result may be much
like two people singing a duet using the same music but different lyrics (Johnson &
Thorpe, 1994; Martinez-Taboas, 2005).
In the United States, cultural clashes may be partly to blame for the underuse of, or
withdrawal from, mental health services by recent immigrants, as well as by African
Americans, Asian Americans, Hispanic Americans, American Indians, and members of
other minority populations (Dingfelder, 2005; Gone, 2004; Sanders Thompson, Bazile,
& Akbar, 2004; Wang, Lane, et al., 2005). Accordingly, major efforts are under way to
ensure that such differences do not impede the delivery of treatment to anyone who
wants or needs it (Richards & Bergin, 2000). Virtually every mental health training program in North America is seeking to recruit more students from traditionally underserved minority groups to eventually make it easier to match clients with therapists
from similar cultural backgrounds (e.g., Kersting, 2004; Norcross, Hedges, & Prochaska,
2002; Rogers & Molina, 2006). In the meantime, many minority clients are likely to
encounter a therapist from a differing background, so researchers have also examined
the value of matching therapeutic techniques with clients’ culturally based expectations
and preferences (Li & Kim, 2004; Preciado, 1994; Sue, 1998; Tanaka-Matsumi &
Higginbotham, 1994).
Today, psychotherapists are more sensitive than ever to the cultural values of particular groups and the difficulties that can impair intercultural communication (Ali,
Liu, & Humedian, 2004; Carrillo & Lopez, 2001; LaRoche & Martin, 2005; Weisman,
2005). Some U.S. states now require psychologists to complete courses on the role of
cultural factors in therapy before being licensed. This cultural sensitivity training helps
clinicians appreciate, for example, that it is considered impolite in some cultures to
make eye contact with a stranger. Armed with this information, a therapist is more
likely to realize that clients from those cultures are not necessarily depressed, lacking
in self-esteem, or overly submissive just because they look at the floor during an interview. More and more graduate students in clinical and counseling psychology are
receiving this training, too (Kersting, 2004; Smith et al. 2006).
There is no guarantee that ethnic matching or cultural sensitivity training for therapists will improve treatment results (McCabe, 2002; Pope-Davis et al., 1995; Quintana
& Bernal, 1995; Ramirez et al., 1996; Shin et al., 2005), but there is some evidence that
sensitivity training can help (e.g., Constantine, 2002; Razali, Aminah, & Umeed, 2002).
And although it is unrealistic to expect all therapists to be equally effective with clients
of all sociocultural backgrounds, cultural sensitivity training offers a way to improve
their cultural competence, an extension of Carl Rogers’s concept of “empathy.” When
therapists appreciate the client’s view of the world, it is easier for them to set goals that