Culturally sensitive therapy? Examining the practice of cross‐cultural family therapy

This article is drawn from a research project that examines cross‐cultural family therapy sessions in order to consider what constitutes culturally sensitive practice. A discourse analytic approach was adopted in the analysis of three sessions from two families where the family and the therapists originated from different ethnic backgrounds. This article is based around part of the research findings connected to one of the families, and focuses upon the ways in which ‘culture’ is talked about in therapy (the term ‘culture’ will be referred to in inverted commas in order to acknowledge its complexity as is emphasized in this article). This allows for an examination of the cultural assumptions that we hold as therapists, which are enacted in therapy with effects on all participants and upon the course of the therapy. The value of qualitative research methods in examining the cultural assumptions we bring to therapy is highlighted as one way of improving culturally sensitive therapeutic practice, especially with regard to therapist reflexivity.     

Learning to be mindful of difference: teaching systemic skills in cross‐cultural encounters

In this paper the author shares some of his experiences of teaching in areas of ‘race’ and culture to mainly white middle‐class family therapy and clinical psychology trainees. He presents a framework for a systemic teaching session on working interculturally. Specific exercises are described that trainers can use to design a new session or incorporate into existing ones. It is meant to increase the cultural awareness and sensitivity of trainees with limited experience of cross‐cultural therapeutic work.     

Building Alliances with (In)Voluntary Clients: A Study Focused on Therapists’ Observable Behaviors

This study aimed to compare therapists’ observable behaviors to promote alliances with involuntary and voluntary clients during brief family therapy. The therapists’ contributions to fostering alliances were rated in sessions 1 and 4 using videotapes of 29 families who were observed in brief therapy. Using the System for Observing Family Therapy Alliances, trained raters searched for specific therapist behaviors that contributed to or detracted from the four alliance dimensions: engagement in the therapeutic process, an emotional connection with the therapist, safety within the therapeutic system, and a shared sense of purpose within the family. The results showed that when working with involuntary clients, therapists presented more behaviors to foster the clients’ engagement and to promote a shared sense of purpose within the family. However, in the fourth session, the therapists in both groups contributed to the alliance in similar ways. The results are discussed in terms of (a) the therapists’ alliance‐building behaviors, (b) the specificities of each client group, and (c) the implications for clinical practice, training, and research.     

Reconsidering the ‘heresy’ of using treatment manuals

Some argue that the medical model and the experimental design that underlies the use of treatment manuals to prove the efficacy of a psychotherapeutic treatment clashes with the theoretical basis of family therapy. From the point of view of the empirically supported treatments (ESTs) movement, treatment manuals are the operationalization of the independent variable in a clinical trial; the therapist is only part of the procedure and the therapeutic relationship is a confounding variable. Applying that logic to the practice of family therapy might be considered a heresy. This article argues that paradoxically, this heresy has a lot to offer the practice of family therapy. Research is the best way to answer questions like ‘how does family therapy work?’ ‘What makes ‘good therapy’ good?’ ‘Do therapists do what they say they do'? This article recommends an alternative framework for integrating ESTs into practice by proposing empirically informed guides to practice which, being less formulaic, encourage process‐outcome research, are coherent with the systemic model and do not constrain the therapist's creativity. Such guidelines allow therapists to use manuals flexibly so that they deepen the understanding of the process of therapy. We encourage you to listen to the JFT Editor, Mark Rivett, as he interviews the author on Manuals in the Practice and Research of Family Therapy. Available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1467‐6427/homepage/jft_podcast_series.htm .     

Back in the mirrored room: the enduring relevance of discursive practice

This article seeks to re‐engage a conversation regarding the importance of acknowledging the discursive content of the therapeutic process. Hare‐Mustin's (1994) article argued that psychotherapy is involved in the generation of values and norms, and thus requires ethical sensibilities. Her analysis recognized how particular socio‐cultural forces go unnoticed and suggested that unless therapists recognize their participation in discursive practices, they may unwittingly collude with and reinforce harmful cultural practices. The goal of this article is to revisit the ‘mirrored room’ so that family therapists can more deliberately evaluate their participation in cultural practices that impact on their work with clients. This article begins with a review of contemporary efforts to grapple with the issues Hare‐Mustin presented, and maintains that even contemporary approaches that assert a commitment to postmodern understandings remain incomplete without an analysis of discourse. The article then outlines the conceptual tools within discursive practice that advance the initial motivation of these contemporary efforts.     

Cultural ruptures in short‐term therapy: Working alliance as a mediator between clients' perceptions of microaggressions and therapy outcomes

Aim: To determine whether or not clients' perceptions of microaggressions varied based on their own and the therapist's race/ethnicity and whether or not they would be negatively related to the effectiveness of therapy and if the working alliance would mediate this effect. Method: The study utilised a cross‐sectional, retrospective, methodology. Clients were recruited from a large university counselling centre in the United States (N=232 clients and 29 therapists). Results: Neither clients' race/ethnicity, therapists’ race/ethnicity, nor client‐therapist ethnic matching predicted perceptions of microaggressions. Clients' ratings of microaggressions were negatively associated with their psychological wellbeing; however, this effect was mediated by clients' ratings of the working alliance. Implications: Therapists should take into account the cultural messages they may be conveying to both white and racial/ethnic minority clients. Therapists should develop strategies that are consistent with a general therapeutic approach that promotes discussions about culture with their clients and, most importantly, should attend to the therapeutic relationship.     

Feminism and family therapy—a possible meeting point

This paper centres on the question ‘Is it possible to be a feminist and to practise family therapy?’ We explore the essence of feminism and family therapy and conclude that a style of feminist family therapy is possible. Feminist family therapy has a particular theoretical base and is characterized by a particular combination of practice principles. It also raises general issues for the training and practice of all family therapists.     

Self‐supervision,surveillance and transgression

Transgression is not only an inevitable part of systemic supervision but is also necessary if we are to work towards innovative and inclusive supervisory and therapeutic practice. Defying culturally generated ‘rules’ of systemic practice can allow for more relevant and productive ways of talking. Systemic practitioners are increasingly finding themselves trying to practice systemic therapy in employing authorities and training courses which are dominated by inflexible professional narratives and manualised procedures. Our profession is committed to ethical inner and outer dialogue, to self‐ and relational reflexivity as distinct from the rule‐bound surveillance culture in which we live and work. Systemic supervisors and therapists may find themselves at odds with monological institutional discourse and attempts from within our own profession to manualise practice. I introduce examples from supervisory conversations to illustrate how supervisors can develop more culturally sensitive practices through supporting practitioners to hear and have heard their own marginalised and oppressed voices and those of their clients.     

Transparency and self-disclosure in family therapy: dangers and possibilities

Therapy is a paid intimate relationship that thrusts clients and therapists into navigating personal and professional boundaries. When, where, why, and how is it appropriate and ethical for family therapists to be transparent, and when is it damaging? Theorists take varied stances from Haley's position of tight boundaries around therapist disclosure—whether in treatment or training—to the narrative viewpoint that therapists should be transparent about models of therapy, personal values, and life experiences that inform their practice and beliefs. However, these positions are not research based, and theorists who support disclosure offer few guidelines other than general statements. This article examines the history of ideas about disclosure in six major family therapy models, and the dangers and possibilities of transparency. It looks at the research on self‐disclosure in individual therapy and whether and how it could apply to family therapy. Guidelines are proposed that take into account the multiple social identities of therapists and clients, and issues of safety and transparency.     

Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: A qualitative study

Primary objective: This is the first qualitative study that elicited the perceptions of both psychological therapists and their clients in the use of Clinical Outcomes in Routine Evaluation with computer software (CORE‐Net), where instant visual feedback for session tracking was given on a computer screen in the therapy room at each therapy session. The study also examined how therapists viewed its potential value in supervision and provides suggestions for improving training. Research design: The study adopted a convenience sample of four therapists in a primary care counselling setting (PCC – General Practitioner referrals) who were experienced in using CORE‐Net, and five therapists in an NHS employee/occupational support counselling service (OH) who had just begun to use CORE‐Net for session tracking with 10 of their clients. Method: A qualitative methodology was used and interview data were collected from the therapists via focus groups; the clients were interviewed individually face to face. All data was analysed inductively. Findings: The study identified six overarching themes: (i) therapists were initially anxious and resistant; (ii) therapists adapt ‘creatively’; (iii) outcome measures help the client/therapist relationship; (iv) clients perceive visual measures as helpful; (v) CORE scores inform supervision; and (vi) proper and ongoing training/support of therapists is necessary. The main limitations are comparability of data and the generalisabilty of results. Conclusions: The implementation of routine outcome measurement (ROM) is a challenge but can be made easier with proper training and supervision. Clients appear happier than their therapists when routine outcome measurement is used.     

The Value of Curiosity and Naiveté for the Cross-Cultural Psychotherapist

Therapists today face a dramatic increase in the cultural diversity of their client populations. Cultural literacy, long the dominant model for preparing to do cross-cultural therapy, advocates study of the prospective client's history and culture. This model, however, poses logistical problems, emphasizes scholarship over the experiential and phenomenological, and risks seeing clients as their culture and not as themselves. In this essay, we argue that teaching culture alone can obscure therapists’ view of human diversity. To balance the cognitive model of preparation, a process-oriented approach is considered, whereby the therapists’ attitudes of cultural naiveté and respectful curiosity are given equal importance to knowledge and skill. We begin from a concern with clients’ vulnerability in the power distribution that inevitably exists in therapy, especially with immigrant and marginalized populations. The use of acculturation narratives, which the therapist explores with naiveté and curiosity, helps clients to find their voices.     

Cultural Studies Methodologies and Narrative Family Therapy: Therapeutic Conversations About Pop Culture

Therapists recognize that popular media culture is an influential force that shapes identities and relationships in contemporary society. Indeed, people have serious relationships with the commodities and practices that emerge from pop culture. However, they often lack the conceptual and conversational resources to engage meaningfully with clients about pop culture's influence in their lives. Cultural studies is introduced as an interdisciplinary approach that provides frameworks for both theory and practice that position therapists and clients to critically examine the role of pop culture in their lives. Cultural studies and narrative therapy are discussed as praxis allies that share a populist political intention and counter‐hegemonic discursive practices. The integration of cultural studies methodologies into narrative therapy practice with a parent and her teenage daughter is illustrated through a case vignette.     

Moving beyond counselling and psychotherapy as it currently is – taking therapy outside

Research was undertaken by the author in order to describe, interpret and explain what happens when counsellors and psychotherapists who have been trained to work indoors with their therapy clients take their therapy practice into outdoor natural spaces. A central research question addressed ‘What happens when counsellors and psychotherapists, who have been trained to work indoors with their therapy clients, take their therapy practice in to outdoor natural spaces?’ Semi-structured interviews were undertaken with therapists who practised outdoors. Three dominant themes emerged critiquing aspects of current counselling and psychotherapy practice. These were related to the unfolding ecological crisis, the context of the work and moving beyond current conceptions of distress and the role of therapy in addressing this.     

Inviting passage to new discourse: ‘Alive moments’ and their spiritual significance

Some social constructionists assert that therapeutic change occurs when clients' meanings for problems and solutions shift from those found in resource‐impoverished discourses to those affording resourceful and preferred possibilities. Referred to as ‘positioning theory’, our research examined this assertion by inviting clients and therapists to speak of a significant, but ambiguous, experience in unfamiliar discourse: spiritual discourse. Clients were asked to review videotapes of their sessions, selecting moments that felt most ‘alive’ to them for discussions with the researcher, including inquiries as to whether ‘alive’ moments held any spiritual significance. The outcomes are portrayed as a ‘poetic collaboration’ between the researcher, clients and therapists — while clients' and therapists' reported experiences for changes in discourse and meaning are highlighted. Implications regarding sensitivities required when co‐constructing meanings for ambiguous but significant experiences in therapy are discussed. Possibilities for more research examining poetic practices and processes in therapy are also considered in terms of positioning theory.     

The Growth of Alternative Therapy: A Valid Argument against the Secularisation Thesis?

The fact that alternative therapy has experienced vast growth during the last 30 years in most of the West is used by both Paul Heelas and Linda Woodhead as an argument against the secularisation theory. The objective of this article is to examine whether such an argument can be seen as being valid. In order to do this, four preconditions are formulated whose fulfilment I consider to be necessary if the above-mentioned arguments against the secularisation theory are to be accepted. The four preconditions are discussed; they are as follows: 1) alternative therapy is of significant magnitude; 2) the alternative therapists themselves consider the practice to be spiritual; 3) the clients seeing such ‘spiritual’ therapists have a spiritually informed motive to do so; 4) ‘spirituality’ as understood both by practitioners and by clients has ‘religious’ connotations.     

Training to Think Culturally: A Multidimensional Comparative Framework

A multidimensional, comparative training framework is designed to integrate culture with all aspects of family therapy. Culture is viewed as occurring in multiple contexts that create common “cultural borderlands” as well as diversity; unpredictability and possibility, as well as regularity and constraint. The framework proposes a search for basic parameters to help therapists think comparatively and pluralistically about families’ cultural configurations and meanings. Further, the parameters chosen — ecological context, migration/acculturation, organization, and life cycle — are used to heighten therapists’ awareness about the “situated knowledge” of their own professional and personal culture. This approach recognizes the potential complexity of both the family's and the therapist's cultural location or ecological niche, and encourages curiosity in the therapeutic conversation rather than reliance on potentially stereotyping, ethnic-focused information.     

Diagnoses,Relational Processes and Resourceful Dialogs: Tensions for Families and Family Therapy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), given its psychiatric focus on mental disorders in individuals, presents families and family therapists with challenges. Despite considerable controversies over its adoption, the DSM‐5 extends a process of standardizing a language for human and relational concerns. No longer a diagnostic language of professionals alone, its use is medicalizing how mental health funders and administrators, as well as clients, respond to human concerns. For family therapists who practice systemically, particularly from poststructuralist and strengths‐based orientations, many tensions can follow when use of the DSM‐5 is expected by mental health administrators and funders, or by clients who present concerns about themselves or a diagnosed family member. In this paper, I explore how such DSM‐5 related tensions might be recognized, navigated, and negotiated in the practice of family therapy with clients, and with administrators and funders.