Cultural Humility and
the Process of Psychotherapy 4
Copyright American Psychological Association. Not for further distribution.
The unlike is joined together, and from differences
results the most beautiful harmony.
—Heraclitus, The Fragments of the Work of Heraclitus
of Ephesus on Nature (Ingram Bywater, Trans.)
Jesse: I have always wondered how therapy works.
There are so many complexities to the therapeutic
process it can be daunting to consider them all.
As psychotherapy researchers, we commonly try to
isolate specific techniques or therapeutic processes to
gauge whether they are associated with better client
outcomes. This approach is common to the scientific
process, in which we try to “control” certain variables
so we can isolate the effect of one particular variable
of interest.
Although we have learned a lot about what
works in therapy over the years, I have frequently
been dismayed by the field’s lack of attention to the
role of culture. Even when culture has been included
as a topic of interest, the results often have not been
satisfying. For example, at times I have found that
the scientific method, when erroneously applied to
culture, can promote generalizations and stereotyping
(e.g., the best treatment for X race is Y treatment).
This prescriptive approach to the study and practice
of culture and psychotherapy just never made sense
to me.
http://dx.doi.org/10.1037/0000037-005
Cultural Humility: Engaging Diverse Identities in Therapy, by J. N. Hook, D. Davis,
J. Owen, and C. DeBlaere
Copyright © 2017 by the American Psychological Association. All rights
reserved.
91
, 92 C u l t u r a l H u m i l it y
In my practice and work with clients, I recognized that my
therapeutic style is a natural expression of how I am on a daily
basis. The language I use, how I sit, the metaphors and examples
are all parts of me. When I train future therapists, I try to
encourage them to find their voice. Theory, the use of techniques,
and empirical support are important to a certain extent. However,
the expression of theory, techniques, and research in the therapy
room has to be real and true to the therapist. With this mind-set,
I think it is important to be genuine and flexible about how we
Copyright American Psychological Association. Not for further distribution.
discuss and conceptualize the role of culture in therapy.
T
is chapter marks the beginning of the second section of this book.
h
The remainder of the book is focused on the practice of therapy and
how to engage clients with cultural humility in the therapy room. This
chapter can be conceptualized as a bridge between the theory and self-
awareness work presented in the first three chapters of the book and
the practical application focus of the chapters to come. The purpose of
this chapter is to integrate the theoretical pillars of the multicultural
orientation model with several of the main tasks of therapy.
Cultural Humility,
Multicultural Orientation,
and Psychotherapy
In Chapter 1, we described the origins, the broad assumptions, and the
three pillars of the multicultural orientation model (i.e., cultural humility,
cultural opportunities, and cultural comfort). In this chapter, we build
on that foundation and discuss the therapeutic mechanisms of cultural
humility in psychotherapy. In other words, how does cultural humility
appear in some of the main tasks of therapy? What differentiates more
culturally humble therapeutic processes from less culturally humble
therapeutic processes? It is these questions we hope to address in this
chapter. First, we discuss how cultural humility can inform intake pro-
cedures, including intake forms, the initial interview, and creating clarity
about the therapy process. Next, we discuss how cultural humility relates
to case conceptualization of clients’ distress, the process of diagnosis, the
development of a treatment plan, and the techniques used in therapy.
Before we begin our discussion of cultural humility in the context
of psychotherapy, we want to be transparent about some of our broad
theoretical assumptions about how therapy works. Of course, you can
agree or disagree with these tenets as you see fit, but we want to make
them explicit, so you know our position. First, it is helpful for therapists
, Cultural Humility and the Process of Psychotherapy 93
to use a theoretical model or an integration of multiple theoretical
models to guide their work with clients. These models can inform
how you approach a client’s course of treatment from start to finish
(e.g., intake processes, termination). Second, the therapeutic relation-
ship is an important mechanism of change (Horvath, Del Re, Flückiger,
& Symonds, 2011), and the therapeutic relationship works in tandem
with therapeutic techniques to maximize the effectiveness of therapy
(e.g., Barber et al., 2006; Owen & Hilsenroth, 2011). Third, therapy is a
Copyright American Psychological Association. Not for further distribution.
cultural process, so there may be a wide variety of therapies and thera-
peutic interventions that could be helpful to clients (Wampold, 2007).
For example, possible helpful interventions could include seeking heal-
ing from a religious leader or taking medication. It can be helpful to
discuss the range of possible therapies with clients. Finally, therapy is
a coconstructed process (by the therapist and client) that unfolds over
time. That is, therapists’ expression of cultural humility should invite
dialogue and joining with clients. Like most relationships, there will be
mutual learning about one’s experiences, values, and beliefs as topics
evolve over time if there is space for those conversations. However, being
culturally humble does not mean that the client moves into a “teacher”
role, providing lessons on their cultural identity. Rather, the client
and therapist work to understand the cultural experiences in the con-
text of clients’ lives. To further explore these points, we start with the
intersection of cultural humility and intake procedures.
Cultural Humility and
Intake Session Procedures
Intake procedures take place in the beginning session (or perhaps the
first few sessions) with clients. There are many ways to conduct an intake
session. Depending on the type of treatment facility (e.g., community
mental health center, university counseling center, private practice,
hospital), there may be a particular protocol requiring the therapist to
obtain specific information during the intake. It is beyond the scope of
this chapter to describe all the various approaches to conducting an intake
session. However, we encourage readers to explore different intake
approaches, such as the therapeutic model of assessment (e.g., Finn &
Tonsager, 1997; Hilsenroth & Cromer, 2007).
Typical goals of the intake are to (a) develop an initial relational
bond between client and therapist, (b) assess the client’s presenting
concerns (e.g., symptoms, characterological patterns), (c) understand
background information (e.g., family history, psychiatric history, edu-
cation), (d) gather information about current contexts (e.g., family,
friends, social network, work or school, legal concerns), and (e) develop
an initial sense of the agreed-on goals for treatment. We believe that
, 94 C u l t u r a l H u m i l it y
an important additional goal of a culturally humble intake should be to
obtain information about the client’s salient cultural identities, how these
identities intersect with the client’s presenting problem, and how the
client might want their cultural identities to be incorporated into
the therapy process.
Although the first session sets the tone for the therapeutic relation-
ship between therapist and client, this relationship may have started
to form even earlier. Therapists can influence clients’ initial impressions
Copyright American Psychological Association. Not for further distribution.
through factors such as (a) how they present themselves on their web-
site or advertisements, (b) how they set up their office and waiting
room, and (c) whether they use intake forms that the client views as cul-
turally appropriate. Clients commonly complete intake forms describ-
ing their demographic information, reasons for seeking help, screening
tools (e.g., depressive screening instrument), and insurance informa-
tion. For instance, consider the following example, which focuses on
messages that a client might receive from a therapist when completing
the intake form.
Intake Form: Cultural Considerations
In Exhibit 4.1 we have copied an example of part of an initial intake
form that a client might fill out before seeing a therapist for the first time.
As you read the intake form, see whether you can think of how it might
cause some clients to feel as if the therapist might not be culturally safe.
As you read the intake form, what aspects did you think were culturally
appropriate? Alternatively, were there any aspects you thought might
alienate clients from certain cultural backgrounds? For example, did you
notice that the gender categories assumed that individuals identify as
either male or female rather than the various other types of gender
Exhibit 4.1
Intake Form Example
Name: _______________________________
Please indicate your age: ______________
Please indicate your gender: Male Female
Please indicate your sexual orientation: ________________________
Please indicate your race or ethnicity: __________________________
Please indicate your religious affiliation: Christian Muslim Buddhist
Hindu Jewish Atheist Agnostic Other: _____________
Please indicate your ability or disability status: _____________
Please describe your primary reason for seeking treatment: ______________
_____________________________________________________________________
_____________________________________________________________________
the Process of Psychotherapy 4
Copyright American Psychological Association. Not for further distribution.
The unlike is joined together, and from differences
results the most beautiful harmony.
—Heraclitus, The Fragments of the Work of Heraclitus
of Ephesus on Nature (Ingram Bywater, Trans.)
Jesse: I have always wondered how therapy works.
There are so many complexities to the therapeutic
process it can be daunting to consider them all.
As psychotherapy researchers, we commonly try to
isolate specific techniques or therapeutic processes to
gauge whether they are associated with better client
outcomes. This approach is common to the scientific
process, in which we try to “control” certain variables
so we can isolate the effect of one particular variable
of interest.
Although we have learned a lot about what
works in therapy over the years, I have frequently
been dismayed by the field’s lack of attention to the
role of culture. Even when culture has been included
as a topic of interest, the results often have not been
satisfying. For example, at times I have found that
the scientific method, when erroneously applied to
culture, can promote generalizations and stereotyping
(e.g., the best treatment for X race is Y treatment).
This prescriptive approach to the study and practice
of culture and psychotherapy just never made sense
to me.
http://dx.doi.org/10.1037/0000037-005
Cultural Humility: Engaging Diverse Identities in Therapy, by J. N. Hook, D. Davis,
J. Owen, and C. DeBlaere
Copyright © 2017 by the American Psychological Association. All rights
reserved.
91
, 92 C u l t u r a l H u m i l it y
In my practice and work with clients, I recognized that my
therapeutic style is a natural expression of how I am on a daily
basis. The language I use, how I sit, the metaphors and examples
are all parts of me. When I train future therapists, I try to
encourage them to find their voice. Theory, the use of techniques,
and empirical support are important to a certain extent. However,
the expression of theory, techniques, and research in the therapy
room has to be real and true to the therapist. With this mind-set,
I think it is important to be genuine and flexible about how we
Copyright American Psychological Association. Not for further distribution.
discuss and conceptualize the role of culture in therapy.
T
is chapter marks the beginning of the second section of this book.
h
The remainder of the book is focused on the practice of therapy and
how to engage clients with cultural humility in the therapy room. This
chapter can be conceptualized as a bridge between the theory and self-
awareness work presented in the first three chapters of the book and
the practical application focus of the chapters to come. The purpose of
this chapter is to integrate the theoretical pillars of the multicultural
orientation model with several of the main tasks of therapy.
Cultural Humility,
Multicultural Orientation,
and Psychotherapy
In Chapter 1, we described the origins, the broad assumptions, and the
three pillars of the multicultural orientation model (i.e., cultural humility,
cultural opportunities, and cultural comfort). In this chapter, we build
on that foundation and discuss the therapeutic mechanisms of cultural
humility in psychotherapy. In other words, how does cultural humility
appear in some of the main tasks of therapy? What differentiates more
culturally humble therapeutic processes from less culturally humble
therapeutic processes? It is these questions we hope to address in this
chapter. First, we discuss how cultural humility can inform intake pro-
cedures, including intake forms, the initial interview, and creating clarity
about the therapy process. Next, we discuss how cultural humility relates
to case conceptualization of clients’ distress, the process of diagnosis, the
development of a treatment plan, and the techniques used in therapy.
Before we begin our discussion of cultural humility in the context
of psychotherapy, we want to be transparent about some of our broad
theoretical assumptions about how therapy works. Of course, you can
agree or disagree with these tenets as you see fit, but we want to make
them explicit, so you know our position. First, it is helpful for therapists
, Cultural Humility and the Process of Psychotherapy 93
to use a theoretical model or an integration of multiple theoretical
models to guide their work with clients. These models can inform
how you approach a client’s course of treatment from start to finish
(e.g., intake processes, termination). Second, the therapeutic relation-
ship is an important mechanism of change (Horvath, Del Re, Flückiger,
& Symonds, 2011), and the therapeutic relationship works in tandem
with therapeutic techniques to maximize the effectiveness of therapy
(e.g., Barber et al., 2006; Owen & Hilsenroth, 2011). Third, therapy is a
Copyright American Psychological Association. Not for further distribution.
cultural process, so there may be a wide variety of therapies and thera-
peutic interventions that could be helpful to clients (Wampold, 2007).
For example, possible helpful interventions could include seeking heal-
ing from a religious leader or taking medication. It can be helpful to
discuss the range of possible therapies with clients. Finally, therapy is
a coconstructed process (by the therapist and client) that unfolds over
time. That is, therapists’ expression of cultural humility should invite
dialogue and joining with clients. Like most relationships, there will be
mutual learning about one’s experiences, values, and beliefs as topics
evolve over time if there is space for those conversations. However, being
culturally humble does not mean that the client moves into a “teacher”
role, providing lessons on their cultural identity. Rather, the client
and therapist work to understand the cultural experiences in the con-
text of clients’ lives. To further explore these points, we start with the
intersection of cultural humility and intake procedures.
Cultural Humility and
Intake Session Procedures
Intake procedures take place in the beginning session (or perhaps the
first few sessions) with clients. There are many ways to conduct an intake
session. Depending on the type of treatment facility (e.g., community
mental health center, university counseling center, private practice,
hospital), there may be a particular protocol requiring the therapist to
obtain specific information during the intake. It is beyond the scope of
this chapter to describe all the various approaches to conducting an intake
session. However, we encourage readers to explore different intake
approaches, such as the therapeutic model of assessment (e.g., Finn &
Tonsager, 1997; Hilsenroth & Cromer, 2007).
Typical goals of the intake are to (a) develop an initial relational
bond between client and therapist, (b) assess the client’s presenting
concerns (e.g., symptoms, characterological patterns), (c) understand
background information (e.g., family history, psychiatric history, edu-
cation), (d) gather information about current contexts (e.g., family,
friends, social network, work or school, legal concerns), and (e) develop
an initial sense of the agreed-on goals for treatment. We believe that
, 94 C u l t u r a l H u m i l it y
an important additional goal of a culturally humble intake should be to
obtain information about the client’s salient cultural identities, how these
identities intersect with the client’s presenting problem, and how the
client might want their cultural identities to be incorporated into
the therapy process.
Although the first session sets the tone for the therapeutic relation-
ship between therapist and client, this relationship may have started
to form even earlier. Therapists can influence clients’ initial impressions
Copyright American Psychological Association. Not for further distribution.
through factors such as (a) how they present themselves on their web-
site or advertisements, (b) how they set up their office and waiting
room, and (c) whether they use intake forms that the client views as cul-
turally appropriate. Clients commonly complete intake forms describ-
ing their demographic information, reasons for seeking help, screening
tools (e.g., depressive screening instrument), and insurance informa-
tion. For instance, consider the following example, which focuses on
messages that a client might receive from a therapist when completing
the intake form.
Intake Form: Cultural Considerations
In Exhibit 4.1 we have copied an example of part of an initial intake
form that a client might fill out before seeing a therapist for the first time.
As you read the intake form, see whether you can think of how it might
cause some clients to feel as if the therapist might not be culturally safe.
As you read the intake form, what aspects did you think were culturally
appropriate? Alternatively, were there any aspects you thought might
alienate clients from certain cultural backgrounds? For example, did you
notice that the gender categories assumed that individuals identify as
either male or female rather than the various other types of gender
Exhibit 4.1
Intake Form Example
Name: _______________________________
Please indicate your age: ______________
Please indicate your gender: Male Female
Please indicate your sexual orientation: ________________________
Please indicate your race or ethnicity: __________________________
Please indicate your religious affiliation: Christian Muslim Buddhist
Hindu Jewish Atheist Agnostic Other: _____________
Please indicate your ability or disability status: _____________
Please describe your primary reason for seeking treatment: ______________
_____________________________________________________________________
_____________________________________________________________________
