Take a Holistic, Psychoeducational Approach

• Teach and utilize a biopsychosocial model of mental illness²
• Maintain a more systemic focus²⁸
• Help resolve relational/social conflicts^4,6
• Explore the consequences of interventions for the client’s family²⁹
• Simplify material, reduce learning load, consolidate complex topics⁶
• Consider increasing session length; teaching time for unfamiliar concepts⁶

Use Cultural Bridging Techniques

• Use a traditional wellness model from the client’s culture such as Yin & Yang⁷ or the Medicine Wheel^30-32 to present mental health strategies
• Utilize the wheel of wellness³³
• Learn and make use of cultural sayings to explain therapeutic concepts^2,34-36
• Frame interventions so as to be congruent with specific cultural values^7,36

Incorporate Client Cultural Beliefs, Strengths, and Resources

• Increase focus on resolving relational problems⁶
• Assess social/familial/environmental contributions to illness and wellness⁴
• Emphasize collaboration over confrontation⁴
• Teach problem-solving for coping with practical environmental stressors⁴
• Present skills together with cultural context within which they will be effective⁴
• Refocus hierarchical, punitive cultural parenting styles on harmonious collectivist values³⁷
• Reframe familial conflict as differences in acculturation and offer assistance as a cultural broker³⁸
• Educate about Acculturative Family Distancing and mental health^39,40
• When acculturation conflicts occur in families, consider reframing acculturation as development of bi-cultural competence, not assimilation
• Emphasize help-seeking as finding solutions rather than admitting failure⁴¹
• Encourage culturally-congruent and inexpensive self-care activities^4,2
• Conduct a cultural strengths/assets search⁴
• Be aware of possible differences in values such as sharing vs. individual achievement, non-interference⁴², dialectical/negotiated problem resolution^43,44

Minimize Perceived Stigma and Shame of Receiving Counselling

• Increase collaboration with cultural healers, doctors, elders, religious leaders, and other physical/spiritual health practitioners²
• Increase visibility in the cultural community⁴⁵
• Distribute materials and raise awareness where clients first seek help⁴⁵
• Address community misconceptions about mental health services⁴⁵
• Stress privacy and confidentiality⁴⁶
• Decrease emphasis on changing cognitions; increase positive thinking, problem solving, and behavioral activation^4,6
• Question the helpfulness rather than rationality of a problematic beliefs, particularly when stressors are real⁴

Provide an Adequate Orientation to Therapy

• Make time for a longer, more detailed orientation^2,6
• Educate explicitly about roles and expectations in therapy^2,6
• Explain the typical course of treatment²
• Build rapport by emphasizing confidentiality¹⁹
• Discuss healthy termination to reduce dropout²
• Reduce stigma by articulating a holistic/biopsychosocial model that doesn’t make clients feel personally blamed for their illnesses and struggles^2,4

Respond to Client Expectations

• Assess if the client may prefer a more active, problem-focused, and expert approach^19-27
• Discuss with clients how needing extra time to acclimatize to a foreign therapeutic culture and having waited longer to seek help may slow initial therapeutic benefits⁶
• Offer the gift of a small solution early on as an example, and for motivation⁵

Establishing Goals and Structure

• Emphasize co-constructing¹⁹ therapy and interventions
• Consider establishing frequent goals and markers of treatment progress with periodic review⁶

Develop Your Own Cultural Knowledge/Self-Awareness

• Read about clients’ cultural backgrounds
• Inquire directly about cultural values and influences
• Expose self to different cultures
• Explore Hofstede’s cultural dimensions for a client’s culture^47,48
• Take cultural workshops, coursework, supervision, and consultation; diversify caseload⁴⁹
• Utilize a White⁵⁰/ethnic¹⁴ identity model to guide own cultural development

Improve Joining With the Client

• Utilize proper cultural etiquette in initial sessions⁶
• Offer tea; show concern about client’s physical comfort; increase self-disclosure⁶
• Discuss/assess family and immigration history as an icebreaker²
• Normalize client feelings/perceptions of stigmatization⁶
• Actively provide validation, praise, emotional support, validate difficulty of sharing⁶
• Convey alignment nonverbally, e.g. moving one’s chair to sit alongside a client while addressing a list of current problems⁵¹

Promote Realistic Expectations

• Explicitly discuss roles and expectations^6,2
• Appear more professional; consider being more proactive with giving advice⁷ if this matches client expectations
• Be aware of transference of expectations: e.g. a doctor, healer, or priest⁵²
• Facilitate development of realistic expectations²
• Be aware that more severe problems may be possible due to delaying treatment due to cultural stigma of mental health help-seeking²
• Begin with easier tasks to inspire confidence⁴
• Share anecdotes or cases that normalize help-seeking, reduce feelings of isolation, or normalize initial difficulties⁶

Be an Ally Against Racism and Prejudice

• Actively broach the topic of race and racism in sessions⁵³
• Anticipate mistrust⁴
• Strongly consider validating any feelings of victimization^4,53
• Validate racial microaggressions^54,55 as real and hurtful

Utilize "Cognitive Matching" in Your Discussions

• Generally avoid challenging cultural beliefs unless this is a client goal⁴
• Use cognitive matching: match responses, discussions, and interventions to individual, sociocultural, or universal levels by following client language⁵⁶

Understand Non-Western Self-Esteem

• Include interdependent traits³ in self-esteem building
• Inquire about group membership when assessing self-esteem
• Ask the question “what would your mother (friend, etc.) say are your personal strengths?”⁴

Respond to Acculturation Level and Personal Values

• Use clients’ level and strategy of acculturation to inform how to “size”^5,6 cultural interventions
• Personalize statements recognizing clients’ cultural values without stereotyping⁶
• But, discuss common cultural experiences if doing so normalizes stigmatized experiences or emphasize the customization of a counseling program⁷
• Assess acculturation formally e.g. through the GEQ⁸, VIA⁹, AVS¹⁰, etc.^11,12
• Assist a client with finding and employing a comfortable acculturation¹³ strategy
• Ask clients about the role of culture and context in their lives when unsure of how to dynamically size interventions

Consider Minority Identity Development

• Utilize a model of minority identity development¹⁴ to set developmental goals when appropriate

Consider Personality in Context

• Reduce the weighting of personality assessment conclusions based on limited cultural norms
• Interpret personality in the context of national differences^15,16 in mean scores
• Consider that newcomer “neuroticism” may simply reflect acculturative stress¹⁷
• Learn about and use indigenous personality tests, such as the CPAI-2¹⁸
• Discuss indigenous personality values and concepts with your participants

Adapt to Differences in Communication

• Consider using silence to demonstrate understanding in initial sessions⁴
• Avoid misinterpreting normal low-key, indirect communicative behavior as passivity, avoidance, or shyness, if such communication is a cultural trait²
• Allow Aboriginal persons ample time to finish speaking⁵⁷
• Be aware of differences in meaning of smiles, silence, and eye contact^19,58
• Increase self-disclosure^19,58-62, invitational body language⁶⁴; invite questions¹⁹
• Employ visuals, translators, supportive friends or family members, multilingual dictionaries⁶⁴
• Be mindful of the ethical limitations of using child translators¹⁹
• Apologize for the limitations of one’s cultural helping style but express a willingness to understand the clients and their situations⁶⁵
• Utilize homework evaluation forms⁶⁶; translated exit/feedback slips (i.e. SRS⁶⁷ and ORS⁶⁸)
• Discuss the cultural meaning of interpersonal distance⁵⁸

Understand Expressions of Distress

• Focus part of early assessment on physical symptoms²
• Inquire about psychosocial symptoms indirectly: “Dealing with headaches and dizziness can be quite troublesome; how are these affecting your mood, relationships, etc.?”⁶⁹
• Help clients differentiate between thoughts and feelings during treatment⁶
• Use a non-stigmatizing procedure to make a co-diagnosis with a client⁷

Educate Yourself on Specific Cultural Issues

• Take the initiative to learn about the strengths and challenges of individual cultural groups²
• Adopt an expanded understanding of responsibilities as a mental health worker^70,71
• Assist/counsel clients on meeting practical needs, overcoming structural barriers^4,68-73
• Use the Three Dimensional Model of Multicultural Counseling⁷⁰
• Consult with the community or community leaders on adapting your counseling approach^6,7
• Utilize the FMAP⁶ or Cultural Adaptation Process Model⁷⁴ to incorporate community feedback into therapeutic modifications

¹ Rapacki, T. M., & McBride, D. L. (2015). An inventory for enhancing cross-cultural group work. In W. Pelech, K. Ring, & S. LaRocque (Eds.), Unity in Diversity: Embracing the Spirit of Group Work: Proceedings of the XXXVI Annual Symposium of the International Association of Social Work With Groups (pp.202-219). London: Whiting & Birch.

² Hwang, W. (2006). The psychotherapy adaptation and modification framework: Application to Asian Americans. American Psychologist, 61, 702–715. doi:10.1037/0003-066X.61.7.702

³ Sedikides, C., Toguchi, Y., & Gaertner, L. (2003). Pancultural self-enhancement. Journal of Personality and Social Psychology, 84, 60–79. doi:10.1037/0022-3514.84.1.60

⁴ Hays, P. A. (2009). Integrating evidence-based practice, cognitive–behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40, 354–360. doi:10.1037/a0016250

⁵ Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440–448.

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⁷ Hwang, W. (2012). Integrating top-down and bottom-up approaches to culturally adapting psychotherapy: Application to Chinese Americans. In G. Bernal & M. M. Domenech Rodriguez (Eds.), Cultural Adaptations: Tools for Evidence-Based Practice with Diverse Populations (pp. 179–199). American Psychological Association Press.

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