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Cultural Humility: Measuring Openness to Culturally Diverse Clients

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Cultural Humility: Measuring Openness to Culturally Diverse Clients

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Building on recent theory stressing multicultural orientation, as well as the development of virtues and dispositions associated with multicultural values, we introduce the construct of cultural humility, defined as having an interpersonal stance that is other-oriented rather than self-focused, characterized by respect and lack of superiority toward an individual's cultural background and experience. In 4 studies, we provide evidence for the estimated reliability and construct validity of a client-rated measure of a therapist's cultural humility, and we demonstrate that client perceptions of their therapist's cultural humility are positively associated with developing a strong working alliance. Furthermore, client perceptions of their therapist's cultural humility were positively associated with improvement in therapy, and this relationship was mediated by a strong working alliance. We consider implications for research, practice, and training. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
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Journal of Counseling Psychology
Cultural Humility: Measuring Openness to Culturally
Diverse Clients
Joshua N. Hook, Don E. Davis, Jesse Owen, Everett L. Worthington Jr., and Shawn O. Utsey
Online First Publication, May 6, 2013. doi: 10.1037/a0032595
CITATION
Hook, J. N., Davis, D. E., Owen, J., Worthington Jr., E. L., & Utsey, S. O. (2013, May 6).
Cultural Humility: Measuring Openness to Culturally Diverse Clients. Journal of Counseling
Psychology. Advance online publication. doi: 10.1037/a0032595
Cultural Humility: Measuring Openness to Culturally Diverse Clients
Joshua N. Hook
University of North Texas
Don E. Davis
Georgia State University
Jesse Owen
University of Louisville
Everett L. Worthington Jr. and Shawn O. Utsey
Virginia Commonwealth University
Building on recent theory stressing multicultural orientation, as well as the development of virtues and
dispositions associated with multicultural values, we introduce the construct of cultural humility, defined
as having an interpersonal stance that is other-oriented rather than self-focused, characterized by respect
and lack of superiority toward an individual’s cultural background and experience. In 4 studies, we
provide evidence for the estimated reliability and construct validity of a client-rated measure of a
therapist’s cultural humility, and we demonstrate that client perceptions of their therapist’s cultural
humility are positively associated with developing a strong working alliance. Furthermore, client
perceptions of their therapist’s cultural humility were positively associated with improvement in therapy,
and this relationship was mediated by a strong working alliance. We consider implications for research,
practice, and training.
Keywords: humility, multicultural orientation, outcome
In recent years, psychologists have recognized the importance of
developing multicultural competencies (MCCs) in the areas of
education, training, research, and practice (American Psychologi-
cal Association [APA], 2003). There are three main components of
MCCs: attitudes/beliefs, knowledge, and skills (D. W. Sue, Arre-
dondo, & McDavis, 1992; D. W. Sue et al., 1982). APA MCCs
guidelines encourage psychologists to (a) develop an understand-
ing of their own cultural background and the ways that their
cultural background influences their personal attitudes, values, and
beliefs (i.e., attitudes/beliefs); (b) develop understanding and
knowledge of the worldviews of individuals from diverse cultural
backgrounds (i.e., knowledge); and (c) use culturally appropriate
interventions (i.e., skills). This tripartite model has greatly influ-
enced the research, practice, and training of psychologists.
Although the field of MCCs has received increasing research
attention over the past 30 years, researchers have called for (a)
innovations in the measurement of MCCs and (b) increased re-
search linking MCCs to actual client improvement (Worthington,
Soth-McNett, & Moreno, 2007). Measurement concerns in this
field include (a) reliance on therapist-report measures (Worthing-
ton et al., 2007); (b) lack of association between therapist-reported
MCCs, client-reported MCCs, and observer-rated MCCs (Con-
stantine, 2001; Fuertes et al., 2006; Worthington, Mobley, Franks,
& Tan, 2000); and (c) conflation of therapist-report measures of
MCCs and therapist efficacy for conducting culturally sensitive
counseling (Constantine & Ladany, 2001).
Some researchers have suggested a shift from measuring ther-
apists’ MCCs to measuring therapists’ multicultural orientation
(MCO; Owen, Tao, Leach, & Rodolfa, 2011). Whereas MCCs
might assess how well a therapist has mastered specific knowledge
or skills for working with a culturally diverse client, MCO might
assess a therapist’s “way of being” with the client, guided by the
therapist’s philosophy or values about the salience of cultural
factors in the lives of therapists and clients. In contrast to MCO,
MCCs can be conceptualized as “ways of doing” that assess how
competent a therapist is at implementing cultural awareness,
knowledge, and skills into therapy (Owen et al., 2011). Related to
this shift from competencies to orientation, others have identified
virtues or dispositions for therapists that align with the values of
diversity in the field of counseling psychology (Winterowd, Ad-
ams, Miville, & Mintz, 2009). For example, Fowers and Davidov
(2006) argued that the primary virtue necessary for multicultural-
ism is openness to the other.
This multicultural focus on openness to the other is closely
related to the concept of humility. In their review of definitions of
humility, Davis, Worthington, and Hook (2010) noted that defini-
tions of humility generally included both intrapersonal and inter-
personal components. On the intrapersonal dimension, humble
individuals have an accurate view of self. On the interpersonal
Joshua N. Hook, Department of Psychology, University of North Texas;
Don E. Davis, Department of Counseling and Psychological Services,
Georgia State University; Jesse Owen, Department of Educational and
Counseling Psychology, University of Louisville; Everett L. Worthington
Jr. and Shawn O. Utsey, Department of Psychology, Virginia Common-
wealth University.
We would like to acknowledge the generous financial support of John
Templeton Foundation, Grant No. 14979 (Relational Humility: An Inter-
disciplinary Approach to the Study of Humility) and the University of
North Texas (Research Initiation Grant).
Correspondence concerning this article should be addressed to Joshua N.
Hook, Department of Psychology, University of North Texas, 1155 Union
Circle #311280, Denton, TX 76210. E-mail: joshua.hook@unt.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Journal of Counseling Psychology © 2013 American Psychological Association
2013, Vol. 60, No. 3, 000 0022-0167/13/$12.00 DOI: 10.1037/a0032595
1
dimension, humble individuals are able to maintain an interper-
sonal stance that is other-oriented rather than self-focused, char-
acterized by respect for others and a lack of superiority (Davis et
al., 2011). In the present study, we focus on the interpersonal
dimension, which we view as potentially more relevant to the
therapy relationship and better able to be accurately perceived (and
rated) by the client (Funder, 1995; Vazire, 2010). Furthermore,
humility may be especially important in order to develop a strong
bond in a situation in which relationship partners may have a
strong tendency to value their own perspective (e.g., cultural
differences; Davis et al., 2013). We posit that for a therapist to
develop a strong working relationship and conduct effective coun-
seling with a client who is culturally different, the therapist must
be able to overcome the natural tendency to view one’s own
beliefs, values, and worldview as superior, and instead be open to
the beliefs, values, and worldview of the diverse client.
The purpose of the present studies was to develop a client-rated
measure of cultural humility as a component of MCO. Namely, we
were interested in the degree to which clients perceived their
therapists as expressing humility in regard to central aspects of
cultural identity such as gender, race/ethnicity, sexual orientation,
or religion/spirituality. Therapists have their own beliefs, values,
and worldviews that likely guide how they understand psycholog-
ical distress and how people make changes in their lives. Thera-
pists who do not create a therapeutic environment that is open to
different beliefs, values, and worldviews may struggle to work
effectively with diverse clients. Cultural humility may help coun-
teract and regulate the sense of superiority that may occur when
cultural differences arise in therapy. As such, cultural humility
involves the ability to maintain an interpersonal stance that is
other-oriented (or open to the other) in relation to aspects of
cultural identity that are most important to the client. Cultural
humility is especially apparent when a therapist is able express
respect and a lack of superiority even when cultural differences
threaten to weaken the therapy alliance. Culturally humble thera-
pists rarely assume competence (i.e., letting prior experience and
even expertise lead to overconfidence) for working with clients
just based on their prior experience working with a particular
group. Rather, therapists who are more culturally humble approach
clients with respectful openness and work collaboratively with
clients to understand the unique intersection of clients’ various
aspects of identities and how that affects the developing therapy
alliance.
The concept of cultural humility is not entirely new. Tervalon
and Murray-Garcia (1998) contrasted the concept of cultural hu-
mility with MCCs in the field of health care. They noted that
whereas MCCs have traditionally focused on building knowledge
of multicultural content areas, cultural humility requires practitio-
ners to engage in self-reflection and self-critique as lifelong learn-
ers. Similarly, S. Sue (1998) has encouraged therapists to develop
scientific mindedness when working with clients from diverse
backgrounds. Thus, therapists should make hypotheses rather than
jump to premature conclusions when working with clients from
diverse backgrounds. Ridley, Mendoze, Kanitz, Angermeier, and
Zenk (1994) have encouraged therapists to develop cultural sen-
sitivity, which involves seeking out, perceiving, and interpreting
cultural information from clients. Ridley et al. note that it is
impossible to understand an individual on the basis of his or her
cultural background alone. Rather, therapists should accept their
naiveté in regard to their assumptions about clients from diverse
backgrounds.
Thus, although the idea of cultural humility has been previously
discussed, models on the development of MCCs (and the existing
instruments) have focused primarily on helping therapists build
and develop competencies (i.e., self-awareness, knowledge, and
skills). Rather than focusing on specific competencies, our con-
ceptualization of cultural humility can be categorized as a virtue or
disposition that comprises one’s MCO. Paradoxically, therapists
who are culturally humble not only strive to be effective but also
cultivate a growing awareness that they are inevitably limited in
their knowledge and understanding of a client’s cultural back-
ground, which motivates them to interpersonally attune themselves
to the client in a quest to understand the individual client’s cultural
background and experience.
Consistent with past theory and research, client perceptions of
their therapist’s cultural humility should be associated with strong
working alliances as well as predict therapy outcomes. Past studies
have found that client perceptions of their therapist’s MCO are
related to a strong working alliance (e.g., Constantine, 2007;
Fuertes et al., 2006; Li & Kim, 2004), and working alliance has
been found to mediate the relationship between MCO and therapy
outcomes (Owen, Tao, et al., 2011). Cultural humility is likely to
have a positive association with working alliance because the
client is likely to develop a sense of trust and safety with a
therapist who engages with his or her cultural background with an
interpersonal stance of openness rather than superiority. Moreover,
a strong alliance can serve as a buffer between therapists’ missteps
(e.g., microaggressions) and therapy outcomes (Constantine, 2007;
Owen, Imel, et al., 2011; Owen, Tao, & Rodolfa, 2010).
The Present Study
In the present study, we first examined whether there is evidence
for the importance of the cultural humility construct. We con-
ducted an analogue pilot study that assessed the extent to which
individuals believed that cultural humility was important when
seeking a prospective therapist. We hypothesized that cultural
humility would be rated as more important than other aspects of
MCCs (e.g., knowledge, skills).
Second, we developed a brief measure of cultural humility. We
hypothesized that our measure of cultural humility would show
initial evidence of reliability and validity. Specifically, we hypoth-
esized that our measure of cultural humility would have simple
factor structure, internal consistency estimates above .70, concur-
rent validity with client reports of MCCs and working alliance, and
predictive validity based on therapy outcomes.
Although there are a plethora of measures related to MCCs, we
focused on the Cross-Cultural Counseling Inventory—Revised
(CCCI-R; LaFromboise, Coleman, & Hernandez, 1991) because it
is widely used and is the only measure that assesses MCCs from
the client’s perspective (Constantine, 2002, 2007; Fuertes & Bro-
bost, 2002; Fuertes et al., 2006; Li & Kim, 2004; Owen, Leach,
Wampold, & Rodolfa, 2011; Owen, Tao, et al., 2011). The
CCCI-R was originally developed as a measure to be completed by
supervisors or other trained observers; however, it has also been
used to assess client reports of a therapist’s MCCs. The CCCI-R
has some possible limitations as a client-report measure of MCCs.
Namely, the content validity of the client-rated CCCI-R is not well
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2HOOK, DAVIS, OWEN, WORTHINGTON, AND UTSEY
understood (Drianne & Owen, 2013). Furthermore, studies have
generally analyzed the total score of the measure, and thus it is
unknown whether the subscales reflect the tripartite model (e.g.,
Fuertes et al., 2006; Li & Kim, 2004; Owen, Leach, et al., 2011).
In fact, Owen, Tao et al. (2011) argued that the CCCI-R is actually
a better measure of MCO than MCCs. Beyond the CCCI-R, the
only other client-rated measure related to MCCs or MCO are
microaggression measures, which have limited data supporting
their use and also have psychometric concerns (see Owen, Imel, et
al., 2011; Owen, Tao, et al., 2011).
We also examined initial evidence for our primary theoretical
hypothesis—namely, clients who perceive their therapists as more
culturally humble will have better therapy outcomes, and this
relationship will be mediated by working alliance. This hypothesis
extends prior theory on the importance of humility for the strength-
ening of relationship bonds (Davis et al., 2013). In the context of
therapy, cultural differences may make it more difficult to form a
strong working alliance, but cultural humility may counteract this
tendency for cultural differences to interfere with the formation of
a working alliance. Related to this point, to provide evidence of
incremental predictive validity, we hypothesized that cultural hu-
mility would be positively associated with working alliance, even
when controlling for a measure of MCCs.
The Pilot Study
The purpose of the pilot study was to gather initial evidence that
individuals perceive cultural humility as an important aspect of a
therapist. Our main hypothesis was that participants would report
that a therapist’s cultural humility would be important to them in
seeking a prospective therapist and that cultural humility would be
more important to them than would other aspects of a therapist that
have been associated with MCCs (e.g., similarity, experience,
knowledge, and skills).
Method
Participants
Participants were 117 college students (31 men, 84 women, two
indicated “other”) from a large university in the southwestern
United States. Participants ranged in age from 18 to 52 years (M
23.4, SD 6.4). Participants reported a variety of racial back-
grounds (29.9% White, 38.5% Black, 7.7% Asian, 21.4% Latino,
0.9% Native American, and 1.7% multiracial). Participants were
predominantly heterosexual (95.7%, 0.9% gay/lesbian, 3.4% bi-
sexual). Of the participants, 8.5% were currently attending ther-
apy, and 38.5% had attended therapy at some point in their lives.
Measures
Cultural background. Participants identified the aspect of
their cultural background that was most central or important based
on the following question: “Please identify the aspect of your
cultural background that is the most central or important to you. If
you do not feel comfortable disclosing this aspect of your cultural
background, please write ‘Not Comfortable.’” This question was
an open-ended question.
Therapist characteristics. Participants rated a series of ther-
apist characteristics that are associated with MCCs (i.e., similarity,
experience, knowledge, skills, humility). We defined each charac-
teristic for participants, and also provided participants with an
example of each characteristic. For each characteristic, participants
thought about the aspect of their cultural background that was most
important to them and reported how important it would be that
their therapist had that characteristic from 1 not at all important
to 9 very important. For example, if participants had reported
that race was the aspect of their cultural background that was most
central and important, participants would rate how important it
would be that their therapist (a) was similar in race, (b) had a large
amount of experience working with other individuals from that
race, (c) had a large amount of knowledge about issues related to
that race, (d) had developed specific skills for working with
individuals from that race, and (e) was humble in regard to the
client’s race. These five ratings were analyzed separately.
Therapy scenario. Participants were asked to imagine they
were attending therapy and were given a description of a therapist.
The descriptions of the therapist were created by the first author
and varied in level of knowledge (high/low) and humility (high/
low) toward the client’s cultural background (see Appendix A for
a description of the four scenarios). Participants then completed
three items regarding their expectations for therapy. First, partic-
ipants rated their confidence that they would be able to develop a
good relationship with the therapist from 1 not at all confident
to9very confident. Second, participants rated the expected
effectiveness of therapy at resolving their problems from 1 not
at all effective to9very effective. Third, participants rated the
likelihood they would continue therapy with this therapist from
1not at all likely to9very likely.
Procedure
We recruited participants from undergraduate courses, who par-
ticipated in exchange for a small amount of course credit and a gift
card. The questionnaires were completed online via SurveyMon-
key. Participants read a consent form that explained the procedures
of the study and their rights as a participant. Participants then
indicated consent and completed the questionnaires. Participants
were randomly assigned to one of four conditions. The four con-
ditions were identical except for the therapy scenario. Specifically,
participants first rated the importance of the therapist characteris-
tics. Next, they read the therapy scenarios and answered questions
about the hypothetical therapy scenario. After completing the
questionnaires, we debriefed participants and gave them course
credit and a gift card for their participation.
Results and Discussion
Prior to conducting the primary statistical analyses, we checked
the data for assumptions. There were no problems with outliers or
normality. Participants reported a variety of aspects of culture that
were most central or important to them (18.8% race, 7.7% nation-
ality, 4.3% gender, 1.7% sexual orientation, 15.4% religion, 2.6%
socioeconomic status, 0.9% language, 17.1% family, 16.2% other,
13.7% did not wish to share, 1.7% none).
Our main hypothesis was that participants would report that
cultural humility was important to them when seeking a prospec-
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3
CULTURAL HUMILITY
tive therapist and that cultural humility would be more impor-
tant than other therapist characteristics typically associated with
MCCs (e.g., similarity, experience, knowledge, and skills). We
tested this hypothesis using participants’ ratings of therapists
and responses to therapy scenarios. For these analyses, we
excluded participants who said the most important aspect of their
cultural background was their family, other, did not wish to share,
or none. We made this decision because some of the questions may
not be applicable for these participants. For example, it may not
make sense for participants to expect that their therapist would
have a large amount of knowledge about their particular family.
We excluded 57 participants, leaving 60 participants for the pri-
mary analyses (cell sizes ranged from 11 to 19 participants per
condition). Participants in this subsample of 60 were 83.3% female
and 26.7% White.
Using ratings of therapist characteristics, participants reported
that the cultural humility of a therapist was very important (M
7.33, SD 2.01). Participants rated cultural humility as more
important than similarity (M5.15, SD 2.81, t5.67, p
.001, d0.75), experience (M5.97, SD 2.41, t3.51, p
.001, d0.45), knowledge (M6.43, SD 2.35, t2.63, p
.011, d0.34), and skills (M5.57, SD 2.52, t4.76, p
.001, d0.62). Ratings of cultural humility were not different
based on participants’ past experience in therapy (p.332), race
(white vs. racially/ethnically diverse, p.135), or gender (p
.174).
For responses to the hypothetical scenarios, we conducted a
series of analyses of covariance (ANCOVAs), with knowledge
(high/low) and humility (high/low) as the independent variables
and confidence in developing a good relationship, expected
effectiveness, and likelihood to continue as the dependent vari-
ables. We also controlled for past experience in therapy, race,
and gender. For each dependent variable, there was a large main
effect for humility (all ps.001), indicating that compared
with participants who rated a therapist low in cultural humility,
participants who rated a therapist high in cultural humility (a)
reported a higher likelihood of developing a good relationship
with the therapist, (b) expected therapy would be more effec-
tive, and (c) reported a higher likelihood of continuing therapy
with the therapist. In contrast, for each dependent variable,
there was not a statistically significant main effect for knowl-
edge (all ps.100), indicating that having a therapist with a
high or low amount of knowledge about the participant’s cul-
tural background did not influence expectations for developing
a good relationship, effectiveness, and continuing therapy. The
interaction between humility and knowledge was also not sta-
tistically significant (all ps.640), indicating that humility
affected the dependent variables regardless of the level of
knowledge.
This study provided initial support for the hypothesis that per-
ceptions of a therapist’s level of humility in relation to an indi-
vidual’s cultural background are important and may affect the
therapy relationship. However, this study relied on an analogue
design, was somewhat underpowered, used single-item measures
of therapist characteristic ratings, and the therapist’s actual level of
cultural humility was not assessed. We addressed these limitations
in the subsequent studies.
Study 1
The main purpose of Study 1 was to develop a client-rated
measure of the cultural humility of a therapist. Our goal was to
develop a measure that was brief and demonstrated initial evidence
of estimated reliability and construct validity. A secondary purpose
of Study 1 was to gather initial evidence that client perceptions of
their therapist’s cultural humility would be related to client out-
comes. We hypothesized that client perceptions of their therapist’s
cultural humility would be positively associated with a strong
working alliance.
Method
Participants. Participants were 472 college students (149
men, 323 women) from a large university in the southwestern
United States who had attended therapy at some previous point in
their lives. Participants ranged in age from 18 to 56 years (M
21.0, SD 4.4). Participants reported a variety of racial back-
grounds (59.1% White, 12.6% Black, 6.6% Asian, 12.8% Latino,
0.9% Native American, and 8.1% multiracial). Participants were
predominantly heterosexual (93.2%, 3.6% gay/lesbian, 3.0% bi-
sexual, 0.2% “other”). No participants were currently attending
therapy.
Measures.
Beginning severity. Participants rated the severity of their
presenting problem for which they attended therapy at the time
they began therapy from 0 absent to 4 severe. Perceptions of
clients’ pretherapy functioning have been used in prior studies
(Moore & Owen, in press; Nielsen et al., 2004). Although these
scores are not as viable as pre–post assessments, they do approx-
imate the degree to which clients felt distressed prior to beginning
therapy. Perceptions of pretherapy functioning are consistent with
actual pretherapy assessments of psychological functioning (rs
range .57–.87; see Moore & Owen, in press). Some researchers
have even argued that a clients’ retrospective assessment of their
pretherapy functioning are more valid than actual pretherapy as-
sessments because the client’s knowledge of functioning at intake
was less sophisticated or essentially different than it is at post-
therapy (Moore & Owen, in press; Seligman, 1995). Regardless,
retrospective assessments of beginning severity provide a rough
estimate of the amount of distress that clients were experiencing
prior to beginning therapy, which has been shown to approximate
pretherapy scores in previous studies (e.g., Nielsen et al., 2004;
Owen, Leach, et al., 2011; Owen, Wong, & Rodolfa, 2009).
Working alliance. Participants completed the short form of
the Working Alliance Inventory (WAI-SF; Tracey & Kokotovic,
1989). The WAI-SF consists of 12 items that measure three aspects
of a strong working alliance with the therapist: task (e.g., “What I
was doing in counseling gave me new ways of looking at my
problem”), goal (e.g., “My counselor and I were working towards
mutually agreed upon goals”), and bond (e.g., “My counselor and
I trusted one another”). Participants rated the degree to which they
agree or disagree with each statement on a 7-point rating scale
from 1 strongly disagree to 7 strongly agree. High scores
indicate a strong perceived working alliance with the therapist.
Tracey and Kokotovic (1989) found evidence supporting the esti-
mated internal consistency and the factor structure of this subscale.
For the present sample, we used the total working alliance score.
The Cronbach’s alpha coefficient was .96 (95% CI [.95, .96]).
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4HOOK, DAVIS, OWEN, WORTHINGTON, AND UTSEY
Cultural humility. Participants were asked to identify the as-
pect of their cultural background that was most central or impor-
tant to them using the following prompt:
There are several different aspects of one’s cultural background that
may be important to a person, including (but not limited to) race,
ethnicity, nationality, gender, age, sexual orientation, religion, disabil-
ity, socioeconomic status, and size. Some things may be more central
or important to one’s identity as a person, whereas other things may
be less central or important (see Appendix B).
Because participants may have more than one aspect of their
cultural background that is important to them, participants were
also given the opportunity to identify a second and/or third aspect
of their cultural background that was important to them. We
created a list of 36 items that corresponded with our theoretical
conceptualization of cultural humility (e.g., “My counselor is open
to explore”). We first pilot tested these items with 12 experts in the
field of MCCs. Experts had published at least one peer-reviewed
article in the field of MCCs. On the basis of feedback from the
experts, we removed four items. We gave the remaining 32 items
to participants. Participants rated the degree to which they agreed
or disagreed with each statement from 1 strongly disagree to
5strongly agree, considering the core aspect(s) of their cultural
background. Specifically, the instructions were: “Please think
about your counselor. Using the scale below, please indicate the
extent to which you agree or disagree with the following state-
ments about your counselor. Regarding the core aspect(s) of my
cultural background, my counselor . . .”
Procedure. We recruited participants from undergraduate
courses. Participants were eligible for the study if they had been in
therapy at some point in the past (median number of months since
termination was 13). Students participated in exchange for a small
amount of course credit. Participants completed the study online.
Participants read a consent form that explained the procedures of
the study and their rights as a participant. Participants then indi-
cated consent and completed the questionnaires. After completing
the questionnaires, we debriefed participants and gave them course
credit for their participation.
Results and Discussion
The main purpose of this study was to develop a brief measure
of the perceived cultural humility of the therapist. We aimed to
develop a scale that had evidence of estimated reliability and
validity. We first examined the cultural humility items for outliers
and normality. All outliers fell within the expected range of values
and were retained in the analyses. Five items showed slight devi-
ations in normality (i.e., skewness or kurtosis values above one).
However, exploratory factor analyses (EFAs) are relatively robust
against violations of normality (Gorsuch, 1983).
To determine the optimal number of components to extract for
the scale, we conducted a Scree test (Cattell, 1966) as well as a
parallel analysis (Steger, 2006). Both tests suggested that we retain
a two-factor solution. Thus, we analyzed all items using an EFA
with principal components extraction first using a varimax rotation
(for orthogonal factors) and second using a promax rotation (for
oblique factors). The factors correlated with each other .59, which
indicated that the two factors were not independent (Tabachnick &
Fidell, 2007). Thus, we retained the promax-rotated solution for
oblique factors. The two factors represented (a) positive other-
oriented characteristics and (b) negative characteristics reflecting
superiority and making assumptions. We dropped 12 items from
the scale that either (a) did not have strong factor loadings on their
primary factor (i.e., less than .70 on the primary factor) or (b) had
moderate factor loadings on both factors (i.e., higher than .15 on
the secondary factor). We also dropped eight items that were
redundant with other items. We did this because we wanted to have
a good spread of items rather than synonyms.
The final version of the Cultural Humility Scale (CHS) con-
sisted of 12 items (see Appendix B), with two factors that repre-
sented positive (seven items) and negative (five items) aspects of
cultural humility. Descriptive statistics and factor loadings for the
CHS are listed in Table 1. The two factors accounted for 71.16%
of the variance in items. The Cronbach’s alphas for the full scales
and subscales were .93 (95% CI [.92, .94]) for the full scale, .93
Table 1
Factor Loadings for the Cultural Humility Scale in Study 1
Scale item MSDPositive Negative
Positive
Is respectful 4.40 .99 .83 .05
Is open to explore 4.07 1.01 .85 .03
Is considerate 4.12 .98 .82 .01
Is genuinely interested in learning more 3.89 1.02 .87 .01
Is open to seeing things from my perspective 3.91 1.05 .83 .08
Is open-minded 3.88 .99 .81 .10
Asks questions when he/she is uncertain 4.06 .92 .84 .05
Negative
Assumes he/she already knows a lot 3.54 1.24 .08 .89
Makes assumptions about me 3.46 1.23 .06 .87
Is a know-it-all 3.89 1.18 .11 .76
Acts superior 3.81 1.19 .01 .88
Thinks he/she understands more than he/she actually does 3.71 1.22 .11 .78
Eigenvalue 6.81 1.73
Variance accounted 56.75 14.42
Note. Higher scores indicate higher cultural humility. The negative items are reverse coded such that higher scores indicate higher cultural humility.
Values in boldface type are factor loadings at or above the criteria for selection.
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5
CULTURAL HUMILITY
(95% CI [.92, .94]) for the Positive subscale, and .90 (95% CI [.88,
.91]) for the Negative subscale. Ratings of cultural humility did not
differ on the basis of race (p.660) or gender (p.592).
Secondary analysis. The secondary purpose of this study was
to examine whether clients who viewed their therapists as more
culturally humble also tended to report stronger working alliances.
Before conducting this analysis, we checked for the data for
assumptions. There were no problems with outliers or normality.
Means, standard deviations, and intercorrelations for all scales are
in Table 2. We tested our hypothesis with a hierarchical regression
with working alliance as the criterion variable. We entered begin-
ning severity, race, and gender in Step 1 to control for these
variables. Then we entered cultural humility in Step 2. Overall, the
hypothesis was supported (see Table 3). Cultural humility was
significantly associated with working alliance after controlling for
the variance in the other variables (␤⫽.74, p.001). There was
also evidence that each subscale of the CHS predicted unique
variance in working alliance. We reran the regression analysis with
the subscales entered separately. Both positive and negative cul-
tural humility were associated with working alliance, although the
Positive subscale was a stronger predictor (␤⫽.57) than the
Negative subscale (␤⫽.26, both ps.001).
This study resulted in the development of a brief measure of the
client’s perception of the therapist’s cultural humility. We also
provided initial evidence that clients who viewed their therapists as
more culturally humble tended to report stronger working alli-
ances. However, in the present study we used a retrospective
design, making conclusions necessarily tentative. Thus, in the next
study, we examined clients who were currently in therapy. We also
wanted to see whether client perceptions of a therapist’s cultural
humility would predict developing a strong working alliance while
controlling for other culturally salient variables used in previous
studies (i.e., CCCI-R).
Study 2
The main purpose of Study 2 was to replicate and expand the
findings from Study 1, using participants who were currently
attending therapy. Specifically, we conducted a confirmatory fac-
tor analysis (CFA) to see whether the factor structure found in
Study 1 would replicate on an independent sample. Also, one
might argue that cultural humility is simply a proxy for developing
cultural knowledge and skills. Thus, we aimed to show that client
perceptions of a therapist’s cultural humility would predict therapy
outcomes, even while controlling for one measure of MCCs as
they have been defined previously in the literature (i.e., CCCI-R).
Our main hypothesis was that client perceptions of their therapist’s
cultural humility would predict developing a strong working alli-
ance while controlling for the effects of client perceptions of their
therapists’ MCCs.
Method
Participants. Participants were 134 adults (40 men, 92
women, two indicated “other”) recruited from a university coun-
seling center and department clinic, all of whom were currently in
therapy. Participants ranged in age from 18 to 71 years (M26.4,
SD 8.9). Participants were predominantly White (70.1% White,
6.7% Black, 8.2% Asian, 6.7% Latino, and 8.2% multiracial) and
heterosexual (76.1%, 9.7% gay/lesbian, 10.4% bisexual, 3.7%
“other”).
Measures.
Beginning severity. As in Study 1, participants rated the se-
verity of the problem for which they attended therapy at the time
they began therapy from 0 absent to4severe.
Working alliance. Participants completed the short form of
the WAI-SF (Tracey & Kokotovic, 1989), as described in Study 1.
For the present sample, the Cronbach’s alpha coefficient was .93
(95% CI [.91, .95]).
Cultural humility. Participants completed the 12-item CHS,
as described in Study 1. To provide further evidence for the factor
structure of the CHS, we used a CFA with maximum likelihood
estimation to test the extent to which a two-factor model with
correlated factors fit the data. Fit indices suggested an acceptable
fit,
2
(53) 81.11, p.008, comparative fit index (CFI) .99,
root-mean-square error of approximation (RMSEA) .06, stan-
dardized root-mean-square residual (SRMR) .04. All factor
loadings were significant (p.001) and ranged from .54 to .88.
We also tested an alternate one-factor model, which did not show
a good fit for the data,
2
(54) 377.90, p.001, CFI .91,
RMSEA .21, SRMR .09. The chi-square difference test
revealed that the two-factor model was superior (p.001). Thus,
we retained the hypothesized two-factor model. For the present
sample, the Cronbach’s alpha coefficients were .92 (95% CI [.90,
.94]) for the full scale, .90 (95% CI [.87, .92]) for the Positive
subscale, and .90 (95% CI [.87, .92]) for the Negative subscale.
There was a trend for clients who identified as racially/ethnically
diverse to rate their therapists lower on cultural humility (M
Table 2
Intercorrelations of the Cultural Humility Scale (CHS) With
Therapy Variables (Study 1)
Variable MSD1234
1. CHS Total 50.15 10.28
2. CHS Positive 28.33 5.86 .91
3. CHS Negative 18.40 5.11 .86
.58
4. WAI-SF 61.31 15.93 .75
.73
.59
Note. WAI-SF Working Alliance Inventory, short form. The CHS
Negative subscale is reverse coded such that higher scores indicate higher
cultural humility.
p.001.
Table 3
Hierarchical Regression Analysis Predicting Working Alliance
(Study 1)
Predictor R
2
sr
2
Step 1 .03
Beginning severity .18
.03
Race .02 .00
Gender .01 .00
Step 2 .54
Beginning severity .11 .01
Race .01 .00
Gender .02 .00
Cultural humility .74
.54
p.001.
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6HOOK, DAVIS, OWEN, WORTHINGTON, AND UTSEY
53.93, SD 10.09) than clients who identified as White (M
56.60, SD 7.62, p.096). Ratings of cultural humility did not
differ on the basis of gender (p.271).
Multicultural competencies. Participants completed the
CCCI-R (LaFromboise et al., 1991). The CCCI-R consists of 20
items that measure a counselor’s multicultural competence in
regard to cross-cultural counseling skill, sociopolitical awareness,
and cultural sensitivity (e.g., “My counselor demonstrates knowl-
edge about my culture”). Participants rated the degree to which
they agree or disagree with each statement on a 6-point rating scale
from 1 strongly disagree to 6 strongly agree. High scores
indicate that clients perceive their therapist to have high levels of
multicultural competence. LaFomboise et al. (1991) found evi-
dence supporting the estimated internal consistency and content
validity for this scale. The CCCI-R was originally designed to be
completed by a third-party observer; it was modified slightly so
that it could be completed by clients (see Constantine, 2002). For
the present sample, the Cronbach’s alpha coefficient was .93 (95%
CI [.91, .94]).
Procedure. We recruited participants from a university coun-
seling center and department clinic using flyers. Participants were
eligible for the study if they were currently attending therapy
(median number of sessions was seven). Participants completed
the study in exchange for a gift card. Participants completed the
study online. Participants read a consent form that explained the
procedures of the study and their rights as a participant. Partici-
pants then indicated consent and completed the questionnaires.
After completing the questionnaires, we debriefed participants and
gave them the gift card for their participation.
Results and Discussion
The main purpose of this study was to examine the relationship
between cultural humility and the working alliance, controlling for
MCCs. Before conducting this analysis, we checked the data for
assumptions. There were no problems with outliers or normality.
Means, standard deviations, and intercorrelations for all scales
are in Table 4. As in Study 1, we used a hierarchical regression to
test the main hypothesis. We entered beginning severity, race,
gender, and CCCI-R in Step 1. We entered cultural humility in
Step 2. Overall, the hypothesis was supported (see Table 5). Client
perceptions of their therapist’s MCCs (i.e., CCCI-R) were a sig-
nificant predictor of working alliance (␤⫽.40, p.001). Client
perceptions of their therapist’s cultural humility were also a sig-
nificant predictor of working alliance, even when controlling for
the CCCI-R (␤⫽.35, p.001). As in Study 1, there was also
evidence that each subscale of the CHS predicted unique variance
in working alliance. We reran the regression analysis with the
subscales entered separately. Both Positive (␤⫽.20, p.058)
and Negative (␤⫽.20, p.021) cultural humility were associated
with working alliance, when controlling for the CCCI-R.
This study provided further evidence that client perceptions of a
therapist’s cultural humility are positively related to high-quality
alliances with the therapist. Cultural humility appears to explain a
modest amount of variance in the alliance over and above tradi-
tional measures of client perceptions of their therapist’s MCCs.
However, we did not assess in the present study client improve-
ment in therapy, which was on a predominately White sample.
Thus, in the next study we sought to address these limitations.
Study 3
The main purpose of Study 3 was to replicate and expand the
findings from Studies 1 and 2 in two main ways. First, we incor-
porated a measure of client improvement in therapy. We hypoth-
esized that client perceptions of their therapist’s cultural humility
would be positively related to client improvement and that this
relationship would be mediated by developing a strong working
alliance with the therapist. A gold standard for most process
variables is the link between therapy process and outcomes. Given
that cultural humility is a relational variable, linked to the alliance
between the client and therapist (Studies 1 and 2), it is likely that
the association between cultural humility and outcomes will be
mediated by the alliance. That is, cultural humility has been
theorized to help form, maintain, and repair social bonds, which in
this case should be evident in the association between cultural
humility and alliance. In turn, the alliance should be associated
with positive therapy outcomes, a common and robust finding in
the therapy literature (Horvath, Del Re, Flückiger, & Symonds,
2011). Second, the previous three studies used samples that were
mostly White. In this final study, we wanted to confirm that
cultural humility would be a useful construct among participants
who identified as racially/ethnically diverse. Because individuals
who identify as Black or African American experience disparities
Table 4
Intercorrelations of the Cultural Humility Scale (CHS) With
Therapy Variables (Study 2)
Variable MSD12345
1. CHS Total 55.80 8.49
2. CHS Positive 31.28 4.30 .90
3. CHS Negative 20.88 4.60 .90
.63
4. CCCI-R 98.60 13.68 .64
.70
.45
5. WAI-SF 69.84 11.00 .60
.60
.51
.62
Note. CCCI-R Cross-Cultural Counseling Inventory—Revised;
WAI-SF Working Alliance Inventory, short form. The CHS Negative
subscale is reverse coded such that higher scores indicate higher cultural
humility.
p.001.
Table 5
Hierarchical Regression Analysis Predicting Working Alliance
(Study 2)
Predictor R
2
sr
2
Step 1 .39
Beginning severity .06 .00
Race .09 .01
Gender .06 .00
MC competencies .62
.34
Step 2 .07
Beginning severity .07 .00
Race .07
Gender .06
MC competencies .40
.09
Cultural humility .35
.07
Note. MC Multicultural.
p.001.
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7
CULTURAL HUMILITY
in regard to using mental health services (Constantine, Kindaichi,
Graham, & Watkins, 2008), we thought this population would be
a good fit to test our construct of cultural humility.
Method
Participants. Participants were 120 adults (87 men, 33
women) recruited using Amazon’s Mechanical Turk website, with
the restriction that all participants must self-identify as Black and
currently be attending therapy. Participants ranged in age from 18
to 55 years (M27.8, SD 7.7). All participants identified as
Black. Participants were mostly heterosexual (87.5%, 5.0% gay/
lesbian, 7.5% bisexual). All participants were currently attending
therapy.
Measures.
Improvement in psychotherapy. Participants completed the
Patient’s Estimate of Improvement (PEI; Hatcher & Barends,
1996). The PEI consists of 16 items that assess improvement
during therapy across a broad range of client functioning (e.g., “To
what extent have your original complaints or symptoms im-
proved?”; response options vary). High scores indicate more im-
provement in therapy. Cronbach’s alphas for the PEI in past
studies have ranged from .89 to .94 (Clemence, Hilsenroth, Ack-
erman, Strassle, & Handler, 2005; Hatcher & Barends, 1996;
Pesale, Hilsenroth, & Owen, 2012). Scores on the PEI have also
been linked to symptom improvement during therapy (Owen &
Hilsenroth, 2011; Pesale et al., 2012). For the present sample, the
Cronbach’s alpha coefficient was .95 (95% CI [.94, .96]).
Working alliance. Participants completed the WAI-SF
(Tracey & Kokotovic, 1989), as described in Study 1. For the
present sample, the Cronbach’s alpha coefficient was .92 (95% CI
[.89, .94]).
Cultural humility. Participants completed the 12-item CHS,
as described in Study 1. For the present sample, the Cronbach’s
alpha coefficients were .86 (95% CI [.82, .89]) for the full scale,
.88 (95% CI [.84, .91]) for the Positive subscale, and .84 (95% CI
[.79, .88]) for the Negative subscale. Female clients rated their
therapist to be higher in cultural humility (M51.06, SD 9.38)
than did male clients (M44.86, SD 7.48, p.001).
Procedure. We recruited participants using Amazon’s Me-
chanical Turk website. Amazon’s Mechanical Turk is a website
through which individuals can complete tasks and receive com-
pensation for their work (Buhrmester, Kwang, & Gosling, 2011).
Participants were eligible for the study if they identified as Black
and were currently attending therapy. Participants were compen-
sated for their time via the Amazon Turk program. Participants
completed the study online. Participants read a consent form that
explained the procedures of the study and their rights as a partic-
ipant. Participants then indicated consent and completed the ques-
tionnaires. After completing the questionnaires, we debriefed par-
ticipants.
Results and Discussion
The main purpose of this study was to replicate and expand the
findings from Studies 1 and 2, using a reliable and valid measure
of improvement in therapy, and using a sample of racially/ethni-
cally diverse participants. We hypothesized that client perceptions
of a therapist’s cultural humility would be positively associated
with their perceived improvement to date in therapy, and this
relationship would be mediated by working alliance. Before con-
ducting this analysis, we checked the data for assumptions. There
were no problems with outliers or normality.
Means, standard deviations, and intercorrelations for all scales
are in Table 6. Controlling for beginning severity and gender, the
direct association between the predictor variable (cultural humil-
ity) and the criterion variable (improvement) was significant (␤⫽
.50, p.001; see Figure 1). Also, the direct association between
the predictor variable (cultural humility) and the mediator variable
(working alliance) was significant (␤⫽.74, p.001). Finally,
controlling for the predictor variable (cultural humility), the asso-
ciation between the mediator variable (working alliance) and the
criterion variable (improvement) was significant (␤⫽.71, p
.001). In this final regression analysis, there was no longer a
significant association between the predictor variable (cultural
humility) and the criterion variable (improvement) (␤⫽⫺.03, p
.736). To test whether the mediated effect of cultural humility on
improvement through working alliance was significant, we used
the bootstrapping procedure outlined by Preacher and Hayes
(2008). Using a bias-corrected bootstrapping procedure based on
5,000 resamples, controlling for beginning severity and gender, we
found that the indirect effect of cultural humility on improvement
through working alliance was significant (est. 1.17, SE .21,
95% CI [.79, 1.64]). Using the R
2
effect size measure for media-
tion analysis (Fairchild, MacKinnon, Taborga, & Taylor, 2009),
about 37.2% of the variance in improvement was explained by the
mediated effect of cultural humility through working alliance (a
large effect size).
General Discussion
The present set of studies created a brief client-rated measure of
a therapist’s cultural humility and provided evidence for the reli-
Table 6
Intercorrelations of the Cultural Humility Scale (CHS) With Therapy Variables (Study 3)
Variable MSD12345
1. CHS Total 46.57 8.47
2. CHS Positive 27.58 5.36 .86
3. CHS Negative 15.42 4.83 .76
.34
4. PEI 92.30 18.66 .59
.73
.17 —
5. WAI-SF 60.47 13.17 .74
.76
.41
.77
Note. PEI Patient’s Estimate of Improvement; WAI-SF Working Alliance Inventory, short form. The CHS Negative subscale is reverse coded such
that higher scores indicate higher cultural humility.
p.001.
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8HOOK, DAVIS, OWEN, WORTHINGTON, AND UTSEY
ability and validity of this measure. Indeed, although the majority
of theory and measurement of MCCs has involved the building or
development of self-awareness, knowledge, and skills, we have
conceptualized cultural humility as a virtue or disposition impor-
tant to one’s MCO that involves having an interpersonal stance
that is other-oriented in relation to another individual’s cultural
background and experience, marked by respect for and lack of
superiority toward another individual’s cultural background and
experience. We decided to focus on the interpersonal dimension of
humility rather than the intrapersonal dimension (i.e., accurate
view of self), because we felt it was more relevant to the therapy
relationship and better able to be perceived (and rated) by clients.
In the present set of studies, we found that client perceptions of a
therapist’s cultural humility could be assessed reliably using a
brief measure. Client perceptions of a therapist’s cultural humility
were positively associated with both working alliance with the
therapist and perceived improvement in therapy. The relationship
between client perceptions of a therapists’ cultural humility and
perceived improvement appears to occur via a stronger working
alliance with the therapist.
The results of the present study indicate that in addition to
focusing on building self-awareness, knowledge, and skill, it may
be important to address developing an interpersonal stance of
humility when engaging with a client about his or her cultural
background. This supports prior theory by Tervalon and Murray-
Garcia (1998) as well as others (e.g., Fowers & Davidov, 2006;
Ridley et al., 1994; S. Sue, 1998) that have emphasized the
importance of humility and being open to the other in order to
work effectively with diverse clients.
There are some notable limitations of the present set of studies.
First, cross-sectional, correlational designs were used in all studies.
Thus, it is impossible to infer causality between the variables in the
present studies. Although the data are consistent with our theoret-
ical model (e.g., perceptions of cultural humility affecting im-
provement via working alliance), there are other theoretical models
that may also fit the data well, including a model that would
suggest that all ratings of a therapist might be affected by improve-
ment to date or by working alliance. Related to this limitation, we
did not assess for temporal stability of the CHS. In the present
article, we take an important first step of articulating our theory
and hypotheses, developing a psychometrically supported measure
to assess the key construct, and testing the hypotheses (albeit in
cross-sectional studies). Longitudinal or experimental research is
necessary to further elucidate our theoretical model. Second, the
primary measures used in the present set of studies were self-report
measures of a client’s experience in therapy and perceptions of the
therapist. Although this appears to be the most widely used mea-
surement strategy in this area of research, it does have some
limitations. For example, retrospective clients may struggle to
remember their experiences in therapy accurately, or current cli-
ents may not wish to report negative experiences with their ther-
apist. Furthermore, future studies could include measures of other
types of constructs associated with MCCs (e.g., microaggressions;
Constantine, 2007). Third, our samples were in some ways limited.
Two samples consisted of college students, and two samples
consisted of mostly White participants. Although we tried to
minimize this limitation by designing our measure to allow par-
ticipants to select the aspects of their cultural identity that were
most important to them and using a sample of racially/ethnically
diverse participants in one study (Study 3), future research should
nevertheless examine other types of samples, particularly samples
of racially/ethnically diverse participants, as well as community or
older adult samples.
More research is needed on the subscales of the CHS (see
Appendix B for the scale and Appendix C for a table of norms to
date). Studies 1 and 2 showed high correlations between the two
subscales, but Study 3 showed a more modest correlation. Further-
more, the pattern of relationships between the subscales and ther-
apy outcomes were mostly consistent, although in some cases the
Positive subscale showed slightly higher correlations with therapy
outcomes than did the Negative subscale. This difference was most
prominent in Study 3, which was also the study in whicha racially/
ethnically diverse sample was used. It may be that for racially/
ethnically diverse participants, the positive characteristics of cul-
tural humility (e.g., openness to explore) are somewhat more
important than the negative aspects of cultural humility (e.g.,
making assumptions) in predicting counseling outcomes. At pres-
ent, we recommend using the total scale score, although future
research may show important differences between positive and
negative aspects of perceptions of cultural humility.
Our findings have several implications for therapy practice and
training of therapists. First, therapists should be aware that humil-
ity appears to be very important to clients when addressing their
cultural worldview. As much as a therapist can be an “expert” in
a certain aspect of diversity, we encourage therapists to engage
with each client with an attitude of humility in relation to the
client’s cultural background. Therapists should not assume that
they understand the client’s cultural background or experience
based on therapists’ prior knowledge, experience, or training.
Rather, therapists should partner with the client to explore the
client’s cultural background and experience, in order to determine
the aspects of the client’s cultural background that may be helping
or hurting the client. This attitude of humility may be especially
important to the development of a strong working alliance with a
client who is culturally different. Furthermore, engaging a cultur-
ally diverse client with an interpersonal stance of humility may
attenuate the tendency for therapists to overvalue their own per-
spectives and worldviews, instead of joining with the client to
explore the client’s perspective and worldview.
Second, when training therapists to competently work with
clients from diverse backgrounds, it may be important to focus on
interpersonal behaviors such as expressions of humility (e.g., being
open to explore the client’s cultural background, asking questions
when uncertain, expressing curiosity and interest about the client’s
cultural worldview) in addition to accruing a specific set of knowl-
.74* .71*
.50*
(-.03, ns)
Cultural
Humility
Working
Alliance
Improvement
Figure 1. Mediator effects of working alliance on the relationship be-
tween cultural humility and improvement. The number in parenthesis is the
effect of the predictor variable on the criterion variable with the mediator
in the model.
p.001.
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9
CULTURAL HUMILITY
edge or skills for working with a particular type of client. The
present studies suggest that as a therapist is continually gaining
new knowledge and skills to work with diverse clients, it is
important for the therapist to also learn to engage with his or her
clients in a humble manner.
Third, cultural humility may also play a role in guiding how
counseling psychologists engage in activities aligned with social
justice goals, such as advocacy, outreach, prevention programs,
and psychoeducational interventions (Vera & Speight, 2003).
These roles often involve partnering with community members
and leaders, and it is likely important to engage in these relation-
ships from an interpersonal stance of humility and openness to the
other, rather than from a superior role as the “expert.”
The push to develop MCCs has changed the face of counseling
psychology over the past 30 years. Most therapists now acknowl-
edge that they must address issues related to culture and diversity
in the therapy session. Our hope is that as therapists develop
greater self-awareness, knowledge, and skills for working with
diverse clients, they will simultaneously engage diverse clients
with cultural humility.
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Appendix A
Description of Counseling Scenarios (Pilot Study)
Scenario 1: High Knowledge, High Humility
Imagine you are attending counseling. Your counselor has a
large amount of knowledge about individuals who share your
cultural background. Your counselor is also humble in regard to
your cultural background. Your counselor does not assume that he
or she understands your particular cultural experience, but rather
your counselor explores your cultural background with openness.
Scenario 2: High Knowledge, Low Humility
Imagine you are attending counseling. Your counselor has a
large amount of knowledge about individuals who share your
cultural background. However, your counselor is not very humble
in regard to your cultural background. Your counselor makes
assumptions about your particular cultural experience (which may
or may not be accurate) based on his or her experiences with others
who share your cultural background.
Scenario 3: Low Knowledge, High humility
Imagine you are attending counseling. Your counselor does not
have much knowledge about individuals who share your cultural
background. However, your counselor is humble in regard to your
cultural background. Your counselor does not assume that he or
she understands your particular cultural experience, but rather your
counselor explores your cultural background with openness.
Scenario 4: Low Knowledge, Low Humility
Imagine you are attending counseling. Your counselor does not
have much knowledge about individuals who share your cultural
background. Your counselor is also not very humble in regard to
your cultural background. Your counselor makes assumptions
about your particular cultural experience (which may or may not
be accurate) based on his or her experiences with others who share
your cultural background.
(Appendices continue)
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11
CULTURAL HUMILITY
Appendix B
(Appendices continue)
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12 HOOK, DAVIS, OWEN, WORTHINGTON, AND UTSEY
(Appendices continue)
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13
CULTURAL HUMILITY
Appendix C
Normative Data for the Cultural Humility Scale (CHS)
Received August 20, 2012
Revision received January 21, 2013
Accepted February 25, 2013
Sample Study nTotal CHS Positive Negative
Past clients, college students (41% REM) 1 472 51.2 (10.3) 28.3 (5.9) 18.4 (5.1)
Current clients, college students and community (30% REM) 2 134 55.8 (8.5) 31.3 (4.3) 20.9 (4.6)
Current clients, community (100% REM) 3 120 46.6 (8.5) 27.6 (5.4) 15.4 (4.8)
Note. Values in three rightmost columns are means (and standard deviations). The Negative subscale is reverse coded such that higher scores indicate
higher cultural humility. REM racial/ethnic minority.
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14 HOOK, DAVIS, OWEN, WORTHINGTON, AND UTSEY
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