In Search of Cultural Competence in
Psychotherapy and Counseling
University of California, Davis
The characteristics involved in cultural competency in
psychotherapy and counseling have been difficult to
specify. This article describes attempts to study factors
associated with cultural competency and addresses 3
questions. First, is ethnic match between therapists and
clients associated with treatment outcomes? Second, do
clients who use ethnic-specific services exhibit more fa-
vorable outcomes than those who use mainstream ser-
vices? Third, is cognitive match between therapists and
clients a predictor of outcomes? The research suggests
that match is important in psychotherapy. The cultural
competency research has also generated some contro-
versy, and lessons learned from the controversy are dis-
cussed. Finally, it is suggested that important and orthog-
onal ingredients in cultural competency are therapists'
scientific mindedness, dynamic-sizing skills, and culture-
ultural competence is one of the most discussed
concepts among scholars and practitioners inter-
ested in ethnic minority issues. Indeed, numerous
groups at local and national levels have been examining
the concept in trying to establish guidelines and standards
for the provision of mental health services to ethnic mi-
nority populations, especially with the advent of managed
care. Why is there such interest and enthusiasm? I believe
that there is a growing realization that competent thera-
pists and counselors must be cross-culturally competent.
Because of the multiethnic nature of U.S. society and
because of the increasingly frequent interactions Ameri-
cans have with people from throughout the world, skills
must be developed to effectively work with people from
different cultures. Furthermore, cultural competency rep-
resents an important philosophical shift in defining ethnic
and race relations, traditionally examined as a conflict
involving assimilation versus pluralism.
The assimilation position was an ideology that cul-
turally different groups should become incorporated into
a largely Anglo mainstream. Gordon (1978) referred to
this process as "Anglo-conformity," in which the desir-
ability is assumed of maintaining the English language
and English-oriented cultural patterns in American life.
(An earlier notion, "the melting pot," sought cultural and
biological merging but was less oriented toward Anglo-
conformity.) Although some assimilation has occurred
among the diverse groups in society, cultural and distinct
ethnic group traditions have persisted in U.S. society as
well as in many other societies. Assimilation has not
progressed very far, especially in what Gordon conceptu-
alized as "structural assimilation," that is, the systematic
inclusion of ethnics in the White, Anglo-Saxon, Protes-
tant social structure (cliques, churches, neighborhoods,
home-visit patterns, etc.). In contrast to the assimilation
position, those who advocated pluralism sought to recog-
nize the ethnic and cultural integrity of different groups
and the coexistence of groups in a pluralistic society. The
concept of pluralism, attacked by assimilationists and
melting-pot advocates, has also not fared well. Although
there is recognition that different cultural groups exist in
the United States, many in society fail to embrace plural-
ism as a desirable goal. Anti-immigration sentiments, the
push for English-only materials, and so forth may reflect
the opposition to pluralism.
Cultural competence (along with the broader con-
cept of multiculturalism) is the belief that people should
not only appreciate and recognize other cultural groups
but also be able to effectively work with them. In a way,
cultural competence is less controversial than assimila-
tion and pluralism--how can one argue against compe-
tencies of any kind? And, whereas assimilation and plu-
ralism are ideologies or philosophies of life, cultural
competency is skill-based--skills that should be in the
repertoire of all practicing psychologists (Hall, 1997).
Given the interest in cultural competency, it is important
to ask what the concept means. Is it old wine in new
In this article, I discuss (a) problems in mental
health services, (b) attempts to study cultural competence
over a period of about a decade, (c) policy issues arising
Editor's note. Articles based on APA award addresses are given spe-
cial consideration in the American Psychologist's editorial selection
A version of this article was originally presented as part of an
Award for Distinguished Contribution to Research in Public Policy
address at the 105th Annual Convention of the American Psychological
Association, Chicago, IL, August 1997.
Author's note. I am grateful for the assistance of Karen Kurasaki and
Shobha Srinivasan in providing me with constructive comments on an
earlier version of this article.
Correspondence concerning this article should be addressed to
Stanley Sue, Department of Psychology, University of California, Davis,
One Shields Avenue, Davis, CA 95616-8686. Electronic mail may be
sent to email@example.com.
440 April 1998 ° American Psychologist
Copyright 1998 by the American Psychological Association, Inc. 0003-066X/98/$2.00
Vol. 53, No. 4, 440-448
from research, and (d) the meaning of cultural compe-
tence in psychotherapy and counseling. By "meaning,"
I am not referring to just its definition. The definition
can be simply stated, that is, one is culturally competent
when one possesses the cultural knowledge and skills of
a particular culture to deliver effective interventions to
members of that culture. Rather, I want to address the
essence or character, namely, what constitutes cultural
The Search for Cultural Competence
The impetus for cultural competence has been the inade-
quacy of services for members of ethnic minority groups
such as African Americans, American Indians, Asian
Americans, and Latinos. One of the most frequently cited
problems in delivering mental health services to ethnic
minority groups is the cultural and linguistic mismatches
that occur between clients and providers (see Aponte,
Rivers, & Wohl, 1995; Comas-Diaz & Griffith, 1988;
Jenkins, 1985; LeVine & Padilla, 1980; Pope-Davis &
Coleman, 1997; D. Sue, Ivey, & Pedersen, 1996; Trim-
ble & LaFromboise, 1985). Cultural differences can af-
fect the validity of assessment as well as the development
of therapist-client rapport, the therapeutic alliance, and
treatment effectiveness. Concerns regarding the problems
in cross-cultural counseling and psychotherapy prompted
the American Psychological Association (APA) to estab-
lish guidelines for the provision of psychological services
to members of ethnic minority groups (APA Office of
Ethnic Minority Affairs, 1993). The guidelines are
largely hortatory in effect and implicitly recognize the
difficulties in relationships between providers and clients.
In view of these problems, the investigators cited
earlier made a series of recommendations to facilitate the
provision of more culturally responsive treatments. The
recommendations included the necessity to know the cul-
ture of clients, to be sensitive and flexible in dealing with
clients, and to achieve credibility. It is interesting to note
that the recommendations were not derived from defini-
tive research findings but were based on theory involving
cultural match or fit. That is, services should be delivered
in ways that are consistent with the cultural background
of clients. Indeed, in two major reviews (Chambless et
al., 1996; S. Sue, Zane, & Young, 1994), not a single
rigorous study examining the efficacy of treatment for
any ethnic minority population was found. By "rigor-
ous," I am referring to research in which (a) pre- and
posttreatment outcomes are assessed for clients from one
or more ethnic groups; (b) clients are randomly assigned
to conditions, and control groups (e.g., no treatment, at-
tention-placebo, or different ethnic groups matched on
demographic characteristics other than ethnicity) are used
when appropriate; (c) type of treatment and ethnicity are
crossed when comparisons of outcomes by ethnicity and
treatment are made; (d) multiple, culturally cross-vali-
dated assessment instruments are used; (e) outcomes are
assessed over time; and (f) findings are replicated. Many
of these criteria were used by the APA Division 12 Task
Force on Psychological Interventions to evaluate empiri-
cally validated treatments (Chambless et al., 1996). Given
the lack of solid research on treatment outcomes for eth-
nic minority populations, it is not surprising that the
recommendations have been based on theory rather than
research. Parenthetically, because of the lack of solid
research, is it possible that ethnics are actually faring
well in the mental health system? The available evidence
suggests that this is not the case and that much can be
done to improve the provision of mental health services
to culturally diverse groups (S. Sue et al., 1994).
The Cultural Match Studies
Because of the lack of a solid research foundation, my
colleagues and I decided to systematically study charac-
teristics of cultural competence. Together with research-
ers at the National Research Center on Asian American
Mental Health and a whole host of graduate students, we
wanted to examine different facets of cultural compe-
tence. We were interested in three questions. First, when
therapists and clients are of the same ethnicity, are treat-
ment outcomes better than when therapists and clients
differ in ethnicity? Over the years, the mental health pro-
fessions have been criticized for not training more ethnic
minority therapists who can serve their own communities.
Is there evidence that ethnic clients benefit from seeing
ethnically similar therapists? Under what conditions is
ethnic match important? Match presumably may not be
effective for everyone, so it is important to determine the
conditions under which match is important. Second,
when ethnic clients utilize ethnic-specific services, are
outcomes better than if they utilize non-ethnic-specific
or mainstream services? Many ethnic-specific services
have been established throughout the country. Are these
services effective, and what is it about such services that
is effective? Third, when therapists and clients think in
the same manner (i.e., exhibit cognitive match), regard-
less of their ethnicity, are treatment outcomes better?
I begin with the first question regarding ethnic
match. Our study of ethnic match was based on thousands
of African American, Asian American, Mexican Ameri-
can, and White clients seen in the Los Angeles County
mental health system (S. Sue, Fujino, Hu, Takeuchi, &
Zane, 1991). The large data set enabled us to accomplish
what other researchers had not done, namely, to report
on large samples of different ethnic clients. The study
was intended to examine length of treatment, dropout
rates (after one session), and treatment outcomes (using
pre- and posttreatment Global Assessment Scale [GAS]
scores) as dependent measures. Specifically, we were in-
terested in finding out if therapist-client matches in eth-
nicity and language were associated with attending more
sessions, less dropping out, and more favorable treatment
outcomes. Length of treatment was considered to be an
important indicator of outcome because it is known to
be directly related to favorable treatment outcomes (Or-
linsky, Grawe, & Parks, 1994). Premature termination
was examined because in my previous studies (see S.
Sue, 1977), ethnic clients were found to drop out of
treatment at a rate of about 50% after the initial treatment
April 1998 • American Psychologist 441
session. In the ethnic match study, we controlled for a
number of variables, including social class, initial level
of functioning, gender, age, and so forth. Results indi-
cated that Asian Americans--especially those who were
unacculturated--generally fared better in terms of more
sessions, less drop out, and better treatment outcomes
when they saw a therapist who was matched ethnically,
linguistically, or both. Similar effects were found for
Mexican Americans, although the effects were less dra-
matic. Ethnic matches were significantly related to at-
tending more sessions for African Americans and Whites;
Whites also had lower rates of premature termination
when they were ethnically matched, although match was
not associated with premature termination among African
Americans. When the results for number of sessions or
premature termination were statistically significant, most
of the effect sizes were large, indicating the clinical sig-
nificance of the findings.
Finally, treatment outcomes for African Americans
and Whites were not related to ethnic match. It is not
known why matching is related to outcomes for some
groups but not others. Perhaps, in this study (S. Sue et al.,
1991), the outcome measure--GAS--lacked sufficient
sensitivity to assess outcomes in a valid fashion. Thera-
pists provided subjective ratings on a 100-point scale of
the level of functioning of clients, and much variability
may have existed in the validity of the ratings given by
the numerous therapists. Alternatively, the importance of
ethnic match may heavily depend on the acculturation
level, ethnic-cultural identity, or ethnicity of clients. For
some clients in the same ethnic minority group, match
may be quite important. It is known that ethnic or lan-
guage matches do not ensure cultural matches, which
may be of major importance. That is, ethnicity is more
of a demographic variable than a psychological variable.
The psychological aspects (e.g., identity, attitudes, be-
liefs, and personality) may be of greater importance.
My colleagues and I also examined the outcomes of
ethnic minority clients who used either ethnic-specific
services or mainstream services (Takeuchi, Sue, & Yeh,
1995; Yeh, Takeuchi, & Sue, 1994). Ethnic-specific ser-
vices are those that have a large ethnic clientele and
presumably try to respond to the cultural needs of clients.
They may respond by improving the accessibility of ser-
vices to ethnic minorities (e.g., by providing flexible
hours or placing treatment facilities in ethnic communi-
ties) and employing bicultural-bilingual staff. Various
practices (e.g., ways of greeting clients) or arrangements
(e.g., serving tea rather than coffee to Chinese clients)
may be used that are congruent with the cultural back-
ground of clients. Ethnic-specific services may also mean
that therapeutic practices are modified or developed so
that the cultural customs, values, and beliefs of clients
are considered (including in treatment indigenous healers
or religious leaders in the community, increasing partici-
pation of family members, etc.).
To study ethnic-specific services, we (Takeuchi et
al., 1995; Yeh et al., 1994) again examined the return
rates, length of treatment, and treatment outcomes of eth-
nic minority adults. This time, however, African Ameri-
can, Asian American, and Mexican American clients were
divided into those who received services from ethnic-
specific programs and those who attended mainstream
programs. Predictor variables included type of program
(ethnic-specific vs. mainstream), severity of disorder,
gender, age, social class, and ethnic match (whether or
not clients had a therapist of the same ethnicity). This
last variable, ethnic match, was important to enter as a
predictor to distinguish the effects of service match from
ethnic match. The results indicated that ethnic clients
who attended ethnic-specific programs had lower dropout
rates and stayed in the programs longer than did those
using mainstream services. The findings were not clear-
cut when treatment outcomes were examined. That is,
treatment outcomes, as measured by the GAS, failed to
show consistent or significant differences. However, the
fact that ethnic-specific services were associated with
lower dropout rates is important. As discussed earlier, a
great deal of concern has been generated over the ten-
dency for ethnic minority clients to prematurely drop out
of treatment and to attend, on average, fewer treatment
sessions (S. Sue, 1977), especially because treatment out-
come has consistently demonstrated a direct relationship
with the number of sessions in treatment (Orlinsky et al.,
1994). The fact that clients stay in treatment longer may
mirror the greater rapport, comfort, or cultural consis-
tency of ethnic-specific services.
It should be noted that in investigations of ethnic
match and ethnic-specific services match, the processes
that account for the results are unknown. Why is ethnic
match beneficial? Why do clients stay in treatment longer
when using ethnic-specific services? Unfortunately, my
colleagues and I could not randomly assign clients to
therapists or services, and we could not directly examine
process variables. However, it is noteworthy that the em-
pirical results suggest that cultural match and treatment
outcomes are related, a relationship hypothesized for
many years by numerous ethnic practitioners and
In our search to define cultural competence, my
colleagues and ! have tried to study variables at a more
micro level than for ethnic or services match. At the
micro level, our interest was in cognitive match, that is,
whether therapist-client similarity in thinking is associ-
ated with better treatment outcomes. Therapists and cli-
ents often have different explanatory models for clients'
problems in terms of etiology, symptom meaning, course,
and appropriate treatment (Kleinman, 1980). S. Sue and
Zane (1987) argued that therapist-client differences in
cultural attitudes and beliefs affect the process and effi-
cacy of psychotherapy. We wanted to see if matches be-
tween therapists and clients in how they conceptualized
goals for treatment and means for resolving problems
would be more beneficial than mismatches. We also ex-
amined the match between therapists and clients in levels
of acculturation. Measures of therapists' and clients' be-
liefs regarding goals for treatment, preferred means for
resolving problems, and acculturation were collected at
442 April 1998 • American Psychologist
a mental health center in San Francisco. The degree of
match between therapists and clients was then used as
a predictor of posttreatment symptoms, adjustment, and
clients' ratings of the treatment sessions, after controlling
for pretreatment status.
In view of the large numbers of analyses for the
numerous criterion measures and their subscales, I pro-
vide a summary of the results that are currently still being
analyzed. There is evidence that match is significantly
related to treatment outcome and clients' perceptions of
the sessions. In various comparisons, therapist-client
matches on goals for treatment and on coping styles were
related to better adjustment and more favorable impres-
sions of the sessions. In no case did a cognitive mismatch
predict better outcome. This study is important because
it demonstrates that therapists' conceptions and their con-
gruence with those of clients are related to therapeutic
outcomes. An additional finding is that within-group dif-
ferences were associated with acculturation levels of cli-
ents and therapists. Whereas our previous studies (S. Sue
et al., 1991; Takeuchi et al., 1995) showed that ethnic
match is important, we now have additional knowledge
about the conditions that are related to favorable out-
comes within ethnic match, that is, cognitive match.
The findings from this research should not be very
surprising. As noted earlier, a number of investigators
have argued that ethnic match and cognitive match are
important. The significant point is that now there is em-
pirical support for these arguments. The findings also
suggest that there is a need to increase the ethnic diversity
of service providers and to train therapists to understand
the worldviews of their clients. Obviously, if clients' cul-
tural beliefs radically differ from those of their therapists,
rapport in treatment and treatment outcomes may be
Dilemmas in Cultural Competence Research
In my search for cultural competency, I have been con-
fronted with several dilemmas (S. Sue, 1992, 1995). The
dilemmas are important to reveal because they illustrate
the problems and misunderstandings that arise in ethnic-
racial research. I review some of them and address the
implications for policy and practice.
First, in psychology, there is growing interest in
basing interventions on findings from rigorously con-
ducted, empirical research because the practice of psy-
chology has proceeded with insufficient guidance from
or adherence to research findings (Dawes, 1995). Yet,
in the case of ethnic minority populations, no rigorous
research has determined if psychotherapy is effective. If
therapists need to base practice on research findings, and
if psychotherapy and assessment tools have not demon-
strated their effectiveness or validity, should psychother-
apy continue to be offered to these populations? How
can guidelines and standards for cultural competency be
devised in the absence of research? I believe that service
providers must continue offering professional services to
ethnic populations and use therapists' best and collective
judgment in organizing services. There is substantial evi-
dence that mental health needs among ethnic minority
populations are substantial (Aponte & Crouch, 1995;
President's Commission on Mental Health, 1978), and
the mental health profession simply cannot wait for re-
search to provide definitive answers. Similarly, one of
the significant questions to address is why more research
and more rigorous research has not been conducted on
ethnic minority populations.
Second, the issue of segregation has been raised in
some of my work. In the past, I recommended that specific
services be created, targeting ethnic minority populations.
This recommendation seemed to make sense because in
communities with large ethnic populations, mental health
services should focus on these populations by tailoring
services--having bilingual-bicultural service providers,
a culturally familiar environment, notices and announce-
ments written in the ethnic language of the clients, and
so on. Would having ethnic-specific services encourage
segregation in that various ethnic groups would have ser-
vices catering to their own group needs? Kramer (1984)
opposed ethnic-specific services precisely because of his
belief that segregation would be perpetuated. Would this
relieve the responsibility for mainstream services (i.e.,
those not specifically designed for an ethnic minority
group) to provide for ethnic minority groups? In principle,
I agreed with the need for integrated services. However,
at the time, integration of services did not seem likely in
the near future because of ethnic patterns of residential
segregation. Furthermore, the tailoring of services to par-
ticular ethnic groups appeared to be wise because these
groups have been underserved or inappropriately served
in the mental health system (President's Commission on
Mental Health, 1978; Rogler, Malgady, & Rodriguez,
1989). This tailoring was not intended to relieve main-
stream services from providing services to ethnic clients;
rather, it was meant to complement existing services.
Third, ethnic matching of therapists and clients has
also raised the issue of segregation. As mentioned earlier,
my research (S. Sue et al., 1991) examined the effects
of ethnic similarity-dissimilarity between clients and
therapists in psychotherapy. The research findings indi-
cated that African American, American Indian, Asian
American, Mexican American, and White clients had
lower premature termination rates, a greater number of
sessions, or better treatment outcomes when matched
with ethnically similar therapists. I suggested that ethnic
similarity is beneficial for many clients and that the re-
cruitment and training of therapists to serve their own
ethnic populations should be encouraged. This suggestion
proved to be a source of controversy. During a talk I
gave at the 1994 Congress meeting of the International
Association of Applied Psychology in Spain (S. Sue,
1994), a member of the audience informed me that some
individuals in South Africa were using my research to
justify segregation, that is, having Whites taking care of
Whites and Blacks taking care of Blacks.
Although researchers often bemoan the fact that
their research is not used for applied purposes or policies,
my colleagues and I had the very opposite reaction. The
April 1998 • American Psychologist 443
research was used. Advocates of certain policy agendas
used our research findings in ways that we never antici-
pated. The research findings were not intended to be used
to argue that clients should be ethnically matched. Rather,
we wanted to find out if ethnic matching was associated
with positive outcomes. We would then be in a position to
examine what about match could account for the findings.
Furthermore, individual differences in the effects of
match appear to be very important, so that match is nei-
ther a necessary nor a sufficient condition for positive
treatment outcomes. In other words, match may be im-
portant for some, but not all, clients. Ethnic diversity
among service providers was essential because it allowed
clients from minority groups the choice to find providers
of the same ethnicity.
Fourth, another example of how ethnic mental health
research has been used for purposes unanticipated by my
colleagues and me occurred from some earlier work (S.
Sue, 1977) that we conducted from data supplied by the
state of Washington. In that National Institute of Mental
Health (NIMH)-funded research project, we wanted to
how ethnic minority clients were faring in the mental
health system. We found that more than 50% of the ethnic
minority clients (African Americans, American Indians,
Asian Americans, and Mexican Americans) at the 17
community mental health facilities in Seattle-King
County terminated treatment after one session, compared
with the 30% dropout rate for Whites. We concluded that
ethnic clients were not being well served by the system.
Unknown to us, when NIMH became aware of our find-
ings, it contacted the Washington State Department of
Social and Health Services (DSHS) to express its deep
concern over the plight of ethnic minority mental health
clients. NIMH essentially used our findings to point out
that the state was not in compliance with standards to
provide quality services to all groups. Fearing that the
state might suffer adverse public reaction because of the
study's results and that future funding from NIMH might
be jeopardized, DSHS then challenged the validity of our
findings. It claimed that 1 of the 17 mental health centers,
which contained a high proportion of ethnic clients,
might not have provided valid data.
We decided to reanalyze the data, excluding the one
mental health center in question. The findings remained
the same. Yet, we were not happy over the situation for
several reasons. First, we felt torn between the need to
understand the nature of the problems in our mental health
system (which would enable us to find means for resolving
these problems) and the need to commend the state for its
openness and support for the research. Second, we and
the state did not know that the research would be used
for compliance purposes; I was worried that in the future
local and state governmental agencies might be reluctant
to provide data to researchers for fear that the findings
might have negative consequences for the agencies. Third,
although I was pleased with the fact that NIMH demon-
strated a determination to see that all clients are able to
receive effective treatment, I was also concerned that the
state of Washington was being singled out for criticism
when other states were experiencing similar difficulties in
the provision of services to ethnic clients. Because of the
controversy, I was asked by the Washington State Psycho-
logical Association to testify at a Senate subcommittee
hearing concerning the entire matter. Fortunately, some
positive outcomes emerged after my testimony. Officials
from the state indicated their genuine concern over the
delivery of services to all clients and their willingness to
collaborate on research in the future. In addition, over the
years, the state made some innovative changes in the men-
tal health system to offer culturally responsive services.
In a 10-year follow-up investigation of the Seattle project,
O'Sullivan, Peterson, Cox, and Kirkeby (1989) found that
the high dropout rates for ethnic minority clients had been
reduced and that the mental health system had hired more
ethnic minority service providers, created more ethnic-
specific services, and established other programs to
Fifth, S. Sue et al.'s (1991) study demonstrated that
dropout rates are reduced and the number of treatment
sessions is increased when clients see ethnically similar
therapists. However, given managed care guidelines, in
which short-term treatment is preferred, what will these
findings mean? That is, because ethnic similarity between
clients and therapists is associated with longer treatment,
under managed care ethnic similarity may pose problems,
for example, the greater the number of sessions, the cost-
lier the treatment. Therefore, the association between eth-
nic match and increased number of treatment sessions
can be used to argue against matching because match
appears to increase the cost of treatment. This is a particu-
lar problem because superior outcomes for ethnically
matched dyads could not be unequivocally demonstrated
from the match studies.
Lessons Learned From the Research
What lessons have been learned? The dilemmas that have
accompanied the work illustrate the possibility that in
conducting ethnic research, investigators are likely to en-
counter the issues and conflicts that have bedeviled U.S.
society with respect to ethnic and race relations. That is,
race relations have always generated considerable emo-
tional reactions. Research into these issues will also en-
gender many emotional responses. The emotional inten-
sity in debates over ethnic research findings is typically
much greater than that found in debates over, for example,
depression research. This intensity is understandable.
Many of the findings from ethnic research have implica-
tions for policies and practices and can support or chal-
lenge cherished personal values and beliefs. In this sense,
ethnic minority research can be distinguished from cross-
cultural research. In comparative cross-cultural research,
evaluations and contrasts are made of people in different
cultures (e.g., Chinese in China and Mexicans in Mex-
ico). In comparative ethnic minority research, the evalua-
tions and contrasts typically involve not only people with
different cultural backgrounds but also those who have
had years of interactions (e.g., African Americans and
White Americans). Therefore, unlike cross-cultural re-
444 April 1998 • American Psychologist
search, ethnic minority research must take into account
the history of race-ethnic relations, prejudice, stereotyp-
ing, and discrimination, in addition to cultural differences
(Jones, 1997; Watts, 1994). It is this history that makes
ethnic minority research a volatile area of investigation.
Partly as a consequence of the potentially controver-
sial nature of ethnic research or the practical, method-
ological, and conceptual problems in such research, in-
vestigators may be reluctant to study ethnicity. This is
unfortunate because ethnic research is beneficial not only
for ethnic individuals but also for all Americans and for
science. As a case in point, having served on the APA
Division 12 Task Force on Psychological Interventions,
I sincerely appreciated the efforts to determine which
treatments have empirical validation. However, as men-
tioned earlier, no rigorous studies have ever been con-
ducted on the efficacy of treatment for members of ethnic
minority groups. Why is there a paucity of research on
the effectiveness of treatment with different client popula-
tions? How can treatments be designated as validated
(i.e., where validity is attributed to the treatments) when
cross-cultural-ethnic minority validity has never been
established? In other words, it is precisely through the
study of different populations that the validity and appli-
cability of theories and practices can be ascertained.
Finally, in acknowledging the difficulties and dilem-
mas that are faced in ethnic research, psychology should
be prepared to deal with the issues. The complexity of
issues must be recognized, especially when research on
ethnicity often has policy, practice, and value implica-
tions. Many actions that are based on research have in-
tended or unintended side effects, so that practices may
be beneficial at one level but harmful at another level.
For example, ethnic match of therapists and clients can be
viewed as either positive (i.e., reducing treatment dropout
rates and increasing the number of treatment sessions) or
negative (i.e., driving up the cost of treatment because
of the increased number of sessions). Psychologists must
begin to anticipate the consequences of research and
practices because it may not be possible to avoid the side
effects of programs and policies that are undertaken. In
this way, conscious and deliberate decision making can
be made that considers costs, benefits, principles, reali-
ties, values, and ultimate goals in a multiethnic society.
It is through this process of deliberation that a more
coherent approach to diversity can emerge.
Researchers have made progress on determining the
nature of cultural competency. Empirical research does
support some of the arguments that ethnic researchers
and practitioners have advanced over the years. However,
findings have frequently raised controversies, and re-
searchers must be aware of the implications of their work,
including misuse of the findings. Many of the controver-
sies reveal society's discomfort regarding issues of race
Cultural Competency Ingredients
Research has provided some insights into the structural
ingredients (ethnic, service, and cognitive match) that are
associated with treatment outcomes. I now return to the
basic issue of what cultural competence is. The simple
definition is that cultural competence involves effective-
ness in psychotherapy. However, what therapist character-
istics or skills are important? Research has not provided
much knowledge into this question or many other ques-
tions. If a person is culturally effective with one group,
is that person a culturally competent therapist? Or does
culturally competent mean that one is effective with more
than one culturally distinct group? If one of the character-
istics of cultural competency is knowing the cultures of
groups, and if it is impossible to really know the cultures
of all groups in society, can one ever be truly culturally
Perhaps the reason for the existence of these ques-
tions is that investigators have not in a clear fashion
conceptually distinguished between general skills that
promote cultural competency and specific skills that en-
hance effectiveness in a particular culture. For example,
just as a psychotherapist may be limited in effectively
applying Western-based treatments to individuals from
non-Western societies, a folk healer who is effective in his
or her culture may be ineffective with people in Western
cultures. There appear to be skills that enhance work
across different cultural groups and skills that may be
specific to particular groups. This is why researchers have
had a very difficult time devising measures of cultural
competency--because culture-specific skills rather than
more general skills may be assessed, or visa versa. Gen-
eral and specific skills need to be considered.
I would like to advance several propositions in try-
ing to uncover the essence of cultural competency. First,
three characteristics are critical in cultural competency:
(a) being scientifically minded, (b) having skills in dy-
namic sizing, and (c) being proficient with a particular
cultural group. Second, these characteristics are orthogo-
nal in that it is possible to be proficient in none, one,
two, or all of them. Third, there are degrees of cultural
competency, and to adequately measure it, all three char-
acteristics must be considered.
There probably are some skills that are beneficial to have
in cultural competency--characteristics or skills that cut
across cultures. Although examples can be found where
some time-honored skills, such an being an empathic
therapist or a good listener, may not be culturally appro-
priate, on the whole, there are some characteristics that
are important to possess.
I believe one of these characteristics is scientific
mindedness. By scientific mindedness, I am referring to
therapists who form hypotheses rather than make prema-
ture conclusions about the status of culturally different
clients, who develop creative ways to test hypotheses,
and who act on the basis of acquired data. In cross-
cultural relationships, many mistakes happen because as-
sumptions are made or theories are applied that are devel-
oped in one culture and applied to clients from different
cultures. The assumptions are based on erroneous beliefs
April 1998 • American Psychologist 445
that clients' processes or dynamics are the same across
different cultures, a phenomenon labeled the "myth of
sameness" (Wilson, Phillip, Kohn, & Currey-E1, 1995).
By forming hypotheses rather than using the sameness
myth, therapists can then test their clinical inferences.
For example, a client who reports seeing spirits may be
experiencing a common cultural hallucination rather than
a psychotic episode. A good clinician who is uncertain
of the cultural meaning of the symptom should engage
in hypothesis testing: For example, if the symptom is a
reflection of a psychotic episode rather than a culturally
influenced characteristic, one would expect (a) the client
to manifest other psychotic symptoms, (b) other individu-
als in the culture to be unfamiliar with the symptom, or
(c) experts in the culture to indicate that the symptom is
unusual in that culture. Ridley (1995) noted that African
American clients exhibiting paranoia in the presence of
a therapist may be doing so because of a healthy or
unhealthy condition. Because of experiences with racism,
those who show discomfort and lack of self-disclosure
with a White therapist may have a nonpathological reac-
tion (cultural paranoia). In this case,Ridley hypothesized
that the reaction is confined to a White therapist and not
an African American therapist. A pathological condition
is functional paranoia, in which self-disclosure is not
made to any therapist regardless of race. The point is that
culturally competent therapists will try to devise means
of testing hypotheses about their clients. This scientific
mindedness may also help to free therapists from ethno-
centric biases or theories.
The second characteristic is dynamic sizing--a phrase
used in computer circles to indicate a fluctuating cache
size. I use it to mean that the therapist has appropriate
skills in knowing when to generalize and be inclusive
and when to individualize and be exclusive. That is, the
therapist can flexibly generalize in a valid manner. One
of the major difficulties in interpersonal and interracial
or interethnic relationships is the stereotyping of mem-
bers of a group (Jones, 1997). Although therapists may
avoid the overt expression of stereotypes (e.g., beliefs
that African Americans are lazy, Chinese are shy, Mexi-
can Americans are family-oriented), stereotypes may,
nevertheless, exist in their belief systems and affect their
behaviors. In such stereotypes, the individual's character-
istics are confounded with the characteristics attributed
to the group. In contrast, the opposite mistake can be
made, such as ignoring cultural group characteristics that
may be affecting that individual. Prejudices, stereotypes,
and failures to consider culture among therapists or ser-
vice providers are frequently no different from those
found among the general population.
Appropriate dynamic sizing is a critical part of cul-
tural competency. It allows one to avoid stereotypes of
members of a group while still appreciating the impor-
tance of culture. The concept is similar to the notion of
"flex" proposed by Ramirez (1991). In flex, individuals
can learn how to switch cognitive styles (e.g., field depen-
dence and independence) to more accurately deal with
the environment. In dynamic sizing, the therapist is able
to place the client in a proper context--whether that
client has characteristics typical of, or idiosyncratic to,
the client's cultural group. Moreover, there is another
important component of dynamic sizing that involves the
ability to appropriately generalize one' s own experiences.
For example, a person who has experienced discrimina-
tion and prejudice as a member of one group may be
able to understand the plight of those in another group
who encounter the same experiences. An African Ameri-
can who has faced oppression may be able to more easily
understand the feelings of women who are oppressed. All
people have felt like outsiders at one time or another. If
this experience can be used to understand the feelings of
many minority group persons, then therapists can become
more empathetic and understanding and better clinicians.
They are able to see and understand common experiences.
However, the mere fact that therapists have experiences
as, for example, an outsider, does not guarantee the ability
to empathize. The ability to dynamically size--to appro-
priately categorize experiences--is important.
The third characteristic is culture-specific expertise. Dif-
ferent cultures may have culture-specific experts--sha-
mans, witch doctors, fortune-tellers, acupuncturists, folk
healers, and so forth. These experts presumably are effec-
tive in their own cultures because they know the cultures
and have the skills to translate this knowledge into effec-
tive interventions. Culturally skilled helping profession-
als have good knowledge and understanding of their own
worldviews, have specific knowledge of the cultural
groups with which they work, understand sociopolitical
influences, and possess specific skills (intervention tech-
niques and strategies) needed in working with culturally
different groups. These helping professionals also are
able to use culturally based interventions and have the
ability to translate interventions into culturally consistent
strategies. These characteristics have been extensively
discussed in the literature as being important in effective
psychotherapy and counseling with members of minority
groups (see Chin, De La Cancela, & Jenkins, 1993;
Helms & Richardson, 1997; Lee, 1996; Paniagua, 1994;
Parham, 1996; Root, 1985; D. Sue et al., 1996).
The three characteristics--scientific mindedness,
dynamic sizing, and culture-specific expertise--are or-
thogonal. That is, the three are independent. It is possible
to be scientific minded and yet naive about the cultural
background of the client (i.e., have good general skills
but no knowledge of the culture of a particular client);
to be able to appropriately generalize and individualize
and yet fail to engage in hypothesis testing; and to under-
stand and work effectively in a particular culture and yet
use stereotypes of individuals in another culture.
Although it would be desirable to have the three
characteristics, most therapists vary in the degree to
which each characteristic is possessed. Scientific mind-
edness and dynamic sizing provide clinicians with gen-
446 April 1998 • American Psychologist
eral tools that can be carried from one cultural client or
situation to another. They provide a modus operandi. For
example, using the skills associated with scientific mind-
edness, a clinician seeing a client from Culture X might
reflect as follows:
I am unfamiliar with Culture X. Therefore, in working with the
client, I first have to address a number of basic questions.
For example, how proficient is the client with English? How
acculturated is the client, and how familiar is the client with
psychotherapy? Will there be communication difficulties? How
will I assess the client? What does the client think of me and
of treatment? I next have to form hypotheses, test the hypothe-
ses, and then modify my behaviors in accordance with the
In dynamic sizing, the therapist treating the client
from Culture X might consider the following questions:
What are my stereotypes or impressions of the client and
the client's culture? How typical is the client of the cul-
ture? What might the client be thinking or feeling as
a member of that culture? As in the case of scientific
mindedness, dynamic sizing is a general tool that can be
applied from client to client. The tools force therapists
to systematically consider issues that therapists typically
ignore or erroneously assume to know the answers. They
can be used with all clients but are especially helpful
with those who come from cultures different than that of
When researchers try to measure cultural compe-
tence, they should not be confined just to the knowledge
that they have about a particular culture. Rather, research-
ers also have to assess general skills such as scientific
mindedness and dynamic-sizing abilities. I believe that
they are among the most important characteristics that
define cultural competency.
In summary, I have tried to reflect on experiences
that my colleagues and I have had in the search for cul-
tural competency. Our empirical research has largely sup-
ported the importance of phenomena that other research-
ers and professionals have proposed as being critical in
cultural competence, namely, ethnic match, service
match, and cognitive match. In following this line of
research, I have encountered many policy and political
issues that have made me aware of the need to constantly
indicate the meaning and limitations of my findings. In
the course of my research, I have come to the opinion
that three independent characteristics involving scientific
mindedness, dynamic sizing, and culture-specific exper-
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