World Journal «Psychotherapy» 2015, №1 (8)
Development of Psychotherapy
World Journal «Psychotherapy» 2015, №1 (8), pp. 33—39
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The role of clinical supervision in moving cultural awareness
to cultural competence through case conceptualization
Cheryl B. Warner
Ph.D. Director, Mental Health Counseling, Associate Professor of Psychology, Division of Science
Indiana University-Purdue University Columbus, Columbus, IN USA. E-mail: [email protected]
Abstract. Cultural competence extends beyond awareness and sensitivity to include implementation of
culturally-appropriate treatment strategies. Studies exploring self-reported multicultural competence
with applied skills revealed a small portion of mental health professionals and trainees actually integrated
cultural factors into their assessment, case conceptualization, and treatment strategies (Hansen et al.,
2007; Ladany, Inman, Constantine, & Holheinz, 1997; Sehgal et al., 2011; Schomburg & Prieto, 2011).
Case conceptualization is the precursor to implementing treatment strategies and when accurately applied,
integrates culture throughout the therapeutic process. Professional training must directly target case
conceptualization skills to improve psychotherapists’ cultural competence. Clinical supervision, with the
explicit goals of exploring culture, plays a critical role in developing case conceptualization skills. The
supervision environment offers supervisees space to explore culture and conceptualize a therapeutic path
culturally congruent with clients’ lives. The author offers best practice strategies in the areas of a) supervisor
characteristics, b) supervision skills, and c) supervisory relationship to ensure clinical supervision is
facilitating case conceptualization skills and, ultimately, cultural competence.
Keywords: clinical supervision, cultural competence, case conceptualization, best practices, supervision
skills, multicultural competence.
Cultural competent psychotherapy is a clientcentered process that facilitates and contributes to case
conceptualization. Brown (2009) wrote, “Cultural competent
psychotherapy practice thus begins with the client at the
center of conceptualization, not with the diagnosis, not with
a treatment manual, not with the therapist’s idea of what to
do next” (p. 349). However, studies exploring self-reported
multicultural competencies by mental health professionals
and trainees revealed a small portion of participants actually
integrated cultural factors into their clinical practice,
specifically into assessment, case conceptualization, and
treatment strategies (Hansen et al., 2006; Ladany et al., 1997;
Sehgal et al., 2011; Schomburg & Prieto, 2011). Another
study found that clinicians, independent of their professional
status, tended to identify cultural themes if and only if clients
made explicit statements or references to the cultural themes
(Lee, Sheridan, Rosen, & Jones, 2013). These findings imply
a disconnection between perceived cultural competence and
actual clinical practice.
Sperry (2012) defined cultural competence as a
multidimensional construct that possesses moderate to high
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levels of competence in four areas: cultural knowledge,
cultural awareness, cultural sensitivity, and skillful actions.
This theory provides an explanation for the presence of high
self-reported multicultural competence with lower rates of
applied skills and strategies that address cultural factors in
simulated cases (Hansen et al., 2006; Ladany et al., 1997;
Sehgal et al., 2011; Schomburg & Prieto, 2011). Low level
of competence may exist in the area of skillful actions;
whereas, higher levels of competence are present in cultural
awareness and cultural sensitivity. This imbalance between
perceptions and actions may occur because of (a) the focus on
multiculturalism and diversity issues in research and clinical
practice (Sue & Sue, 2008), (b) the psychometrics of the selfreported assessments of multicultural competence, and (c)
other characteristics, such as cultural factors (e.g., a member
of an ethnic minority group, cultural awareness, cultural
affect), educational level (master’s versus doctoral), and job
position (administrator versus clinician) (Gloria, Hird, &
Tao, 2008; Holcomb-McCoy & Myers, 1999; Schomburg &
Prieto, 2011; Spanierman, Poteat, Wang, & Oh, 2008; Sue &
Sue, 2008).
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Development of Psychotherapy
Whaley (2008) conducted a multivariate analysis to
understand the association between cultural sensitivity and
cultural competence and discovered cultural sensitivity
provides the foundation for cultural competence. In other
words, cultural sensitivity alone is not enough, but is
necessary, for cultural competence to develop. Studies
(Lee, Sheridan, Rosen, & Jones, 2013; Sehgal et al., 2011;
Schomburg & Prieto, 2011) utilizing different methodologies
illustrate Whaley’s assertion that cultural sensitivity is
the foundation for cultural competent behaviors but not
sufficient for cultural competence. The implications directly
impact training. Whaley’s (2008) recommended a two-step
process for training: The first step builds or increases cultural
sensitivity and the second step advances cultural competence.
This recommendation resembles what occurs in training
programs. However, most training programs emphasize
cultural awareness and knowledge, placing less focus on
culturally applied skills (Sehgal et al., 2011; Sperry, 2012).
Additionally, multicultural courses provide marginal to
adequate covered of content that professionals, in retrospect,
believe were critical to their clinical practice (Hastings, &
Cohen, 2013; Holcomb-McCoy & Myers, 1999).
As an instructor of a multicultural course, this is troubling
news. It is imperative we begin to understand the gap
between self-perceptions and cultural competence and the
developmental trajectory of cultural competence. Returning
to Whaley’s (2008) recommendation, redistributing training
efforts to culturally applied skills and strategies can reduce the
gap between self-reported cultural competence and the actual
demonstration of cultural competence in clinical practice. The
thesis of this paper emphasizes that clinical supervision is a
critical training modality in developing cultural competence,
especially when utilizing case conceptualization skills.
Clinical Supervision
If formal learning or training enhances cultural knowledge,
cultural awareness and cultural sensitivity, then clinical
supervision can merge these elements into developing
case conceptualization skills and further enhance cultural
competence (Bernard & Goodyear, 2013). Clinical supervision
provides an ideal learning environment for merging theory and
practice, allowing for strategic assessment and customization
of supervisees’ training needs. The supervisory relationship
fosters an environment that allows supervisees to shift from
talking about how they may work with clients to actually
demonstrating their work. As a learning environment,
supervision encourages greater transparency into supervisees’
internal processes about how they perceive themselves, their
clients, and their work as psychotherapists. It facilitates
supervisee’s growth in their confidence and feelings of
autonomy as emerging professionals.
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The formation of the supervisory relationship is based
on the parties agreeing to the boundaries and expectations
of the relationship and negotiating their shared goals
(Rosenbaum & Ronen, 1998). This leads to establishing
a working alliance similar to the therapeutic relationship.
Developing cultural competence through supervision must
be explicitly identified as a goal and consistently addressed
throughout the process (Inman, 2006). Hence, it is important
for supervisors to acknowledge the relevancy of culture in
practice and establish the foundation for creating an open and
receptive environment for exploring cultural information and
dynamics. The responsibility of creating an environment for
the development of cultural competence lies with supervisors
not with supervisees (Fukuyama, 1994; Fong & Lease, 1997,
cited in Inman, 2006). This is critical due to the inherent
imbalance of relational power existing in supervisory
relationships, which also parallels the power dynamics
between therapist and client. In both cases, individuals with
less power (clients and supervisees) may defer to unspoken
rules (intentional or unintentional) of what is acceptable
content for the relationship. The intentional behavior of
broaching cultural content offsets the silence or waiting for
client or supervisee to initiate dialogue by having the therapist
or, in the case of supervision, supervisor acknowledge and
invite open dialogues on culture (Day-Vine, et al., 2007).
Day-Vine et al. (2007) described five broaching styles
employed by therapists while addressing culture with clients:
(a) avoidant, (b) isolating, (c) continuing/incongruent, (d)
integrated/congruent, and (e) infusing. These styles are also
applicable to supervision. A word of caution: Broaching is
necessary but not sufficient to develop or demonstrate cultural
competence. For instance, two broaching styles, isolating and
continuing/incongruent, involve talking about culture but fail
to demonstrate how culture influences human development
or can be integrated into conceptualization or treatment.
Supervisors’ styles that reflect the integrated/congruent
and infusing styles, contrary to the isolating or continuing/
incongruent styles, exhibit a more advanced understanding of
culture, its meaning in the client’s life, and its application to
therapeutic practice.
Lastly, supervision occurs in dyads, triads, or small
groups, warranting a different relational structure and level
of intimacy in supervisor-supervisee interactions than what
is usually experienced in the traditional classroom. Thus, the
supervisory relationship encourages exploration of content
that may trigger feelings of vulnerability, often associated with
genuine dialogues exploring cultural dynamics or cultural
development (Cashwell, Looby, & Housley, 1997). Studies
have linked cultural variables with multicultural competence,
noting psychotherapists at higher levels of cultural identity
are more culturally sensitive, open to interacting with diverse
groups of individuals, engage in broaching behaviors, and
World Journal «Psychotherapy» 2015, №1 (8)
World Journal «Psychotherapy» 2015, №1 (8)
promote multiculturalism and social justice (Day-Vine et al.,
2007; Neville, Spanierman, & Doan, 2006). Thus, supervisors
who have higher levels of cultural identity will broach culture,
be more open in their discussions, and will explicitly engage
supervisees in the development of cultural competence.
Furthermore, cultural identity impacts the relational dynamics
of the supervisory relationship (Constantine, Warren, &
Miville, 2005; Inman & Kreider, 2013). A supervisory
relationship that facilitates cultural competence occurs when
the supervisor’s cultural identity is at a higher level of the
supervisee (progressive) or the cultural identity levels of
both individuals are high (parallel-advanced). Conversely,
relationships where the supervisor’s cultural identity is lower
than the supervisee (parallel-delayed) or both individuals
possess low cultural identity levels (regressive) are less likely
to facilitate cultural competence. Interestingly, supervisees
rated their supervision as more positive and with greater
satisfaction when they perceived their supervisors as open to
discussions about culture (Inman, 2006).
Although research shows strong support for a positive
relationship between supervisor’s level of cultural competence
and supervisee’s satisfaction with supervision, Inman (2006)
discovered a negative correlation between supervisor’s
cultural competence and supervisee’s development of
cultural competence on etiology conceptualization skills.
Inman hypothesized time affected the findings, noting
participants’ average time in supervision was approximately
10.66 weeks, ranging from one to 60 weeks. The findings
implied shorter time in supervision might require different
supervision strategies than the strategies useful for facilitating
advanced clinical skills, such as integration of cultural factors
into case conceptualization. This is consistent with the
recommendations of developmental model of supervision
that varies supervision strategies with the developmental
levels and needs of supervisees (Bernard & Goodyear, 2013).
Case Conceptualization
The prominent skills of clinical practice involve
assessment, diagnosis, and treatment. These skills link to case
conceptualization (Sue & Sue, 2008). Case conceptualization
involves gathering and making meaning of client information
to (a) identify client’s presenting issues, (b) understand client’s
dynamics and worldview, (c) determine treatment strategies,
and (d) assess the progress of treatment. Sue and Sue (2008)
wrote, “[c]onceptualization is an ongoing process that begins
with the initial intake interview, assessment, and continues
throughout the course of therapy” (p. 77). Furthermore,
conceptualization allows psychotherapists to work with more
forethought and intentionality (Halibur & Halibur, 2011).
Case conceptualization is both informational and explanatory.
Sperry (2005) identified three types of conceptualization: (a)
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Development of Psychotherapy
symptom-focused (highlights symptomatoloy, impairment,
treatment goals and outcomes); (b) theory-focused (identifies
symptoms and impairment and provides theoretical
explanation of “why’;” primarily therapist-centered); and
(c) client-focused (based on phenemological approach; aim to
“fit” client needs and dynamics with treatment). In practice,
case conceptualization tends to be more about theoretical
orientation and diagnoses and less about explanations
and treatment decisions (Groenier, Pieters, Witteman, &
Lehmann, 2014; Sperry, 2005). Sue and Sue (2008) believe
conceptualization can overlook clients’ perspectives on their
presenting problems and be influenced by psychotherapists’
“values, worldview, and beliefs on their practice.” (p. 81).
Thus, they recommend a collaborative conceptualization
approach that involves including clients’ input in determining
the problem definition and formulation of clinical hypotheses.
Theorists believe conceptualization is an advanced
cognitive and clinical skill (Bernard & Goodyear, 2013) that is
challenging for many students and novice psychotherapists to
learn (Falvey, Bray, & Hebert, 2005). It builds on a hierarchy
of cognitive processes that moves from “simplistic, concrete,
and dichotomous thinking to complex, abstract, and relativistic
thinking processes” (Ellis, Hutman, & Deihl, 2013, p. 247).
The inclusion of cultural factors and dynamics adds another
level of complexity to conceptualization skills. However,
there is caution in believing conceptualization is an objective
clinical skill (Sue & Sue, 2008). Researchers (Falvey et al.,
2005; Mayfield, Kardash, & Kivlighan, 1999) discovered
novice and experienced professionals use different cognitive
processes to derive their conceptualization. Clinicians’ ideas
about wellness and psychopathology, lifestyles and cultural
factors affect what they deem as relevant clinical information
and the interpretation and application of the information to
clients’ lives (Sue & Sue, 2008). Conceptualizing clinical
cases integrated with cultural factors is a challenge for
students and psychotherapists who (a) are uncomfortable
broaching culture with clients, (b) are working from a
culturally universal perspective (or color-blind ideology),
or (c) have limited experience or working knowledge of
integrating cultural information into their conceptualization
skills (Day-Vine et al., 2007; Spanierman et al., 2008). Case
conceptualization has a tremendous impact in our clinical
work since it reflects what and how we think about our clients
and affects our diagnostic and treatment decisions.
The Role of Clinical Supervision
in Developing Cultural Competence
Psychotherapists who are culturally competent are
“culturally self-aware, aware of the client’s culture, and
willing to bring culture into the discussion during interactions
with clients (Sue, Arredondo, & McDavis, 1994).” (Ahmed,
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Development of Psychotherapy
Wilson, Henriksen, & Jones, 2011, p. 22). They are able
to integrate various dimensions of culture (e.g., personal,
institutional, societal) with clients’ uniqueness to understand
clients’ experiences and problems. Culturally competent
psychotherapists also adapt strategies and interventions that
are culturally relevant and beneficial to clients (refer to Hays,
2009; Nápoles-Springer, Santoyo, Houston, Pérez-Stable, &
Stewart, 2005; Whaley & Davis, 2007 for examples). As
previously stated, case conceptualization is an advanced skill.
The integration of cultural factors into case conceptualization
adds another level of complexity and is essential for cultural
competence. The achievement of this complex skill occurs
through a steep learning curve for novice therapists or those
with low or minimum levels of cultural awareness, cultural
sensitivity, or cultural knowledge. Furthermore, cultural
awareness and cultural knowledge as specific training goals
are not enough (Sehgal et al., 2011; Weatherford & Spokane,
2013) to ensure culturally competent behaviors.
There are several models that provide a framework to
implement supervision strategies to assist supervisees’
development of cultural competence (refer to Inman &
Kreider, 2013; Ober, Granello, & Henfield, 2009; Stoltenberg,
2005; Stoltenberg & McNeill, 2010) or conceptualization
skills (see Bob, 1999; Ellis et al., 2013; Sarnat, 2010). Many
of the early models identify cultural awareness and cultural
knowledge as supervision goals but few provide guidance for
helping supervisees move from cultural awareness to skillful
actions. For these reasons, utilizing a developmental model
of supervision can assist supervisors to (a) assess supervisees’
personal characteristics and knowledge and skills levels, (b)
link their levels to cultural knowledge, and (c) determine
supervisory strategies for integrating cultural understanding
in building conceptualization skills.
Recommended Strategies
for Developing Cultural Competence
through Case Conceptualization
The development of cultural competence through case
conceptualization skills must be nurtured and practiced
through a different learning process than provided in
traditional classroom environments. Clinical supervision
occurs in dyads, triads, and small groups, face-to-face or
electronically through the variety of available communication
technologies. In any format, research has documented
strategies that provide supervisors with a blueprint of best
practices. This paper separates the strategies into three areas
that collectively contribute to the effectiveness of supervision
in developing cultural competence. The areas are: (a)
supervisor characteristics, (b) supervision skills, and (c)
supervisory relationship.
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Supervisor Characteristics
1. Exhibit self-awareness about your cultural heritage
and understand the meaning of culture in your personal and
professional development.
2. Display transparency of your cultural development with
supervisees by discussing your own cultural development.
3. Possess knowledge of cultural identity development
models and the intersectionality of multiple identities on
human development.
4. Possess knowledge of sociopolitical influences
on culture, such as the presence of “isms”, power and
privilege, oppression, marginalization and discrimination and
understand their implications on organizations, institutions,
and individuals (Warner, Phelps, Pittman, & Moore, 2013).
5. Realize you are modeling openness, willingness to be
“imperfect”, and continual learning about self and others.
Supervision Skills
1. Assess supervisee characteristics, such as selfawareness, openness, cognitive process, cultural empathy,
broaching styles, and clinical skills (Day-Vines et al., 2009;
Ellis et al., 2013; Glosoff & Durham, 2010; Weatherford &
Spokane, 2013)
2. Utilize concept mapping models to assist supervisees
in developing conceptualization skills (Ellis et al., 2013).
3. Possess knowledge about supervision models (Bernard
& Goodyear, 2013; Ober et al., 2009; Stoltenberg, 2005).
4. Develop a supervision philosophy that explicitly
explains how you integrate culture into supervision style.
5. Incorporate activities to encourage dialogue and
awareness about culture (Berkel, Constantine, & Olson, 2007;
Cashwell et al., 1997; Davis, 2007; Schomburg & Prieto, 2011).
6. Challenge supervisees to explore the sociopolitical
influences on culture, such as the presence of “isms”, power
and privilege, oppression, marginalization and discrimination,
and assist them in applying this knowledge to organizations,
institutions, and individuals (Warner et al., 2013).
7. Utilize supervision interventions and strategies
applicable to supervisees’ developmental levels and
intended goals (Loganbill, Hardy, & Delworth, 1982 cited in
Stoltenberg, 2005).
8. Share your conceptualizations of client presenting
concerns, emphasis cultural information and implications.
9. Encourage supervisees to practice verbalizing and
writing their case conceptualizations.
10.Link learning from didactic classroom training directly
to the practice of psychotherapy (Schomburg & Prieto, 2011).
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Supervisory Relationship
1. Establish working alliance to establish a collaborative
agreement on the structure, expectations (including evaluation
component), and goals of supervision (Inman, 2006; Inman
& Kreider, 2013).
2. Establish norms earlier in the supervisory relationship
for open discussions and exploration of cultural dimensions
and dynamics.
3. Attend to the relational dynamics of the relationship.
4. Explore cultural dynamics occurring in the therapeutic
relationship that mirror the supervision process.
5. Attend to supervisees’ emotional responses to cultural
context and dynamics (Spanierman et al., 2008; Sarnat,
2010).
6. Recognize and understand the types of interpersonal
interactions as a function of culture that can occur in the
therapeutic and supervision relationship (Ancis & Ladany,
2010 cited in Inman & Kreider, 2013).
7. Embrace discourse and conflict and demonstrate how
to navigate them by modeling the process.
8. Understand the cultural and power dynamics within
the supervision relationship and discuss them openly with
supervisees.
Conclusion
Didactic learning activities are effective in developing
cultural awareness, cultural sensitivity, and cultural
knowledge. However, they fall short in developing culturally
skillful actions that are demonstrated in clinical practice. Thus,
research on cultural competence as demonstrated through
case conceptualization unveiled a negative association
between self-perceived cultural competence and the clinical
skills of case conceptualization.
Case conceptualization is an advanced cognitive and
clinical skill that is generated from psychotherapists’ internal
processing of client information (refer to Ellis et al., 2013
for a description of the cognitive process). The inclusion
of cultural information adds another level of complexity
to effectively acquiring case conceptualization skills.
There are many personal and professional characteristics
and variables associated with cultural competence and
conceptualization.
Clinical supervision provides a different learning
environment than didactic learning to assess and integrate these
variables and address case conceptualization skills. It relies on
the working alliance of the supervisory relationship to facilitate
learning with targeted goals of addressing culture in clinical
practice. This paper provided specific recommendations
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Development of Psychotherapy
from the literature to facilitate culturally competent case
conceptualization skills in supervisees’ development
through clinical supervision. The recommendations can help
supervisors become more intentional about their style of
supervision and, conversely, assist supervisees in knowing
the expectations from supervisors who emphasize cultural
competence as supervision goals.
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