Journal of Counseling Psychology
2015, Vol. 62, No. 3, 337–350
© 2015 American Psychological Association
0022-0167/15/$12.00 http://dx.doi.org/10.1037/cou0000086
A Meta-Analysis of Multicultural Competencies and Psychotherapy
Process and Outcome
Karen W. Tao
Jesse Owen
University of Utah
University of Denver
Brian T. Pace and Zac E. Imel
University of Utah
For decades, psychologists have emphasized the provision of multiculturally competent psychotherapy to
reduce racial and ethnic disparities in mental health treatment. However, the relationship between
multicultural competencies (MC) and other measures of clinical process and treatment outcome has
shown heterogeneity in effect sizes. This meta-analysis tested the association of client ratings of therapist
MC with measures of therapeutic processes and outcome, including: (a) working alliance, (b) client
satisfaction, (c) general counseling competence, (d) session impact, and (e) symptom improvement.
Among 18 studies (20 independent samples) included in the analysis, the correlation between therapist
MC and outcome (r ⫽ .29) was much smaller than the association with process measures (r ⫽ .75), but
there were no significant differences in correlations across different types of MC or clinical process
measures. Providing some evidence of publication bias, effect sizes from published studies (r ⫽ .67) were
larger than those from unpublished dissertations (r ⫽ .28). Moderator analyses indicated that client age,
gender, the representation of racial– ethnic minority (R–EM) clients, and clinical setting were not
associated with effect size variability. Based on these findings, we discuss implications and recommendations for future research that might lead to a better understanding of the effects of therapist MC on
treatment process and outcome. Primary needs in future research include the development and evaluation
of observer ratings of therapist MC and the implementation of longitudinal research designs.
Keywords: multicultural competence, psychotherapy, meta-analysis, process and outcome
psychology has emphasized increasing the number of multiculturally competent providers (Korman, 1974; Pederson, Carter, &
Ponterotto, 1996; Whaley & Davis, 2007). Multicultural competence has generally been defined as having both the ability to work
effectively across diverse cultural groups and the specific expertise
to treat clients from certain culturally diverse groups as well as
minority and underrepresented groups (Sue, Arredondo, & McDavis, 1992; Sue, Zane, Nagayama Hall, & Berger, 2009). Since
1973, the American Psychological Association (APA) has maintained that the provision of multiculturally competent mental
health services is an ethical imperative (Korman, 1974; Ridley,
1985). In 2008, the APA Task Force on the Implementation of the
Multicultural Guidelines detailed recommendations for integrating
multicultural competencies (MC) into all psychology-related activities, including education, practice, research, and policy (American Psychological Association, 2008). The expectation is that
efforts to train more multiculturally competent providers will
result in a more effective mental health workforce and ultimately
reduce treatment disparities. However, whether different levels of
therapist MC actually correspond to better psychotherapy outcomes for R–EM clients remains unclear. In the current study, we
provide an empirical analysis of the current literature assessing the
relationship between measures of MC and treatment process and
outcome. We begin with a brief description of the MC construct
and various ways it has been measured, followed by a review of
studies that have tested the relationship between MC and critical
Cultural factors are crucial to diagnosis, treatment, and care. They
shape health-related beliefs, behaviors, and values. But the large
claims about the value of cultural competence for the art of professional care-giving around the world are simply not supported by
robust evaluation research showing that systematic attention to culture
really improves clinical services. (Kleinman & Benson, 2006, p.
1673)
There are clear racial and ethnic disparities in access to and
quality of mental health services (Alegria et al., 2008; Fortuna,
Alegria, & Gao, 2010; Lee, Martins, Keyes & Lee, 2011; Smedley,
Stith, & Nelson, 2002). Similarly, there is evidence that some
therapists achieve poorer outcomes with racial– ethnic minority
(R–EM) clients relative to White clients on their caseload (Hayes,
Owen, & Bieschke, 2014; Imel et al., 2011; Owen, Imel, Adelson,
& Rodolfa, 2012). To address these inequalities and more effectively serve a rapidly diversifying U.S. population, the field of
Karen W. Tao, Department of Educational Psychology, University of
Utah; Jesse Owen, Department of Counseling Psychology, University of
Denver; Brian T. Pace and Zac E. Imel, Department of Educational
Psychology, University of Utah.
Correspondence concerning this article should be addressed to Karen W.
Tao, Department of Educational Psychology, University of Utah, 1721
Campus Centre Drive, Sorenson Art and Education Complex Room 3247,
Salt Lake City, UT 84112. E-mail: [email protected]
337
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TAO, OWEN, PACE, AND IMEL
measures of psychotherapy process and outcome. We also note
potential factors that may influence observed associations, consistency across effects, and reasons for variability.
Defining Therapist Multicultural Competencies
The dominant model of therapist MC is Sue et al.’s (1992)
tripartite model, which outlines a specific set of knowledge, skills,
beliefs, and attitudes intended to describe the culturally competent
provider. These providers are those who continuously work toward
(a) expanding their knowledge of their clients’ cultural background
and worldview; (b) developing and utilizing culturally relevant
interventions and treatment strategies that are appropriate to clients; and (c) gaining awareness of one’s own assumptions, beliefs,
and values and how they can impact interactions with a client or
perceptions of the presenting issue. This understanding of therapist
MC was later expanded to include a provider’s ability to recognize
how the confluence of heritage or personal backgrounds influence
his or her own and clients’ behavior (Sue, 1998; Whaley & Davis,
2007). This definition has led to several distinctions in how therapist MC is operationalized,1 including direct measures that focus
on assessing specific MC models or indirect measures that examine conceptual correlates to therapist MC.
Direct measures include those that focus on therapist skills or
interventions (Sue, 2001; Sue & Sue, 2012), individual counselor
characteristics (Pope-Davis & Ottavi, 1994; Worthington, Mobley,
Franks, & Tan, 2000), or assess in-session processes (López, 1997;
Toporek & Reza, 2001; see discussions in Huey, Tilley, Jones, &
Smith, 2014 and Sue et al., 2009). Commonly used direct self-report
measures of therapist MC include the Multicultural Awareness/
Knowledge/Skills Survey (MAKSS; D’Andrea, Daniels, & Heck,
1991), the Multicultural Counseling Inventory (MCI; Sodowsky,
Taffe, Gutkin, & Wise, 1994), the Multicultural Counseling Knowledge and Awareness Scale (MCKAS; Ponterotto, Gretchen, Utsey,
Rieger, & Austin, 2002), and the Cross-Cultural Counseling Inventory—Revised (CCCI–R; LaFromboise, Coleman, & Hernandez,
1991).
Indirect therapist MC measures assess attributes or indicators
related to MC, including those that are conceptually antithetical
(e.g., microaggressions) or parallel (e.g., feminist orientation, cultural humility). For example, the perpetration of racial microaggressions (whether conscious or not) has been discussed as a
specific manifestation of culturally incompetent behavior. Theoretically, therapists who commit microaggressions more frequently
are less likely than therapists with higher levels of MC to be aware
of biases and stereotypes, as well as less knowledgeable about the
potential harm microaggressions may have on historically marginalized clients (e.g., Constantine, 2007; Owen, Imel, et al., 2011;
Owen, Tao, & Rodolfa, 2010). Indirect measures include microaggression scales—for example, the Racial Microaggressions in
Counseling Scale (RMCS; Constantine, 2007), the revised RMCS
(Owen, Tao, Imel, Wampold, & Rodolfa, 2014), and the Microaggressions Against Women Scale (MAWS; Owen et al., 2010), as
well as measures of therapist cultural humility (Cultural Humility
Scale; Hook, Davis, Owen, Worthington, & Utsey, 2013) and
scales assessing counseling competencies in working with women
(Counseling Women Competencies Scale; Ancis, Szymanski, &
Ladany, 2008; Owen et al., 2010).
Relationship of Therapist MC to Psychotherapy
Process and Outcome
Despite differences in underlying theoretical perspectives, each
of the conceptions of therapist MC broadly hold that there is
variability in how well specific cultural processes are navigated by
therapists. Current research also suggests that higher ratings on
therapist MC are associated with more positive ratings on treatment processes and outcomes. Research focused on the relationship of MC with psychotherapy process and outcome typically
includes a client rating of therapist MC, which is then correlated
with another client-reported outcome (e.g., measures of working
alliance or treatment outcome).2 Findings from MC studies have
generally revealed that higher client ratings of therapists’ MC are
positively related to important therapeutic processes, including
working alliance, client satisfaction, general counseling competence, and session impact. However, it is also possible that associations vary across measures of treatment process and outcome
(e.g., alliance vs. psychological well-being) or different types of
MC measures (direct vs. indirect measures of MC). We provide a
brief review of current findings below.
Therapist MC and working alliance. Working alliance refers to the collaboration between the therapist and the client, as
well as the contribution of both individuals in directing the process
of therapy (Bordin, 1979; Horvath & Greenberg, 1989; Horvath &
Symonds, 1991). Overall, correlations between client-rated alliance and MC have ranged from moderate to large, indicating that
higher ratings of therapist MC are positively related to ratings of
the alliance. For example, a study with African American clients
(n ⫽ 40) treated by White therapists demonstrated a strong positive relationship between client-rated working alliance and therapist MC (r ⫽ .70) and a negative relationship with client-perceived
racial microaggressions (r ⫽ ⫺.40; Constantine, 2007). In another
study, researchers found a similar pattern, wherein clients’ ratings
(n ⫽ 51) of working alliance were strongly correlated with perceived MC (r ⫽ .73; Fuertes et al., 2006). Furthermore, in a study
of university counseling center clients (n ⫽ 232), there was a
negative relationship between working alliance and microaggressions (r ⫽ ⫺.29; Owen et al., 2012).
Much smaller effects were found in two unpublished dissertations. For example, in a study with racial and ethnic minority
clients from a community mental health setting (n ⫽ 15), the
relationship between clients’ ratings of working alliance and perceptions of therapist MC was very small and not statistically
significant (r ⫽ .04; Ward, 2002). Similarly, in a study with 19
therapy dyads (African American clients and White therapists), the
relationship between client-rated provider level of color blindness,
a form of racial microaggression, and working alliance was also
close to zero and not statistically significant (r ⫽ ⫺.01; Morton,
2011).
1
See Ridley and Shaw-Ridley (2011) for conceptual and semantic
distinctions between multicultural competence and multicultural competencies.
2
We were unable to locate studies that utilized observer ratings to test
the relationship between MC and clinical processes or outcomes. Accordingly, in our analysis, references to therapists’ MC and results correlating
therapists’ MC to other clinical processes or treatment outcomes are based
entirely on client ratings.
MULTICULTURAL COMPETENCIES META-ANALYSIS
Therapist MC and client satisfaction. Client satisfaction
pertains to clients’ sense of fulfillment and whether their expectations were met by services received in therapy sessions (Druss,
Rosenheck, & Stolar, 1999). Overall, studies indicate a strong
relationship between client satisfaction and client perceptions of
their therapists’ MC. For example, two studies with racial minority
participants (ns ⫽ 112, 40; Constantine, 2002, 2007) found that
client ratings of their therapists’ MC, using the CCCI–R (LaFromboise et al., 1991) and Client Satisfaction Questionnaire– 8
(CSQ– 8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979), were
positively associated with satisfaction with therapy (rs ⫽ .59, .64).
In a study examining similar processes, Fuertes et al. (2006)
measured 51 clients’ perceptions of their counselors’ MC using the
CCCI–R and found that they were strongly related to client satisfaction scores (r ⫽ .83) on the Counselor Evaluation Inventory
(CEI) satisfaction subscale (Linden, Stone, & Shertzer, 1965). In
another study with racial minority clients (n ⫽ 61; Kim, Ng, &
Ahn, 2009), researchers utilized the CCCI–R and two satisfaction
items: (a) “If a person you knew wanted to see a counselor, how
likely would you be to recommend your counselor?” and (b) “How
likely are you to return for your next session?” Results indicated a
moderate to large positive association between client perceptions
of therapist MC and these satisfaction items (rs ⫽ .61 and .43,
respectively).
Therapist MC and general counseling competence. General
counseling competence (GCC) refers to therapist expertness (e.g.,
skills and knowledge), trustworthiness (e.g., openness, genuineness), and attractiveness (e.g., admiration toward, liking; Atkinson
& Wampold, 1982; Barak & LaCrosse, 1975; Strong, 1968). A
primary question in multicultural counseling research has been to
determine if GCCs are distinct from MC (Coleman, 1998; Drinane,
Owen, Adelson, & Rodolfa, 2014; Sue et al., 2009). In one study,
both MC and GCC measures were administered to R–EM clients
(n ⫽ 112) to determine predictors of satisfaction with therapy.
Results indicated that MC and GCC were highly correlated (r ⫽
.78). This was corroborated in a study with a similar population
(Fuertes & Brobst, 2002), which demonstrated a strong correlation
between clients’ (n ⫽ 85) perceptions of therapist GCCs and MC
(r ⫽ .72). In three studies with Asian American clients (Kim, Li,
& Liang, 2002; Kim et al., 2009; Li & Kim, 2004), the relationship
between GCC and MC was also quite large (ns ⫽ 78, 61, and 52;
rs ⫽ .62, .65, and .68, respectively). However, these large correlations were not verified in another study where the relationship
between clients’ (n ⫽ 51) ratings of their therapists’ MC and GCC
were relatively small and not statistically significant (r ⫽ .23;
Fuertes et al., 2006). Overall, the variability in correlations—from
small to large—across these five studies raises questions as to the
actual association between MC and GCC.
Therapist MC and session impact. Session impact refers to
clients’ evaluations of a psychotherapy session, including immediate effects and post-session mood (Stiles & Snow, 1984), and has
been linked to working alliance and treatment outcomes (Horvath
& Greenberg, 1994; Owen, Hilsenroth, & Rodolfa, 2013; Stiles,
Shapiro, & Firth-Cozens, 1988; Watson, Schein, & McMullen,
2010). A component of session impact is depth, broadly defined as
the extent to which a therapy session was considered powerful or
valuable to the client (Stiles & Snow, 1984). An empirical examination of session depth and its association to perceptions of
therapist MC indicates a moderate to strong correlation. For ex-
339
ample, the relationship between session depth and client-rated MC
with Asian American clients (ns ⫽ 78, 52) resulted in both
moderate (r ⫽ .39; Li & Kim, 2004) and strong relationships (r ⫽
.69; Kim et al., 2002).
Therapist MC and treatment outcomes. Whereas the relationship between therapist MC and clinical processes is important
to clarify, two decades of reviews on MC research (Constantine,
Gloria, & Ladany, 2002; Dunn, Smith, & Montoya, 2006; Ponterotto & Alexander, 1996; Ponterotto, Rieger, Barrett, & Sparks,
1994; Pope-Davis & Dings, 1995; Worthington, Soth-McNett, &
Moreno, 2007) have identified one critical gap—the dearth of
studies that actually assess the impact of therapist MC on client
psychotherapeutic or treatment outcomes. Treatment outcomes
have commonly been assessed via client ratings of psychological
symptoms (e.g., depression and anxiety), well-being (e.g., the
Schwartz Outcome Scale [SOS–10]; Blais et al., 1999), or retrospective reports of clients’ perception of change due to therapy
(e.g., patient estimate of improvement [PEI]; Hatcher & Barends,
1996). Overall, there has been scant evidence that therapists who
are rated as having greater MC demonstrate better treatment outcomes (Sue et al., 2009).
Several studies have begun to address the relationship between
client ratings of their providers’ MC (e.g., CCCI–R; LaFromboise
et al., 1991) and client ratings of treatment outcome (e.g., symptoms or distress; PEI; SOS–10). Effect sizes from these studies
vary widely from small to large. For example, there was a small
but significant correlation between client perceptions of racial
microaggressions in therapy and client-reported symptom reduction (n ⫽ 232; r ⫽ ⫺.18; Owen, Imel, et al., 2011). An unpublished dissertation with minority clients (n ⫽ 80) reported small
and nonsignificant correlations between MC and depression and
anxiety symptoms (rs ⫽ .03 and .12, respectively; Sarmiento,
2012). However, another study indicated a moderate correlation
between perceptions of therapist MC and clients’ reports on psychological outcomes measured by the SOS–10 (n ⫽ 143; r ⫽ .31;
Owen, Leach, Wampold, & Rodolfa, 2011). Finally, in a study
conducted with African American clients (n ⫽ 120), there was a
large positive (r ⫽ .59) relationship between ratings of MC and
psychological symptoms, as well as social and personal improvement (Hook et al., 2013). While the results of this final study
provide promising evidence for the effect of MC on client mental
health improvement, the inconsistency in these studies raises questions about the actual relationship between MC and treatment
outcome.
Summary and Potential Sources of Variability
The above review examines the association between therapist
MC and clinical processes and outcomes over the past two decades. Based on the extant literature, it appears that MC is linked
to variables such as client satisfaction and session impact (e.g.,
depth), although the latter has been less frequently studied. Several
discrepancies do emerge, however. The first involves MC and
working alliance, in which study effects range from small to large.
In an inspection of dissertations, we found some evidence for
smaller effects, which may serve to inflate the observed effects in
the literature. Similarly, some studies indicate strong connections
between GCC and MC such that it appears that measures may be
assessing a similar underlying construct (e.g., overall competence),
340
TAO, OWEN, PACE, AND IMEL
but recent studies have demonstrated smaller associations. The
association between MC and treatment outcome appears to be
generally smaller than associations with process measures and also
appears to be inconsistent across studies.
Different effects within and across types of process and outcome
association (MC and alliance vs. MC and outcome) might suggest
actual variability in these relationships or simply may be a result of
sampling error—for example, we would expect a certain amount of
variability in correlations across studies by chance even if the true
correlation were large and stable. Alternatively, different patterns
of association across measures may provide important information
regarding the nature and impact of MC. Meta-analysis allows a test
of whether variability in effects between studies is larger than we
would expect by chance and also allows for the examination of
moderators that might explain observed variability. For example, if
the correlation of MC with client satisfaction is higher than the
alliance, this may suggest that MC provides more general information about a client’s feelings about counseling rather than more
specific information about a client’s relationship with a therapist.
It may also be that correlations with process and outcome are
stronger in measures explicitly designed to measure therapist MC
(e.g., direct MC measures like the CCCI–R) as compared to
indirect measures that are thought to capture some aspect of MC
from a client rating of therapist behavior (e.g., RMCS).
In addition to the variability in effects due to the type of MC
measure or outcome, there are other study-level variables that may
moderate the relationship between MC and psychotherapeutic processes and outcomes, including demographics (e.g., client R-EM
status, age, and gender) and setting (e.g., university vs. community). As a primary example, it has been claimed that MC is of
most importance when working with racial and ethnic minority
clients as compared to White clients (Sue et al., 1982, 1992; Sue
& Sue, 2012). For example, clients’ R–EM status has been shown
to influence the relationship between their perceptions of their
therapists’ MC and client satisfaction ratings (Constantine, 2002).
This stance is held in contrast to others who argue that MC is
important for all clients and should be considered regardless of
clients’ racial and/or ethnic background. For example, clients are
likely to have intersections of and multiple cultural identities,
which may all be significant to their lives (Collins, Arthur, &
Wong-Wylie, 2010; Owen, Tao, Leach, & Rodolfa, 2011; Pedersen, 2007; Vontress & Jackson, 2004). A relationship between the
representation of R–EM clients (i.e., percentage of R–EM clients)
in a study and the correlation of MC with other outcomes would
provide a test of whether the importance of MC is specific to
R–EM clients. It is possible that for White clients, ratings of MC
are less connected to other process ratings. Therefore, in studies
with a greater percentage of White clients, associations may be
attenuated. Alternatively, if therapist MC is important for all
clients, we do not expect to see differences in the strength of
association with other clinical processes or outcomes.
In terms of other demographic variables, age is associated with
the endorsement of mental health symptoms among racial and
ethnic minorities (Vega & Rumbaut, 1991; Yeh, 2003). Moreover,
a tendency for younger clients to defer to a therapist could potentially impact perceptions of MC (also known as credibility; Sue &
Zane, 1987) and increase associations of MC with other ratings of
the provider (e.g., GCC). Gender differences have also been a
focus of psychotherapy outcome and process research for several
decades (Ogrodniczuk, 2006; Owen, Wong, & Rodolfa, 2009), but
few studies have examined the potential variation in effects of MC
for men and women (see Griner & Smith, 2006). Thus, a closer
examination of the role gender may play in MC is warranted.
In addition to client demographic factors, we also consider
where psychotherapy was being provided. MC training is highly
emphasized within the field of counseling psychology (Bieschke &
Mintz, 2012; Council of Counseling Psychology Training Programs [CCPTP], 2009), and many counseling psychologists have
been frequently employed by university counseling centers
(CCPTP, 2009); Illfelder-Kaye, Lese-Fowler, Bursley, Reyes, &
Bieschke, 2009). However, community mental health centers
(CMHCs) have historically served a more diverse clientele as well
as employed multidisciplinary mental health professionals, which
has led to the development of service and training models that
address therapist MC and provision of multiculturally competent
counseling (Chu et al., 2012; Park-Taylor et al., 2009). As such,
we tested whether clinical setting (e.g., university counseling center vs. CMHC) would moderate the association between MC and
clinical processes and/or treatment outcomes.
Current Study
The purpose of this meta-analysis was to determine the relationship of MC to relevant clinical processes and outcomes in psychotherapy. Although individual MC studies have provided critical
knowledge about this relationship, the current study presents a
comprehensive summary of empirical findings to date. We also
explored the heterogeneity of associations between therapist MC
and clinical process and treatment outcomes, including publication
status, and tested other potential sources of variability through a
series of moderator analyses that include: (a) type of outcome
measure (e.g., alliance vs. satisfaction vs. treatment outcome), (b)
type of MC measure (e.g., CCCI–R or Cultural Humility Scale
[CHS]), (c) demographics (i.e., mean age, gender percentage,
R–EM percentage), and (d) clinical setting. Our first hypothesis
was that higher therapist MC would generally be associated with
measures of positive psychotherapy process. In particular, we
expected (Hypotheses 1a– d) that MC would be strongly positively
associated with (1a) working alliance, (1b) client satisfaction, (1c)
GCC, and (1d) session impact. We predicted a smaller but still
positive association between MC and treatment outcome (Hypothesis 2). We predicted no evidence of different associations across
process outcomes (Hypothesis 3), but did predict that the association of MC with clinical outcome would be significantly smaller
than the association with treatment process (Hypothesis 4). However, based on the extant literature, other moderator analyses for
MC measure type (i.e., direct vs. indirect), as well as demographics, setting, and publication status, were considered exploratory,
and therefore no formal hypotheses were stated.
Method
Literature Search
A doctoral student and the first author conducted an electronic
search of relevant published and unpublished studies in the following databases: Academic Search Premier, CINAHL, Dissertation Abstracts, ERIC, Family and Society Studies Worldwide,
MULTICULTURAL COMPETENCIES META-ANALYSIS
Health Source: Nursing/Academic Edition, MEDLINE, PsycArticles, PsycINFO, PubMed, and Social Services Abstract. The
search terms used were (cultural competenceⴱ or culturally competentⴱ or multicultural competenceⴱ or multiculturally competentⴱ) and (counselorⴱ or counselingⴱ or therapistⴱ or psychotherapistⴱ or psychotherapyⴱ). We also conducted an iterative search in
reference sections of reviews of counselor cultural competence and
primary references of the published and unpublished primary
studies of cultural competence. We also sought information (e.g.,
other papers in press) from authors with two or more publications
identified in the search.
Initially, we identified approximately 43,000 peer-reviewed articles using the search terms listed above, including duplicates. We
examined the titles of these articles and subsequently retrieved 130
potential journal articles or dissertations. The doctoral student and
primary investigator reviewed these studies independently by reading abstracts and method sections to decide whether to include
them for further analysis. Decisions regarding which studies to
include involved ascertaining if studies were actual psychotherapy
or counseling studies (vs. analogue), if the procedures included
some type of MC measure or assessment, and if clinical processes
or outcomes were correlated with the MC measures. We did not
consider qualitative, analogue, or case studies. This process
yielded 39 studies of which the reference sections were also
checked to ensure that all potential studies were located.
Final inclusion criteria for analysis were (a) the study included
a client3 rating of therapist MC or a highly related construct; (b)
the research was based on ratings from actual psychotherapy/
counseling sessions—thus, analogue studies from a lab setting
(e.g., client ratings of therapist videotapes) or those evaluating case
management services (e.g., rehabilitation, vocational) were excluded; and (c) the study presented values or allowed for a calculation of a correlation coefficient (r) between MC and therapy
processes or outcomes. Twenty-one studies were excluded, as they
did not meet all inclusion criteria. The inclusion criteria did not
restrict studies to specific years; however, all of the summarized
studies were conducted between 2002 and 2014. Of the 18 included studies (20 independent samples), 13 were published studies in peer-reviewed journals and five were unpublished dissertations (see Figure 1; for more detailed information about the
excluded studies, see the Appendix).
Coding Procedures
The coding team consisted of two members, in which one coder,
a doctoral student in counseling psychology (the third author),
determined characteristics from each study, followed by the second coder (the first author), who checked for accuracy. The following descriptive information was coded: (a) sample size and
participant characteristics, including age, gender, and race or ethnicity4; (b) average number of psychotherapy sessions that clients
received; (c) the types and names of measures used to assess MC;
and (d) the types and names of measures used to assess clinical
processes and treatment outcomes. Information from all of the
included studies was extracted directly from the published articles
or dissertations.
MC measures included inventories or self-report tools used to
assess client perceptions of therapist multicultural awareness,
skills, and knowledge (e.g., sociopolitical awareness, cultural sen-
Figure 1.
341
Primary study inclusion flowchart.
sitivity); cultural processes or interactions within therapy (e.g.,
racial microaggressions, cultural humility); or perceived approaches or stances related to cultural identity variables (e.g., gender).
MC measures were categorized into two types—MC direct and MC
indirect. An MC direct measure included inventories like the CCCI–R
or MCI in which items explicitly ask participants to rate a therapist’s
MC. An MC indirect measure is one that assesses clients’ perceptions
of more nuanced and implicit MC congruent behavior (e.g., nonsexist
language) or MC antithetical behavior (e.g., racial microaggression,
color blindness; see Table 1).
Clinical process measures were categorized as those intended
to examine aspects of the psychotherapeutic relationship or
what transpires during the course of therapy and through the
client–therapist interaction (Orlinsky & Howard, 1986). These
included the alliance, session impact, satisfaction, and general
competence. Outcome measures were defined as those designed
to assess symptoms or complaints related to a specific presenting issue (e.g., depression) or broader psychological functioning (e.g., general life satisfaction, social interactions, ability to
enjoy activities).
Statistical Analyses
For each measure (i.e., clinical process or treatment outcome)
within each study, the primary effect size of interest was the
Pearson product–moment correlation (r). To correct for nonnormality of the correlation effect size and stabilize variance
estimation, rs were converted to z scores for the meta-analysis
and then back-transformed to rs for interpretation (Fisher,
1924). Variability in effect sizes across studies was examined
3
Only studies that included client ratings of their therapists were selected. While observer ratings of MC are clearly important, there were not
a sufficient number of studies. We address limitations of client ratings of
MC in the Discussion section.
4
Race and/or ethnicity were coded as the percentage of racial and ethnic
minority clients included in the study. Gender was coded as the percentage
of men and women included in the study.
TAO, OWEN, PACE, AND IMEL
342
Table 1
Multicultural Competencies (MC)—Direct and
Indirect Measures
Results
Descriptive Characteristics and Publication Bias
MC measure
Type
Color-Blind Racial Attitudes Scale (CoBRAS)
Cross-Cultural Counseling Inventory—Revised (CCCI–R)
Cultural Humility Scale (CHS)
Feminist-oriented approach (FOA)
Multicultural Counseling Inventory (MCI)
Racial Microaggressions in Counseling Scale (RMCS)
Indirect
Direct
Indirect
Indirect
Direct
Indirect
using the I2 statistic, which quantifies the amount of “true”
between-study heterogeneity in effect sizes not due to chance
(Huedo-Medina, Sánchez-Meca, Marín-Martinez, & Botella,
2006).
We conducted several specific meta-analyses. First, we provided an overall estimate of client perceptions of their therapists’
MC to all psychotherapy process and outcome measures. To account for dependencies between multiple observed correlations
within a single study, we aggregated associations within the study
such that there was one observed correlation between MC and the
outcome within a study. Second, we conducted separate metaanalyses, each associating the correlation of MC with a different
process or outcome measure. When there were multiple observations of the same type of correlation within a study (e.g., a study
reported two correlations between MC and satisfaction), these
correlations were aggregated. However, when different types of
associations were reported within a study (e.g., MC with treatment
outcome vs. MC with alliance), effects were not aggregated in
order to allow for different patterns of association across outcomes. Specific moderators (e.g., measure type, percentage of
R–EM clients) were tested via meta-regression. We restricted
moderator analyses regarding demographics and setting to the total
set of studies (i.e., we did not explore moderators within specific
types of process measures). This was for two reasons: (a) the
number of studies within each specific clinical process or outcome
was relatively small and thus underpowered and (b) we did not
have a specific rationale for why the effect of specific moderators
(e.g., the percentage of R–EM clients) would be different across
outcomes. Moderator results are reported in terms of d(r) or the
predicted difference (d) in the correlation coefficient (r) across
levels or values of the moderator.
For each meta-analysis, we utilized a random effects model,
which assumes that the studies in our database were drawn from
a population of studies and therefore allows estimation of
study-level heterogeneity as well as generalizing to the population of studies examining the association of MC and psychotherapy process and outcome (Cooper, Hedges, & Valentine,
2009). All analyses were conducted in R (R Core Development
Team, 2011) with the meta-analysis package “metafor” (Viechtbauer, 2014). Effect size aggregation within a study was conducted using formulas outlined by Hunter and Schmidt (2004),
utilizing the package “MAc” in R (Del Re & Hoyt, 2010),
assuming a correlation of .50 between different outcomes
within a study (Wampold et al., 1997).
Eighteen studies (20 independent samples5, 53 effects) met the
inclusion criteria of measuring clients’ perceptions of their therapists’ MC and treatment process and outcome (see Table 2). Of
these 53 effects, 25 (47%) examined the relationship between MC
and therapeutic alliance, nine (17%) the relationship between MC
and treatment outcomes, eight (15%) the relationship between
MC and client satisfaction, eight (15%) the relationship between
MC and general competencies, and three (8%) the relationship
between MC and session depth. Across all studies, the mean
number of sessions was eleven (median ⫽ 5.7), ranging from one
to 58 sessions. The mean number of participants across studies was
93 (median ⫽ 78; range ⫽ 15– 472). Across studies, the majority
of clients were women (68%; range ⫽ 26 –100%). Men represented 32% of clients (range ⫽ 0 –74%), and 1.3% of clients
identified as Other (range ⫽ 1–2%). Across studies, an average of
80% of clients reported race– ethnic minority group membership
(range ⫽ 30 –100%). The mean age of clients was 24 years old
(median ⫽ 22 years old; range ⫽ 19 – 48 years old; note that one
study did not report age).
We tested for the presence of publication bias in several ways.
First, we examined the difference in effect sizes between published
and unpublished studies. There was a significant difference, with
dissertations providing weaker associations across all outcomes as
compared to published articles, d(r) ⫽ ⫺.39, 95% confidence
interval (CI) [⫺0.65, ⫺0.05]. However, the rank correlation test
(Begg & Mazumdar, 1994) did not reveal a significant relationship
between observed correlations and sampling variance, r ⫽ .11, p ⬎
.50, indicating that there was no clear relationship between the
sample size and the observed correlation. Notably, there was still
no relationship even when dissertations were included in the
meta-analysis, r ⫽ ⫺.04, p ⬎ .50. This pattern held when publication tests were restricted to associations with process variables
as well as clinical outcomes.
Client Perceptions of Their Therapists’ MC and
Therapy Process
The effect sizes for the various outcomes are listed in Figure 2.
Supporting Hypotheses 1a– d, the associations between perceptions of MC across four specific clinical processes were large, but
heterogeneity in effect sizes was moderate to large for each outcome: (a) therapeutic alliance, r ⫽ .61, k ⫽ 16, 95% CI [.50, .71];
I2 ⫽ 90.35%, Q(15) ⫽ 155.48, p ⬍ .001; (b) client satisfaction,
r ⫽ .72, k ⫽ 5, 95% CI [.63, .80]; I2 ⫽ 63.82%, Q(4) ⫽ 11.05, p ⫽
.03; (c) general counseling competencies, r ⫽ .62, k ⫽ 7, 95% CI
[.49, .73]; I2 ⫽ 79.51%, Q(6) ⫽ 29.29, p ⬍ .001; and (d) session
depth, r ⫽ .58, k ⫽ 3, 95% CI [.37, .73]; I2 ⫽ 70.74%, Q(2) ⫽
6.83, p ⫽ .033. These findings suggest that client ratings of their
therapists’ MC account for approximately 37% of the variance in
working alliance, 52% of the variance in client satisfaction, 38% of
the variance in GCC, and 34% of the variance in session depth.
5
One study (Hook, Davis, Owen, Worthington, & Utsey, 2013) involved three independent samples and corresponding analyses that fit the
criteria for inclusion in our meta-analysis.
MULTICULTURAL COMPETENCIES META-ANALYSIS
343
Table 2
Studies of Provider Multicultural Competence and Psychotherapy Processes and Outcomes
N
Age
Percentage of
racial– ethnic
minority (R–EM)
clients
Constantine (2002)
112
21.0
100%
Constantine (2007)
40
19.7
100%
Source
Gender percentage
70% women
30% men
65% women
35% men
Clinical context
Multicultural
competencies
(MC) measure
University students
CCCI–R
University students
RMCS
CCCI–R
Outcome or process
measure
CRF–S
CSQ
WAI–SR
CSQ
WAI–SR
CSQ
EUS
CRF–S
CEI
CRF–S
WAI–SR
Fuertes & Brobst
(2002)
85
30
42%
80% women
20% men
Graduate students
CCCI–R
Fuertes et al. (2006)
51
26.5
76%
53% women
47% men
University students
CCCI–R
Hook, Davis, Owen,
Worthington, &
Utsey (2013)
472
134
120
21
26.4
27.8
40%
30%
100%
University students
UCC
Online survey
CHS
CHS
CCCI–R
CHS
CHS
WAI–SR
WAI–SR
WAI–SR
PEI
Kim, Li, & Liang
(2002)
78
20.1
100%
68% women
32% men
68% women
32% men
28% women
72% men
63% women
37% men
University students
CCCI–R
Kim, Ng, & Ahn
(2009)
61
21.0
100%
66% women
34% men
UCC
CCCI–R
Li & Kim (2004)
52
18.9
100%
69% women
31% men
University students
CCCI–R
100%
68% women
32% men
26% women
74% men
70% women
30% men
60% women
40% men
72% women
26% men
Churches, university
students
VA, UCC, and
CMH
UCC
CCCI–R
CERS
EUS
WAI–SR
SIS–Depth
Physical attractiveness
CERS
EUS
WAI–SR
SIS–Depth
Recommend
Return
CERS
EUS
WAI–SR
SIS–Depth
Physical attractiveness
CRF–S
CoBRAS
RMCS
RMCS
University students
CHS
SOS–10
WAI–SR
PEI
UCC
CCCI–R
SOS–10
SOS–10
WAI–SR
RRI–C
SOS–10
WAI–SR
SOS–10
WAI–SR
WAI–SR
CES–D
GAD–7
WAI–SR
WAI–SR
McCann (2006)
Morton (2011)
115 NR
19
47.7
100%
Owen, Tao, &
Rodolfa (2010)
Owen et al. (2014)
232
22
48%
45
24
76%
Owen, Leach,
Wampold, &
Rodolfa (2011)
Owen, Tao, Leach,
& Rodolfa (2011)
143
25.0
45%
176
25.0
46%
77% women
22% men
UCC
CCCI–R
Owen, Tao, &
Rodolfa (2010)
121
23.0
40%
100% women
UCC
MAWS
FOA
Rasheed (2011)
Sarmiento (2012)
40
80
29.1
21.4
100%
100%
100% women
78% women
22% men
Online survey
UCC
CCCI–R
CCCI–R
Ward (2002)
15
34.7
100%
85% women
15% men
CMH
MCI
WAI–SR
r
0.78
0.64
⫺0.40
⫺0.66
0.70
0.59
0.55
0.72
0.79
0.23
0.73
0.81
0.83
0.75
0.60
0.62
0.74
0.59
0.62
0.52
0.56
0.39
0.27
0.65
0.63
0.59
0.64
0.61
0.43
0.68
0.54
0.72
0.69
0.25
0.70
⫺0.01
⫺0.39
⫺0.18
⫺0.29
0.33
0.31
0.30
0.73
0.65
⫺0.22
⫺0.33
0.09
0.36
0.35
0.03
0.12
0.44
0.04
Note. CCCI–R ⫽ Cross-Cultural Counseling Inventory—Revised; CEI ⫽ Counselor Evaluation Inventory; CERS ⫽ Counselor Effectiveness Rating
Scale; CES–D ⫽ Center for Epidemiologic Studies Depression Scale; CHS ⫽ Cultural Humility Scale; CMH ⫽ community mental health; CoBRAS ⫽
Color-Blind Racial Attitudes Scale; CRF–S ⫽ Client Rating Form–Short; CSQ ⫽ Client Satisfaction Questionnaire; EUS ⫽ Empathic Understanding
Subscale; FOA ⫽ Feminist-Oriented Approach; GAD–7 ⫽ Generalized Anxiety Disorder–7; MAWS ⫽ Microaggressions Against Women Scale; MCI ⫽
Multicultural Counseling Inventory; NR ⫽ not reported; PEI ⫽ Patient Estimate of Improvement; RMCS ⫽ Racial Microaggressions in Counseling Scale;
RRI–C ⫽ Real Relationship Inventory–Client; SIS–Depth ⫽ Session Impact Scale–Depth; SOS–10 ⫽ Schwartz Outcome Scale–10; UCC ⫽ university
counseling center; VA ⫽ Veterans Administration Hospital; WAI–SR ⫽ Working Alliance Inventory—Short Form Revised.
344
TAO, OWEN, PACE, AND IMEL
settings (i.e., university [r ⫽ .73] vs. community setting [r ⫽ .46])
was notable but not significant, r(d) ⫽ .27, 95% CI [⫺.09, .57];
Q(1) ⫽ 2.16, p ⫽ .14. Notably, there were only five effects from
community settings in the entire meta-analysis, and one of these
effects was near zero and from an unpublished dissertation with a
small sample (r ⫽ .03, n ⫽ 15; Ward, 2002).
Discussion
Figure 2. Effect sizes for relationship between client perceptions of
therapist MC and psychotherapy outcomes and processes (Clinical ⫽
Therapy Outcomes).
The correlation between perceptions of MC and treatment outcomes was moderate in size with large heterogeneity in effect
sizes, r ⫽ .29, k ⫽ 7, 95% CI [.16, .41]; I2 ⫽ 76.12%, Q(6) ⫽
25.13, p ⬍ .001, which supports Hypothesis 2. This finding
suggests that client perceptions of their therapists’ MC account for
over 8% of the variance in therapy outcomes.
Moderator Analyses
The heterogeneity observed above suggests that the relationship
between MC and clinical processes and treatment outcomes varied
quite substantially across studies. To examine potential explanations for heterogeneity across studies, we conducted separate moderator analyses in three areas: (a) type of measures, (b) participant
demographics, and (c) setting.
There was no significant difference in the correlation of MC
across the four different measures of treatment processes, Q(3) ⫽
2.11, p ⬎ .50 (Hypothesis 2). However, there was a significant
difference between the correlation of MC with process measures
(i.e., alliance, satisfaction, depth, GCC) and clinical outcome,
r(d) ⫽ 0.45, 95% CI [0.24, 0.64]; Q(1) ⫽ 14.39, p ⬍ .001, where
the correlation between MC and process variables in aggregate
(r ⫽ .75) was more than twice as large as the correlation with
treatment outcomes (r ⫽ .29; Hypothesis 3).
The type of MC measure (direct vs. indirect) did not have a
significant influence on the strength of the relationship between
MC and outcomes, r(d) ⫽ ⫺.18, 95% CI [⫺.45, .11]; Q(1) ⫽ 1.53,
p ⫽ .22. In addition, there was no significant effect of average
client age, r(d) ⫽ ⫺.01, 95% CI [⫺.05, .01]; Q(1) ⫽ 1.58, p ⫽ .21,
the percentage of R–EM clients within a study, r(d) ⫽ .0002, 95%
CI [⫺.006, .006]; Q(1) ⫽ 0.005, p ⬎ .50, or the percentage of
women in a study, r(d) ⫽ ⫺.006, 95% CI [–.02, .004]; Q(1) ⫽
1.41, p ⫽ .24. Finally, the effect size difference between clinical
This is the first known meta-analysis to summarize the relationship between client perceptions of therapist MC and psychotherapeutic processes and outcomes. Beyond summarizing the effects
of clients’ perceptions of therapist MC in psychotherapy, we
addressed Kleinman and Benson’s (2006) call for evidence that
“culture really improves clinical services” (p. 1673). To this end,
our analysis of 20 independent samples and 53 effects demonstrated strong and positive effects of client perceptions of therapist
MC on four important clinical processes (rs ranged from .58 to .72
across measures) and a moderate relationship between MC and
treatment outcomes (r ⫽ .29). In other words, client perceptions of
therapist MC account for approximately 8.4% of the variance in
therapy outcomes, and therapist MC is closely linked to other core
clinical processes. Our analysis also showed that the associations
between client-rated MC and therapy outcomes were consistent
with other correlational estimates cited in the literature on empirically supported therapeutic variables, such as working alliance,
empathy, genuineness, goal census and collaboration, and
alliance–rupture repair (e.g., Elliott, Bohart, Watson, & Greenberg,
2011; Horvath, Del Re, Flückiger, & Symonds, 2011; Kolden,
Klein, Wang, & Austin, 2011; Norcross & Lambert, 2011; Safran,
Muran, & Eubanks-Carter, 2011; Tryon & Winograd, 2011). Accordingly, therapist MC should be considered an important empirically supported therapeutic relational factor, similar to those listed
above.
The moderate to large heterogeneity in effect sizes for all of the
clinical process and treatment outcome variables warranted moderator analyses, which offer potentially important explanations for
the variability. Accordingly, we discuss interpretations of moderation results found after testing the strengths of association of MC
with publication status, the type of psychotherapy outcome measure, client demographics, and clinical setting.
Interpretation of Moderator Analyses
Process versus treatment outcome measures. The association between MC and clinical processes was twice as large as the
relationship with clinical processes (r ⫽ .75 vs. r ⫽ .29). To start,
the correlation between client-rated MC and clinical process variables was fairly large (rs ranged from .58 to .72). These large
correlations indicate that these processes may occur concurrently,
such that a strong working alliance is more likely to exist when the
therapist exhibits more multicultural competencies (and vice
versa). Alternatively, these high correlations could indicate that
cultural processes and other clinical processes, such as alliance or
session depth, are fused. It may be tempting to conclude that high
correlations suggest that therapist MC is not unique or distinct
from these other clinical processes (see Coleman, 1998). However,
it will be important to examine the construct validity of such
tightly interrelated variables. For example, a factor analysis exam-
MULTICULTURAL COMPETENCIES META-ANALYSIS
ining the correlation between the CCCI–R–7, a modified version
of the CCCI–R, and the WAI-SR (Hatcher & Gillaspy, 2006)
found evidence for treating MC and alliance as separate constructs
(vs. a model in which items from both scales were loaded onto one
global factor; Drinane et al., 2014). Thus, the high correlations
demonstrated in our analysis might simply suggest that therapist
MC works in concert with other clinical processes to produce
therapeutic change (see, e.g., Owen, Tao, et al., 2011).
A moderate association between MC and clinical treatment
outcomes was found in several studies, albeit not consistently
so. The lack of longitudinal studies limits our understanding of
the association between client perceptions of their therapists’
MC and therapy outcomes. To our knowledge, a classic process
study design wherein changes in clients’ psychological functioning from pre- to posttreatment are correlated with their
perceptions of therapist MC early in treatment has yet to be
done. While moderate associations between therapist MC and
therapy outcomes may be evident in such designs (see commonalities in associations between retrospective and longitudinal designs; Moore & Owen, 2014), this research remains a
critical gap in the MC literature.
Client demographics and clinical setting. Our results indicated that the clinical setting (i.e., UCC vs. CMHC) and client
demographics, including age, gender, and percentage of R–EM
clients in the study, did not affect the relationship between MC and
either clinical processes or treatment outcomes. Whereas the percentage of R–EM clients in each study was not a significant
moderator, this result warrants some attention. Specifically, this
“no-difference” finding contributes to an ongoing discussion regarding whether therapist MC is most important for R–EM clients
or perhaps (and corresponding to our findings) a critical factor for
clients regardless of their R–EM status. Simultaneously, our results highlight a need for MC research that is sensitive to client
differences, including consideration of client-defined group membership and intersections of identities. This is in contrast to limiting clients to a set of predefined identity statuses based on
researcher-determined categorical indicators. For example, studies
on client and therapist racial– ethnic match may be overlooking the
importance of intersectionality or other cultural identity variables
(e.g., sexual orientation, religion, etc.; see Ibaraki & Hall, 2014).
Publication status. There were mixed results for tests of
publication bias. Dissertations provided smaller effects on average
as compared to published studies, suggesting that there is some
tendency for unpublished studies to have lower overall effects.
However, there was no clear relationship between study sample
size and effect size (both when dissertations were and were not
included in analyses). While these analyses are somewhat limited
by the low number of effects (k ⫽ 20), these results suggest that
both small and large effects have been published regardless of
sample size.
Our results also contribute to a growing corpus of meta-analyses
examining the role of cultural factors in psychotherapy, including
the effect of culturally adapted treatments on clinical outcomes
(e.g., Benish, Quintana, & Wampold, 2011; Griner & Smith, 2006;
Smith, Rodriguez, & Bernal, 2011). For example, Benish et al.
(2011) conducted a meta-analysis comparing culturally adapted
versus unadapted bona fide therapies. Whereas the summary of
studies found that culturally adapted treatments were more efficacious than unadapted bona fide treatments, the researchers found
345
that the efficacy of these culturally adapted treatments was moderated solely by the incorporation of the clients’ beliefs about the
meaning behind their presenting issues (also known as the illness
myth). In other words, therapists’ integration of clients’ cultural
narratives into the intervention significantly accounted for differences in client improvement (see also Huey et al., 2014). Consistent with this finding, our study indicates that client perceptions of
how a therapist navigates cultural factors in treatment are correlated with outcome. Despite this contribution, there are important
limitations to consider, which we describe next.
Limitations and Directions for Further Research
The first limitation of our study was the reliance on clients to
assess therapist MC. Although client perspectives are certainly
critical (Constantine, Kindaichi, Arorash, Donnelly, & Jung,
2002), it is not clear that clients can conduct nuanced assessments
of therapist behaviors (e.g., how well a client can assess the
provider’s ability to recognize the impact of their personal heritage; see Ridley & Shaw-Ridley, 2011, for a full discussion). For
example, 13 out of the 20 independent samples included in our
analysis utilized an adapted version of the CCCI–R, a measure
originally intended for use by trained observers (see Drinane et al.,
2014 for a critique). Additionally, we must note that a comparison
between types of MC direct measures was not possible, as the only
other measure in the set of studies was the MCI (and it was only
used once). Accordingly, correlations between self-, observer-, and
therapist-rated measures need to be addressed (Hoyt, Warbasse, &
Chu, 2006).
With respect to therapist-reported measures, we excluded two
studies that examined therapists’ own ratings of their MC that were
associated with changes in their client outcomes (Larrison, Schoppelrey, Hack-Ritzo, & Korr, 2011; Menapace, 1997). Larrison et
al. (2011) found that therapists who rated themselves higher on one
subscale of the MCI (Sodowsky et al., 1994) with R–EM clients
had better treatment outcomes (e.g., client-reported symptom reduction). Menapace (1997) found that therapists who rated their
MC higher also rated their outcomes with Black clients as being
more favorable. Although these studies are consistent with the
findings of our meta-analysis, the validity of therapist self-ratings
have been considerably questioned (Hoyt et al., 2006; Owen, Imel,
et al., 2011; Worthington & Dillon, 2011).
Our meta-analysis also highlights the lack of behavioral detail in
client-reported MC measures. What exactly are providers doing in
sessions? For MC psychotherapy research to progress, a greater
willingness to wade into the raw data of actual counselor– client
interactions is required. At present, there is not a single study
correlating an observer rating of therapist MC with treatment
outcome. Similarly, there are no studies that have examined the
correlation of observer ratings of MC with other measures of
treatment process. Developing useful observer ratings will be
complicated, as initial work suggests that observer, therapist, and
client ratings do not agree (Hoyt et al., 2006). For example, in two
MC studies (ns ⫽ 52, 55), the correlation between observer ratings
and therapists’ self-reports of MC was not significant (rs ⫽ .03,
.09; Constantine, 2001; Worthington et al., 2000). Additionally,
clients of the same therapist tend to disagree on their therapist’s
MC (e.g., intraclass correlation [ICC] ⬍ .01, as measured by the
CCCI–R; Owen, Leach, et al., 2011). However, there appears to be
346
TAO, OWEN, PACE, AND IMEL
more agreement among clients of the same therapist in their
perceptions of some indirect MC measures, such as the cultural
humility scale (ICC ⫽ .20; Owen et al., 2014). The next wave of
MC research will have to consider these discrepancies, which
could result from measurement issues or from the need to increase
use of other approaches to determine MC (e.g., observing the
behavior of providers with known levels of treatment outcomes
with racial– ethnic minority patients). Accordingly, there was a
notable shortage of outcome measures included in our analysis
intended to assess improvement for specific diagnoses or type of
treatment provided. Whereas the SOS–10 and PEI are helpful in
determining clients’ overall psychological well-being, only one
study (i.e., Sarmiento, 2012) utilized scales that assess reduction
(or increase) in depression or anxiety (i.e., CES–D; GAD–7).
Moreover, this particular study revealed a nonsignificant relationship between MC and these measures. Future MC therapist psychotherapy studies would benefit from including measures to
determine whether treatment outcome measures or specific diagnoses moderate effect size (e.g., Lambert, 2007; Wampold et al.,
1997).
Finally, a major limitation of the current state of MC research is
the overrepresentation of retrospective studies and the absence of
longitudinal studies. A major disadvantage of the former is the
potential difficulty for clients to recall specific and more nuanced
aspects of their therapy experience. Similarly, only the most recent
events (Rubin & Baddeley, 1989) and/or incidents that are more
personally relevant (Beckett, Da Vanzo, Sastry, Panis, & Peterson,
2001) are likely to be recalled. These reporting biases restrict a
fuller understanding of the influence of MC across all clients.
Also, the need for repeated observations in studies of therapist MC
is clear. It is critical that future research utilize approaches that
assess influence of MC on clients over time and the potential
cause-and-effect relationship between MC and clinical outcomes.
It is important to note, however, that retrospective analyses allow
for clients to reflect on the totality of their psychotherapy sessions,
which may account for perception changes and responses that are
more attuned to the gestalt experience (e.g., Moore & Owen,
2014). Moreover, retrospective analyses offer more representative
explanations regarding utilization, including data from both clients
who remain in therapy and those who drop out.
Whereas there is a dearth of studies that correlate treatment
outcome with ratings of therapist MC (only nine were found and
included in this analysis), we have provided meta-analytic evidence that therapist MC is tightly related to other important clinical processes at the intervention level. This provides convincing
evidence for continued examination of therapist MC. However, the
approaches researchers should take to move the literature forward
remain a major question. We have identified several areas to
consider, including longitudinal studies that examine MC in psychotherapy, which aim to discriminate between those therapists
who demonstrate relatively better or poorer outcomes with R-EM
clients (Hayes et al., 2014; Imel et al., 2011; Larrison et al., 2011).
Another recommendation is to improve and develop observerrated measures that directly assess provider behaviors as well as
address the lack of an established correlation between observer-,
self-, and therapist-reported MC ratings (Hoyt et al., 2006). Ultimately, the goal of providing all clients with multiculturally competent care will require the field of psychology to identify and
rigorously test the specific cultural processes that can effect
change in psychotherapy. We hope that this meta-analysis will
reinforce the importance of therapist MC and provide an “empirical compass” to explore new approaches to understanding the
effects of MC as well as galvanizing the importance of MC as a
critical psychotherapeutic factor.
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Appendix
Excluded Studies
Of the excluded studies, 12 focused on providers’ MC but did
not include an MC-related measure or specifically examine the
relationship of MC to treatment processes or outcomes (Barratt,
2007; Bellini, 2003; Constantine, 2001; Godley, Hedges, &
Hunter, 2011; Hayes et al., 2014; Imel et al., 2011; Lie, Lee-Rey,
Gomez, Bereknyei, & Braddock, 2011; Matrone & Leahy, 2005;
Owen et al., 2012; Schwan, 2007; Woidneck, Pratt, Gundy, Nelson, & Twohig, 2012; Worthington et al., 2000), three utilized
analytic approaches that did not allow for calculation of the correlation between MC and clinical processes or outcomes
(Grantham, 1973; Guerrero & Andrews, 2011; Jones, 1978), two
addressed organizational MC (Costantino, Malgady, & Primavera,
2009; Hamada, 2006), two utilized therapist report of MC versus
client report (Larrison et al., 2011; Menapace, 1997), one assessed
case-management-type services rather than psychotherapy
(Damashek, Bard, & Hecht, 2012), and one assessed the MC of
physicians (not psychiatrists; Fuertes, Boylan, & Fontanella,
2009).
Received November 1, 2014
Revision received April 3, 2015
Accepted April 7, 2015 䡲